In this section, the results are reported based on the seven themes of discussion: (1) perceived severity of malaria, (2) perceived susceptibility to malaria, (3) perceived self-efficacy to use bed nets, (4) perceived response efficacy of bed nets, (5) perceived barriers to use bed nets, (6) IRS acceptance, and (7) strategies to enhance the consistent use of malaria preventive measures. As shown in the sections below, some of these themes indicated more variation among participants compared to others, hence these are reported using different categories that emerged during the discussion.
Perceived severity of malaria
Participants indicated that the incidence of malaria clearly increased in 2017 relative to 2016. Malaria severity and an increase in the number of malaria cases was discussed and four categories emerged: (1) malaria is perceived as an epidemic, (2) a high number of malaria cases in relation to high mosquito density, (3) increased malaria cases in relation to weather as well as (4) repetitive episodes of malaria in relation to low perceived effectiveness of Coartem® (brand name of artemether–lumefantrine, one of the medicines recommended for artemisinin-based combination therapy).
Malaria is perceived as an epidemic
Malaria was widely believed to be a serious disease and more severe than it used to be in the past (in 2017 compared to 2016). With no exception, participants perceived that malaria posed a very real threat. They expressed worry as most of the household members suffer from malaria from time to time and it is hard to find a family without a malaria case:
“In the past, malaria was not considered as a severe disease, however nowadays it has become an epidemic. When you visit one household, you find that, for example, five members suffer from malaria. For this reason, people are even telling us to ask the health professionals on their behalf whether this is malaria as it used to be or whether it is an epidemic.” (CHWs FGD)
“Nowadays people are asking themselves what kind of disease is this? 2017 came with a difference in relation to malaria,, compared to 2016. Even people are calling each other to go to the health centre together as if they are going to pray together!.” (Male FGD)
A high number of malaria cases in relation to high mosquito density
Some participants indicated that there is a high mosquito density and mosquito nuisance. The participants also reported an increase in perceived severity of malaria. Mosquitoes were reported to be everywhere in or outside the house and they can bite anytime especially during the night when sleeping:
“These days in the evening, you hear a lot of mosquito noises like bee buzzing. There are a lot of mosquitoes these days, and this makes me think that even if you are protected under the bed net at night you can even get a mosquito bite outside the house, and get malaria.” (Female FGD)
Increased malaria cases in relation to weather
Few participants associated the malaria burden with seasonality. In this line, it was perceived that malaria cases increase when it starts raining (in September) as a result of rapid mosquito reproduction, and malaria cases decrease during the dry season (in July):
“Because of change in weather so many people are being affected. Nowadays, we are in a short rainy season (locally termed Umuhindo), and we know that there is a lot of multiplication of mosquitoes in this period. Although mosquitoes multiply throughout all seasons, this can be one of the reasons for this increase of malaria cases. “(Cooperative FGD)
Repetitive episodes of malaria in relation to the low perceived effectiveness of Coartem®
By having repetitive malaria episodes without cure, respondents reported that these episodes may be due to low effectiveness of the malaria medicine, and reported a need to either replace the current medicines and bring ones with high effectiveness or find out a malaria vaccine. Participants believed that normally when you have malaria and get treated, one cure of Coartem® is enough for the sick person to get better. However, their experience is that this is no longer the case. Some of the participants reported to prefer buying some medicines in private pharmacies and perceived that they have a higher quality than those found at the health centre:
“Malaria has increased this year (2017), there are many malaria cases. We have observed that the medicines that used to cure malaria patients, now it seems like they are not curing. These days a person completes the cure without getting better, and after some days a person falls sick again. Thus, personally, I see that the current medicines may no longer have a strong capacity to cure malaria.”(KII Female participant)
“When you discuss with people, they tell you that when they go to the health centre and get medication, they don’t get cured, but when they go to the private pharmacy and buy medications [there are some medications for 3500 Rwf, approximately 4 US dollars] they get cured. Why this, they asked? Do the medicines from the health centre have the same capacity to treat malaria as those at the pharmacy?” (Youth FGD)
Perceived susceptibility to malaria
There was a general agreement about susceptibility to malaria among the participants and there was not much variation in the responses indicated. Everybody was considered at risk of getting malaria, and this was mainly due to the observed increase in malaria prevalence. Participants reported that there are many people who are going for treatment and that during the last years they did not suffer from malaria, but now they got it. There is a diversity in those people affected and you can not say that it is only one group of people or certain age group, rather all people, men, women, and children:
“This year was so special to me. I have never suffered from malaria before, but some months ago I got it and it was serious. I went to the CHW and had it diagnosed. After a few days, my wife and children also had it. Now, being either a child, young adult, or old person does not matter. Everybody is getting malaria.” (Male FGD)
