The University of Dodoma University of Dodoma Institutional Repository http://repository.udom.ac.tz
Social Sciences Master Dissertations
2017 The contribution of socio-cultural practices to the outbreak of cholera in Tanzania: A case study of Ukerewe district
Massawe, Ester G.
The University of Dodoma
Massawe, E. G. (2017). The contribution of socio-cultural practices to the outbreak of cholera in Tanzania: A case study of Ukerewe district. Dodoma: The University of Dodoma http://hdl.handle.net/20.500.12661/768 Downloaded from UDOM Institutional Repository at The University of Dodoma, an open access institutional repository. THE CONTRIBUTION OF SOCIO-CULTURAL PRACTICES TO
THE OUTBREAK OF CHOLERA IN TANZANIA:
A CASE STUDY OF UKEREWE DISTRICT
ESTER G. MASSAWE
MASTER OF ARTS IN SOCIOLOGY
THE UNIVERSITY OF DODOMA
JULY, 2017 THE CONTRIBUTION OF SOCIO-CULTURAL PRACTICES TO
THE OUTBREAK OF CHOLERA IN TANZANIA:
A CASE STUDY OF UKEREWE DISTRICT
By
Ester G. Massawe
A Dissertation Submitted in Partial Fulfilment of the Requirements for the Degree of
Master of Arts in Sociology of the University of Dodoma
The University of Dodoma
July, 2017 CERTIFICATION
The undersigned certifies that he has read and hereby recommends for acceptance by the
University of Dodoma a Dissertation entitled: “The Contribution of Socio-Cultural
Practices to the Outbreak of Cholera in Tanzania: A Case Study of Ukerewe District” in partial fulfilment of the requirements for the Degree of Master of Arts in Sociology of the
University of Dodoma.
…………………
Dr. I. Kombo
(SUPERVISOR)
Date………… …..
i DECLARATION
AND
COPYRIGHT
I, Ester G. Massawe declare that this dissertation is my own original work and that it has not been presented and will not be presented to any other university for a similar or any other degree award.
Signature………………………….
No part of this dissertation may be reproduced, stored in any retrieval system, or transmitted in any form or by any means without prior written permission of the author or the University of Dodoma.
ii ACKNOWLEDGEMENTS
To begin with, I would like to thank God, for his power, strength, and protection he has given me, especially during the time of writing this dissertation.
Also, I express my sincere gratitude to my supervisor, Dr. I. Kombo, who has been generous in giving feedback and intelligent insights in a very friendly manner. I am very much touched by his patience and compassion which he exercised tirelessly from day one until the end of my Master's journey. Without his contributions, this study could have not been successfully accomplished. I would also like to thank my colleagues in Master of
Arts in Sociology Programme of 2015/2017, my fellow Master's students of different
Programs and all other people who have played a role in this study.
Furthermore, I wish to acknowledge all my lecturers from the College of Humanities and
Social Sciences at the University of Dodoma for their academic support and cemented foundation of this work. I would also like to appreciate my Head of Department of
Sociology and Anthropology, Dr. N. Ishengoma and all members of the Department for their encouragement, assistance and contribution in materials for this report. May the
Almighty God bless you all.
Above all, I am honestly thankful to my beloved daughter, Caroline for her tolerance and prayers to the successful completion of my study. Special thanks are also extended to my parents and my young brother Alex, for their prayers, moral support, encouragement, and cooperation during my studies.
In addition, I would like to extend my special thanks to my research assistants, Belina
Seleman and Sophia Minja for enhancing data collection activities. Thanks are also due to all research participants for their willingness in providing relevant information with a maximum cooperation which helped me to complete this study.
iii Last but not least, I would like to show appreciation to the District Health Officer, Health
Workers, Government Officers at Ilangala ward and all community members of Ilangala ward for their contribution in the accomplishment of this study.
iv DEDICATION
This dissertation is dedicated to my beloved parents Mr. and Mrs. Boniphace O. Ungando for their supports since I was young up to this stage. May the grace of God be upon you and have a long life.
v ABSTRACT
This study aimed at exploring the contribution of socio-cultural practices to the outbreak of Cholera. The study involved three villages of Kaseni, Galu, and Kamasi in Ilangala ward within Ukerewe District. Data were collected through social survey, in-depth interview, focus group discussion and documentary review. Both purposeful and simple random sampling procedures were used for sample selection. About 119 respondents were involved in this study. Statistical Package for Social Science (SPSS version 20) and
Microsoft Excel were applied to analyze the data and then presented through tables, figures, plates, and texts. The research divulged that the objective of this study was to exploring the contribution of socio- cultural factors practices to the Outbreak of Cholera.
The specific objectives of this study were to identify socio-cultural practices that contribute to the outbreak of Cholera. The second was to examine awareness of hygiene and sanitation and its contribution to Cholera outbreak, and the last one, is to identify the ways of preventing Cholera outbreak.
The findings revealed that the main cause of the cholera outbreak in Ukerewe was undergoing defecation out of toilets, not washing hands after visiting latrine, drinking unboiled water, eating uncovered and cold food, poor hygiene, and sanitation including the absence of the pit latrines. Find also revealed ways of preventing cholera outbreak including thorough provision of education is highly encouraged, improving existing physical infrastructure, enforcement of laws on hygiene and sanitation to curb the situation and to end the cholera history in Ukerewe. Hence the study suggested that intersectoral collaborations among institutions, like Government Ministries, departments, and NGOs on preventing and controlling the outbreak of cholera are essential.
vi TABLE OF CONTENTS
CERTIFICATION ...... i
DECLARATION AND COPYRIGHT ...... ii ACKNOWLEDGEMENTS ...... iii DEDICATION ...... v ABSTRACT ...... vi TABLE OF CONTENTS ...... vii LIST OF TABLES ...... xii LIST OF FIGURES ...... xiii LIST OF PLATES ...... xiv LIST OF ABREVIATIONS AND ACRONYMS ...... xv
CHAPTER ONE ...... 1 INTRODUCTION AND BACKGROUND TO THE STUDY ...... 1 1.1 Introduction ...... 1 1.2 Background to the Study ...... 2 1.3 Statement of the Problem ...... 5 1.4 Research Objectives ...... 6 1.4.1 General Objectives ...... 6 1.4.2 Specific Objectives ...... 6 1.5 Research Questions ...... 6 1.6 Significance of the Study ...... 7 1.7 Conclusion ...... 7
CHAPTER TWO ...... 8 LITERATURE REVIEW ...... 8 2.1 Introduction ...... 8 2.2 Definition of Key Terms ...... 8 2.2.1 Socio-Cultural Practices ...... 8 2.2.2 Concept of Cholera ...... 8 2.3 Theoretical Literature Review ...... 9 2.3.1 The Social Construction of Reality ...... 9 2.3.2 Structural Functionalism Theory ...... 10
vii 2.4 Empirical Literature Reviews ...... 11 2.4.1 Outbreak of Cholera in Latin America ...... 11 2.4.2 The State of Cholera in Bolivia and Peru ...... 12 2.4.3 Situation of Cholera Outbreak in Brazil ...... 12 2.4.4 Outbreak of Cholera in Asia ...... 13 2.4.4.1 State of Cholera Outbreak in Pakistan ...... 13 2.4.4.2 State of Cholera Outbreak in India ...... 13 2.4.4.3 State of Cholera Outbreak in Haiti ...... 14 2.4.5 Outbreak of Cholera in Sub-Saharan Africa ...... 14 2.4.5.1 Cholera Outbreak in Guinea-Bissau ...... 15 2.4.5.2 Congo (DRC) Cholera Outbreak Situation ...... 16 2.4.5.3 Cholera Outbreak in Burkina Faso ...... 16 2.4.5.4 Cholera Outbreak in Papua New Guinea ...... 16 2.4.5.5 Cholera Outbreak in Tanzania ...... 17 2.5 Identification of Knowledge Gap ...... 18 2.6 Conceptual Framework ...... 19 2.7 Conclusion ...... 20
