Fifteen FGDs were conducted in six villages; five with male ITN owners, one with female ITN-owners, five with male non-owners, and four with female non-owners. Eighty-two men and approximately 40 women participated. Rank-ordering and pile-sorting exercises were successfully completed in men's but not women's FGDs owing to moderator inexperience; thus pile-sorting and ranking analysis is restricted to data from men's FGDs.
Thirty in-depth interviews were conducted in eight districts; eight with men and six with women from ITN-owning households, and seven with men and eight with women from non-owning households. Most women chose to be interviewed with female relatives or friends present, due to the absence of a female interpreter. Seven key informant interviews, completed with health-related workers (i.e. three doctors, one laboratory technician, one traditional healer, and two ITN implementers), were analysed separately.
Two-hundred ITN-owning and 214 non-owning households completed survey interviews. The response rate was 95%, with non-participation reported as due to ongoing poppy harvesting. All but five household heads were male, and only 48 (11.6%) respondents were female. Most self-identified as Pashtun, while 36% in Bihsood district were of Tajik ethnicity. Half of households (58%) relied on agriculture. Main crops were wheat, opium poppy, corn, and cotton. Most (83%) came to the area in 1993, when security improved in eastern Afghanistan.
Knowledge and reported behaviour
Interview, survey, and remaining FGD results are reported under key themes: malaria knowledge and perceptions; malaria prevention and treatment; ITN knowledge and perceptions; reported ITN purchasing; reported ITN coverage and usage; and health-related workers' perceptions.
Malaria knowledge and perceptions
There appeared to be little difference in knowledge of malaria transmission between genders or between ITN owners and non-owners. Table
1 shows approximately 75% of survey respondents said mosquitoes caused malaria, though 19% said it was caused by water. Unsurprisingly, participants could not distinguish between vector and nuisance mosquitoes.
Table 1
Percentage reported malaria knowledge and practices, comparing ITN-owning to non-owning households
What causes malaria?
| | |
Mosquitoes | 77 | 73 |
Water | 18 | 20 |
Other/Don't know | 6 | 8 |
Where do mosquitoes breed?
| | |
Water | 58 | 69 |
Grass | 23 | 20 |
Other/Don't know | 19 | 12 |
Malaria season
| | |
Summer | 46 | 40 |
Spring/Summer | 33 | 39 |
Autumn | 11 | 11 |
Other/All | 10 | 10 |
Who is at most risk from malaria?
| | |
Children | 50 | 48 |
Women and children | 25 | 19 |
Everyone | 21 | 17 |
Pregnant women and under-fives* | 1 | 10 |
Women | 3 | 4 |
Aged | 1 | 2 |
What is the best malaria protection?*
| | |
ITNs | 74 | 86 |
IRS | 12 | 7 |
Other (e.g. electric fans) | 7 | 5 |
Traditional | 3 | 1 |
Don't know | 4 | 1 |
What current malaria protection do you use?*
1
| | |
ITNs | 4 | 95 |
Other (e.g. smoke, chadors) | 92 | 1 |
Insecticide spray | 4 | 3 |
Traditional | 0 | 1 |
Who in your household was seriously ill this year?
| | |
All | 57 | 54 |
Children | 35 | 32 |
None | 4 | 8 |
Aged | 3 | 3 |
Women | 1 | 3 |
What is the best treatment for malaria?*
| | |
Chloroquine | 68 | 79 |
Don't know | 21 | 11 |
Traditional/Other | 7 | 7 |
Paracetamol | 4 | 3 |
Who makes treatment-seeking decisions?
| | |
Household head | 92 | 90 |
Other | 8 | 10 |
Where do you go for malaria treatment?
