Study design

The study used a cross-sectional study design employing a qualitative approach with focus group discussions (FGDs), in-depth interviews (IDIs), and key informant interviews (KIIs) to assess people’s knowledge, perceptions, and acceptability of the community-led implementation of HI.

Study setting

As mentioned above, the study was carried out in the communities surrounding the MWRP, located in Chikwawa district (16° 1′ S; 34° 47′ E), 54 km from the commercial city of Blantyre in southern Malawi. The area is host to 90,000 people. The study area has been described in detail elsewhere [35]. The area’s main income activities include subsistence farming of maize, sorghum, millet and beans, livestock rearing, small retail businesses, and brick-making [36].

Agriculture is the key livelihood activity, employing over 80% of the total population [36]. Chikwawa is hot and dry from September to December, hot and rainy from January to April, and mild and dry from June to August. The district is generally dry with typical savannah vegetation. The main public health problems in the area are malaria, diarrhoea, acute respiratory infections (including pneumonia), skin infections, common injuries and wounds, and sexually transmitted diseases [36]. Malaria transmission in this area is predominantly by Anopheles arabiensis and Anopheles funestus, with a small proportion of Anopheles gambiae s.s [27,37,38].

House improvement was implemented in 22 villages as part of a cluster-randomised controlled trial within the MMP’s catchment area from May 2016 through May 2018 as a cluster-randomised trial [25,26] and then continued as a rolled-out intervention in the remaining villages within the MWRP until April 2019. In brief, all of the MMP trial interventions were carried out at the village level, with the trial involving four arms. Villages were randomly assigned to one of these four groups: (a) a control arm, (b) HI, (c) LSM, and (d) HI + LSM [25,27]. All arms used interventions recommended by the NMCP and community engagement [25,27]. This study included all the 22 villages involved with the HI intervention, i.e. the HI and HI+LSM arms. The study villages were divided into three sub-regions, called focal areas (namely A, B, and C), spaced evenly around the MWRP and covering approximately 25,000 people in 65 villages (S1 Fig).

Study population

We identified five different groups of participants in the qualitative survey, namely: health animators (HAs), HI committee members, members from the broader community, health surveillance assistants (HSAs), and traditional leaders (Chiefs). Traditional leaders are the primary gatekeepers of the communities. They act as a point of contact between the local government and the community and are key players in facilitating development, including promoting health in their communities. In this research project, chiefs oversaw HI implementation in their respective villages.

The duty of HAs was to take a leading role in educating, informing, and promoting malaria control initiatives and implementation of HI in their respective villages. These individuals are volunteers and were selected by chiefs in consultation with their respective community constituents. These individuals received education and training from the MMP and The Hunger Project (THP). The training was in two parts; classroom experience, where knowledge was imparted on various topics concerning malaria prevention and control, and hands-on experience on how HI would be established at the household level using model houses. The roles of health animators are further described elsewhere [23,39,40].

The HI committees comprised 8 to 10 individuals from the respective villages selected by members of each village at community meetings. These HI committees were formed to carry out HI activities in each selected village. They were tasked with storing the materials used in improving households, such as gauze wire, hammers, and measuring tapes. They were responsible for distributing gauze wire in houses requiring it, lobbying for and coordinating community participation in HI implementation at household and village levels. Members of the broader community were responsible for implementing HI in their households, with full eave closure, closing open spaces, and installing gauze wire on the windows.

HSAs form the largest group of community health workers (CHWs) in Malawi. The government deploys them in peri-urban, rural, and hard-to-reach areas to provide and implement preventive, curative, and promotive health programmes [41,42]. In this project, their main task was to promote HI as an intervention for malaria control.

Other potential study participants included HI committee drop-outs (e.g., individuals who once were part of the HI committees but, due to other circumstances, relinquished their positions) and non-participants of the trial (individuals who refused to implement HI). However, these participants (HI committee drop-outs and non-participants) were not available for interviews as some had relocated to other areas and the two non-participants found refused consent.