CHAPTER THREE ...... 21 RESEARCH METHODOLOGY ...... 21 3.1 Introduction ...... 21 3.2 Research Design ...... 21 3.3 Research Approach ...... 21 3.4 Description of the Study Area ...... 22 3.4.1 Selection of the Study Area ...... 22 3.4.2 Location of the Study Area ...... 23 3.4.3 Climate ...... 24 3.4.4 Economic Activities ...... 25 3.5 Target Population ...... 25 3.5.1 Study Population ...... 25 3.6 Sampling Techniques and Sample Size ...... 25 3.6.1 Sampling Procedures ...... 26 3.6.2 Sampling Frame ...... 26 3.6.3 Sampling Size ...... 26
viii 3.6.4 Size Distribution ...... 27 3.7 Types of Data ...... 28 3.7.1 Primary Data ...... 28 3.7.2 Secondary Data ...... 28 3.8 Methods of Data Collection ...... 29 3.8.1 Social Survey ...... 29 3.8.2 In-depth Interview ...... 30 3.8.3 Focus Group Discussion ...... 30 3.8.4 Documentary Review ...... 31 3.9 Data Analysis Procedures ...... 31 3.10 Reliability and validity ...... 31 3.10.1 Validity ...... 31 3.10.2 Reliability ...... 32 3.11 Ethical Consideration ...... 32 3.12 Conclusion ...... 33
CHAPTER FOUR ...... 34 DATA PRESENTATION, ANALYSIS AND DISCUSSION OF THE FINDINGS ...... 34 4.0 Introduction ...... 34 4.1 Demographic Information of Respondents ...... 34 4.1.1 Respondents‟ Villages ...... 35 4.1.2 Sex of the Respondents ...... 36 4.1.3 The Age of Respondents ...... 37 4.1.4 The Occupation of the Respondents ...... 38 4.1.5 Respondents‟ Education Level ...... 39 4.2 Socio-Cultural Practices that Contributing to the Outbreak of Cholera ...... 40 4.2.1 Socio- Cultural Norms towards Outbreak of Cholera ...... 40 4.2.2 Beliefs towards Cholera Outbreak ...... 42 4.2.3 Causes of Cholera outbreak ...... 44 4.2.4 Cholera Patients‟ Caring ...... 46 4.2.5 Place and Burying of the Deceased Person from Cholera ...... 47 4.2.5.1 Burial Place of the Deceased Person from Cholera ...... 47 4.2.5.2 Burial Ceremony and Peoples‟ Involvement ...... 48
ix 4.3 Awareness of Hygiene and Sanitation and its Contribution to the Cholera Outbreak 49 4.3.1 Activities Resulting in Cholera Outbreak ...... 50 4.3.2 Latrine and its Cleanliness at the Study Area ...... 51 4.3.2.1 Latrine in the Study Area ...... 51 4.3.2.2 Types of Latrines in the Study Area ...... 53 4.3.2.3 Latrine Cleanliness Timetable ...... 55 4.3.2.4 Covering Latrine with a Lead/ Stopper ...... 57 4.3.2.5 Washing Hands with Soap after Visiting the Latrine ...... 59 4.3.3 Source of Water ...... 61 4.3.4 The Places of Getting Foods ...... 62 4.3.5 Boiling Water for Drinking ...... 64 4.4 Ways of Preventing Cholera Outbreak in Ukerewe ...... 65 4.4.1 Community‟s Perceptions towards being Free from Cholera ...... 66 4.4.2 Educating the Community on Outbreak of Cholera ...... 67 4.4.3 Improving the Existing Physical Infrastructure ...... 68 4.4.4 Enforcement of Laws on Hygiene and Sanitation ...... 70 4.4.5 The Motivation of Workers ...... 72 4.4.6 Conclusion ...... 74
CHAPTER FIVE ...... 75 SUMMARY, CONCLUSION AND RECOMMENDATIONS OF THE STUDY ...... 75 5.1 Introduction ...... 75 5.2 Summary of the Findings ...... 75 5.2.1 The Socio-cultural Practices for Cholera Outbreak ...... 75 5.2.2 Awareness of Hygiene and Sanitation ...... 76 5.2.3 Ways of Preventing the Outbreak of Cholera ...... 77 5.3 Conclusion ...... 78 5.4 Recommendations of the Study ...... 78 5.4.1 Recommendations to the Government and Institutions ...... 78 5.4.2 Recommendations to the Community level ...... 79 5.4.3 Recommendations to the Health Workers ...... 79 5.4.4 Recommendations to the NGO‟s ...... 80 5.5 Areas for further research ...... 80
x REFERENCES ...... 81 APPENDICES ...... 89
xi LIST OF TABLES
Table 3. 1: Cholera Outbreak in Mwanza Region- 2015/2016 ...... 23 Table 3. 2: Number of Households ...... 27 Table 4. 1: Gender of the Respondents ...... 36 Table 4. 2: Socio-Cultural Norms towards the Outbreak of Cholera ...... 41 Table 4. 3: Causes of cholera outbreak ...... 45 Table 4. 4: Caring Cholera Patient ...... 46 Table 4. 5: People Involved in the funeral of Deceased Person From Cholera ...... 48 Table 4. 6: Activities Resulting to Cholera Outbreak ...... 50 Table 4. 7: Respondents‟ Perceptions Towards Free From Cholera ...... 66
xii LIST OF FIGURES
Figure 2. 1: Conceptual Framework ...... 20 Figure 3. 1: Location of the Study Area ...... 24 Figure 4. 1: The Respondents‟ Village ...... 35 Figure 4. 2: The Age of Respondents ...... 37 Figure 4. 3: The Occupation of the Respondents ...... 38 Figure 4. 4: Education Level ...... 39 Figure 4. 5: Beliefs towards Cholera Outbreak ...... 43 Figure 4. 6: Respondents‟ View on Burial Place for the Deceased Person ...... 47 Figure 4. 7: Latrine in the Study Area ...... 52 Figure 4. 8: Kinds of a Latrine in the Study Area ...... 54 Figure 4. 9: Latrine Cleanliness Timetable ...... 56 Figure 4. 10: Responses on Covering Latrines ...... 58 Figure 4. 11: Washing Hands after Visiting the Latrines ...... 60 Figure 4. 12: Source of Water for the Domestic Purpose ...... 61 Figure 4. 13: Boiling Water for Drinking ...... 64 Figure 4. 14: Awareness through Education ...... 67 Figure 4. 15: Enforcement of the Laws on Hygiene and Sanitation ...... 71 Figure 4. 16: The Motivation of Worker on Cholera Outbreak ...... 73
xiii LIST OF PLATES
Plate 4. 1: Poor Latrine Found at Kamasi Village ...... 52 Plate 4. 2: Kinds of Latrines in the Study Area ...... 55 Plate 4. 3: Traditional Latrines, Wooded Floor and Grass Thatched Walls ...... 57 Plate 4. 4: Covering of Latrines ...... 59
xiv LIST OF ABREVIATIONS AND ACRONYMS
CBOs Community Based Organizations CCHP Council Comprehensive Health Plan CDC Centre for Disease Control CFR Case Fatality Rate CTC Cholera Treatment Center DEWS Disease Early Warning System DHO District Health Officer DNO District Nurse Officer DRC Democratic Republic of Congo EPOA Emergency Plan of Action FGD Focus Group Discussion MOH Ministry of Health NGOs Non-Governmental Organizations SPSS Statistical Package for Social Sciences UDC Ukerewe District Council UN United Nations UNICEF United Nations Children‟s Fund URT United Republic of Tanzania WHO World Health Organization
xv CHAPTER ONE
INTRODUCTION AND BACKGROUND TO THE STUDY
1.1 Introduction
This chapter provides background information about the contribution of socio-cultural practices to the outbreak of cholera in Ukerewe District. It focuses on the measures and interventions of the plight of this epidemic disease. Besides that, this chapter scans the global picture of the prevailing situation, that is, the cholera outbreak in different countries and the strategies in place, to address the phenomenon.
Cholera is an infectious disease that causes severe watery diarrhea which can lead to dehydration and even death if untreated (Cook-Gordon, 2009). According to Center for
Disease Control (2014), Cholera is an acute diarrheal illness caused by infection of the intestine with the bacterium Vibrio-Cholerae. The disease is transmitted through ingestion of food or water substances contaminated with a bacterium, and it is closely associated with poor sanitation and overcrowding. Tanzania like any other developing countries faces a number of developmental challenges. Among such challenges, disease stands out as the major problem. Other challenges include inadequate access to safe and clean water, hygiene, sanitation and sewage systems, which have contributed to the prevalence of the waterborne infections, including cholera (Kandachar et al., 2011)
According to the United Nations (2005), about 1.1 billion people lack access to improved water sources, which has resulted in 1.8 million deaths as a result of water-borne related diseases. Again, about 2.8 million cases of cholera occur annually worldwide, the incidence being 2 cases per 1000 people at risk (Kosek, 2003).To date, the world is experiencing several large outbreaks of the disease, specifically in developing countries.
This preliminary chapter provides the background information to the outbreak of cholera.
1 The chapter thus, presents a statement of the problem, research objectives, research questions and winds up with the significance of the study.