| | |
Get treatment at NGO clinic | 42 | 48 |
Private doctor (unregulated) | 35 | 24 |
Other/Combination | 22 | 28 |
Private drug seller (unregulated) | 2 | 1 |
Average reported costs for malaria treatment
2
|
(US$08)
|
(US$08)
|
Adult visit | 0.58 | 0.44 |
Adult drugs | 8.19 | 5.98 |
Child visit | 0.56 | 0.42 |
Child drugs | 5.25 | 3.89 |
Average costs per ITN
2
|
(US$08)
|
(US$08)
|
ITN (insecticide added at point-of-purchase) | 6.50 | 6.50 |
ITN retreatment (annual) | 0.07 | 0.07 |
"When mosquitoes bite healthy people they catch malaria." (Female non-owner, Ghazgay, Muhmand-Dara)
Approximately one-third of interviewees suggested mosquito bites were only one way of catching malaria with the main contributor reported as drinking dirty water. Most survey respondents (64%) knew that mosquitoes breed in water, but most participants did not know how mosquitoes transmit malaria, often describing faecal-oral routes (e.g. mosquitoes breed in dirty water and garbage, and this dirt infects people when they are bitten).
"Malaria is caused by mosquitoes who get parasites from dirty water" (Male ITN owner, Muhmand-Dara)
Another belief reported in each district was that malaria, if it continues or increases in severity, becomes moriqa (typhoid).
"Malaria comes from mosquitoes and dirty water. Mosquitoes breed in dirty ponds, cow dung and refuse. malaria becomes typhoid if it is not cured" (Male non-owner, Bati Kote)
"The clinic doctors told us typhoid is from malaria." (Female ITN owner, Ghani Khel, Shinwar)
Participants reported that malaria was a serious illness. In interviews, researchers attempted to estimate its perceived importance by asking participants the three greatest health concerns in their community. The top three concerns reported were diarrhoea, 'maternal problems,' and tuberculosis.
While not directly related to this research, it is interesting that as early as 2000, maternal ill health was reported as a major concern by both genders in all districts. It was described as a particular concern due to female travel restrictions, and lack of female health staff or culturally acceptable facilities. Several women mentioned the lack of confidential contraception as their main health concern.
"It's not appropriate for our women to give birth publicly in the clinic. Many women have serious problems during childbirth. We can't afford when the lady doctor comes to the house and anyway she usually doesn't because she can't come alone. There is no one around who knows how to birth the baby properly and so many die."(Male non-owner, Bati Kote)
Health messages, aimed at men for cultural reasons, did appear to reach women. Women interviewees reported getting most of their health and ITN information from clinics, their husbands, or most commonly from each other.
"When one of us learns something, then she tells it to the others." (Female non-owner, Shinwar)
"Our husbands don't let us listen to radio because it uses up the batteries. We are encouraged to listen to religious programmes. I learned about ITNs from my husband and the clinic doctors." (Female ITN owner, Nazyan)
Malaria prevention and treatment
Eighty percent of survey respondents said ITNs were the best means of malaria prevention. Interviewees reported that other common forms of protection against mosquitoes were burning grass, rubbing lamp or motor oil on the skin, and sleeping wrapped in wet chadors (traditional outer garments).
"Preventive measures are good against malaria, but there are no effective ones; sprays wash off, ITNs only protect part of the time. Burning straw is very effective against mosquitoes, but there is some problem with coughing and TB. Electricity is better because we can use fans." (Female non-owner, Shinwar)
Many participants said previous government IRS campaigns had been very effective against mosquitoes, though only 9% of survey respondents considered IRS to be the best means of malaria prevention. These IRS campaigns were generally described as intrusive, but most said they favoured a return to spraying. IRS provision had been free and sprayers reportedly paid for information on households with malaria cases. Now households needed to spend their own money on ITNs.
"We are talking about 20 years ago when the government authorities were spraying houses by force. We didn't know the benefits of spraying and now we know how effective it was!" (Male ITN owner, Pakhail, Achin)
"Spraying should be done by the government, because if we spray individually or have ITNs, mosquitoes will keep coming from our neighbours' houses." (Female non-owner, Bihsood)
Most participants, including 73% of survey respondents, named chloroquine as the best treatment for malaria. Some interviewees, though only 7% of survey respondents, favoured traditional treatments The main reason reported was cost, though a minor percentage were concerned about safety (e.g. for pregnant women). Traditional treatments included cooling drinks, such as dogh or lassie (from yoghurt), or various plants, the most common of which was a tea from shamaki roots. Shamaki is a Pashtu term for a plant used locally in traditional medicine, said by some respondents to contain quinine.
