Qualitative Study on Barriers to Net Use among Most at Risk Populations

in Kenya

Results

April 18th 2013

Outline of the presentation

1. Background

2. Study design and methods

3. Preliminary Results

4. Interpretation

5. Discussion

page 2

Background

page 3

Background (1)

• Long Lasting Insecticide Treated Nets (LLINs) are an effective method of preventing malaria and reducing the incidence of clinical malaria and anaemia in young children

• Kenya is seen to be successful in the delivery methods for routine and mass distribution of LLINs.

page 4

Background (2)• PMLLIN evaluation exercise was aimed at

estimating indicators of LLIN retention, usage and ownership in households that received bed nets

• Key findings– Increased household net ownership in the

Lake Endemic and Highland Epidemic Malarial zones (70.7 % [KMIS 2010] to 88.3%).

– However, net usage had not increased

page 5

Background (3)•Of concern from that evaluation:

•Only 16.9% of children under five in the Lake Epidemic areas who slept under LLIN the previous night prior to the study compared to 26.9% in the Highland Epidemic areas

•Only 52.5% of pregnant women slept under LLIN the night preceding the survey

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Overall study objective

• To develop a better understanding of the factors associated with and barriers to net use among vulnerable populations living in malaria endemic and epidemic areas in Kenya.

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Specific objectives

• To explore factors that influence net use within the household

• Barriers to net use among most at risk populations

• Decision making factors and processes regarding net use

• Preferred source of information on malaria prevention strategies and,

• Alternative uses for nets.

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Study Design and Methods

Literature Review• Literature shows reasons for non use of nets to coalesce

around three major issues (Alaii JA et al., 2003) (Pulford J et al. 2011). – Environmental factors: weather patterns, temperature, lack

or presence of mosquitoes – Social factors: age, household sleeping arrangements,

cultural attitudes and norms, fears such as ants will climb up the net, absence of caregiver

– Technical factors: ability to hang nets, no room to hang net, inconvenience to hang net, size of net smaller than bed, spoilt net, net being mended, house construction affects net use, net has been washed, etc

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Theoretical Approach• Used the Theory of Planned Behaviour (TPB) which

allows the examination of an individual’s intention to use bed nets (or not) (Ajzen, 1991). – Can thus help explain why bed net usage is low despite

reported high bed net ownership

• Components:– Attitude toward the behaviour - evaluation or appraisal of the

desired behaviour (i.e., consistent bed net use) in question. – Subjective norm; it refers to the perceived social pressure to

perform or not to perform the behaviour. – Perceived behavioural control - perceived ease or difficulty of

performing the desired behaviour.

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Methods

Qualitative research methods were used:• Desk review• Focus group discussions (FGDs)• In-depth interviews (IDIs)• Vignettes

– An hypothetical approach that seeks to explore informants views issues with a focus on ‘’how things ought to be’

– Other methods describe ‘what is’

• Observation

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Sampling • Multi-stage sampling using the maximum variation

approach was used to identify potential informants • Informants included:

– Household Heads– Pregnant women– Caregivers of children under five years old– Household members

page 13

Site selection

• Sites in Nyanza and Western provinces to represent regions where mass net distribution as follows:– LLIN use and non-use; – Whether rural or urban; and,– Either malaria highland epidemic or Lake Endemic

zones– Reported high numbers of non-users – Selection result in 12 locations in Nyanza and

Western provinces

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Study sites

page 15

Malaria Qualitative Study - Sampling points

Region District Location Sub-location

Western

Lugari Chekalin MusembeLikuyani Nzoia MatundaBungoma Webuye TownshipNambale Bukhayo LwanyangeBusia Township Mjini CEButula Marachi Bukhalalire

Nyanza

Muhoroni God Nyithindo OregoNyakach East Nyakach Jimo EastNyando Kakola TuraGucha South S.M.Chache TabakaKenyenya M. Chache NyansakiGucha M. Masaba Bokimonge

Blue – Rural; Red-Urban

Respondents’ inclusion criteria

• Male and female respondents (18-49 years)– Household heads, – Pregnant women, – Caregivers of children under five, – Other household members

• Received free nets during mass distribution exercise

• Have consented to participate in study

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Data collection• Study received ethical approval from the KNH / UON ERC

• Consisted of in-depth interviews (IDIs) administered face-to-face by same-sex interviewers (133 respondents) – Observations done at end of IDI

• Focus group discussions (FGDs) held with men and women separately (21 groups). – Vignette at end of FGD

