Qualitative evaluation of the training (MPE)
Twenty-five participants (9 trainers and 16 trainees) were interviewed for qualitative evaluation of MPE: 18 men, 7 women, 17 in rural and 8 from urban area’s and their characteristics were described in Additional file 1.
Four big themes were identified after the analysis of the data on how the participants experienced the training. These are the setup of the training, the challenges for the success of the training, anticipated challenges for practice as per the protocol of the trial and immediate perceived influences of the training (Fig. 2).
Setup of the training
The participants appreciated the content and its coverage: exploring the perceptions of the cause of malaria and corrections made, the way of transmission and how malaria can be prevented.
“The training was good; it was about how to prevent malaria, cares to be taken, ways of transmission and cause of malaria”-[IM7].
“Language, active participation, correcting misconception and misuse of bed net are good”-[ IM2].
As for the way of delivery participants liked that the training was given in a quiet, disturbance free environment; the training being delivered by well experienced teachers in comprehendible manner and with active participation of the trainee. They also appreciated the mix of participants (both SAC and their parents) involved in the training.
“All students were in classroom except those who are called for the training, so there was no disturbance”- [ IM7]. “The trainer’s education was very nice, really very nice because he was not too hurry; he delivered education slowly in suitable way. In fact, there was no disturbing situation”-[ PAR1]. “Everyone asks and got answer for all questions. We have got the training in this way”-[IM7].
Challenges for the success of the training
The main challenge mentioned was the low attendance that was attributable to several reasons. Some of the parents come to the school late, others hurry to go back for their regular activities, and still some others missed the training at all because of overlapping meetings in the kebele, government employees for their office jobs in the town, weak communication and other regular duties. The parents were sensitized to come to the school for the training by the trained teachers and the selected children. However, the participants argued that communicating the participants through kebele leaders and the village leaders could increase the participant numbers.
“During the training, some people come late, others were absent due to mud in the road and raining as it was raining season”-[IM5].
“As this is town, most people are government employee, merchant and daily laborer. Due to this people responded lately as they are unable to participate. Some others made phone calls to inform that they were unable to participate”-[IM2].
Other challenges were logistics related factors. Participants reported that note taking materials for literate individuals and coffee and tea service provision would reduce the numbers hurrying to go back to their home and wait patiently for those coming late for the training.
“If training room, notebook, coffee and tea are considered, it would be good”-[PAR6].
“what do you say about the need of coffee, tea and others? [Interviewer]. If these were available it would be good. It would help people to sit long time-[IM7].
In one of the schools conflict of interest between the trainer and the headmaster of the school made the training to be started late.
A final challenges for the success of the training was other health emergency. In few of schools, the training was delayed due to public health emergency; children did not resume the regular school activities soon after the control of the emergency.
“There is other public health emergency in our community- even schools were closed for couple of days. After schools are opened, students were not coming to school”-[IM1].
Anticipated challenges for practice as per the protocol of the trial intervention
Two main challenges for implementing the intervention as indicated in the trial protocol were access to the bed nets and perceived low self-efficacy to conceptualize and use the malaria prevention measures. The participants reported that the bed nets that they have were not adequate to prevent their children from malaria.
“The main issue is not on the content, but we need bed net. Cause, manifestation and prevention of malaria were the contents of the training. These were good content those we need”- [PAR6].
The study participants perceive that they were not able to conceptualize the training given at once and need repeated training and follow-up.
“As we are farmers, we may forget it. For this reason, we need the training to be delivered repeatedly”-[PAR8].
Perceived immediate influence of the training
The immediate positive influences reflected by the participants after the training were improved malaria health literacy and intention to change practice. The participants reported that their knowledge on transmission of malaria and the consequences of untreated malaria was improved. Improved malaria health literacy changed participants intention to practice. It was mentioned that the sleeping behavior, sleeping anywhere before the dinner than under the bed net, was seen as bad behavior to be improved to protect children from the bite of mosquitoes.
“Yeah! The strong side was that it was all about malaria. If one of the family members is sick of malaria and not treated early, he/she will transmit it to rest of the family members. Malaria is lethal if not treated, so early treatment and malaria prevention were the messages delivered in the training. I consider this as strong side of the training”-[PAR4].
