Africa’s Lake Victoria shimmers on the horizon. In the shadow of one of a cluster of grass-thatched mud huts facing the lake is a small dirt mound, a baby’s grave.
“Catherine died three days ago,” said the baby’s mother, Benter Akech. “She was three- and-a-half months old. She had some problems with her breathing. She had a fever, and the back of her head was becoming hot. Maybe it was measles. I don’t think it was malaria.”
Akech’s belief that it was not malaria that killed her baby is somewhat surprising. In Asembo in western Kenya, malaria is endemic, and a child gets bitten by an infected mosquito almost every day. Infant mortality is approximately 120 deaths for every 1,000 births, and malaria accounts for almost half of those deaths. Even though the Akech family live in a district where the Centers for Disease Control (CDC) and the Kenya Medical Research Institute (KEMRI) conduct regular malaria projects, they seem unaware of any possible connection between the vector-borne parasitic infection that kills more than 2,000 African children a day and the death of their daughter.
Many of those who live in the most endemic regions are unaware of the nature and severity of malaria. Appropriate communication strategies have to be implemented to effectively combat the disease by raising awareness.
Credit: Stephenie Hollyman/WHO |
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A fatal lack of awareness
A widespread lack of awareness of the nature and severity of malaria allows the disease to ravage communities not just in Kenya and in sub-Saharan Africa but in most rural affected communities worldwide. The persistence of sweeping in affected and vulnerable communities has illustrated to those working to combat malaria that past educational efforts have failed and prompted a rethink of existing communication strategies.
The Akeches, whose two children died after manifesting the same symptoms, acknowledged that malaria is a problem in their community but could not identify anyone who had lost a child to the disease. In their own case, they blamed the loss of their children on the mother’s supposed difficulties breastfeeding.
“It doesn’t look like it is a big problem because many of the adults, who have an acquired natural immunity, don’t get sick with malaria. In fact, adults consider diseases like measles to be more dangerous,” said Frank Odhiambo, a CDC researcher who works in Asembo.
Most communities consider malaria as part of everyday life. “Malaria here is like background noise,” explains Jane Alaii, a health behavioral scientist in western Kenya.
Credit: IRIN |
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Children are less likely to recover from an attack of malaria, and misdiagnosis is also more probable, given the different ways in which the disease manifests itself. Adults experience symptoms that are easier to recognise – fever, trembling, headaches and sometimes nausea – whereas children first tend to suffer from severe anaemia.
“When mothers see their children dying, they don’t think of malaria,” said Mercy Omollo, a nurse at a mother-and-child clinic in Lwak, Asembo. “Some think their children were bewitched, so they don’t come to the clinic. Instead, they spend a lot of time taking herbal medications and only arrive here when their child is really sick.”
Even evidence of a fever may not be enough to ensure the accurate diagnosis of malaria in adults or children. A fever may not be linked with mosquito bites, for example, or local beliefs may require that people turn to traditional cures. “Malaria here is like background noise,” explained Jane Alaii, a health behavioural scientist in western Kenya, near Lake Victoria. “If it is always there, then after a while you stop noticing it. Most communities consider malaria as part of everyday life. You fall sick, you have some fever or as they call it out there, ‘a headache’. Then you take some medication and you are OK, and then you go back to work. It is not until scientists like us go out there and tell them this is more than just a headache that these people even begin to suspect that there is a problem here.”
The imperative of local participation
The implications of widespread ignorance of the disease suggest that without the active collaboration of affected communities the struggle against malaria will never be won. Indeed, the participation of local people is considered fundamental if the core strategies of treatment and prevention, as outlined in the Abuja Declaration of 2000, are to be realised. Successful treatment requires fast and accurate diagnosis combined with an adherence to the appropriate form of medication. Crucially, the correct dose of the relevant drug must be taken to prevent resistance.
The future success of prevention strategies will also depend on behaviour change among affected communities. The effective use of insecticide-treated bed nets (ITNs), which form the backbone of prevention tactics, requires an understanding of the true causes of the disease. Misperceptions concerning the root causes of malaria highlight the failure of education. People, for example, may associate the rainy season with malaria without understanding that this is because it is the breeding season for mosquitoes.
