Demographic characteristics of study participants
In total, 101 people—made up of 76 householders, 8 AGA Mal officials, 17 AGA Mal spray operators—participated in the study. Most household participants were aged between 30-60 (62.7%), with only a few exceeding 60 years of age (4). Also, almost half (48%) of the household participants had no formal education and 82% of householders were employed in the informal sectors, particularly, farming. All the AGA Mal spray operator were male, and the recruitment of male-only spray operators was said to be a deliberate attempt to avoid the adverse health impact of exposing women to spray insecticides. Finally, the officials of AGA who participated in the study were male-dominated, and aged between 31-60 years of age. Table 1 gives a summary of the demographic characteristics of the study participants.
Table 1: Demographic characteristics of study participants.
Participant groups/variables
|
Householders
|
AGA Mal Spray Operators
|
AGA Mal officials
|
Age range
|
18-30
|
21 (28%)
|
10 (59%)
|
2 (25%)
|
31-60
|
51 (67%)
|
7 (41%)
|
6 (75%)
|
61-80
|
4 (5%)
|
0 (0%)
|
0 (0%)
|
Sex
|
Male
|
45 (59%)
|
17 (100%)
|
7 (87.5%)
|
Female
|
31 (41%)
|
0 (0%)
|
1(12.5%)
|
Level of education
|
No formal education
|
36 (48%)
|
0 (0%)
|
0 (0%)
|
Primary level
|
10 (13%)
|
0 (0%)
|
0 (0%)
|
JHS
|
10 (13%)
|
3 (18%)
|
0 (0%)
|
SHS
|
10 (13%)
|
5 (29%)
|
0 (0%)
|
Tertiary
|
10 (13%)
|
9 (53%)
|
8 (100%)
|
Employment status
|
Employed (formal)
|
5 (7%)
|
17 (100%)
|
8 (100%)
|
Employed (informal)
|
62 (82%)
|
0 (0%)
|
0 (0%)
|
Unemployed
|
8 (10%)
|
0 (0%)
|
0 (0%)
|
Student
|
1 (1%)
|
0 (0%)
|
0 (0%)
|
JHS=Junior High School; SHS=Senior High School
The themes identified in relation to IRS acceptability by householders were expressed in terms of facilitators and barriers.
Facilitators of IRS acceptability
Perceived effectiveness of indoor residual spraying
Many householders believed that indoor residual spraying (IRS) was effective in preventing malaria, and killing insects such as mosquitoes, flies, mice, cockroaches, spiders and scorpions. This was said to have resulted in a reduction in malaria-related hospital admissions, and hence, enabled householders to continue engaging in important economic activities. Other householders reported that IRS contributed to their general good health. For some other householders, the incidental benefits IRS such as the killing of mice and cockroaches were the primary reason for their acceptance of IRS, and this was corroborated by AGA Mal spray operators. While most householder participants believe that IRS was generally effective in preventing malaria, they perceived recent spray insecticides to be less efficacious in killing mosquitoes and insects. Some householders associated the perceived inefficacy of IRS sprays to the quantity of insecticides that is mixed for spraying, with some blaming spray providers for mixing less insecticides than the standard quantity required, potentially resulting in low dosage. Thus, most householders preferred the previously used insecticides compared to the currently used insecticides. This householder preference was confirmed by AGA Mal officials and spray operators.
“I also want to say something to those responsible for supplying insecticides for spraying that they should send the insecticide they sent some years back. That the previous insecticide is the one that can help us because as for the recent insecticide, it is only called insecticide but it doesn’t do the work of insecticides” [Household participant 10; Daffiama FGD1].
“What they like most is the Pro-guard because of its efficacy, that is the immediate effect because when Pro-guard is used, cockroaches, lizards, rats, even reptiles like snake die instantly, and even houseflies, they die instantly so people prefer that [insecticide] to any other chemical used. The recent one we used, this actellic 300 CS, well, there have been a lot of complains” [AGA Mal official 7].
Respect for authority
A few householders acknowledged accepting IRS due to their respect for IRS sprayers as figures of authority or as representatives of government.
“But I see that it’s not only because of the disease; when they say, you should do something, maybe the government gave them the permission, the people doing the spraying have the permission of the government so they were given the right to spray. It is a show of commitment to malaria prevention to spray one’s house but it also demonstrates how obedient householders are to the government and its agencies” [Household participant 1; Sombo FGD1].