1.2 Background to the Study
In the industrialized countries such as Europe, North America, and the Western Pacific, cholera is largely eliminated as a result of improved water and sewage treatment infrastructure as well as improved housing conditions which have limited the survival of cholera causative agents (Prüss-Üstün and Corvalán, 2006).
Countries in Southern Asia and sub-Saharan Africa have the highest incidences of contracting the disease which kills approximately 91,000 people annually. The mortality rate varies from 0.1% in developed countries compared to 15.2% in developing countries
(CDC, 2014). Many people still die of the disease notably in Sub-Saharan Africa and
Hispaniola, clearly showing that cholera remains a significant public health problem
(WHO, 2015).
Again, Prüss-Üstün and Corvalán, (2006) have asserted that Water-related diarrheal diseases, including cholera, are widespread in areas where water resources are scarce and the majority of diarrheal diseases can be attributed to environmental factors such as unsafe drinking water, poor hygiene and lack of sanitation. In other studies such as Mpazi and
Kagoma, (2005), Traerup et al., (2010), it is said that the spread of cholera has been related to floods caused by heavy monsoons which then contaminate drinking water with the bacterium. In droughts, the bacterium can grow more easily in stagnating water in ponds and rivers. Cholera has been found to vary with climate fluctuations over long time periods (Pascual, 2002)
2 Singh (2001) noted that cholera is associated temperatures and rainfall anomalies with diarrhea and cholera, and these stress the role of climate variability in transmission of diarrheal diseases.
While Kosek, (2003) have associated cholera with the prevailing poverty, which is a phenomenon common in all developing countries. In these countries, cholera has remained to be a significant health and economic burden both to the government and the households. For example, Peru experienced cholera outbreak in 1990. Cholera was spread throughout the Latin America in 1991(Nicki, 2010). Other countries in which cholera has been endemic include India, Pakistan, Bangladesh, Afghanistan, South East Asia, Middle
East and South America as it is localized. Also, cholera has been endemic in Gulf Coast such as Florida, Alabama, Mississippi and Louisiana of the USA, all of which are developing countries (Kotloff et al., 2013).
Elsewhere, in Haiti, the prevalence of cholera is associated with the poverty of the country, which has resulted in the inadequate supply of clean and safe water, inadequate housing and unsanitary conditions (WHO, 2011). Cholera outbreaks were intensified in
January, 2010 in Haiti as a result of the earthquake, which destroyed the few existing infrastructure. With repeatedly occurring of hurricanes and earthquakes, cholera remains endemic in the country, where only a quarter of the population is said to have access to decent toilets and safe water (UNICEF, 2016).
In Sub-Saharan Africa, cholera has become endemic since 1970 and remains a recurring cause of large, deadly, multinational epidemics in West, Central, and East Africa (Griffith et al., 2006). In 2012, twenty-five (25) African nations reported a total of 94,553 cholera cases, with large epidemics in the Democratic Republic of Congo, Sierra Leone, Ghana,
Guinea, Uganda, and Niger (WHO, 2013). However, the sub-Saharan Africa takes lead in
3 cholera outbreaks due to a large number of people who lack improved water sources
(61%) and covered with poor sanitary services (UNICEF, 2012).
Similarly, East African countries have experienced outbreaks of cholera in various areas, such as Kenya since 26, December 2014, in Nairobi. Recently, cholera cases (893 cases) have been reported in Mandera (EPoA, 2016). In Uganda, outbreaks are reported in
Kayunga District (21 cases with 8 deaths), and in Sironko District (70 cases with 7 deaths) and this is due to heavy rainfall experienced in the areas (WHO, 2016).
In most cases, cultural factors such as gender inequality, myths, beliefs, taboos, and attitudes are all known to be closely associated with the outbreak and spread of cholera in various localities (WHO, 2002). The greatest burden of health risks is borne by the poor populations in poor countries, and by the disadvantaged in all societies with little education, and with low-status occupations but strictly abiding by their cultural life.
Therefore, people‟s cultural practices reflect the pattern of diseases and the ways in which they respond to the situations (Lubos et al., 2013).
In Tanzania, cholera remains endemic both in rural and urban areas. Cholera cases are repeatedly reported to hit most of the regions of the country, with nine of the regions being dominant in reporting the outbreaks. The regions include Dar es Salaam, Dodoma,
Kigoma, Lindi, Mbeya, Morogoro, Mtwara, Pwani, and Tanga (WHO, 2008). Recent reports indicate that there has been an ongoing outbreak of cholera in Morogoro, Dar es
Salaam, Tanga, Arusha, Singida, Mwanza and Zanzibar, which informs that much is to be done to combat the outbreaks. For example, as of 20th April 2016, a total of 25,276 cases including 390 deaths had been reported national wide. Tanzania mainland alone, reporting
20,961 cases with 329 deaths and the remaining deaths and cases are from Zanzibar (URT,
2016).
4 1.3 Statement of the Problem
Cholera is a public health problem and epidemic in Tanzania (Hounmanou et al., 2016).
The cholera outbreaks have been responding adequately: Cumulatively, 8,185 cholera cases (both Mainland and Zanzibar) and 116 deaths have been recorded (as of November
9, 2015). Over 50% of the cases were reported from Dar es Salaam and Mwanza (URT,
2015). Recently, (as for 20th April 2016) a total of 25,176 cases, including 390 deaths had been reported from 23 regions (URT, 2016). Out of all cases, Ukerewe District recorded
988 cases including 18 deaths, constituting to 4.6% of all deaths in the country (Wang et al., 2016)
Cholera outbreak is said to be contributed by several factors including contaminated water and food substances, areas surrounded by water bodies like lakes, ponds, and swampy are risk areas for cholera (WHO, 2008). The WHO (2016) argues that the spread of cholera was due to a limited access to safe water and sanitation, low coverage to improved latrines, myths and misconceptions on hygienic practices.
There were efforts taken by the government through different institutions, NGOs,
International organization like WHO, UNICEF, to fight against cholera outbreak including the establishment of the Multisectoral National Cholera Task Force which provides oversight and coordination responding to the outbreak (WHO, 2016). Despite the collaborative initiatives in controlling and eradicating cholera, the epidemic is still persisting in various parts of Tanzania including Ukerewe.
Different studies have been done on cholera outbreak such as a study by WHO (2008) which focused on causes of cholera outbreak, WHO (2016) on effective means of combating cholera, Figueroa et al.,(2010) on cultural practices, Mpanzi and Kagoma,
(2005) on hygienic practices, and lastly a study by Traerup et al., (2010) which focused on
5 climate change. From the above studies, there is partial documentation of the findings on socio-cultural practices to the outbreak of cholera.
Therefore, from these studies, little is documented on socio-cultural practices in relation to the outbreak of cholera. Limited application of social theories is another gap, which cast a shadow on the cultural aspects of life. Differently from (WHO 2002) where cultural zone were mentioned but it relay only on cultural factors that associated to the outbreak of cholera, rather than socio-cultural practices that contribute to the disease. This research, therefore, was set to fill the aforesaid knowledge gap. That is, this study aimed at exploring the contribution of socio-cultural practices to the outbreak and spread of cholera in Ukerewe District in Tanzania.
1.4 Research Objectives
1.4.1 General Objectives
The objective of this study was to explore the contribution of socio-cultural practices to the outbreak of cholera.
1.4.2 Specific Objectives
i) To identify socio-cultural factors that contribute to the outbreak of Cholera.
ii) To examine the awareness of hygiene and sanitation and its contribution to
cholera outbreak.
iii) To identify the ways of preventing cholera outbreak.
1.5 Research Questions
i) How do social-cultural practices contribute to the outbreak of cholera in
Ukerewe District?
ii) To what extent is the awareness of hygiene and sanitation a factor toward the
outbreak of Cholera in Ukerewe District?
6 iii) How can cholera outbreak be prevented in Ukerewe District?
1.6 Significance of the Study
This is a community-based study, which aimed at obtaining information from the society and the health practitioners. The information obtained from this study could contribute to the knowledge on the socio-cultural practices and the outbreak of cholera in Ukerewe
District, Tanzania, and Worldwide. Again, the knowledge obtained could help policy, decision makers and other partners to plan and design appropriate and effective interventions that will trigger efforts towards eradicating the epidemic to the vulnerable population in Ukerewe District and Tanzania at large. Moreover, the study findings may be applicable for academic purposes and grounds for establishing further investigation on the phenomenon under study.
1.7 Conclusion
In summary, this chapter has put the study problem in context. It has also outlined the background to the study from global to local contexts, highlighting the policy-practice dimensions to the contribution of socio-cultural practices to the outbreak of cholera.
