Community-based house improvement for malaria control in southern Malawi: Stakeholder perceptions, experiences, and acceptability

Assessing the implementation fidelity, feasibility, and sustainability of community-based house improvement for malaria control in southern Malawi: a mixed-methods study

BACKGROUND

Despite significant success in the fight against malaria over the past two decades, malaria control programmes rely on only two insecticidal methods: indoor residual spraying and insecticidal-treated nets. House improvement (HI) can complement these interventions by reducing human-mosquito contact, thereby reinforcing the gains in disease reduction. This study assessed the implementation fidelity, which is the assessment of how closely an intervention aligns with its intended design, feasibility, and sustainability of community-led HI in southern Malawi.

METHODS

The study, conducted in 22 villages (2730 households), employed a mixed-methods approach. Implementation fidelity was assessed using a modified framework, with longitudinal surveys collecting data on HI coverage indicators. Quantitative analysis, employing descriptive statistics, evaluated the adherence to HI implementation. Qualitative data came from in-depth interviews, key informant interviews, and focus groups involving project beneficiaries and implementers. Qualitative data were analysed using content analysis guided by the implementation fidelity model to explore facilitators, challenges, and factors affecting intervention feasibility.

RESULTS

The results show that HI was implemented as planned. There was good adherence to the intended community-led HI design; however, the adherence could have been higher but gradually declined over time. In terms of intervention implementation, 74% of houses had attempted to have eaves closed in 2016-17 and 2017-18, compared to 70% in 2018-19. In 2016-17, 42% of houses had all four sides of the eaves closed, compared to 33% in 2018-19. Approximately 72% of houses were screened with gauze wire in 2016-17, compared to 57% in 2018-19. High costs, supply shortages, labour demands, volunteers' poor living conditions and adverse weather were reported to hinder the ideal HI implementation. Overall, the community described community-led HI as feasible and could be sustained by addressing these socioeconomic and contextual challenges.

CONCLUSION

Our study found that although HI was initially implemented as planned, its fidelity declined over time. Using trained volunteers facilitated the fidelity and feasibility of implementing the intervention. A combination of rigorous community education, consistent training, information, education and communication, and intervention modifications may be necessary to address the challenges and enhance the intervention's fidelity, feasibility, and sustainability.

Community perceptions, acceptability, and the durability of house screening interventions against exposure to malaria vectors in Nyimba district, Zambia

BACKGROUND

House screening remains conspicuously absent in national malaria programs despite its recognition by the World Health Organization as a supplementary malaria vector-control intervention. This may be attributed, in part, to the knowledge gap in screen durability or longevity in local climatic conditions and community acceptance under specific cultural practices and socio-economic contexts. The objectives of this study were to assess the durability of window and door wire mesh screens a year after full house screening and to assess the acceptability of the house screening intervention to the participants involved.

METHODS

This study was conducted in Nyimba district, Zambia and used both quantitative and qualitative methods of data collection and analysis. Both direct observation and questionnaires were employed to assess the durability of the screens and the main reasons for damage. Findings on damage were summarized as percentages. Focus group discussions were used to assess people's knowledge, perceptions, and acceptability of the closing eaves and house screening intervention. Deductive coding and inductive coding were used to analyse the qualitative data.

RESULTS

A total of 321 out of 400 (80.3%) household owners of screened houses were interviewed. Many window screens (90.3%) were intact. In sharp contrast, most door screens were torn (n = 150; 46.7%) or entirely removed (n = 55; 17.1%). Most doors (n = 114; 76%) had their wire mesh damaged or removed on the bottom half. Goats (25.4%), rust (17.6%) and children (17.1%) were cited most as the cause of damage to door screens. The focus group discussion elicited positive experiences from the participants following the closing of eaves and screening of their windows and doors, ranging from sleeping peacefully due to reduced mosquito biting and/or nuisance and having fewer insects in the house. Participants linked house screening to reduced malaria in their households and community.

CONCLUSION

This study demonstrated that in rural south-east Zambia, closing eaves and screening windows and doors was widely accepted. Participants perceived that house screening reduced human-vector contact, reduced the malaria burden and nuisance biting from other potentially disease carrying insects. However, screened doors are prone to damage, mainly by children, domestic animals, rust, and termites.

Knowledge and Practices of Women Regarding Malaria and Its Prevention: A Community-Based Study in an Area under Malaria Elimination Programme in Iran

Background

Indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are two core interventions for control and prevention of malaria infection. This descriptive cross-sectional study aimed to determine the knowledge and practices of women regarding malaria and its preventive measures in a malarious area in the Jask County, southeast of Iran.