Education on malaria and malaria prevention
Educational activities by AGA Mal personnel was another important facilitator of IRS acceptability and implementation. Information, education and communications (IEC) personnel routinely educate the public on malaria prevention and IRS while AGA Mal spray operators educate householders during their spraying activities in the communities. Community based volunteers, chiefs, and opinion leaders were all involved in the disseminating information at the community level. For many householders, education on IRS activities through different strategies promoted its acceptance. AGA Mal spray operators regarded education was the main strategy for managing spray refusals, thereby, facilitating the implementation of IRS.
“Mostly in every community we have the advocates who are key people who are known by everyone. So, the stakeholders and advocates are able to spread the information to the others, aside that there are also community forums” [AGA Mal official 5].
“Just the day before the spray day people came to our area; an information van came around to announce about spraying in the evening” [Household participant 7; Konta FGD1; recent status: IRS & ITN].
Training and capacity building for personnel
AGA Mal officials and spray operators reported that seasonal training and monthly refresher trainings are conducted for spray operators. According to AGA Mal spray operators and officials, the training is intended to provide education on the importance of spraying to spray operators, as well as equipping them with the technical skills they need to conduct spraying on the walls. Also, the training activities were reportedly intended to develop the communications and data collection skills of spray operators. These were intended to facilitate the collection of spray data, but also to enhance spray operators’ interactions with householders during spraying.
“The management of the district organize them [spray operators], have a training session with them, educate them on the importance of IRS and how they are going to operate when they go to the field… You know, we cannot force them [householders] to accept the programme so they are being trained in such a way that when they go to the community, this and how should talk to the householders in this way or this manner for them to understand the programme so that we can spray their homes for them” [AGA Mal official 3].
Barriers to indoor residual spraying acceptability
Inadequate information dissemination prior to spraying
Inadequate information and education was reported by householders across all the communities as one of the major barriers to the acceptance of spraying, especially, inadequate prior notifications and education about the scheduled spray day. This challenge was attributed to the fact that house to house spray notifications was no longer undertaken by AGA Mal personnel, resulting in householders’ unavailability to accept spraying, or the unexpected arrival of sprayers.
“When they are coming to spray, they don’t send us prior information about the spraying. By the time they come some of us would have gone to the farm or elsewhere so we wouldn’t be around to open our rooms for them to spray. We don’t hear the information that in this month they will be coming to spray or so and that we should try to be around for the spraying. You will just be sitting there and they will come and say, come and move out your belongings for them to spray” [Household participant 5; Daffiama FGD1].
“At first they came to your house and notified you that your house will be sprayed the next day. But now you just sit there and they will appear and say that they have come to spray your house; but you may also just be leaving for work and you cannot go and prepare for spraying. So now the supervisors, the mosquito supervisors are not doing their work” [Household participant 4; Konta FGD1].
Inconvenience in packing belongings outside for spraying
The packing, arrangement and rearrangement of householders’ belongings prior to and after spraying was one of the major reported barriers to indoor residual spraying (IRS) acceptability. It was explained that because spraying is conducted on the walls, householders are required to pack some of their belongings outside before sprays can be conducted. However, some householders reported that the workload and time requirement was a significant challenge for them. Also, most AGA Mal spray operators reported difficulties with packing as a challenge to spraying, particularly, in urban communities where householders tend to have a lot of possessions or belongings compared to those in rural communities. It was emphasised that because some communities are larger than others, spray teams sometimes spend two or more days spraying one community. Some householders lamented that sometimes they may pack their belongings outside in readiness for spraying but no spray operator turns up to spray their house on the first day. When this happens, households wishing to spray their houses may need to pack their belongings outside again for the second time on spray-day two, and this affects the acceptance and implementation of indoor residual spraying.
“For some people when they need to prepare their house for spraying, they say they cannot pack their house items to allow the sprayers to spray. Others cannot pack their house items because of the nature of their belongings because the spraying is done on the wall” [Household participant 2; Busie FGD2].
Fear and dislike for spray insecticides
Householders were very concerned about the side-effects of spray insecticides. The odour of indoor residual spray (IRS) insecticides was reportedly as one of the contributory factors responsible for refusals. Whereas some householders were concerned about the health implications such as the exposure of asthmatic patients to the odour, other householders associated the odour with inability to sleep. Insecticides odour was also perceived by some householders to be related to the type of insecticides sprayed (some being less favourable than others). Moreover, the debris left on sprayed walls were reported by a few householders as a barrier to spraying. AGA Mal officials and spray operators confirmed householders concerns about the odour of spray insecticides.
“…So yes, you may decorate your room, but the spraying will stain the wall and it’s not appealing to see your room in that way” [Household participant 7; Busie FGD3].
