The results of FGDs and IDIs are organized under subheadings corresponding to the research questions and themes derived from the coding process. These themes include: community and CHW perceptions of the MTAT campaign; challenges experienced by CHWs and district staff; refusals and non-adherence in the community; and needs for programme improvement, sustainability, and scale-up.
Community perceptions of the MTAT campaign
Focus group discussions with the MTAT community members indicated that in general they were pleased with the MTAT programme. As expressed by a community member: “People have started accepting to be tested and if found with the parasite they were treated there and then”. Another emphatically stated: “This programme should continue because nowadays we feel that our health is good in terms of malaria disease. I am happy because all the time I am able to see, if at all I have malaria or not, so I am really happy because all the time my children are able to know if there is any malaria and to trust that they are doing fine in terms of being sick of malaria”.
Community members appreciated the programme because they perceived it as being good for the health of their families as well as having the capacity to reduce malaria, as the following quote from a community member illustrates:
“I am thankful because malaria has reduced, there used to be so much malaria especially when maize is about to be eaten. Here [at the clinic] there are no people on these benches-- before there used to be long lines under those trees, on these benches, and the veranda used to be filled with malaria people, so right now malaria has reduced. So I am encouraging that this work should not stop but continue, maybe this disease can leave us”.
An additional stated benefit of the programme from the perspective of the community was not having to walk long distances to the health facilities to receive malaria services, as one community member stated: “people are happy because they are being visited in their homes. Even if you did not prepare to go to the hospital, they come and treat the malaria you have. So people are really happy in the village because of the same”. Another community member observed:
“I would encourage them to continue with the programme of testing us from our villages because if they stop we are going to suffer a lot. You find that an elderly person is sick [and] no one is able to bring him/her to the hospital, so if they come and do the testing [that is better] because there is no one to take them to the hospital”.
Combining MTAT activities with ITN distribution evoked mixed responses from the community. One community member expressed the following:
“Me, I am just happy that they help us to prevent this disease through this programme…instead of walking all the way here, you find that they bring you medicine and distribute mosquito nets so that we prevent malaria, so we are just encouraging them to see us when they come again that is through this programme. We thank them in that they protect us through mosquito nets and treatment of malaria”.
However, another community member expressed some concerns with the ITN provisions associated with the campaign: “The only thing I will complain about in this malaria programme is that they protect us but they only give one mosquito net. In my household I have a son who is 7 years old, a small child, and also I have a school going big boy, let me just say there are three beds, then they just gave me one net where my husband and I sleep under, the other two there is nothing. So because of not wanting the children to die– instead it is better we the adult die– I gave my net out to the children so that I can sleep without, that is all I ask for so that they can include some more so that we all benefit”.
Community health worker perceptions of the MTAT campaign
Key informant interviews and FGDs demonstrated that in general, CHWs involved in conducting test and treat activities understood the rationale for the MTAT intervention, as illustrated by a quote from one health worker: “In my opinion [MTAT] is one of the interventions where we want to target the communities in order to further reduce malaria in terms of transmission and eventually reduce the burden, where health workers go into the communities and screen the members of the community using a Rapid Diagnostic Test, and those found to be positive are treated, and this also helps us to identify places where there are hot spots of malaria, where there is focal transmission…..For me it’s an extra intervention from the usual interventions to do with prevention in malaria”.
Similar to community member responses, there was a great amount of satisfaction expressed by CHWs involved in programme activities. Some of the key themes that emerged around satisfaction with the programme included a perceived reduction in the malaria burden, the ability to reach people who live far from health services, and acquisition of knowledge and new skills. In the words of one CHW:
“I am happy because from the time we starting the malaria testing in this village, malaria in the villages has reduced, nowadays you can go round the villages, it is not like it used to be at all.”
Several CHWs indicated satisfaction in their ability to reach people who live far from health services, who might otherwise have to travel long distances. In the words of one CHW: “it makes me happy because the distance from the villages to the health clinic is far, so I help the people from those villages by carrying medicine for them and treating them in their villages”.
