Nineteen interviews were conducted. Out of the 10 female informants, nine were mothers aged 26–44 and one was an elderly 70-year-old aunt. The women's education level varied from no formal education to secondary education. All mothers worked in farming in addition to their household chores and most were also engaged in small-scale home-run businesses. The male informants were 27–55
year old fathers, and two of them were also caring for their nephews. Six were working as farmers, fishermen or daily laborers, while three were professionals (artist, retired soldier and an employee of the ministry of agriculture).
The findings are presented under the Health Belief Model (HBM) element clusters, i.e. ‘susceptibility and severity of malaria’, ‘benefits and barriers to bed-net usage’ and ‘self-efficacy and cues to action’.
Susceptibility and severity of malaria
Caretakers generally felt that malaria was no longer a common disease. However, perceived susceptibility was strongly linked to mosquito density, and was considered higher when mosquitoes were more prevalent. Susceptibility was also considered greater in children.
"I pity the child because an adult can at least hit it [the mosquito] and it will leave, but a child is not able to do that….A child's health is delicate so he can get infected quickly" (Informant 17).
Prevention activities were suggested as the reason for the reduction in malaria burden felt by the caretakers interviewed. Thus, the perceived susceptibility to malaria while using vector control measures, especially bed-nets, was considered very low. Malaria medication and the provision of intermittent preventive treatment (IPT) to pregnant women were also mentioned as reasons for malaria reduction. While caretakers had experienced malaria in the past, it was often long since they or their children had had a malaria episode.
"We will not get malaria because we protect ourselves and it has been long since we had it … Like her [3-year-old child], she has not had that kind of fever [malaria] since she was born" (Informant 6).
Despite the risk reduction, caretakers thought that there was still a risk of contracting the disease if, for example, the mosquitoes bite through or from within the net, if malaria is contracted outside the house, or if God wishes.
"Sometimes it [mosquito] penetrates the net, or without penetrating you may lean or touch the net, then the mosquito bites you from outside" (Informant 12).
Caretakers viewed malaria as a mild illness that can easily be cured if timely and appropriate treatment is given, and were confident that they could easily access this treatment. However, they also acknowledged the fact that severe complications might develop if proper treatment is delayed and that children with malaria needed to be taken urgently to hospital for appropriate medication. Among its complications, malaria was known to develop into a mental problem, cerebral malaria, convulsions and fits, which could sometimes cause disability or death. The severe form of malaria was considered dangerous and even life-threatening, especially for young children.
"There is danger because if she [the child] continues to have fever and getting irritable she will have severe fever which might turn to another fever. The convulsions, stiffness, death will happen." (Informant 10).
Other consequences of malaria were the costs involved in seeking and obtaining care and the disruption of the family's daily life and routines. The caretakers explained that they would not be able to go on with their daily activities because they would have to seek care and look after the sick children. Economic consequences when a child was ill included spending money on treatment seeking, diagnosis and treatment as well as loss of work-days. Emotional consequences as a result of malaria were also mentioned, as caretakers would be sad and worry about the sick child.
"When my child was sick I was feeling very uncomfortable because I couldn't work; you are forced to concentrate on the child and saving the child from illness" (Informant 16).
Benefits and barriers to bed-net usage
The caretakers acknowledged the benefit of bed-nets as protection against malaria, as well as other vector-borne illnesses. Caretakers also reported that using bed-nets had helped the family's well-being in general and that they and their children did not get ill as often when the bed-nets were being used.
The important benefit of bed-nets in the protection against mosquito nuisance and other insects was also highlighted. Caretakers mentioned that the mosquitoes disturbed sleep by biting and making noise.
"I think it is good [to use a bed-net] because the mosquitoes cannot penetrate. During the night I just enter into it and sleep well. If you do not cover yourself with a bed-net, you will not be able to sleep. You will have to chase the mosquitoes away here and there, they bite you sometimes, but if you sleep with it you will get a very nice sleep without problems." (Informant 1).
Caretakers believed that bed-nets were even more effective when treated with an insecticide. The LLINs were thought to have additional advantages including their wider square shape which covers the bed properly, the strong texture that does not tear easily and the large mesh-size allowing for more ventilation. However, big mesh-size was also mentioned as a disadvantage due to the fear that mosquitoes would penetrate the net, and the square shape was mentioned as difficult to mount. Caretakers stated that the insecticide of the ITNs and LLINs only affect malaria-carrying mosquitoes but not the other mosquito types.
One factor that clearly reduced consistent bed-net use was seasonality, whereby usage was stated to vary due to temperatures and rainfall. Figure shows the different ways in which seasonality was perceived to have an effect on the different HBM elements. While the discomfort of sleeping under a net in the hot season was perceived as a barrier, in the cold season keeping warm under the net was seen as a benefit. Additionally, in the rainy season mosquito density was perceived to be higher, affecting both the perceived intensity of malaria burden and mosquito nuisance. It remained unclear, however, whether seasonality affected the perceived malaria burden directly or solely through mosquito density. The mosquito nuisance affects the perceived added benefit of the bed-nets as protection against mosquito bites. The malaria burden might have an effect on the perceived susceptibility to malaria and the perceived benefit of using the net as protection against malaria, although this was not clearly stated.