“Last time I treated an old woman (81 years) and she told me that it was her first time to suffer from malaria in her life. She told me that it is an epidemic and not malaria as such. She was advising me to go and ask the health professionals about this epidemic in [cell name was removed] this cell.”(CHWs FGD)
Perceived self-efficacy to use a bed net
There was not much variation in the reported self-efficacy to use a bed net. All participants agreed that community members are confident in their ability to use a bed net when available. They reported that sleeping under a bed net is an activity that they are confident to perform. In addition, they also mentioned that it is their responsibility to monitor their children (mostly children under 5 years of age, as these cannot put the bed net on the bed themselves) so that they are sure that they sleep under the bed net once they own it:
“Sleeping under a bed net does not cost anything and I believe that even for those who don’t have a bed frame it is not a problem, they hang the bed net on the wall and it looks fine.” (CHWs FGD).
Perceived response efficacy of LLINs
Many participants believed LLIN to be an effective measure to prevent malaria. Although this was reported, many participants indicated the observed high-perceived effectiveness of LLINs to be related to the increase of malaria incidence (reported as an increased number of malaria cases), and the reduction of the number of bed nets owned. This reported effectiveness of LLINs was extended beyond malaria prevention as some participants highlighted the non-malaria benefits of the LLINs. However, few participants noted that the observed increase of malaria incidence is beyond the capacity of LLINs protection. The reported perceived effectiveness of LLINs could be split into three categories: (i) increase of malaria incidence in relation to the decrease in the number of LLINs owned; (ii) non-malaria benefits of LLINs; and (iii) perceived absence of insecticide and type of LLINs owned.
The increase of malaria incidence in relation to the decrease in the number of LLINs owned
It was clear that the increase of malaria cases and associated consequences is related to the reported high-perceived effectiveness of bed nets. Given the high malaria incidence, participants reported that even when it is too hot to use bed nets, the nets are an important tool in preventing being bitten by mosquitoes including those causing malaria. The reported effectiveness is also linked to the decrease of LLINs ownership as many participants reported planning to use them, and, unfortunately, they do not own them anymore as some of the participants noted that the LLINs received from last distribution were used for other unintended purposes:
“Since malaria severity has gone up people started appreciating the importance of the bed nets. Unfortunately, some of them don’t have the bed nets as from the last distribution some people received the bed nets but they used them for other purposes.” (KII Male participant)
“During the previous years, people did not value the bed nets and there weren’t many malaria cases. However, nowadays as malaria cases have increased, they started giving them value when they don’t have them. It is similar to the other proverb “utaribwa ntakinga” meaning that you increase awareness when you lose.” (FGD CHWs)
Non-malaria benefits of LLINs
Apart from being a malaria preventive measure, protection against other insects or reptiles that may fall from the roof while sleeping were reported as non malaria related benefits of LLINs. Some of the participants highlighted that sleeping under a LLINs has become a common practice. They are considering bed nets as something that protects them without thinking necessarily about mosquitoes. Even if it can be hot, they prefer to sleep under the bed net and leave aside the bed sheets:
“I have never slept without a bed net because it can even protect me from other insects or reptiles like lizards that may fall over. For example, I was sleeping one day and I started feeling sand/pebble falling from the roof. When I looked, it was a snake climbing the wall. Therefore, if I had not slept under the bed net, it would have bitten me. Thus, sleeping under the bed net and making sure you insert it properly under the mattress protects you from so many things.” (CHWs FGD)
Perceived absence of insecticide and type of LLINs owned
Due to high-perceived severity of malaria, some community members believe that this severity of malaria exceeds the capacity of the LLINs. People believe that the LLINs do not have the proper insecticidal protection, or the insecticides are not effective anymore and the LLINs are no longer able to keep the mosquitoes away. Participants indicated that normally mosquitoes would die immediately when they get into contact with the LLINs, however, that is not the case, rather mosquitoes just remain alive on LLINs. Few participants reported also the large mesh size of some type of LLINs and perceived that they can allow mosquitoes to enter and bite the person while sleeping:
“A few months ago, I got a new bed net from the health centre, and I currently sleep under it, but my child gets sick very often and sometimes everybody at home is sick, then I am wondering why? I think the bed nets are not effective anymore.” (Male FGD)
“I think the main reason why many people are affected by malaria is that these bed nets do not have the insecticide for protection, therefore the mosquitoes can bite anytime. I have also seen that the current bed nets have big mesh and I believe that they can even allow mosquitoes to enter and bite the person sleeping under it. Truly they are not protecting us.” (Female FGD)
Perceived barriers to use LLINs
Participants indicated three types of barriers that affect the use of LLINs. This can be thematically grouped under: (i) lack of or limited availability of LLINs; (ii) discomfort due to hotness, irritation, and bed bugs; as well as (iii) weak malaria risk perception.
