"People will say that I am proud": a qualitative study of barriers to bed net use away from home in four Ugandan districts.

BACKGROUND: Despite increased access and ownership, barriers to insecticide-treated bed net (ITN) use persist. While barriers within the home have been well documented, the challenges to net use when sleeping away from home remain relatively unexplored. This study examines common situations in which people sleep away from home and the barriers to ITN use in those situations. METHODS: To explore these issues, a group of researchers conducted 28 in-depth interviews and four focus groups amongst adults from net-owning households in four Ugandan districts. RESULTS: In addition to sleeping outside during hot season, participants identified social events, livelihood activities, and times of difficulty as circumstances in which large numbers of people sleep away from home. Associated challenges to ITN use included social barriers such as fear of appearing proud, logistical barriers such as not having a place to hang a net, and resource limitations such as not having an extra net with which to travel. Social disapproval emerged as an important barrier to ITN use in public settings. CONCLUSIONS: Unique barriers to ITN use exist when people spend the night away from home. It is essential to identify and address these barriers in order to reduce malaria exposure in such situations. For events like funerals or religious "crusades" where large numbers of people sleep away from home, alternative approaches, such as spatial repellents may be more appropriate than ITNs. Additional research is required to identify the acceptability and feasibility of alternative prevention strategies in situations where ITNs are unlikely to be effective.

Decision-making on intra-household allocation of bed nets in Uganda: do households prioritize the most vulnerable members?

BACKGROUND: Access to insecticide-treated bed nets has increased substantially in recent years, but ownership and use remain well below 100% in many malaria endemic areas. Understanding decision-making around net allocation in households with too few nets is essential to ensuring protection of the most vulnerable. This study explores household net allocation preferences and practices across four districts in Uganda. METHODS: Data collection consisted of eight focus group discussions, twelve in-depth interviews, and a structured questionnaire to inventory 107 sleeping spaces in 28 households. RESULTS: In focus group discussions and in-depth interviews, participants almost unanimously stated that pregnant women, infants, and young children should be prioritized when allocating nets. However, sleeping space surveys reveal that heads of household sometimes receive priority over children less than five years of age when households have too few nets to cover all members. CONCLUSIONS: When asked directly, most net owners highlight the importance of allocating nets to the most biologically vulnerable household members. This is consistent with malaria behaviour change and health education messages. In actual allocation, however, factors other than biological vulnerability may influence who does and does not receive a net.

Changes in stigma and discrimination of onchocerciasis in Africa.

Forms of onchocerciasis-related stigmatisation, following over 10 years of implementation of community directed treatment with ivermectin (CDTI), were documented through a survey conducted between September and November 2009 to look at perceived changes in stigma over the past 7-10 years. We documented people's perceptions towards stigma before and after the introduction of CDTI from 1600 structured interviews with households selected from the community treatment registers; in-depth interviews with 57 community leaders, community directed distributors and health personnel; 33 focus group discussions with male and female community members in different age groups (18-24, 25-54 and ≥55 years) and 13 case studies. People with onchocercal skin disease (OSD) with rough skin, swellings and rashes were the most stigmatised. People still fear sexual intimacy with infected persons. In the past, people with OSD were considered unclean and stigmatised because of fear of OSD transmission and embarrassment. People who had lived in the community less than 5 years tended to stigmatise OSD patients more than those people who had lived in the community for longer than 5 years. The youth stigmatised the most. Although stigmatisation persists, avoidance of people with OSD decreased from 32.7% to 4.3%. It is notable that treatment availability has improved relationships between healthy people and those with OSD symptoms in endemic communities and this can be attributed to CDTI. Health education should be emphasised in the communities during distribution.

Drawing and interpreting data: Children's impressions of onchocerciasis and community-directed treatment with ivermectin (CDTI) in four onchocerciasis endemic countries in Africa.

Although the depiction of a child leading a blind man is the most enduring image of onchocerciasis in Africa, research activities have hardly involved children. This paper aims at giving voice to children through drawings and their interpretation. The study was conducted in 2009 in Cameroon, Democratic Republic of Congo (DRC), Nigeria and Uganda. Children aged 6-16 years were asked to draw their perceptions of onchocerciasis and community-directed treatment with ivermectin (CDTI) in their communities. A total of 50 drawings were generated. The drawings depicted four main aspects of onchocerciasis: (1) the disease symptoms, (2) the negative consequences of onchocerciasis among children and in the community generally, (3) the ivermectin distribution process, and (4) the benefits or effects of taking ivermectin. Out of the 50 drawings, 30 were on symptoms, 7 on effects of the disease on children, 8 on distribution process, and 5 represented multiple perceptions on symptoms, drug distribution processes, benefits, and effects of treatment. The lack of clarity when treatment with ivermectin can be stopped in endemic areas requires working with children to ensure continued compliance with treatment into the future. Children's drawings should be incorporated into health education interventions.

Community-directed interventions for integrated delivery of a health package against major health problems in rural Uganda: perceptions on the strategy and its effectiveness.

Despite growing interest at national and international levels to use community-directed interventions (CDI) for delivery of health interventions in Africa, inadequate information on its acceptability and effectiveness remains. This study aimed to examine community perceptions on CDI strategy and its effectiveness for integrated delivery of health interventions with different degrees of complexity (insecticide treated nets, vitamin A supplements to children, home management of malaria and direct observation treatment of tuberculosis), using community-directed treatment with ivermectin (CDTI) as an entry point, compared to conventional delivery channels. The interventions were implemented in an incremental manner and both qualitative and quantitative methods were used at evaluation, three years after implementation. Coverage was significantly higher in CDI arm, compared to conventional delivery channels for all interventions (P < 0.05), except for direct observation treatment of tuberculosis (P > 0.05). Community members expressed interest in CDI because it responds to their perceived health problems, actively engages them and improves access to health care services. CDI seemed to be appropriate for interventions that are relatively simple, intervention materials are available, the disease is perceived as a health problem affecting all sections of the community and can be easily integrated into their daily lives, and community structures with full community participation.