The effect of seasonality on elements of the health belief model.
"[I use bed-nets] Everyday, during the rainy seasons, except for the very hot seasons …as is too hot, and there are no mosquitoes" (Informant 5).
Although all caretakers received a free LLIN during the distribution campaign, it was felt that these nets were insufficient and that they would eventually need to be replaced once they wore out. The cost of bed-nets was mentioned as a barrier to bed-net ownership as the cost of 5,000 Tanzanian shillings (3 US dollars) for a net was seen as unaffordable.
While caretakers’ awareness of the link between mosquitoes and malaria was high, female caretakers in particular had strong beliefs in alternative causes of malaria which potentially could reduce the perceived benefit of bed-nets as a malaria prevention method. Apart from mosquitoes, malaria was also perceived to be caused by dirty surroundings and dirty water as well as eating dirty things, having a bad diet and being hungry. Prevention for these causes included keeping surroundings clean and removing rubbish or water ditches, not allowing children to play with dirty water, providing the children with a good diet and caring for their personal hygiene. Religious beliefs about the role of God and spirits in relation to malaria and illness included the idea that mosquitoes are brought by God or that malaria is caused by bad spirits. Belief in spirits often coincided with the interpretation that malaria symptoms should be treated by a traditional healer.
"If someone gets malaria, it [care-seeking behavior] will depend on the way the people think. Some will tell you 'let us take him to the hospital. Why is he like this today? Why is he shouting? Why is he doing like this?' But others will say 'it is the devil so let us take him to the traditional healer'. Now everyone has his own way of thinking" (Informant 1).
All interviewed caretakers had had indoor residual spraying (IRS) done in their homes at least once. IRS was often perceived to be a useful way of killing mosquitoes and other insects such as cockroaches and bed bugs. However, the reduction in insects and mosquitoes was sometimes perceived as short-lived.
"[After IRS] for a few days it was better. Even those [mosquitoes] who are just flying around were few. But nowadays they are as many as before" (Informant 8).
Another drawback of IRS which was mentioned was the belief that IRS only kills malaria-carrying mosquitoes. Although the caretakers stated that they were not able to differentiate between malaria-carrying mosquitoes and other mosquitoes, they were told that if mosquitoes remain after spraying, they were not mosquitoes that can cause malaria.
"According to what the sprayers say, those normal mosquitoes survive the spraying but the malaria-carriers die" (Informant 18).
Self-efficacy and cues to action
Clear separate roles between men and women were described, whereby women were mainly responsible for household chores, caring for children and farming activities, and men were responsible for providing livelihood and decisions on purchases. While male informants claimed to be the main decision-makers in all matters concerning the household and children, the women also claimed that they were quite independent with regard to issues concerning raising the children, as the fathers were often away from the home. Some responsibilities and decisions were shared, such as farming activities, some purchasing decisions (including bed-nets), bed-net usage and other issues concerning the children's health.
Female caretakers were mostly the ones responsible for covering the children with a bed-net at night, and self-efficacy of bed-net use was reported to be high, as this was an activity they mentioned they could easily master and control. Caretakers reported that they did not encounter any difficulties in using the bed-nets and that it had become part of every caretaker's routine to arrange the bed-nets for the children when putting them to bed.
"If the mosquitoes are there, it is easy to bring the net down. If there are no mosquitoes, then it is also not difficult to fold it up" (Informant 5).
Another indication of high self-efficacy in female caretakers was due to their more frequent exposure to health information through the health facilities.
"Mostly it is the women who get these instructions in the hospital at the time of pregnancy or even before or after delivery…. Once the mother has gotten instructions and advice about the children from hospital, we just sit down and discuss" (Informant 19).
Despite the high perceived self-efficacy, there was an indication of a strong dependency on the government to provide and re-treat bed-nets. Although caretakers stated that they could take these actions on their own, they reported that they often rely on the government to provide them with malaria control interventions.
The main cue to using bed-nets was the increase in mosquito burden, both seasonal (Figure ) and the observed general increase in recent years.
"[We started using bed-nets] to protect us from mosquitoes. Before there were no mosquitoes in our village… you could sleep anywhere without seeing a mosquito, but now people have constructed big houses with many sewage tanks. That's why the mosquitoes have started to breed, there used to be no mosquitoes in our village" (Informant 9).
Other cues to bed-net use included being told to do so by health workers or after hearing about malaria in the media. The age of the child was also a cue to action whereby young children were prioritized when there were not enough bed-nets in the house. Parents, especially the mother, would often share a bed-net with a child. Children were also more likely to have continuous, rather than seasonal, bed-net use. The caretakers were especially aware of, and complied with, the fact that the LLINs given to them in the free distribution were intended for their under-five children.
"We say it is the small children's right [to use LLINs] because they were especially given to help them" (Informant 15).