Lack of or limited availability of LLINs
Lack of bed nets was mentioned by most of the participants to be the first barrier to use them and automatically put them at risk of getting malaria. Even for LLINs that are still intact, participants mentioned that they no longer contain insecticidal effects which underscore the need for replacement or retreatment (a procedure that was done by using “Karishya” kits that could be found in different shops, but they are no longer available). However, with the LLINs, retreatment is no longer necessary as they are treated with insecticides in the factory and this eliminates the needs for retreatment. Participants highlighted that the LLINs are only available for those attending antenatal consultation or vaccination:
“These days, people don’t have bed nets. Most of the households do not have bed nets. It is even clear because once an infected malaria mosquito bites somebody in the family, you will see that after some time all family members are sick because of lack of preventive measures. This means that the same malaria mosquito stays in the house and bites all of them.” (CHWs FGD)
“These days people get bed nets at the health centre from antenatal consultation or child vaccination at 9 months. Those who don’t attend consultation or vaccination services have a problem of getting bed nets.” (Male FGD)
Discomfort due to hotness, irritation, and bed bugs
Discomfort while sleeping under LLINs in the dry season, irritation (especially for those using the bed net with a strong texture or getting in contact with LLINs when using it for the first time), and presence of bed bugs while sleeping under the bed net were reported as hindrances to use bed nets. Many participants noted that the discomfort used to be the main hindrance. However, it was reported by few participants only, as perceived malaria risk exceeds the reported discomfort and many people have changed their opinion/perception:
“There is a time you go around mobilizing people to sleep under the bed net, but some, honestly tell you that if they use a bed net, they get irritated. And these days many people have bed bugs in their beds which prevent people to use bed nets even if they own the nets.” (KII Female participant)
“In my house, I have not moved from my sleeping room because of a mosquito, but I have moved because of bed bugs. It is really annoying. Therefore I pay much attention to the bed bugs more than I do for the mosquitoes and I can not sleep in a bed net when bed bugs are there.” (Male FGD)
“Due to the hotness that is here in Bugesera, sleeping under the bed net sometimes is like a punishment. And you may say that “even if I get a mosquito bite and get malaria, I will get treated instead of sleeping the whole week in this condition, it is really very hot.”(KII Male participant)
Weak malaria risk perception
Although some respondents mentioned bed bugs as a barrier to sleep under a bed net, others believe that more attention should be on mosquitoes rather than bed bugs. This was explained in relation to the consequences of malaria where also the cost of treatment is involved once the person gets sick. Participants added that when a person is sick, his/her routine activities are disrupted, hence his/her economy is affected. Hence, the perceived malaria risk outweighs the perceived beg bugs’ bites:
“If there is a room in my house that I can move in and not get into contact with the bed bugs, but no room I can go in and say that I am safe from the mosquitoes, then I should be worried. I know bed bugs are bad and when they bite they cause itching, but after all, I get up in the morning and go to my farms without any problem. In contrast, when an infected mosquito bites me, and I get malaria, in the morning I have to look for somebody to take me to the health centre as I cannot reach there alone. Consequently, this affects my economy”(Male FGD).
