Magaço et al. Malar J (2019) 18:27 https://doi.org/10.1186/s12936-019-2653-x Malaria Journal RESEARCH Open Access Community knowledge and acceptance of indoor residual spraying for malaria prevention in Mozambique: a qualitative study Amílcar Magaço1*, Carlos Botão1, Pedroso Nhassengo1, Mohomede Saide1, Arminda Ubisse1, Sérgio Chicumbe1 and Rose Zulliger2 Abstract Background: Malaria control remains a leading health challenge in Mozambique. Indoor residual spraying (IRS) is an efective strategy to control malaria transmission, but there are often barriers to reaching the coverage necessary for attaining maximum community protective efect 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 accept- ability 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 mem- bers, 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 feld 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 efcacy. The main factors that participants mentioned as having infuenced their IRS acceptance or refusal were: understanding of IRS; community leader level of support; characteristics of IRS programmatic implementation; environmental, political and historical factors. Specifcally, 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 efectiveness. 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 conficts, difculty in removing heavy or numerous household assets, and preference for insecticide- treated nets over IRS. Conclusions: Acceptance of IRS was infuenced 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. Keywords: Malaria, Indoor residual spraying, Acceptability, Mozambique *Correspondence: [email protected] 1 Sistemas de Saúde, Instituto Nacional de Saúde, Ministério da Saúde, Moçambique, Maputo, Mozambique Full list of author information is available at the end of the article © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Magaço et al. Malar J (2019) 18:27 Page 2 of 12 Background protection. Individual and household level protection Malaria is one of the leading public health problems in is largely derived from community level coverage [10, Mozambique where the national prevalence in children 11]. Tus, the WHO has emphasized the importance of between 6 and 59 months of age was 40% in 2015 [1]. community acceptance and cooperation for successful Prevalence was even higher in the two most populous IRS implementation [9]. Tis is critical as a study from provinces of the country, Zambézia and Nampula, where diverse epidemiological settings found that malaria pro- approximately two-thirds of children under fve were tection from IRS was much more strongly associated infected [1]. Malaria accounts for approximately 45% of with high community level coverage than with household outpatient clinic visits, 56% of pediatric ward admissions acceptance [12]. and 29% of all deaths in hospitals [2]. Malaria is endemic Mozambique has a long history of IRS implementa- throughout the country and considered to have stable tion dating back to the 1940s [13], but the NMCP has transmission, despite epidemic peaks generally related struggled in recent years to achieve the desired cover- to the rainy season [3]. Important progress has been age in areas targeted for IRS in parts of the country. For made in reducing malaria mortality in Mozambique, but example, in 2016 the reported IRS coverage of structures the overall burden of disease reported in routine health found by spray operators in Zambézia, the province with service data has steadily increased in recent years. In the highest burden of malaria in the country, ranged 2017 there were over 9.5 million malaria cases reported between 72 and 89% [14]. Given the inherent challenges throughout the country [4]. in identifying the houses that should be included in the Te cornerstone of malaria control in Mozambique is spray coverage denominator [10], the true community early diagnosis and treatment of malaria cases with efec- coverage was likely even lower. Tis challenge is not, tive drugs and vector control [4]. Te primary malaria however, unique to Mozambique as community level vector control interventions are universal distribution coverage was found to be poor throughout sub-Saharan of insecticide-treated mosquito nets (ITNs) through- Africa [11], underscoring the importance of identifying out the country and indoor residual spraying (IRS) with factors to facilitate better coverage. non-pyrethroid insecticide in districts with evidence of Evidence from other African settings demonstrate that pyrethroid resistance, continued high transmission of numerous factors motivate and inhibit IRS acceptance. malaria, and/or that are targeted for malaria elimina- For example, a 2010–2011 qualitative study in Tanza- tion by regional initiatives [4]. In Mozambique, the main nia found that level of education, lack of understanding vectors of malaria are endophagic (feeding indoors) and of IRS efectiveness, fears of increases in other insects, endophilic (resting indoors), which makes these vectors potential side efects of IRS, embarrassment at removing vulnerable to ITNs and IRS [2, 4, 5]. Tere is now wide- limited household possessions, and association of the IRS scale resistance to the pyrethroid insecticides on the ITNs campaign with politics infuenced IRS acceptance [15]. A used in Mozambique [2, 4–7] which has underscored the 2015 quantitative study from Uganda noted that the most importance of using more efective insecticides, whether important barrier to IRS acceptance was fear of adverse delivered with IRS or ITNs. Presently, IRS ofers a greater efects from insecticide and that age, socio-economic sta- variety of efective insecticides for malaria control than tus, prior IRS experience, belief that IRS was benefcial ITNs and is a critical tool for management of insecti- and roof composition were associated with IRS accept- cide resistance. As such, understanding of social factors ance [16]. afecting coverage and acceptance of IRS is needed. Prior research in Mozambique from 2006 to 2008 in a IRS for malaria prevention has the potential to be a district with a low burden of malaria found limited per- highly efective strategy for malaria control, particularly ceived efcacy of IRS for malaria prevention; however, in the presence of pyrethroid resistance, but its efective- participants accepted IRS in their homes based on trust ness is contingent upon achieving high coverage through and compliance with community leaders and health vectorial mass efect [8]. Te World Health Organiza- authorities, the perceived efect of IRS on other insects, tion (WHO) recommends coverage of greater than 85% and trusted relationships with spray operators [17, 18]. of households in a community in order to have commu- Another study in southern Mozambique of malaria pre- nity-level protective efect [9]. IRS works to interrupt vention preferences during pregnancy noted that IRS was malaria transmission through killing and repelling mos- the least preferred prevention strategy [19]. quitoes, thereby reducing vector density, longevity and Te relevance of these data to high burden areas and transmission. Importantly, it is most efective in prevent- in the context of next generation insecticide products ing transmission of malaria after feeding, underscoring is unknown. As such, this study sought to determine the importance of high IRS coverage at the community factors associated with IRS acceptance in the highest level in order for there to be household and individual burden provinces of Mozambique in order to guide Magaço et al. Malar J (2019) 18:27 Page 3 of 12 development of strategies to improve acceptance of Data collection IRS in