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The Whole World Will Be Able to See Us: Cultural Factors Affecting Insecticide-Treated Bed Net Use for Malaria Control in the Peruvian Amazon

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The Whole World Will Be Able to See Us: Cultural Factors Affecting Insecticide-Treated Bed Net Use for Malaria Control in the Peruvian Amazon The whole world will be able to see us: Cultural factors affecting insecticide-treated bed net use for malaria control in the Peruvian Amazon by Steven A. Harvey A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland January 2006 © Steven A. Harvey 2006 All rights reserved Abstract According to the most recent WHO estimates, 107 countries worldwide are endemic for malaria, putting about 3.2 billion of the world’s population at risk. Malaria causes or contributes to between 1.5 and 3 million deaths and up to 500 million acute clinical cases each year. Because of their demonstrated effectiveness at reducing malaria-related morbidity and mortality, insecticide-impregnated bed nets (IBNs) are distributed and promoted by malaria control programs throughout the world. This dissertation draws upon qualitative evidence to document how social, cultural, and economic factors affect malaria exposure and bed net use in rural mestizo villages around the city of Iquitos in the Peruvian Amazon. The introduction presents an overview of malaria epidemiology worldwide, in the Americans, and in the Peruvian Amazon. It describes the theoretical framework of the research, the study sites, and the data collection methods employed. Paper #1 describes the use of nighttime household observations to determine the type and extent of bed net use and document evening and nighttime social, cultural, and economic activities that might increase exposure. Data confirm that untreated net use is nearly universal in the study area, but IBN use less common. Entering and leaving nets frequently throughout the night is likely to reduce their protective effect. Findings also point to early evening television viewing, religious services, and vending as potentially risky activities. Paper #2 draws upon in-depth ethnographic interviews to determine the barriers to uptake of the most common type of IBN and then explore the characteristics of a more ii culturally appropriate net. Users identify warmth, privacy, protection against small biting insects, and esthetic appeal as important net characteristics. Paper #3 describes a series of household trials carried out over six months to test home-based insecticide impregnation of nets and cultural acceptability of a pre-treated nylon netting fabric designed to address preferences identified by net users in paper #2. Based on the findings, I recommend promotion of both home-based treatment of existing (mostly cotton) nets and distribution of a more densely woven nylon IBN that better fulfills non health-related functions of nets sought by net users. Advisor: Peter J. Winch Readers: Janice Bowie William Brieger Clive Shiff iii Acknowledgements I wish to thank the many people whose contributions of time, labor and thought made possible and greatly enriched this study. First and foremost, my thanks to all the residents of the study communities. Thanks as well to the village officials and promotores de salud (volunteer community health workers) who welcomed us into their communities, introduced us to residents, helped us gain community consent to participate in the project, and assisted in many ways throughout the research. Though the specific villages and individual participants remain anonymous here for reasons of confidentiality, I am grateful for their participation and their patience with our many visits and many questions over a period of nearly two years. They were willing hosts and capable teachers, and it was a privilege to work, talk and exchange ideas with them. I sincerely hope that the results of this study serve at least in some small way to alleviate the burden of malaria they suffer. I am also most grateful to my colleagues at the Dirección Regional de Salud de Loreto (Loreto Ministry of Health) who provided work space, input on the study protocol, and assistance in numerous ways. Special thanks to my co-investigators Lic. Clara Delfina Bustamante Pezo and Lic. Luz Marina Olórtegui Pezantes and to the director of malaria and infectious diseases during most of the study, Dr. César Ramal Asayag. Thanks also to the regional directors of health who served in Loreto while the study was being carried out: Dr. Carlos Calampa del Aguila, Dr. Jorge Luis Reyes Dávila and Dr. Carlos Efraín Vidal Oré and to their respective sub-directors, Dr. Luis Alberto Valdivia Espinoza, Dr. José Univazo Muñoz, and Dr. Martín Casapía Morales. I am particularly indebted to Dr. Valdivia for his enthusiasm about the project and for his many hours of work helping me develop and revise the protocol and win support for it from the DISA Loreto, the Instituto Nacional de Salud, the iv Programa Nacional de Malaria, and Proyecto Vigía. Many other members of the DISA Loreto helped in various ways throughout the study. While it would be impossible to name them all individually, they