Besides, the chapter has scanned the global picture of the prevailing situation that is the cholera outbreak in different countries and the strategies in place, to address the phenomenon. The chapter further has stated the problem and rationale for the study, and then it has outlined the significance of the study. The next chapter (Chapter Two) focuses on reviewing the relevant literatures about cholera cases.
7 CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
This chapter presents an overview of literature related to socio-cultural practices and the outbreak of cholera. The chapter starts with the definition of key terms, theoretical and empirical review related to the outbreak and spread of cholera. The chapter also presents a theory which guides the inquiry, identification of knowledge gaps and conceptual framework and winds up with chapter conclusion.
2.2 Definition of Key Terms
2.2.1 Socio-Cultural Practices
The term „socio-cultural practices‟ refers to a combination of material artifacts and non- material formations that guide human behavior, whose reflection is contained within human consciousness (Berger and Luckmann 1967). The products manifest subjective meanings or intentionally of those who produced them. Culture encompasses beliefs, attitudes, perceptions, norms (rules), customs, traditions, values, ideologies, and religions that govern people‟s ways of life.
2.2.2 Concept of Cholera
Cholera represents the archetypal disease in the context of small-intestinal secretory
(watery) diarrhea. Cholera is caused by eating or drinking substances contaminated with bacteria called Vibrio cholerae, a comma-shaped bacteria which is not invasive and exerts its effects by means of an enterotoxin. If untreated, the disease results in about 20% - 80% mortality. The cholera outbreak is mainly appearing in the area associated with poverty, overcrowding and low socioeconomic status (Cook-Gordon, 2009).
8 2.3 Theoretical Literature Review
The study was guided by two theories namely, the Social Construction of Reality theory and the Structural Functionalism Theory.
2.3.1 The Social Construction of Reality
The Social Construction of Reality theory asserts that reality is socially constructed
(Berger, and Luckmann, 1967). The theory seeks to explain knowledge creation processes through which reality on a particular phenomenon is created through social interactions and socialization process. From this assumption, the validity of the constructed reality needs a contextual understanding from which the meaning of peoples‟ actions influences their attitudes and practices. Hence, people‟s decision to act on a phenomenon is guided by the reflection of the existing social realities. In this study, therefore, this theory was valuable because it addresses issues regarding knowledge creation process, the creation of reality through social interactions and socialization which are key functions of socio- cultural practices.
It can be regarded that socio-cultural practices are the ones that guide lifestyle of the people in a society but may contribute to the outbreak of cholera. Health is as well socially constructed through socialization, the definition of health, disease and even treatment.
Thus this theory held strength to be used in this study.
According to Ritzer (1999), the constructed and shared meanings are internalized by individuals to consolidate it as the social reality. As for Durkheim (1961), the human being is viewed as products of society, shaped by the shared norms and values, whereas societies are human products and human beings are social products, who create meanings and reality through the socialization process. As for Furst et al. (1996), the reasons for acting in a certain manner are socially constructed. As far as this study is concerned,
9 internalized meanings derived from norms, values, and perceptions that govern the interaction of the people were important in trying to understand the disease itself, transmission mode and even carrying of the patient. It was therefore important to examine how these factors can be associated with the spread of cholera.
Although the theory gives a clear stipulation of how reality is constructed, it does not pinpoint the contribution of institutions in the society in both reality construction and equilibrium maintenance. Therefore in order to accomplish this theory, the structural functionalism theory was also employed in this study.
2.3.2 Structural Functionalism Theory
Structural functionalism theory has its origin from the English philosopher, Herbert
Spencer‟s conceptualization of a social organism in the 1850s (Longhofer and Winchester,
2016). The theory describes society as a complex system whose parts work together to promote solidarity and stability. It asserts that human life is guided by social structures, with relatively stable patterns of social behaviour (Longhofer and Winchester, 2016).
According to Zuberi (2015), actors continually act to adjust their behaviour to reflect the existing social structures. In this light, sociological explanation of complex phenomenon like cholera in the society needs socialization in order to understand people's life, since individuals live in a pre-structured world (Andrews and Ritzer, 2007). Thus, structural functionalism theory is suitable for providing a sociological explanation for a social phenomenon in the society with complex structures and social relations as it is in Ukerewe
District (Ritzer, 1999).
This theory was thought to be important in this study because it shows the way different institutions in the society work together in order to maintain stability and equilibrium of the society. Among these institutions are education, family, and cultural practices. If all
10 these institutions collaborate and work together, the society will be free from cholera.
Nevertheless, if one of the institutions fails to work properly, it affects other institutions hence leading to an outbreak of cholera within the community. In this study it was thought that socio-cultural practice as one of the institutions does not work properly, that‟s why the study was trying to examine its contribution to the outbreak of cholera in Ukerewe
District.
2.4 Empirical Literature Reviews
2.4.1 Outbreak of Cholera in Latin America
Cholera outbreak has been occurring in the societies as the result of insufficient safe and clean water, inadequate hygiene and sanitation ranging from improper waste disposal, food handling, processing, and preservation, poor housing, improper and inadequate sewerage systems (Pascual 2002; Mpazi and Kagoma, 2005; Prüss-Üstün and Corvalán,
2006; WHO, 2009). However, cholera infection has been perceived differently across the societies and nations, where, a person‟s perceived risk of contracting an illness and the severity of its consequences are likely to trigger healthy practices (Becker, 1981).
In Latin America, certain cultural practices encourage people to leave food that had been cooked permanently open, especially during funerals and pilgrimages to religious sanctuaries (Kumate et al., 1998). Again, water for domestic use is preserved in containers that promote contamination, making the risk of contracting cholera by drinking stored water 2 to 3 times higher than by drinking water from streams or rivers. This practice provides room for contamination as flies will settle on the food and increase the risk of infection if such food is eaten (Wasonga, et al., 2014)
11 2.4.2 The State of Cholera in Bolivia and Peru
According to Balderston et al., (2002) the Andean Indians prefer using the coca leaf despite its great chance of causing lung cancer. Culturally, coca leaf is used as a medium of exchange as well as a means of communicating with the supernatural world as well as a bonding mechanism for the promotion of kinship ties and cultural royalties. Even though the leaf affects the health of the Andean Indians, it is continuously used for cultural purposes. Moreover, Rogers (1995) explains the outbreak of diarrhea among the Peruvian villagers, and he argued that boiling water was associated with caring for the sick person or a symbol that there is someone sick in the household. So, the community members were not allowed to boil water by their customs, boiling of water was a taboo. Any community member attempting to boil water was violating the taboo, regarded as deviant and subjected to sanctions such as isolation. Thus, any intervention introduced in the area failed to combat diarrhea diseases as a result of cultural practices of the local communities
(Figueroa and Kincaid, 2010).
2.4.3 Situation of Cholera Outbreak in Brazil
In Brazil, the dominant belief was in water treatment whereby it was conceived as unnecessary practice and that it was associated with the intoxication of drinking water
(Quick et al., 1996). With such a misconception, water treatment for prevention of diarrheal diseases could not be effective, hence, a frequent outbreak of epidemics.
Moreover, Ritter and Tondo, (2014) added that the boiling of water as an alternative to the use of chlorine was not practiced because it is expensive and time-consuming.
Although access to safe water and sanitation in Brazil has made important advances in the last decades, gastrointestinal infections remain a public health concern in Brazil from 2000 to 2013. The Brazilian Ministry of Health reported an average of 665 foodborne outbreaks
12 per year (Brazilian MOH 2014). According to Marcynuk et al (2013) due to the effort made by the government from the last nine years, Brazil has reported non-imported cases.
2.4.4 Outbreak of Cholera in Asia
2.4.4.1 State of Cholera Outbreak in Pakistan
Nielsen et al. (2003) narrated that in Pakistan, water-borne infections have been recurring in the local communities as a result of people‟s attitudes towards hygiene practices. For example, in Punjab area of Pakistan, hygiene practices were related to the wife‟s perception of her “social status” rather than a measure to prevent diseases. Floods in
Pakistan have affected millions of people and greatly increased the risk of diseases outbreak. The operations guidance was developed in order to strengthen surveillance using the Disease Early Warning System (DEWS) and allow a coordinated approach to disease outbreak preparedness and response in the floods affected the population. The DEWS system has been functioning in Pakistan since 2005 (Rahim et al.,2010)
Pakistan is a developing country, currently facing the double burden of disease with infectious diseases contributing to 26% of the total disease burden. The outbreak of cholera is attributed to poor environment and sanitation condition and consumption of contaminated water and food due to natural calamities which have displaced a large population. These have become a major cause of morbidity and mortality in Pakistan
(Noor et al., 2010, WHO 2011).
