MAN. UNITED WIN 1-0 SUNDERLAND.

 

Man United have history in sights

With Manchester City having conceded defeat in the Premier League title race, runaway leaders Manchester United are switching their focus to the pursuit of records and the preservation of freshness in their squad.

United visit Sunderland on Saturday, when victory would provisionally take them a massive 18 points clear of second-place City, who host Newcastle United later in the day and whose manager, Roberto Mancini, accepts United can no longer be caught.

Eighteen points is the record margin by which United won the title from Arsenal in 2000, while manager Alex Ferguson has spoken of his desire to eclipse Chelsea's unprecedented haul of 95 points from the 2004-05 campaign.

United are also out to gain revenge for the exuberant celebrations of Sunderland's fans after Ferguson's men lost out on the title to City at the Stadium of Light on the final day of last season.

However, thoughts of both vengeance and the history books must be weighed against the need to retain focus for Monday's FA Cup quarterfinal replay at Chelsea.

With such a short turnover between the games, and in the immediate aftermath of the international break, Ferguson has given a strong hint that he will make changes for the visit of Martin O'Neill's side.

"Every coach is praying that their players come back fit (from international duty)," said Ferguson.

"I have to make sure I have some freshness in the team because we also have Chelsea on Monday lunchtime.

"It is a big ask for our squad and something we need to concentrate on because I need to make sure I pick the right teams."

The resumption of the league programme sees City, Chelsea, Tottenham Hotspur, Arsenal and Everton resume their five-way battle for the three Champions League places below United.

Chelsea, four points off City in third place, visit Southampton on Saturday, while fourth-place Spurs are at Swansea City and fifth-place Arsenal host second-bottom Reading.

Everton, two points behind Arsenal in sixth, tackle Stoke City.

Spurs' momentum has begun to ebb in recent weeks, following consecutive defeats by Liverpool and Fulham, and Arsenal are now only four points behind their local rivals with a game in hand.

Arsene Wenger's men, however, will once again be without Jack Wilshere, who has an ankle injury, while the injury-prone Abou Diaby has been ruled out for up to nine months with knee ligament damage.

Arsenal are also likely to encounter a Reading side invigorated by the mid-week appointment of manager Nigel Adkins, who has eight games to bridge the seven-point gap that currently separates the club from safety.

Third-bottom Wigan Athletic preserved the three-point gap that separates them from the teams above the drop zone with a last-gasp 2-1 win at home to Newcastle last time out.

Roberto Martinez's side, who also have a game in hand, host Norwich City on Saturday and victory will lift them out of the relegation zone at the expense of Aston Villa, who do not welcome Liverpool to Villa Park until Sunday.

The writing appears to be on the wall for Queens Park Rangers, who are level on points with Reading but occupy the last place in the table due to an inferior number of goals scored.

However, ahead of Monday's derby with London rivals Fulham, manager Harry Redknapp has urged his players to draw inspiration from the very best as they seek to change their fate.

"The best teams work the hardest," said Redknapp.

"People think the best teams just play football. It's a fallacy. The best team in the world is Barcelona and they are the hardest-working team."

Coach remain calm despite Sunderland missing key players to face Man Utd

Martin O'Neill remains calm ahead of Sunderland's home tie against Manchester United, despite missing key players.

While the Black Cats are without leading goalscorer Steven Fletcher as well as captain Lee Cattermole through injury, O'Neill remains confident ahead of the game.
"You have to do it, you have to overcome odds that sometimes seem as if they are stacked against you," he said.
"There is a lot of spirit in the dressing room and that spirit alone might wrest a couple of points.
"Anyone coming in and telling you they are completely nerveless, I am not so sure that would be the case.
"You have to have some sort of nervousness - but you have to be able to deal with that, take care of it and not let it affect your game.
"From that viewpoint, yes, I think nerves and tension all become a part of it, but it's something you shouldn't be subjecting yourself to every single minute."
With Fletcher and Cattermole ruled out for the remainder of the season, O'Neill remains calm, adding: "I am not overly worried about the clamour. What you try to do is put out a side to win some games.
"We have used Steven on his own there for most of the season, Sessegnon playing in behind him.
"With Steven out now, we will have to make some sort of adjustments, but we will see how we go."

Rio Ferdinand can handle abuse from fans.

 

The 34-year-old defender was the subject of alleged racial abuse from England supporters during the recent World Cup qualifier from San Marino, which has led anti-racism campaigners FARE to report the Football Association to FIFA.
Ferguson believes the defender is strong enough to cope should he receive similar treatment from the stands while on duty with United.
"If there is criticism out there I don't think it will bother him," said Ferguson.
"In modern society there is always a venting of spleen against someone who displeases them at any particular moment in time. It will blow over quite quickly.
"Most people realise Rio's international career had been in doubt for a while anyway. He hadn't been picked for a few games."

"If there is criticism out there I don't think it will bother him."
Sir Alex Ferguson

Ferdinand cited his training programme as the reason for his England withdrawal and Ferguson defended his player's decision.
"The way our physio and sports science departments had been handling him has been correct," said Ferguson. "That has allowed him to have one of his best seasons. That is why Roy has picked him.
"But there is a way we treat Rio in terms of getting him ready for big matches.
"The programme we have got for him is detailed in the sense of the games he plays in and the type of training he does in the build-up to games.
"We don't play him in every game, as everyone knows. We try to have him ready for the games that really matter."
When asked whether Ferdinand would play for England again, Ferguson replied: "I couldn't tell you. I have not spoken to him about it.
"He has had issues with his back obviously. Age catches us all. There is no question about that. In football you don't grow old without penalties.
"Rio has lost that lightning speed he had five or six years ago. But he has adapted in a different way in the sense of how his game is.
"You have to adjust to the situation and Rio has done that very well."

JENGO LA GHOROFA 15 LAANGUKA SAMORA DAR ES SALAM.

Tingatinga likifukua kifusi katika eneo la tukio leo asubuhi.

 

 

Gari lililokuwa karibu na jengo hilo likiwa limebonyezwa kama chapati likitolewa eneo la tukio kuweza kuwato majeruhi waliofunikwa na kifusi cha gorofa hilo.

England goalkeeper: Failure not an option

© AFP

Joe Hart insists England are refusing to contemplate the possibility of failing to qualify for the 2014 FIFA World Cup Brazil™.
Roy Hodgson's side remain in second spot in their group after surrendering a half-time lead in the 1-1 draw with leaders Montenegro in Podgorica.
It was a similar scenario to the draw in Poland in October when last night's scorer, Wayne Rooney, also put England ahead before they were pegged back.
But Hart believes such challenges away from home are not easy to overcome and that England have to try and capitalise on a promising position in their remaining games at Wembley.
The Manchester City goalkeeper said: "People ask about not holding on against Poland and Montenegro but they are tough places to come. Hopefully we will look back at last night as a good point earned.
"You've got to give respect to the opposition. I thought Montenegro were great in the second half and they made it hard for us.
"How I do assess the group? It is going to be tough. It is a really tough thing to qualify for a World Cup and you kind of take it a bit for granted.
"That's what we expect as a nation. We are England, we should be qualifying for things but it is easier said than done.
"But that's our plan (to qualify) and it is going to be difficult, but we aim to really capitalise on the home
Hart added: "We are not contemplating failing to qualify. That's not even crossing our minds at the moment.
"We've got ourselves in a strong position and we've got Montenegro to come at home and, if we win all the games now, we finish top of the group.
"That's the way we are going to have to view things. We are in this position now so we've got to move on from it."
Hart praised the performance of defender Chris Smalling against Montenegro striker Mirko Vucinic.
He said: "Chris did well, Vucinic is a well respected player, but our boys are not young in terms of experience.
"It's not like we are chucking them out to the lions, they are at good clubs, and have played in massive games before.
"It is another game but at the same time it's nothing new to them."

FIFA/COCA COLA WORLD RANK: TANZANIA TAIFA STAR RAISE.

When Kim Poulsen assumed the Tanzania reins in May 2012, the Taifa Stars were ranked 145th on the FIFA/Coca-Cola World Ranking and 42nd in Africa. In less than a year, the Dane has helped the east Africans climb to 119th in the world and 33rd on the continent, after leaping up eight spots in the last edition of the global ladder. A surprising 3-1 victory over Morocco in a 2014 FIFA World Cup Brazil™ qualifier on 24 March will undoubtedly see the team rise even further in the next month.

Tanzania have only once managed to qualify for the CAF Africa Cup of Nations. That was in 1980, when two defeats and one draw was not enough to see them escape the first round. Their Ranking story is similarly disappointing, reaching their all-time low in October 2005, when they were 175th in the world. Although they climbed to 89th in December 2007, they were caught in a downward spiral since then.

When Poulsen, who up to then had been in charge of the Tanzania U-20 team, replaced his Danish namesake Jan Poulsen, he introduced several of the players with whom he had worked with in the youth side.

"I look for players who have the class, of course, but they also have to have the character to do well and they have to have pride," Poulsen, who also mentioned that the team had benefited from a new long-term sponsor, which enabled the Taifa Stars to embark on a series of international friendlies, told FIFA.com

IVORYCOAST BEAT GAMBIA 3-0,KENYA 1-1 NIGERIA.