Sample size

This was a qualitative study where IDIs, KIIs, and FGDs were conducted. We opted for IDIs because of the depth they guarantee in understanding a social phenomenon [43]. For data triangulation, we used FGDs to stimulate varying responses from various participants [44]. The IDIs with community participants and KIIs were used to supplement the content of the FGDs. Twenty IDIs were conducted with members from the general community in the study villages. Twenty-three key informant interviews were conducted with traditional leaders and HSAs in their respective villages or workstations. Nine mixed-village FGDs (men and women) were undertaken with community members, HAs, and HI committee members drawn from different HI villages. These did not include participants of the IDIs.

Sampling of study participants

Purposive sampling method was used to select participants in the study villages for the interviews. Purposive sampling was used to facilitate the identification and selection of participants who had adequate information (Information-rich cases) about the topic of interest. Studying these cases yields insights and in-depth understanding rather than empirical generalisations [45]. Community participants, HAs, and HI committee members were purposively selected for the FGDs. Three group discussions (one for each group) were organised in each of the three focal areas. Each group was made up of a minimum of 6 and a maximum of 10 members. The FGDs included group reflections and experiences, shedding more light on the knowledge and perception of HI as an intervention for malaria prevention. Views were also sought from the study participants on the acceptability of HI, which had been implemented in their respective villages.

Recruitment and training of data collectors

The interviews were conducted by four postgraduates (first, second, sixth, and eighth authors), who were research associates with assistance from six research assistants (Diploma holders) from the MMP. Before the interviews, all data collectors received intense training for one week with guidance from the last author. The highly interactive training included an overview of the study, with an emphasis on the main objective of the study, the study design, qualitative interviewing techniques, and strategies, and participants were encouraged to ask pertinent questions throughout. The consent forms and interview guides were also given to data collectors in English and then translated into Chichewa, the local language. The data collectors were trained on the consenting process and the use of digital voice recorders. The data collection tools were piloted on individuals in non-intervention villages to ensure they were clear, relevant, and comprehensive. These individuals from non-intervention villages had similar characteristics to those in the intervention villages.

Questions identified as ambiguous were changed, and questions identified as irrelevant to answering the primary study objectives were omitted. Initial questions for the different interview participants focused on the participants’ experience, impression, and challenges in implementing house improvement. Questions related to health problems in the community, the community’s response towards malaria, and health promotion. However, questions on the role/influence of position were restricted to the chief and HSA KIIs because they were technical and pertained to community leadership, whether administratively for the chiefs or health-related for the HSAs. This section was followed by questions focusing on participants’ knowledge, attitudes, perceptions, and acceptability of house improvement as a malaria control intervention and the perceived benefit for screening eaves, windows, and doors during house improvement. (S1 Text) summarises the interview guides.

Data collection

Before the interviews, all study participants were booked for face-to-face meetings on the specified date, time, and location. The interviews were conducted at various meeting points at the community level. All FGDs were conducted in private spaces and were held either in a classroom or a private room at the community epicentres. All participants were adults of 18 years and above, composed of both sex and different age groups. IDI and KII administration took around thirty minutes, while the FGD interview took 1.5 to 2 hours. All the interviews were conducted in Chichewa. All the potential study participants who were contacted agreed to participate in the study. In total, 47 females and 65 males participated in FGDs, IDIs, and KIIs in the area. We recorded field notes that were subsequently shared and discussed with the whole research team when we completed each day’s task. Data collection took place between 18^th March and 20^th April 2019.

Data analysis

All data were audio-recorded, transcribed verbatim, and translated into English by the first author and research assistants. Field notes were continuously recorded, shared, and discussed with research team members as reflections to inform preliminary data analysis at the end-of-day meeting briefs. First, the first author listened to all the audio recordings and read the transcripts multiple times to check the accuracy and understand the issues raised. The first author familiarised himself with the whole dataset to ensure that the data was clean, had proper flow, and accurately conveyed the participants’ responses. Secondly, we used thematic analysis to analyse the data. The first author coded the transcripts sent to the last author for comments and agreement on a common coding framework. A codebook was developed using inductive and deductive coding methods (S2 Text) shows the codebook that was developed. The inductive approach is bottom-up with codes derived from the data, i.e. the participants’ words were used to code the data (in vivo coding) as shown in (S3 Text). At the same time, the deductive approach was based on a predefined set of codes, which guided the coding process [46,47]. These codes were defined from the question guide. The translated transcripts were entered and coded using Nvivo 12 Plus (QSL international, Victoria, Australia). (S4 Text) shows deductive coding results using Nvivo 12 plus. Key themes in the coding framework included the community’s knowledge, perceptions, barriers, facilitators with HI, acceptability, and sustainability of HI. All audios and transcripts were saved in a password-protected computer with access only granted to the researchers. The quotes selected were the most encompassing quotes from all the feedback on the topic. Feedback from different participants was incorporated on that theme to create a balanced representation of the quotes.