2.4.4.2 State of Cholera Outbreak in India
Naveen et al., (2012) argued that the Indian tradition, do not allow people of the scheduled caste hamlet to collect water from the other hamlet even in the case of a crisis such as cholera outbreak. Scheduled Caste community believed that the outbreak was due to the wrath of the goddess, and a sacrificial goat was offered to appease her. This suggests that
13 these social factors are obstacles in prevention and control of communicable diseases.
Poor sanitation and poor personal hygiene were not regarded as determining factors for the outbreak.
2.4.4.3 State of Cholera Outbreak in Haiti
In Haiti, during a cholera outbreak in 2010 following the powerful earthquake which devastated the country, people believed that cholera was brought by foreigners in order to use or to harm their citizens (HRC, 2010). Some people believed that cholera was a deliberate infection spread through a magic „cholera powder‟ ("kolera poud") prepared by
Voodoo priests and transmitted by Voodoo worshippers. Such believes made the natives to be reluctant with the real causes of cholera, making it persistent.
After the earthquake in Haiti 2010, International Medical Corps made more effort on combating the outbreak by progressing out a network of cholera treatment centers (CTCs) and mobile medical units in Haiti‟s villages and affected areas. Furthermore, International
Medical Corps made the Ministry of Health (MoH) together with local doctors, nurses and community health workers central to its cholera reaction and be a part of the country‟s long-term infrastructure to prevent and treat cholera in Haiti (Tu et al., 2009).
2.4.5 Outbreak of Cholera in Sub-Saharan Africa
Cook-Gordon (2009) argues that in middle of the 1990s epidemics of cholera in Africa was partly associated with mass refugee‟s movements in central Africa, but also in Eastern and Southern regions. Cook-Gordon (2009) asserted that in 1994, the largest proportion of all cholera cases were in Africa, while forty-two percent (42%) of all cholera deaths were witnessed in Africa South of Sahara. These were due to the explosive epidemic and genocide in Rwanda. Refugees who were displaced to the eastern region of the
Democratic Republic of Congo (DRC) reported 70,000 cases of cholera and 12,000
14 deaths. Between 2001 and 2009, African countries accounted for 93% - 98% of all reported cholera cases worldwide. In 2009, several countries in Africa experienced large cholera outbreaks.
A total of 217,333 cholera cases were reported from Africa in 2009 (WHO, 2009).
Cholera was viewed as an important cause of epidemics in Western Kenya and Zimbabwe resulting from drinking water from the lake or streams, feasting in funerals and in traditional marriage ceremonies (WHO, 2002).
2.4.5.1 Cholera Outbreak in Guinea-Bissau
The study conducted by Einarsdóttir et al., (2001) show that, in Africa, cholera outbreaks have been associated with the impacts of evil spirits to the society. Owing to these, the villagers believed that local ceremonial practices such as offerings to the spirits can help to remedy the situation. In such local ceremonials, chickens and alcohol are placed at entry points to the village, around the village, and in every house, with the intention of preventing cholera as it has been evidenced in some local communities in Guinea-Bissau.
Furthermore, according to Einarsdóttir et al., (2001), other local practices include the designation of religious leaders of the area or women and men with special religious status to go to the most important shrines with offerings and requests for intervention from the gods. Also, women gather at the shrine of the deity, with offerings, dance naked in the night, seeking help from the gods. Older women would sleep at the shrine until the epidemic was over.
In Guinea-Bissau, the attack during the funerals was higher in villages where bodies were not disinfected, and that eating at a funeral with a non-disinfected corpse is recognized risk factor for cholera (Onyango et al., 2013). The burial of cholera victims without disinfection and feasting at these funerals definitely fuelled the spike in cases. People have
15 their own ways of viewing, explaining and responding to epidemics depending on their cultural practices. Khan et al, (1981) had previously suggested that the only effective means to control cholera outbreak is to protect water supply and the prevention of using contaminated water. In addition, in African settings, particularly in densely population areas, another control measure can be through chlorination of water.
2.4.5.2 Congo (DRC) Cholera Outbreak Situation
According to Hewlett and Hewlett (2008), when a person dies in Congo following cholera outbreak, the traditional healers conclude that the death is due to poisoning by sorcery. To avoid more outbreaks and deaths, offerings and sacrifices in terms of food and drinks need to be prepared and shared with relatives while a special ritual is performed. Understanding of human culture leads to successful control of outbreak, as the case of Ebola in Congo in
2003 (Hewlett and Hewlett, 2008). In most cases, a wide belief on outbreak is that external interventions culminate the epidemics. Outbreaks and deaths are traditionally associated with not sharing, that is they are not shared with neighbour‟s families.
2.4.5.3 Cholera Outbreak in Burkina Faso
In Burkina Faso, one of the reasons mothers followed the hygiene advice provided at health education sessions may have been “they were wanting to be modern rather than believing in germ” (Curtis et al., 1995). In some Muslim communities, the practices of rinsing the mouth with water before prayers are considered as a risk factor for cholera
(Birmingham et al., 1997). However, mouth rinsing and religion are not related to the disease. It is the use of contaminated water for rinsing the mouth that causes the disease.
2.4.5.4 Cholera Outbreak in Papua New Guinea
In Papua New Guinea, cholera was believed to be a disease that „jumps‟ from one person to another (WASH news Asia & Pacific, 2009). From such beliefs, no one takes trouble
16 when one dies by the roadside on that basis. Even the nurses at the hospital did not want to have physical contact like handshakes with other nurses working in the cholera treatment center, during the cholera outbreak in 2009. This misconception has resulted into a regular outbreak of the disease in this community and other communities in cholera epidemic regions.
2.4.5.5 Cholera Outbreak in Tanzania
Tanzania, like any other developing countries faces a number of developmental challenges. Among such challenges, disease stands out as the major problem. Other challenges include inadequate access to safe and clean water, hygiene, sanitation and sewage systems, which have contributed to the prevalence of the waterborne infections, including cholera. According to UN (2005), about 1.1 billion people lack access to improved water sources, which have resulted in 1.8 million deaths as a result of water- borne related diseases. Again, about 2.8 million cases of cholera occur annually worldwide, the incidence being 2 cases per 1000 people at risk (Kosek, 2003).
Mpazi and Kagoma (2005), indicated that Cholera outbreaks are a result of many factors ranging from improper waste disposal, food handling, processing and preservation and poor housing. He further added that improper and inadequate sewerage systems, water shortages, geographical and socio-economic backgrounds of the people are the contributory factors. With this pattern of conceptualization, lacking access to improved drinking water sources without access to improved sanitation is the globally recognized cause of cholera (Water Aid, 2012).
Traerup et al., (2010) added that health impacts of climate change in Tanzania noted that climate change is the results of variability in temperatures and changes in the patterns of rainfall which entails serious consequences for human health, including the risk of
17 diarrheal diseases. Indeed, there is a strong evidence that temperature and rainfall patterns affect the disease pattern that has a link with the incidence of cholera.
According to WHO (1998), the first major outbreak of cholera in Tanzania occurred in
1992 and led to 18,526 cases with 2,173 deaths. In 1997, Tanzania had an alarming outbreak which started in Dar es Salaam with 40,249 cases including 2,231 deaths as a result of El Nino phenomenon (WHO, 1998). To date, there have been a series of cholera outbreak in which the government has been responding adequately.
2.5 Identification of Knowledge Gap
From the reviewed literature, the spread of cholera in the developing countries was due to changing in temperatures which influence patterns of rainfall, scarcity of water resources, and floods caused by heavy rainfall that contaminates drinking water. Also inadequate health education program measures, inadequate infrastructure for a sewage system and contacting disinfected corpses have been other factors. However, all the findings are capable of being quantified. For instance, the study by Mpazi and Kagoma (2005) indicated that the outbreak of cholera was culminated by inadequate hygienic practices concerning cholera by the community due to misconceptions on the transmissibility of cholera, that it cannot be transmitted through young children stool.
Moreover, the research by Traerup et al. (2010) shows that the spread of cholera is due to increased temperature and changes in patterns of rainfall due to changes in climate. Again, the study conducted by Cowman (2015), indicated that the spread of cholera was due to differing climatic conditions, open defecation, in access to improved sanitation, improved water sources, poverty and level of education.
For that reason, from the studies above, little is explained on socio-cultural practices in relation to the outbreak of cholera in Tanzania. Limited application of social theories is
18 another gap, which cast a shadow on the cultural aspects of life. This study aims to fill the abovementioned knowledge gap.
