Household knowledge and practices concerning malaria and indoor residual spraying in an endemic area earmarked for malaria elimination in Iran
Madani et al. Parasites & Vectors
Household knowledge and practices concerning malaria and indoor residual spraying in an endemic area earmarked for malaria elimination in Iran
Abdoulhossain Madani 1
Moussa Soleimani-Ahmadi 0 1
Sayed Hossein Davoodi 2
Alireza Sanei-Dehkordi 0
Seyed Aghil Jaberhashemi 4
Mehdi Zare 3
Teamur Aghamolaei 1
0 Department of Medical Entomology and Vector Control, Faculty of Health, Hormozgan University of Medical Sciences , P.O. Box: 79145-3838, Bandar Abbas , Iran
1 Social Determinants in Health Promotion Research Center, Hormozgan University of Medical Sciences , Bandar Abbas , Iran
2 Department of Nutrition Research, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences , Tehran , Iran
3 Department of Occupational Health Engineering, Faculty of Health, Hormozgan University of Medical Sciences , Bandar Abbas , Iran
4 Bashagard Health Center, Hormozgan University of Medical Sciences , Bashagard , Iran
Background: Indoor residual spraying of insecticide (IRS) is a key intervention for reducing the burden of malaria infection. Effectiveness and success of this strategy are to a considerable extent dependent on knowledge and practice of the target community regarding the IRS. Iran has entered the malaria elimination phase, and IRS has been considered as the main strategy for malaria vector control. Therefore, this study was conducted to determine the household knowledge and practices about malaria and IRS in Bashagard County, one of the malaria-endemic areas in the southeast of Iran. Methods: A community-based cross-sectional survey was conducted among 420 households in Bashagard County. The participants who were selected using a two-stage randomized cluster sampling procedure were subjected to a tested structured questionnaire. During the survey, direct observations were made concerning the use of IRS as well as housing conditions. The data were coded and analysed using SPSS version 19. Results: Knowledge levels about malaria as a disease and the mosquito as its vector were high and of equal magnitude (85.5% and 85.4%, respectively), while knowledge levels of IRS were even higher (91.6%). The main source of households' information about malaria and IRS was primarily community health workers (73.3%). Despite positive perceptions towards IRS only 26.7% of respondents had sprayed their houses which is lower than the WHO targeted coverage of 80%. Respiratory disorders and headache (33.3%), food contamination (24.9%), discolouring of inner house walls (17.7%), difficulty in furniture's movement (13.8%), and unpleasant odour (10.4%) were the main reasons for IRS refusal. Conclusion: There is a discrepancy between knowledge about symptoms and the transmission route of malaria and control practices related to IRS use. Therefore, IRS campaigns accompanied with education for behaviour change should be considered to ensure householders' participation and cooperation in the IRS programme. Moreover, continuous evaluation and monitoring of IRS as well as conducting more surveys on knowledge, attitude, and practices are recommended to improve malaria control measures and to identify indicators for effective, successful, and sustainable malaria elimination programme.
Malaria; Knowledge; Practices; Household; Indoor residual spraying; Iran
Malaria remains a major contributor to worldwide disease
burden and is currently endemic in 91 countries [
2015, approximately 212 million new cases of malaria
were diagnosed, and about 429,000 people died from
malaria worldwide [
In Iran, the malaria eradication campaign was initiated
in 1951 and changed to malaria control in 1985 as a result
of constraints and challenges [
]. Iran has been in the
current elimination phase since 2010. In 2009, the number
of malaria cases in Iran were 6122, and it was reduced to
720 in 2015 [
Iran, as in other malaria-endemic countries, has employed
effective vector control measures including indoor residual
spraying (IRS), long-lasting insecticidal nets (LLINs), and
application of larvicides as the main vector control
]. Challenges to the elimination of malaria in
low socioeconomic areas, such as Bashagard County,
include the inability to sustain control programmes due to
community perceptions and practice for malaria control.
Promotion of community participation through health
education and communication programmes can be
considered as a strategy against these challenges.
