Introducing insecticide treated mosquito nets in the Kilombero Valley (Tanzania) : social and cultural dimensions

Malaria remains one of the most important causes of suffering, death
and poverty. The provision of prompt diagnosis and treatment should
be a key component of any malaria control programme, but in reality
disease management is often not adequate due to weaknesses in the
health systems. Especially in areas, where access to health services and
proper medication is limited and where parasites have become
resistant to anti-malarial drugs, insecticide-treated nets (ITNs) present
an attractive option to complement the other tools in malaria control.
Under trial conditions, ITNs have been shown to have an impact in
reducing clinical malaria episodes and related mortality. A large-scale social marketing programme has implemented ITNs to
reduce child mortality in an area of intense, perennial malaria
transmission in southern Tanzania. The present study formed part of this
programme. It examined social and cultural aspects of the distribution,
delivery, acquisition and use of ITNs, paying particular attention to local
knowledge and practice, interactions between project staff and
villagers and to household dynamics. The main goal of this qualitative
research was to contribute to the improvement of the intervention
process within the framework of the Kilombero Treated Net Project. Fieldwork was carried out in two stages: 1) formative research and 2)
ethnographic monitoring. Formative research began with a community
study in 18 villages from July to August 1996. More contextualized
information on local knowledge and practices about malaria,
treatment and prevention was collected during a short ethnographic
study in two villages between September and December 1996. Based
on the findings from the community study and the focused
ethnographic assessment, a questionnaire was developed for a survey
in four villages. The second stage, ethnographic monitoring, was
designed to capture the interactions and social processes surrounding the project implementation in one particular locality over a period of
time.
An important finding of this study is that people have integrated ideas
derived from biomedical knowledge into their interpretation of malaria.
Villagers commonly use the term maleria but only to refer to a mild and
easily cured type of fever which they see as caused by mosquitoes.
Swahili terms such as degedege (convulsions), bandama (enlarged
spleen) and homa kali (high fever), on the other hand, are used for
conditions that are commonly feared as life threatening, especially for
small children, and - from the biomedical perspective - related to the
complicated forms of clinical malaria. The local interpretations of malaria and related illnesses are closely
linked to the logic of actions taken in specific situations, for instance,
since severe forms of malaria are linked to "supernatural" causes,
identified as attacks of witches and bad spirits, an amulet (hirizi) from a
traditional healer is thought more desirable than an ITN for protecting
(kinga) a vulnerable child. In this context, the promotion of ITNs as an
effective preventive tool may not make much sense from the villager's
point of view. The findings further show that the local understanding of malaria
transmission in the study area acknowledges the mosquito-malaria link.
Moreover, most villagers (52%) already had untreated nets and
insecticide net treatment was not a new idea in the study area.
Although the majority of villagers (76%) are aware of the role of
mosquitoes in malaria transmission, they seriously doubt the link
between severe malaria and mosquitoes. An often heard argument
was: If mosquitoes caused severe maleria, everyone would be dead
by now. Why would vulnerable young children who live in the village
and get bitten by mosquitoes continue to survive? And why would malaria attack people who sleep under nets in a similar way as those
who do not?
These findings clearly show that researchers should not conceptualise
people's knowledge about malaria and its prevention as something
that is there, that belongs to a cultural tradition and remains the same
over time, in other words, as something static. The knowledge which
informs villagers' practices relating to malaria is a result of the
interaction of diverse strands of knowledge from different sources.
Moreover, people's questions and arguments demonstrate that they
do not just have but that they do seek knowledge. On a more theoretical level, knowledge can be seen as a result of
interpretive practices. Such an understanding of knowledge has great
potential for the planning and implementation of interventions. This
study drew attention to the interface between locally available
knowledge and the knowledge brought into the area by the project.
Drawing on a typology developed in research on cultural dimensions
of development (Mundy and Compton 1995), the study examined
processes of social interaction and communication through which
knowledge was constructed, negotiated and reinterpreted. The data
clearly showed that, in addition to a promotional campaign at the
beginning of a project, a continuous dialogue between the project
and the villagers is needed to enhance the sustainable delivery,
distribution and use of ITNs over time. In the last analysis, an ITN intervention can only be sustainable, if
people implement it at the household level. Therefore, an investigation
into social and cultural aspects of effectiveness includes an
examination of social interactions within and across households.
Households play an important role in day-to-day health production.
More precisely, it is not the household but different members of a
household who produce health; what each of them contributes is, to a large extent, defined by gender. Headship is often used as a proxy for
gender relations. This study shows that headship is a meaningful
analytical category, it should not be assumed but investigated in
particular settings. Moreover, the study argues that headship is closely
associated with the acquisition, ownership and use of ITNs. According
to the dominant gender model in the study area, the husband provides
household necessities, and the wife depends on his good will and
economic ability. If women live by themselves or with children and
head a household, their own skills to generate income determines their
acquisition, ownership and use of ITNs.
This study demonstrates that a dynamic view of malaria related
knowledge and practice opens innovative lines of inquiry which may
contribute to enhancing the effectiveness of ITN interventions.