2.6 Conceptual Framework
This study conceptualizes that there are interrelations between factors in relation to the outbreak of cholera. These factors include the personal factor (Age, Sex, Occupation, and
Education) as the independent variables. Cultural factors (Attitudes, Norms, and Customs) and other factors including the institutional factors (community awareness, health programs, and legal and policy framework) as intervening variables and the outbreak of cholera which is a dependent variable. The personal factors and cultural factors
(independent variables) under certain condition (intervening factors) have an influence on the prevalence of cholera (dependent variable).
The framework has been used to show the interrelation among the variables because they are more than two. The study has independent, intervening and dependent variables.
Independent variables includes age, education, sex, and occupation, where by intervening variables comprises health programs, legal and policy framework, and community awareness, attitude, norms, customs, perception, beliefs, and taboos. Lastly was dependent variable which stands for the outbreak of cholera.
In connection to the study, factors like age, education, sex, and occupation influence the actors such as health programs, legal and policy framework, and community awareness regarding to outbreak of cholera. Therefore, the community seems to influence the outbreak of cholera, since people‟s attitudes, perceptions, customs, norms, beliefs, and taboos are socially constructed to the reality which will contribute to have or to be free from cholera outbreak. So, people‟s mindset has to be changed positively towards the outbreak of cholera in order the community to be free from cholera.
19
INDEPENDENT INTERVENING DEPENDENT VARIABLES VARIABLES VARIABLE
Personal Factors Institutional factors Age Health programs Education Outbreak of Legal and policy cholera Sex framework Community Occupation awareness
Attitudes
Norms Customs Perception Beliefs Taboos
Figure 2. 1: Conceptual Framework
Source: Researcher (2017)
2.7 Conclusion
This chapter has focused on the connected literature, introduction of it, definition of key terms, theoretical literature review, conceptual framework, empirical review, research gap as well as a conclusion. The subsequent chapter( chapter three) present the research methodology, focusing on the research design, research approach, description of the study area, target population, sampling techniques and sample size. Also, types of data, methods of data collection, data analysis and interpretation, reliability and validity are in order.
20 CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Introduction
This chapter provides details on how information was extracted from various sources and the methodology used to carry out the research. Therefore, the chapter comprises of research design, research approach, description of the study area and its selection criteria, targeted population, sampling techniques and sample size, types of data, methods of data collection, data analysis procedure, and ends up with reliability and validity.
A methodology is a general approach of studying a research topic in a certain area (Seale,
2004). In this study, methodology was prepared to get data which explore the contribution of socio-cultural practices to the outbreak of cholera in Ukerewe District.
3.2 Research Design
The study used a cross-sectional research design. The design was used in collecting a wide range of information from the population with relatively homogeneous characteristics
(similar cultural practices) for establishing explanatory and descriptive associations
(Creswell, 2007). Cross-sectional research design has the potential of communicating the findings in narration basing on perceptions, experiences, and attitudes (Marshall et al,
2014). Furthermore, the design assumed to give an understanding of contribution of socio- cultural practices to the outbreak of cholera within the study area.
3.3 Research Approach
The study used a combined or mixed approach (qualitative and quantitative), with the qualitative approach being dominant. Qualitative approach dominated the study as the researcher aimed to examine the socio-cultural practices towards the outbreak of cholera.
According to Creswell (2003), combined approach is appropriate when the researcher
21 intends to collect both qualitative and quantitative data. The analysis offers a better and detailed understanding of human behaviour and its contribution to cholera outbreak through social cultural practices.
3.4 Description of the Study Area
Ukerewe is one of the seven Districts forming Mwanza region in Tanzania. The District is composed of islands in Lake Victoria, located between Longitudes 31 degrees and 30‟ and
32 degrees 5‟ East and Latitude 1 degree 30‟ and 2 degrees 20‟south. The District has a total area of 6,400 km2, of which 640 km2 is an island surface and 5760 km2 is occupied by water bodies. Other Districts in Mwanza region are Ilemela, Nyamagana, Magu,
Sengerema, and Buchosa. The District has 38 islands, Ukerewe being the biggest island.
Out of 38 islands, only 15 are permanently inhabited due to the nature of the environment to support permanent settlement. The rest are only inhabitable seasonally due to fishing activities. Therefore, people are migrating from one place to another following the season of the environment to engage in their activities. According to the 2012 population census,
Ukerewe District had 345,147 people, 169,279 males and 175,868 females (URT, 2012).
3.4.1 Selection of the Study Area
This study was conducted in Ukerewe District, Mwanza region. The District was selected being among the Districts in Mwanza region with regular outbreaks of cholera (Table.
3.1). At the regional level, the data obtained from Mwanza Region Health Officer indicated that cholera cases were 2,311. The data are demonstrating that forty-two point seven percent (42.7 %) equivalent to 988 cases was in Ukerewe District. Total death cases were 39 at the regional level, with 46.1% of cases being from Ukerewe District. On the other hand, within Ukerewe District, the most affected ward was Ilangala. Similarly, within Ilangala ward the most affected villages were Galu, Kaseni, and Kamasi. It is in this situation of frequently recurring cholera outbreaks that these villages were selected for
22 the study. As well, little has been explained on cultural practices towards the outbreak of the disease.
Table 3. 1: Cholera Outbreak in Mwanza Region- 2015/2016
District name Cumulative Cases Cumulative deaths CFR % Ukerewe 988 18 1.7% Ilemela 575 7 2.9% Nyamagana 251 3 3.0% Sengerema 282 7 2.9% Magu 140 3 1.7% Misungwi 2 0 3.6% Kwimba 17 0 0.0% Buchosa 56 1 1.8% Total 2311 39 1.7%
CFR=Case Fatality Rate
Source: Regional Health Office (2017).
3.4.2 Location of the Study Area
Ukerewe District is divided into four divisions, namely, Mumbuga, Mumlambo, Ilangala, and Ukara. There are 24 wards which are subdivided into 74 villages. Nansio being the
Districts headquarter and the main gateway into and out of Ukerewe.
23
3.3.2 Location of the Study Are
Figure 3. 1: Location of the Study Area
Source: Developed by the Researcher (2017).
3.4.3 Climate
Ukerewe is characterized by two agro-ecological zones namely, the Eastern and Western zone with an annual average temperature of 24.5oC. The eastern zone enjoys a four humid months period (October to May) while the western zone has a longer growing humid period of five to six months (September to July), hence the western zone experiences more rainfall (1800mm) than the eastern zone (900mm). Also, the District has two different agricultural zones, with different planting seasons.
24 3.4.4 Economic Activities
The main economic activities include fishing and small-scale agriculture. Fishing is the dominant attracting fortune-seekers from the neighboring Districts (CCHP, 2016). The major crops cultivated in Ukerewe District include cassava, rice, sweet potatoes, and maize on peasantry basis. Cassava is the staple food for the natives. The peasants also keep livestock in small scales such as cattle and poultry. The prominent tribes in Ukerewe
District are the Kerewe, Kara, and Jita (CCHP, 2016).
3.5 Target Population
The target population refers to the part of the population in research‟s mind and control
(Kothari, 2004). In this study, the target population included the selected households (aged
18 years and above) from three villages in Ilangala ward and the health workers. The selection based on the fact that respondents had a wide knowledge and experience regarding the socio-cultural practices and the outbreak of cholera, and hence they were expected to provide accurate information.
3.5.1 Study Population
Population refers to all elements under study (Singh, 2006). Similarly, Mugenda and
Mugenda (1999) explain population as a set of individuals, cases or objects with some common observable characteristics. It also refers to all members or individuals or group or other elements that a researcher hopes to represent in the study (Vans, 1990). Population for this study was drawn from the households in Ilangala ward, and health workers and
VEOs from Ukerewe District.
3.6 Sampling Techniques and Sample Size
Sampling design refers to research plan that shows the way respondents or subjects were selected for the study (Kothari, 2004). Sampling technique refers to the processes used in
25 selecting a number of individuals from a population (Cohen et al, 2000). The reason for using sampling techniques in qualitative and quantitative research was to get respondents who would be able to give information and explanations on socio-cultural practices within the study area.
3.6.1 Sampling Procedures
The respondents were selected using area sampling and purposive sampling. Area sampling often is used when the total geographical area of interest happens to be big, whereas, a purposive sampling is employed when the universe happens to be small and a known characteristic needs to be studied intensively (Kothari, 2004). Purposive sampling method was used to select the key informants including health workers, and government officials (VEOs) so that they can able to give an explanation and information about society which they are serving on the knowledge on socio-cultural factors and its contribution to the cholera outbreak.
3.6.2 Sampling Frame
The sampling frame is the source list from which the sample is drawn. It includes the number of all items in the population (Kothari, 2004). The sampling frame for this study was households from three villages of Ilangala ward. In addition, key informants were obtained from the health officers, health workers and Village Executive Officers (VEOs) in the respective villages.
