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The importance of understanding the local context: Women's perceptions and knowledge concerning malaria in pregnancy in rural Malawi
Acta Tropica 98 (2006) 111–117
The importance of understanding the local context: Women’s perceptions and knowledge concerning malaria in pregnancy in rural Malawi Annika Launiala ∗ , Teija Kulmala School of Public Health, FIN-33014 University of Tampere, Finland Received 21 January 2005; received in revised form 26 October 2005; accepted 13 December 2005 Available online 2 May 2006
Abstract A current problem of malaria prevention programmes is that not enough attention is paid to understanding the local socio-cultural context prior to programme implementation. The aim of this study is to discover how Yao women in rural Malawi understand and explain malaria in pregnancy, how they perceive it and what type of knowledge they have on it. Women’s knowledge of the adverse effects of malaria in pregnancy is also investigated. At first phase a total of 34 in-depth interviews were conducted. At second phase a KAP survey (n = 248) was conducted for cross-validation of the qualitative information. The findings showed that there is neither a vernacular word for malaria nor malaria in pregnancy. Women used a local word, malungo, to refer to malaria. Malungo is an ambiguous disease term because of its multiple meanings which are used interchangeably to refer to many types of feverish illnesses of various causes, not only malaria. Most women did not perceive malungo during pregnancy as a serious illness. There were several other diseases from anaemia, STDs to cholera etc. that were perceived to be more dangerous than malungo. The local meaning of malungo also entailed an assumption that it is a common but fairly harmless illness. Women had limited knowledge of the adverse effects of malaria in pregnancy, the best-known adverse effect being miscarriage (28%, 52/189). A socio-cultural understanding of the implementation context is prerequisite for planning meaningful programmes for the pregnant women in rural Africa. © 2006 Elsevier B.V. All rights reserved. Keywords: Malaria; Prevention; Pregnancy; Malawi; Perceptions; Malungo
1. Introduction More than 30 million women become pregnant every year in malaria-endemic areas of Africa. All these women are exposed to the risk of malarial infection during pregnancy which may cause maternal anaemia, impaired fetal growth, miscarriage, stillbirth, prema-
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Corresponding author. Tel.: +358 50 3747069. E-mail address: [email protected] (A. Launiala).
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ture birth and intrauterine growth restriction (Schulman, 1999; Menendez et al., 2000). Gestational malaria infection has been estimated to cause 75,000–200,000 infant deaths every year in stable malaria transmission areas (Steketee et al., 2001). Today, global initiatives, such as roll back malaria (RBM), have raised malaria in pregnancy as one of the priorities in malaria prevention programmes (AFRO, 2002; Williams and Jones, 2004). The RBM target regarding pregnant women is that 60% of them should have access to preventive measures such as insecticide
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treated nets (ITNs) and intermittent preventive treatment (IPT) twice during pregnancy (The Africa Malaria Report, 2003). Social scientific literature focusing on malaria perceptions, treatment-seeking practices and prevention during pregnancy is scarce (Williams and Jones, 2004; see also McCombie, 1996). Major findings have stated that pregnant women perceive malaria as a common problem, yet the use of IPT during pregnancy is rather low (Helitzer-Allen et al., 1994; Schultz et al., 1994; Massele et al., 1997; Ndyomugyenyi et al., 1998; Ashwood-Smith et al., 2001). Women’s perceptions and knowledge about the threat of malaria in pregnancy have varied from acknowledged danger (Kengeya-Kayondo et al., 1994; Nuwaha, 2002; Comoro et al., 2003) to contradictory beliefs (Dulhunty et al., 2000) and no problem in pregnancy (Helitzer-Allen et al., 1993; Winch et al., 1996). It has been recognised that the success of worldwide malaria control depends on paying enough attention to the importance of socio-cultural factors in local treatment and prevention practices (Heggenhougen et al., 2003). Thus it is crucial to examine the local context before implementing preventive measures and to gain a thorough understanding of what the women consider dangerous for their pregnancies. It is also crucial to review the local malaria problem in relation to the local understanding and meaning of the disease. This article reports the results of descriptive social science research focusing on socio-cultural issues affecting the treatment and prevention of malaria in pregnancy among Yao women in rural Malawi. It aims to explain the local meaning of malaria, how women perceive and understand malaria in relation to pregnancy and what type of knowledge they have regarding malaria in pregnancy. The research is based on previous studies carried out in this area (Kulmala, 2000; UNICEF, 2001). 2. Subjects and methods The Ministry of Health and Population (MOHP) in Malawi granted ethical approval and a research permit, and data collection was carried out between September and December 2002 in rural Lungwena, Mangochi District on the eastern shore of Lake Malawi. The main ethnic group in the area is Yao, who are matrilineal and practice Islamic religion. The main occupations are farming and fishing (Kulmala et al., 2000). The catchment area consists of about 30,000 people, 6958 households and 25 villages. The area is divided into four traditional administrative divisions, called gulu in local language, and they are run by a chief of a gulu (Mitchell, 1956).