A further commonly reported positive aspect of MTAT by CHWs was the acquisition of new knowledge and skills, including greater knowledge of malaria. In the words of one CHW: “I have learnt a lot because I did not know what brings malaria is mosquitoes, I thought maybe what brought malaria is sugar, but through being sensitized know that what brings malaria is mosquitoes”.
Additionally, some reported that the learning process extended to issues beyond malaria, as another CHW shared: “We learned that when we reach the village we must respect the people, not forcing them, talking to them with respect, greeting them very well. We were taught very much; if a person insults you don’t return”.
Challenges experienced by community health workers
In addition to these positive experiences, CHWs reported numerous challenges in conducting the campaign. The most common themes related to challenges encountered during implementation of MTAT included inadequate transport, the need to cover long distances, problems with PDAs, and inadequate compensation and supplies.
Numerous CHWs complained that transport provided for them to conduct MTAT activities was insufficient. Often the allocated vehicles were so few that they were required to make multiple trips to intervention sites, or to share vehicles between several catchment areas. As one CHW lamented: “transport is not working well for us; Sinafala, Chipepo Secondary and Chabbobboma all depend on one source of transport, so when it does not show up we start off because we work with time, so we carry our luggage to go … the vehicle will meet us with our luggage”.
Several CHWs reiterated that although the MTAT benefited community members by allowing them to receive health care services at home, CHWs were required to walk long distances in order to provide these services. CHWs were required at times to cover distances of up to 20 km on foot due to lack of transport. In the words of one CHW: “
we don’t have transport to use, [and] we walk long distances, so we felt it could be better if each centre could have a vehicle to use because we work from 3 centres, at least if they would get us and drop us some where instead of [us] walking long distances”.
PDAs were used to record testing and household data during MTAT campaigns. However, the testing teams encountered challenges in keeping PDAs charged as most live in houses without electricity, and although some had access to solar chargers at health facilities, these did not provide enough chargers for all the PDAs. In some cases this disrupted or delayed testing activities. As one CHW observed: “we also find problems in the charging system, like the PDAs that we use, if the batteries are flat then the work will not move well at all…. we don’t have solar to charge with and we don’t find electricity where we go…”.
Another CHW noted:
“So charging of the PDA was a big challenge and even it made our work to be delayed because you have to go and ask from those people who have panels [and] pay them a bit of money, buy fuel and pay them so that they can charge your PDAs. Like these people who have solar panels they would maybe charge them early in the morning maybe up to 10 hrs and people would start work late, maybe after 10 hrs to 12 hrs”.
As the MTAT programme was implemented through CHWs who are volunteers, CHWs and facility staff felt that appropriate incentives to maintain motivation would be essential for sustainability and programme scale-up. Study participants observed that incentives such as lunch allowances, transport and uniforms were a great motivation for the CHWs.
Another key theme shared regarding challenges faced by CHWs during the MTAT campaign programme was inadequate supplies. Coartem (AL) and RDTs were supplied continuously based on requests made by each district from MSL using the national drug supply and logistics routine distribution mechanism. Other supplies such as sharp boxes, gloves and swabs were supplied by NMCC and MACEPA during programme implementation; these were distributed to the district health office, health facilities, and finally health facility catchment teams. However, in the early months of implementation, some teams experienced stock-outs of AL and RDTs, which was attributed to inconsistent coordination between the MOH and MSL. While this situation had improved at the time of the interviews, facility health staff and CHWs felt that it would be essential to ensure that programme requisites are consistently available. A CHW explained: “I remember the first round I think we ran out of commodities so we had to produce [look for] extra rapid diagnosis tests”.
Reasons for refusing to participate
Participants in the community FGDs acknowledged that some members of the community did not readily participate in the MTAT activities. The primary reported reasons for refusing to be tested included suspicion that CHWs could be practicing Satanism and may use their blood for rituals, fear of collected blood being sold or used to test for HIV infection, other uncertainties about how the collected blood would be used, and anxiety about the entire process of testing and treating. Personal religious beliefs and not feeling adequately informed about the study also contributed to refusals to participate.
