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Tropical Medicine and International Health Community factors associated with malaria preventionby mosquito nets: an exploratory study in ruralBurkina Faso Jane Okrah1, Corneille Traore´2, Augustin Pale´2, Johannes Sommerfeld3 and Olaf Mu 1 Ministry of Health, Public Health Division, Accra, Ghana2 Centre de Recherche en Sante´ de Nouna, Nouna, Burkina Faso3 Department of Tropical Hygiene and Public Health, Ruprecht-Karls-University, Heidelberg, Germany Malaria-related knowledge, attitudes and practices (KAP) were examined in a rural and partly urbanmultiethnic population of Kossi province in north-western Burkina Faso prior to the establishment of alocal insecticide-treated bednet (ITN) programme. Various individual and group interviews wereconducted, and a structured questionnaire was administered to a random sample of 210 heads ofhouseholds in selected villages and the provincial capital of Nouna. Soumaya, the local illness conceptclosest to the biomedical term malaria, covers a broad range of recognized signs and symptoms.
Aetiologically, soumaya is associated with mosquito bites but also with a number of other perceivedcauses. The disease entity is perceived as a major burden to the community and is usually treated by bothtraditional and western methods. Malaria preventive practices are restricted to limited chloroquineprophylaxis in pregnant women. Protective measures against mosquitoes are, however, widespreadthrough the use of mosquito nets, mosquito coils, insecticide sprays and traditional repellents. Mosquitonets are mainly used during the rainy season and most of the existing nets are used by adults, particularlyheads of households. Mosquito nets treated with insecticide (ITN) are known to the population throughvarious information channels. People are willing to treat existing nets and to buy ITNs, but only if suchservices would be offered at reduced prices and in closer proximity to the households. These findingshave practical implications for the design of ITN programmes in rural areas of sub-Saharan Africa (SSA).
keywords Africa, malaria control, mosquito nets, insecticide, community, Burkina Faso correspondence Olaf Mu¨ller, Department of Tropical Hygiene and Public Health, Ruprecht-Karls-University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany. E-mail: [email protected] interest as a tool in malaria control. In Africa, five major trials in areas of different malaria transmission intensities Of the estimated annual 300–500 million clinical malaria have documented a reduction in all-cause mortality of cases and 1.5–2.7 million deaths that are directly attribut- young children associated with ITN protection (Alonso able to malaria, the great majority occur in young children et al. 1991; D’Alessandro et al. 1995; Nevill et al. 1996; of remote rural areas of sub-Saharan Africa (SSA) (WHO Binka et al. 1997; Habluetzel et al. 1997). A meta-analysis 1997; Snow et al. 1999). As malaria control mainly relies of all randomized controlled trials showed an overall on early diagnosis and prompt treatment with effective and protective efficacy against all-cause mortality and malaria affordable first-line antimalarial drugs, the rapidly increas- disease episodes of 18 and 45%, respectively (Lengeler ing level of resistance to chloroquine in SSA is likely to contribute substantially to observed reversals in child ITNs have since become an integral part of the global mortality rates (Mu¨ller & Garenne 1999; Trape 2001).
malaria control strategy and the global ‘Roll Back Malaria’ For more than two decades now, insecticide-impregna- partnership (World Bank 1993; Nabarro & Tayler ted bednets and curtains (ITN) have raised renewed 1998). Until today, the distribution of ITN through the Tropical Medicine and International Health J. Okrah et al. Community factors associated with mosquito nets governmental health system and the sale through the examined issues of acceptability of ITNs by the local private sector by a social marketing approach are the two major strategies for implementing community-based ITNinterventions in SSA (Lines 1996).
To date, however, experience with local factors influ- encing the effectiveness and sustainability of ITN pro- grammes remains limited. In the Gambian NationalImpregnated Bednet Programme (NIBP), the introduction Our study was conducted in the research zone of the Centre of fee-for-service was accompanied by a sharp drop in de Recherche en Sante´ de Nouna (CRSN), Burkina Faso impregnation coverage from 85% during the first year to (Kouyate´ et al. 2000). Nouna, the capital of Kossi province, 14% in the second year (D’Alessandro et al. 1995). An is situated about 280 km northwest of Ouagadougou. The evaluation of the activities of the NIBP during its third CRSN study area comprises Nouna town (20 000 popula- year showed that offering insecticide through private tion) and a rural area of 41 villages (35 000 population).
