Outline of the presentation

1. Qualitative Study on Barriers to Net Use among Most at Risk Populations in KenyaResultsApril 18th 2013

2. Outline of the presentation • Background • Study design and methods • Preliminary Results • Interpretation • Discussion

3. Background

4. 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.

5. 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

6. 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

7. 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.

8. 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.

9. Study Design and Methods

10. 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

11. 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.

12. 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

13. 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

14. 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

15. Study sites Blue – Rural; Red-Urban

16. 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

17. 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

18. 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

19. 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

20. Preliminary Results

21. IDI demographics

22. FGD demographics

23. 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

24. 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.

25. 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)

26. Acquisition Stories Definition: • 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)

27. 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)

28. 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

29. 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)

30. 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)

31. 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

32. 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)

33. 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)

34. 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)

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

36. 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)

37. 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

38. 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)

39. 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

40. 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)

41. 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)

42. 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

43. 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)

44. 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)

45. 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)

46. 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)

47. 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)

48. 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

49. 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)

50. 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)