"We usually resort to traditional treatment rather than clinical treatment unless the traditional treatment doesn't work. It is due to poverty and people can't afford to cover doctor's and transportation costs." (Male ITN owner, Gharzay, Muhmand-Dara)
Some interviewees said they would only buy half the recommended tablets to reduce treatment costs, while others reported they could be treated on credit.
"...sometimes we borrow from doctors for treating our patient. For instance, doctors in the clinic treat our patient and we will pay them later in the harvest time or as soon as we get cash. The other way is to pay them with wheat or corn." (Male non-owner, Gharzay, Muhmand-Dara)
While participants agreed it was less costly to prevent than to treat malaria, emergency funds for treatment could be borrowed from relatives or neighbours, while funds for protective goods, such as ITNs, could not be readily mobilised.
"I saved money for four years to buy ITNs. I can borrow money from my neighbours and relatives to pay for treatment, but they're not willing to lend for something like a bednet." (Widow, ITN owner, Bihsood)
ITN knowledge and perceptions
All participants could accurately describe ITNs and how they should be used. Authors found no differences between genders or ITN-owners and non-owners in recall of health messages about the benefits of sleeping under ITNs.
"Using ITNs has two benefits. One is that it protects you from malaria and the second is that you sleep well." (Male non-owner, Achin)
"We need ITNs for protection against malaria, not for having fun!" (Male non-owner, Achin)
While ITNs were frequently mentioned as playing an important role in the prevention of both nuisance biting and malaria, some participants said they did not want to make the initial investment.
"Malaria is not something that much can be done about, just to endure. ITNs are out of reach and not useful enough to buy." (Male non-owner, Shinwar)
Participants in a women's FGD, asked their views on possible inclusion of ITNs as part of a dowry, responded with laughter. As this differed from men's pile-sorting and ranking results, it indicates that either women valued ITNs less than did men or that ITNs were affordable for many households and thus not of sufficient monetary value to feature in a dowry.
"That is totally absurd! How should we let this stupid boy get married with our daughters by providing us with nets rather than paying?" (Female non-owner, Meydanak, Achin)
"We work hard to bring up our daughter and then to give her for ITNs? It is an absolutely silly thing to do! We are not stupid." (Female non-owner, Meydanak, Achin)
Reported ITN purchasing
Table
2 shows 84% of survey respondents said they were planning to buy ITNs. While 57% wanted them to reduce mosquito nuisance, 38% wanted them for malaria protection. Of those not planning to buy ITNs, the primary reasons given were cost (39%) and already having enough (30%). Responsibility for purchasing decisions rested with the household head, almost invariably an adult male - husband, father, or grandfather.
Table 2
Percentage reported purchasing intentions, comparing ITN-owning to non-owning households
Planning to buy ITNs* |
89
|
78
|
Not planning to buy ITNs | 9 | 19 |
Not sure about buying ITNs | 2 | 3 |
We'll buy ITNs when they're available |
81
|
83
|
We'll buy ITNs this month | 12 | 12 |
We'll buy this year/Unknown | 7 | 5 |
Want ITNs to prevent mosquito bites* |
51
|
62
|
Want ITNs to prevent malaria | 42 | 35 |
Other/Unsure | 7 | 3 |
Don't want ITNs due to cost* |
46
|
35
|
Don't want ITNs due to having enough already | 0 | 47 |
Other/Unknown* | 54 | 19 |
"Head of the family - father or grandfather - is responsible for making the decision to buy something like nets and protection of the family." (Male ITN owner, Hazar Naw, Muhmand-Dara)
Heads of ITN-owning households were significantly better educated. Comparing ITN-owning to non-owning households, household heads with above secondary-school education were 1.85 times more likely to own ITNs than were those with no education (95% confidence interval 1.2-2.8).
