Description of the study population
Most of the study population was within the age range 20–40 years and the great majority was illiterate. All respondents in the qualitative research with the exception of two FGD participants and four key informants were farmers, with different ethnic background. While roughly half of the participants on the qualitative interviews and discussions were females, the great majority (87%) of the heads of households interviewed during the survey were males. Of those, 80/210 (38%) were from Nouna town and 130/210 (62%) were from the six villages. The distribution of ethnicity was as follows: Bwaba 71/210 (34%), Marka 55/210 (26%), Mossi 46/210 (22%), Samo 26/210 (12%), Peulh 9/210 (4%) and others 3/210 (1%). Most respondents were married (190/210=90%) and most were in a monogamous union (137/190=72%).
Knowledge and awareness of malaria
There is no one-to-one equivalent for the biomedical concept of malaria in any of the local languages. The Djoula term soumaya, a broad syndromic entity, is closest, and generally used in public health discourse to communicate with the population on malaria-related matters. Soumaya literally means `a state of being cold'. Although most people acknowledge that mosquitoes can transmit soumaya, other aetiological factors such as humidity, exposure to rain and cold are widely being held as causative factors.
Soumaya is unanimously considered a serious illness, as expressed by the following citation from one of our FGDs: `When we hear of soumaya, it is a serious illness … Because it is the mother of all illnesses. All illnesses which have not yet developed, begin to appear when you have soumaya. Headache, backache, constipation, all come from soumaya.'
Soumaya is perceived to manifest through different signs and symptoms, the more general ones being headaches, constipation, muscle weakness, eye pains, stomach pains, fever, tiredness, cold, itching of hands, neck and back pain. According to our respondents, these symptoms indicate a simple type of malaria common to adults as well as children. The more serious reported manifestations of soumaya are jaundice, dizziness and joint pains. The latter symptoms were associated with the Djoula term djokadjo, which means `yellow eyes'. All the ethnic groups further knew of djokadjo as an illness common in adults and children.
Virulent fevers with convulsions during childhood are often interpreted as resulting from an ibou bird (translated as kono in local language and engoulevent in French language) flying during full moon over the village taking away the soul of the child. A variety of preventive efforts are undertaken to avoid this, for example, women clap their hands when they see an ibou flying over a village at night. Pregnant women are forbidden to sleep outside during full moon.
The serious types of malaria were perceived as very problematic and characterized by severe suffering of victims. Participants of our FGDs considered the disease very disturbing, especially in households with children. Some of their typical statements are captured in the following citations: `When we hear of soumaya, and we have children, our heart is not at peace. Soumaya in any 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 big thing because a lot of our children are losing their lives from it …'
Some of the reported impact is economic and social distress and hardship, including the inability to work. During our FGDs, it was emphasized that soumaya is an illness burden particularly during the high time of agricultural activities when households have depleted most of their food stocks and have neither time nor money for transport and treatment.
Most FGD participants stated that mosquitoes cause soumaya. This was partly explained by mosquitoes transmitting the disease from a sick person to a healthy one, and partly through dirty water deposits responsible. Typical statements were as follows: `There are also a lot of mosquitoes here, if they bite you, after biting a sick person, you know that the sickness has come. The wicked soumaya does not leave any part. It is the mosquito, which brings all that …' `The mosquitoes which live in water, when they bite you, they leave the water under your skin. That can also give you soumaya'.
The interview participants reported a number of other causes for soumaya, ranging from specific food to hygiene and poverty (Table 1).
Table 1. Perceptions of the causes and the mechanisms of soumaya
Malaria treatment and prevention
Malaria treatment was often reported to be a combination of both modern and traditional methods. Depending on the type of malaria and its severity, people usually started with some traditional therapy, followed by modern treatment in case of failure. For serious disease, the nearest health centre was the most frequently cited option.
Malaria was reportedly cured with `anti malaria drugs' such as chloroquine, paracetamol and aspirin, which were bought from merchants or governmental health services. Although there was evidence for incorrect dosages in several instances, perceived effectiveness was emphasized by many respondents: `We often treat malaria by taking antimalaria drugs. That is to say, you can even have the germ in the organism, but if you take antimalaria products, they completely neutralize the germ.'