One community member stated the following as a reason for refusing to be tested by CHWs:
“Others think it is Satanism. People know that getting blood is associated with Satanism. People think that blood is going to be sold somewhere. So people had such problems”.
Others observed that refusals may occur among some community members belonging to some churches which insist that their people should not test or drink conventional medicine because healing comes from God. In the words of a community member:
“In our area there is one from a certain church who refuses because they worship their God who sustains them”
The fear that their blood would be used to test for HIV infection was a common reason for refusals, as one CHW noted:
“Others refuse because they think you want to test them for HIV and AIDS and others think the blood I take maybe I want to take it somewhere or buy vehicles because of their blood”. Another CHW iterated “the reason they refuse other than the church is because of the test; in these villages people don’t know to read even when the t-shirts are written they think we are there to test HIV/AIDS”.
In addition to these cultural and literacy barriers, participants described inadequate information as another reason why communities refused to participate in MTAT activities. The lack of information ranged from people not knowing enough about the intervention and the inability to dispel some of the existing myths around testing.
Some community members refused to participate in MTAT because they believed they could not have malaria, as they did not feel sick, as one CHW shared:
“Actually that was where we experienced some difficulties; it’s like people could not understand the importance of being tested… what we told them was that once they are tested we were going to find that malaria was going to be there because it could be just that people are carriers… So we educated them in all that, saying if you are a carrier it doesn’t matter, but if you are having that infection you are going to keep on infecting other people so mosquitoes which bite you will just be getting an infection from you and giving it to other people. So it’s better that each one of us is tested so that we can remove that malaria parasite from our bodies and our communities where we are staying. And they accepted that though it was a little bit hard for these people…”
A minority reported that refusals could result from incentives paid to the CHWs that were conducting the test and treat campaigns. One CHW highlighted this issue in the following words:
“Others were saying we don’t want to be tested because our friends who are testing are given money (sorry for me to say such a thing), but with us who are being tested, why don’t they give us maybe K5.00 ($1) or whatever thing. So we should also be given something for testing our blood”.
Additionally it was reported that some of the community members refused to be tested for malaria because they felt that CHWs did not have adequate skills and knowledge to conduct the activities even though they had undergone training. As one community member said:
I think people were a bit suspicious now, how can this one hammer me an injection and yesterday we were together in the village. Which of course- you know even for teaching I may not just come from the village and come in class and start teaching, no!”
Respondents further disclosed that there was a need to provide more training to equip the CHWs to do this work efficiently. In the words of a community member: “We are happy that they employed the (indigenous) people but let them take them to a special training where they can learn how to handle these things because some of them could even fail to prick people - those could be some of the challenges that made people to shun away from the activity”.
Reasons for non-adherence with treatment regimens
An important aspect of this study was to ascertain the extent to which those treated for malaria actually adhered to the prescribed drug regimen. The general consensus among the community and CHWs was that people on treatment largely adhered to the drug regimens; however, respondents agreed that some did not adhere due to reasons including inadequate information given to the person on the rationale for treatment, lack of understanding of the benefits of completing the full course for malaria treatment, religious beliefs, and simply not wanting to take more drugs once they felt better. These are reflected in a statement by a community member:
“Some they continue, others not. They only take the first and second then they stop saying they are healed. They also give their children when they are not well in their bodies disrupting their own course. When any member of your family is sick don’t give him your medicine, take them to the clinic as well so that they can receive their own medication. So others they follow while others they don’t, they just take first, second and third stop”.
