Understanding the Impact of Local Community Knowledge, Attitudes, Practices, and Beliefs on the Persistence of Malaria Transmission in North-western and Southern Regions of Tanzania: A Study Published in Malaria Journal


Demographic characteristics of study participants

A total of 276 individuals participated in the present study whereby 260 took part in the FGDs while 16 took part in IDIs. FGD respondents’ age ranged from 18 to 85 years. Most (~ 75%) of HHs were below 50 years while most of IDIs participants (75%) were between 41 and 60 years old, with the remaining quarter aged 21–40 years (Fig. 2). A high proportion of FGD participants (72.3%) had primary education; and there was a significant difference in the level of education attained by participants of different sex; with more male participants who had higher levels of education than female. The main occupation of FGD participants was small-scale farming (95.0%). The IDIs participants (mainly DMOs and DMFPs) had College or University education and their age ranged from 27 to 59 years and 12 (75.0%) were males (Fig. 2).

Fig. 2
figure 2

Socio-demographic profiles of FGD (left panel) and IDI (right panel) participants

Key themes which emerged from FGDs and IDIs

The findings of this study are presented within the following five themes, which emerged during the analysis of the FGDs’ and IDIs’ transcripts: the themes include: (1) general knowledge of malaria (transmission and causes; and prevention); (2) reasons for low use of mosquito vector control interventions, long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), such as LLINs/IRS & bedbugs; LLINs and erectile dysfunction; LLINs usage and climatic conditions; LLINs & poverty; and misconceptions on IRS); (3) IRS and larviciding use and related challenges; (4) malaria health-seeking behaviour and care experiences (self-medication, decision to visit the health facility, and the use of local herbs); and (5) availability of health workers and health financing [use of and dissatisfaction with the community health fund (CHF) services].

In the next sections, the term ‘bed nets’ has been used in quotes in place of LLINs unless stated otherwise, similarly the term ‘participants’ refers to either FGDs’ or IDIs’ respondent unless stated explicitly.

General knowledge of malaria (cause, transmission, symptoms and prevention)

Cause and transmission

FGD participants were asked about the cause of malaria, its symptoms, transmission, and how it can be prevented. The majority were aware of its symptoms and that mosquitoes transmit malaria. In general, they understood that the disease is transmitted by a mosquito, and in many cases, most of the participants mentioned that only female mosquitoes are responsible for transmitting malaria. This was well articulated as referenced by this 29-year-old participant:

“Malaria is transmitted by a female mosquito called Anopheles” (P 127-FGD-Female-29yrs- Geita)

Another participant echoed what was spoken by others:

“Malaria is a disease transmitted by mosquitoes. Not all mosquitoes can transmit malaria but female mosquitoes called Anopheles are the ones responsible for transmission of malaria” (P 15-FGD-Female- 30yrs- Kigoma)

However, not all FGD participants possessed the correct knowledge of malaria and its transmission. A misconception about malaria transmission was that the disease could affect someone through different routes apart from a bite from an infected mosquito. Some of the participants were of the view that malaria parasites get into the human body through bathing and drinking un-boiled water, or consuming contaminated food that had malaria parasites without warming it. For example, some participants had this to say:

“Here in our village, the majority of us are using water from the river for bathing and drinking. Water from the river is not safe, and we are drinking this water without boiling; that is why we have malaria in our community.” (P171-FGD-Male-24yrs-Ruvuma)

Another participant explained that:

“I urge everyone to stop eating contaminated food, especially leftovers. The majority of the people here do not properly cover their leftovers, and when they wake up in the morning, they quickly rush to eat such food without heating it. During the night, mosquitoes tend to leave parasites on the food, and when someone eats leftovers, they will get malaria” (P 172- FGD- male-27yrs- Ruvuma)

What was interesting in these two perceptions about water and food in relation to malaria transmission was the association of heating or boiling as a preventive measure. While FGD participants could debate about transmission; the actual cause of malaria which is the parasites, was not well articulated. It was narrated by some participants that in the community, some people still think that demonic possessions are to blame for and are believed to be a cause of complicated/severe malaria which sometimes lead to convulsions.