Ethical considerations

Before study implementation, the University of Malawi’s College of Medicine Research and Ethics Committee granted ethical approval (COMREC protocol number P.07/18/2442). The Chikwawa District Health and Social Services (DHSS) office provided permission to collect data in the study villages. Before recruiting participants, we communicated the study to the community through local village heads in liaison with HAs. Written informed consent was obtained from all participants during data collection. All the participants were men and women aged 18 years and above. Literate participants provided a signature on the consent form. Participants that could not read nor write thumb-printed on the consent form after it was read to them in the presence of an impartial witness. Participants were assured that their personal details would be omitted from transcripts, and no personal information would be divulged to ensure confidentiality. Finally, participants were informed that their involvement in the research was voluntary and that withdrawal was permitted at any time and without personal consequence.

Socio-demographic characteristic of participants

One hundred twelve (112) people participated in the 52 interview sessions: 43 IDIs and 9 FGDs (Table 1). Most of the participants were in the age group 25 to 44 (58.0%) and reported primary education as their highest level of formal education (51.8%). More males (58.0%) than females (42.0%) participated in the interviews.

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Table 1. Demographics of study participants.

https://doi.org/10.1371/journal.pgph.0000627.t001

Main themes of the study

There were four main themes drawn through the inductive and deductive methods that emerged from our data: Community knowledge and perceptions of HI as an intervention for preventing malaria, the community experienced barriers and facilitators with implementing HI, acceptability, and sustainability. A description of themes is presented in (Table 2) below.

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Table 2. Main themes from the qualitative study.

https://doi.org/10.1371/journal.pgph.0000627.t002

Community knowledge, perceptions, and experiences with HI for malaria prevention

There was widespread knowledge among all participants about HI as an intervention for malaria prevention. HAs and HI committee members received theoretical and practical training on HI and malaria in general. After the initial training in May 2016, they had refresher training two years later, in November 2019. As a result, these groups had a higher level of knowledge about HI than their community counterparts. HSAs, who are technical people in charge of public health, were highly knowledgeable about the intervention. Participants were able to describe how the intervention works and the materials required to build a standard HI house. Almost all participants reiterated that HI prevents malaria by minimising mosquito entry. Interestingly, some community members could even describe the mosquito behaviour on what attracts it to identify the human host inside a house.

“HI includes closing eaves, sleeping under mosquito nets, and installing gauze wire at windows. Mosquitoes can enter the house to bite the human host by following the smell of the host inside the house, and they usually enter through the eaves.” (IDI, Community participant, FA-A)

When asked what other procedures are involved in HI, participants gave varied responses. Sealing small holes or spaces on walls and doors was explicitly mentioned to prevent mosquito entry. Some of the participants were able to identify simple and readily available materials such as mud and small pieces of wood to use to close off or seal the open spaces in their homes.

“HI involves the closure of eaves. When we have closed the open eaves, sometimes there are still small openings, which cannot be closed with bricks; we close them with mud. The other thing is that our doors have spaces that can let mosquitoes in. So we look for small pieces of timber and fit them in the spaces so that mosquitoes have no entry into the house.” (FGD, HA, FA-C)

However, community members’ knowledge of the intervention differed from their experiences with implementing it. They had a good understanding of what HI entails. However, they were surprised by the level of attention to detail and time required for the implementation. People in the community cited reasons such as requiring a lot of manual labour, which would interfere with their day-to-day activities, resulting in less time spent on economic activities as unanticipated and unexpected experiences with the implementation of HI.