Data presented in this article was collected in two phases with triangulation of data sources to crossvalidate the collected information and to check the reliability of responses (Helitzer-Allen and Kendall, 1992; Agyepong et al., 1995; Bhattacharyya, 1997). Phase I was carried out between September and November, and phase II in December. Data collection methods used in phase I were in-depth interviews (IDIs) with women in reproductive age (verified by last born <1.5 years and still menstruating) and key informant interviews with four traditional advisers (anankungwi), two traditional birth attendants (TBA), one traditional healer and two men. Participants for IDIs were selected from eight villages (two villages from each gulu) by using convenience sampling (Agyepong et al., 1995; Bernard, 2002). Interviewees were selected in collaboration with gulu chiefs following specific selection criteria (reproductive age 15–44 years, not a relative of the chief, and women with single pregnancy or with many pregnancies). The principal author conducted the interviews with help of a research assistant who acted as a translator. All interviews were translated and transcribed by another assistant who was not present at the interview. Fifteen percent of the interviews were randomly checked for accuracy of translation. All interviews began with broad unstructured and non-directive questions about pregnancy, delivery and health of the pregnant women and gradually focused towards malaria in pregnancy, its treatment and prevention with more specific themes. The purpose was to gain a proper understanding of the socio-cultural context of managing pregnancy and malaria. Interviews ceased with the respondents when no new data emerged, i.e. saturation was reached (Bernard, 2002; Agyepong et al., 1995). A total of 34 women were interviewed. Phase II consisted of a cross-sectional KAP survey. The questionnaire was designed by the principle author based on the main findings from phase I. It contained 64 questions (12 open-ended) concerning the same issues as had been discussed or which had emerged from indepth interviews. The questionnaire was translated from English to Chiyao and back to English to ensure the accuracy of translation and it was pre-tested before actual use. The catchment area was divided into four geographical areas for logistical reasons, of which the Lungwena Trading Centre was one area. Interviews with women in reproductive age were organised at the antenatal clinic (ANC) of the Lungwena Health Centre and in two villages of the three other geographical areas each. In the six villages, altogether 200 interviews were aimed at, with samples proportional to the size of the village, which implied that a woman in every 8th household was inter-
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viewed in each village. The first household was selected randomly from the Health Centre register and determined the starting point for the interviews. Thereafter, a woman in every 8th household along the path from the index house was systematically interviewed. If there was no success in the sampled household, a woman in the next household on the path was interviewed instead. At the ANC, every third woman was selected over 4 days. An exclusion criterion for survey respondents was participation in the IDIs. This sampling procedure resulted in 248 interviews, 200 in the villages and 48 at the Health Centre. In-depth interviews were analysed by using an ethnographic approach for identifying categories and concepts from the data as they emerged. Analysis was made by looking for similarities, differences, variations and contradictions. Local meaning of malaria and its types were analysed by developing disease taxonomies (Bernard, 2002). The Atlas.ti computer programme for Windows version 5.0 (Scientific Software Development GmbH) was used to sort the qualitative data after code creation. Survey data were described as frequency distributions in relation to the qualitative findings. No further statistical analysis was undertaken at this point because of the qualitative nature of the study. 3. Results 3.1. Background characteristics of respondents The background characteristics of the respondents are presented in Table 1. All women were in reproductive age, between 15 and 44 years. Those women who did not know their actual ages were asked specific questions to verify that they were in reproductive age (see Section 2). Most of the respondents were married, and the median number of previous pregnancies was four among IDI respondents and three among survey respondents. The majority of the women had no education and 23% of survey respondents were able to read. 3.2. Local meaning of malaria The women used a local word malungo to refer to malaria and to the fever caused by malaria. Moreover, it was used as a synonym for body pains and feeling unwell. Literally translated, malungo means joint pain. It was described as a term covering several feverish illnesses, varying in symptoms, severity and aetiology. The women identified two types of malungo, which were known to all of them, namely, malungo caused by mosquitoes and malungo caused by hard work. The
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Table 1 Background characteristics of respondents in in-depth interviews (IDIs) and KAP survey in rural Malawi Background characteristics
IDIs number of participants (34)
KAP survey number of participants (248)
Age (years) 15–19 20–24 25–29 30–34 35–39 40–44 Age unknown Missing data
1 (3%) 8 (24%) 4 (12%) 2 (6%) 1 (3%) 1 (3%) 17 (50%)
18 (7%) 58 (24%) 46 (19%) 27 (11%) 13 (5%) 3 (1%) 82 (33%) 1
Marital status Married Co-habiting Missing data
30 (88%) 13 (38 %)
215 (87%) 125 (51%) 1
4 (1, 6)
3 (1, 6)
Parity Median (min, max) number of previous pregnancies Number of primigravid women Pregnant at the time of interview Education No education Primary education Secondary education Literate (tested)
3
16
8
70
21 (62%) 9 (26%) 4 (12%) n/a
160 (65%) 49 (20%) 39 (16%) 56 (23%)
women did not recognise any malungo type with specific references to pregnancy. They also described many other types of malungo according to their causes and symptoms as follows: “There is malungo caused by hard work, and malungo that causes body pains and stiff neck”. However, not all the women knew all the different types. The different types mentioned were malungo with body pains, malungo with vomiting and diarrhoea, malungo with joint pains and feeling cold, malungo with headache, malungo with convulsions, malungo with stiff neck, and malungo with shortage of blood. Further, many women made a distinction between normal malungo and severe malungo (malungo gamakulungwa). Sixtysix percent (160/241) of survey respondents said that there is only one type of malungo, which is the normal malungo. The connection between evil spirits (majini) and malaria was also investigated during the in-depth interviews. Most women knew that a majini (evil spirit) causes illnesses, but they argued that there is no such malungo type as malungo wa majini (malungo caused by evil spirits).