For example, an IDI participant said:

“Public awareness regarding complicated/severe malaria is still low. There are different beliefs among community members; for example, if a child gets severe malaria with convulsions, they say the child was possessed by demons and parents do not take the child to the health facility, instead they send him/her to a traditional healer. Eventually, the child ends up dying there” (P 271-IDI- 53yrs- Ruvuma)

Prevention

Strategies of malaria prevention were well articulated in all FGDs and IDIs. Participants reported preventative methods categorizing them into those used inside the house and those applied outdoors. Most of discussants reported to rely on LLINs to protect themselves from mosquito bites. They reported that they have been hearing about LLINs in different media outlets for many years. Nearly all participants reported LLINs as the main malaria prevention method:

“The way to protect yourself, personally I think we should have bed nets. Because if you don’t use a bed net malaria can hit you” (P 222-FGD-Male-54yrs-Mtwara)

“We protect ourselves using bed nets when we go to sleep” (P 89-FGD-Female-32yrs-Geita)

An IDI participant also supported what were reported by FGD participants:

“Most of the people in the community prefer to use bed nets; if you educate them properly they make good use of nets” (P 263-IDI- 51yrs- Kigoma)

Participants were aware of the strategies used to prevent mosquitoes outside their houses including destroying standing water bodies which provide breeding sites, trimming grasses and shrubs in peri-domestic areas and use of local herbs such as burning eucalyptus leaves to expel mosquitoes. However, participants from each of the study regions possessed their own types of herbs which they used to expel mosquitoes. For example, a participant from Geita reported use of eucalyptus while those from Ruvuma reported to use other types of smelly leaves:

“For example, there are leaves called “MNUNGANGU” (a YAO word which means a leaf with very bad smell) which are normally used to deter mosquito” (P 271-IDI-53 yrs-Ruvuma)”

“In the past, we were using eucalyptus leaves to deter mosquitoes. When you burn the green leaves, mosquitoes will disappear. But now we are using bed nets” (P 129-FGD-Female-29 yrs-Geita)

A participant echoing his fellow discussant said:

“We normally protect ourselves by using “MALUMBA” (a Sukuma word) leaves; once you put them in the house, they release smell and mosquitoes vanish from the house” (P 98-FGD-Male-37 yrs-Geita)

IRS and larviciding were mentioned by both FGD and IDI participants as important tools in the prevention of malaria outdoors. The emphasis and importance of IRS and larvicides were mainly reported in Geita Region that had extensive experience of using them. However, even in the regions such as Mtwara and Ruvuma where IRS was yet to be implemented, both FGD and IDI participants acknowledged its potential. They associated persistence of malaria in their regions with a possible lack of these important control tools (IRS and larvicides):

“We are being asked by the people in the community, why are you always pushing people to use bed nets only as a means of fighting malaria? Why don’t you think of another way to fight malaria such as IRS? Even me as a malaria focal person, I agree that we need to employ this strategy of IRS. We have never sprayed chemicals in this District” (P 271-IDI-Male-53yrs-Ruvuma)

An FGD participant added;

“Perhaps what can be done to prevent malaria is that; we get chemicals which can be sprayed in all mosquito breeding sites in order to destroy the mosquito eggs and kill the mosquito themselves completely so that there is no further reproduction of mosquitoes” (P134-FGD-Male-36yrs-Ruvuma)

Reasons for low use of vector control interventions (LLINs and IRS)

Despite the fact that participants acknowledged the use of LLINs for malaria control, there were different views that suggested that LLINs were infrequently used and sometimes misused. Although most participants reported that they possessed LLINs, their use was mostly hindered by factors related to LLINs quality and misconceptions.