• No overlap of IDI and FGD participants

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Data management and analysis• Verbatim transcription of audio recorded data, translated

from Swahili, Luo, Kisii, and Luhya into English • Transcripts imported into NVIVO 10 software to facilitate

indexing, categorizing and theorizing• Use of sample transcripts and audio recordings to

develop a coding framework included: Listening to a sample of audios from a selected number of

interviews conducted by different research assistants Immersion in the raw data by reading through15 interviews Read descriptions of the interview summaries and discussed with

the field team during the debrief sessions for each site Initial coding framework developed Tentative analysis framework developed

page 18

Analytical process

• Coding alongside the coding framework• Key ideas emerging from the data are

presented alongside the objectives of the study

• Data interpretation workshop held with stakeholders on March 27th 2013

• Layered analysis to explore associations in data, e.g., tease out association between education, knowledge and practice

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Preliminary Results

page 20

page 21

NyanzaN=66 (%)

WesternN=67(%)

Total

Gender Male17 (26) 22 (33) 39 (29)

Female49 (74) 45 (67) 94 (71)

Age 18-2623 (35) 25 (37) 48 (36)

27-4943 (65) 42 (63) 85 (64)

Marital Status

Married52 (79) 54(81) 106 (78)

Separated1(1) 6(9) 7(5)

Single 7(11) 5(7) 12 (9)Widowed

6 (9) 2(3) 8 (8)

IDI demographics

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Nyanzan=66 (%)

Westernn=67(%)

Total N

Gender Male 58 (49) 35 (44) 93 (47)Female 61 (51) 45 (56) 106 (53)

Age 18-26 25 (21) 23 (29) 48 (24)27-49 94 (79) 57 (71) 151 (76)

Education level None 1 (1) 0 (0) 1 (1)

Primary 42 (35) 30 (38) 72 (36)

Secondary 60 (50) 40 (50) 100 (50)

Tertiary 16 (13) 10 (12) 26 (13)

FGD demographics

Presentation of preliminary results

• The following codes were used to present the results– Archetype– Brand association– Knowledge/Sophistication – Beliefs to reinforce– Beliefs to change– Category experience– Openings

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Archetype

Definition: Statements that describe the personality and circumstances of the target audience • demographic facts (gender, age, educational level,

occupation, etc.)• number of nets owned in households including

colour, shape and length.

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Archetype• Number of bed nets owned in households

– Both IDI and FGD average is 2-4. Range from 1 to 6 Average of 2.

• Net preferences: Vary but with a preference for dark colours

• Int: With respect to your family. You said you have four children.– Resp: Yes, I have four children.

• Int: How old is the firstborn?– Resp: Nine years old.

• Int: Boy or girl?– Resp: A boy.

• Int: What of the second born?– Resp: The second born is a girl aged six. The third born is a boy, four and a

half years old. This little one, the fourth, is one month old. (IDI, Female, 23 years, User, Western)

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Acquisition StoriesDefinition:•How respondents received bed nets during the mass net distribution exercise

•Challenges during net distribution • Int: When you said people should be given nets in a proper

way what did you mean by that? Were people given nets in a way that displeased you or in a way that some people were not able to get nets?– Resp4: Yes. There was a lot of struggling to get the nets and some

people ended up not getting the nets. Those who were sick could not get the nets since there was a long queue and a lot of heat. (FGD, Female, 42 years, User, Nyanza)

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Acquisition Stories•Challenges during net distribution • Resp1: When they were going from door to door with the

assistant chief giving out nets, there are people who were not at home but at work so they skipped those houses and so those people ended up without nets. They did not inform people about giving of nets door to door to allow people ask permission from work to stay home and get the nets (FGD, Female, 25 years, User, Nyanza)

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Brand Associations (1)Definition: • Respondent’s emotional attachment to a brand or

behavior. • Respondent’s ideas and attitude about the brand

or behavior as it exists today

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Brand Associations (2)• Protection: Provides a barrier that mosquitoes cannot pass

through. Means that families are safe

• Int: What benefits do people derive from sleeping under a bed net?– Resp9; The net is good because I used to get sick before I started

using the net but now that I do I do not fall sick. (FGD, Male, 33 years, User, Western)

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Brand Associations (3) • Economic benefits: Reduced incidences of illness means

households are able to save and use money for other purposes• Resp 11: Bed nets really improve the economic status of a family

because the family members then do not contract malaria and therefore the money that was previously used to seek treatment are then used for other ventures. (FGD, Male, 44 years, User, Western)

• Confidence: Net use enables individuals to undertake daily duties without fear of being sick. Suggests positive attitudes towards net use

• Resp7: The net gives me strength because I do not fall sick with malaria so am strong and I go about my daily affairs (FGD, Male, 41 years, User, Western)

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Knowledge / Sophistication (1)Definition: • Respondents factual knowledge of how malaria is caused,

susceptible persons and how it can be prevented• Statements by respondents that indicate their ability to

distinguish between desired and competing behaviours

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Knowledge / Sophistication (2)• General knowledge on malaria causation is high:

– Majority report that malaria is caused by mosquitoes whose bites cause infections.