3.6.3 Sampling Size
The sample size under this study was drawn from 1900 households in the three villages
(Galu 469, Kamasi 842, and Kaseni 589) (URT, 2013). The sample size was determined using a formula by Yamane (1967); n= N/[1+N(e)2]
26 Where n –is the sample size; N -is the sampling frame; e - is the sampling error
n= 1900/[1+1900(0.1)2]= 95
This study covered, with a total number of 119 participants, whereby it includes a sample size of 95 households, 6 Key Informants, and three focus group discussion of 18 participants who were involved from three villages.
3.6.4 Size Distribution
The sample size of 95 respondents was distributed using proportionate sampling. The number of respondents in each village was proportioned based on its population size. The formula by Israel formula (2009) was used in equation
n= (P*N)/P Whereas
P =Total households in three villages.
N=Total sample size. n=Sample proportional.
p=number of households in one village.
Table 3. 2: Number of Households
Village name Number of households to be surveyed Number of households (n=N*p/P) Kamasi 842 42 Galu 469 24 Kaseni 589 29 Total 1900 95 Source: URT (2013).
27 3.7 Types of Data
The study used both primary and secondary data. Primary data were collected through questionnaires, in-depth interviews and focus group discussions, while the secondary data were collected from relevant sources such as books, journals, manuscripts, District health reports, and internets.
3.7.1 Primary Data
Primary data are those collected afresh and for the first time, and thus happen to be original in character (Kothari, 2004). In this study, the primary data were collected through questionnaires, in-depth interviews and focus group discussions. For example during the interview with one of the health worker asked about the effective use of water guard to the community members and replayed that
“Use of water guards failed due to local communities associated it with the sexual reproductive system, arguing that, water guards affect reproductive organs and in particular male organ”.
Also in focus group discussion one of respondent said that, they do not want to boil water because boiled water had artificial test compared to un-boiled.
Primary data collection helped the researcher to get information related to socio-cultural practices and cholera outbreak.
3.7.2 Secondary Data
The secondary data are those data that had already been collected by someone which supplement the primary data (Kothari, 2005). Therefore in this study, the secondary data were collected from relevant sources such as books, journals, manuscripts, District health reports, and internets so as to extract information related to cholera and socio-cultural practices.
28 For example URT (2015) reported that cholera outbreaks have been responding adequately: Cumulatively, 8,185 cholera cases (both Mainland and Zanzibar) and 116 deaths have been recorded (as of November 9, 2015). Over 50% of the cases were reported from Dar es Salaam and Mwanza (URT, 2015). Recently, (as for 20th April
2016) a total of 25,176 cases, including 390 deaths had been reported from 23 regions
(URT 2016)
Furthermore WHO (2016) argue that the spread of cholera was due to a limited access to safe water and sanitation, low coverage to improved latrines, myths and misconceptions on hygienic practices.
3.8 Methods of Data Collection
According to Kombo and Tromp (2006), data collection refers to gathering information aimed at providing some facts. The case study research design allows the researcher to use different methods of data collection including an in-depth interview, questionnaire, documentary review and focus group discussion. Primary data of this study were collected through key informants‟ interviews, questionnaires survey, and focus group discussion.
Secondary data were collected through review of related literature, books, and journals.
3.8.1 Social Survey
The study used social survey to collect data, in which questionnaires consisting of both closed and open-ended questions were administered to the respondents. The survey is an appropriate means by which quantitative data were gathered; given that the researcher has a prior knowledge of a range of responses likely to be obtained (Kothari, 2004). If the survey is well planned and conducted, the results are always reliable and representative of a much wider population (McNabb, 2002). Questionnaires were administered to the ninety five (95) selected households in the study area after obtaining their informed consent.
29 However, questionnaires were administered in Swahili for the purpose of reducing the risk of misunderstanding and misconceptions.
3.8.2 In-depth Interview
This method of data collection was involved during the interview with the key informants.
Mugenda and Mugenda (1999) explains in-depth interview as a detailed process consisting of dialogue or verbal responses between two persons or between several persons, by using a checklist as a tool. In this study, in-depth interviews were conducted from six key informants including health officers, a health worker at the village, Village Executive
Officers (VEOs) and the researcher. Duration of one session was fifteen minutes. And the data was taken through a tape recorder to make the important information to be noted easier. The checklist was used in guiding the interview (see Appendix II).
3.8.3 Focus Group Discussion
McNabb (2002) defines focus group discussion (FGD) as the organized group of resource persons to discuss issues of interest to the researcher from required data that can be assembled. Focus group discussion (FGD) is a convenient method for gathering information quickly and in identifying and exploring beliefs, ideas, and opinions from groups (Kombo and Tromp, 2006).
The discussion guide was used as data collection tool. FGDs were conducted to community members and health providers. Three FGDs were conducted one from each village, even though two FDGs in two villages were for female only while the other group discussion was for males only in the third village. Each group consisted of six participants.
Male were guided by their fellow man, a research assistant in order for them to be free to discuss issues on cholera outbreak. The groups of female were guided by the researcher herself. The data were obtained through tape recorder and each FDG take a half an hour
30 during the discussion. This data collection method was employed to supplement information gathered from the questionnaires.
3.8.4 Documentary Review
Documentary review refers to analyzing the contents of documentary materials such as books, magazines, newspapers, internet, and the contents of all other verbal materials in either spoken or printed (Kothari, 2004). Information related to cholera outbreak were collected to enrich the study findings.
3.9 Data Analysis Procedures
According to Kothari (2004), data analysis implies editing, classifying, and tabulating the collected data so that they are amenable to analysis. In this study, both qualitative and quantitative data were collected. The data were verified, compiled, coded, and summarized before carrying out statistical analysis based on objectives stated. Statistical
Package for Social Science (SPSS) version 20 was employed as a tool for data coding and analysis for qualitative and analyzing quantitative data and socio-demographic data such as age and sex (Kothari, 2004).
3.10 Reliability and validity
3.10.1 Validity
According to Hedberg and Harper (1991), validity is commonly used in determining whatever the findings are accurate from the standpoint of the researcher, participants or the reader of an account. It is used to judge whatever the researcher accurately describes the phenomena which are intended to describe (Bryman, 2001). To ensure validity, the researcher conducted a pilot study in which focus group discussion guide, interview guides and questionnaires were tested to eliminate the language ambiguity and to make
31 questions clear so that every respondent can be able to understand it clearly. The pilot study was conducted at Ilangala village, in Ilangala ward.
3.10.2 Reliability
Reliability is a measure of the degree to which research instruments yield same results or data after repeated trial (Mugenda and Mugenda, 1999). A reliable instrument measures data in a consistent and accurate manner rather than randomly. In order to make the instrument reliable, the researcher provided clear instruction for the instrument and clarified them in order to remove ambiguous instructions. Moreover, to ensure reliability, multiple methods of data collection were employed. These methods included focus group discussion, in-depth interview, and questionnaires. Moreover, the appropriateness of the research instruments was checked after the pilot study and solicited the required information. Some of the items which were found to be not necessary for the study were removed and the important ones were modified.
3.11 Ethical Consideration
Protection of human rights was ensured by the researcher. Mugenda and Mugenda, (1999) asserted that respondents should be protected by keeping the information given confidential, especially if confidentiality has been promised. The data obtained were only accessed by the researcher and the respondent participated in the research voluntarily.
The first thing was to respect his or her informants and understand their rights, needs, values, and desires. Secondly, the research objectives were verbally articulated to the respondents before the study took place. The researcher obtained the introduction letter from the University of Dodoma. The letter was presented to the District Executive
Director for permit approval in data collection. The researcher administered questionnaires to the respondents, conducted focus group discussions, and interviews with the key
32 informants. The respondents were ensured that the information obtained will be confidential.
3.12 Conclusion
Briefly, this chapter has presented the entire research process. It has explained the study location and its characteristics, research approach and design, sample and sampling techniques (purposive and simple random sampling), the study population, methods of data collection (primary and secondary data), issues of reliability and validity. Moreover, it has explained the methods used in data analysis and it have ended up with issues of ethical consideration during the research process. The following chapter (Chapter Four) deals with data presentation, analysis and discussion of the findings.
33 CHAPTER FOUR
DATA PRESENTATION, ANALYSIS AND DISCUSSION OF THE FINDINGS
4.0 Introduction
This chapter presents the research findings. These are based on primary and secondary data which were collected in Ilangala ward. To be able to elucidate these results clearly, results were presented and discussed in three sub-sections. The first part presents respondents‟ general information. The second and the third part present and discuss the findings on the contribution of socio-cultural practices to the outbreak of cholera in
Ilangala ward. The data are presented by using frequencies, percentages, tables, graphs, plates, and charts.
