Malaria, Bednets and Local Knowledge

I recently saw a posting on the HIFA2015 listserve that called for more culturally appropriate health information/behavior change communication in Kenya. Beatrice Muraguri a Health Information Officer with the Ministry of Health from Kenya observed, “barriers to LLINs use as an intervention in malaria control especially from Kenya’s Coastal region. In 2006 when we did our last mass distribution, refusals were many as rumours went round that the white rectangular nets were talking to the people and this hampered the use. We had to do a lot of social mobilization for acceptance.”

llins-for-goal-post-2.jpgI discussed this experience with colleagues, one of whom asked if there was any overview of such net experiences from which programs could learn. In fact I am not aware of any broad based publication on cultural aspects of net use and misuse, but there has certainly been much information generated locally that is of anthropological relevant.

In a sense the challenge is that relevant information about nets is often quite localized. It would be useful to find out how much this information was gathered before major campaigns and actually used, and how much information was gathered after the fact when coverage was less than expected.

The concept of an ‘overview’ is in fact embodied in the anthropological process of inquiry that guides people to look for local perceptions and also hold the attitude to respect these local ideas, not as curiosities, but a alternative realities. When we deal with “local knowledge” we must consider the components of the perception – in this case we must consider how people perceive ‘malaria’ and in that context what are appropriate (if possible) preventive measures (not every group perceives ‘malaria’ as something that can be prevented in the western orthodox sense).

Then we need to consider perceptions of the nets themselves as well as the perceptions about insecticides/chemicals. In one setting nets may make people think of funeral shrouds, while in another they may appear to be wedding veils or fishing nets. People are always re-purposing artifacts from one culture to fit into what they perceive as relevant in their own.

So it is such ‘general lessons’ about how to obtain and use local knowledge that can be an overview or guidance.  We need to assume first and foremost that innovations like LLINs will just as likely NOT be seen by a local community in the same way that we western scientists see them.

There are also basic lessons from marketing. People reject products that are inconvenient or poorly designed.  People have always complained about nets restricting ventilation, and recent research has shown this to be true. Scientists have previously persisted with the ‘it’s good for you’ approach and assume people will do what is ‘good’. In contrast commercial companies are usually very sensitive to how people react to product function and design and try to find out what people think before expending great resources scaling up something in the market.

In the marketplace the customer may not always be ‘right’, but the customer does have the money. Since many public health interventions are free, we act as though people should be so grateful for getting those free commodities that they should not question how we tell them to use the nets. We forget that people are still public health ‘customers’.

So maybe there has not been a compendium written about net experiences from which one might draw lessons, but the basic anthropological skills exist and could be employed for each setting should program managers wish. Instead they often prefer to give IEC/BCC contracts to their friends and relatives to produce pretty posters at great cost that convey nothing meaningful to the public.

Maybe we can begin by sharing our experiences on listserve groups like HIFA2012 and our malaria update listserve and create a useful body of knowledge in terms of local approaches to improving net acceptance and use.This will work only if such feedback gets to the net designers and manufacturers!

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