A stoppage-time equaliser from Nnamdi Oduamadi spared Nigeria's blushes as the African Nations Cup winners struggled to 1-1 draw with Kenya in FIFA World Cup™ qualifying Group F.

Francis Kahata gave the Harambee Stars a shock lead in the 36th minute and, after nearly an hour of fruitless toiling, Nigeria forced a point through Oduamadi three minutes into time added on.

Malawi then took their share of first place with Stephen Keshi's team by beating Namibia 1-0 in Windhoek thanks to Gabadin Mhango's 69th-minute winner.

Cameroon claimed top spot in Group I from Libya, who play DR Congo tomorrow, as Samuel Eto'o scored a brace in a 2-1 win over Togo. The Anzhi Makhachkala striker's 42nd-minute penalty was cancelled out by Dove Wome in first-half stoppage time, but Eto'o managed to turn home a winner eight minutes from full-time

 

.

Christopher Samba scored the only goal as Congo extended their lead at the top of Group E to six points with a 1-0 victory against Gabon.

Second-placed Niger could have reduced the gap if they had secured a positive result in Burkina Faso. However, Niger instead slipped to third after suffering a comprehensive 4-0 defeat to Burkina Faso in Ouagadougou.

The Menas were up against it from the third minute when Jonathan Pitroipa notched and further strikes from Aristide Bance (36), Charles Kabore (78) and Prejuce Nakoulma (86) fired Burkina Faso into second place, where they lie six points shy of Congo.

Emphatic Elephants

In tonight's other games, Côte d'Ivoire threw down the gauntlet to Group C rivals Tanzania with a comprehensive 3-0 win over Gambia. Second half goals from Wilfried Bony (49), Yaya Toure (59) and Salamon Kalou (70) pushed the Elephants four points clear at the top with Tanzania hosting Morocco tomorrow.

Senegal, however, can be caught by Uganda in Group J after being held to a 1-1 draw at the Stade du 28 Septembre. Moussa Sow (39) put the 2002 World Cup quarter-finalists on track for a five-point lead but Amaro's 75th-minute equaliser gives Uganda the chance to catch up should they take any points from Liberia tomorrow.

And, buoyed by a superb opener from Thabo Matlaba, South Africa closed out a 2-0 win over the Central African Republic to replace Ethiopia at the top of Group A. The Orlando Pirates left-back thundered the ball home from 40 yards in the 34th minute and the shellshocked Wild Beasts were helpless to resist when Bernard Parker made the points safe 20 minutes from time.

Elsewhere, substitute Wahbi Khazri scored the winner as Tunisia resisted a Sierra Leone rally to win 2-1. Oussama Darragi's 57th-minute opener was cancelled out by Alhassan Kamara in the 74th minute but Khazri ensured Nabil Maaloul's men a five-point lead in Group B.

TANZANIA WIN 3-1 AGAINST MOROCCO,ETHIOPIA WIN 1-0 BOTSWANA.

Ethiopia snatched a dramatic 1-0 home victory over Botswana on Sunday to keep alive hopes of a first appearance at the World Cup in Brazil next year. Substitute Getaneh Kebede, who replaced fellow-striker Adane Girma for the second half in Addis Ababa, snatched the lone goal two minutes from time in the high-altitude east African city.

 Ethiopia returned to the top of Group A with seven points, two more than overnight leaders South Africa, who overcame Central African Republic 2-0 in Cape Town thanks to goals from Thabo Matlaba and Bernard Parker.

Tanzania scored three second-half goals to thrash four-time World Cup qualifiers Morocco 3-1 in Dar es Salaam and climb to within a point of Group C pacesetters Ivory Coast.


Thomas Ulimwengu broke the deadlock a minute after half-time and there was a brace for Mbwana Samata before Youssef El Arabi reduced arrears four minutes into stoppage time.

 This humiliating loss, coupled with draws against Gambia and Ivory Coast, means Morocco are all but out of the running for Brazil, and the future of recently appointed coach Rachid Taoussi must be in doubt.

 Litsebe Marabe levelled a minute from time to give minnows Lesotho a 1-1 draw with 2012 African champions Zambia in Maseru after Collins Mbesuma opened the scoring entering the closing stages.


 The failure to collect maximum points was a bitter blow for Zambia, who stay top of Group D with seven points, but Ghana can close the gap to just one point if they defeat Sudan in Kumasi later on Sunday.

Mozambique and Guinea drew 0-0 in a dour Group G clash in Maputo, leaving leaders Egypt with the possibility of opening a five-point gap should they beat generally poor travellers Zimbabwe in Alexandria on Tuesday.   


 Mali, third behind Nigeria and Burkina Faso at the recent Cup of Nations in South Africa, fought back to overcome Rwanda 2-1 in Kigali and rise two places to the Group H summit.

 Meddy Kagere scored after 37 minutes to raise hopes of a first qualifying win for the Rwandan Wasps after a heavy away loss to Algeria and a last-gasp home draw with Benin.

 But Mali scored twice within six minutes early in the second half through Mahamadou Samassa and Abdou Traore to take a two-point lead over Benin with twice World Cup qualifiers Algeria a point further back
 

FIFA WORLD CUP QUALIFY MALI BEAT RWANDA 2-1

The Eagles of Mali have briefly gone top of Group H in their 2014 World Cup qualifiers after a hard earned 2-1 win over hosts Rwanda at the Amahoro Stadium in Kigali on Sunday.

The Eagles fought from a goal down scored in the 37 minute through Meddie Kagere, but fought back strongly in the second half to score two quick goals.

Ugandan-born striker Kagere gave the home fans something to smile about with a good finish past Mali’s goalkeeper Soumaila Diakite.

But the Eagles returned after the interval to score two quick goals in a space of five minutes.

Mohamadou Samassa made it 1-1 after 55 minutes, before Abdou Traore gave the West Africans the lead.

Rwanda Coach Milutin ‘Micho’ Sredejovic tried to make changes to his team taking off the colourful skipper Oliveir Karekezi and Fabrice Twayizimana for Elias Uzamukunda and Jeff Reindorf, but to no avail.

The visitors further contained the game when Coach Patrice Carteron brought on the fresh legs of Mana Dembele, Salif Coulibaly and Sigamary Diarra.

“We started well, but failed to contain well in defence,” said a disappointed Rwanda Coach after the match.

Carteron was a happy man saying they must also make use of their home games.

“We started poorly, but I told the team to settle and pile more pressure,” added the coach.

Mali now leads the group with six points before Benin face Algeria in the other group game.

DIET AND NUTRITION.

Vitamin D supplements significantly reduced blood pressure in the first large controlled study of African-Americans, researchers report in the American Heart Association journal Hypertension

Vitamin D is a steroid vitamin a group of fat-soluble prohormones, which encourages the absorption and metabolism of calcium and phosphorous. People who are exposed to normal quantities of sunlight do not need vitamin D supplements because sunlight promotes sufficient vitamin D synthesis in the skin.

Five forms of vitamin D have been discovered, vitamin D₁, D₂, D₃, D₄, D₅. The two forms that seem to matter to humans the most are vitamins D₂ (ergocalciferol) and D₃ (cholecalciferol).


Researchers at the University of Minnesota found that Vitamin D levels in the body at the start of a low-calorie diet predict weight loss success, suggesting a possible role for vitamin D in weight loss.

Data collected from the National Health and Nutrition Examination Survey (NHANES), USA found that 9% (7.6 million) of children across the USA were vitamin D deficient (defined as less than 15 ng/mL of blood), while another 61 percent, or 50.8 million, were vitamin D insufficient (15 to 29 ng/mL) (reference "We expected the prevalence of vitamin D deficiency would be high, but the magnitude of the problem nationwide was shocking," says lead author Juhi Kumar, M.D., M.P.H., a fellow in pediatrics at Children's Hospital at Montefiore Medical Center, The University Hospital and Academic Medical Center for Albert Einstein College of Medicine.
Vitamin D for humans is obtained from sun exposure, food and supplements. It is biologically inert and has to undergo two hydroxylation reactions to become active in the body. The active form of vitamin D in the body is called Calcitriol (1,25-Dihydroxycholecalciferol).

Calcitriol promotes the absorption of calcium and phosphorus from food in the gut and reabsorption of calcium in the kidneys - this increases the flow of calcium in the bloodstream. This is essential for the normal mineralization of bone and preventing hypocalcemic tetany. Hypocalcemic tetany is a low calcium condition in which the patient has overactive neurological reflexes, spasms of the hands and feet, cramps and spasms of the voice box (larynx). Calcitriol also plays a key role in the maintenance of many organ systems.

Various forms of vitamin D

We know about 5 forms of vitamin D, of which vitamins D₂ and D₃ are the major forms as far as humans are concerned. They are known collectively as calciferol.

• Vitamin D₁, molecular compound of ergocalciferol with lumisterol.
  
• Vitamin D₂, ergocalciferol (made from ergosterol).
  