Most respondents reported the regular use of traditional treatments like flowers of eucalyptus plants, acacia, citronella, 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 severity of the illness. However, unlike biomedical drugs, the effectiveness of the herbal treatments was considered uncertain, as expressed by some respondents: `When one has soumaya, we uproot the leaves and bathe … it is a question of chance. For some people it works, others use the traditional plants in vain and go to the hospital.'
Specific malaria prevention measures reported during the FGD were the use of chloroquine for pregnant women, the use of mosquito nets, the evacuation of dirty stagnant water, and the use of a specific plant (Djoula: Fariwêgnè yiri) as an insect repellent in rooms. The most frequently mentioned specific practice against mosquitoes reported from participants in the survey was the use of mosquito coils (142/210=68%). Mosquito coils and insecticide sprays were sold, under various brand names, in the local markets. Most of the measures against mosquitoes targeted at the perceived mosquito nuisance rather than for malaria prevention.
A statement from a key informant, a health officer, is summarized below: `As for the preventive measures in general, it is individual protection. At the moment, where we can say something better is only with pregnant women. All the rest, we cannot say that any measure is in place …'
Mosquito net prevalence, characteristics and use
Forty-nine percent (103/210) of respondents in the survey reported 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 rural households owned mosquito nets (55% vs. 34%).
About two-thirds of the nets were rectangular, white and synthetic, of various origins and sold in the local markets. The materials are usually imported from Europe or Asia, and the mosquito nets produced by local tailors. Some were locally made mosquito nets and curtains, made from thick cotton. These were particularly preferred by older individuals, as a means to provide warmth during the colder periods of the year. Most mosquito nets were used for more than 3 years (60/103=58%). Most of households had devices on their walls (77/103=75%) and/or ceiling beams (63/103=62%) for fixing nets. Seventy-three percent (75/103) of respondents used their mosquito nets only during the raining season, only 12/103 (12%) used their nets throughout the year.
Adult men were the group who reportedly used mosquito nets most often (35/103=34%), followed by mothers with young children (20/103=19%) and elderly persons (17/103=17%) (Table 2).
Table 2. Mosquito net use in households by age and sex
Cost of mosquito nets and factors associated with net ownership
Most mosquito nets were purchased at local markets and the shops of Nouna, while a few were purchased in the major towns of Bobo Dioulasso and Ouagadougou. The price for a mosquito net ranged from 9 to 22 US$ (mean 9.2 US$), depending on material and size. High costs of these mosquito nets were the most frequently stated reason for not owning nets.
Ninety-five percent (98/103) of households owning mosquito nets used them as a measure against the nuisance of mosquitoes. Only a minority stated other reasons, such as privacy, protection against cold, flies and falling debris (8/103=8%).
Acceptability of insecticide-impregnated mosquito nets
Among the respondents owning mosquito nets, 42/103 (41%) had ever heard about the method of treating nets with insecticide. Of these, 13/42 (31%) obtained the information from health personnel, 11/42 (26%) from friends and neighbours, and 18/42 (42%) from the media (radio, television, newspapers). All these respondents were interested in the future use of treated nets, mostly because they felt it would provide them with better protection against mosquitoes (90/103=87%). Only a minority stated that treated nets would provide them with better protection against illnesses (3/103=3%). When asked about how much money they would be willing to spend on net treatment, the majority did not want to spend more than 0.5–1 US$ on treatment (Fig. 1).
Most rural and urban respondents stated that they would prefer to have mosquito net treatment services close to their home (78/103=76%); a few wanted to have such services to be established centrally at Nouna hospital and the surrounding health centres (22/103=21%).
Asked about the type of assistance needed to enable them to acquire new mosquito nets and/or to get existing ones treated with insecticide, 38/103 (37%) of respondents wanted them for free, 46/103 (45%) indicated their preference for reduced prices, and 10/103 (10%) preferred the nets to be provided on credit.