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3.3. Perception and knowledge about malaria in pregnancy
Table 3 Known adverse effects of malungo in pregnancy among KAP survey respondents (n = 189) in rural Malawi
The women did not regard malungo in pregnancy as a dangerous disease unless intentionally probed during the in-depth interviews, and even then some women perceived a number of other diseases more dangerous than malungo, as was, for example, described by one woman: “It is dangerous if you suffer often from malungo, but STDs are also very dangerous because of the infection that can lead to miscarriage”. Diseases considered common and more dangerous than malungo were anaemia, diarrhoea, STDs, AIDS, cholera and kambanga (convulsions due to severe malaria) etc. Forty-eight percent of the survey respondents (118/247) nevertheless perceived malungo as the most dangerous disease for pregnant women. The women explained that malungo caused by hard work is common throughout the year, but malungo caused by mosquitoes is common in the rainy season due to the abundance of mosquitoes. “The most worrisome malungo is the one caused by mosquitoes. This malungo and diarrhoea we suffer a lot during rainy season. We are bitten by so many mosquitoes. There are also other malungo types like malungo caused by hard work, this you can get any time of the year”. Thirty-six percent of the survey respondents (85/239) considered malungo as a year-round problem. Twenty-four percent (58/241) perceived pregnant women to be the biggest risk group, but around 58% (140/241) perceived children under 5 years as the biggest risk group. Eighty-eight percent of the survey respondents (213/241) worried about malungo. The reasons for worry are described in Table 2, showing that pregnancy-related reasons are almost non-existent. The same respondents were asked if they considered malungo in pregnancy as
Known adverse effects of malaria in pregnancy
Table 2 Reasons for worrying about malungo given by KAP survey respondents (n = 213) in rural Malawi Reasons for worrying about malungo Causes death (children) Causes body pains Disability to work It is a dangerous disease It is a common disease Causes shortage of blood Causes convulsions in children It is a painful disease Causes miscarriage Because of the pregnancy Other
n 70 (33%) 25 (12%) 25 (12%) 22 (10%) 9 (4%) 8 (4%) 5 (2%) 11 (5%) 4 (2%) 1(0.5%) 33 (15%)
Causes miscarriage Causes maternal death Causes shortage of blood (anaemia) Causes weakness Because of the pregnancy Causes premature delivery It is common in pregnancy Causes body pains Disability to work Causes convulsions during labour It is a dangerous disease It is a painful disease Other
n 52 (28%) 23 (12%) 20 (11%) 14 (7%) 13 (7%) 11 (6%) 11 (6%) 9 (5%) 6 (3%) 2 (1%) 1(0.5%) 1(0.5%) 36 (19%)
a problem. Seventy-eight percent agreed (189/241) that it was a problem, but they were unable to give a detailed description of the adverse effects of malungo in pregnancy (Table 3). The aetiology of malungo was also studied. In the survey, 56% of the women (135/241) said that malungo is caused by mosquitoes. Thirty-six percent of women (87/241) said that they did not know what causes it. The in-depth interviews allowed the women to elaborate their ideas of the causal factors. “If it is the rainy season, malungo is caused by mosquitoes because rotten garbage causes problems. In the rainy season, mosquitoes bite you and they give you different diseases making you feel uncomfortable. You can also get malungo after working hard in the maize field. In the hot season, you can get malungo from overheating in the sun”. A general opinion in the communities was that malungo is a natural illness. The women described it as an illness that just happens. Some said that it is an illness from God. The women did not associate witchcraft with normal malungo although witches (afiti) pose a threat in everyday life, regularly causing all kinds of misfortunes and illnesses. For example, kambanga (convulsions due to severe malaria), a local children’s illness, was said to be caused by witchcraft. Furthermore, pregnant women were not considered more susceptible to mosquito bites nor did they report that the aetiology of malungo changed when a woman is pregnant. However, women perceived pregnancy as a sensitive condition and pregnant women more exposed to illnesses caused by witchcraft than the general population. One respondent described: “When you are pregnant you are advised not to talk loudly about it. Your enemies in the village can use witchcraft to cause harm to your unborn
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baby. Because of the pregnancy you are vulnerable to ill will.” The women were asked to list symptoms of malungo. Ninety-five percent of the survey respondents (230/241) mentioned one to three symptoms of malungo. Those most frequently emerging were feeling cold, joint pain and fever. For severe malungo the women listed less symptoms than for malungo. Thirty-one percent of the survey respondents (75/241) knew of no symptoms for severe malungo, and those mentioned included convulsions, high fever, unconsciousness and headache. Women did not rank fever as the most important symptom of malungo. In fact, the in-depth interviews revealed that a mild fever during pregnancy was considered normal and some even interpreted fever as one sign of pregnancy (kuloka). “When someone is pregnant, fever becomes the first visible sign of the pregnancy. Some say that malungo is a sign of the beginning of pregnancy, but some say it is just a natural disease”. 4. Discussion As a disease term, malungo is ambiguous on account of its multiple meanings and definitions, which are used interchangeably to refer to many types of feverish illnesses, not just malaria. This finding conforms to other research findings in the region (Agyepong, 1992; Helitzer-Allen et al., 1993; Kengeya-Kayondo et al., 1994; Bisika, 1996; Winch et al., 1996; Launiala and Raijas-Walch, 1999; Espino et al., 1997; UNICEF, 2001). Further, more than 10 malungo types were discovered, which is comparable to earlier research among the Yao. Contrary to previous findings, however, the women in this study did not recognise malungo wa majini (malaria caused by evil spirits) as one malungo type (Helitzer-Allen et al., 1993). Despite the great number of varying malungo types presented, a specific malungo type related to pregnancy did not exist among the Yao women. Further, the meaning of malungo neither changed during pregnancy, nor was there a vernacular word used for malaria in pregnancy. Our results suggest that, overall, the local malungo categories are very vague, ambiguous and not shared by all members of the community. Categories are produced and reproduced in encounters with local people as argued by Pool in his studies in Cameroon (1994). There is a direct association between women’s knowledge about the causes and symptoms of malungo and the type of malungo; the more causes and symptoms a woman knows, the more types she is able to list. Thus, the local illness categories should not be automatically generalized to concern a particular ethnic group or other
