A survey of knowledge, attitudes and practices regarding malaria and bed nets on Bubaque Island, Guinea-Bissau

Malaria remains a significant public health issue in Guinea-Bissau, West Africa [1]. Whilst it is well-characterized in the capital, Bissau [2], published data from elsewhere in the country are scarce. Rural communities are known to hold different beliefs about malaria and typically exhibit a higher disease burden [3‐9]. The Bijagos Archipelago, lying off the Atlantic coast, consists of 88 islands and islets, approximately 20 of which are inhabited by small permanent and semi-permanent populations living predominantly in forest villages supported by subsistence agriculture. The islands’ isolation presents significant challenges to healthcare provision, with no recent published epidemiological data to guide programmatic activities.

Government malaria control measures include enhanced case finding, intermittent preventive treatment in pregnancy (IPTp) and free triennial long-lasting insecticidal net (LLIN) distribution nationwide, most recently in May 2017. This latter intervention is at the core of national malaria control: it is employed across Guinea-Bissau, targets every citizen and significantly reduces malaria prevalence in other settings [10]. Distribution campaigns aim for universal coverage, for which there is greater evidence of efficacy than for previous targets of only pregnant women and children under five [11‐15]. Campaigns are centrally organized and supplied, but implemented by voluntary local health workers within their communities. They aim to distribute one net per two people and provide basic information about malaria and bed nets, including their importance and correct use. Free nets are also supplied at antenatal clinic appointments. Optimizing net delivery has been shown to improve ownership and be important in malaria control [14]. Net ownership and usage behaviour are currently undescribed in these communities.

Understanding of malaria is variable across sub-Saharan African populations [9, 16, 17] but no studies specifically examining Guinea-Bissau have been published since 1994. Other West African studies suggest good net uptake and that use persists, despite inconvenience, due to generally good understanding of their role in health [12, 13, 15, 18]. Observations point to bed nets being highly valued and frequently repaired, retreated or replaced by users [18, 19]. The impact of LLIN distribution has been evaluated in Bissau, suggesting a partial effect on an already falling prevalence [1, 2], and in rural areas of neighbouring Senegal, where it was associated with a dramatic reduction in malaria [11‐13, 15, 20].

Despite their importance to public health there is a paucity of information on the knowledge, attitudes and practices relating to malaria and bed nets in rural Guinea-Bissau, including the Bijagos Archipelago. The geographical and socio-cultural isolation of the islands make them an interesting study site, and given the central role LLIN play in Guinea-Bissau’s malaria control programme, understanding their current status and use could have a profound impact on improving control of this important disease.

The socio-demographic characteristics of the 100 household heads participating in the survey are shown in Table 1. The mean age was 37.2 years (standard deviation = 14.4), 57.0% were female and 78.0% had at least a primary education. The average household contained 6.8 people; 67.0% of households contained a child aged under 5 years, 16.0% contained a pregnant woman and 64.0% were in rural villages. One village had migrated to another island for farming and contributed no participants, however all other villages were included, covering the length of the island.

Socio-economic status was approximated using a novel simplified score based on ownership of 10 locally relevant items, weighted by luxury, with a maximum value of 19 (Appendix 1): the median was 3.5 (interquartile range 3.0–5.0, range 1–13). Education was considered separately [26, 27].

Awareness and knowledge of malaria was high in this study population. Individuals displayed knowledge encompassing transmission, prevention and risk groups, suggesting a broad comprehension of malaria and the success of education efforts; 72.0% of participants felt well informed but there remains room for improvement, especially as younger participants felt less informed. This may be related to knowledge, experience or awareness of their limitations.

Although infrequently listed as a source of information, contact with distribution campaigns was associated with feeling well informed. This supports their future use as education platforms. Their potential could be significant given campaign household coverage of 80.0% and participants’ stated preference for receiving information from healthcare sources. Given the limited resources of the local health system, distribution campaigns constitute an important additional contact opportunity [28]. Radio is highlighted as a popular and accessible alternative whilst school programmes, effective elsewhere [29‐32], could increase the small numbers currently reporting learning about malaria in school here.

Population perceptions of malaria as a severe problem suggest an appetite for education and preventive interventions. Human and financial loss, the primary drivers of this perception, could be targeted during education to reinforce its importance. The complexity or breadth of information provided could also be expanded given participants’ strong baseline understanding, perhaps challenging specific misconceptions around net safety or seasonal use.

Eighty per cent of pregnancies correctly received IPTp; as IPTp adherence was associated with correct net use and belief in their safety, improving this figure may yield significant benefits. However, the potential role of variable education between households as a confounder for these effects requires further evaluation. It was striking that Bruce village had twice the average adherence of other villages. Awareness of the programme and local promotion are both known to improve uptake [33, 34], suggesting positive work by community health workers; alternatively Bruce’s size and association with a small hotel may improve its access to transport for healthcare. Applying these to other communities may improve uptake.

