Community knowledge and acceptance of indoor residual spraying for malaria prevention in Mozambique: a qualitative study.

BACKGROUND: Malaria control remains a leading health challenge in Mozambique. Indoor residual spraying (IRS) is an effective strategy to control malaria transmission, but there are often barriers to reaching the coverage necessary for attaining maximum community protective effect of IRS. Mozambique recorded a high number of household refusals during the 2016 IRS campaign. This study sought to evaluate household and community factors related to the acceptability of IRS to inform strategies for future campaigns in Mozambique and the region. METHODS: A cross-sectional, qualitative study was conducted in eight urban and rural communities in two high malaria burden provinces in Mozambique. Data were collected through in-depth interviews with community members, leaders, sprayers, and representatives of district health directorates; focus group discussions with community members who accepted and who refused IRS during the 2016 campaign; systematic field observations; and informal conversations. Data were systematically coded and analysed using NVIVO-11®. RESULTS: A total of 61 interviews and 12 discussions were conducted. Community participants predominantly described IRS as safe, but many felt that it had limited efficacy. The main factors that participants mentioned as having influenced their IRS acceptance or refusal were: understanding of IRS; community leader level of support; characteristics of IRS programmatic implementation; environmental, political and historical factors. Specifically, IRS acceptance was higher when there was perceived community solidarity through IRS acceptance, desire to reduce the insect population in homes, trust in government and community satisfaction with past IRS campaign effectiveness. Participants who refused were mainly from urban districts and were more educated. The main barriers to acceptance were associated with selection and performance of spray operators, negative experiences from previous campaigns, political-partisan conflicts, difficulty in removing heavy or numerous household assets, and preference for insecticide-treated nets over IRS. CONCLUSIONS: Acceptance of IRS was influenced by diverse operational and contextual factors. As such, future IRS communications in targeted communities should emphasize the importance of high IRS coverage for promoting both familial and community health. Additionally, clear communications and engagement with community leaders during spray operator selection and spray implementation may help reduce barriers to IRS acceptance.

Barriers and facilitators to the uptake of Test and Treat in Mozambique: A qualitative study on patient and provider perceptions.

BACKGROUND: In mid-2016, Mozambique began phased implementation of the 'Test-and-Treat' policy, which enrolls HIV positive clients into antiretroviral treatment (ART) immediately regardless of CD4 cell count or disease stage. Novel insights into barriers and facilitators to ART initiation among healthy clients are needed to improve implementation of Test and Treat. METHODS AND FINDINGS: A cross-sectional qualitative study was conducted across 10 health facilities in Mozambique. In-depth interviews (IDIs) were conducted with HIV-positive clients (60 who initiated/20 who did not initiate ART within Test and Treat) and 9 focus group discussion (FGDs) were conducted with health care workers (HCWs; n = 53). Data were analyzed using deductive and inductive analysis strategies. Barriers to ART initiation included: (1) feeling 'healthy'; (2) not prepared to start ART for life; (3) concerns about ART side effects; (4) fear of HIV disclosure and discrimination; (5) poor interactions with HCWs; (6) limited privacy at health facilities; and (7) perceptions of long wait times. Facilitators included the motivation to stay healthy and to take care of dependents, as well as new models of ART services such as adaptation of counseling to clients' specific needs, efficient patient flow, and integrated HIV/primary care services. CONCLUSIONS: ART initiation may be difficult for healthy clients in the context of Test-and-Treat. Specific strategies to engage this population are needed. Strategies could include targeted support for clients, community sensitization on the benefits of early ART initiation, client-centered approaches to patient care, and improved efficiency through multi-month scripting and increased workforce.