Causes of malaria
As shown in Table all but one participant indicated that they believed mosquitoes were at least one of the causes of malaria, and for 15 participants (44 percent), mosquitoes were, in fact, named as the only cause of malaria. For other participants, however, several mediating factors were listed along with mosquitoes as causing malaria. For example, nine participants believed that mosquitoes combined with environmental factors related to shrubbery, standing water, and pollution provided more complete explanations for the cause of malaria, sometimes with a detailed and accurate description of the role of such factors in the mosquito's life cycle (see Figure ). As displayed in Figure several participants noted that standing or stagnant water creates an environment that breeds mosquitoes. Additionally, a few participants indicated an inaccurate attribution of the environment, particularly the role of pollution and "dirt":
Malaria causation beliefs among participants, and among other villagers as described by participants, IPC, Kenya
Malaria Causation Beliefs (self), Qualitative Responses.
"Malaria is caused by dirt that is thrown about outside." (man, late 40s)
"Malaria is brought about by dirty things." (woman, late 40s)
Two specific components of weather (cold and rain) were commonly perceived as causes of malaria (in addition to mosquitoes) by 13 (38 percent) participants, and often characterized (Figure ) as the type of cold requiring warm clothing, or a dampness that enters the body through exposed feet. Finally, eight participants (24 percent) indicated that consumption of bad food or water can - sometimes along with exposure to mosquitoes - cause malaria, though as shown in Figure participants do not generally implicate specific foods beyond "bad" and "dirty" in this explanation.
Overall, 16 participants (47 percent), while indicating that mosquitoes caused malaria, also indicated that some other cause - such as cold temperature, rain, consumption of bad food - causes malaria, independent of those items' relationships to mosquito breeding conditions (for instance, "water" is implicated causally in local notions of malaria beyond its role as a breeding condition, for example in consumption).
When asked what other people in their villages believed about the causes of malaria, participants were less clear and were less likely to name mosquitoes as part of what the respondents perceive that other people think causes malaria. Mosquitoes, however, remained the most commonly named cause attributed to others; other categories named included environmental elements, weather, and consumption of bad food and water:
"Eating of young maize which has a lot of water they think brings malaria, also this other newly harvested food, that is what they think." (woman, late 50s)
"According to the people in Lurambi, the cause of malaria is dirty environment and also dirty waste water and water that is not treated." (man, mid-40s)
"It is mostly mosquito bites and cold weather. It reaches a time when the weather is too cold then malaria gets its way into the body." (man, early 40s)
"Dirty water brings malaria. Using dirty utensils and other things too. It is grass that brings mosquito." (woman, early 20s)
Several respondents, however, indicated that while these conceptions were common in former times, now most people knew that mosquitoes caused malaria:
"Previously they have been thinking of different things, maybe they say, they have drunk water somewhere. They used to think that drinking water in some places can cause malaria. Sometimes they have thought that if you have new harvests and the moment they start testing the new harvest they used to think that you get malaria. But now they know that it is only mosquitoes that can cause malaria." (man, early 50s)
"You know, there's that talk that people like telling their children that when they play in the rain they will get malaria, the say cold rain. But when we go for the lessons, we are told that cold can't cause malaria." (woman, early 40s)
In some cases, misguided beliefs regarding malaria causation led participants to report actions or other concepts that did not relate to the biomedical understanding of malaria:
"You see, sometimes you could make love to your husband and after that you feel your body has malaria. You then start feeling what has come to me." (woman, mid-40s)
"One way of protecting myself is to avoid moving in company of people who are involved in bad activities. We have drunkards and smokers who are not using protective package that was given. Anyone who uses what was given cannot get malaria." (man, late 40s)
Additionally, one participant who reported not currently using the LLIN responded when asked "What do you do to protect against malaria" said:
"We used to boil water, put in a clean pot and cover it with a piece of cloth. Once the water cools we used to sieve it before pouring the water in another clean pot for drinking. [Interviewer: What are you doing to protect yourself against malaria:] Currently, we just boil our water for drinking because we were not given a water filter." (woman, mid-30s)
LLIN practice and attitudes
As shown in Table overall 20 participants (59 percent) had LLINs before this campaign. After the campaign, 30 participants (88 percent) used the LLIN received from the campaign themselves, with another three participants indicating that someone else (their children or grandchildren) was using the new LLIN they received.