“We discovered that closing eaves and installing gauze wire is time-consuming and exhausting because it necessitates the acquisition of additional materials such as bricks and other equipment. We complained to HAs that it would have an impact on our day-to-day work.” (IDI, Community participant, FA-B)

However, a thorough engagement with HAs and HI committee members who taught them about the importance of the intervention resulted in a shift in perspective.

“This work was difficult at first because we did not understand what it was like to close the eaves. Afterwards, we were taught that closing the eaves helps prevent malaria. Once we were taught, we began to close the eaves and cracks in the walls of the houses with gauze wire.” (FGD, Community participant, FA-A)

Furthermore, people’s experiences with HI changed over time. Their initial experiences with implementing HI turned into delight when they experienced the benefits of the intervention. For example, people linked the closing of eaves and gaps and installing gauze wire in their houses to reduce malaria infection rates in the community and lower household costs for clinic visits.

“People expressed happiness because firstly, malaria cases are minimal, people are less sick. If they were sick, they would go to the Kapichira clinic and pay for the health services, but this has reduced. Very few cases are going there at the clinic. So this money saved by not going to the clinic is now being used for other household developments.” (KII, HSA, FA-B)

This experience of having reduced episodes of household illness helped shape their way of thinking because they could establish a link that prevention is less costly than seeking treatment.

We also solicited views from study participants about their knowledge and perceptions of HI as a supplementary malaria intervention and how it complements other interventions. A majority of the community participants knew that ITNs were the main intervention used for malaria prevention. They understood the difference and significance of the two interventions. When asked about the relationship between the two interventions, HAs, HI committee members, HSAs, community participants, and chiefs demonstrated knowledge on how these two interventions are related to malaria control.

“Yes, there is a very strong relationship because when people are using mosquito nets only, they get mosquito bites when outside the house or while chatting in the living room before going to bed. However, when we close the windows and spaces, there are few or no mosquitoes inside the house, preventing mosquito bites while chatting before going to bed. Therefore, when they sleep under mosquito nets besides installing gauze wire in windows and spaces, there is an increased chance of preventing malaria than using mosquito nets only.” (KII, HSA, FA-C)

However, some participants did not understand how the different malaria control intervention tools complement each other, as explained by the HSA below.

“I can say that this can be a challenge. That is the reason I at first said it is surprising that the cases of malaria are increasing. I think when people implement HI, they think that using mosquito nets is not necessary. Many think that because they have improved their houses and do not hear any mosquitoes, there is no need to use mosquito nets.” (KII, HSA, FA-A)

To understand how HI functions, there is a need to know why and how it acts as a barrier to mosquito entry. Participants were asked if their respective communities were aware of the risk of open eaves for malaria transmission. Several participants knew about this, but one community participant had this to say:

“Previously, people were unaware that when we leave the eaves open, mosquitoes can easily enter the house. With the arrival of the Majete Malaria Project, they realised that by leaving the eaves open, they were allowing mosquitoes easy access into the house.” (FGD, Community participant, FA-B)

Factors enabling and impeding the community’s implementation of HI

Factors that motivated or demotivated the implementation of HI were varied. These variations were observed in different groups. However, the main factors influencing the community’s implementation of HI were the influential role community leaders played in promoting HI in the selected focal areas of the study, and community ownership in the implementation of HI was fundamental. Chiefs and other community leaders play a significant role in making critical decisions that affect the well-being of their people. In this study, chiefs mobilised volunteers (HAs and HI committee members) to lead HI implementation. They were also on hand to resolve any problems or disagreements that these volunteers encountered while discharging their duties in the community. They also assisted in the organisation of village meetings led by these volunteers. Community leadership and community ownership appear to have generated a sense of community buy-in for HI.

Most chiefs reported that they played a role in encouraging their people to participate in the intervention while also serving as the last resort for dealing with uncooperative people who were challenging to deal with by the HAs and HI committee members.