– Malaria described as 'troublesome’, ‘huge burden’, ‘killer disease’ or 'bad thing'.

• Int: Please tell me what you think of malaria. When you hear talk of malaria, what comes to your mind?– Resp: Malaria is just a disease that is spread by mosquitoes. (IDI,

Female, 34 years, User, Nyanza)• Int: Ok, please tell me about malaria.

– Resp: Malaria is a disease which is brought about by mosquitoes. (IDI, Female, 22 years, User, Western)

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Knowledge / Sophistication (3)• Susceptibility to malaria is seen to arise from

– low immunity of children, pregnant women, elderly or those sick e.g., suffering from HIV/AIDS

– non-use of nets thus all persons are vulnerable

• Int: In your viewpoint, who are especially at risk of contracting malaria?– Resp: Anyone who does not sleep under a bed net to

protect themselves.(IDI, Female, 34 years, User, Nyanza)

Resp8: Young children and pregnant women...they should be completely surrounded by the net because their immunity is low and it’s easy for them to get malaria. (FGD, 35 years, Male, User, Western)

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Knowledge / Sophistication (4)• Reported malaria prevention method is use of bed nets• Int: So why do you think that people should sleep under a

bed net?– Resp: To prevent them from contracting malaria. (IDI,

Female, 31 years, User, Western)

• Other prevention methods reported include clearing bushes around houses or use of insecticides, going to hospital when sick

• Int: Methods of preventing malaria?– Resp: One of them is using a net, and around the compound

to remove the dirt where the mosquitoes can hide and remove containers around the compound. (IDI, Male, 26 years, User, Nyanza)

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Category Experience (1)Definition:• Respondent’s past experiences of the desired behaviour• Respondent’s past experiences with competing behaviour

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Category Experience (2)• Experiences facilitating use: responsibility for ensuring

household members sleep under nets• mainly performed by women and sometimes the

husband when the mother is away.• older children also required to ensure siblings sleep

under net• however, participation of men is low

• Int: Who is responsible in making sure that the family is sleeping under a net?– Resp: My wife. She is the one who has the

responsibility to know how the children are sleeping. (IDI, Male, 30 years, User, Western)

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Category Experience (3)• Experiences facilitating use: secondary benefits

• protection from insects such as bed bugs, fleas, and snakes or lizards

• comfort from less or no noise of mosquitoes • Int: Which other reasons make people sleep under a

net?– Resp: It’s important because the net prevents crawling

insects and flying animals as well that are present during the night (IDI, Female, 23 years, User, Western)

– Health concerns • Feelings of suffocation, especially for asthmatics• Skin and eye irritation associated with insecticide

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Category Experience (5)• Technical

• House shape / structure not allow hanging of nets• Rough net texture not liked by some respondents • Not aware of where to dispose nets when damaged /

old• Int: Why do you think they decide not to [use a net]?

– Resp: Some because of the size of their houses. It might be a room that is half the size of this room being occupied by a whole family. So maybe all they do during sleeping time is to have a mat spread for four of their children to share and in that case you can’t fix a bed net over them. (IDI, Female, 31 years, User, Western)

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Beliefs to Reinforce (1)• Definition:

– Statements by respondents that express the benefits of net use.

– Statements by respondents that express positive attitudes towards net use

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Beliefs to Reinforce (2)• Benefits:

– Prevention of malaria infections– Resp: According to what I know, first and foremost bed nets

prevent mosquitoes from attacking and biting those who sleep under them. (IDI, Male, 33 years, User, Nyanza)

– Reduced malaria infections as a result– Resp: Yes, I wanted to explain that the use of bed nets is quite

important. This is because ever since I received some education on the use of bed nets, ten years ago, I have noticed that the malaria incidence in my family has been reduced greatly. That means that even one year may pass before any of my family members’ contracts malaria. (FGD, Male, 40 years, User, Western)

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Beliefs to Reinforce (3) • Other benefits of bed net use