  It is produced by invertebrates (animals without a spine, vertebral column), fungus and plants in response to sunlight (UV irradiation). Humans and other vertebrates do not produce vitamin D₂. We don't know much about what vitamin D₂ does in invertebrates. We know that ergosterol is a good absorber of ultraviolet radiation which can damage DNA, RNA and protein; consequently many scientists believe it may serve as a sunscreen that protects organisms from sunlight damage.

Vitamin D₃, cholecalciferol (made from 7-dehydrocholesterol).

Vitamin D₃ is made in the skin when 7-dehydrocholesterol reacts with ultraviolet light at 270-300 nm wavelengths - peak vitamin D₃ production occurs between 295-297 nm. It is only when the UV index is greater than 3 that these UVB wavelengths are present.

A UV index of more than 3 occurs every day in the tropics, every day during some of spring, all of summer, and parts of autumn in temperate areas, and hardly ever at all in the arctic circles. Temperate regions are all regions outside the tropics and arctic circles. The number of days of the year when the UV index is greater than 3 become fewer the further you move away from the tropics.

A human requires ten to fifteen minutes of sun exposure at least twice a week on the face, arms, hands, or back without sunscreen with a greater than 3 UV index for adequate amounts of vitamin D₃. Longer exposure results in the extra vitamin supply being degraded as fast as it is generated.

• Vitamin D₄, 22-dihydroergocalciferol.
  
• Vitamin D₅, sitocalciferol (made from 7-dehydrositosterol).

Which is more important for humans, vitamins D₂ or D₃?

Both vitamins D₂ and D₃ are used in human nutritional supplements. Pharmaceutical forms include calcitriol (1alpha, 25-dihydroxycholecalciferol), doxercalciferol and calcipotriene. The majority of scientists state that D₂ and D₃ are equally effective in our bloodstream. However, some say that D₃ is more effective. Animal experiments, specifically on rats, indicate that D₂ is more effective than D₃.

Manchester United's Sir Alex Ferguson wants full focus.

 

• • Manchester City 11/8
  • Manchester Utd 11/4
  • Chelsea 7/2
• Sky Bet are offering all new customers a £10 Free Bet

  Claim your free bet now
  Manchester United manager Sir Alex Ferguson is adamant his side will not allow complacency to deny them a 20th league title.

A 1-0 win over Reading on Saturday evening thanks to Wayne Rooney's deflected first-half goal moved the Old Trafford club to within 13 points of winning the Premier League.
The title is therefore within touching distance but, having seen his side blow an eight-point lead in the last six games of last season, Ferguson is demanding full focus.

"It wasn't a great performance but where we are today is not down to today but the last six months"
Sir Alex Ferguson

"You don't get points and medals for being complacent and we won't be," he told MUTV. "I think the players are conscious of the importance of the games now and that concentration, which has improved, has helped us do that [in terms of keeping clean sheets].
"I think, before the game, we always thought that winning was the important thing today.
"It wasn't a great performance but where we are today is not down to today but the last six months.
"The team has shown great consistency and played a lot of great football. Our goal difference is big over City now - 13 goals. It's a great position to be in but the only thing we can do is win our next game."
The Premier League now goes on hold for the international break and Ferguson has confirmed Rio Ferdinand will meet up with England after his surprise recall.
Ashley Young is expected to be fit to also join the Three Lions squad on Monday night despite being substituted with an apparent knee problem against Reading.

"Tiredness is a great leveller but we'll do our utmost to make sure we field the freshest possible teams"
Sir Alex Ferguson

Ferguson has already bemoaned his United squad suffering from fatigue and the international break is consequently far from ideal for the Scot considering they travel to Sunderland on 30th March for a lunchtime kick-off, and Chelsea 48 hours later for their FA Cup quarter-final replay.
"With the problem I've got, a lot of players are away on international duty and play two games," said Ferguson, who made eight changes to his first team to face Reading.
"They come back and we've got a lunchtime game against Sunderland on Saturday and then it's lunchtime again against Chelsea on Monday.
"Why have we got a squad if we don't use it and we did today."
Ferguson added: "We are making arrangements for some players to fly home by privately hired jet after their matches to make sure they get home as quickly and as smoothly as possible.
"Tiredness is a great leveller but we'll do our utmost to make sure we field the freshest possible teams.
"Private planes are going to cost the club an awful lot of money but it is something we feel we have to do."

Rooney downs Reading; City suffer at Everton; Vital Villa victory.

Manchester United have one hand on the Premier League trophy after their 1-0 victory over Reading at Old Trafford and Manchester City's 2-0 defeat by Everton at Goodison Park.

Queens Park Rangers suffered a damaging defeat away to Aston Villa in their battle to beat the drop with Paul Lambert's side claiming victory in a five-goal thriller.
Southampton halted Liverpool's recent charge to boost their own survival hopes, Arsenal edged out Swansea 2-0 at the Liberty Stadium, with Stoke's home meeting with West Brom ending in stalemate.

Manchester United now hold a surely insurmountable 15-point lead at the top of the Premier League table following their narrow, but routine, victory over Reading at Old Trafford.
Wayne Rooney scored the only goal of a low-key and largely one-sided game with a deflected effort from outside the box in the 21st minute to condemn the managerless Royals to their sixth successive top-flight defeat.
With just nine games remaining for Sir Alex Ferguson's side it will take a collapse of Devon Loch proportions to prevent them claiming their 20th top-flight crown.

Christian Benteke scored a priceless late winner for Aston Villa in a five-goal thriller against Queens Park Rangers to lift Paul Lambert's men six points clear of the drop zone and leave the rock-bottom visitors seven from safety.
The Rs forged ahead when Jermaine Jenas was gifted possession just inside the Villa half and he drove forward before releasing Bobby Zamora. The striker saw his shot saved by Brad Guzan, who had earlier made two superb stops from Chris Samba, but Jenas had continued his run and was on hand to tuck home the loose ball.
Villa were back on terms just before the interval as Matt Lowton's hanging cross had the QPR defence back-pedalling towards their own goal and, with Julio Cesar rooted to his line, Gabriel Agbonlahor was able to nod home from close range.
Villa Park erupted in the 59th minute as Andreas Weimann's superb turn and shot from the edge of the area saw his low drilled effort beat Cesar at his near post, only for Andros Townsend to level with a scrappy effort from distance.
And it was left to Benteke to have the final say in the 81st minute, with the powerful striker converting after Weimann's persistence had seen him burst into the box before pulling the ball back for his team-mate.

Everton delivered what will surely be a fatal blow to Manchester City's already fading Premier League title hopes with a 2-0 success at Goodison Park.
Leon Osman's long-range effort curled away from a static Joe Hart and into the top corner in the 32nd minute as the home side banished the memories of their limp FA Cup exit to Wigan last weekend.
Steven Pienaar was issued with a deserved red card following a late and high challenge on Javi Garcia in the 61st minute before City were denied a clear penalty when Marouane Fellaini handled Carlos Tevez's shot well inside the box, only for referee Lee Probert to award a free-kick outside the area.
With the visitors pressing for a late equaliser they were hit on the break in injury time as Fellaini burst away and released substitute Nikica Jelavic, who ended his goal drought with a deflected effort.

Liverpool's recent resurgence was brought to a shuddering halt with a 3-1 defeat at Southampton, who now have a seven-point cushion over the relegation zone.
Brendan Rodgers' side went into the game on the back of three successive Premier League victories, but fell 2-0 down inside 33 minutes after goals from Morgan Schneiderlin and Rickie Lambert.
Schneiderlin's deft touch from Jay Rodriguez's knockdown after Gaston Ramirez's cross went beyond Brad Jones, before the Liverpool keeper was beaten by Lambert's free-kick, which took a big deflection off the backside of Daniel Sturridge in the wall as he jumped and turned his back.
Sturridge then used his body to good effect at the right end of the field before seeing his shot blocked as Philippe Coutinho opened his account for the Reds to pull one back on the stroke of half-time.
But Liverpool's defence, and Martin Skrtel in particular, then allowed Rodriguez to advance unchecked into the area, with the Saints man converting at the second attempt after Jones' initial save.

Arsenal's bid to return to the UEFA Champions League following their midweek exit at the hands of Bayern Munich continued with a 2-0 success away to Swansea.
January signing Nacho Monreal opened his account for the Gunners with a scuffed effort from outside the box which Swans goalkeeper Michel Vorm will certainly feel he could have done better with.
And the much-maligned Gervinho made it two in the closing stages as he rolled home under Vorm after being played in by Aaron Ramsey.
Stoke halted a run of three successive Premier League defeats but there was still very little for the Britannia Stadium faithful to cheer in their 0-0 draw with West Brom

Southampton impress in 3-1 home win over Liverpool.

Rickie Lambert: Southampton striker celebrates after scoring second goal.

 

Southampton took a major step towards Premier League survival with an impressive 3-1 win over a lacklustre Liverpool at St Mary's.