“When the HI committee that we assembled is carrying out its duties within the village and comes across some people who are speaking negatively about the project and are unwilling to participate in any HI-related activity, they approach us as chiefs for assistance in dealing with this problem, and it is our duty as chiefs to call these people and help them understand so that they can participate.” (KII, Chiefs, FA-A)

In addition, the sense of community ownership in the implementation of HI was also a factor for participating in HI. As one health animator reports:

“People reacted very positively to this HI intervention. Why? Because they were in charge of improving their houses. Whenever we were out in the villages, people from nearby villages asked, “When are you going to start in our village?” This means that people have been positive about the project.” (FGD, HA, FA-C)

However, not all community members embraced or took ownership in the implementation of HI. When asked about what they felt were the reasons affecting the community’s support for HI activities, the participants cited several issues. Though not common to all participants, some of the factors cited were that HI causes a lack of ventilation in HI houses resulting from poor air circulation, it impedes the natural light that filters in through the eaves making the houses too dark inside and causing the indoor heat to become extremely uncomfortable.

“People were saying that there was not enough ventilation in their houses when they closed the eaves. So, they would not close the eaves and screen their windows with gauze wire. They also wanted the light to be getting into the house through the open spaces.” (FGD, Community participant, FA-C)

Some HAs stated that the architectural design of most houses within the village, which includes not closing eaves and leaving a gap between the wall and the roof, also aids in termite prevention. Termites would destroy the wood/timber and grass used to build houses if no insecticide was applied. The existence of termites prevented some community members from implementing HI.

“I experienced that challenge in my village where someone complained about closing open eaves leading to a problem of termites eating poles on the roof because the walls are now in contact with the roof. Moreover, when fixing the roof, they have to remove the bricks they had closed open eaves with.” (FGD, HA, FA-C)

Another concern expressed by community members was in the supply and durability of the materials used to seal off their houses. They complained that the gauze wire that they received was rusting and sometimes experienced perforations. They also reported the unavailability of HI equipment at times when they needed it the most.

“Yes, complaints indeed will always occur, for instance at first the gauze wire which we received for the windows rusted, so people complained that the wire was going bad and was rusting. Apart from that, people that had newly built houses and those in old houses who wanted to build new houses when they told the HI committee that they were looking for wire gauze, they received a response that wire gauze is no longer in stock.” (KII, HSA, FA-B)

Lastly, as with many community-based projects, tensions between the drivers (community-based volunteers) and implementers (community members) of a programme bred negative sentiments. Some HAs and HI committee members encountered problems in the execution of their duties. As a result, some community members refused to implement HI in their respective households.

“At the inception of the project, some people had a feeling that the project had a lot of money and accused us of being paid by the project for us to conduct our duties: “You are taking the money for yourself, you should not fix the gauze wire on the window of my house.” This caused friction between us and certain community members such that we had to involve chiefs in some cases to intervene." (FGD, HA, FA-C)

Acceptability of HI as an approach to malaria control

We solicited the views of study participants regarding the level of acceptability of the HI intervention. The results showed that despite the unanticipated and unexpected experiences with implementing HI, the acceptability of the intervention was high. A majority of the community participants said they were happy that they implemented the intervention. They maintained that nobody forced them to implement this intervention and that they did not regret having it. They reported that they were happy about the intervention and that they were willing to sustain it.

In general, community engagement with HI committees and HAs and the village workshops improved community members’ knowledge, support, and acceptability of HI. They expressed that their experience in helping reduce malaria cases within their villages increased their acceptance of HI. The following excerpts show how stakeholders in the study area describe their happiness and willingness to accept the HI intervention:

“HI was well received in our villages because, at first, we were people with no knowledge, but after the project arrived, they trained HAs and HI committees who educated us on HI. Everyone improved their house on their own, knowing that we were protecting ourselves from malaria. Everyone in the village agreed to do the work and have high-quality HI with properly closed eaves and gauze wire on windows. So there is no problem in the village, and everyone has accepted this development wholeheartedly and is pleased.” (FGD, Community Participants, FA-A)

“People were sceptical at the start of the project because they were unfamiliar with the benefits of HI. They gradually realised that the money they had previously spent on paying medical bills for family members suffering from malaria was excessive compared to their current situation, in which they can now save some money for household developments. As a result, they accepted the intervention that HI is indeed beneficial.” (FGD, HI Committee, FA-C)

Equally important in determining acceptability were the views of the volunteer HAs. Their experience implementing this intervention with the community informed us that it did not interfere with their way of life or violate their social norms.