• Economic benefits from lack of malaria infections• Comfort from less noise from mosquitoes (they do

not buzz over one’s head or ears), • Prevention of other pests or animals from harming a

user while in the net

Resp8: When you have a net it reduces your expenditure because mostly people prefer to take their children to private hospitals so that they can be treated quickly and go back home. So if you have a net, children will not get malaria and you will not spend any money on hospital bills, instead the money will be channelled to other uses. (FGD, Male, 32 years, User, Nyanza)

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Beliefs to Change (1)Definition: – Statements by respondents that express cost or

disadvantages of net use– Statements by respondents that express negative

attitudes towards net use

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Beliefs to Change (2)– Seasonal use due to changes in weather

• less use of bed nets associated with lower risk perceptions during hot weather conditions

– Health concerns • Skin irritation from sleeping under a net

• Int: What problems have you heard people complain about when they sleep under a net?– Resp1: The major thing is that these nets have itching

especially when they are new and have just been opened. When it is new it makes some people cough, sneeze and itch. (FGD, Male, 46 years, User, Nyanza)

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Beliefs to Change (2)– Culture

• taboos related to sharing of nets with in-laws • children aged above 10 years are separated into gender -

where nets are few, some do not sleep under nets • Int: you would give her your net to use, mmh, number 2 you are

shaking your head what do you have to say?– Re4: According to our Luhya traditions, what you cover yourself

with you are not allowed to give your mother in law, now if you have one net, it means they will be a scapegoat [sleep without a bed net]. (FGD, Male, 21 years, User, Western)

• Resp1: According to our traditions, when a child reaches 10 years and above, and they are not of the same gender they are not supposed to sleep on the same bed or if one is circumcised he does not share the bed with the rest of the children so I have to look for two nets for the boys and the girls. (FGD, Female, 25 years, User, Nyanza)

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Beliefs to Change (3)– Alternative uses: net use for economic gains

• protect seedbeds, vegetables from chicken, chicken from hawks

• wall decorations or seat covers, bathroom walls• beddings or shower cloths

• Int: Are there other problems associate with using nets?– Resp 1: It was good that we got this aid from outside – the bed

nets, that is. However, people have changed the use of those bed nets to fencing material for chicken pens and vegetable gardens. (FGD, Male, 40 years, User, Western)

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Beliefs to Change (4)– Challenges with net hanging

• Difficulties with hanging square nets

• Int: Ok. He had raised his hand up earlier on. So he will start, then you will follow, then you next.– Resp 9: The four-cornered nets are tedious to tie up,

because it is even hard to fix the ropes that are long enough to the nets on across the room. While trying to tuck the others at the bed corners, you will find that one edge may be higher than the other. (FGD, Male, 35 years, User, Western)

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Beliefs to Change (5)– Myths and misconceptions

• bed nets laced with contraceptives to slow child birth• sleeping in bed nets leads to death• children playing in water, use of dirty water leads to

malaria (transmission of malaria)• Belief that washing the net reduces insecticide

• Int: Ok, he had raised his hand up earlier, before we come to you.

• Resp 6: I’ve heard some say that the bed nets have been laced with family planning chemicals. (FGD, Male, 37 years, User, Western)

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Strategies to Behave (1)Definition: Techniques or tactics that respondents use to overcome barriers to net use (which include enacting desired behaviors and utilizing services)

Three elements are necessary: intent to behave; an obstacle, an action to overcome the obstacle

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Strategies to Behave (2)• Coping mechanisms to overcome

• Health challenges• Interpersonal relations • Structural challenges

• Int: How did you go about solving the problem?– Resp: I changed the nail where I had hung it so that

the net does not come off. The string I had used broke so I decided to make another out of sisal and use it instead. (IDI, Female, 28 years, User, Western)

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Openings (O)Definition: When and where we can reach the respondents.

How we can communicate to them effectively (channels and media preferences)

Who respondents listen to and trust (trusted references)

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Openings (O)• Information sources include: television, radio, newspapers,

advice from health personnel, community health workers, public meetings (Baraza's), children's pays, information from schools through children

• Preferred sources: radio in local languages, interpersonal communication (CHWs), chief's meetings, Churches, school plays (drama shows)

• Int: Who was delivering the lessons? The sub-chief or who?– Resp: Sub-chief taught us...sometimes he would bring…

one time he arranged for a drama...Children were performing a drama and we went to watch. (IDI, Male, 45 years, User, Western)

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Openings (O)• Trusted references: hospital / health workers

• Int: Which method do you think is the best for people to be taught on nets and prevention of malaria?– Resp: Health workers are the ones that teach us on how

things are. (IDI, Female, 26 years, User, Nyanza)

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Observation• Examined places where children sleep to confirm

respondents statements about children's bed net use• Observation also examines difficulties in hanging nets

– Int: ok, I would now like to check your net• Resp: ok, this way

– Int: so you let it down when you come to sleep? • Resp: yes…these are the holes but you see it covers the whole

bed and reaches the floor? – Int: yes

• Resp: and here are where the children sleep, now you can see the difficulty in hanging the net by all the corners here and here and here?