included Lic. Anita Aguilar Garcia, Dr. Christian Armando Carey Angeles, Lic. Wilma Casanova Rojas, Dr. Ernesto Colán Bernal, Dra. Karina Gil Loyaza, Dr. Luis Santillan Espinar, Obst. María Elena Yumbato Pinto, Sr. Abner del Aguila Gevara, Sra. Sara Navarro Gaviria and Sra. Roxana Nunes Noronha. Special thanks to Dra. Graciela Meza Sánchez for her help in arranging and coordinating the final presentation of research findings to the Loreto College of Medicine and the staff of the DISA Loreto. Special thanks to Lic. Lucia Ruiz Escalante for her friendship, support, and guidance on the ins and outs of how things work at the DISA Loreto. From the Asociación Benéfica PRISMA, I am indebted to Dr. Robert Gilman for advice and support and to Lic. Lilia Cabrera Rojo and Srta. Paula Maguiña for a million things. From the U.S. Naval Research Center Detachment (NMRCD) in Lima, my special thanks to Sra. Roxana Lescano and Dra. Monica Negrete for their collegial support and their friendship. Thanks also to Dra. Carmen Flores Mendoza, Dr. George Schoeller, and Lt. Jeffrey Stancil for entomological information. Many thanks to Sr. Manuel Silva Fasabi, a wise and experienced promotor de salud who helped arrange many field activities, answered many questions and explained the whys and wherefores of many local practices. Thanks to Sr. Elisban Dávila Teran, Lisa Nutting, Sr. William Ramos Rodriguez, and Diane Reidy for their help with data collection in the field. Thanks to Sr. Jorge Luis Carranza Gonzales, Srta. Nair Irasema da Costa Olórtegui and Sr. Henrry Echeandia Rossell for their help transcribing interview tapes and entering data. Thanks to Ing. Jorge Enrique Mercado Muro of Aventis for donation of the v KO-Tabs™ used in our trials of home-based net treatment and for technical information about their use. Dr. Trenton K. Ruebush, III, then at the U.S. Centers for Disease Control, now at USAID, was generous with his time and experience His feedback on the study protocol was most helpful and his willingness to act as a resource on technical issues was, and is, invaluable. Thanks to Dr. Dwight Mount and Dr. Robert Wirtz, also of the CDC for their analysis of insecticide residuality on cotton (“tocuyo”) bed nets. Dr. Victor Zamora Mesía of Proyecto Vigía and Dr. Jaime Chang Neyra of USAID asked thoughtful questions that significantly sharpened and strengthened the proposal, then provided invaluable assistance shepherding it through the review and approval process at both the Ministry of Health and USAID. Both continued to offer constructive and valuable feedback throughout the data collection process. Dra. Luz Ester Vásquez generously made Proyecto Vigía’s facilities available for meetings and discussions at several points throughout the project and was instrumental in bringing its results to the attention of directors and personnel from the Programa Nacional de Control de Malaria, the Instituto Nacional de Salud, DIGESA and OGE. At the Johns Hopkins Bloomberg School of Public Health, thanks to Velma Pack and Stephanie Steele for their help with financial administration. Their friendly and capable assistance with the complexities of petty cash accounts, payment of local field staff, budget reporting requirements, and even shipping of bed nets from Bangkok to Iquitos via Baltimore was invaluable to the day-to-day management of the project. Thanks to Carol Buckley and Nancy Stephens for their unfailing cheerfulness, their sympathetic ear(s), and their assistance navigating the sometimes bewildering process of course requirements, exams, committees, forms, and even long-distance registration. vi I am most grateful for the support and constructive feedback from the members of my preliminary exam committees: Bill Brieger, David Celentano, Joel Gittelsohn, Suzanne Maman, Michael McQuestion, Dick Morrow, and Bill Moss. David Celentano neatly summed up the whole of my academic history with his comment at the end of my schoolwide preliminary oral exam: “Congratulations, you passed. We’re going to recommend that you greatly narrow the focus of your proposal, but we realize that you probably won’t pay any attention to our recommendation.” To Janice Bowie, Bill Brieger, Larry Moulton, Phyllis Piotrow, and Clive Shiff, the members of my final defense committee, it’s been a pleasure working with and learning from you over the years. Many thanks for your support and thoughtful comments on the dissertation and other things along the way; I hope we’ll have many opportunities to continue working together in the future. Many many thanks to my mentors at the Johns Hopkins Bloomberg School of Public Health, Dr. Peter Winch and Dr. Elli Leontsini for their generosity both personal and professional. They have participated in every phase of this project and have demon- strated great patience with the fits and starts of both the investigation and the investigator. Peter’s feedback on my writing over the years (“It’s a good start, but…”) has sharpened my thinking, helped me understand the importance of providing enough context (but not too much), and always led to a better end product, even if I grumbled about it along the way.
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