ITPS acceptability – follow-up survey findings
Five (5/40) participants reported experiencing some concerns about having the ITPS installation team enter their home. Reported concerns included embarrassment about current living situation (n=3), anxiety about the possible side effects of ITPS (n=2), and apprehension at not being present when the installation team was in the home (n=1).
All participants (40/40) reported a perceived reduction in the number of mosquitoes in and around the house and a reduction in the number of mosquito bites following ITPS installation. Thirty-nine participants (39/40) reported a reduction in other insect species and 11/40 participants reported a reduction in rodents.
Three participants reported that one or more household members experienced ill health after the installation. One of these participants explicitly stated the illness was not related to the installation, another reported that a number of family members experienced flu-like symptoms, and one participant reported another family member having experienced a malaria episode.
Twenty-five participants reported a perceived change in the inside temperature following ITPS installation. In 19/25 cases the perceived change was an increase in temperature and in 6/25 cases a decrease in temperature (n-b, 12 of the 19 participants that reported an increase in temperature were from the cooler highlands region, where the temperature increase was considered a positive side effect). Twenty-one participants reported that the room was darker following ITPS installation and a further 15 reported an unusual smell following ITPS installation. The smell was typically described as that of insecticide and in all cases was reported as no longer perceptible at the time of follow-up interview.
Thirty participants reported that they liked the blue colour of the ITPS material; 10 did not. A range of colour preferences was identified, although the most frequently expressed preferences were for blue (n=20) or lighter ‘bright’ colours (n=8). The most frequently expressed least preferred colours were ‘dark’ colours as they would darken the room (n=17) or white or ‘light’ colours (n=9) as they would more readily reveal dirt or dust. No participant suggested a colour that would be either favourable or unfavourable for customary or cultural reasons.
Thirty-four participants reported that the ITPS material enhanced the aesthetics of their home in some way. Thirty-seven participants reported that one or more visitors had witnessed the ITPS installation; all reported that the visitors considered it favourably. All participants opted to retain the ITPS installation at the four-week follow-up.
ITPS acceptability – group interview findings
Analysis of the GI transcripts indicated high acceptability of the ITPS product amongst all participants, across all study sites. The high acceptability was seemingly influenced by five key factors. Firstly, many GI participants reported observing insects dying during, or immediately following, ITPS installation.
"‘The first day after [ITPS] installation I saw mosquitoes flying into the house, contact the material and then just fall off and die. The cockroaches climbed up the [ITPS covered] wall and died instantly.’ (Lowlands village, installation GI, male)."
Witnessing the ITPS working so quickly and effectively led to the early formation of a positive impression, as did the apparent repellent effect of ITPS on larger pests such as rats and mice. Secondly, the observed impact of ITPS on mosquitoes and other insects translated into better nights’ sleep as a result of the reduction in mosquito nuisance, further enhancing the positive impression formed:
"
‘I do not see any more cockroaches, rats or ants inside my house…
w
e are now sleeping peacefully inside the room.’
"
"(Islands village, follow-up GI, female)."
Thirdly, the initial effectiveness of the ITPS was sustained over the four week period,whilst the anticipated ‘risks’ (discussed in detail below) failed to materialize.
"‘
The [ITPS] is still effective because the insects just disappear…the insects just inhale the smell and became unconscious.’
"
"(Highlands urban, follow-up GI, male),"
The fourth key influence on ITPS acceptability pertained to the product aesthetics, rather than its function as an insecticidal intervention. Most participants felt that the blue ITPS material enhanced the internal appearance of their home as exemplified in the following excerpt:
"‘When I opened the door and went into the house it looked a lot different [following ITPS installation]. My house looked beautiful and was glowing.’"
"(Highlands urban, installation GI, male)."
Many participants also noted that the ITPS acted as an additional building material by blocking holes in the existing walls, reducing draughts, noise levels and the amount of dust entering the home. Finally, the high acceptability of the ITPS product among study participants was seemingly influenced by a level of prestige associated with ‘owning’ a new and largely unavailable (to non-study participants) malaria control intervention. This prestige value was perhaps most evident when GI participants discussed the reactions of non-household members to the ITPS product, which were invariably positive and suggestive of a degree of envy. For example,
"‘One of my sisters came and saw the durable lining sheets and liked it and said she wished she could have got one like this too.’"
"(Islands village, installation GI, female)."
Whilst all five of the aforementioned factors contributed to the high acceptability of ITPS among GI participants, the primary influence on acceptability was the observed effectiveness of the insecticidal properties of the ITPS and the protection this confers against malaria and other vector-borne disease. This is perhaps best exemplified in the following quote:
"‘We do not want to be sick with malaria. If the kids are sick, we will struggle to walk a long way to go to the hospital. We do not want this to happen. This plastic sheeting will help protect us and our children from getting sick with malaria.’"
"(Lowlands village, follow-up GI, male)."
No GI participant expressed dissatisfaction with the ITPS installation at the four-week follow-up. However, a number of issues emerged that warrant consideration for future ITPS trials in PNG or elsewhere. Firstly, a number of participants expressed concerns about the ITPS product at the time of installation and a smaller number expressed concerns about the installation process itself. The primary concern was the possibility of side effects from the insecticide used in the ITPS product, especially among small children:
"‘I have a small child and I was worried that the insecticide on the durable lining sheet might have a bad effect on my child.’"
"(Islands village, installation GI, female)."
Other expressed concerns included the potential flammability of the product, the appearance of the product and the possibility of theft (by the installation team) during the installation process. Whilst the perceived risks had not materialised at the four-week follow-up and the concerns regarding installation did not prevent installation, the presence of such concerns pose a potential threat to ITPS acceptability and/or utilisation if not properly managed.
As previously noted, the ITPS product sustained no damage in most study homes during the four-week trial period and the installation remained securely fastened in all homes. Nevertheless, many participants perceived the product to be relatively fragile and expressed some concern about its potential longevity over an extended period of time:
"‘The material is not strong. It is just made of plastic.’"
"(Highlands urban, follow-up GI, female)."
A number of participants even reported taking specific precautions to avoid damaging the product,
"‘When the children go inside the house I always shout to them [reminding them not to touch the ITPS material], they might forget and pull it and then it will get loose.’"
"(Lowlands village, installation GI, female)."
These precautions are unlikely to be maintained over time, especially as the material starts to discolour, degrade or lose its perceived effectiveness.
Mosquito net use prior to ITPS installation was variable in all study sites, with many participants reporting little or inconsistent use. The ITPS product reportedly reduced mosquito net use even further as exemplified by the following quote:
"‘I only used the mosquito net when I see a lot of mosquitoes around. After the installation of the plastic sheeting I do not bother to use the net anymore.’ (Islands village, follow-up GI, female)."
Similar instances of reducing or ceasing mosquito net use as a result of a perceived reduction in mosquito numbers following ITPS installation were reported across all study sites. Many participants considered the ITPS to be a superior malaria control intervention compared to mosquito nets and this perception further contributed to the subsequent reduction in net use:
"‘They have distributed [long-lasting insecticide treated] mosquito nets and informed us that it will kill the mosquitoes, but we could still see the mosquitoes flying and buzzing around. When using the plastic sheeting we could practically see the mosquitoes and other small insects falling to their death.’"
"(Highlands village, follow-up GI, female)."