Women participants said they had little decision-making power or opportunity to make purchases, but some said their husbands could be persuaded to buy items that they requested. Young women, even if married, were not able to go outside without accompaniment by their husband or parent-in-law.
"We don't go ourselves. Our husbands don't allow us to go for shopping. They usually provide us with what we want them to buy." (Female non-owner, Sunduq, Achin)
"No woman can go anywhere without asking the permission of her husband." (Female ITN owner, Meydanak, Achin)
A common perception of HNI-TPO among interviewees was as an ITN sales company rather than a humanitarian organization. This was despite several local clinics being sign-posted as run by HNI-TPO. However, it was not clear whether this perception was likely to help or hinder HNI-TPO's activities.
Four main purchasing constraints were reported. The first was cost. ITNs were sold for the average equivalent of US$6.50 in 2008 constant prices, with insecticide retreatment costing the current equivalent of US$0.07. Poorest people said they had more urgent problems for daily survival than mosquitoes and fever.
Cost was the most frequently mentioned ITN purchasing constraint among non-owners. Some participants appeared unable to afford an ITN at prevailing prices. Poorest households appeared to be those headed by widows, women whose husbands were disabled or working in Pakistan, and those who did not own enough land to support their household. Women whose husbands were in Pakistan could purchase some supplies from local shops on credit. Credit limits were unclear, though several women said that making ITNs available on credit would increase their ability to buy them.
"ITNs are the best way to protect against malaria, but we can't afford to buy them because we barely have enough to get food every day, and if we have enough for food, we have to buy clothes to cover our bodies. We can't go around naked!" (Female non-owner, Bati Kote)
"We know everything about ITNs but don't have the money to buy." (Male non-owner, Muhmand-Dara)
A second purchasing constraint reported was that participants did not have sufficient money for enough ITNs to cover everyone in their households. Some non-owners expressed reluctance to buy ITNs unless they could provide for the whole household.
"Fifteen people in my family and we have only one net! I don't have any money in hand to buy more nets." (Male ITN owner, Gerday-Ghous, Muhmand-Dara)
"The other problem is that there are 20-30 people in each household and to cover them all with ITNs we need at least 8-10 ITNs that we can't afford to provide." (Male non-owner, Ghazgay, Muhmand-Dara)
A third purchasing constraint, mentioned by both non-owners and owners purchasing additional ITNs, was that seasonal income did not match ITN availability. Several participants complained that ITNs were made available at the beginning of malaria season when they didn't have enough cash to purchase them, and when they did ITNs were no longer available.
"ITNs are available in this village only for a couple of weeks and that's usually the time which doesn't match harvest time (March/April) or when we don't have money" (Male ITN owner, lower Meydanak, Achin)
This lack of consistent availability led some non-owners to speculate that ITN sellers were favouring certain families and health staff were selling ITNs in Pakistan or charging more than they should. However, recent purchasers reported paying the price recommended by HNI-TPO.
"We had money last year, but ITNs were not available. Only relatives and friends of the sellers were able to buy them." (Male, non-owner, Bati Kote)
"Clinic staff sell the ITNs and drugs in the bazaar to make money. If you don't know someone in the clinic, you won't get help." (Female, non-owner, Bihsood)
The final purchasing constraint reported was that perceptions of poor-quality ITN retreatment were discouraging ITN purchasing. Several non-owners reported as a strong purchasing disincentive ITN-owning neighbours telling them ITNs were not as useful as previously. HNI-TPO had recently switched from permethrin to deltamethrin, and complaints about retreatment with watered down or expired insecticide may have affected ITN sales and retreatment uptake.
