Social and cultural factors affecting rates of regular retreatment of mosquito nets with insecticide in Bagamoyo District, Tanzania.

Insecticide-treated mosquito nets have an impact on mortality and morbidity in young children under controlled conditions. When integrated into larger control programs, there is the danger that rates of regular retreatment of the nets with insecticide will drop, greatly limiting their effectiveness as a public health intervention. In Bagamoyo District, Tanzania, rates of retreatment dropped significantly when payment for the insecticide was introduced. A series of neighbourhood (hamlet) meetings were held in all study villages to discuss people's concerns about the insecticide and ways to increase rates of retreatment. Although changes were made in the procedure for retreatment, rates of retreatment remained lower than expected and showed marked variation within as well as between villages. We then conducted unstructured key informant interviews as well as informal discussions in a village with strong variation between different sectors of the villages in rates of retreatment. While logistical problems were most frequently cited as reasons not to bring nets for retreatment, political and social divisions within the community provided a better explanation. This is borne out by the low response to rearrangements in logistics which made retreating the nets significantly easier for households, and the higher response when changes were made in the channels of communication as well as the logistic features. It is clearly more difficult for villagers to appreciate the benefits of the insecticide than those of the nets. Great emphasis needs to be placed on the insecticide and its beneficial effects from the outset for any large-scale programme to be sustainable.

Mosques against malaria.

In a community-based malaria control project covering a predominantly Muslim population in the United Republic of Tanzania, difficulty was encountered in motivating people to have their mosquito nets reimpregnated with insecticide at six-monthly intervals. Education on this subject was therefore provided in mosques during Friday noon prayers. People who attended these services considered them an appropriate forum for discussing health concerns and viewed them as a credible source of information.

PIP: Insecticide-impregnated bednets help to control the spread of the malaria parasite Plasmodium falciparum. The Bagamoyo Bednet Project is a community-based scheme to develop a sustainable system for the distribution and promotion of such bednets among 21,000 people in a rural coastal area 60 km north of Dar es Salaam. While the 13 village committees have sold and distributed the bednets, they have been unable to motivate people to have their nets impregnated with insecticide every 6 months, key to thwarting the spread of malaria. Posters and meetings also had only a limited impact upon user motivation. The target population is mainly Muslim. The sheikh in each of 4 villages was therefore recruited to teach during Friday noon religious services, when attendance levels are relatively high, the merits of regular bednet impregnation. This approach was chosen because people expect to receive some form of teaching or instruction during the service, and the religious leaders who run it are respected and seen as reliable sources of information. There are also many health teachings in the Koran and Sunna. Although only a minority of villagers attended, a considerable proportion disseminated the information to family and friends. This approach seemed most effective in reaching men aged 30-50 years, and ineffective in reaching youth; fewer women attended prayers than men. The project achieved 52-98% regular bednet reimpregnation except in one village where the level reached only 25%.

Treatment practices for degedege, a locally recognized febrile illness, and implications for strategies to decrease mortality from severe malaria in Bagamoyo District, Tanzania.

Malaria remains one of the chief causes of mortality among young children in sub-Saharan Africa. Verbal autopsies for cases of childhood mortality in Bagamoyo District, Tanzania demonstrated that degedege, a locally defined illness of children characterized by fever and convulsions, is frequently treated by traditional healers. To investigate this further, an ethnographic study was carried out in one village that included in-depth interviews with 14 traditional healers and 3 focus groups with parents. Parents and traditional healers were unanimous in their conviction that degedege requires traditional treatments, at least initially, and that these treatments are effective. While traditional healers do refer cases that are not improving to the District Hospital, this frequently occurs late in the course of the illness, after one or more stages of traditional treatments. The prognosis will thus be poor for those children who are suffering from severe malaria. Consideration should be given to enlisting the support of traditional healers in efforts to improve treatment for severe malaria, including teaching them how to distinguish febrile convulsions from cases of severe malaria.

Local terminology for febrile illnesses in Bagamoyo District, Tanzania and its impact on the design of a community-based malaria control programme.

This paper reviews results of several ethnographic studies that have examined the issue of local terminology for malaria in Africa, then presents findings from an on-going study in Bagamoyo District, Tanzania. The study used a mixture of qualitative and quantitative interview methods to examine local perceptions of malaria and malaria treatment practices. Although the local term homa ya malaria or malaria fever appeared on the surface to correspond closely with the biomedical term malaria, significant and often subtle differences were found between the two terms. Of perhaps greatest importance, common consequences of malaria in endemic areas such as cerebral malaria in young children, severe anaemia and malaria in pregnancy were not connected with homa ya malaria by many people. A set of guidelines are described that were used to determine how best to promote acceptance and use of insecticide-impregnated mosquito nets, given these results. It is demonstrated that the position of the term used to denote malaria in the local taxonomy of febrile illnesses has important implications for the design of health education interventions.

Seasonal variation in the perceived risk of malaria: implications for the promotion of insecticide-impregnated bed nets.

Bed nets (mosquito nets), impregnated every 6 months with pyrethroid insecticides, are a simple, low-cost malaria control method well suited to conditions in sub-Saharan Africa. As large seasonal variations in levels of net usage may seriously limit the potential impact of the nets on malaria transmission, a study was conducted on local definitions of seasons, perceptions of seasonal variation in mosquito populations and incidence of febrile illnesses in Bagamoyo District, Tanzania, to aid in the design of a communication strategy for promoting sustained use of the nets. Both the diagnosis and treatment of febrile illnesses are affected by what season people think it is, by what illnesses they think are common in each season, and also by their perceptions of how abundant mosquitoes are. During dry seasons when mosquitoes are scarce and malaria is thought to be unlikely, it will be difficult to attain high rates of net usage. It will be necessary to develop locally-appropriate messages and communication materials that explain how it is possible that malaria can be a threat even when mosquitoes are few. Cultural consensus analysis was found to be a particularly valuable tool for understanding the reasons behind large variations in local perceptions of seasonality.