Individual religious beliefs and cultural practices
Many householders in rural communities reported that some householders refused IRS spray due to their unwillingness to reveal their traditional religious practices such as the ownership of ‘smaller gods’ which were reportedly held in some household rooms. Also, acceptance of IRS in such instances was perceived to be tantamount to exposing the ‘gods’ to spray insecticides, and this was believed to incur the wrath of the ‘gods’, who may inflict punishment on their owners. It was also feared that the spirit of the ‘gods’ may flee or die due to spraying, resulting in the loss of the protective powers of the ‘gods’. Also, funeral attendance was reported by householders to be one of the main reasons for their inability to spraying, especially, when funeral events coincide with the spray day. AGA Mal officials also reported funeral attendance as a barrier to the implementation of IRS. For AGA Mal spray operators, the hanging of charms and amulets on walls and doors by some householders restricted spray activities. In their opinion, because women—who are mostly home when spray men arrive—are not allowed to touch these spiritual objects, spray operators usually conduct spraying while these charms remain hanging on the walls, a situation that was said to be quite worrying to spray operators.
“Because of funerals, I can go to a funeral and by the time I’m back they might have finished spraying my community. Or you may go to the farm early or go to fetch some firewood and by the time you return they have finished spraying” [Household participant 1; Busie FGD1].
“They don’t want the spray men to go in and see the gods, and some of the gods if their shrines are sprayed then there will be serious consequences for the owner. So, they will say that no, you can’t enter that room, that room is never to be entered” [Household participant 1; Daffiama FGD1].
Privacy and security
Fears about having the content of ones’ possessions revealed to the public by AGA Mal spray operators was one of the concerns raised by household participants as a barrier to acceptability. This was especially so where the householders perceive their rooms as not being nice enough or where householders perceive their belongings to be in a disorganized many not befitting of their public image. AGA Mal officials believed that refusals could also stem from householders fears about potential ulterior motives of spray operators.
“Some people do not want the spray men into their houses to discover their secrets, so they do not allow the spray men in to spray their houses. Because their house is not nice enough, or because they could not arrange their belongings well; someone can leave their items in a disorderly manner” [Household participant 5; Konta FGD1].
Spray operators unprofessional conduct
Householders perceived spray operators’ lack of professionalism as a barrier to indoor residual spraying (IRS) acceptance. There was a perception among householders that the allocation of targets to spray operators resulted in their reluctance to spray once they achieve their targets for the day. The need to achieve targets was said to be the primary motive spurring operators to be selective in the choice of houses to spray, with a preference for bigger houses because such houses are more likely to have many rooms. However, AGA Mal spray operators reported that some householders were indecisive when the spray operators arrived at their house for spraying as they were often asked to come back later in the day when spraying is almost over.
“The last season the spray men came to spray my place…but this year when they came to spray I heard they were around and I went and informed them to come and spray my room but they did not come so that is why my room was not sprayed” [Household participant 3; Daffiama FGD2].
“Sometimes you’ll be there, you will inform them that you have come to spray, but I don’t know, they wouldn’t give you the permission to spray but when you are done and you are about moving to the next house and then they will come and call you and you need to go back to that section to spray, and it makes the work tedious” [AGA Mal spray operator 6; DBI FGD].
Operational barriers to spraying
Operational barriers such as limited vehicles and mobility challenges were reported as barriers to the implementation of IRS. AGA Mal officials reported that the use of limited vehicles affected the transportation of spray operators from operational sites to the communities for spraying. According to the officials, the rainy season compounded the difficulties involved in transporting spray operators to rural communities due to the bad nature of the road network. AGA Mal spray operators reported congestion in buses and the transportation of spray operators in batches as some of the challenges they encounter. These challenges reportedly led to a late arrival of spray operators in rural communities when most householders may have gone to their farms, especially, during the rainy season. Spray operators were also concerned about the difficulties involved in carrying their spray logistics such as spray pump, insecticides, and personal protective equipment from house to house to conduct spraying in the communities, especially, in communities with dispersed housing. Moreover, frequent breakdown of spray equipment was reported by both AGA Mal officials and spray operators as a barrier to spraying.
“Most of the times we are always many in the bus, sometimes the bus has to go and come two times or even more than three times sometimes. When we are going to a far village, by the time the second bus gets there the first bus operators have already finished, and even by then you get there and the people have already gone to farm… There is also another challenge with carrying of our equipment, it’s like you have to carry your bag, your bucket, your pump. This is a lot; it’s always a lot for us to carry these from one house to another” [AGA Mal spray operator 7; DBI FGD].
“One other challenge we have is the frequent breakdown of our spray equipment, the spray pump. These are things that are not manufactured here in Ghana, they are imported without the necessary spare parts for replacement. It affects the spraying in a sense that, when the equipment is not working you lose production for that day” [AGA Mal official 2].