“I said successful because before the intervention people did not want to have bed net, but after the training was given, they want even to buy for themselves. I think people accepted the message”-[IM6].
“Before dinner children sleep outside the bed net; the only time they sleep under bed net was after dinner which is not good practice. So, the training clarified such ambiguities”-[ PAR6].
ITN use and PDAT of malaria
Consistent Insecticide-treated bed net (ITN) use and prompt diagnosis and treatment (PDAT) of malaria are the output of the trial that the participants should adhere to reduce malaria among SAC. A total of 12 parents of SAC (8 with history of malaria during the follow-up and four without history), five malaria focal persons from the five health centers in the two districts, two directors from the intervention schools and two health extension workers were involved in the interview. The mean age of the participants was 36.6 years with the standard deviation of 6.5 years and 14 of the participants were male in gender (Additional file 2).
There are different themes identified from the analysis of interview with the parents on context specific factors affecting the outputs of the intervention (Fig. 3).
ITN use
Four barriers (quality and quantity of bed net, malaria health literacy, housing condition and bed net associated discomfort) and three facilitators ( perceived at high risk of malaria, collateral benefits and MPE) to ITN were identified.
Barriers to ITN utilization
Participants reported that the warmth inside the bed net was not comfortable to sleep under it. In addition, they view that the bed net attracts the bed bugs, mainly when it gets dirty or not clean and in hot temperature. It was perceived that the hot temperature triggers the bed bugs to be placed on the bed net and become nuisance for sleeping.
“…If it (bed net) becomes dirty, the bed bugs enter into the bed net and become problematic” – [PAR4].
“When the environment becomes hot, the bed bugs came out from where they are hidden. In cold conditions though the bed bugs were there on the bed, they do not came out.” -[PAR1].
“Now the time is sunny. As a result, the bed net is in its rolled place and he(participated SAC) is not using it” [PAR10].
The 2nd important barrier for bed net utilization by SAC was housing condition where they are living. This theme was identified from interview with the key informants. In some large household sizes, it is noted that the area of the house was not adequate to have the required number of sleeping places to properly fix the bed nets. In such conditions, children sleep together in a single temporary make-up bed over which a bed net is fixed; but it did not remain in the fixed place for the whole night.
“In some of the households with larger household size, the area of the house is narrow to have adequate number of sleeping places. As a result of this, people are not using bed nets properly or timely”-[KEY7].
The other housing condition believed to affect the proper utilization of the bed net was the structure of the houses, particularly in rural area. The traditional houses in the rural area were observed as not suitable to fix the bed nets unlike the homes made of corrugated iron sheet with its own sleeping bed rooms in urban areas.
“In the rural areas where the house type is traditional, it is difficult to properly use the bed nets in the rural areas. If the houses are made of corrugated iron sheet with its own bed room, it is convenient to use the bed nets” – [KEY6].
The respondents perceive that there was variation among the participants regarding malaria health literacy. It was felt that those educated people living in the urban area could better adhere to malaria related information delivered than those farmers residing in the rural areas.
“Those who had formal education use the bed nets as instructed by the health professionals”- [KEY6].
The other point was the belief that it is supernatural power that can protect their children from malaria.
“They say it is God that keeps them safe from attack of malaria and they pass the night outside the bed nets”- [KEY7].
Another notion related to the low malaria health literacy was taking the IRS as a replacement of bed nets in houses where it is sprayed and children being given low priority in houses where the bed nets are inadequate for the household members. Some people also appear to be unaware of the importance of using bed nets on a regular basis. These people were aware that mosquitos might spread malaria, yet they were ignorant to use bed nets even after detecting mosquitos in their home.
“Sometimes, even in the presence of mosquitoes, we do not use bed net due to ignorance”- [PAR3].
“Sometimes, if there is spray inside the house, we do not use bed net. During these times, we do not see mosquitoes. The spray destroy the mosquitoes, as result we do not use bed net”- [PAR3].
The other barrier to bed net use is bed net quantity and quality. In case of shortage of bed net, SAC use bed nets only when they share sleeping places together with the prioritized ones or the prioritized ones were not around home.