– Int: yes (IDI, Female, 22 years, User, Western)

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Vignette• Based on a hypothetical story - offers FGD respondents

opportunity to engage with topic on a hypothetical basis• Explored decision making processes associated with bed

net use in a household

• Int: What should David put in mind while deciding about the usage of the nets?– Resp1: If he has been given less nets, he should first

consider the children under five years and his wife, then the rest of the children (FGD, Female, 25 years, User, Nyanza)

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Other Findings (1): Willingness to pay for nets

• Data drawn from FGDs – more discussion on prices– In both regions, net prices range from:

• 50/= when purchase from hospital, • 150/= to 800/= in the market; no clear average in either

region– Respondents willing to buy nets at various prices ranging from

as low as 10/= and as high as 150/=– The preferred price was 50/=

• Price of nets bought from the hospital • Price point payable by most village members.

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Other Findings (2): Net preferences• Net shape, length & texture

– Bed net lengths are OK– Round shape preferred by most as easy to hang– Rectangular by some as nets are large but difficulty to find places to

hang– Rough textured nets liked as strong and last long, preferred by men– Soft textured nets easy on skin but not last long, liked by women

• Bed net colours - blue, green and white– White preferred by single women;

• easy to notice when dirty, thought to be smart – Dark colours (blue, green) preferred by persons with children or in

rural areas• Takes long to be dirty, thus long period before washes

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Other Findings (3): Decision making in households• Women reported to be main decision maker

• Can discuss with men but this not reported by many

• At times, person bringing net (man) can decide but daily use is woman

• Decisions for net use based on• Expectation of not getting malaria infections in

households• Vulnerability of children under five to malaria

• Linked to responsibility of net use in households

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Other Findings: Regional Differences• Myths and misconceptions

– Incorrect knowledge similar in both sites (cold weather, dirty water or dirty food causes malaria)

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Interpretation

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Interpretation

1. Inconsistency of bed net use– Low risk perception in hot season (fewer mosquitoes)– Absence of caregivers– Disruption in sleeping patterns (visitors , esp. in-laws)

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Users (N=124) Non-Users

Consistent users

67

Inconsistent users

579

Further analyses of users by education and age

• Education does not account for any differences in informants knowledge and practices

• Incorrect knowledge and practices reported in both primary and secondary level groups

• Age also does not explain any differences in incorrect knowledge and practices reported in both groups

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Interpretation (2)2. Net care

– Information on what to do before initial use– Fear that net washing reduces insecticide potency

3. Misinformation and misconceptions– Incorrect knowledge on malaria transmission

4. Disposal of nets– Uncertainty over what to do with previously owned nets after

getting mass distributed nets

5. Female involvement in bed net use– Women were key in ensuring people sleep under nets

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Interpretation (3)6. Overcoming challenges with net use

– Trusted references (i.e. CHWs, friends) seen to be a critical mechanism in overcoming issues with net hanging

– Coping with health issues done by visiting health facilities or talking to peers

7. Openings for communication – Trusted sources are hospitals / health care workers, CHWs– Radio in local language

8. The preferred price was 50/=

- Price of nets bought from the hospital

- Price point payable by most village members

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Interpretation (3)9. Net preferences

– Length: ok as is– Shape: Round shape preferred by most as easy to hang– Texture: Rough textured nets preferred by men, soft textured

nets preferred by women– Color: Dark especially for rural

10. Regional differences

- No regional differences in any of the issues discussed.

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Recommendation for Communication

• Behaviour change communication will focus on;

• Seasonality- you are at risk even during the dry season- will be addressed by regional radio and interpersonal activities (at the community, ANC visits, through health workers etc).

• Net care at the interpersonal level• Myths and misconceptions- at the interpersonal level

• The approach to risk will be different from before and will be about “going back to the basics” to change this strongly held belief that you cannot get Malaria during the dry season. The approach will be more “factual”.

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Next plan of Action

• Develop a communication campaign around this factors – with DOMC, partners and DHP

• Pretest the concepts before full production• Placement of campaign with focus on Malarious

areas• Routine monitoring and evaluation of the campaign

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Acknowledgements

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Discussion

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