Community sensitization to improve acceptability of indoor residual spraying (IRS) in Mewat district of Haryana, India: A community-based interventional study

Pawan Kumar Goel; Arun Kumar; Manju Rahi; PL Joshi; VP Maheshwari

doi:10.4103/0972-9062.318319

RESEARCH ARTICLE

Year : 2021 | Volume : 58 | Issue : 3 | Page : 206-212

Community sensitization to improve acceptability of indoor residual spraying (IRS) in Mewat district of Haryana, India: A community-based interventional study

Pawan Kumar Goel¹, Arun Kumar¹, Manju Rahi², PL Joshi³, VP Maheshwari⁴
¹ Department of Community Medicine, Shaheed Hasan Khan Mewati Govt Medical College Nalhar, Mewat, Haryana, India
² General Division of Epidemiology and Communicable Diseases, Indian Council of Medical Research, New Delhi, India
³ National Vector Borne Disease Control Program, India
⁴ Health Department, HQ at Mandikhera, District Mewat Haryana, India

Date of Submission	31-Dec-2019
Date of Decision	02-Sep-2020
Date of Web Publication	15-Feb-2022

Correspondence Address:
Dr. Arun Kumar
Department of Community Medicine, Shaheed Hasan Khan Mewati Govt Medical College Nalhar, Mewat, Haryana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0972-9062.318319

Abstract

Background & objectives: Indoor Residual Spraying (IRS) is an important part of malaria prevention and control strategies for villages with annual parasitic incidence (API) of more than 5, or other criteria by National Program of the country. At the time of conception of the study, i.e., in 2012, district Mewat in Haryana state, India was malaria endemic including 35 malaria high risk villages with API more than 5. The current study aimed to improve acceptability of IRS among the residents of Mewat district.
Methods: This was a community based interventional study. Out of the 14 sub-centers, there were 12 sub-centers catering the population of 79 villages, out of which 35 villages had API of more than five, and hence, fulfilled the criteria for regular IRS. Considering sub-center as the unit of randomization, out of all the 12 sub-centers which cater population of villages with API > 5, equal number of the sub-centers matched according to the population size of those villages were assigned to the intervention and non-intervention (control) groups by randomization using lottery technique. The intervention comprised community sensitization through community meetings, wall paintings and distribution of pamphlets. Baseline and post intervention acceptability of IRS was measured and compared.
Results: There was 21.7% (95% CI 16.12 to 27.15) increase in intention to accept IRS as per guidelines, and 15.2% (95% CI 9.50 to 20.80) increase in the actual acceptance of IRS in intervention group of villages in Mewat district.
Interpretation & conclusion: The intervention can bring about significant increase in the acceptability of IRS which is an important component of malaria control under national programme in district Mewat, Haryana, India.

Keywords: Acceptability; Behavior; Community sensitization; Indoor Residual Spraying; malaria

How to cite this article:
Goel PK, Kumar A, Rahi M, Joshi P L, Maheshwari V P. Community sensitization to improve acceptability of indoor residual spraying (IRS) in Mewat district of Haryana, India: A community-based interventional study. J Vector Borne Dis 2021;58:206-12

How to cite this URL:
Goel PK, Kumar A, Rahi M, Joshi P L, Maheshwari V P. Community sensitization to improve acceptability of indoor residual spraying (IRS) in Mewat district of Haryana, India: A community-based interventional study. J Vector Borne Dis [serial online] 2021 [cited 2023 Mar 30];58:206-12. Available from: http://www.jvbd.org//text.asp?2021/58/3/206/318319

Introduction

According to Census 2011^[1], District Mewat of Haryana State, India has a population of 1089263 with about 89% of population living in rural areas. Malaria was endemic in the District of Mewat. The topography of the district was also favourable for breeding of mosquitoes. According to the office records of District Malaria Officer (Mewat), at the time of conception of the study i.e., in 2012, the total number of positive cases reported during the preceding year were 1567. Malaria has already been prioritized in the National Health Strategic Plan and National Rural Health Mission. The country’s goal is to interrupt indigenous transmission of malaria in a phased manner by 2027 and sustain zero indigenous cases and deaths due to malaria upto 2030 and beyond, to achieve the level desired for certification of malaria elimination status^[2]. According to National Vector Borne Disease Control Program (NVBDCP) strategies to control adult mosquito i.e., indoor residual spraying (IRS) and insecticide treated nets (ITNs) are costly methods and are based on insecticides^[3]. Hence, they are targeted in high risk areas. In spite of the fact that IRS is the preferred method for vector control in areas where summer temperatures are so high that people do not like to use bed nets, its acceptability or usage in the way as recommended has been a great challenge for the implementing authorities. Moreover, IRS would be effective if more than 85% of the households/ structures in the area are covered as per the guidelines^[4]. The acceptability and/or coverage rates of IRS in various studies had been found to be as low as 29% to even above 80%^{[5],[6],[7],[8],[9]}. Poor acceptability of IRS as per guidelines could be because of the barriers like - lack of awareness of beneficial effects or fear of adverse effects like - with blurred vision, dizziness, sneezing/coughing, numbness, watery eyes, or itching^{[5],[6],[7],[8],[9],[10],[11]}. With this background in mind, the investigators planned to assess the effect of community sensitization to improve acceptability of IRS in District Mewat of State Haryana, India.

