title: Outdoor-sleeping and other night-time activities in northern Ghana: implications for residual transmission and malaria prevention.
abstract: BACKGROUND
  Despite targeted indoor residual spraying (IRS) over a six-year period and free mass distribution of long-lasting insecticide-treated nets (ITNs), malaria rates in northern Ghana remain high. Outdoor sleeping and other night-time social, cultural and economic activities that increase exposure to infective mosquito bites are possible contributors. This study was designed to document these phenomena through direct observation, and to explore the context in which they occur.
  
  
  METHODS
  During the late dry season months of February and March 2014, study team members carried out continuous household observations from dusk to dawn in one village in Ghana's Northern Region and one in Upper West Region. In-depth interviews with health workers and community residents helped supplement observational findings.
  
  
  RESULTS
  Study team members completed observations of 182 individuals across 24 households, 12 households per site. Between the two sites, they interviewed 14 health workers, six community health volunteers and 28 community residents. In early evening, nearly all study participants were observed to be outdoors and active. From 18.00-23.00 hours, socializing, night school, household chores, and small-scale economic activities were common. All-night funerals, held outdoors and attended by large numbers of community members, were commonly reported and observed. Outdoor sleeping was frequently documented at both study sites, with 42% of the study population sleeping outdoors at some time during the night. While interviewees mentioned bed net use as important to malaria prevention, observed use was low for both indoor and outdoor sleeping. Net access within households was 65%, but only 17% of those with access used a net at any time during the night. Participants cited heat as the primary barrier and reported higher net use during the rainy season.
  
  
  CONCLUSIONS
  Outdoor sleeping and other night-time activities were extensive, and could significantly increase malaria risk. These findings suggest that indoor-oriented control measures such as ITNs and IRS are insufficient to eliminate malaria in this setting, especially given the low net use observed. Development and evaluation of complementary outdoor control strategies should be prioritized. A research agenda is proposed to quantify the relative risk of outdoor night-time activities and test potential vector control interventions that might reduce that risk.
authors: Johns Hopkins Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD, 21202, USA. amonro10@jhu.edu.
authors: April
authors: A
authors: Monroe
authors: Malaria Consortium NetWorks Ghana, Cantonments, PO Box CT 5573, Accra, Ghana. obedasamoah@gmail.com.
authors: Obed
authors: O
authors: Asamoah
authors: Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. yukyan@jhu.edu.
authors: Yukyan
authors: Y
authors: Lam
authors: Johns Hopkins Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD, 21202, USA. hkoenker@jhu.edu.
authors: Hannah
authors: H
authors: Koenker
authors: University of Florida Emerging Pathogens Institute, PO Box 100237, Gainesville, FL, 32641, USA. ppsychas@ufl.edu.
authors: Paul
authors: P
authors: Psychas
authors: Johns Hopkins Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD, 21202, USA. mlynch@jhu.edu.
authors: Matthew
authors: M
authors: Lynch
authors: Johns Hopkins Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD, 21202, USA. ericotta@jhu.edu.
authors: Emily
authors: E
authors: Ricotta
authors: President's Malaria Initiative (PMI)-Ghana, US Agency for International Development No 24 Fourth Circular Road, Cantonments, PO Box 1630, Accra, Ghana. sehornston@usaid.gov.
authors: Sureyya
authors: S
authors: Hornston
authors: Johns Hopkins Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD, 21202, USA. amanda.berman@jhu.edu.
authors: Amanda
authors: A
authors: Berman
authors: Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. Steven.Harvey@jhu.edu.
authors: Steven A
authors: SA
authors: Harvey
mesh_terms: D000203:Activities of Daily Living; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D005260:Female; D005869:Ghana / Q000453:epidemiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D057148:Insecticide-Treated Bednets; D008288:Malaria / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission*; D008297:Male; D008875:Middle Aged; D009032:Mosquito Control; D011247:Pregnancy; D012890:Sleep; D055815:Young Adult
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