channels leads to increased impregnation coverage, and Most of the population belongs to the Marka, Mossi, that providing insecticide through maternal and child Bwaba, Peulh and Samo ethnic groups. The main socio- health services is effective in targeting young children economic activity is subsistance farming. Malaria is holo- (Mu¨ller et al. 1997). More recently, in Tanzania, a major endemic but markedly seasonal, with most transmission ITN social marketing pilot project achieved high coverage and disease occurring at the end of the rainy season, which of the intervention, which was associated with a sub- usually lasts from June to October (Mu¨ller et al. 2001).
stantial reduction in malaria morbidity in young children The study focused on 10 of the 41 rural CRSN study (Armstrong-Schellenberg et al. 1999; Abdulla et al. 2001).
villages and all sectors of Nouna town. The villages were Prior to the intervention, a number of ITN programmes purposely selected to represent the rural study population conducted community-based research to elucidate com- in its socio-cultural, demographic and geographical munity knowledge, attitudes, and practices (Procacci et al.
1991; Aikins et al. 1993, 1994; Ettling et al. 1994;Gyapong et al. 1996; Van Bortel et al. 1996; Vundule & Mharakurwa 1996). Much of this research was basedexclusively on survey research. Only in the late 1990s, The study was exploratory and descriptive in nature, using triangulated public health research using both qualitative both qualitative and quantitative approaches to data and quantitative approaches to data collection was collection. The research team comprised of the investiga- promoted (Agyepong et al. 1995; Gyapong et al. 1996; tors and four trained interviewers who were familiar with Agyepong & Manderson 1999; Rashed et al. 1999) and the local setting and the local languages. All questionnaires anthropologically informed studies were undertaken were translated into Dioula, the lingua franca of the study (Agyepong 1992; Winch et al. 1994; Makemba et al. 1996; area, and were pre-tested before being administered. The Winch et al. 1996; Binka & Adongo 1997; Winch et al.
survey instrument was informed by findings of the 1997). Profound, long-term ethnographic research related to malaria and its prevention is still an exception and muchneeded (Hausmann Muela et al. 1998).
This body of research suggests that mosquito nuisance, perceived malaria risk, household income and other Focus group discussions (FGD), individual interviews and household variables such as ethnicity, age and gender are key informant interviews were conducted in four of the 10 the most important determinants of mosquito net owner- study villages and in Nouna town. Ten FGDs (five with ship and use (Aikins et al. 1993, 1994; Winch et al. 1994; men and five with women) were held with groups of 10 Gyapong et al. 1996; Zimicki 1996). As mosquito nuisance participants each. We selected participants with at least is one of the major determinants for use of mosquito nets, one child below 5 years in their household, because we felt compliance is usually much lower during the dry season that they would have more specific experience with malaria than the rainy seasons (Winch et al. 1994; Zimicki 1996; and would be able to contribute more to the discussions.
The discussions dealt with community knowledge of As an exploratory study prior to a district-based ITN malaria-related concepts, and attitudes and practices programme in northwestern Burkina Faso, we conducted regarding malaria prevention and treatment. We deliber- descriptive research on community factors associated with ately focused on naturalistic illness concepts close to the malaria prevention including mosquito net use. We also biomedical concept of malaria, relevant and amenable to Tropical Medicine and International Health J. Okrah et al. Community factors associated with mosquito nets the mosquito net programme as a public health interven- tion, at the expense of a more elaborate ethnographic investigation of local illness terminologies and taxonomies,supernatural aetiologies and their ethnographic context Most of the study population was within the age range (Hausmann Muela et al. 1998). The local illness termino- 20–40 years and the great majority was illiterate. All logy reported by FGD participants was supplemented by respondents in the qualitative research with the exception information from semistructured interviews with 40 of two FGD participants and four key informants were persons of mixed ethnicities in Nouna town. We also farmers, with different ethnic background. While roughly conducted nine key informant interviews with medical half of the participants on the qualitative interviews and personnel, local tailors and traders of mosquito nets, users discussions were females, the great majority (87%) of the of mosquito nets, traditional healers and ambulant drug heads of households interviewed during the survey were peddlers. The interviews assessed the respondents’ beliefs males. Of those, 80/210 (38%) were from Nouna town concerning malaria aetiology, nosology and prevention, and 130/210 (62%) were from the six villages. The and their practices on current malaria prevention and distribution of ethnicity was as follows: Bwaba 71/210 treatment measures including pattern of mosquito net (34%), Marka 55/210 (26%), Mossi 46/210 (22%), Samo 26/210 (12%), Peulh 9/210 (4%) and others 3/210 (1%).
Raw field notes and tape recordings were first transcribed Most respondents were married (190/210 ¼ 90%) and and translated. The data were processed and analysed with most were in a monogamous union (137/190 ¼ 72%).