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ethnic groups in the same country, although similarities are found (see also Nichter, 1994). It is difficult to compare the results regarding perceptions and knowledge of malaria in pregnancy in the region because of the small number of pre-existing studies, which moreover differ in focus and methodology (Kengeya-Kayondo et al., 1994; Schultz et al., 1994; Comoro et al., 2003; Dulhunty et al., 2000; Winch et al., 1996; Helitzer-Allen et al., 1993). The findings from this study indicate that malungo is such a common disease as not to be considered a major problem, even during pregnancy. The women agreed that malungo is a worrisome illness, but not specifically in relation to pregnancy. Pregnancy-related concerns were expressed mainly when reference was made explicitly to malaria in pregnancy. Fever during pregnancy was likewise perceived normal by some women and a sign of pregnancy. As hard work in the maize field is likely to raise the body temperature, it might explain why some women considered fever normal in pregnancy. Our study results indicate that although women say that they worry about malaria and perceive it as a problem, it does not necessarily mean that they perceive malaria as dangerous and a threat to their pregnancy. Women’s knowledge regarding the aetiology, symptoms and adverse effects of malaria in pregnancy varied. About half of the respondents said that mosquitoes transmit malaria. Most women mentioned one to three symptoms of malaria, and zero to one symptoms of severe malaria. Also, one third of the women linked miscarriage to malaria, and a few linked malaria with low birth weight, stillbirth, anaemia, premature birth etc. Women’s low educational level in the study area, which is below women’s national average (31.1%) in rural areas, offers some explanation for women’s understanding of malaria (National Statistics Office (Malawi) and ORC Macro, 2001). In conclusion, the results from this study clearly demonstrate that the local meaning of malungo contains an assumption that malaria is a common and fairly harmless disease for pregnant women. Moreover, the women have little detailed knowledge on the adverse consequences of malaria in pregnancy. It is, therefore, a major challenge for the malaria prevention programmes to improve their knowledge about the local understanding of malaria. These programmes should also focus on malaria in a wider context, in order to gain a perspective of which issues women consider dangerous for pregnancy, and of why and how malaria is related to these issues. Focusing on malaria in relation to other pregnancy problems will give insight into the multiple challenges women face in the local context and how they cope with these challenges. For example, one possible
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entry point for prevention programmes is to raise the issue of miscarriage and its causes, and to develop messages that stress the linkage between malaria and risk of miscarriage. It should be born in mind that these illiterate women do not comprehend complicated medical terminology yet they are a continuous target of all kinds of health education messages. Furthermore, knowledge and awareness do not necessarily entail changes in behaviour and practices (Farmer, 1997; Nations and Monte, 1997). Only if a proper understanding of the implementation context is achieved, can meaningful health programmes for pregnant women in rural Africa be planned. Acknowledgements Our sincere thanks are expressed to all the women in the Lungwena area who participated in this research. In addition, a warm thank you belongs to the Lungwena Health Centre staff and the hardworking research assistants: Rashid Osman, Eunice Willy, Misontzie Tweya, Shaibu Msosa, Ben Mwema, Gertrud Moses and Zacharia Abdul. Valuable institutional support was provided by the Finnish Family Federation and the Nordic Institute of African Studies (NAI) provided funding for the fieldwork. Doctoral Programs in Public Health (DPPH) of the University of Tampere deserve special thanks for providing funding that made it possible to write this article. And finally, our warmest thanks to Prof. Matti Hakama regarding his valuable advice in the field of epidemiology, and Heini Huhtala and AnnaMaija Kivisto for their statistical advice, all from the University of Tampere, Finland. References AFRO, 2002. Strategic framework for malaria control during pregnancy in the WHO Africa region, November 1. Agyepong, I., 1992. Malaria: ethnomedical perceptions and practice in an Adangbe farming community and implications for control. Soc. Sci. Med. 5, 131–137. Agyepong, I., Aryee, B., Dzikunu, H., Manderson, L., 1995. The malaria manual. Guidelines for the rapid assessment of social, economic and cultural aspects of malaria. Methods in tropical diseases, no. 2, UNDP/World Bank/WHO Special programme for Research and Training in Tropical Disease (TDR), TDR/SER/MSR/95.1. Ashwood-Smith, H., Coombes, Y., Kaimila, N., Bokosi, M., Lungu, K., 2001. Availability and use of sulphadoxine–pyrimethamine (SP) in pregnancy in Blantyre district. A safe motherhood and Blantyre Integrated Malaria Initiative (BIMI) Joint Survey. Malawi Med. J. 14, 8–11. Bernard, H.R., 2002. Research methods in anthropology. In: Qualitative and Quantitative Approaches, 3rd ed. Altamira Press, England. Bhattacharyya, K., 1997. Key informants, pile sorts, or surveys? Comparing behavioural research methods for the study of acute respiratory infections in West Bengal. In: Inhorn, M.C., Brown, P.J. (Eds.),
The Anthropology of Infectious Diseases. Theory and Practice on Medical Anthropology and International Health, vol. 4. Gordon and Breach Publishers, The Netherlands, pp. 211–238. Bisika, T.J., 1996. Malaria Case Management in Children in Malawi: the Case of Namasalima. A Report of a Rapid Ethnographic Study. Centre for Social Research, University of Malawi. Comoro, C., Nsimba, S.E.D., Warsame, M., Tomson, G., 2003. Local understanding, perceptions and reported practices of mothers/guardians and health workers on childhood malaria in a Tanzanian district—implications for malaria control. Acta Trop. 87, 305–313. Dulhunty, J.M., Yohannes, K., Kourleoutov, C., Manuopangai, V.T., Polyn, M.K., Parks, W.J., Bryan, J.H., 2000. Malaria control in central Malaita, Solomon Islands. 2. Local perceptions of the disease and practices for its treatment and prevention. Acta Trop. 75, 185–196. Espino, F., Manderson, L., Acuin, C., Domingo, F., Ventura, E., 1997. Perceptions of malaria in a low endemic area in the Philippines: transmission and prevention of disease. Acta Trop. 63, 221–239. Farmer, P., 1997. Ethnography, social analysis, and prevention of sexually transmitted HIV infection among poor women in Haiti. In: Inhorn, M.C., Brown, P.J. (Eds.), The Anthropology of Infectious Diseases. Theory and Practice on Medical Anthropology and International Health, vol. 4. Gordon and Breach Publishers, The Netherlands, pp. 413–438. Heggenhougen, K., Hackethal, V., Vivek, P., 2003. The behavioural and social aspects of malaria and its control: an introduction and annotated bibliography. Geneva, UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), (TDR/STR/SEB/VOL/03.1). Helitzer-Allen, D.L., Kendall, C., 1992. Explaining differences between qualitative and quantitative data: a study of chemoprophylaxis during pregnancy. Health Educ. Quart. 19 (1), 41–54. Helitzer-Allen, D.L., Kendall, C., Wirima, J.J., 1993. The role of ethnographic research in malaria control: an example of Malawi. Res. Sociol. Health Care 10, 269–286. Helitzer-Allen, D.L., Macheso, A., Wirima, J., Kendall, C., 1994. Testing strategies to increase use of chloroquine chemoprophylaxis during pregnancy in Malawi. Acta Trop. 58, 255–266. Kengeya-Kayondo, J.F., Seeley, J.A., Kajura-Bajenja, E., Kabunga, E., Mubiru, E., Sembajja, F., Mulder, D.W., 1994. Recognition, treatment seeking behaviour and perception of cause of malaria among the rural women in Uganda. Acta Trop. 58, 267–273. Kulmala, T., 2000. Maternal Health and Pregnancy Outcomes in Rural Malawi. Acta Universitatis Tamperensis 870, University of Tampere. Kulmala, T., Vaahtera, M., Ndekha, M., Cullinan, T., Salin, M.-L., Koivisto, A.-M., Ashorn, P., 2000. Socio-economic support for good health in rural Malawi. E. Afr. Med. J. 77, 168–171. Launiala, A., Raijas-Walch, H., 1999. Biomedical and local concepts of malaria among the Baganda in Uganda. J. Finn. Anthropol. Soc. 4, 142–153. Massele, A.Y., Mpundu, M.N., Hamudu, N.A.S., 1997. Utilization of antimalarial drugs by pregnant women attending the antenatal clinic at Muhimbili Medical Centre, Dar es Salaam. E. Afr. Med. J. 74, 28–30. McCombie, S.C., 1996. Treatment seeking for malaria: a review of recent research. Soc. Sci. Med. 43, 945–993. Menendez, C., Ordi, J., Ismail, M.R., Ventura, P.J., Aponte, J.J., Kahigwa, E., Font, F., Alonso, P.L., 2000. The impact of placental malaria on gestational age and birth weight. J. Infect. Dis. 181, 1740–1745.