Another community member noted “you will find a sick person takes medication in the morning and feels well then he stops taking medicine there and then. They hide the remaining medicine so they can use the other time. That element is there in people”
Yet another CHW observed: “Some are not difficult, they finish, but others who don’t know the goodness don’t take, but a lot appreciate because they know that they would prevent the disease before falling sick”
The perception of not feeling sick was a common hindrance to completing drug regimens: “The difference is you will find that others are not sick or complaining but will be found positive, so when we give him/her medicine the difference is he/she won’t put her mind to the medicine…most of the time some don’t finish and that is the difference. So those that come and are tested when they are given medicine, they drink because they are feeling sick or are complaining….”
Religious beliefs were also reported to cause non-adherence to treatment regimens, as one CHW shared: “Like saving the drug it happens that I will drink when I fall sick but mostly we just find challenges with people who go to a certain church who are not using drugs, but their number has started reducing. Others have started taking the drug”.
Social habits were also cited as a cause for non-adherence as stated by one CHW: “What caused others not to finish their medicine is beer. When they go for beer drinking they forget their medical course, they drink in the morning, but in the evening he is drunk, he comes home from the tavern at 24 hrs he will not take his medication, he will just go straight to sleep. He can’t finish his medication”.
Needs for programme improvement, sustainability, and scale-up
National, provincial, district and health facility staff were asked to address scalability, sustainability, and suggestions for MTAT improvements. As highlighted by previous responses, the MTAT campaign was generally perceived as a beneficial programme that could be improved and possibly scaled-up for more effective results. Further discussions with interviewees revealed that sustainability and scale-up of MTAT would rely on a number of issues being addressed including: greater capacity-building of CHWs and MOH personnel, increased sensitization of the target populations, improved coordination of supplies and logistics between central and community levels, and improved communication at all levels of the campaign.
Several health workers commented on the need to conduct more training for CHWs to enable them to carry out the MTAT duties effectively. One CHW commented:
“And then you need to train people, health workers including community health workers and must understand the importance of this intervention especially of going to the community and treat and screen and test and then treat within the community”.
Another interviewee noted that in as much as it was appreciated that local people were being empowered with skills and knowledge during the trainings, it would be good to increase the duration of the training for CHWs to increase their competency: “[There] should be ample time for them to be doing the training. We are happy that they are from the village. Why not train them for a long time so that they keep on sustaining these programmes in the village”.
Participants reported that in order to improve acceptance of the programme and reduce refusals, it is imperative to sensitize communities on the MTAT programme. As a CHW observed: “One of the things that needs to be improved on is the sensitization part, it has not been done so effectively and I think people need to go flat out in the field to go and do more sensitization because people don’t understand the programme”.
Another emphasized the need to utilize community leaders for this purpose “If we sensitize the local leaders and they understand the programme [and] they accept it, then we can get the local leaders the chiefs, headmen, political leaders. We can actually give them a message, have it recorded and have it broadcasted either on the radio, television or public address system, because we go round and inform them using the recorded message. Listening to the voices of their own leaders can increase the acceptance levels in the community because they are getting voices of their own leaders. I think if we used the local leader in every corner of our area I think we have may be 100% acceptance”.
A key theme that emerged regarding sustainability of the programme was the need to improve supply and logistics coordination. Interviewees mentioned that the teams experienced stock outs of AL, RDTs, and ITNs/LLINs and that in the future it would be necessary to ensure stocks are continuously available for the MTAT programme to succeed. In the words of an interviewee from the national level:
“The only problem probably which we incurred was the supplies. Probably before we started the programme we did not prepare adequately and then we relied much on Medical Stores. In the midst of the programme we incurred a lot of problems, like the gloves we had to borrow from other Districts, and probably the Coartem was okay we had enough supplies but what was difficult was the RDTs at one time in the country, the Medicals Stores didn’t have”.
Although only mentioned in interviews at provincial level, it was evident that while communication channels were clear between the district and provinces, there was inadequate communication to facilitate staff from the provincial office to provide technical support to the districts, as noted by an interviewee from the provincial level:
“I think we are doing well apart from the communication at provincial level and maybe getting the staff at the provincial health office a little bit more involved because you need to understand that our mandate as provincial medical officers is giving that technical support and technical backstop to the districts.