A T L A S.ti, a software package for qualitative data analysis,using a pre-established code list (ATLAS.ti 1997).
There is no one-to-one equivalent for the biomedical concept of malaria in any of the local languages. The Concepts and categories emerging from qualitative Djoula term soumaya, a broad syndromic entity, is closest, research informed the construction of the survey instru- and generally used in public health discourse to commu- ment, notably the definition of variables. Respondents were nicate with the population on malaria-related matters.
sampled through a modified Expanded Programme for Soumaya literally means ‘a state of being cold’. Although Immunization (EPI) cluster sampling methodology. This most people acknowledge that mosquitoes can transmit was carried out by first dividing the CRSN study area into soumaya, other aetiological factors such as humidity, two geographical clusters, urban and rural. The urban exposure to rain and cold are widely being held as cluster comprised Nouna town while the rural cluster comprised a random sample of six of the 10 purposely Soumaya is unanimously considered a serious illness, as selected villages for this study. In the second stage, the expressed by the following citation from one of our FGDs: urban cluster was subdivided into seven subclusters (all ‘When we hear of soumaya, it is a serious illness … Because seven Nouna sectors), and the rural cluster into six it is the mother of all illnesses. All illnesses which have not subclusters (all six study villages). Overall, 210 households yet developed, begin to appear when you have soumaya.
were selected proportional to the size of the geographical Headache, backache, constipation, all come from soumaya.’ cluster, and the participating households were finally Soumaya is perceived to manifest through different signs chosen at random in each cluster. A structured question- and symptoms, the more general ones being headaches, naire was administered to the heads of the selected constipation, muscle weakness, eye pains, stomach pains, households. The questions focused on socio-demographic fever, tiredness, cold, itching of hands, neck and back pain.
characteristics, ownership and use of mosquito nets, According to our respondents, these symptoms indicate a factors determining the possession and use of mosquito simple type of malaria common to adults as well as nets, knowledge and acceptability of insecticide-impreg- children. The more serious reported manifestations of nated mosquito nets and the knowledge and practice of soumaya are jaundice, dizziness and joint pains. The latter other malaria prevention and treatment methods.
symptoms were associated with the Djoula term djokadjo, The data were analysed with the Statistical Package for which means ‘yellow eyes’. All the ethnic groups further Social Sciences (SPSS) for Windows 95. Simple proportions knew of djokadjo as an illness common in adults and were used to describe the parameters investigated.
Approval was granted by the Ethical Committee of the Virulent fevers with convulsions during childhood are Heidelberg University Medical School and the Ministry of often interpreted as resulting from an ibou bird (translated as kono in local language and engoulevent in French Tropical Medicine and International Health J. Okrah et al. Community factors associated with mosquito nets language) flying during full moon over the village taking Most FGD participants stated that mosquitoes cause away the soul of the child. A variety of preventive efforts soumaya. This was partly explained by mosquitoes trans- are undertaken to avoid this, for example, women clap mitting the disease from a sick person to a healthy one, and their hands when they see an ibou flying over a village at partly through dirty water deposits responsible. Typical night. Pregnant women are forbidden to sleep outside statements were as follows: ‘There are also a lot of mosquitoes here, if they bite you, after biting a sick person, The serious types of malaria were perceived as very you know that the sickness has come. The wicked soumaya problematic and characterized by severe suffering of does not leave any part. It is the mosquito, which brings all victims. Participants of our FGDs considered the disease that …’ ‘The mosquitoes which live in water, when they very disturbing, especially in households with children.
bite you, they leave the water under your skin. That can Some of their typical statements are captured in the following citations: ‘When we hear of soumaya, and we The interview participants reported a number of other have children, our heart is not at peace. Soumaya in any causes for soumaya, ranging from specific food to hygiene way is a true problem among us here … If your child is sick and lying down how do you get money to care for him.
You either think of the work on the farm or the child and you must leave one to do the other … Soumaya is a bigthing because a lot of our children are losing their lives Malaria treatment was often reported to be a combination of both modern and traditional methods. Depending on the Some of the reported impact is economic and social type of malaria and its severity, people usually started with distress and hardship, including the inability to work.
some traditional therapy, followed by modern treatment in During our FGDs, it was emphasized that soumaya is an case of failure. For serious disease, the nearest health centre illness burden particularly during the high time of agri- was the most frequently cited option.
cultural activities when households have depleted most of Malaria was reportedly cured with ‘anti malaria drugs’ their food stocks and have neither time nor money for such as chloroquine, paracetamol and aspirin, which were bought from merchants or governmental health services.