In a dominant first-half performance, goals from Morgan Schneiderlin and a deflected Rickie Lambert free-kick put Mauricio Pochettino's side in the ascendancy.
Philippe Coutinho got Liverpool back into the game just before the interval, but Jay Rodriguez scored a deserved third goal with 10 minutes to go to lift Southampton seven points away from the relegation zone.
Southampton were ahead after just six minutes when Rodriguez nodded down Gaston Ramirez's cross into the path of Schneiderlin, who nonchalantly flicked the ball past Brad Jones.
Liverpool were sluggish for much of the first half and almost fell further behind on 10 minutes when Jones had to come off his line to deny Lambert after the striker had broken free.
Rodriguez had a well-struck shot from distance saved before the forward volleyed over on the turn from close range after Jones had parried Adam Lallana's attempt from a tight angle.
All Liverpool had to offer was an ambitious 35-yard shot from Daniel Sturridge which was easily gathered by Artur Boruc before Southampton extended their lead on 33 minutes.
The home side were awarded a free-kick 30 yards from goal and Lambert's shot took a wicked deflection off the jumping Sturridge before creeping inside the post.
Jones then saved again from Rodriguez before Coutinho had the chance to pull a goal back five minutes before half-time after bursting clear, only to shoot straight at Boruc.
Southampton were playing some sublime football on the South Coast and another slick move created an opening for Lallana, but he shot just wide.
Liverpool gave themselves hope for the second half by scoring in first-half stoppage-time when Coutinho fired home the loose ball after Sturridge's shot had been blocked.
Chances proved to be more scarce after half-time, with Sturridge scuffing wide before Luis Suarez and Steven Gerrard both drew comfortable saves out of Boruc.
Jones was out again to deny Lallana on 77 minutes, but three minutes later he was beaten for a third time when Rodriguez was allowed to run virtually unchallenged from the halfway line and he tucked away the rebound after his initial shot had been pushed out by the Liverpool keeper.
Southampton manager Mauricio Pochettino believes his side's win was fully deserved and sees the result as a reward for their recent performances.
He said: "We were fully focused on the game. My team believed and we had the correct mentality to compete well today. We prepared really well for this game and we fully deserved this victory."
Brendan Rodgers agreed with the Saints boss that the hosts were justified winners and the Liverpool manager admits the Reds were not at their best on Saturday.
"I said before the game that this game was arguably going to be one of the toughest games for us this season and overall I can't complain," said Rodgers.
"We weren't at our best and we're not the sort of team yet when, if we're not at our best, we can see through results."

Arsenal win at Swansea to maintain top-four push.

Arsenal closed the gap on Chelsea and maintained their push for a top-four finish with a 2-0 win at Swansea.

Second-half goals from Nacho Monreal and substitute Gervinho were enough to sink the Swans and leave the Gunners just two points behind fourth-place Chelsea.
Arsene Wenger left Wojciech Szczesny and Thomas Vermaelen on the bench after they were omitted from the impressive win over Bayern Munich in midweek and Arsenal started brightly.
Alex Oxlade-Chamberlain had the first chance of the game as he forced his way past Angel Rangel on the left before beating Michel Vorm with the shot only to see the ball clip the crossbar.
Swansea then enjoyed a good spell, starving the visitors of the ball and going close to taking the lead on two occasions in quick succession through the Spanish duo of Angel Rangel and Michu.
Ki Sung-Yueng threaded a neat ball through to the advancing Rangel only for the full-back to skew his shot wide and then Michu seized on a Jonathan de Guzman pass but dragged his effort wide.
That seemed to jolt the Gunners to life and they dominated the remainder of the first half with Oxlade-Chamberlain striking the top of the crossbar for a second time with a long-range drive.
Despite those contributions, it was a quiet start to the second half and the young England international was substituted with 20 minutes remaining as Wenger made a double change.
Gervinho was one of those players introduced and he added some energy to the Arsenal play with the winning goal arriving soon after courtesy of Monreal.
Santi Cazorla drove into the box and squared the ball to Olivier Giroud who forced the ball back to Monreal, despite pressure from Ashley Williams, and the Spaniard scuffed his shot past Vorm.
Swansea introduced in-form striker Luke Moore in search of an equaliser but could create little and were punished in stoppage time when Arsenal added a second to seal it.
With the Swans pushing for a goal, Aaron Ramsey found himself with a two-on-one situation and had the awareness to square the ball to fellow substitute Gervinho and the Ivory Coast international calmly slotted past Vorm.

Manchester City boss Roberto Mancini 'angry' after 2-0 defeat at Everton.

David Platt revealed Roberto Mancini was too angry to talk after Manchester City suffered a 2-0 defeat by Everton at Goodison Park.

Goals from Leon Osman and Nikica Jelavic gave 10-man Everton the points, but City should have been awarded a penalty when the score was 1-0 after Marouane Fellaini handled in the box.
A free-kick was given instead by referee Lee Probert and first-team coach Platt said City boss Mancini did not want to land himself in trouble with the Football Association.
"He's angry, as you can imagine," Platt told Sky Sports when asked why Mancini had not appeared. "He's just taking stock of the situation and calming himself down.

"He's angry, as you can imagine. He's just taking stock of the situation and calming himself down. He doesn't want to come out and say things that might get him in trouble."  

"He doesn't want to come out and say things that might get him in trouble."
When asked what Mancini was angry about, Platt replied: "One, our performance as I don't think we were really at it throughout the game. We got outworked by Everton.
"And two, even when we do have moments where we can get back into it, it doesn't go for you.
"From where I was live, he's given the handball and I don't know if it's inside the area or not, but you've just replayed it and it's not even on the line of the area, he's three yards off it.
"We didn't get it and perhaps our performance didn't deserve it, but we could have got a little more out of the game had the decisions gone for us."
City could now end the day 15 points adrift of leaders Manchester United, who face Reading at home in the evening, but Platt is adamant the reigning champions will stay focused.
Platt added: "I think nobody was shouting from the rooftops saying we were chasing Man Utd down.
"They would still have had a significant points advantage over us even if we had won today. It would probably have still been 12 points as you'd expect them to win at home.
"We have an obligation to win matches between now and the end of the season regardless of the points advantage and regardless of if it's mathematically impossible, which it isn't, but even when it is, we have still got to be professional and go out and win football matches."

Roy Hodgson recalls Rio Ferdinand to England squad.

Rio Ferdinand has been recalled to the England squad for this month's World Cup qualifying double-header.

The Manchester United centre-half, whose last cap came against Switzerland in June 2011, is among a 26-man squad picked to take on San Marino and Montenegro in Group H.
And Roy Hodgson has given every indication Ferdinand will be back in the side in Serravalle on 22 March.
"A player of Rio's calibre and of Rio's age you don't necessarily bring into the squad as back-up," he said. "You bring them in because you hope they're going to make the team better.

"A player of Rio's calibre and of Rio's age you don't necessarily bring into the squad as back-up. You bring them in because you hope they're going to make the team better."
Roy Hodgson

"It wouldn't take too much guesswork to work out that now he's in the squad he's there in order to play, not to make up numbers."
Asked whether he thought Ferdinand could play further games for England, Hodgson said: "I'm sure he could. In the past I've chosen other players. At the moment I think Rio is the right man to help us in these games and probably games ahead but I can't make guarantees for the future.
"If Rio Ferdinand is still playing like he is now in 2014 he's going to be a major candidate for a place in the squad."
Hodgson hopes any potential differences between Ferdinand and Ashley Cole can be resolved after the pair clashed following the John Terry race row.
Hodgson said: "Let's hope (there are no issues) I will cross that bridge when I come to it.
"I would be unhappy, I suppose, if there were tensions between players in a group.
"But we are talking about two very experienced professional players here and we are talking about the England football team. I don't envisage any problems."
Hodgson left the player out of his plans for Euro 2012, citing footballing reasons rather than an ongoing court case involving Ferdinand's brother Anton and Terry.
As recently as February Hodgson responded tetchily to questions about Ferdinand's impressive United form, claiming England had "moved on", but injuries to Phil Jagielka and Phil Jones have forced the manager to rethink.West Brom goalkeeper Ben Foster is also named just days after coming out of international retirement. He will act as back-up to regular No 1 Joe Hart along with Celtic's Fraser Forster.
And Tottenham pair Scott Parker and Michael Dawson have also been called up after long absences - nine months for Parker and almost two years in Dawson's case.
England are away at San Marino on 22 March, four days before they take on current group leaders Montenegro in Podgorica.
Squad: Forster, Foster, Hart, Baines, Cahill, Cole, Dawson, Ferdinand, Johnson, Smalling, Walker, Carrick, Cleverley, Gerrard, Lampard, Lennon, Milner, Osman, Oxlade-Chamberlain, Parker, Walcott, Young, Defoe, Rooney, Sturridge, Welbeck.

HUU NDIO MLIMA KITONGA

LIVE MATCH ARSENAL 2-0 BAYERN.

Milan's test for Barcelona today,Schalke 04 Vs Galatasaray AS

Captain Massimo Ambrosini says that attitude will be everything if AC Milan are to resist FC Barcelona in Tuesday's round of 16 second leg – and an away goal would not go amiss either.

