Durham E-Theses Exposing multiple malarias: A photo-ethnography of young people's malaria-related health practice in the Philippines Iskander, Dalia How to cite: Iskander, Dalia (2015) Exposing multiple malarias: A photo-ethnography of young people's malaria-related health practice in the Philippines, Durham theses, Durham University. Available at Durham E-Theses Online: http://etheses.dur.ac.uk/11338/ Use policy The full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-prot purposes provided that: • a full bibliographic reference is made to the original source • a link is made to the metadata record in Durham E-Theses • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders. Please consult the full Durham E-Theses policy for further details. Academic Support Oce, Durham University, University Oce, Old Elvet, Durham DH1 3HP e-mail: [email protected] Tel: +44 0191 334 6107 http://etheses.dur.ac.uk 2 Exposing multiple malarias: A photo-ethnography of young people’s malaria- related health practice in the Philippines. Dalia Iskander This thesis explores malaria in the municipality of Bataraza in the Philippines. It shows how multiple versions of malaria exist inside (and in between) various bodies. These malarias are situated in both time and space, emerge interrelationally and are enacted through embodied practice. It focuses on young people in this context and shows how their identity is similarly enacted through practice. With this in mind, the thesis critically examines how photovoice, a participatory action research method can be used to both depict young people’s malaria-related health practice as well as potentially alter it. During a 15-week photovoice project, 44 school-going children took photographs of their lived experience of different malarias and worked in groups to identify possible changes they might make. As a result of engaging in the photovoice process, young people’s interactions with each other and their families appeared to change as well as their role in promoting health in relation to others. However, in contrast to the literature that highlights the ability of approaches like photovoice to ‘empower’ individuals to make changes to their lives by generating critical consciousness, this thesis makes a unique theoretical contribution by suggesting that photovoice might be effective precisely because it directly operates at and therefore interacts with the level of situated, relational and embodied practice. Taking seriously the context-specific, situated, relational and embodied nature of practice is a key message of this thesis, with important implications for behaviour change initiatives. i Exposing multiple malarias: A photo- ethnography of young people’s malaria- related health practice in the Philippines. Dalia Iskander Department of Anthropology Durham University 2015 Thesis submitted for the degree of Doctor of Philosophy ii Table of contents Table of contents iii List of figures and appendices viii Abbreviations xi Declaration and statement of copyright xiv Acknowledgements xv Dedication xvii Chapter 1: Introduction 1 Chapter 2: Study site 15 2.1 Study location: Bataraza 15 2.2 Demographics and economy 15 2.3 Study population: the Palawan 17 2.3.1 The ‘creation’ of Palawan identity 18 2.3.2 Subsistence and economy 21 2.3.3 Social and political organisation 23 2.3.4 Palawan spiritual world 27 2.3.4.1 Palawan spiritual life – Ampu, diwata and the tandayag 28 2.3.4.2 The components of a person 29 2.4 Conclusion 31 Chapter 3: Methods 33 3.1 Study design: a mixed-methods approach 33 3.2 Fieldwork 33 3.3 Research team 34 3.4 Qualitative data collection tools 36 3.4.1 Participant observation 36 3.4.2 Interviews and focus groups 38 iii 3.4.3 Photovoice 41 3.5 Quantitative data collection tools 42 3.5.1 A note on existing questionnaires 43 3.5.2 Developing, translating and piloting the questionnaire 44 3.5.2.1 Part 1: General information 44 3.5.2.2 Parts 2-6: Knowledge, practices and medicines related to fever and malaria 45 3.5.2.3 Part 7: Self-esteem 47 3.5.2.4 Part 8: Self-efficacy 48 3.5.3 Recruitment and sampling 48 3.5.4 Descriptive statistics of photovoice/questionnaire sample 49 3.5.4.1 Young people 49 3.5.2.2 Adult caregivers 53 3.6 Ethics, confidentiality and the use of pseudonyms 54 3.7 Data analysis 57 3.8 Conclusion 57 PART 1 59 Chapter 4: The malarias of governance 59 4.1 The wider context of malaria control in the Philippines 59 4.3 The Malaria Control Programme in Bataraza 67 4.4 Malarias of governance 69 4.4 Conclusion 80 Chapter 5: The malarias of professionals 81 5.1 Healers in Bataraza 81 5.2 The Balyan 84 5.3 The manghihilot 88 5.4 The Barangay Health Worker (BHW) 91 5.5 The pharmacist 95 5.6 The practice of professionals 97 5.6.1 Training to be a professional – the ‘calling’ 98 5.6.2 The