Table 1 Perceptions of the causes and the mechanisms of soumaya Number of times mentioned duringFGDs (n ¼ 10) Inability to provide good care, to prevent Fruits (i.e. mangoes), shea nut, leaves of Tropical Medicine and International Health J. Okrah et al. Community factors associated with mosquito nets Although there was evidence for incorrect dosages in Table 2 Mosquito net use in households by age and sex several instances, perceived effectiveness was emphasized by many respondents: ‘We often treat malaria by takingantimalaria drugs. That is to say, you can even have the germ in the organism, but if you take antimalaria products, Most respondents reported the regular use of traditional treatments like flowers of eucalyptus plants, acacia, citro- nella, papaya, guava and leaves and roots of the neem tree.
The herbs were used in various combinations, the common one being eucalyptus plants with acacia and neem leaves.
They are reportedly boiled, and the concoctions drunk,bathed in or perfused, depending on the perceived severityof the illness. However, unlike biomedical drugs, the for more than 3 years (60/103 ¼ 58%). Most of house- effectiveness of the herbal treatments was considered holds had devices on their walls (77/103 ¼ 75%) and/or uncertain, as expressed by some respondents: ‘When one ceiling beams (63/103 ¼ 62%) for fixing nets. Seventy- has soumaya, we uproot the leaves and bathe … it is a three percent (75/103) of respondents used their mosquito question of chance. For some people it works, others use nets only during the raining season, only 12/103 (12%) the traditional plants in vain and go to the hospital.’ used their nets throughout the year.
Specific malaria prevention measures reported during the Adult men were the group who reportedly used mos- FGD were the use of chloroquine for pregnant women, the quito nets most often (35/103 ¼ 34%), followed by use of mosquito nets, the evacuation of dirty stagnant mothers with young children (20/103 ¼ 19%) and elderly water, and the use of a specific plant (Djoula: Fariweˆgne` yiri) as an insect repellent in rooms. The most frequentlymentioned specific practice against mosquitoes reported Cost of mosquito nets and factors associated from participants in the survey was the use of mosquito coils (142/210 ¼ 68%). Mosquito coils and insecticidesprays were sold, under various brand names, in the local Most mosquito nets were purchased at local markets and markets. Most of the measures against mosquitoes targeted the shops of Nouna, while a few were purchased in the at the perceived mosquito nuisance rather than for malaria major towns of Bobo Dioulasso and Ouagadougou. The price for a mosquito net ranged from 9 to 22 US$ (mean A statement from a key informant, a health officer, is 9.2 US$), depending on material and size. High costs of summarized below: ‘As for the preventive measures in these mosquito nets were the most frequently stated reason general, it is individual protection. At the moment, where we can say something better is only with pregnant women.
Ninety-five percent (98/103) of households owning All the rest, we cannot say that any measure is in place …’ mosquito nets used them as a measure against the nuisanceof mosquitoes. Only a minority stated other reasons, suchas privacy, protection against cold, flies and falling debris Mosquito net prevalence, characteristics and use Forty-nine percent (103/210) of respondents in the surveyreported at least one mosquito net in their household (21% owned one, 13% two, and 15% more than two mosquito nets). More urban households compared with ruralhouseholds owned mosquito nets (55% vs. 34%).
Among the respondents owning mosquito nets, 42/103 About two-thirds of the nets were rectangular, white and (41%) had ever heard about the method of treating nets synthetic, of various origins and sold in the local markets.
with insecticide. Of these, 13/42 (31%) obtained the The materials are usually imported from Europe or Asia, information from health personnel, 11/42 (26%) from and the mosquito nets produced by local tailors. Some friends and neighbours, and 18/42 (42%) from the media were locally made mosquito nets and curtains, made from (radio, television, newspapers). All these respondents were thick cotton. These were particularly preferred by older interested in the future use of treated nets, mostly because individuals, as a means to provide warmth during the they felt it would provide them with better protection colder periods of the year. Most mosquito nets were used against mosquitoes (90/103 ¼ 87%). Only a minority Tropical Medicine and International Health J. Okrah et al. Community factors associated with mosquito nets Figure 1 Amount of money mosquitonet owners are willing to pay for nettreatment with insecticide1 US$ ¼ 650 CFA.
stated that treated nets would provide them with better and/or available western drugs (Deming et al. 1989; protection against illnesses (3/103 ¼ 3%). When asked Guiguemde et al. 1994; Ruebush et al. 1995; Djimde et al.
about how much money they would be willing to spend on 1998; Nsimba et al. 1999; Hausmann Muela et al. 2000; net treatment, the majority did not want to spend more Thera et al. 2000). Only in case of non-response or clinical than 0.5–1 US$ on treatment (Fig. 1).