Related Item

The veteran midfielder is adamant that Milan's character in the face of a potential Barcelona fightback at the Camp Nou will determine whether or not they can protect their 2-0 advantage and reach the UEFA Champions League quarter-finals.
"Our attitude will define this match," said the 35-year-old former Italian international. "We have to face the match in a certain way – we have to prepare with a lot of courage. We have to read the game properly otherwise we will be making a big mistake. Our attitude has to be to want to hurt Barcelona. One goal would increase our chances massively."
Indeed, Kevin-Prince Boateng and Sulley Muntari's second-half strikes at San Siro three weeks ago will be no guarantee of progress according to Ambrosini – hence the comment "it would be fantastic to score a goal". Which tallies with his opinion that the Rossoneri have to concentrate fully on their own strengths rather than fret too much about Barcelona.

"We have to make the most of this situation," said the 2003 and 2007 UEFA Champions League winner. "The more you worry about things, the more you are likely to play badly. Barcelona are so strong that they will play as they usually do: have possession and control the match. They can't have a different attitude. They might be fiercer but we're ready for that. Messi is their most important player but not the only one. Tomorrow we have to stop the whole of Barcelona."


The experience of Ambrosini – who made his third European appearance of the campaign in the defeat of the Blaugrana – may be vital to a Milan side that could feature the youth of M'Baye Niang, Stephan El Shaarawy and Mattia De Sciglio. The tie, he cautions, still hangs in the balance. Last season's last-16 meeting with Arsenal FC is warning enough, considering how the Italian club's 4-0 lead was almost eaten away during a 3-0 second-leg defeat in north London.

"We have so much to lose but also so much to win," he went on. "We are in a positive situation, but in my opinion this tie still stands at 50-50. Last year we beat Arsenal 4-0 yet we were still close to being knocked out. We have players with a lot of experience, but I also know it won't be easy for our younger players, although the experience will do them good. Honestly, I don't think what happened against Arsenal will happen tomorrow. We don't see the match any other way than to play it with a knife held with our teeth."

Arsenal can beat Bayern Munich in Champions League.

Arsene Wenger will not accept he is sending Arsenal on a "mission impossible" at Bayern Munich on Wednesday.

Arsenal trail the Champions League tie 3-1 from the first leg and must score at least three times in Bavaria to deny their hosts a place in the quarter-finals.
No side has managed that all season against Bayern, who have conceded twice on just two occasions and go into the game on the back of 11 straight wins.
Arsenal travel without Jack Wilshere and Bacary Sagna, but Wenger told the club website: "It is not mission impossible.
"It can be done, but first of all you need 100 per cent commitment, attitude and things to go your way. But usually football goes your way when you have the right attitude.
"There is a kind of feeling of 'let's really play with freedom'. Let's start strong. We have to create doubt in their mind and you only do that if you have a real go.
"The chance you have is to make insecure the certainty Bayern have at the moment. That you can only do if you perform at your best.
"We can have a real go without being silly. We can't think that the game lasts 30 minutes and throw everything forward from the first minute on. We want to be positive but also intelligent."
Arsenal have not played since defeat at Tottenham nine days ago left them seven points behind their neighbours in the pursuit of Champions League places for next season.
Wenger said: "We have practised a lot and prepared for this game. It came out of a very stressful period.
"Mentally it was good to have a little breather and refresh. And on the other side, on the football front, we could mix up recovery and preparation."

RESEARCH: Perception of malaria risk in a setting of reduced malaria transmission:a qualitattive study in Zanzibar.

Julie A Bauch1*†, Jessica J Gu1†, Mwinyi  Msellem  2, Andreas Mårtensson3,4, Abdullah S Ali2, Roly Gosling1,5 and Kimberly A Baltzell1,6
* Corresponding author: Julie A Bauch juliebauch@gmail.com
† Equal contributors
Author Affiliations

1. Department of Global Health Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA, 94105, USA

2. Zanzibar Malaria Control Programme, Zanzibar Ministry of Health, PO Box 503, Zanzibar, Tanzania

3. Department of Medicine Solna, Malaria Research, Retzius väg 10, Karolinska Institutet, 171 77, Stockholm, Sweden

4. Department of Public Health Sciences, Division of Global Health (IHCAR), Nobels väg 9, Karolinska Institutet, 171 77, Stockholm, Sweden

5. Malaria Elimination Initiative, Global Health Group, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA, 94105, USA

6. Department of Family Health Care Nursing, University of California San Francisco, 2 Koret Way, #431M, San Francisco, CA, 94143, USA

For all author emails, please log on.

Malaria Journal 2013, 12:75 doi: 10.1186/1475-2875-12-75

The electronic version of this article is the complete one and can be found online at: http://www.malariajournal.com/content/12/1/75

Received:19 December 2012

Accepted;19 February 2013

Published:22 February 2013

© 2013 Bauch et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background
Malaria transmission has declined dramatically in Zanzibar in recent years. Continuing use of preventive measures such as long-lasting insecticidal-treated nets (LLINs), and use of malaria rapid diagnostic tests (RDTs) are essential to prevent malaria resurgence. This study employed qualitative methods to explore community perceptions of malaria risk and adherence to prevention measures in two districts in Zanzibar.

 Methods
Key informant interviews with 24 primary health care providers and 24 focus group discussions with local residents in Zanzibar districts Wete and Central were conducted during April and May 2012 focusing on perception of malaria risk, current preventive practices used, reasons for using preventive practices and effective strategies for malaria control.

Results

Health care providers and residents appear to be aware of the decreasing incidence of malaria. Both groups continue the use of malaria preventive practices in this low and seasonal transmission setting. The most important preventive measures identified were LLINs, indoor residual spraying (IRS), and education. Barriers to malaria prevention include: lack of staff at clinics, insufficient number of LLINs distributed, and inadequate malaria education. Reasons for continued use of preventive practices include: fear of malaria returning to high levels, presence of mosquitoes during rainy seasons, and concern about local cases from other villages or imported cases from mainland Tanzania. Mosques, clinics, schools and community meetings were listed as most important sources of education. However, residents express the desire for more education.

 Conclusion

Health care providers and residents generally reported consistent use of malaria preventive measures. However, maintaining and continuing to reduce malaria transmission will require ongoing education for both health care providers and residents to reinforce the importance of using preventive measures. Successful efforts to reduce malaria in Zanzibar will be jeopardized if residents believe that they are no longer at risk for malaria. In future studies, a year-round evaluation of the perception of malaria risk and use of preventive measures will inform the timing of education and prevention strategies for sustained malaria control.

Keywords:
Perception of risk; Malaria; Zanzibar; Qualitative; Focus group

Background
Malaria transmission has declined significantly in Zanzibar, from 35-40% prevalence in 1995 to less than 2% in 2010 [1]. Currently Zanzibar is working towards an elimination goal on both Unguja and Pemba islands [1]. Historically, Zanzibar has come close to achieving elimination, however, due to a complex interplay of factors including the relaxation of vector control measures, malaria resurged and the last attempt at elimination was in the 1980s [1].

Importantly, Zanzibar has the characteristics of a pre-elimination country: it is at the margins of a malaria-endemic region (East Africa), transmission has been reduced and incidence is low [2]. To maintain current gains in malaria reduction, the continued use of preventive measures are necessary. In 2009 in Zanzibar, 96% of surveyed individuals identified at least one malaria preventive measure [3]. Eighty-eight percent of households own at least one mosquito net [2]. However, use of insecticide-treated nets (ITNs) or long-lasting insecticidal nets (LLINs) ranges widely across districts in Unguja and Pemba [1]. The 2010 Demographic and Health Survey showed 65.9% of children under five years of age and 64.1% of pregnant women sleep underneath an ITN [2]. These numbers indicate a three-fold increase from the 2004–05 survey [4]. In spite of recent improvements in bed net use, further studies are needed to understand reasons a third of children under five years of age and pregnant women are not using bed nets [2].

Current indoor residual spraying (IRS) coverage in Zanzibar is high with over 85% of targeted households receiving IRS treatment [5]. Recently the strategy for IRS use in Zanzibar has changed from universal coverage to targeted spraying. However, a study on IRS use in rural villages of Mozambique found many residents refused to participate in IRS when malaria transmission was perceived to be low. Additionally, the purpose of IRS was unclear to both accepting and non-accepting households [6].

 Social and cultural factors, although less directly studied, are also important determinants to net usage and adherence to other preventive behaviour. Men are not targeted for interventions although in some contexts they are at elevated risk for malaria. For instance, men in Vanuatu and Solomon Islands are more active outdoors during evening hours, which puts them at risk [7,8]. Additionally, financial constraints are cited as a limitation for net ownership [9,10].

Decision-making around malaria prevention involves multiple sources of input [11,12]. In Zanzibar, health care and health education is available through public and private health facilities, local privately owned dispensaries, and traditional healers [12]. To ensure compliance with malaria prevention strategies, it is necessary to understand how and where residents are receiving information on this topic.

As the burden of malaria decreases in Zanzibar, it will be increasingly important to understand residents’ perception of continuing preventive measures to avoid “elimination fatigue” [1].

The aim of this study was to describe community and health care providers perception of malaria risk, reasons for adherence and non-adherence to malaria preventive practices and to identify effective communication strategies and educational information used to encourage malaria prevention in a setting of low malaria transmission.