IRS is the large-scale application of insecticides to
spray the interior of homes for killing mosquitoes. It
remains one of the main components of the malaria
control strategy, which aims to prevent parasite transmission
through interventions targeting Anopheline vectors [
IRS has been employed to eliminate malaria from different
malaria endemic areas including Europe, Asia, Latin
America, and Africa . National malaria control
programmes in the 91 endemic countries reported that 106
million people worldwide were protected by IRS in 2015
]. Several factors which influence the effectiveness of
IRS interventions include spraying coverage, type of
insecticide, type and situation of houses, community
awareness and cooperation, household acceptance, and
informing the households about the programme benefits
and spraying time during the spraying campaign [
Spraying coverage is also dependent on the household’s
perception of the effectiveness of IRS programme against
mosquitoes and other nuisance insects, as well as the
number and intensity of unwanted side effects [
perceived side effects of indoor insecticide spraying can
decrease the acceptance of these types of interventions
]. It is thus necessary to understand community
knowledge about house spraying for the IRS programmes to be
Previous studies have demonstrated that communities
have positive expectations when interventions such as
IRS are introduced [
]. However, they may refuse
IRS due to their concerns about IRS with regards to
chemicals being a health hazard or doubts about its
According to the recent reports, almost all areas of
Iran are considered as malaria-free, except some regions
in the south-east of the country which are still
considered as endemic malaria area [
]. Bashagard is one of
the malaria-endemic regions in this area with two
seasonal peaks in autumn and spring. In this county 1406
cases of malaria were reported during 2008–2015, out of
which 1394 (99.15%) and 12 (0.85%) cases were
attributed to Plasmodium vivax and P. falciparum,
respectively (Bashagard Health Center, unpublished data, 2015).
Six species including Anopheles stephensi, An. fluviatilis,
An. dthali, An. culicifacies, An. superpictus and An.
pulcherrimus have been reported as malaria vectors in this
]. One of the WHO recommended
strategic approaches for malaria elimination by the use of
indoor residual spraying programmes which are highly
dependent on pyrethroid insecticides [
]. Regarding this
recommendation, IRS has been focused on, by Iranian
Ministry of Health and Medical Education as the main
component of the malaria vector control intervention
]. The target of National Malaria Control
Programme is to cover at least 85% of all targeted
households to achieve community coverage sufficient to
interrupt transmission of malaria [
Community participation is the key component of
malaria elimination programmes, and improved
community knowledge of malaria control methods can promote
preventive practices against malaria [
]. To achieve
efficient IRS coverage, a key factor is identifying and
addressing the behavioural factors that may lead to IRS
refusal. Increasing the community knowledge about
malaria and IRS will lead to behavioural changes which
would help in designing sustainable malaria control
programmes . In line with assuring for sustainability of
the malaria elimination programme in Iran, this study
was conducted to determine the community knowledge
and practice about malaria and IRS, as a preventive
strategy, in Bashagard County, southeast of Iran.
Bashagard County is located between 26°04′–26°58′N
latitudes and 57°23′–59°02′E longitudes in Hormozgan
province, southeastern Iran, with an estimated population
of 40,037 individuals in 2015. The climate in Bashagard is
categorized as tropical dry, with mean annual temperature
of 28.4 °C ranging from 18.8 °C to 37.4 °C, and a relative
humidity between 18 and 38%. The average annual rainfall
is about 251 mm (Fig. 1). Water bodies such as rivers and
streams normally exist in the area. The county is mostly
mountainous and hilly, with scattered population
inhabited mainly close to rivers. The villages are small and
relatively difficult to access with a low population who live in
houses made of cement blocks and shelters (Fig. 2).
Farming and livestock herding are the main economic
activities in this County. Malaria transmission occurs in
this area year-round with peaks after the two rainy seasons
(April-June and October-December), and Plasmodium
vivax accounts for the majority of malaria cases [
this region, IRS activities began in 1953, and since then at
least two campaigns per year has taken place [
This community-based cross-sectional study was
conducted between January and March 2016 in
Sample size calculation
Assuming expected knowledge regarding malaria and
IRS to be 50% and the desired precision of 5%, the
sample size determined to be 420 [
Inclusion criteria included being a permanent member
of the community, being an adult (a woman or head of
the household), and being resident in the sprayed
houses. The exclusion criteria were being unable to
communicate normally and non-cooperative households
who refused to furnish necessary information. A
twostage randomized cluster sampling procedure was used
to select the participants. In the first stage, six villages
with similar epidemiological and topographical
characteristics, where IRS has been ongoing, were randomly
selected (Fig. 3). In the next stage, 70 households were
selected from each village randomly. Since the fathers of
families were mostly out of the house to work, mothers
were interviewed using a pre-tested structured
questionnaire. In case that mothers were absent, another adult
member was interviewed instead. Questionnaires were
filled via face-to-face interviews conducted by trained
research assistants and supervised by the chief investigator.