IRS acceptance
Many of the participants reported the effectiveness of IRS to be good. Participants generally agreed that, after spraying, a person could observe that mosquitoes and other insects were dead. At that time, one could enter in the house without fear as there is no way to get into contact with mosquitoes. However, changing the spraying company was reported to be a problem by the participants. The last spraying activity was done by the Inkeragutabara group (members of the District Administration Security Support), whereas the CHWs used to be responsible for spraying. Therefore, this new group was seen as an outsider in the community and participants highlighted that they did not spray properly. Participants believed that the sprayers had diluted the insecticide, or they are simply not well trained and qualified for the spraying activity. Thus, people were reluctant to accept IRS in their houses:
“CHWs used to be the one spraying, and to be honest the community members have very much trust in CHWs. But last time the people called “Inkeragutabara” were selected to do the spraying activities. Even some households were not sprayed. We don’t know whether they were entering the house and remain there until getting out without spraying.” (CMATs FGD)
“People are willing to receive the sprayers, but the main problem is those sprayers who don’t spray properly. The last team came to spray, but really, they were not spraying, because even at the end of the day (after spraying) you could see the mosquitoes flying. Therefore, some people were hesitant to stay at home and wait for the sprayers as people think that they are wasting their time, waiting for those people for nothing, and they close and go in their farms.” (Female FGD)
Strategies to enhance the consistent use and acceptance of malaria preventive measures
A number of strategies to enhance the consistent use and acceptance of malaria preventive measures was mentioned by the participants. These were classified into three categories: (i) availability of LLINs and regular spraying of insecticide; (ii) community mobilization; and (iii) citizen engagement in malaria preventive activities.
Accessibility of LLINs and regular spraying of insecticide
Making LLINs available, and regular spraying of insecticides both in houses and in marshlands were reported to be strategies to increase consistent use and acceptance of these measures. For LLINs, participants reported that if they were available in local shops for a cheaper price, then they would buy them. However, others indicated that there are those who cannot buy them either because they cannot afford them or simply because they used to get them from the government for free and believe that they cannot spend money buying the LLINs:
“Even if the bed net cannot be freely distributed, at least they can be put in local shops and at cheap prices for us to be able to buy them. But you need to have a place where you can buy it. For example in my family, I only have two bed nets and I need three more, therefore, if there is a place to buy, definitely I will buy them unless they are too expensive.” (KII Male participant)
Community mobilization
Community mobilization was generally highlighted as a strategy to promote the consistent use of malaria preventive measures. The focus should be more on those who do not use or accept the malaria preventive measures. Mobilization can be done through monthly community work, akagoroba k’ ababyeyi (parents’ evening meeting), and isibo meetings (roughly 15 households neighbouring each other), and home visits. Mobilization should be the responsibility of every community member in collaboration with CHWs:
“We need to continue community mobilization. I know people hear mosquitoes when they make much noise, especially in the rainy season. So, we need to tell them that even in the dry season mosquitoes are there and they have to use the preventive measures consistently even when having bed bugs.” (IDI Youth participant)
“Community mobilization related to malaria severity, its consequences, and benefits of bed net use is still lacking. This can be done in a formal and informal meeting at the amasibo, village, and cell levels. Community work and parents’ evening meetings also are good opportunities to share this type of information and mobilize people to remove all kinds of mosquito breeding sites that can be around their homes. Those who never attend the meetings can be visited at their home.” (Youth FGD)
Citizen engagement
As everybody is at risk of getting malaria, participants noted that every citizen should be actively involved in malaria prevention activities. When everybody feels responsible and actively contributes to malaria prevention through using LLINs consistently, controlling mosquito breeding sites, and accepting IRS, then mobilization could be easier. Thus, proactive mechanisms, discussions, and interactions between community members can be enhanced:
“Every community member should feel it [malaria prevention and control] as a personal responsibility, because even if you can mobilize, but people don’t feel responsible, then nothing can be changed. But if everybody engages in malaria prevention, I believe that perceptions can be improved.” (Youth FGD)
“Even if you distribute the bed nets today, tomorrow you will not find them as long as the perceived discomfort and bed bugs are still there. Do you know what they are saying? They are saying that the bed bugs go to the bed net in the night. In their feeling, they say that bed nets bring bed bugs. They remove them and burn them. Consequently, even if you distribute bed nets today, you will not solve the problem. First of all, let’s target the issue of bed bugs and related perceptions, and then we distribute the bed nets later.” (KII female participant)