 Methods

Study population and study sites
This qualitative study was conducted in two districts in Zanzibar. The study population for both the focus groups and key informant interviews was drawn from six villages and primary health care facilities in each Wete and Central districts on Pemba and Unguja islands, respectively. Malaria prevalence in 2008 was 0.1-0.2% in Central District and 0.6-2.5% in Wete [1]. These districts were chosen based on a recent increase in reported malaria cases [13]. These districts are also considered representative of their respective islands based on a recent modest increase of malaria prevalence. A total of 12 villages and 12 primary health care facilities were included in the study. Villages in Central District included; Uzini, Mwera, Pongwe, Tunguu, Charawe, and Umbuji. Villages in Wete District included; Mzambarauni, Pandani, Ukunjwi, Kiuyu Minungwini, Kangagani, and Ole.

Key informants were identified in collaboration with Zanzibar Malaria Control Programme (ZMCP) and district health officers. The study team visited identified facilities and briefly explained the purpose and objectives of the study. Key informants included clinical officers, nurses and medical assistants to capture the range of health care providers interacting with patients.

Focus group discussions were conducted with men and women in villages adjacent to the primary health care facilities. Eligible participants for focus groups included residents in Central or Wete Districts, aged 18 years and older, and willing to provide informed consent for participation. Researchers verified eligibility and chose participants to represent different demographics in the village.

 Procedures

The study used a semi-structured interview guide for key informant interviews and focus group discussions. Additionally, observation of malaria prevention messages posted in primary health care facilities and surrounding villages was carried out to assess information given to local residents about malaria.
Data collection
Interviews and focus group discussions were conducted during a six-week period in the rainy season, April to May 2012, which historically coincides with the yearly peak malaria transmission period in Zanzibar.

Focus group discussions explored residents’ perceptions of malaria risk, preventive practices used (i e, bed net use, IRS, and biomedical treatment of febrile illness), factors influencing adherence (i e, persons who influence health-seeking behaviour, effects of health messages and campaigns), and health communication strategies.

The key informant interviews explored health care providers’ perceptions of malaria risk, current preventive practices used by residents from the surrounding villages, current resident perceptions of malaria risk, and efficacy of health messages in the communities. Perspectives from health care providers were compared to that of residents in the community for congruency.

Focus group discussions were conducted in the villages at a location and time convenient for the residents. Focus groups were separated by gender. Key informant interviews were conducted in a private setting at primary health care facilities. Interviews and discussions ranged from 30 to 60 minutes. Each interview or discussion was conducted in Kiswahili by a translator and by a researcher. The interviews were audio recorded, and handwritten notes were taken to supplement recordings.

Observations of clinic equipment and educational posters were made in primary health care facilities and in the village environments to provide context to the qualitative information gathered in key informant interviews and focus groups. These observations included informal conversations with the health care providers and site tours.

 Data analysis

The audio recordings were transcribed and translated to English by a bilingual Kiswahili-English Ministry of Health staff member. Data were imported into DedooseTM qualitative analysis software. Open in vivo coding, based on thematic content analysis was carried out by two researchers to identify major themes. Themes were compared and consensus was reached for each theme.

Ethical considerations
This study was approved by the Zanzibar Medical Research and Ethics Committee and the University of California, San Francisco Committee on Human Research. All participants signed a written consent prior to participation in the study. No personal identifiers were recorded or transcribed. Participants were not paid in this study.

Results

nterviews were conducted with 24 practicing health care providers and 24 focus groups were conducted with 134 residents of 12 villages in Central and Wete Districts.

Key informants included clinical officers, public health nurses, staff nurses, health orderlies and medical assistants. To maintain cultural sensitivity, focus groups were divided between men and women in each village. All participants were between the ages of 18 and 72.
The following major themes were identified (Table 1):

Theme 1 Health care providers and residents believe they are at risk for malaria, but expressed numerous barriers to care for protecting themselves

Health care providers and residents reported that RDTs and ACTs are consistently available at primary health care facilities. However, health care providers listed barriers to care for their patients including lack of staff, and lack of laboratory equipment.

“Challenges. We have many of them. Our centre is big but we have very few staff. There is a lot of equipment in the lab we don’t have.” (HCP 1)

[Author’s note: HCP indicates Health Care Provider]
Residents stated an understanding of the importance of environmental sanitation for malaria prevention. They actively eliminate mosquito-breeding sites around houses, trees, and by removing standing water. However, they expressed a lack of equipment for cleaning the environment.

The tools have decreased…the equipment to work, like rakes…” (R 10 - M)
[Author’s note: R indicates Resident, M indicates Male, F indicates Female]
There are a lot of challenges. Some understanding the importance, but others don’t want to understand. You will tell them ‘in this ditch there is dirty water and it’s dangerous. Clean your environment.’ But in a week you follow up and it’s like they didn’t understand what you meant. And this is a challenge.” (HCP 25)
Residents and health care providers reported the existence of village health committees. The health committees consist of village members and local health care providers. Residents stated that inactive and under-informed health committees prevent them from receiving better information on malaria prevention methods. Long-lasting insecticide treated nets were distributed throughout Zanzibar in March 2012. Rumours circulated that the new nets had caused serious side effects. Residents expressed that better informed and more active village health committees can improve information dissemination.

“People have been complaining…We haven’t been given any instructions about using nets. Only after the effects showed were we told to wash the nets…others said to leave it outside for a time…” (R 12 - F)

“The way to get rid of malaria completely is to increase the services that we have right now, to make them better. The health committee in the village needs to be given resources to move forward, they need to get more education to improve those who are giving education.” (R 9 - M)

Health care providers express the desire to educate patients on malaria, but express time restraints as a barrier. Health care providers also expressed that they need more frequent training on malaria in order to better teach the local community.

“I see it’s not good. For now it’s really difficult. You yourself, you have to be the doctor, give the shots, give the medicine, take care of the women the children, and give counselling for family planning.” (HCP 12)

“The easiest way is for us to get education, to get refresher course… to give us the education then we can give it to the people in the community.” (HCP 12)
Theme 2 Residents believe education is critical in malaria prevention. Mosques, clinics, schools and community meetings provide education. However, residents consistently express desire for more education

Zanzibar residents and health care providers discussed the importance of multiple strategies in disseminating health education. Current education strategies include the use of mosques, clinics, schools and community meetings to distribute health information. Residents have also heard malaria health messages through radio or television. However, the education methods most preferred by residents are group meetings or seminars.

These meetings are the best ways…because education will reach faster…those who come here [clinic] are those who are sick. We need to reach even those who are not sick, therefore doing meetings outside are better.” (HCP 14)

“… we need all kinds of education because education will take us out of the darkness.” (R 3 - M)
Residents and health care providers differed on their opinion on the effectiveness of mass media campaigns. Some residents described radio, television and posters as important health messaging routes, while others preferred theatre presentations.

“To bring it [education] through TV is easy to spread to those who go watch…and there are those who don’t know how to read… There can be education through the radio, but some don’t listen to the radio.” (R 9 - F)
“All three ways are good but it is on each person’s time. I can read the newspaper, you read, you watch TV and I don’t, that person listens to the radio and another doesn’t listen. It is important to have education available through village meetings so that we can get the training. Although there will be some cost to it…but if you give a person something of quality, he will take it and it will stay in his head.” (R 4 - M)
“A good way - I have seen people understand - is to do theatre…if a person has fever what is it like, what should he do, so that they will know that it is dangerous. If you show with theatre they will understand very much…role play will teach a lot.” (HCP 17)

Residents expressed a desire for education before net distribution or IRS distribution campaigns in order to improve understanding and use of prevention methods.

“Just health education, then net…. health education about malaria…health education first and then the nets.” (HCP 1)
“Bring the malaria education, very few got it the day they did spraying. Some shehias (Author note: shehia is the general name for a village in Zanzibar) had education…that came with the spraying…to finish this issue completely, they who have the purpose of giving education, they should come to remind us.” (R 6 - F)
School-based health education is expressed as an important way to educate children about malaria. As fewer children are experiencing malaria in Zanzibar, there is concern that children may not have the memory of malaria to continue use of preventive methods. Health care providers and residents emphasize the need to educate children about malaria.

“Children are supervised by their parents, so father and mother should use prevention strategies and explain to children the danger of the disease and to make sure that they stay in the net to avoid mosquito bite…so by the time they have grown they have received education. Maybe in school also, school children can get education…to prevent malaria.” (HCP 19)

Zanzibar residents receive malaria prevention education periodically, but are concerned if they do not receive education frequently they will forget. As all participants in this study were over the age of 18, they have experienced the rise and fall of malaria transmission in Zanzibar in recent years.

“First is education…the most basic thing is to give education once in a while, so that it can continue…because today you give education and after a year you have to continue with education again and again.” (HCP 13)

According to the study participants, without education to the community, acceptance and use of prevention methods may decline.