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Schulman, C.E., 1999. Intermittent sulphadoxine–pyrimethamine to prevent severe anemia secondary to malaria in pregnancy: a randomized placebo-controlled trial. Lancet 353, 632–636. Schultz, L.J., Steketee, R.W., Chitsulo, L., Macheso, A., Nyasulu, Y., Ettling, M., 1994. Malaria and childbearing women in Malawi: knowledge, attitudes and practices. Trop. Med. Parasitol. 45, 65–69. Steketee, R.W., Nahlen, B.C., Parise, M.E., Menendez, C., 2001. The burden of malaria in pregnancy in malaria-endemic areas. Am. J. Trop. Med. Hyg. 64 (Suppl. 1/2), 28–35. The Africa Malaria Report, 2003. World Health Organization and UNICEF, WHO/CDS/MAL/2003.1093. UNICEF, 2001. Ethnographic Malaria Study. Research Report. UNICEF, Malawi. Williams, H.A., Jones, C.O.H., 2004. A critical review of behavioural issues related to malaria control in sub-Saharan Africa: what contributions have social scientists made? Soc. Sci. Med. 59, 501–523. Winch, P.J., Makemba, A.M., Kamazima, S.R., Lurie, M., Lwihula, G.K., Premji, Z., Minjas, J.N., Shiff, C.J., 1996. Local terminology for febrile illnesses in Bagamoyo district, Tanzania and its impact on the design of a community-based malaria control programme. Soc. Sci. Med. 42, 1057–1067.
The importance of understanding the local context: Women’s perceptions and knowledge concerning malaria in pregnancy in rural Malawi Annika Launiala ∗ , Teija Kulmala School of Public Health, FIN-33014 University of Tampere, Finland Received 21 January 2005; received in revised form 26 October 2005; accepted 13 December 2005 Available online 2 May 2006
Abstract A current problem of malaria prevention programmes is that not enough attention is paid to understanding the local socio-cultural context prior to programme implementation. The aim of this study is to discover how Yao women in rural Malawi understand and explain malaria in pregnancy, how they perceive it and what type of knowledge they have on it. Women’s knowledge of the adverse effects of malaria in pregnancy is also investigated. At first phase a total of 34 in-depth interviews were conducted. At second phase a KAP survey (n = 248) was conducted for cross-validation of the qualitative information. The findings showed that there is neither a vernacular word for malaria nor malaria in pregnancy. Women used a local word, malungo, to refer to malaria. Malungo is an ambiguous disease term because of its multiple meanings which are used interchangeably to refer to many types of feverish illnesses of various causes, not only malaria. Most women did not perceive malungo during pregnancy as a serious illness. There were several other diseases from anaemia, STDs to cholera etc. that were perceived to be more dangerous than malungo. The local meaning of malungo also entailed an assumption that it is a common but fairly harmless illness. Women had limited knowledge of the adverse effects of malaria in pregnancy, the best-known adverse effect being miscarriage (28%, 52/189). A socio-cultural understanding of the implementation context is prerequisite for planning meaningful programmes for the pregnant women in rural Africa. © 2006 Elsevier B.V. All rights reserved. Keywords: Malaria; Prevention; Pregnancy; Malawi; Perceptions; Malungo
1. Introduction More than 30 million women become pregnant every year in malaria-endemic areas of Africa. All these women are exposed to the risk of malarial infection during pregnancy which may cause maternal anaemia, impaired fetal growth, miscarriage, stillbirth, prema-
∗
Corresponding author. Tel.: +358 50 3747069. E-mail address: [email protected] (A. Launiala).