Malaria prevention practice by participants, IPC, Kenya
"I am still using the mosquito net. I also used to use some tablets for treatment of malaria but I am currently using a mosquito net, cleaning my compound, and avoiding stagnant water." (man, mid-40s)
"Before we had the health campaign, I in person had already had a net. The family was also using a net to prevent malaria. I was also trying to get people educated to clear around their places so that we avoid mosquitoes harboring there we were also using insecticides to spray in the houses, mosquito coils and at least clearing the bush around where we stay. And also destroying where we feel that mosquitoes can breed. In one way it was helping. Because of poverty people were not doing it the way it is supposed to be done. But it was at least helping in one way." (man, early 50s)
Participants reported benefits from using the LLIN. In total, shown in Table , 88 percent of all participants (n = 30) reported a positive benefit, most commonly that they and their family did not get sick from malaria any more (68 percent). For instance, participants frequently mentioned that they no longer became sick with malaria when using the LLINs, and that costs associated with malaria treatment previously were reduced or eliminated (see Figure ). In addition to noting reduced malarial illness through use of LLINs, participants also commonly mentioned that protection from insects (and other creatures) while sleeping was an additional LLIN benefit. Further, participants also commonly note that they and others feel more comfortable and "warmer" when sleeping under an LLIN, as detailed in Figure .
Long-lasting Insecticide-treated nets (LLINs) benefits.
Two participants reported they experienced a minor adverse reaction themselves in using the LLIN, both relating to skin reactions:
"The contact of the mosquito net made me itch before I followed the instructions." (man, mid-40s)
"The problem was at the time I was given it, it was written on the net that I finish 24 hrs. The time I opened and removed it was at night. When I did that I started scratching myself. That is when I was told that I got to see the instructions. The instructions were that I leave it for 24 hours before I cover myself." (woman, mid-40s)
Additionally, two participants reported that they heard of others who experienced complications:
"But some of my friends who got those mosquito nets were saying the nets had got some drugs in them that affected their stomachs. That they felt bad in their stomachs when using the net. I have personally not experienced that. In my house there has been no such a thing and even my wife has not complained." (man, early 50s)
"Other people just said that when they used it their bodies were itching but I did not feel itchy, no, I followed the instructions I was given." (woman, late 40s)
Suggestions to increase LLIN usage
Finally, as participants commonly noted that LLINs were helpful and that their use should increase, a variety of suggestions provided ideas about how best to increase LLIN usage, including:
Continue to increase LLIN awareness
Participants suggested several ideas around increasing LLIN awareness and their utility:
"People should be told the uses of the net when they go to the hospital to seek treatment, also they can be told when they go to church."
"I advise them if they received a bed net they should sleep under it because it reduces malaria and mosquito bites."
"There are people who get malaria but they don't know why they should use a net. They should be convinced to use them and they will provide themselves the goodness of using the net. They should be told the truth about the use of the net. Some are not aware how they should us it even it if is possible, the way you people are coming back, you need to tell them to use the net."
Some participants suggested that having "champions" or "witnesses" promoting LLIN use would be effective, and offered specific examples for programme planners:
"By those examples, like me, I can get my friend and tell him or her that when I started using the net, I have ceased to get malaria so it is better for you to use a net, if possible."
"Acting as the example I will make them to admire according to my illustration of how I am safe by using a net. I would love you to advise and also tell those people that already have nets to be witnesses and give advice to those who don't want to use the net."
"Maybe people should be told that the best way to stop malaria is by using the net, also they should be given nets for free and be told to be taking them for treatment for free. I think this will make them use nets every time."
"They [others who don't use nets] need to be told to use it because it helps us so much, there is no malaria on the children."
Finally, participants discussed the perception that LLIN recipients were obligated to use them ("If you were given one, then you need to use it") and also the perceived intransigence of resistance to using LLINs if someone opposes them:
"The clever ones use it, only a few of them don't use it. Trying to convince those ones to use it is like "playing a guitar to a goat" if they don't want to use it they will never appreciate the fact that it is useful, even if you tell them."
Though not designed as a quantitative assessment, this study did not detect statistical variation in comments by gender or age.