Material & Methods

Study area and situation analysis of problem of malaria

The study was carried out in district Mewat of State Haryana, India. There are a total of three Community Health Centers (CHCs) located in the district i.e., CHC Nuh, CHC Punhana, and CHC Firozpur Zhirkha. In district Mewat, villages with API more than 5 were located in the area catered by two PHCs i.e., PHC Nuh and PHC Ujina, which fall under the jurisdiction of CHC Nuh. According to the information collected at the time of the inception of study, there were a total of 14 sub-centers under these two PHCs which were providing services to population of 213001 spread over 84 villages. Out of these 14 sub- centers, there were 12 sub-centers catering the population of 79 villages, out of which 35 villages had API of more than five, and hence, fulfilled the criteria for regular IRS. The sub-centers and villages are geographically close enough to permit monitoring by the investigators, but not so close that the intervention activities in the villages of intervention group would affect the control group. Annual Blood Examination Rate (ABER) in the district had been 13.3 percent i.e., more than 10%. Hence, API could be considered as a reliable indicator of malaria situation in the district. Plasmodium falciparum (Pf) %age in those 35 villages was reported as 10.21% and the rest of the parasite was P. vivax. The insecticide which was being used for regular IRS in the district Mewat, was the wettable powder (WP) formulation of deltamethrin 2.5%.

Considering sub-center as the unit of randomization, out of all the 12 sub-centers which cater population of villages with API > 5, equal numbers of the sub-centers matched according to the population size of those villages were assigned to the intervention and non-intervention (control) groups by randomization using lottery technique. Randomization check was also performed to ensure that it was done appropriately and that the intervention and non intervention (control) groups were similar for the important baseline characteristic of API [Table 1].

Table 1: Distribution of baseline characteristic of annual parasite incidence (API) in the intervention and non intervention groups

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Sample size

To have maximum sample size for pre-intervention (baseline) and post-intervention IRS acceptability/usage surveys, assuming acceptability/usage of IRS as 50%, confidence interval (CI) of 95%, design effect of 2 (for 30 cluster sampling technique) and acceptable absolute error of 6%, sample size was calculated to be 534 households. To cover the assumed risk of non-responses of up to 10% among the selected study households, the final sample size was calculated as 587 households. Hence for carrying out pre-intervention (baseline) and post-intervention surveys, a rounded figure of 600 households, a figure higher than the calculated sample size, was chosen as the final sample size for selecting households from each group (i.e., non-intervention or control group, and intervention group).

Sampling technique

Six hundred households were selected separately from each of intervention and non-intervention groups by 30 cluster sampling technique. So, 20 households were selected from each cluster. For identification of the clusters, the villages of the two groups i.e., interventional and non- interventional groups, were listed separately along with their total number of households and populations. Cumulative numbers of households were calculated by adding the households of the next village to the combined total of all the households in preceding villages. Sampling interval for non-intervention and intervention groups were calculated by dividing total number of households by 30. The random numbers having the same number of digits as the sampling intervals and that were less than or equal to the respective sampling intervals, were found for the intervention group and non-intervention group using the last three digits of the serial number on available lowest and highest denomination bank notes respectively. To identify the village in which Cluster 1 was located, the first village in which the cumulative households equalled or exceeded the random number was located and “1,” representing the “cluster number,” was written beside this village in the column entitled “Cluster”. Similarly, ‘2’ was written beside the listed village in which cumulative number of households equalled or exceeded the number calculated by adding sampling interval and random number (i.e., random number + sampling interval). Likewise, clusters 3–30 were identified for both the groups, i.e., intervention and non-intervention groups, by adding the number that identified the location of the previous cluster and sampling interval, and the numbers of clusters so identified were written beside the appropriate village names. Few villages contained more than one such identified clusters. Each such cluster was selected by randomly selecting a different mohalla of the village. The same sampling procedure was repeated while selecting clusters for the post-intervention survey.

