Advantages and disadvantages at 6 months
The two FGDs at 6 months post-distribution were conducted only with women, because they reported that they were the ones in charge of managing their homes and making decisions regarding whether to and where to hang ITCs. Participants liked the ITCs because they saw them working instantly: “They work well: you could see all kinds of dead insects at the bottom of the ITCs, even cockroaches and spiders….” The enthusiasm among all participants was clear. However, very early on in the discussion of both FGDs, one participant mentioned, “They worked well for a few months, but then they stopped working. You could see dead insects on the floor of your house when we first placed the ITCs, but then after a few months, you didn’t see any dead insects any more…” Once one woman raised the issue, all the other participants agreed; this happened independently in both FGDs, resulting in the women reporting that the ITCs were effective, but only for 2–6 months after the initial distribution. As a result of the ITCs’ initial effectiveness, the participants commented that they decreased use of other mosquito repellents, no longer had to use bed nets at night because there were fewer mosquitoes in the home, or stopped fumigating: “After 2 months they came to fumigate and I didn’t allow them to because it was no longer necessary…because I had the curtains.”
The participants perceived the ITCs to be
“beautiful” and noted that they would continue to hang the ITCs in their homes for decorative value, even if they were no longer effective at controlling mosquitoes. Some participants reported that family and friends were envious of the ITCs and asked if they could borrow the ITCs. One participant told of loaning her ITCs to a relative organizing a birthday party for her child in order to beautify her home. The ITCs were also reported to provide additional privacy in the home, particularly as a “
separator between beds, it gives privacy.” At this point in time, most ITCs did not require mending (only six had been mended, albeit 5.5 % (159) of the ITCs were observed by our research team to be in poor state [
20]) and participants reported that all colors of the ITCs were working equally well at controlling mosquitoes. There were also placement preferences based on ITC colors and how these were perceived: the pink ITCs were considered more “
elegant” by FGD participants and were selected for placement in locations such as their living rooms, whereas the dark blue ITCs were harder to see through and, hence, selected for locations where the participants might want more privacy, such as bathroom or bedroom doors.
Similar to the findings from surveys, there were few ‘dislikes’ reported. The main problems included that the ITCs were initially itchy or stingy on the skin because of the insecticide (but that itchy feeling had disappeared after the first week), that the ITCs could not be moved once placed because the study team told them not to move the ITCs, and that the ITCs got dirty quickly and could not be washed quickly enough to keep clean: “Both colors (pink and blue) get equally dirty -- they get dirty quickly.”
All participants stated they used the ITCs in the way they were expected to (i.e., left hanging loosely), but in every group several women mentioned tying up the ITCs during certain times of the day to avoid physical contact with the ITCs, particularly if the ITCs were hung in the door or passageway. One mentioned, for example,“I have to tie it up during the day because it bothers the clients who come to my house for my photocopy business” (the ITC is near the machine). She would then let it hang loosely again in the evening and overnight. Some felt that the wear and tear on some ITCs was high due to all the movement in certain locations of their home.
The FGD participants also noted creative uses for the ITCs, which were not consistent with the study instructions. For example, multiple participants reported turning the ITC into a bed net to sleep under (either for themselves or children): “it is safer as a mosquito net – it is better because it protects more at night”. One participant took her ITCs back and forth with her to her farm on the outskirts of Iquitos because she wanted the protection of the ITCs while at her farm.
Information arising from this set of FGDs regarding a perceived drop in the effectiveness of the ITCs led to an increase in the number of curtains that were tested for insecticide bioefficacy between 6–12 months post-distribution. These FGD data were the first indication that the ITCs were not functioning as expected, and indeed bioefficacy testing corroborated the FGD data. As a result, all ITCs were collected after 12 months of distribution and were re-treated with insecticide, and then returned to the houses.
Advantages and disadvantages at 12 months
A further three FGDs were conducted with female participants 12 months post-ITC distribution. These FGDs aimed to understand how the ITCs were functioning immediately after the re-treatment with insecticide. All of the FGDs reported the ITCs worked best in the first few months of use, when they came from the manufacturer; however, all re-treated ITCs worked better than they had prior to re-treatment.
The comments about how the ITCs worked after re-treatment were different than the comments in the first set of focus groups. At 12 months, the participants noted that “the amount of mosquitoes only went down the first time,” but they did not notice a drop in mosquitoes after the second re-treatment. Mosquitoes were reported as being stuck to the ITCs after re-treatment, though they were still alive on the ITCs rather than being dead like when the ITCs were new. The participants also commented that the ITCs had a strong smell and burned the skin after re-treatment. There were also complaints about the re-treatment process, because it required study personnel to come repeatedly to the house; it would have been preferable if study personnel had arranged set appointments to pick up their curtains for re-treatment.
When asked if they would rather have future ITC re-treatments performed inside or outside the home (i.e., rather than removing ITCs and re-treating them off-site, have a research team member re-treat the ITCs at the participants’ homes), there were mixed responses. Some participants preferred that it occurred outside the home due to the believed toxicity of the insecticide and the desire to protect their families’ health. Others wanted the treatments to be done inside “so I can see how it’s done and do it myself one day.”
Other comments during the FGDs highlighted the fact that the ITCs had come to be valued by the participants as a means to protect against dengue. They reported that fear of dengue was a motivator for hanging the ITCs correctly, “I’m more attentive to using [the ITC] after the second re-treatment, in case of a dengue outbreak.” Though others noted that they still had to pull the ITCs aside during the day due to fear of allergies and to allow transit in their homes.
One-on-one interviews
One-on-one interviews were only conducted with participants who had rejected or returned their ITCs. The reasons for returning their ITCs were similar to those disadvantages listed during the FGDs. The main concerns were allergic reactions, inconvenience of the study staff coming to re-treat the ITCs, and the ITCs’ loss of effectiveness.
Four of 11 interviewees reported allergic skin reactions as the reason for rejection. For example, one interviewee reported that she loved having the ITCs in her home because they were pretty and there were less mosquitoes, but that her two young grandchildren had many allergies and their skin became irritated when they walked by the ITCs. She would have liked to keep the ITCs, but felt that she had no option but to return them because of the allergic reaction of her grandchildren.
Another interviewee mentioned that she had turned the ITC into a bed net for her baby and did not want the study staff re-treating it because she feared that the insecticide would give the child an allergic reaction. Three interviewees mentioned being inconvenienced by study personnel constantly coming to the door for follow-up visits and re-treatment of the ITCs, as well as the short term effectiveness of the ITCs.
Five interviewees reported that the ITCs were no longer effective. One interviewee reported that the ITCs were not effective even after the re-treatment and that there were many more mosquitoes in her home now. Another interviewee reported that the ITCs had to be tied up all day due to their location in the hallway and she concluded that they were not working well enough for her to keep them.