“People are not getting enough education, which leads to people not agreeing to have their houses sprayed, this is a lack of education…a lack of education is related to malaria being present.” (R 12 - F)
“We need to educate people to understand that malaria is still present. Not to take the idea that there is no malaria. Even if you test someone negative, if they say there isn’t anything it means they already forgot. Therefore we need to tell them that malaria is still present, and we need to educate our patients…to continue to prevent malaria, to cover ourselves with our nets, to have anyone with fever come to the hospital to get tested.” (HCP 4)

In areas where the health committee is not active, residents request more health committee involvement. In addition to radio, television, and posters, residents also feel that health committees are important avenues for malaria education. However, residents expressed concern that information provided to health committee members was not being delivered to the community.

“A good way is to come together like this, to have meetings or group seminars.” (R 9 - M)

“I agree with shehia that education is not enough…it is the leaders of that committee who are often getting the education and not the community… Now I am saying that it is the leaders of the committee who are getting the education, and each leader is understanding on a different level. …the leaders are important to get education because they are elected from the people. But in addition to this the education must reach the community.” (R 5 - M)
Theme 3 Residents are aware of decreasing malaria transmission. However, there is fear that people can get malaria, and that malaria transmission will rise if preventive measures are not used Residents believe that malaria levels used to be high five years ago, and much higher 10 years ago, but are now much lower. They attributed some of the decline to use of bed nets, better anti-malarial medications, and IRS. However, some residents expressed concern that immunity to malaria has also declined, leaving them at greater risk of malaria should it resurge.
“Malaria, to say the truth, has decreased by 90%, since using nets.” (R 8 - M) “It was high before, not so high a few years back, but 10 years ago.” (R 3 - F)

“From 10 years ago it has gone down.. from five years ago, somewhat.” (HCP 4)

Even though residents and health care providers believe malaria is lower now, they think that it is still possible to get malaria.

“It is possible to get [malaria] because we have no certainty that malaria is completely gone.” (HCP 18)
Significant fear persists for getting malaria and for malaria levels to rise again. Although malaria cases are less frequent, residents and health care providers are aware when they occur in a community. Residents understand that every malaria case presents the possibility of getting malaria and the potential rise in malaria transmission again.

“We’re afraid because it has killed. Malaria has killed a lot.” (R 10 - F)
“Myself I am afraid. Even though there is no malaria like other years, I am afraid even a little because now we have no immunity.” (HCP 19)

We fear malaria because it will rise up again to how it was before.” (HCP 21)

“We know that this problem is decreasing and is leaving, but it is possible that it will come up again. Therefore, it is important to stay in the condition to be afraid and to use nets.” (HCP 20)
Health care providers and residents believe travellers pose a threat for continued malaria transmission. Residents and health care providers were asked to describe the differences in malaria transmission between Zanzibar and mainland Tanzania. Both residents and health care providers perceive that malaria transmission is higher in mainland Tanzania than in Zanzibar. There is concern that travellers from mainland Tanzania are bringing malaria to Zanzibar. Within Zanzibar, there is concern that villages with higher reported cases of malaria incidence may spread malaria to other villages.

“There are a lot of things, maybe transfer in transfer out maybe because our neighbour has no project like us. Maybe from Tanga mainland…we have a lot of fishers…so malaria comes. Other travellers may transfer in the same country to and from Zanzibar, maybe Dar es Salaam. Also malaria is not finished in Pemba, still we have but in low amounts. If one stays in Wete and then goes to rural areas with malaria, so malaria in the rural area will remain, this is the problem also.” (HCP 19)

“They are afraid that it will come again, because there are other shehias that still have malaria.” (HCP 24)

There are differing opinions on whether travellers use bed nets and other prevention methods while travelling. Some travellers are reported to carry nets with them when travelling. Residents suggested possible testing for those entering Zanzibar to ensure that infection is not being imported from elsewhere.

“Because people are coming and going every day now, maybe people don’t use nets so malaria will come again I think.” (HCP 19)
“We need to enter from one way only and we need to get tested whether we like it or not. The government must put this on its agenda because we can finish malaria. …. I think it will be an easy way to ensure that someone has come but they don’t have malaria.” (R 4 - M)

Theme 4 People currently use malaria preventive methods, and perceive that they are useful to prevent malaria
Residents and health care providers were asked to describe current prevention methods that they use to prevent malaria. Residents state that using bed nets, receiving IRS every year, and doing environmental sanitation have worked in reducing malaria transmission.

“A good way is to use nets, to agree to spraying, to clean the environment and get rid of standing water to take away mosquito breeding sites.” (HCP 23)

“It is possible for malaria to happen, we believe in nets, education, sanitation, that which we have been hearing. But if we were to cover our ears, malaria will come. If we do not use nets, don’t clean…mosquitoes will breed.” (R 3 - F)
However, they state that the number of nets distributed is insufficient. The maximum number of nets distributed per family is three. Most families are large and cannot place each family member under a distributed net. Therefore, parents choose to place children under the nets and the adults sleep without nets.
“We need to get more nets because in the family, some even use kangas (Author note: kanga is a cloth used for clothing and to carry infants currently costing approximately $1 USD) as nets to cover themselves. We need to distribute to all.” (HCP 7)

“We have received nets but not enough because for families of five or four they got two [nets], families of 10 they got three, now you find others that haven’t received them.” (R 2 - M)

“The children sleep under the nets, father and mother sleep outside of the net.” (R 10 - M)

Additionally, residents express that purchasing a net is unrealistic for their budget. Cost for an ITN or LLIN in Zanzibar is currently approximately $4-6 USD. Large families with many children state that they cannot afford to purchase enough nets for the entire family.

“Some will buy…but you need to have the ability to buy a net. It requires the ability to buy for 12 children, it is not something easy.” (R 9 - M)

Residents have heard rumours that the distributed nets were harmful. However, through conversations with village leaders and radio announcements, these rumours have been dispelled and residents believe that nets continue to be useful in malaria prevention. Residents suggest that the rumours were started by private bed net companies to sway people to purchase nets instead of using the free, distributed nets.
People died, people felt sick, people were itching, but the Ministry of Health sat together and found the answer that this rumour was disproven because in every shehia there was not a single report from a hospital in Zanzibar or in Pemba that anyone had gotten side effects from the nets.” (R 4 - M)

“We haven’t heard of it, we only heard rumours but we don’t know if it is for business or what…” (R 7 - F)
When specifically asked about heat-related issues and net use, residents express that increased heat plays a role in inconsistent use of nets. Furthermore, residents report inconsistent use of nets in the dry season when there are fewer mosquitoes.

“A big percent of people are not using, because it causes heat.” (HCP 24)

“We use it…when there are mosquitoes we use it, maybe unless it is hot.” (R 8 - F)
“If mosquitoes are not present, to say the truth we don’t like to use the nets because of the heat. But when mosquitoes are around we do our best with it.” (R 8 - F)

Finally, residents believe that IRS contributes to the control of malaria. Zanzibar now uses targeted spraying in hotspot areas. A hotspot is defined as an area experiencing a two-fold or higher increase in malaria incidence from the previous week (per communication with Zanzibar Malaria Control Programme). However, few residents understand the purpose of targeted spraying in selected villages, and are concerned about malaria transmission in their village. In non-hotspot areas, residents are requesting that IRS remains consistent throughout the villages. Furthermore, residents feel that spraying more than once a year is necessary for the continued control of malaria.

“This time the work only went to some of the shehias and still now we have not received it, because if you say to spray one shehia and not another, Anopheles is here and is there, but if we plan programmes we want to spray the whole of Zanzibar, this will help.”

(R 2 - M)
“… increase the efforts of IRS, and to use the spray more often to get rid of [malaria] entirely. It should not be that they think malaria is low and then they stop. Therefore there needs to be more education, and more spraying.” (R 9 - M)

“…We should increase spraying, spraying is done every six months meaning if we do it every three months we will get rid of malaria entirely.” (R 6 - M)
Table 1. Major result themes

Discussion

This qualitative study in Zanzibar examined the perception of current malaria risk in health care providers and residents who visit government primary health care facilities. Overall, both health care providers and residents believe that malaria transmission has decreased dramatically over the past 10 years. Importantly, both groups also believe that although transmission rates are lower, they are still at risk for contracting malaria. The fear of malaria and having transmission rates rise again drives residents to continue with preventive measures. These findings, plus four additional findings from this study could be useful in other settings where an improved understanding of malaria risk perception is needed to guide pre-elimination measures.

First, interviews with health care providers and residents reveal that public health facilities are perceived to be consistently stocked with RDTs and ACT free-of-charge. This finding is important as self-treatment without testing (via purchasing medication at private dispensaries) may contribute to development and spread of anti-malarial drug resistance [12].
The majority of health care providers and residents report that public health care facilities are understaffed. Understaffed facilities can result in inadequate care given to residents. Health care providers interviewed feel that additional staff would benefit the health care facilities. Currently, staff members fulfil multiple roles in the health care facility, limiting the volume of patients seen and the quality of care given. Residents have long wait times at government health care facilities to see a health care provider, and often are not seen the day they arrive. Health care providers feel they do not have enough time to see all patients who present to the health care facilities. If there is not adequate time to see and teach each patient, the possibility of a patient disbelieving a negative malaria test increases. Lack of trust in malaria testing results may lead to self-treatment, increasing the risk for drug resistance, improper treatment of the true underlying disease and under reporting of true malaria cases.