LLIN ownership was universal and very few residents were reported sleeping without them, which is exceptional for the region [35‐38]. All participants believed nets were effective at preventing malaria and > 95.0% believed they were safe for pregnant women and children. Non-users were so few that characteristics for targeted interventions could not be identified. However, only 77.2% of label-identifiable nets were in-date, meaning the true figure is likely lower, and correct use stood at only 35.0%, with intra-household variability; 2.07 users per net is also slightly in excess of targets and occupants are more likely to sleep against the net, reducing efficacy [39]. The incorrect use and damage, including frequent washing, of bed nets reduces their effectiveness, contributing to the ongoing circulation of malaria in this community [40]. Only 48.0% of households felt they had sufficient nets for their needs and 94.0% desired more frequent replacements. While education may raise awareness, improved access to quality nets is ultimately needed.

As participants are reluctant and often unable to purchase nets, replacement must be government-driven. WHO/Global Malaria Programme recommend comprehensively resourced triennial distribution campaigns with trained and motivated staff as the only proven cost-effective method to achieve this, with continuous supplementary distribution from antenatal clinics and immunisation programmes [41]. Top-up campaigns are not recommended. An ideal campaign would reach every household, distribute one net per 1.8 people and provide information aimed at eliminating misconceptions and increasing correct net use to 100% year-round. A thorough census is key to a successful delivery programme [14].

Given malaria’s continued presence despite the notably high bed net coverage, it can be concluded that distribution campaigns, the cornerstone of malaria control in Guinea-Bissau, are insufficient to eliminate malaria. New techniques will be required to supplement these if elimination is to be achieved. Further research is required to identify locally appropriate methods, perhaps improving IPTp access or vector control. A summary of recommendations is given in Table 6.

Bed nets were clearly valued; participants described conscientious maintenance behaviour, nets were used long past expiration and frequently showed signs of repair, although retreatment was unpopular. Teaching and providing repair supplies were used effectively in Senegal [18, 19] and could feasibly be applied here if net distribution proves inadequate. Improving awareness of, and access to, antenatal clinic net distribution may improve household access to nets, IPTp and antenatal care. Opportunistic malaria advice can also be given, as in Nigeria [42], satisfying local preference for replacing nets and receiving malaria information via healthcare sources. Providing free nets is especially important to Bubaque’s poorer families which had fewer nets per person, and evidence from elsewhere in Africa suggests a complex bidirectional relationship between malaria and poverty [27, 43, 44].

Whilst net repurposing was rarely reported by participants, it was a visible problem. Observational or qualitative studies could quantify this and illuminate underlying reasons. Behaviour change and convincing populations of their greater value as healthcare tools are required, especially as malaria’s falling prevalence reduces its visibility [1]. Health-seeking, malaria prevention and net-replacement behaviour are heavily influenced by financial impact in this low-resource population: reducing healthcare costs will be an important mechanism in reducing malaria.

There are several limitations to this work. Social acceptability bias is likely given that researchers were healthcare workers, but was mitigated by observing net practices and training assistants in interview technique (to also reduce interviewer bias). Collecting data during the rainy season, when malaria is more visible, may produce biased results. At this time, three villages migrate to another island for farming, therefore contributing fewer/no participants; a comparative dry season survey would limit both issues. Rural and smaller communities were over-represented and differences with Praça may be hidden by type 2 error, but including every village was deemed desirable as behaviour might reasonably cluster within communities and this was accounted for by using a design effect in the sample size calculation. Increasing the sample by including remaining bairros or other islands may reduce this error. Due to being a cross-sectional study, the unemployed, farmers or those lacking the resources to travel may be over-represented relative to economic migrant workers, however attitudes and practices transpired to be reasonably homogenous across socio-economic groups. Improved telecommunications may capture more household heads. Lastly, given the islands’ isolated and distinct nature, generalisability may be limited to the Bijagos: work on other islands and the mainland may be required to assess this due to a paucity of data, but results seem markedly different to surveys in nearby Guinea-Conakry and Sierra Leone [38, 45].

The ultimate aim of this work was to improve the delivery of malaria control measures in these communities. To this end, an executive summary will be produced in Portuguese and English, and forwarded to the regional health office, the Bissau-Guinean public health institute and the malaria control office at the Ministry of Health, alongside this paper. Meetings will be held in-person with these stakeholders at the earliest opportunity, and results presented at the Bandim Health Project research meeting in Bissau. Results have been discussed at a meeting with field assistants and community healthcare workers, who were asked to share the outcomes with their communities. Consideration will be given to the feasibility of a local radio broadcast by HH and ETdS to discuss the results and improve awareness.

This is the first study to examine knowledge, attitudes and practices towards malaria and bed nets in Guinea-Bissau. Knowledge of malaria is good in these communities and it is an important local concern due to its health and economic impact. LLINs are widely used and highly valued, however their quality and use could be improved. Properly resourced bed net distribution campaigns might provide a solution through both net provision and education, making them an exciting potential component of future malaria control programmes, acknowledging that with such high existing coverage and the difficulty of effecting behaviour change, additional measures will be required to eliminate malaria from the Bijagos Archipelago.