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)