deterioration, and depending on distance to the next health Most rural and urban respondents stated that they care facility, as well as on funds and time available for would prefer to have mosquito net treatment services close transport and treatment, patients visited formal health to their home (78/103 ¼ 76%); a few wanted to have such services. Although it is reassuring that western drugs are services to be established centrally at Nouna hospital and considered more effective as compared with traditional the surrounding health centres (22/103 ¼ 21%).
treatment, the fact that most villages in our study area are Asked about the type of assistance needed to enable several kilometres away from the next health centre results them to acquire new mosquito nets and/or to get existing in the great majority of illness episodes not being seen by ones treated with insecticide, 38/103 (37%) of respondents trained health staff. There are major problems associated wanted them for free, 46/103 (45%) indicated their with this type of treatment-seeking behaviour. First, few preference for reduced prices, and 10/103 (10%) preferred cases are treated with an effective antimalarial drug in a timely manner (chloroquine is the officially recommendedfirst line treatment in Burkina Faso). Second, biomedicaldrugs are frequently dosed incorrectly. For example, chloroquine is often given as a single dose, but sometimes Soumaya, the local equivalent to malaria, is considered a daily for weeks. Third, dangerous drugs are frequently widespread and important health problem in northwestern administered, for example aspirin and tetracycline are Burkina Faso. As particularly young children of this area often given to children in case of fever. As a result, it is are experiencing a number of soumaya episodes during rather common that patients present with already each rainy season, a significant additional burden is put on advanced disease at health centres or hospital (unpublished families at the time when agricultural work is most demanding and resources are most limited (Sauerborn However, it has repeatedly been demonstrated that the et al. 1996; Mu¨ller et al. 2001). Soumaya manifests effectiveness of malaria control in SSA can be increased through various signs and symptoms. Although the substantially through involving communities and partic- majority of our study population knew that mosquitoes ularly through training of the mothers of young children on cause malaria, other natural and supernatural causes for correct antimalarial drug use (Menon et al. 1988; Pagnoni malaria were frequently stated during interviews. These et al. 1997; Kidane & Morrow 2000). In our study area, a local perceptions of malaria are strikingly similar to project focusing on training of village-based women groups findings from other malaria-endemic areas of SSA in malaria treatment has recently shown to be feasible (Makemba et al. 1996; Ahorlu et al. 1997; Minja et al.
Malaria prevention in our holoendemic study area is As in most of SSA and depending on accessibility, costs restricted to prescription of chloroquine prophylaxis to and on whether the entity is perceived as a ‘normal’ or an pregnant women during antenatal care visits. In reality, ‘out of order’ illness, malaria symptoms in our study area antenatal care coverage is strongly associated with living in were usually first treated with traditional herbal remedies Nouna town or in one of the few villages with a health Tropical Medicine and International Health J. Okrah et al. Community factors associated with mosquito nets centre (unpublished observations). Prevention of mosquito bites through use of specific repellent plants, burning ofmosquito coils and use of mosquito bednets is common.
We thank the staff of the Centre de Recherche en Sante´ de However, as also reported from many other places in SSA, Nouna and the population of the Nouna study area for these measures are primarily targeted against the nuisance their support. The study was funded by the Deutsche of mosquitos and not against malaria (Aikins et al. 1994; Forschungsgemeinschaft (SFB 544, Control of Tropical Van Bortel et al. 1996; Zimicki 1996).
Infectious Diseases). Jane Okrah was supported by a grant There are great variations in the proportions of house- from the German Academic Exchange Service (Deutscher holds using mosquito nets in malaria-endemic communities Akademischer Austauschdienst, DAAD, Germany.
of SSA (Zimicki 1996). While some countries such as TheGambia have a strong tradition of using mosquito nets for several purposes, mosquito net use is not very common inGhana and Malawi (Binka et al. 1994; D’Alessandro et al.
Abdulla S, Armstrong Schellenberg J, Nathan R et al. (2001) 1994; Ziba et al. 1994). Thus, the households of CRSN Impact on malaria morbidity of a programme supplying study area demonstrate intermediate rates of mosquito net insecticide treated nets in children aged under 2 years in ownership in the SSA context. Our findings confirm the Tanzania: community cross sectional study. British Medical higher mosquito net ownership rates in urban compared Agyepong IA (1992) Malaria: ethnomedical perceptions and with rural areas observed in other SSA countries (Zimicki practice in an Adangbe farming community and implications for control. Social Science and Medicine 35, 131–137.
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