0001-706X/$ – see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.actatropica.2005.12.008
ture birth and intrauterine growth restriction (Schulman, 1999; Menendez et al., 2000). Gestational malaria infection has been estimated to cause 75,000–200,000 infant deaths every year in stable malaria transmission areas (Steketee et al., 2001). Today, global initiatives, such as roll back malaria (RBM), have raised malaria in pregnancy as one of the priorities in malaria prevention programmes (AFRO, 2002; Williams and Jones, 2004). The RBM target regarding pregnant women is that 60% of them should have access to preventive measures such as insecticide
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treated nets (ITNs) and intermittent preventive treatment (IPT) twice during pregnancy (The Africa Malaria Report, 2003). Social scientific literature focusing on malaria perceptions, treatment-seeking practices and prevention during pregnancy is scarce (Williams and Jones, 2004; see also McCombie, 1996). Major findings have stated that pregnant women perceive malaria as a common problem, yet the use of IPT during pregnancy is rather low (Helitzer-Allen et al., 1994; Schultz et al., 1994; Massele et al., 1997; Ndyomugyenyi et al., 1998; Ashwood-Smith et al., 2001). Women’s perceptions and knowledge about the threat of malaria in pregnancy have varied from acknowledged danger (Kengeya-Kayondo et al., 1994; Nuwaha, 2002; Comoro et al., 2003) to contradictory beliefs (Dulhunty et al., 2000) and no problem in pregnancy (Helitzer-Allen et al., 1993; Winch et al., 1996). It has been recognised that the success of worldwide malaria control depends on paying enough attention to the importance of socio-cultural factors in local treatment and prevention practices (Heggenhougen et al., 2003). Thus it is crucial to examine the local context before implementing preventive measures and to gain a thorough understanding of what the women consider dangerous for their pregnancies. It is also crucial to review the local malaria problem in relation to the local understanding and meaning of the disease. This article reports the results of descriptive social science research focusing on socio-cultural issues affecting the treatment and prevention of malaria in pregnancy among Yao women in rural Malawi. It aims to explain the local meaning of malaria, how women perceive and understand malaria in relation to pregnancy and what type of knowledge they have regarding malaria in pregnancy. The research is based on previous studies carried out in this area (Kulmala, 2000; UNICEF, 2001). 2. Subjects and methods The Ministry of Health and Population (MOHP) in Malawi granted ethical approval and a research permit, and data collection was carried out between September and December 2002 in rural Lungwena, Mangochi District on the eastern shore of Lake Malawi. The main ethnic group in the area is Yao, who are matrilineal and practice Islamic religion. The main occupations are farming and fishing (Kulmala et al., 2000). The catchment area consists of about 30,000 people, 6958 households and 25 villages. The area is divided into four traditional administrative divisions, called gulu in local language, and they are run by a chief of a gulu (Mitchell, 1956).
Data presented in this article was collected in two phases with triangulation of data sources to crossvalidate the collected information and to check the reliability of responses (Helitzer-Allen and Kendall, 1992; Agyepong et al., 1995; Bhattacharyya, 1997). Phase I was carried out between September and November, and phase II in December. Data collection methods used in phase I were in-depth interviews (IDIs) with women in reproductive age (verified by last born <1.5 years and still menstruating) and key informant interviews with four traditional advisers (anankungwi), two traditional birth attendants (TBA), one traditional healer and two men. Participants for IDIs were selected from eight villages (two villages from each gulu) by using convenience sampling (Agyepong et al., 1995; Bernard, 2002). Interviewees were selected in collaboration with gulu chiefs following specific selection criteria (reproductive age 15–44 years, not a relative of the chief, and women with single pregnancy or with many pregnancies). The principal author conducted the interviews with help of a research assistant who acted as a translator. All interviews were translated and transcribed by another assistant who was not present at the interview. Fifteen percent of the interviews were randomly checked for accuracy of translation. All interviews began with broad unstructured and non-directive questions about pregnancy, delivery and health of the pregnant women and gradually focused towards malaria in pregnancy, its treatment and prevention with more specific themes. The purpose was to gain a proper understanding of the socio-cultural context of managing pregnancy and malaria. Interviews ceased with the respondents when no new data emerged, i.e. saturation was reached (Bernard, 2002; Agyepong et al., 1995). A total of 34 women were interviewed. Phase II consisted of a cross-sectional KAP survey. The questionnaire was designed by the principle author based on the main findings from phase I. It contained 64 questions (12 open-ended) concerning the same issues as had been discussed or which had emerged from indepth interviews. The questionnaire was translated from English to Chiyao and back to English to ensure the accuracy of translation and it was pre-tested before actual use. The catchment area was divided into four geographical areas for logistical reasons, of which the Lungwena Trading Centre was one area. Interviews with women in reproductive age were organised at the antenatal clinic (ANC) of the Lungwena Health Centre and in two villages of the three other geographical areas each. In the six villages, altogether 200 interviews were aimed at, with samples proportional to the size of the village, which implied that a woman in every 8th household was inter-
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viewed in each village. The first household was selected randomly from the Health Centre register and determined the starting point for the interviews. Thereafter, a woman in every 8th household along the path from the index house was systematically interviewed. If there was no success in the sampled household, a woman in the next household on the path was interviewed instead. At the ANC, every third woman was selected over 4 days. An exclusion criterion for survey respondents was participation in the IDIs. This sampling procedure resulted in 248 interviews, 200 in the villages and 48 at the Health Centre. In-depth interviews were analysed by using an ethnographic approach for identifying categories and concepts from the data as they emerged. Analysis was made by looking for similarities, differences, variations and contradictions. Local meaning of malaria and its types were analysed by developing disease taxonomies (Bernard, 2002). The Atlas.ti computer programme for Windows version 5.0 (Scientific Software Development GmbH) was used to sort the qualitative data after code creation. Survey data were described as frequency distributions in relation to the qualitative findings. No further statistical analysis was undertaken at this point because of the qualitative nature of the study. 3. Results 3.1. Background characteristics of respondents The background characteristics of the respondents are presented in Table 1. All women were in reproductive age, between 15 and 44 years. Those women who did not know their actual ages were asked specific questions to verify that they were in reproductive age (see Section 2). Most of the respondents were married, and the median number of previous pregnancies was four among IDI respondents and three among survey respondents. The majority of the women had no education and 23% of survey respondents were able to read. 3.2. Local meaning of malaria The women used a local word malungo to refer to malaria and to the fever caused by malaria. Moreover, it was used as a synonym for body pains and feeling unwell. Literally translated, malungo means joint pain. It was described as a term covering several feverish illnesses, varying in symptoms, severity and aetiology. The women identified two types of malungo, which were known to all of them, namely, malungo caused by mosquitoes and malungo caused by hard work. The
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Table 1 Background characteristics of respondents in in-depth interviews (IDIs) and KAP survey in rural Malawi Background characteristics
IDIs number of participants (34)
KAP survey number of participants (248)
Age (years) 15–19 20–24 25–29 30–34 35–39 40–44 Age unknown Missing data
1 (3%) 8 (24%) 4 (12%) 2 (6%) 1 (3%) 1 (3%) 17 (50%)
18 (7%) 58 (24%) 46 (19%) 27 (11%) 13 (5%) 3 (1%) 82 (33%) 1
Marital status Married Co-habiting Missing data
30 (88%) 13 (38 %)
215 (87%) 125 (51%) 1
4 (1, 6)
3 (1, 6)
Parity Median (min, max) number of previous pregnancies Number of primigravid women Pregnant at the time of interview Education No education Primary education Secondary education Literate (tested)
3
16
8
70
21 (62%) 9 (26%) 4 (12%) n/a
160 (65%) 49 (20%) 39 (16%) 56 (23%)
women did not recognise any malungo type with specific references to pregnancy. They also described many other types of malungo according to their causes and symptoms as follows: “There is malungo caused by hard work, and malungo that causes body pains and stiff neck”. However, not all the women knew all the different types. The different types mentioned were malungo with body pains, malungo with vomiting and diarrhoea, malungo with joint pains and feeling cold, malungo with headache, malungo with convulsions, malungo with stiff neck, and malungo with shortage of blood. Further, many women made a distinction between normal malungo and severe malungo (malungo gamakulungwa). Sixtysix percent (160/241) of survey respondents said that there is only one type of malungo, which is the normal malungo. The connection between evil spirits (majini) and malaria was also investigated during the in-depth interviews. Most women knew that a majini (evil spirit) causes illnesses, but they argued that there is no such malungo type as malungo wa majini (malungo caused by evil spirits).