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LLINs and bedbugs

The majority of FGD participants reported that LLINs, especially those provided free by the government and distributed during the national campaigns, brought a lot of bedbugs. When asked to clarify, most participants were not aware of how bedbugs were brought by LLINs. Participants in Ruvuma region however, believed that LLINs were infested with bedbug’s eggs at the time they were distributed to community members. Because of that, some participants mentioned that they decided to abandon the LLINs. This response from one participant in Ruvuma resonates well with this popular view around bedbugs and LLINs:

“I agree those bed nets which were given for free by the government brought bedbugs. In my house, there was no single bedbug before, but after getting the bed net, I saw many bedbugs. I decided to throw it away and buy another one from the shop; to date there is no bedbug in my house” (P170-FGD-Male-24 yrs-Ruvuma)

In addition, when an IDI participant was asked if there are any issues related to the use of LLINs, he replied:

“Yes. Very much! I am saying very much because we have evidence of these claims. There are some areas where people report that free nets provided by the government and distributed by district officials bring bedbugs” (P 271-IDI-Health officer—Male-53yrs-Ruvuma)

LLINs and erectile dysfunction

Another misconception related to possible low LLINs use was that, it was reported to cause erectile defects and low libido in men (suggested that sex drive in men decreased by using LLINs). This was widely reported by participants in FGDs, although other participants vehemently refuted this claim. In elaborating on how actually LLINs caused low sex drive, participants associated it with the lowered ability of men (who use LLINs) to sexually satisfy their sexual partners:

“Ooh yes! It is true when you sleep under a bed net, you cannot sexually satisfy your partner because you can ejaculate once, but if you sleep without a bed net you can ejaculate thrice” (P167-FGD-Male-44yrs-Ruvuma)

This view was also echoed by an IDI participant:

“To be honest, for men to use bed nets it is a challenge. There were some rumours; men believe that sleeping under the bed net makes them weak during sexual activity. I remember sometimes ago when there was a national campaign of distributing free bed nets which were donated by the Americans, those bed nets with Zebra lines, men claimed that when you sleep under those bed nets, you can clearly smell the chemical. The chemical was claimed to cause low sexual desire among men” (P269-IDI-Male-27yrs-Ruvuma)

LLINs and climatic conditions

Low LLINs use was also associated with seasonal variations. Participants generally perceived abundance of mosquitoes that may cause malaria to be in the rainy seasons and immediately after and therefore it was important for them to use LLINs during these periods. In addition, it was reported that sleeping in a bed covered with a bed net (not exclusive for LLINs) during warm and humid weather, the room becomes hot with no air movement. The heaviness of the air was reported to somehow affect the ability of the users to breathe properly and caused discomfort, in their attempt to enjoy their sleep:

For example, a participant said:

“There are some people who say that they do not prefer to sleep under bed nets (not exclusive for LLINs), especially in this month of September because the weather is warm; they say the bed nets increase warm condition while sleeping and they decide to remove them, while in this month of September there are mosquitoes everywhere” (P16-FGD-Female-30yrs-Kigoma)

An IDI participant was with the view that, his clients oftentimes did not use bed nets (not necessarily LLINs) in both the warm and wet weathers:

“During warm season, people do not prefer to use bed nets (not necessarily LLINs) because it worsens the heat. On the other hand, during the cold season in June and July mosquitoes tend to change behaviours, their wings become thicker because of the cold weather, so you cannot hear mosquito’s noise. People say in cold season there are no mosquitoes as a result they do not use bed nets” (P 271-IDI-Male Health officer–53yrs-Ruvuma)

LLINs and poverty

In the study regions, participants reported that most low-income families are unable to afford LLINs. Moreover, it was reported that the majority of low-income communities have poor-quality housing, which makes it difficult to use LLINs.