“The selected SAC did not pass the night under the bed net when the number of children in the household are high. At that time, the selected child passes the night together with her mother. However, when her big brothers went to farm area to keep their agriculture products from wild animals, she passes the night under bed net”-[PAR4].
The size of the bed net and the perceived low protective efficacy of the insecticide impregnated to the bed nets are qualities described as barriers for be net utilization.
“The previous bed nets are strong; it kills anything that lands on it. However, the current bed nets were not strong in killing. The previous one attracts like electric does and kills all insects. A mosquito that makes sound in the house cannot escape the killing of the previous bed net. Thus, we need such bed nets” – [PAR7].
Facilitators of ITN utilization
The participants mentioned three main facilitators to bed net use by the SAC. The 1st one is the observed collateral benefit of the bed net. The bed nets, specifically when the chemical impregnated was strong, destroys all insects those land on the bed net. This, as expressed by the participant, protects the individual sleeping under the bed net from the annoyance of such insects.
“If the bed net is new, it also kills the house flies. The fly that lands on the bed net gets died because the bed net is with the treatment. It also benefits us in this way”-[PAR10].
The 2nd facilitator of bed net use by the SAC was perceived increased risk to malaria. Participants felt that children with repeated attack of malaria should use the bed nets consistently. In addition, they perceive that they were at high risk to acquire malaria due to the seasonal abundance of mosquito and being resident in the lowland area.
“We are using the bed net to protect the entry of mosquito. The mosquito number becomes very high during torche ( local term for summer season)”-[PAR9].
“They use bed nets when they are repeatedly affected by malaria”- [KI7].
Finally, the training they received also supported bed net use. As to the interview with the school director and the parents of SAC, the SAC were seen as actively participating in protecting themselves from malaria by using the bed nets.
“Since he is taught that the children should sleep under the bed net, we hang the bed net properly as instructed during the training. Those who go to the lowland area also take the bed net with them and protect from malaria by using bed net”-[PAR10].
“After following the last malaria prevention education in this school, children were using bed nets in a better way. I am exposed to this while moving from house-to-house for the different reasons”- [KI7].
After the intervention, the participants stated that their malaria health literacy has improved. Their impression of the protective efficiency of bed nets improved, as seen by their restricted usage of bed nets to protect from mosquito bite. Prior to the intervention, participants indicated that malaria was caused by a variety of factors other than mosquito bites.
“It gave us knowledge to care about our children to prevent from malaria”- [PAR5].
“Previously, we take bed net and use it for maize-to expose to sun light. We did this because of poor awareness we have regarding bed net utilization. Now, we are using the bed net only for the protection from bite of mosquitoes”-[PAR6].
In addition, they gained practical skills during the training in using the bed nets and applied it at home, like properly fixing the bed nets. Furthermore, their acceptability of other malaria prevention interventions like spray of the IRS chemical is improved; they were more actively engaged in malaria prevention; and they participate in the dissemination of their knowledge to the neighbors.
“Previously the way how we use the bed net is not like how we are using after the training. In this year, we gave due emphasis to the place where the children pass the night” –[PAR5].
Prompt diagnosis and treatment (PDAT) of malaria
Severeness of malaria symptoms and malaria health literacy influenced the health seeking behavior of parents. How parents judge the severeness of the symptoms influenced whether they would go to a health facility; and this is perceived to be linked to how knowledgeable they were. If the parents view that their child was showing symptoms of sever malaria such as cerebral malaria, called as “bicha woba” in local language, they soon took the sick child for the treatment to avoid death or absenteeism from the school.
“We take soon to the health facility in fear of bicha woba (cerebral malaria). This malaria is placed in the brain” - [PAR11].
“Unless the child is bed ridden and severely affected, we do not take him to the health facility”-[PAR5].
“I did not spend much time after noticing the symptoms of malaria. I prefer to be diseased than my child being diseased”- [PAR11].
“We are rural people that might be the reason”. “What is the difference between people in the urban and rural area?” [interviewer]. “In the urban area, there are people who are more educated, they take the child to the health facility immediately”. “How about the rural?” [interviewer]. Now we are also improving as compared to the previous behavior. Thus, it is lack of knowledge”-[PAR6].