expertise of the healer – a conduit to the unseen 102 iv 5.6.3 Anting-anting (charms) and healing objects 104 5.7 Conclusion 105 Chapter 6: The malarias of patients 107 6.1 Narcita’s malaria 107 6.2 Isabelle’s recurring body pain and fever 108 6.3 Nelsa’s headaches 110 6.4 The house of Bernas’ father 111 6.5 The practice of ‘feeling better’ and maintaining wellness 112 6.5.1 Restoring and maintaining balance 112 6.5.2 Straddling different systems and the ‘second spear’ 120 6.5.3 Ambivalence, fatalism and the ‘bahala-na’ attitude 126 6.5.4 A communal issue 128 6.6 Conclusion 130 Chapter 7: Summary of Part 1 131 PART 2 134 Chapter 8: Growing up in the Palawan setting 134 8.1 Adolescence: a universal biological category? 134 8.1.1 Adolescence as a distinct age category? 136 8.1.2 Puberty as a marker of the transition into adolescence? 137 8.1.3 Adolescents as autonomous individuals? 139 8.2 Growing up in Palawan society - the enactment of relational identity 142 8.2.1 The sangkesawanan (family) 143 8.2.2 The marriage unit 148 8.2.3 School 154 8.3 Conclusion 158 Chapter 9: Doing photovoice as a research method 159 9.1 Methods: the implementation of photovoice 160 9.1.1 Phase 1: introduction and training 160 9.1.2 Phase 2: iterative process of photo-taking and discussion 162 9.1.3 Phase 3: planning and implementing outputs 164 v 9.2 Situating photovoice in context 169 9.2.1 Reflexivity, positionality and power 169 9.2.2 Co-facilitators 173 9.2.3 Working in a low-resource setting 176 9.2.4 Reactions to and use of cameras 177 9.2.5 Participatory analysis 179 9.2.5.1 Selecting images: a selected view 179 9.2.5.2 Contextualising 181 9.2.5.3 Codifying: images as a point of departure 188 9.3 Conclusion 192 Chapter 10: What pictures did: photovoice, action and change 194 10.1 Photovoice outcomes 194 10.1.1 Learning new skills 195 10.1.2 Making friends and being together 197 10.1.3 Feeling less shy and more able to teach others new things 199 10.1.4 Altering malaria-related health practice 207 10.1.5 Young people’s role in promoting health in relation to others 213 10.2 Conclusion 224 Chapter 11: How doing photovoice potentially alters doing malaria: bodily participation and empowerment 225 11.1 Empowerment through participation: what we are looking for? 226 11.2 Looking for participation 228 11.3 A phenomenological approach 230 11.4 What does participation look like? 231 11.4.1 The act of taking pictures 231 11.4.2 Picturing the self 233 11.4.3 Looking at pictures 235 11.4.5 Participating in meaning-making 238 11.4.6 Participating in doing malaria 242 11.5 Rethinking participation as a bodily not cognitive process 246 11.5.1 Acquiring unconscious habitus 247 11.5.2 Imitation, mimesis and the making of mimetic objects 250 vi 11.6 Taking fun seriously 253 11.7 Group participation 258 11.8 Conclusion 258 Chapter 12: Discussion 260 12.1 How and why do people do multiple malarias? 260 12.2 How and why are young people’s identities enacted? 263 12.3 How and why does photovoice illuminate and alter practice? 265 12.4 Suggestions for future research 267 Appendix one 269 Appendix two 296 Appendix three 320 Appendix four 322 Appendix five 325 References cited 326 vii List of figures and appendices FIGURE 1.1: MALARIA CASES BY PROVINCE IN PALAWAN, PHILIPPINES. SOURCE (APMEN 2011). ............. 3 FIGURE 2.1: POLITICAL MAP OF PALAWAN ISLAND INDICATING LOCATION OF BATARAZA. SOURCE: (BALINGIT 2012). ..................................................................................................................................................................... 16 FIGURE 2.2: MAP SHOWING THE MAIN STUDY SITE BARANGAYS IN BATARAZA. .............................................. 17 FIGURE 3.1 FIGURE ILLUSTRATING PROJECT PHASES. ..................................................................................................... 34 FIGURE 3.2: TABLE SHOWING CHARACTERISTICS OF SCHOOL CHILDREN IN EACH OF THE FOUR GROUPS/SCHOOLS. ................................................................................................................................................................. 49 FIGURE 3.3: TABLE SHOWING CHARACTERISTICS OF ADULT CAREGIVERS OF SCHOOL CHILDREN IN EACH OF THE FOUR GROUPS/SCHOOLS. ...................................................................................................................... 53 FIGURE 4.1 DIAGRAM SHOWING PHILIPPINES HEALTH SYSTEM ORGANIZATION. SOURCE: LIU, NEWBY ET AL., (2013). ........................................................................................................................................................................... 67 FIGURE 5.1 PHOTOGRAPH SHOWING SARIO USING HIS TARI-TARI. SOURCE: SARIO. ....................................... 85 FIGURE 5.2 PHOTOGRAPHS SHOWING SARIO USING ROCOROCO AND SILAD.