The questions included respondents’ sociodemographic
characteristics and knowledge and practices about malaria
and IRS focusing on malaria symptoms and transmission,
IRS coverage, the frequency of spraying, and positive and
negative effects of the IRS programme.
As part of the data collection process, a checklist was
completed through direct observations to investigate the
use of IRS as well as housing conditions including water
containers, indoor plumbing, construction materials,
and status of windows.
The data were coded and then analyzed using SPSS
version 19. Descriptive statistics were used to determine
averages, relative frequencies and percentages of the
variables. Chi-square test was used to determine the
association between the knowledge and practice
regarding malaria and IRS and different variables. The results
were considered significant at 5% levels of significance
(P < 0.05).
A total of 420 households participated in this study. The
age of participants ranged from 17 to 75 years with an
average of 29.8 years. The majority of the women had no
formal education (55.8%), and 32.3% had completed
primary school education. Most of the participants
(96.5%) were unemployed and engaged in housework;
others were self-employed, farmer/stockbreeder, and
office workers. The average family size was 4.9 individuals
and ranged from 1 to 11 people. Socio-demographic
characteristics of the study population are illustrated in
About 42% of households had a home constructed of
cement blocks, and 8.3% of houses had screens over the
window openings (Table 2). More than half of the
participants were living in sheds which were made of palm
leaves (56.8%), where domestic animals were mostly kept
in the sheds (86.4%). About half of the population
(50.7%) had access to piped water, 91.7% had electricity
in their houses, and 60.4% had cooler (evaporative cooler
or air conditioner) in their houses. More than half of the
houses (62.5%) were built within 20 m of domestic animal
shelters such as chickens, goats, and sheep (Table 2).
Malaria knowledge and practices
The majority of the study population (85.5%) knew
about malaria as a disease, and 85.4% of them knew that
malaria is transmitted through a mosquito bite and level
of knowledge was significantly associated with the level
of education (χ2 = 3.41, df = 4, P = 0.03) (Table 3). This
study showed that some respondents had
misunderstandings about malaria transmission causes considering
the responses such as eating contaminated food, drinking
dirty water, and inhaling polluted air they gave (Table 3).
The most commonly mentioned symptoms of malaria
were fever (81.1%), followed by a chill, joint/muscle pains,
and nausea (Table 3). About half of the respondents
(53.3%) mentioned having experienced cases of malaria
infection in their family within the past 5 years (Table 3).
The households who had a case of malaria infection in
their family had a better knowledge of malaria symptoms
compared to those with no history of malaria infection
(χ2 = 7.26, df = 4, P = 0.01).
Stagnated water considered by the majority of the
respondents (75%) as breeding place of mosquitoes,
although garbage also was mentioned as a breeding place
(Table 3). Statistical analysis revealed a significant
association between correct knowledge of mosquito breeding
places and educational level of households (χ2 = 4.28, df =
2, P = 0.001).
More than half (56.4%) of households reported they
stored drinking water in containers inside the houses
and 82% of them reported that they covered the water
containers. The majority of respondents (83.3%) had
LLINs, and approximately 69% reported that they
covered the windows using mosquito screen.
Most of the participants reported LLINs, IRS, the
screen on doors/windows, and chemoprophylaxis as
preventive measures against malaria transmission (Table 3).
The proportion of households with higher levels of
knowledge on prevention and transmission of malaria that used
preventive measures was significantly higher than in
households with lower knowledge.
Community health workers were reported to be the
main source of households’ information about malaria and
IRS. Other information sources were mass media including
television, radio, newspapers, and books (Fig. 4).
Knowledge and practice regarding IRS
This study’s results showed that most of the respondents
(91.6%) had previously heard that insecticides were used
for IRS. Out of those who had heard of IRS, 88.2%
reported that IRS would be beneficial. A significant
association was found between IRS acceptability and malaria
knowledge of respondents (χ2 = 6.42, df = 2, P = 0.002).
In addition, most of the respondents (73.1%) mentioned
that IRS should be conducted every six months and
1.9% said they did not know the frequency of IRS.
Details of spraying frequency are shown in Table 4.