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3.3. Perception and knowledge about malaria in pregnancy
Table 3 Known adverse effects of malungo in pregnancy among KAP survey respondents (n = 189) in rural Malawi
The women did not regard malungo in pregnancy as a dangerous disease unless intentionally probed during the in-depth interviews, and even then some women perceived a number of other diseases more dangerous than malungo, as was, for example, described by one woman: “It is dangerous if you suffer often from malungo, but STDs are also very dangerous because of the infection that can lead to miscarriage”. Diseases considered common and more dangerous than malungo were anaemia, diarrhoea, STDs, AIDS, cholera and kambanga (convulsions due to severe malaria) etc. Forty-eight percent of the survey respondents (118/247) nevertheless perceived malungo as the most dangerous disease for pregnant women. The women explained that malungo caused by hard work is common throughout the year, but malungo caused by mosquitoes is common in the rainy season due to the abundance of mosquitoes. “The most worrisome malungo is the one caused by mosquitoes. This malungo and diarrhoea we suffer a lot during rainy season. We are bitten by so many mosquitoes. There are also other malungo types like malungo caused by hard work, this you can get any time of the year”. Thirty-six percent of the survey respondents (85/239) considered malungo as a year-round problem. Twenty-four percent (58/241) perceived pregnant women to be the biggest risk group, but around 58% (140/241) perceived children under 5 years as the biggest risk group. Eighty-eight percent of the survey respondents (213/241) worried about malungo. The reasons for worry are described in Table 2, showing that pregnancy-related reasons are almost non-existent. The same respondents were asked if they considered malungo in pregnancy as
Known adverse effects of malaria in pregnancy
Table 2 Reasons for worrying about malungo given by KAP survey respondents (n = 213) in rural Malawi Reasons for worrying about malungo Causes death (children) Causes body pains Disability to work It is a dangerous disease It is a common disease Causes shortage of blood Causes convulsions in children It is a painful disease Causes miscarriage Because of the pregnancy Other
n 70 (33%) 25 (12%) 25 (12%) 22 (10%) 9 (4%) 8 (4%) 5 (2%) 11 (5%) 4 (2%) 1(0.5%) 33 (15%)
Causes miscarriage Causes maternal death Causes shortage of blood (anaemia) Causes weakness Because of the pregnancy Causes premature delivery It is common in pregnancy Causes body pains Disability to work Causes convulsions during labour It is a dangerous disease It is a painful disease Other
n 52 (28%) 23 (12%) 20 (11%) 14 (7%) 13 (7%) 11 (6%) 11 (6%) 9 (5%) 6 (3%) 2 (1%) 1(0.5%) 1(0.5%) 36 (19%)
a problem. Seventy-eight percent agreed (189/241) that it was a problem, but they were unable to give a detailed description of the adverse effects of malungo in pregnancy (Table 3). The aetiology of malungo was also studied. In the survey, 56% of the women (135/241) said that malungo is caused by mosquitoes. Thirty-six percent of women (87/241) said that they did not know what causes it. The in-depth interviews allowed the women to elaborate their ideas of the causal factors. “If it is the rainy season, malungo is caused by mosquitoes because rotten garbage causes problems. In the rainy season, mosquitoes bite you and they give you different diseases making you feel uncomfortable. You can also get malungo after working hard in the maize field. In the hot season, you can get malungo from overheating in the sun”. A general opinion in the communities was that malungo is a natural illness. The women described it as an illness that just happens. Some said that it is an illness from God. The women did not associate witchcraft with normal malungo although witches (afiti) pose a threat in everyday life, regularly causing all kinds of misfortunes and illnesses. For example, kambanga (convulsions due to severe malaria), a local children’s illness, was said to be caused by witchcraft. Furthermore, pregnant women were not considered more susceptible to mosquito bites nor did they report that the aetiology of malungo changed when a woman is pregnant. However, women perceived pregnancy as a sensitive condition and pregnant women more exposed to illnesses caused by witchcraft than the general population. One respondent described: “When you are pregnant you are advised not to talk loudly about it. Your enemies in the village can use witchcraft to cause harm to your unborn
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baby. Because of the pregnancy you are vulnerable to ill will.” The women were asked to list symptoms of malungo. Ninety-five percent of the survey respondents (230/241) mentioned one to three symptoms of malungo. Those most frequently emerging were feeling cold, joint pain and fever. For severe malungo the women listed less symptoms than for malungo. Thirty-one percent of the survey respondents (75/241) knew of no symptoms for severe malungo, and those mentioned included convulsions, high fever, unconsciousness and headache. Women did not rank fever as the most important symptom of malungo. In fact, the in-depth interviews revealed that a mild fever during pregnancy was considered normal and some even interpreted fever as one sign of pregnancy (kuloka). “When someone is pregnant, fever becomes the first visible sign of the pregnancy. Some say that malungo is a sign of the beginning of pregnancy, but some say it is just a natural disease”. 4. Discussion As a disease term, malungo is ambiguous on account of its multiple meanings and definitions, which are used interchangeably to refer to many types of feverish illnesses, not just malaria. This finding conforms to other research findings in the region (Agyepong, 1992; Helitzer-Allen et al., 1993; Kengeya-Kayondo et al., 1994; Bisika, 1996; Winch et al., 1996; Launiala and Raijas-Walch, 1999; Espino et al., 1997; UNICEF, 2001). Further, more than 10 malungo types were discovered, which is comparable to earlier research among the Yao. Contrary to previous findings, however, the women in this study did not recognise malungo wa majini (malaria caused by evil spirits) as one malungo type (Helitzer-Allen et al., 1993). Despite the great number of varying malungo types presented, a specific malungo type related to pregnancy did not exist among the Yao women. Further, the meaning of malungo neither changed during pregnancy, nor was there a vernacular word used for malaria in pregnancy. Our results suggest that, overall, the local malungo categories are very vague, ambiguous and not shared by all members of the community. Categories are produced and reproduced in encounters with local people as argued by Pool in his studies in Cameroon (1994). There is a direct association between women’s knowledge about the causes and symptoms of malungo and the type of malungo; the more causes and symptoms a woman knows, the more types she is able to list. Thus, the local illness categories should not be automatically generalized to concern a particular ethnic group or other