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For example, a participant said:

“Poverty contributes to malaria persistence because someone cannot afford to buy a bed net” (P 125-FGD-male-26yrs-Geita)

In agreement, another participant added:

“Poverty contributes greatly to the increase of malaria. Although we are getting free bed nets from the government, we have poor-quality houses. We also sleep on the floor where there is no proper place to hang and fix the bed nets” (P 120-FGD-Male-56yrs-Geita)

Misconception regarding IRS

IRS has been used for vector control in some Regions in the Lake zone of Tanzania including Geita. FGDs participants had some concerns with IRS which are similar to those raised by the users of LLINs. They claimed that chemicals used for IRS facilitated the appearance of bedbugs in the sprayed houses. Participants believed that bedbugs appeared and increased in the houses after spraying. However, when probed further, they could not explain exactly how this was possible but to them, it was what they experienced. For example, an FGD participant reported:

“We do not like the chemicals used for IRS because they bring bedbugs in our houses. The houses sprayed tend to have more bedbugs than those houses which have not being sprayed” (P 127-FGD-Female-29yrs-Geita)

When an IDI participant was asked to give her opinion related to the acceptability and misconception related to the use of IRS, she had this to say:

“The IRS program has been implemented in this District for the past 5 years. During early years of implementing IRS program, there was a very good response and acceptance from the community. However, last year the campaign encountered several challenges since some people were reluctant to cooperate. People in the community had beliefs that the chemicals used for IRS bring bedbugs in their houses while others see IRS as a disturbance because they are asked to shift their domestic items outside the house and then bring them inside again. Others claimed that the chemicals have bad smell” (P 265-IDI-Health officer-Female-32 years old-Geita)

IRS and larviciding use and related challenges

Participants from regions that had implemented Larviciding and IRS acknowledged the benefits of these malaria control interventions. The majority of participants, especially in the Geita region, reported that they have witnessed regular implementation of the IRS, and a few reported about larviciding. They specifically noted that in the beginning when these interventions were implemented, there was a sustained reduction of mosquitoes and malaria cases. But in their views, these positive outcomes have not been sustained and raised suspicion about the implementation of the interventions, which possibly resulted into re-emergence of mosquitoes and increased malaria cases in the communities.

Some participants reported ineffectiveness of both interventions explaining that dishonest individuals entrusted with the task of mixing and spraying, over-diluted the chemicals used for IRS. They further reported that some of these unfaithful individuals stole IRS or larviciding chemicals, an act that deeply jeopardized effective spraying and larviciding efforts. Others reported that the quantity of IRS chemicals which is allocated to them is always inadequate:

“Those who are involved in spraying IRS are not faithful, they sell the chemicals. They mix small amounts of chemicals with water and sell the rest” (P115-FGD-Female-28yrs-Geita)

In agreement with the above, one participant from the same region had this to say:

“I do not like IRS chemicals, they are just over diluted and I feel that they just spray water on the walls of our houses” (P114-FGD-Female–25yrs-Geita)

An officer from Kigoma was concerned with the quantity of the larvicides provided:

“We have been given larvicides but are not sufficient for the whole district. We were given only 45 cans” (P265-IDI–Male-39 years old-Kigoma)

Indeed, there were some participants who offered a way out to the above challenges. They acknowledged the potential benefits of IRS and saw that there was an opportunity to improve on the current practice. To them, it seemed that IRS as an intervention demanded more community engagement, continued education and public communication to increase its acceptance. A FGD participant from Geita had these words that were well supported by the rest of the participants in his group:

“Chemicals used in IRS are effective; the primary issue is to educate the community so that they can understand the whole exercise of IRS.” (P 120-FGD-Male-56yrs-Geita)

Comments from other participants alluded to household owners’ reluctance to have their houses sprayed fearing the chemicals:

“The chemical used for IRS are really good, but sometimes the community itself is the problem. You will find some people do not want the chemicals to be sprayed inside their houses, they just tell the sprayers to only spray the chemicals outside the house. But generally, the chemicals are good” (P 118-FGD-Male-35yrs-Geita)