"Retreatment is good, but not like it was. Salesmen add more water now, but they say they know what they are doing." (Female ITN owner, Bihsood)
"There has been a gradual decrease in effectiveness since 1994. Maybe the insecticide is not good quality or they're mixing it with too much water. There have been many complaints and many surveys, but nothing ever changes" (Male ITN owner, Bihsood)
"Poor quality retreatment stops people buying ITNs." (Male ITN owner, Pakhail, Shinwar)
Reported ITN coverage and usage
Table
3 shows most owners (69%) paid for ITNs from savings. ITN-owning households had an average of three ITNs and four occupants per ITN. Where ITNs were limited, 70% of survey respondents said children and women were given preference. Participants said available ITNs were used by children and women, because they were the weakest and most vulnerable household members and keeping children covered by blankets to protect them from mosquitoes was very difficult. These practices may result from effective health messages, which emphasize the need to cover the most vulnerable (i.e. young children and pregnant women), but also reflect prevailing beliefs that women and children are weak, uninformed and unable to protect themselves.
Table 3
Percentage reported ITN usage among ITN-owning households
No. of ITNs per household
| Mean = 2.9 (SD = 2.4) |
Who sleeps under ITNs in your household?
| |
Children | 36 |
Women/Children | 31 |
Everyone (sufficient ITNs for all) | 29 |
Women | 3 |
Aged/Other | 1 |
Are your mosquito nets insecticide treated?
| |
Yes | 61 |
No/Unknown | 39 |
How often are your ITNs retreated?
| |
Yearly | 78 |
Bi-annually | 12 |
Don't know/Never | 10 |
After cleaning | 1 |
Where did you get funds to pay for your ITNs?
| |
Savings | 69 |
Loan | 17 |
Gift | 8 |
Crop sales | 4 |
Other | 4 |
"They (women and children) are weak in nature and also we men keep covered the exposed parts of our body, though children don't care about this." (Male ITN owner, Meydanak, Achin)
"If malaria mosquitoes bite children they will immediately get ill and can't resist against fever either, and the same applies to women. It is OK with men; they can go to the clinic on foot." (Male ITN owner, Gerday Ghaus)
The average number of children under five per ITN was 1.6 (± SD 1.4), though the number of children under five per household was not associated with ITN ownership (logistic regression p = 0.86). Only one man reported using the household ITN for himself, since as the family bread-winner he wanted to stay healthy. However, a few respondents (1%) said they gave preferential ITN use to the weak old men.
Interviewees reported that most ITN users did not sleep under them throughout the year. The primary reasons given for ITN use were to prevent both nuisance biting and malaria. Malaria was reported to be a more serious but less frequent problem, while nuisance biting was an everyday frustration. Many owners said that they used ITNs only in summer when mosquito densities and nuisance biting were highest and perceptions of malaria risk increased. However, some participants were aware that malaria could be transmitted in other seasons.
"We use ITNs only during the nights and particularly in the summer - only in summer." (Female ITN owner, Ghazai)
"There is (malaria) in winter but not as high as in the summer." (Male ITN owner, Ghazai)
While there was still some risk of both nuisance biting and malaria in winter, several participants said that people slept under blankets in winter so the likelihood of mosquito bites was reduced.
Interviews with health workers and ITN implementers supported general findings and sometimes provided additional insight.
Those doctors interviewed considered malaria an important contributor to morbidity and lost productivity, though not the primary disease priority in communities.
"The most dangerous (disease) is TB because it's transmissible easily and also if a person is diseased by this microbe and doesn't take care of himself he will die. But in malaria death is not essential, and the treatment of TB requires more time, at least 6 months, and the drugs are very expensive" (Doctor, Bati Kote)
Almost half of participants reported first going to public/NGO clinics for treatment, because they were cheapest. However, if treatment results were unsatisfactory many also went to private doctors. Several health workers described this type of treatment seeking negatively.
"If the clinic technician says it's not malaria she will think he's no good and go to a private lab where they will tell her it's malaria. There's a lot of overprescribing of chloroquine to make people happy." (Laboratory technician, Bihsood)
While most participants favoured the idea of credit schemes, and said that purchasing ITNs through small weekly or monthly sums would be beneficial, ITN implementers were not so eager:
"I'm only working seven months a year. It would take at least nine months to collect money from credit. We (ITN implementers) know who needs and deserves credit and could take responsibility for monitoring, but they would need to pay us all year round" (ITN implementer, Bihsood)