Intervention

The villages of the intervention group received the community-based behavior change intervention comprising the following various active community sensitization efforts for improving acceptability and usage of IRS as per guidelines.

Group approach

Sensitization meetings for multipurpose health workers male and female [MPHW(M), MPHW(F)], concerned Accredited Social Health Activists (ASHAs) and anganwadi workers (AWWs) of the villages of interest (six, ie, one for each subcenter)
Sensitization meetings with women self help group (SHG) members belonging to these villages were organized by the field workers under their direct supervision. One meeting in each village i.e., total of 16 such meetings were organized.
Sensitization meetings to promote active participation of and to engage with the community opinion leaders, members of Village Health and Sanitation Committees (VHSC), members of Gram Panchayats and the community members of villages belonging to the intervention group, were organized every fortnight by the SHG members and/or the project field workers at the respective villages.
Mass approach: In each village of the intervention group, two behavior change communication messages in local language were got painted on walls at strategically selected sites, and pamphlets were distributed during and after the community sensitization meetings.

The other group (non-interventional group) did not receive any such additional active intervention. However, routine measures as already in place for these areas (non interventional group) were allowed to continue as such without any modification. Total duration for the period of intervention was 18 months.

Data collection, collation and analysis

Baseline pre-intervention and post-intervention surveys in both the intervention and non-intervention groups were carried out by conducting in-depth interviews of heads of the selected households with the help of trained field workers (FWs) using a predesigned, pretested survey instrument. A respondent with more than 50 percent chances of using IRS as per guidelines during future IRS operations was counted as an “intender” of using IRS as per guidelines and the one with 50 percent or less chances of using IRS as per guidelines was taken as the “non-intender” of using IRS as per guidelines. Similarly, if the respondent had actually used IRS he or she was counted as “user” and a “non-user,” if he had not used IRS due to one reason or the other. The data so collected were entered in Microsoft Excel spreadsheet, collated and analyzed and effect of the intervention efforts was measured as in, change in intention to use IRS as per guidelines and the actual usage of IRS as per guidelines, and conclusions were drawn.

Ethical statement

Written informed consent was obtained from the respondents before conducting the in-depth interviews of the respondents during pre-intervention baseline and post-intervention surveys. Written informed consent from Block Development and Panchayat Officer of the block i.e., supposedly the guardian of the communities of interest, was also obtained for including the villages of the block for participation in randomization, intervention and data collection. Prior approval from the Institution Ethics Committee had also been sought.

Results

Out of the total selected 1200 study participants, 589 out 600 in intervention group and 591 in non-intervention (control) group completed the interview. Hence, the response rate was good (i.e., ~98 percent) for the baseline surveys in both the groups. Response rate during the post- intervention surveys in the two groups was even higher. In the non-intervention group, only 7 out of 600 (1.2%) were the non-respondents i.e., who either refused to participate or did not complete the interview. There was no non-respondent in the intervention group of villages.

Mean age of the participants of baseline surveys in villages of the non-intervention and intervention group was 41.9 years and 44.7 years respectively. Out of 1180 study participants of the pre-intervention baseline surveys in non-intervention and intervention groups, 325 (55%) and 345 (i.e., 58.6%) respectively were the males whereas, 266 (i,e., 45%) and 244 (i.e., 41.7%) respectively were the female participants [Table 2]. In post-intervention surveys, mean age of interview participants was 42 years and 41.2 years in the non-intervention and intervention group respectively. Out of 593 and 600 respondents of the non-intervention and intervention group respectively, 346 (i.e., 58.3%) and 272 (i.e., 45.3%) respectively were males [Table 3].

Table 2: Socio-demographic characteristics of study participants of baseline surveys

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Table 3: Socio-demographic characteristics of study participants of post-intervention surveys

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As compared to the pre-intervention acceptability levels, there is an increase of 21.7% (95% Confidence interval 16.12 to 27.15; p value <0.001) in the intention to use IRS as per guidelines and an increase of 15.2% (95% Confidence interval 9.50 to 20.80; p value <0.001) in the actual usage of IRS as per guidelines in the intervention group [Table 4]. The findings in the non-intervention group evidenced a slight decrease in intention to use IRS as per guidelines (Non-significant; P >0.05). The change in the actual usage of IRS as per guidelines was also non-significant (p value >0.05) in the non-intervention group [Table 4].