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ethnic groups in the same country, although similarities are found (see also Nichter, 1994). It is difficult to compare the results regarding perceptions and knowledge of malaria in pregnancy in the region because of the small number of pre-existing studies, which moreover differ in focus and methodology (Kengeya-Kayondo et al., 1994; Schultz et al., 1994; Comoro et al., 2003; Dulhunty et al., 2000; Winch et al., 1996; Helitzer-Allen et al., 1993). The findings from this study indicate that malungo is such a common disease as not to be considered a major problem, even during pregnancy. The women agreed that malungo is a worrisome illness, but not specifically in relation to pregnancy. Pregnancy-related concerns were expressed mainly when reference was made explicitly to malaria in pregnancy. Fever during pregnancy was likewise perceived normal by some women and a sign of pregnancy. As hard work in the maize field is likely to raise the body temperature, it might explain why some women considered fever normal in pregnancy. Our study results indicate that although women say that they worry about malaria and perceive it as a problem, it does not necessarily mean that they perceive malaria as dangerous and a threat to their pregnancy. Women’s knowledge regarding the aetiology, symptoms and adverse effects of malaria in pregnancy varied. About half of the respondents said that mosquitoes transmit malaria. Most women mentioned one to three symptoms of malaria, and zero to one symptoms of severe malaria. Also, one third of the women linked miscarriage to malaria, and a few linked malaria with low birth weight, stillbirth, anaemia, premature birth etc. Women’s low educational level in the study area, which is below women’s national average (31.1%) in rural areas, offers some explanation for women’s understanding of malaria (National Statistics Office (Malawi) and ORC Macro, 2001). In conclusion, the results from this study clearly demonstrate that the local meaning of malungo contains an assumption that malaria is a common and fairly harmless disease for pregnant women. Moreover, the women have little detailed knowledge on the adverse consequences of malaria in pregnancy. It is, therefore, a major challenge for the malaria prevention programmes to improve their knowledge about the local understanding of malaria. These programmes should also focus on malaria in a wider context, in order to gain a perspective of which issues women consider dangerous for pregnancy, and of why and how malaria is related to these issues. Focusing on malaria in relation to other pregnancy problems will give insight into the multiple challenges women face in the local context and how they cope with these challenges. For example, one possible
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entry point for prevention programmes is to raise the issue of miscarriage and its causes, and to develop messages that stress the linkage between malaria and risk of miscarriage. It should be born in mind that these illiterate women do not comprehend complicated medical terminology yet they are a continuous target of all kinds of health education messages. Furthermore, knowledge and awareness do not necessarily entail changes in behaviour and practices (Farmer, 1997; Nations and Monte, 1997). Only if a proper understanding of the implementation context is achieved, can meaningful health programmes for pregnant women in rural Africa be planned. Acknowledgements Our sincere thanks are expressed to all the women in the Lungwena area who participated in this research. In addition, a warm thank you belongs to the Lungwena Health Centre staff and the hardworking research assistants: Rashid Osman, Eunice Willy, Misontzie Tweya, Shaibu Msosa, Ben Mwema, Gertrud Moses and Zacharia Abdul. Valuable institutional support was provided by the Finnish Family Federation and the Nordic Institute of African Studies (NAI) provided funding for the fieldwork. Doctoral Programs in Public Health (DPPH) of the University of Tampere deserve special thanks for providing funding that made it possible to write this article. And finally, our warmest thanks to Prof. Matti Hakama regarding his valuable advice in the field of epidemiology, and Heini Huhtala and AnnaMaija Kivisto for their statistical advice, all from the University of Tampere, Finland. References AFRO, 2002. Strategic framework for malaria control during pregnancy in the WHO Africa region, November 1. Agyepong, I., 1992. Malaria: ethnomedical perceptions and practice in an Adangbe farming community and implications for control. Soc. Sci. Med. 5, 131–137. Agyepong, I., Aryee, B., Dzikunu, H., Manderson, L., 1995. The malaria manual. Guidelines for the rapid assessment of social, economic and cultural aspects of malaria. Methods in tropical diseases, no. 2, UNDP/World Bank/WHO Special programme for Research and Training in Tropical Disease (TDR), TDR/SER/MSR/95.1. Ashwood-Smith, H., Coombes, Y., Kaimila, N., Bokosi, M., Lungu, K., 2001. Availability and use of sulphadoxine–pyrimethamine (SP) in pregnancy in Blantyre district. A safe motherhood and Blantyre Integrated Malaria Initiative (BIMI) Joint Survey. Malawi Med. J. 14, 8–11. Bernard, H.R., 2002. Research methods in anthropology. In: Qualitative and Quantitative Approaches, 3rd ed. Altamira Press, England. Bhattacharyya, K., 1997. Key informants, pile sorts, or surveys? Comparing behavioural research methods for the study of acute respiratory infections in West Bengal. In: Inhorn, M.C., Brown, P.J. (Eds.),
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