Group-based citizenship in the acceptance of indoor residual spraying (IRS) for malaria control in Mozambique

Abstract

In 2006, the Mozambican Ministry of Health expanded its existing Indoor Residual Spraying (IRS) programme into Manhiça District in the south of the country. Widespread household coverage is required to have a significant impact on malaria transmission, making acceptability fundamental to success. Between 2006 and 2008 we conducted anthropological research in order to understand acceptability of IRS in the context of the implementation process, policy debates, local and regional politics and historical processes. In the first phase of this qualitative study, conducted between January and April 2006, 73 interviews and 12 focus groups were conducted with key stakeholders from 14 locales in and around the town of Manhiça: householders, community leaders, health care professionals, sprayers, and District officials. Analysis revealed IRS to be broadly acceptable despite very low levels of perceived efficacy and duration of effect. In contrast to previous studies which have linked acceptance to a reduction in mosquitoes, nuisance biting and malaria, we found people's compliance with the programme to be founded on a sense of group-based citizenship. The involvement of local governmental leaders in the intervention appears to have led many to accept spraying as part of their civic duty, as decreed by post-war decentralisation policy in rural areas. We discuss the implications of this ‘passive’ form of compliance for the acceptability and sustainability of malaria control and other public health programmes.

Introduction

One of the primary vector control interventions for reducing malaria transmission is indoor residual spraying (IRS), whereby long-acting chemical insecticides are sprayed on the walls and roofs of all structures in a determined area to kill the mosquitoes that land and rest there. The World Health Organization's Global Malaria Programme recommends IRS as one of three interventions that must be scaled up by countries to achieve the Millennium Development Goals for malaria by 2015 (World Health Organization, 2006). As with other disease vector control programmes, a high level of community acceptance is required for effective implementation of IRS; in order to have a significant impact on malaria transmission, widespread household coverage is required (>80% of premises within the target area) (WHO, 2006). This requires householders to cooperate with spraying personnel by being present on the designated day and removing some household contents outside.

The social science literature on vector control and community perceptions has long recognised the need for community participation in vector control programmes (Gubler and Clark, 1994, Gubler and Clark, 1996, Klein et al., 1995, Lloyd et al., 1994, Manderson, 1992, Winch et al., 1992). Exploring the forms such participation can take, Winch et al. have argued that “community participation can be effective if changes are made in the way participation is defined, and if there is increased commitment on the part of local governments to addressing community concerns” (Winch, Kendall, Gubler, 1992: 348). A number of studies have indicated that purely technocratic interventions encourage the perception that the government is responsible for vector control, thereby reducing the perceived self efficacy of target communities (Bermejo and Bekui, 1993, Rosenbaum et al., 1995, Toledo et al., 2008). Recently, the literature has reflected an increased focus on local engagement with vector control, largely evaluating the sustainability of integrated programmes (Hanh et al., 2009, Romani et al., 2007, Vanlerberghe et al., 2009).

The substantial literature on community participation in vector control programmes relates for the most part to dengue fever and other diseases, such as dracunculiasis, onchocerciasis and urinary schistosomiasis. As Opiyo et al. note, “in malaria control, specifically in Africa, few of the projects have been truly ‘bottom-up’ community initiated…but the term is widely used to refer to community co-operation or acceptance” (Opiyo, et al., 2007: 2). Reflecting this trend in the design of programmes, few studies have specifically evaluated the acceptability of IRS for malaria control to individuals and communities, or considered in depth the role of human and cultural factors in the success or failure of programmes.

Two notable exceptions are Govere et al. (Govere, Durrheim, la Grange, Mabuza, & Rooman, 2000) and Rodriguez et al. (Rodriguez, et al., 2006), both of which used survey methods to ask about specific factors taken to be the key determinants of acceptability. In South Africa, Govere et al. used a structured KAP (knowledge, attitudes and practices) questionnaire, asking amongst other things about satisfaction with spraying personnel, washing and re-plastering after spraying and perceived effects. Rodriguez's study in Mexico focused on side effects and started from the premise that “spraying coverage depends on whether householders perceive the intervention as beneficial, in terms of how effective the insecticide is against mosquitoes and other nuisance insects, as well as the number and intensity of unwanted side effects” (Rodriguez, et al., 2006: 318). Although both studies found IRS compliance acceptably high, worrying findings, such as the fact that only 1.9% of respondents associated the spraying with malaria transmission prevention were not explored (Rodriguez, et al., 2006). This raises questions as to the nature of the perceived benefits that have been associated with IRS acceptability to date and the adequacy of the current approach, which is to ask about the physical effects (both positive and negative) of spraying.

The neglect of the socio-cultural context of malaria control is not limited to IRS as an intervention, but is a hallmark of public health approaches to malaria. Although there are notable examples of culturally compelling interventions (see for example Panter-Brick, Clarke, Lomas, Pinder, & Lindsay, 2006), historically, public health approaches have tended to focus on the parasite and the mosquito as vector, and to see solutions in technological rather than human terms (Opiyo et al., 2007, Packard, 2007). Writing of the eradication era, Packard notes, “nowhere was it stated that surveys should consider the social, cultural, and economic setting within which spraying was to occur. The problem was medicalized and defined as if the area under attack were depopulated….The population at risk could be ignored” (Packard, 1997: 290–1). A review of the current literature suggests little has changed, in spite of calls for more far-reaching social science research in this area (Brown, 1997a, Dunn, 1979, Rajogapalan et al., 1986). Indeed, a recent special supplement of the Malaria Journal entitled “Towards a research agenda for global malaria elimination” demonstrates that technological fixes remain the priority, to the exclusion of research into socio-cultural factors pertaining to disease elimination (Hommel, 2008).

With eradication back on the agenda, it is fitting – now more than ever in the past 50 years – to consider the cultural dimensions of malaria interventions. An excellent body of historical work has laid the foundations for contemporary research in this area (Packard, 2007), but is largely overlooked within current debates. Drawing attention to post-war visions of economic and social development, Packard suggests that many of the problems that hampered the eradication efforts of the 1950s were not simply technical, organizational or financial but linked to the association between eradication and third world modernization (Packard, 1997). Brown has explored the cultural dimension of the relationship between malaria and economic productivity in the case of Sardinia (Brown, 1997b); Silva has situated the origin and development of malaria control within the colonial context of Sri Lanka (Silva, 1997); and Packard and Jones have analysed the cultural model of health and development deployed in International Health to mobilise for malaria eradication (Packard & Jones, 1997). In spite of the strong message that this historical perspective sends out about the centrality of socio-economic, political and ideological factors, little work has been published recently that analyses these dimensions in current malaria control programmes.

Packard has highlighted how in the Malaria Eradication Programme, “little effort was made to understand local reactions to spraying, or how local social conditions and cultural attitudes might affect how populations reacted to spraying operations” (Packard, 2007: 168). We address this in the present day by turning our attention to current attempts at malaria control through the use of indoor residual spraying. In this paper, we explore local reactions to a contemporary spraying campaign in southern Mozambique, situating this response in the context of local and national politics, specifically post-war decentralisation policy in rural areas.