 Second, it is important that residents are continuing to receive malaria education that encourages the use of malaria prevention practices. Residents interviewed for this study are concerned that reducing education may lead to a reduction in the use of prevention methods. Health messaging and education from existing community gatherings were cited most often as the preferred educational strategies. For example, mosques are frequent gathering places in this predominantly Muslim community. Health messaging through mosque loudspeakers and involving religious teachers in delivering health education was suggested by residents as an effective education technique.

Community meetings are routinely used to convey information in Zanzibar villages; therefore, taking advantage of this existing infrastructure may be an efficient way to deliver health messages. In this study, residents frequently cited community meetings led by health committees as the preferred method of receiving health education. Health committees exist in every village, where the village leader (Sheha) and local health care providers convene. Under the direction of Shehas and health care providers, correct health messages may reach a greater number of village residents. Education during net distribution campaigns strengthens the message of proper net use and proper net hanging. Active and informed health committees may be instrumental in dispelling rumours, such as bed nets are dangerous. Residents consistently suggest improving the quality of education that they received. Therefore, it is important to ensure that health care providers and health committee members are informed regularly on local malaria epidemiology and updated on preventive measures used.
Inserting malaria education into school curricula may be useful in this setting of low malaria transmission. Due to decreased malaria transmission rates, many Zanzibari children have not experienced malarial illness. Residents suggest that the best way to teach children to use malaria preventive measures is through formal health education at school.

Third, residents understand that malaria transmission rates are low, but still fear getting malaria. Harnessing the current ‘malaria-is-still-present’ perception is vital to strengthen adherence to prevention practices. Residents remember the history of malaria resurgence in Zanzibar and believe that relaxing preventive measures may lead to resurgence. Now that malaria transmission is reduced, it is important to remind residents that consistent use of preventive measures may ensure the past does not repeat itself. In general, residents and health care providers feel that the risk of malaria is higher in mainland Tanzania than in Zanzibar. Residents and health care providers have expressed concern about travellers bringing malaria from mainland Tanzania. Continued research on malaria transmission patterns is important to guide elimination efforts. Furthermore, malaria preventive measures are inconsistent for those who travel, according to study participants. Stressing the importance of travelling with personal nets is important to consider for malaria control on Zanzibar. Screening travellers in Zanzibar may be necessary in the future to avoid imported infections.

Finally, despite a recent net distribution in Zanzibar, residents consistently expressed that insufficient numbers of nets were distributed to large households. As reported above, residents find kangas more economical than LLINs, however, there seems to be a misunderstanding regarding the lack of protection provided by kangas. Additionally, as the children are primarily placed under the nets, adults are often left outside of nets and at risk for mosquito bites. Future net distributions should include universal coverage for all household members. Decreased immunity in adults will take on more public health significance as malaria transmission decreases, as adults will suffer from more serious disease when infected.

The issue of IRS was controversial among the study participants. Most residents in this study felt spraying an entire village is more effective than targeted IRS, the current strategy in Zanzibar. Island-wide IRS campaigns have now changed to become targeted IRS in villages where malaria rates have increased. As a result, some residents are concerned that malaria can increase in areas that do not receive IRS. Residents express a desire for consistent IRS in every village, instead of waiting for malaria to increase in order to receive IRS. With limited resources for malaria control, Zanzibar has chosen to move forward with targeted IRS. Therefore, information about targeted IRS and the implications of this strategy need to be clarified and disseminated to prevent misconceptions of the absence of IRS in selected villages.

Interestingly, men in focus groups often mentioned the issue of spending time outside after dusk. It is not uncommon for men to gather during the evening and night to talk, eat, and watch television. However, they mentioned that during this time they are not protected from mosquitoes, and know that they are exposed to mosquito bites. As a solution to this problem, they have requested the use of outdoor spraying, a strategy some residents remembered from the past. Looking forward, a culturally sensitive solution that accounts for this daily practice will be important for their protection.

Limitations
This study has some limitations. First, it was conducted during the rainy season when risk of malaria is increased. This may have had the effect of enhancing residents’ perception of the importance of using preventive measures. Second, it is possible that the attitudes and answers of the informants may have been impacted by the fact that they were chosen by the Zanzibar Malaria Control Programme. Finally, the study was conducted approximately one month after net and IRS distribution. Therefore, our results may be influenced by heightened awareness of malaria at this time. Future studies may consider exploring how risk perception changes throughout the seasons in Zanzibar.

Conclusion
Health care providers and residents generally reported consistent use of malaria preventive measures. In Zanzibar, it appears that residents and health care providers understand the significance of using preventive measures, even in areas of very low malaria transmission. However, maintaining and continuing to reduce malaria transmission will require ongoing education for both health care providers and residents to reinforce the importance of using preventive measures. Successful efforts to reduce malaria in Zanzibar will be jeopardized if residents believe that they are no longer at risk for malaria. In future studies, a year-round evaluation of the perception of malaria risk and use of preventive measures will inform the timing of education and prevention strategies for sustained malaria control.
Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

JB and JG conceived of the study and conducted initial data analysis. KB and RG provided supervision on all aspects of study design, data analysis and manuscript preparation. MM and AA coordinated all aspects of the study in Zanzibar and assisted with study design. All authors have read and approved the final manuscript.

Acknowledgements

This study was supported by an award from the Bill and Melinda Gates Foundation to the Malaria Elimination Initiative at UCSF Global Health Group and UCSF Global Health Sciences. We would like to thank our field team, Badru Ali Badru, Raya Mkoko, Masoud Salim Mohammed, Riziki Suleiman Said and Faiza Abdul Kadir. We thank Karolinska Institutet for their support of this project. Finally, the authors thank the participants in Central and Wete Districts for their time and insights.

References

1.Zanzibar Malaria Control Program:

Ministry of health and social welfare. 2010. [Malaria elimination in Zanzibar: a feasibility assessment]
2.Feachem RG, Phillips AA, Hwang J, Cotter C, Wielgosz B, Greenwood BM, Sabot O, Rodriguez MH, Abeyasinghe R, Ghebreyesus T, Snow RW: Shrinking the malaria map: progress and prospects.

Lancet 2010, 376:1566-1578. PubMed Abstract | Publisher Full Text | PubMed Central Full Text

3.Zanzibar Malaria Control Programme: Ministry of health and social welfare. 2009. [Zanzibar communication strategy for malaria control 2008–2012]

4.National Bureau of Statistics (NBS): ORC macro. Dar es Salaam; 2005. [Tanzania demographic and health survey 2004–05]

5.Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC): National bureau of statistics (NBS), office of the chief government statistician (OCGS), macro international Inc. Dar es Salaam; 2008. [Tanzania HIV/AIDS and malaria indicator survey 2007–08]

6. Munguambe K, Pool R, Montgomery C, Bavo C, Nhacolo A, Fiosse L, Sacoor C, Nhalungo D, Mabunda S, Macete E, Alonso P: What drives community adherence to indoor residual spraying (IRS) against malaria in manhica district, rural Mozambique: a qualitative study.

Malar J 2011, 10:344. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text

7. Atkinson J, Fitzgerald L, Toaliu H, Taleo G, Tynan A, Whittaker M, Riley I, Vallely A: Community participation for malaria elimination in tafea province, Vanuatu: part I. Maintaining motivation for prevention practices in the context of disappearing disease.

Malar J 2010, 9:93. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text

8.Atkinson J, Bobogare A, Fitzgerald L, Boaz L, Appleyard B, Toaliu H, Vallely A: A qualitative study on the acceptability and preference of three types of long-lasting insecticide-treated bed nets in Solomon Islands: implications for malaria elimination.

Malar J 2009, 8:119. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text

9 Kinung’hi SM, Mashauri F, Mwanga JR, Nnko SE, Kaatano GM, Malima R, Kishamawe C, Magesa S, Mboera L: Knowledge, attitudes and practices about malaria among communities: comparing epidemic and non-epidemic prone communities of muleba district, north-western Tanzania.

BMC Publ Health 2010, 10:395. BioMed Central Full Text

10. Minja H, Schellenberg JA, Mukasa O, Nathan R, Abdulla S, Mponda H, Tanner M, Lengeler C, Obrist B: Introducing insecticide-treated nets in the kilombero valley, Tanzania: the relevance of local knowledge and practice for an information, education and communication (IEC) campaign.

Trop Med Int Health 2011, 6:614-623.

11. Williams HA, Jones C: A critical review of behavioral issues related to malaria control in sub-Saharan Africa: what contributions have social scientists made?

Soc Sci Med 2004, 59:501-523. PubMed Abstract | Publisher Full Text

12. Alilio MS, Eversole H, Bammek J: A KAP study on malaria in Zanzibar: implications for prevention and control. A study conducted for UNICEF Sub-office Zanzibar.

Evaluat Program Planning 1998, 21:409-413. Publisher Full Text

13.Zanzibar Malaria Control Programme: Zanzibar malaria early epidemic detection system biannual report. 2009.1 (No.2); March 2010