Table 4: Effect of intervention as measured by change in intention and actual usage of IRS

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Discussion

Statistically there was no significant difference between the two groups in most of the socio-demographics characteristics. This finding bore out the previous findings of randomization check [Table 1]. In the post intervention survey, the intention to use IRS as per guidelines was found to be significantly higher in the intervention group as compared to that in the villages of non-intervention group. (p < .001). The difference in actual usage of IRS as per guidelines between the two groups was also found to be highly significant. (p < .001). On applying the statistical tool Chi-square test for the intervention group, before and after the intervention, these comparative findings were found to be highly significant i.e., p value <.001 (Chistatistic = 59.127; df =1) for the intention to use IRS as per guidelines and p value <.001 (Chi-statistic 28.213; df =1) for the actual usage of IRS as per guidelines. It is also mentioned here that seasonal IRS operation rounds happened before this change could be observed in post intervention surveys. In the non-intervention group, there was no statistically significant change (p > .05) seen in the intention or actual usage of IRS as per guidelines. This study actually shows that both intention to accept/use and actual usage increased after sensitization. And the difference pre and post intervention was statistically significant. Before the actual performance of a behavior, there is formation of an intention to perform the behavior^[12]. Hence, the results show that the intention to use IRS as per guidelines did translate into the actual usage of IRS.

Most of the studies conducted on the topic have been limited to measuring the acceptability / usage or coverage of IRS^{[5],[6],[7],[8],[9]}. But hardly few have been carried out on measuring the effect of sensitizing efforts to improve the acceptability. The current study was an effort to sensitize the community to improve acceptability/usage of IRS as per guidelines and measure the effect of sensitization efforts. In the current study, the increase in intention to use and actual usage of IRS as per guidelines was seen in the group of villages where the intervention i.e., community sensitization through community meetings with SHGs, community opinion leaders, and wall paintings, and pamphlets distribution, was delivered over a period of 18 months. In simpler words, there was a need to emphasize on the component of community mobilization, participation and acceptance - i.e., without the community engagement and involvement - making any public health programme a success would be difficult.

In a case study carried out in Zambia, success of IRS operation programs was tried to be achieved by suggesting ways focusing on generating better data to improve the accuracy of decision making for targeted IRS^[13]. In this study, community sensitization per se was not part of the assessment though. In a cluster randomized trial conducted in 4922 households in Peru^[14] it was found that among households who had declined to participate/accept previously, advanced planning increased the chances of participation/acceptance in IRS campaign to 2.5 times. However, focus of study was primarily for prevention and control of insect vector for Chagas disease and other vector borne diseases controlled by IRS. Overall, the trial was though viewed by the authors as unsuccessful in improving participation/acceptance in comparison to the ongoing campaign of Ministry of Health^[14].

In the current study, the community sensitization efforts targeted to change the beliefs of the people continued even during non-IRS operation seasons/months of the year. This might have been the contributing factor in improving the acceptability by changing the beliefs of beneficiaries regarding using IRS as per guidelines in the positive direction i.e., its beneficial effects, ways for correctly using IRS, and ways for overcoming the barriers in using it. Some of the people’s thoughts or barriers identified and targeted for change during community sensitization efforts were - only water is used for spraying, spraying causes difficulty to the females in the house, foul smell after spraying causes headache, foul smell will remain for a long time in the sprayed rooms, and spraying will cause loss of work or wages.

The current study had a limitation that the applicability of the findings in areas with different populations, is required to be assessed before generalizing the findings to those areas. But even so, population being relatively homogenous, they can be fairly generalized within the district itself.

In areas where IRS is part of the malaria prevention and control strategies, further research is required to explore the other ways as well to increase the chances of success of the IRS operations. Overall, acceptability to use IRS as per guidelines has increased in the intervention group as shown and discussed above. Behavior Change Communication (BCC) is one of the strategic components of supportive interventions under NVBDCP^[2],[15]. The current study findings add value to this strategy by facilitating its better implementation by adopting the suggested ways to change the behavior of the beneficiaries in the desired direction, by ensuring that these services offered by the NVBDCP program are widely and correctly utilized by families and communities, by inculcating participatory approaches, and hence, ensuring good coverage of IRS.

Conclusion

The intervention described in our study can bring about significant increase in intention to use IRS and actual usage of IRS as per guidelines in district Mewat. The study thus generated evidence on how to improve acceptability and hence implementation of IRS operations component of National Vector Borne Disease Control Program in the district Mewat and other similar areas where malaria is still a problem and would be covered by IRS as per the new operational guidelines^[10].

Conflicts of interest: None

Acknowledgements

The study was funded by Indian Council of Medical Research, New Delhi through competitive Grant-in-aid scheme. The study was part of a larger community based interventional study that was funded by Indian Council of Medical Research, New Delhi.

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