Methods

Data was collected from 400 households through a two-stage random cluster sampling method in six villages. Pre-tested structured questionnaire was used to collect data. During the survey, visual observations were also made by the interviewers to check use of LLINs and IRS. The data were analyzed by SPSS software version 21.

Results

The majority of households had a high level of knowledge about symptoms (98%, n=392) and transmission (74.5%, n=298) of malaria. The main preventive measures against malaria were: LLINS (39.5%, n=158), IRS (32%, n=128), and screens on doors/windows (16.7%, n=67). In addition, participants with primary or higher educational level reported that they practice more malaria preventive measures, compared to those who were illiterate (OR=3.3, 95% CI= 1.6-6.6, p=0.0001, Table 6). In spite of positive perceptions about IRS and LLINs, only 35.5% (n=142) and 17% (n=68) of households used IRS and LLINs, respectively.

Conclusion

According to the results of this study, despite a high level of knowledge about malaria and its preventive measures, a small number of participants use LLINs and IRS for malaria prevention. Therefore, implementation of effective educational interventions is recommended to improve preventive practices against malaria in the study area.

Exploring the potential of village community banking as a community-based financing system for house improvements and malaria vector control in rural Tanzania

House improvement is associated with remarkable reductions in indoor mosquito bites and disease incidences, even in typical rural houses. However, its exploitation remains extremely poor in Tanzania and other endemic countries due to limited financial resources. Nevertheless, village community banks (VICOBA), practiced in Tanzania for nearly two decades, have proven to provide financial services to rural communities that would otherwise not be able to get them from formal financial institutions. This study explored the need, opinion, and willingness of VICOBA members to use VICOBA platforms as a source of finance for improving local houses and eventually controlling mosquito-borne diseases. A mixed-methods approach was used in this study, whereby a survey was administered to 150 participants and twelve focus group discussions were done in three villages in Ulanga district, rural Tanzania. The FGDs comprised eight participants each, with equal representation of males and females. The FGD guide was used to probe the opinions of study participants on malaria transmission, housing condition improvements, and financial resources. About 99% of all participants indicated the urgent need to improve their houses to prevent mosquito bites and were willing to utilize VICOBA for improving their houses. In the focus group discussion, the majority of people who participated were also in need of improving their houses. All participants confirmed that they were at the highest risk of getting mosquito-borne diseases, and they were willing to use money that was either saved or borrowed from their VICOBA for housing improvements and vector control. A self-sustaining financial system destined for house improvement and related interventions against malaria and other mosquito-borne diseases is crucial. The community members were willing to use VICOBA as a source of finance for house improvement and disease control; however, there was limited knowledge and sensitization on how they could utilize VICOBA for disease control.

The needs and opportunities for housing improvement for malaria control in southern Tanzania

BACKGROUND

Malaria disproportionately affects low-income households in rural communities where poor housing is common. Despite evidence that well-constructed and mosquito-proofed houses can reduce malaria risk, housing improvement is rarely included in malaria control toolboxes. This study assessed the need, magnitude, and opportunities for housing improvement to control malaria in rural Tanzania.

METHODS

A mixed-methods study was conducted in 19 villages across four district councils in southern Tanzania. A structured survey was administered to 1292 community members to assess need, perceptions, and opportunities for housing improvement for malaria control. Direct observations of 802 houses and surrounding environments were done to identify the actual needs and opportunities, and to validate the survey findings. A market survey was done to assess availability and cost of resources and services necessary for mosquito-proofing homes. Focus group discussions were conducted with key stakeholders to explore insights on the potential and challenges of housing improvement as a malaria intervention.

RESULTS

Compared to other methods for malaria control, housing improvement was among the best understood and most preferred by community members. Of the 735 survey respondents who needed housing improvements, a majority needed window screening (91.1%), repairs of holes in walls (79.4%), door covers (41.6%), closing of eave spaces (31.2%) and better roofs (19.0%). Community members invested significant efforts to improve their own homes against malaria and other dangers, but these efforts were often slow and delayed due to high costs and limited household incomes. Study participants suggested several mechanisms of support to improve their homes, including government loans and subsidies.

CONCLUSION

Addressing the need for housing improvement is a critical component of malaria control efforts in southern Tanzania. In this study, a majority of the community members surveyed needed modest modifications and had plans to work on those modifications. Without additional support, their efforts were however generally slow; households would take years to sufficiently mosquito-proof their houses. It is, therefore, crucial to bring together the key players across sectors to reduce barriers in malaria-proofing housing in endemic settings. These may include government subsidies or partnerships with businesses to make housing improvement more accessible and affordable to residents.