The results also showed that 26.7% of all the surveyed
households had been sprayed in the previous summer
and out of them, 65.6% reported that spraying was
useful. The majority of the participants (96.6%) reported
that several days before the spraying, they had received
information about the IRS campaigns and community
health workers were the main source of their
Protection against anopheline mosquito bites was
reported to be the main reason for using IRS (82.1%).
The other reasons were protection against other insects’
nuisance (10%), and scorpion stings (5.7%) and a few of
the respondents (2.1%) reported that they did not know
the importance of IRS application. The results revealed
that there was a significant association between IRS
acceptability and the level of education of households
(χ2 = 8.62, df = 6, P = 0.02). Some of the perceived
negative health effects of IRS were an unpleasant odour,
respiratory disorders, and headache. Difficulty in
furniture’s movement, discolouring of inner house walls by
insecticide, and contaminating the foods were other
reported reasons for IRS refusal (Fig 5).
About 43% of study populations lived in simple houses
made of cemented bricks with plastered cement walls.
Most of the plastered cement walls (82.3%) were smooth
with surfaces that lent themselves well to insecticide
treatment. The results of the analysis indicated a
significant relationship between the IRS acceptability and
building materials (P < 0.001). Out of all households, 54.2%
who were living in cemented brick buildings rejected IRS
campaign. The exact parts of the houses to be sprayed
with the insecticides are shown in Table 4. In this regard,
most of the respondents (47.1%) mentioned that the
surfaces of inner walls and roof should be sprayed.
According to the results, most of the respondents
(75%) were interested in taking part in IRS campaign
voluntarily (Table 3). A statically significant relationship
was observed between the educational levels of
households and their interest in participating in IRS
programme as a volunteer (χ2 = 4.12, df = 4, P = 0.032).
This study was conducted to provide baseline information
on knowledge and practices regarding malaria and IRS
which can be used in decision-making processes, the
design of sustainable interventions with active community
participation, and the implementation of educational
programmes towards the prevention and control of malaria.
This study showed a high level of knowledge about
malaria transmission and symptoms in the study
population. Similar findings have also been reported from other
malaria-endemic areas in the southeast of Iran [
10, 14, 19
Also, high awareness of people about malaria transmission
and symptoms has been reported from other
malariaendemic countries including Malaysia, Saudi Arabia,
Swaziland, Ethiopia, Ghana and Tanzania [
Results of this study showed that Community Health
Workers were the main source of household’s
information about malaria and IRS. This finding is consistent
with findings in other studies from different malaria
endemic regions around the world which indicates that
Community Health Workers are frequently in contact
with people [
21, 25, 26
]. This is in contrast to findings
from a recent study conducted in Saudi Arabia, India
and Uganda that reported the social media as the
primary source of malaria information [
20, 27, 28
Access to Community Health Workers and
communication facilities had previously been reported to play an
important role in prevention and control of malaria [
This study revealed a significant relationship between
knowledge levels of the households about malaria
symptoms and the history of malaria infection in the family.
High awareness of the symptoms of malaria, which is a
key to seeking early treatment, has been reported in
populations in endemic malaria areas where people
frequently suffer from malaria infection [
25, 30, 31
Understanding the treatment-seeking behaviours in
populations will assist in identifying the possible barriers to
surveillance and response activities that might exist such as
reasons for delays in diagnosis and treatment. Moreover,
understanding community behaviour about
treatmentseeking will assist in the sustained community and health
system efforts that will be required to prevent the
resurgence of malaria following elimination [
In this study, the majority of the participants knew
that mosquitoes transmit malaria and awareness about
malaria transmission were positively associated with the
age and seeking treatment. High levels of awareness
about malaria transmission in the studied area can be
explained by long-term exposure to malaria over the
years and receiving information from health workers.
Contrary to these findings, in other malaria-endemic
countries such as Malaysia and Malawi only those with a
higher level of education knew about the symptoms and
vector of malaria [
]. In this regard, results of some
studies indicate that improving the community’s
knowledge of malaria transmission can greatly contribute to
prevention and success of control measures [
Results of this study revealed that majority of the
participants knew stagnated water as a breeding place of
malaria vectors. This finding is consistent with findings
in other studies in Iran which revealed high knowledge
of people about mosquitoes breeding places [
Similar results have been reported from other
malariaendemic countries such as Tanzania, and India [
Awareness of mosquitoes breeding site could influence
parameters which are involved in the vector control
including the selection of residential areas and use of preventive
methods aiming to decrease mosquito population density.