This knowledge gap has serious implications for the use of ITNs. The Akech family, for example, owns an insecticide-treated bed net, but it is torn. They do not plan to mend it, despite probably having lost both of their children to malaria. Financially impoverished, their priorities are food and water. A 1999 to 2004 survey of 34 African countries reflected how communication so far has failed to raise awareness of the severity of the threat of malaria, finding that in affected areas only 3 percent of children under age five slept under bed nets.
Alaii described a similar situation. “I remember going up to a family and asking them, ‘Did you use a net last night?’ ‘Yes.’ ‘Did you use it the night before?’ ‘No.’ ‘When do you use it?’ ‘I use it all the time.’ With careful questioning and patience you get to understand that this ‘all the time’ is actually all the time they hear mosquitoes. What we learn from this is that we have to change our message. We shouldn’t say, ‘Use it all the time,’ but ‘Use it every night, all year round.’”
Grass-roots education the key
Conveying key messages about ITNs — that they must be hung properly; be impregnated at regular intervals; and that the most vulnerable groups, children and pregnant women, be given priority use — requires information to be communicated in a manner that can be understood.
Radio for Development, a UK-based media consultancy, conducted an assessment of community health education strategies in five African countries in 2003 and found the top-down, didactic and traditional manner of communicators to be problematic. The language of blame and prescriptions of good behaviour were identified as particularly unhelpful. While experts may be able to impart all manner of technical information, the way in which this information is conveyed is regarded by agencies on the ground to be critical to the up-take of the messages.
Chris White of the African Medical and Research Foundation (AMREF) cited “a shortage of people with the right social science skills, people who know enough about communication techniques. … It’s time for a more participatory approach.”
Such an approach would ideally focus on local input in the design of culturally appropriate programmes, participation by members of communities in both education and in diagnosis and treatment provision, as well as on the employment of familiar languages and means of communication. While participatory communication strategies are yet to be widely deployed in combating malaria, there are a number of examples of programmes successfully featuring a community-based focus.
Making it work
A positive model demonstrating the adaptation of strategies to local needs was implemented in Sudan. In both southern and western Sudan, bed nets were designed according to the preference of Nuer pastoralists for sleeping in dumuria (opaque cotton sheets). When standard ITNs were introduced to little effect, new ITNs modelled on dumurias — and impregnated with long-lasting insecticide — were produced and well-received by the community.
In some settings, local communicators have been instrumental in combating the disease. The Bagamoyo Bednet Project in Tanzania employed the local sheikh to teach during Friday meetings, and bed net impregnation levels rose from 53 percent to 98 percent. In another example, mothers in Tigray, Ethiopia, became community coordinators of the diagnosis and treatment of the disease, playing a vital role in a 40 percent drop in child mortality.
In Mozambique, the United Nations Children’s Fund (UNICEF) emphasised community participation in its landmark programme in Gaza Province, combining the free distribution of bed nets with theatre performances and simple drawings. With 189,000 participants, a follow-up survey 10 months later yielded results suggesting that 100 percent of the interviewees knew what malaria was, that 98 percent still had and were using their net, and that 91 percent understood that malaria was transmitted by mosquitoes (up from 30 percent in a baseline study of the same area).
Community participation and education strategies are a vital step in the fight against malaria, which remains the number one killer in most sub-Saharan countries.
Credit: Stephenie Hollyman/WHO |
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Tactics for the future
White, one of two people representing the nongovernmental-organisation sector on the World Health Organization’s Roll Back Malaria Partnership board, believes that participation promotes receptiveness. “I was running a malaria workshop in Liberia, and I asked: ‘Can you tell me where you get malaria from?’ One of them offered the suggestion that it was as a result of drinking beer.
“My answer to that was: ‘Well, actually, in a way you are right. Can I now ask you when do you drink beer and where?’ He explained that men of the village would often meet on a Friday night, or maybe every night, and drink copious amounts of beer. It is likely some of them didn’t make it home and would end up sleeping outside somewhere. And that is, of course, a perfect spot for these men to get bitten by night-biting female malaria mosquitoes. ‘So yes,’ I said, ‘in a way you’re right.’ And after that they were much more receptive to the information I had to give to them.
“This is an important approach to communication,” he said. “Build on what they know rather than demolish it.”
Researchers and activists agree that until communication and education strategies uniformly emphasise participation, malaria will remain a silent killer. To break this silence, those living in the most affected areas, who are therefore the most vulnerable, must be engaged in such a manner that the nature and severity of the malarial threat is more widely known, and thereby more effectively eliminated.
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