“People accepted this intervention. The intervention did not cause any harm in our way of living at all to the extent that when we were carrying out our duties in the villages, people from neighbouring villages that were not implementing the intervention would ask, "When are we going to have this intervention in our village?" (FGD, HA, FA-C)

In short, there was a general perception among some of the community participants that HI as a practice was agreeable within their communities.

Sustainability and plans for community-led HI

Almost all community members, HAs, HI committee members, chiefs, and HSAs strongly supported the HI intervention and pledged to continue to do so because they believe it has helped reduce the malaria burden in their respective villages. All the participants in this study were confident that their colleagues would be willing to continue implementing the intervention even if the project ceased to exist. Participants believed that the training and skills received by HAs, HI committee members, and themselves would be shared over time and help sustain the programme.

“I will continue doing this HI work. I will not stop even if the project ceases to exist. I will encourage people to do HI, sleep under a mosquito net, empty swamps, and drain stagnant water for safety from getting mosquito bites that could lead to malaria. I will continue doing this because I am one of the people in the village with the necessary skills.” (IDI, Community participants, FA-C)

The availability and accessibility of materials can either help or hinder the implementation of HI. Some community members, HI committee members, and HAs expressed concern that delays in the project’s provision of wire gauze and the unavailability of some resources within their community setting would make it difficult to sustain the intervention.

“The resources required for HI are not easily accessible or readily available. When we go from house to house in the villages, we frequently notice houses with open eaves. When we contact the house owners, we usually find out that many things are required. Closing the eaves necessitates the search for bricks, nails, and other such items. This would make it difficult to sustain the intervention, particularly in low-income families.” (FGD, HA, FA-B)

Participants were asked about how to promote HI to ensure the sustainability of the introduced intervention for malaria control. Some suggested that there should be model houses built within the villages for people to benchmark.

“To ensure uptake of HI, we improve houses that are at strategic points such as along the roads so that they have quality HI. We use these houses as demonstration houses so that everyone passing by can see and ask: “Whose house is this? How are they doing this? Where are they getting these things from?” (FGD, HA, FA-C)

Others highlighted the significance of sensitisation and continuous education within the communities.

“HI could be promoted through community sensitisations, and continuous meetings and education conducted by health animators where we can educate people on HI, so that they may be motivated.” (IDI, Community participant, FA-B)

Recommendations

These findings have significant implications for malaria control in SSA. We developed the following policy recommendations based on a policy framework proposed by Walt and Gilson [65] that describes key elements (content, process, context, and actors) that influence policy development and implementation. The strategy involving the capacity building of community volunteers by MMP on HI and malaria, community mobilisation, and sensitisation by chiefs, substantially improved knowledge and understanding of malaria and HI. It also enhanced participation, increased acceptability of the intervention, and improved community trust among various community stakeholders. This strategy is recommended for widescale implementation in rural areas where malaria is endemic. Implementing community-led HI involved various actors within the community, with each actor playing a pivotal role in the implementation process. This is a recommendation to the programme planners and policymakers involved in malaria control to consider the involvement of various actors at the community level using the bottom-up approach of community engagement to enhance intervention buy-in. The scale-up of community-led HI would necessitate policymakers to address the logistical supply of materials such as gauze wire, price regulation, and quality monitoring of these supplies. Communities should be informed of the cost and availability of these materials. If adopted by the government, it should be recommended that a proper mechanism for ensuring access and equity of resources, particularly in rural areas, be implemented.

Limitations

Participants such as HI committee drop-outs and trial non-participants either refused consent or were unavailable due to relocation. It would have been preferable to have the perspectives of these participants in this study for the significance of having alternative viewpoints. Additionally, the study was conducted by a team of investigators affiliated with MMP. It could be possible that the investigators’ background may have influenced participant responses. Furthermore, purposive selection of participants who had adequate information about the topic may have biased the results, which may not have been representative of the population.