Malaria health seeking behaviour and health care experiences

Self-medication

Health care seeking for malaria became an important theme that all participants had something to talk about. Two main practices dominated: first, participants reported to self-medicate before reporting to health facilities for check-ups whenever they experienced malaria-related symptoms. In case symptoms persisted, that is when they decide to visit health facilities. They usually go to the drug outlets and buy pain killers such as paracetamol (Panadol) and/or even purchase anti-malarial, popularly known as “Mseto” (a Kiswahili term for “combination drug” and may be used to refer to artemether-lumefantrine—ALu or other artemisinin—based combinations—ACT). In other words, presentation at health facilities is done late when malaria has become complicated:

“I will speak the truth, we are making mistakes. In our village we have a tendency when someone is sick, we usually rush to the drug outlet to buy drugs. We are taking medications without knowing what we are suffering from. This is a mistake” (P229-FGD-Male-64yrs-Mtwara)

When an IDI participant was asked about health-seeking behaviour, he gave this statement:

“No! Health care seeking behaviour is still low, extremely low, very low. For example, when a child has fever or even an adult, community members tend to hurry to the drug shop to buy Panadol and when they have temporary relief they will go to the farm. Remember this person is in the early stages of uncomplicated malaria, then after two days that child may develop complicated/severe malaria. Some of the community members do not adhere to the recommendations of seeking health care services from health facilities within 24 h after early symptoms of suspected malaria” (P271-IDI-Male-53yrs-Ruvuma)

Decision to visit the health facility

Some FGD participants reported to seek treatment for suspected malaria by visiting the health facilities. These facilities were mostly government dispensaries and health centres. Moreover, some participants suggested that sometimes it really depends on someone’s views and preferences because there are several factors that influence decision making of where to seek medical care from, as explained below.

“When I feel I have symptoms of malaria, I always rush to the dispensary” (P 250-FGD-Female-49yrs-Mtwara)

Another participant had this to say,

“It is true, you know for this case, everyone has his/her own understanding, others prefer to go to the dispensary, others go to the hospital directly for testing, it really depends on someone’s understanding” (P 55-FGD-Male-60yrs-Kigoma)

Another participant added:

“We always rush to the pharmacy to buy drugs because it is cheap. The majority of us avoid going to the dispensary where there are experts because we don’t contribute to the CHF (community health fund) services” (P 26-FGD-Male-39yrs-Kigoma)

In agreement with the above, one participant from Mtwara Region had this to say:

“We always prefer to go to the pharmacy because when you go to the dispensary you pay a lot of money” (P 251-FGD-Female-39yrs-Mtwara)

Use of local herbs

In Kigoma and Mtwara regions, some participants reported the use of local herbs to treat malaria symptoms and they got temporal relief after using such herbs. Although the practice was not widely reported, it suggests that other avenues are being employed to address malaria related challenges:

“There are some people who still use traditional medicine to treat malaria. They use the leaves of “MLULUNGUNJA” or “MFUMYA” trees. They grind the leaves, strain them, mix with water and drink. When they have temporary relief, they ignore going to the health facility” (P09-FGD-Female-40yrs-Kigoma)

Interestingly, this local herb can be taken orally or per rectal famously known as “KUHINIKA” in local language, using a small pipe that is inserted per rectal. To support this assertion, a FGD male participant from Kigoma, 51 years old had this to say:

“Yes, others are taking this traditional medicine through “KUHINIKA” (A liquid local herb taken through the rectal route). In Kiswahili language it is famously known as kupiga bomba (to pump dirt out of the rectum). After a while, the patient will have very serious diarrhoea, and all dirt will come out from the stomach and malaria patient will have some relief” (P 07-FGD-Male-51yrs-Kigoma)

In Mtwara, the use of herbs to treat malaria was done through consumption of leaves from the popular neem tree (Azadirachta indica), locally known as MUAROBAINI:

“When someone has malaria symptoms, nowadays there is “MUAROBAINI”; they grind the leaves of MUAROBAINI, boil them and drink. When they drink the extracts, they get relief, other people boil the leaves of MUAROBAINI and inhale its vapour” (P 09-FGD-Female-35yrs-Mtwara)

Availability of health workers and dissatisfaction with the community health fund (CHF)

Almost all participants reported issues related to availability of health workers and implementation of CHF and how they affect access and utilization of health care services for malaria in their communities. Participants in all four regions reported that there were insufficient numbers of health workers in their areas to satisfactorily attend malaria cases. They stated that it is common to find only one health worker in a dispensary that serves a lot of people. For example, an IDI participant from Kigoma had this to say:

“With regard to staffing level, we are understaffed by 64%. We really have shortage of staff in all carders: clinicians, nurses and laboratory staff” (P262-IDI-Male- 39yrs-Kigoma)

In support of the above assertion, one FGD participant said:

“I am not happy with the health care services at our dispensary. First there is a shortage of qualified health workers to the extent that even health attendants are attending patients with serious illnesses. At our dispensary, there is no clinician but only nurses and health attendants” (P 170-FGD-Male-32yrs-Ruvuma)

In agreement with the above comment, another FGD participant said:

“We are not satisfied at all with the number of health workers. The issue is, we have only one health worker here and above all he has his own problems too” (P 04-FGD-Male-32yrs-Kigoma)

On the other hand, the majority of the participants, especially in FGDs, expressed their dissatisfaction with the CHF services. They lamented that CHF services are very poor, as there are always no medications, and some health workers are also very rude. Others claimed that there is no difference between CHF users and non-CHF beneficiaries. Participants reported that CHF is ineffective, and the majority of community members hesitate to join the scheme due to the poor quality of their services. For example, an FGD participant said:

“I am a beneficiary of CHF. But one day when I was sick with suspected malaria, I went to the dispensary with my CHF card, when I arrived at the dispensary the health worker refused to attend me. He told me that, I am still young and energetic therefore I must contribute some money to be able to get treatment, claiming that CHF is only for children and the elderly” (P 259-FGD-Male-29yrs-Mtwara)

Another participant commented:

“We have a CHF program in our village, but this program is ineffective because our clinician is often absent from work” (P 04-FGD-Male-35yrs-Kigoma)

Another participant added:

“The majority are fearful to join CHF because their services are poor. Every time you go to the health facility they will tell you there are no drugs and ask you to buy drugs from the pharmacy” (P 129-FGD-Female-29yrs-Ruvuma)

There were mixed opinions among IDIs participants regarding the services provided by the CHF scheme. Some denied but others admitted that there were some valid challenges and complaints from community members about CHF. In addition, they reported other operational and administrative challenges; for example, some participants reported that:

“We have challenges; there are some health workers who are not faithful, they steal CHF money. There is one health worker at a certain facility who stole 1.5 million Tanzanian shillings (~ 650USD), this particular person has been suspended to date” (P262-IDI- 39yrs -Kigoma)

Another participant said:

“The majority do not bother joining CHF, claiming that its services are poor. People say that every time you go to a health facility, you will be told there is no medicine. This is the main reason why people hesitate to join CHF” (P 275-IDI-Female- 35yrs-Mtwara)

Another participant had this view:

“CHF coverage is low, the coverage is about 40%, regional wise. The eagerness to join the scheme is minimal because potential members say that there is no difference between CHF users and non-CHF beneficiaries” (P 271-IDI-Male-53yrs-Ruvuma)

In contrast to the above statement, some IDIs participants attributed the shortage of drugs to systemic challenges that are now a thing of the past. One participant commented that:

“In the past, CHF services were poor and were not accepted by many people because we had no drugs, but now we have sufficient drugs” (P 265-IDI-Health officer-Female, 32yrs-Geita)

Source

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