According to the results, more than half of households
lived in poorly constructed houses and lacked window
mosquito screens. Poor and inappropriate housing
conditions have been proved to be associated with
insufficient mosquito protection practices and a higher risk of
malaria infection [
]. Other studies have shown that
in areas with low to moderate transmission, improving
house design and using mosquito screens decreases
mosquito densities and reduces malaria transmission
]. Furthermore, mosquito screens for houses are
an appropriate, affordable, long-lasting, and acceptable
protection method used in different communities [
This study indicated that despite having positive
perceptions towards IRS, a large number of participants in
the study population did not apply it. In this regard,
82.1% of the studied population mentioned IRS as an
effective preventive measure against malaria vector, but
only 26.7% of the houses had been sprayed as reported
by the participants. This rate of IRS coverage is lower
than 80% which is the targeted coverage by WHO [
Although this rate of IRS coverage is more than
previously reported data from Iran [
], it is considerably
lower than those reported form other malaria-endemic
countries, such as Swaziland, Mozambique, Namibia,
and Haiti [
]. Therefore, the IRS coverage in
the study area is much lower than the level required for
effective control of the malaria vector.
According to our results, one of the explanations for
such low IRS coverage can be a negative perception about
it due to suspected IRS negative health effects, difficulty in
furniture’s movement, and discolouring of inner house
walls by insecticides. These results are consistent with the
findings from other studies that reported insecticide smell,
the mess left by the sprayers, the inconvenience of
removing household items from houses before spraying as the
causes of IRS refusal [
]. Moreover, other causes of IRS
refusal have been reported to be poisoning of domestic
animals, poisoning of children, and infertility of family
]. Another reason for low IRS coverage in this study, as
it has been reported from endemic malaria areas in
Uganda, Yemen and South Sudan, can be the perceived
low susceptibility and exposure to malaria infection as
well as the perceived low severity of malaria infection in
the community [
44, 46, 47
The effectiveness of IRS in malaria control is the main
reason Iran adopted IRS as the main control strategy.
However, it is of concern that IRS coverage was very low
in the study population. This is especially so in light of
the malaria elimination phase status which Iran carries.
Therefore, efforts should be made for increasing the IRS
coverage through promoting the attitude and practice of
households regarding IRS for effective malaria control.
There is a discrepancy between knowledge about
symptoms, transmission route and control of malaria and use
of IRS. Low socio-cultural and socio-economic status of
the community are the main limitations to sustainable
malaria elimination. These factors, along with community
attitudes and practices, ultimately influence community
participation in malaria elimination despite high
knowledge. There is need to facilitate correct attitudes towards
IRS use in Bashagard county if the disparity between
knowledge and use should be bridged. Therefore, IRS
campaigns accompanied with education for behaviour
change should be considered as key elements for malaria
control in the studied population. Moreover, continuous
monitoring and evaluation of IRS and conducting more
surveys on knowledge, attitude and practices are
recommended to improve malaria control measures and to
identify indicators for successful and sustainable malaria
IRS: Indoor residual spraying; LLINs: Long-lasting insecticidal nets
The authors would like to appreciate the collaboration received from
Dr Darakhshan, Head of Bashagard Health Center for his logistic
support for collecting samples. We are also thankful to personnel of
the Bashagard Health Center for their cooperation in the field. This
study received financial support from Research Deputy of Hormozgan
University of Medical Sciences (Project.
This research has been funded by Research Deputy of Hormozgan University
Sciences (Project No. 586).
Availability of data and materials
The datasets supporting the conclusions of this article are included within the
MSA, AM, ASD, SHD and MZ conceived and designed the study. MSA and
MZ drafted the manuscript. MSA, AM and TA analysed the data. MSA and
SAJ coordinated in field activity, collected data and trained field researcher.
All authors read and approved the final manuscript.
Ethics approval and consent to participate
The participants were informed about the objectives and procedures of the
investigation. They signed an informed consent document to ensure the
willingness of participation and they were free to withdraw from the study
at any time. Identification numbers were used instead of participant names
to maintain the confidentiality throughout the study. This study has been
registered and approved by Hormozgan University of Medical Sciences
Ethical Committee (No. 586). Study registration date: November 25, 2014.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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