Facilitators of PDAT of malaria
The perceived attitude of the health professionals was another facilitator. They believe that the health care provider diagnosing the child would be angry if the child was presented to the health facility after long duration after onset of malaria symptoms.
“If we delay for longer time, the health professionals in the health center become angry up on us. For this reason, we took her soon to the health center”- [PAR8].
The participants also expressed, that the MPE influenced their behavior in taking a sick child sooner to the health facility.
“Previously, before the training, we may delay up to one month. Now, we wait only up to two days to take the child to the health facility”- [PAR6].
“How MPE training influenced in treatment seeking? [ Interviewer]. “Yes, it benefited us. It benefited us to use antimalaria drugs from the health facility” [PAR8].
Barriers to PDAT of malaria
Poverty was seen as a barrier for PDAT of malaria. The interviewees stated that poor socioeconomic position and lack of cash in rural dwellers' wallets were the identified reasons for the delay in malaria diagnosis and treatment. The other point of view was that once a SAC is diagnosed with malaria in a health institution, they self-medicate against malaria based on previous experience. Furthermore, it was thought that the malaria their children were suffering from should not be familiar with contemporary treatment because such drugs would be required during all the time their child was suffering from malaria. These viewpoints also seem to stem from a perception of being unable to afford the cost of healthcare.
“We are farmers. When the child says, aba (common name for fathers in Ethiopia), I am suffering from headache. Since we do not have money in our pocket, we should look for harvesting our agricultural product to sell. For this reason, we wait for some time hoping that it will be resolved spontaneously”- [PAR5].
“If malaria becomes familiar with modern treatment, it will not respond to this treatment in the future or may also always need that treatment. Tomorrow there will be a time in which we may be in shortage of money, at that time we may face problem if we make the disease familiar with the modern medicine” -[KI7].
The other factors that contributed to the delay in PDAT of malaria were health facility problems: lack of staff, private pharmacies selling antimalaria drugs without prescription and unavailability of drugs in the health centers. Because of these issues at the health facility and lack of a rule requiring parents to obtain a prescription before purchasing antimalarial drugs for their sick children, parents purchase antimalarial drugs without getting a proper diagnosis.
“First, we went to the health post. There is no person to diagnose and treat. Then, we went to the pharmacy and bought antimalarial drug and gave it to her” -[PAR5].
“Some others also purchase drugs from outside and give it to their children. Without any investigation, they take drugs from pharmacy. If the child is previously diagnosed as malaria case, they suspect the next cause of disease as malaria too. Thus, they buy antimalarial drugs from private pharmacy. If I take the child to health center and diagnose by giving blood, it would not be different from the previous disease”- [KI6].
Use of traditional or homemade remedies and religious beliefs were the other reported barriers for PDAT of malaria. People who were strong in their religious beliefs prefer praying for the child by the church leaders than taking their children to the health facility. Some others perceive that the symptom of malaria will go away by the traditional medicine or homemade remedies.
“There are certain traditional medicines which we used. it is …, garlic, fenugreek seed and others to treat malaria” -[PAR5].
“Some do not take the child to the health center. Rather, they wait for the symptom to go away by itself. We will not take the child to the health center. We should take the child to church to pray by the religious leaders”- [KI6].
The last barrier was COVID-19 pandemic. People were afraid of COVID-19 in the early stages of the pandemic, which caused a delay in the diagnosis and treatment of malaria. They conceived that COVID-19 was a disease of health professionals since it was health workers who were first infected by the virus. Fear of contracting the virus from a health institution or quarantine, and a sense that they are unable to adhere to COVID-19 preventative measures such as wearing a face mask, were among the other concerns mentioned.
“The health facility does not allow us to enter the health facility without a face mask. We do not have access to face mask because this is a rural area. Thus, I came back to home”- [PAR12].
“Due to COVID-19, for some weeks, even malaria patients do not come to the health center. This is because of fear of acquiring COVID-19 since about 15 of our staff were diagnosed to be infected by the virus”- [KI4].
“We measure the temperature of those visiting health center. This created fear that they will be quarantined. You cannot easily enter into this health center; rather, you are expected to wash hands, use hand sanitizer and get your temperature taken to screen for COVID-19. They do not know as sample should be collected to diagnose COVID-19”- [KI12].