Data were collected from Galu, Kamasi, and Kaseni village in Ilangala ward. About 119 respondents where involved in this study; whereby ninety-five (95) were the number of household, 6 respondents were key informants and three groups consisting 18 respondents during the focus group discussions. Focus group discussions were organized and covered six participants from each village. Key informants were three Village Executive Officers, that is one from each village and three health practitioners in Ukerewe District. The data obtained through questionnaires were encoded in Statistical Package for Social Sciences
(SPSS) and Microsoft Excel for analysis and interpretation.
4.1 Demographic Information of Respondents
This part presents respondent‟s demographic characteristics. These include age, sex, education, and occupation. The purpose of presenting these characteristics was to make a connection between them and the contribution of socio-cultural practices to the outbreak of cholera among the community living in Ukerewe District.
34 4.1.1 Respondents’ Villages
Household interviews were carried out in three villages of Ukerewe District. A total of 95 households were interviewed (Figure1). Villages were selected from Ilangala ward because it was highly affected by cholera outbreak than other wards. This was due to the nature of the environment, migration, interaction among people and fishing activities
(UDC 2016). From these for examples villages, the researcher was able to identify the socio-cultural practices which influence the outbreak of cholera among the Kerewe people.
Figure 4. 1: The Respondents’ Village
Source: Field Survey (2017)
35 Respondents included men and women above 18 years from the three villages of Ilangala
Ward. The data shows that the respondent from three villages is as follows: Galu has 24
(25%), Kaseni 29 (31%) and Kamasi has 42 (44%). Kamasi had more respondents because it is a camp place for fishing activities. Structured questionnaires were used to solicit responses from participants on the contribution of socio-cultural practices to the outbreak of cholera.
4.1.2 Sex of the Respondents
The data show that 48 (51%) of the respondents were males while 47 (49%) were females.The males dominated compared to females because of the nature of the environment depends on fishing activities and small-scale agriculture.
Table 4. 1: Gender of the Respondents
Sex Frequency (N) Percentage (%) Male 48 51 Female 47 49 Total 95 100 Source: Field Survey (2017)
These data shows that the total number of males was greater than that of females. This was caused by the nature of the environment and economic activities carried around the study area. That is it was found that males were the ones who engaged mostly in fishing activities and small scale agriculture than females. However, the socio-cultural practices it involved both, males and females and affect the whole community. When cholera outbreak occurs it affects all members of the community. It includes children, youth(boys and girls), males, females, and elders This is not far from a study done by Ujah at el
(2015) argues that both gender and age groups were affected by cholera outbreak.
36 4.1.3 The Age of Respondents
Figure 4.2 presents the data about the age of the respondents. The data indicated that 13
(14%) of the respondents aged between 18- 29 years. As well, 35 (37%) of the respondents aged between 30-45 years, while 38 (40%) of the respondents were 46-60 years of age, and lastly 9(9%) of the respondents were 61 and above years old. As the figure displays, the data show that the majority of respondents ranged between 46 to
60years.
Figure 4. 2: The Age of Respondents Source: Field Survey (2017)
This entails that in both villages the communities were dominated by the energetic groups, with the age between 30- 60 years old involved in both small scale agriculture and fishing activities. Therefore due to the outbreak of cholera caused death to a large number of people especially energetic group hence the country lacks the manpower that will work for their country and bring development in their family level and the nation at large. This is corresponding to URT, (1977) both, 18-60 years are energetic and working age group class in the country.
37 4.1.4 The Occupation of the Respondents
With regarded to the aspect of occupation, the data showed that the majority of respondents in the study area about 36 (38%) respondents were fishermen. The other group 35 (36%) of the respondents were a peasant, while 13 (14%) respondents were business and few of the respondents 11 (11%) were employed by the government offices or institutions.
Source: Field Survey (2017)
Figure 4. 3: The Occupation of the Respondents
The data indicate the main occupation in the study area were farming and fishing activities followed by business in fishing sector and small retail shops. This corresponds with URT
(1999a) that, majority of the Tanzanian population, mainly smallholder farmers living in villages depend almost entirely on land resources through agriculture and fishing activities.
38 4.1.5 Respondents’ Education Level
Figure 4.4 shows the data about education level of the respondents. 48 (51%) of the respondents had primary education, 16 (17%) of the respondents had secondary education,
19 (20%) of the respondents had informal education (didn‟t attend the school) while, only
12 (12%) of the respondents had college or university education.
Source: Field Survey (2017)
Figure 4. 4: Education Level
The data indicated that the majority of respondents in the three villages had attended at least primary education. These results are not far from the study by Kashikila (2013) who revealed that 88.5% of the respondents had primary education and were engaging in fishing activities and small-scale agriculture. Consequently the people with low level of education, most of them they are living in hardship and poor condition hence easier for them to get conterminated disease including cholera. Also is difficult for them to change their beliefs and customs and attitude as the result can accelerate to the high increase of cholera outbreak compares to the people who are highly educated, it is easy for them to
39 change their attitude for their benefit of their health. This result joins the study conducted by Katega (2007), who argues that education determines person‟s level of understanding to interact with his or her surrounding environments.
4.2 Socio-Cultural Practices that Contributing to the Outbreak of Cholera
This section is a response to the first research objective and question which sought to investigate the socio-cultural practices that are responsible for the outbreak of cholera in
Ukerewe District. In addition the researcher wanted to examine as to how these socio- cultural practices contributed to this deadly disease.
The data to attain this objective were collected through Questionnaire, In-depth interview and Focus group discussion; whereby respondents were asked identify different norms that contribute to the outbreak of cholera, how they cared cholera patients, and beliefs towards cholera outbreak.
4.2.1 Socio- Cultural Norms towards Outbreak of Cholera
The findings with regard to this objective have shown that 16 (16%) respondents argued that, bearing mothers should take shower to the lake, 28 (29%) respondents had norms of eating together using one plate, 17 (18%) respondents had norms of washing hand in one bowl, 11 (12%) respondents had norms of drinking “hands washed water” as a sign of reconciliation. Likewise, 9 (10%) respondents had norms of not sharing one toilet, 5 (5%) respondents had norms of drinking using one cup and, 9 (9%) respondents did not respond
(see Table 4.2). This is in line with Berger and Luckmann, (1967) who argue that every society has its own norms, beliefs, customs which guide them in their social and cultural life activities.
40 Table 4. 2: Socio-Cultural Norms towards the Outbreak of Cholera
Norms guides the socio-cultural Frequency (N) Percentage (%) Shower of bearing mother to water lake 16 17 Eating together by using one plate 28 29 Washing hands in one bowl 17 18 Drinking of washed water as a 11 12 reconciliation No sharing toilet 9 10 Use of one cup in drinking 5 5 No response 9 9 Total 95 100
Source: Field Survey (2017)
Moreover, the respondents were probed as to why they preferred to eat together using one plate and washing hands in one bowl. Among the reasons given were to: maintain unity, love, and sharing among themselves which is grounded in the traditions and customs of
African societies. As well, they believed that their children and future generation would learn to avoid jealous and separation. During the interview with key informants, the finding revealed that Kerewe tribes were very strictly to their norms, as stated by one of the Village Executive Officers from Kaseni saying:
“Kerewe tribe follow their norms strictly, they must eat together outside to the house as a sign of love, unity and sharing among them in order sustain the good norms to the next generation of their tribe”.
As well, during the focus group discussion in Galu village, it was revealed that drinking of washed hand water was a sign of reconciliation between two parties that are in conflicts.
This was said by an older man saying:
“ if there is a misunderstanding within the family, the sign of reconciliation is to put water in a dish, and everyone should wash his/her hand and after that those who are in quarreling are supposed to drink the water in order to purify their heart and showing love to each other”.
41 The study shows that if these different norms to the society like the Kerewe remain unchecked, they could be one of the causes towards the outbreak of cholera. These results correspond with other studies whereby WHO, (2002) found that cultural factors such as gender inequality, myths, beliefs, taboos, and attitudes are all known to be closely associated with the outbreak and spread of cholera in various localities. In Peru, the study by Figueroa and Kincaid (2010) revealed that interventions to combat cholera failed as a result of cultural practices of the local communities. A similar study by Nielsen et al.,
(2003) in Punjab area (Pakstan), revealed that water borne infections were recurring in the local communities due to people‟s attitudes towards hygiene practices.
4.2.2 Beliefs towards Cholera Outbreak
The respondents were asked about their beliefs towards the outbreak of cholera. The data from Figure 4.5 shows that people within the society had different beliefs on cholera outbreak. The results revealed that, 31 (33%) respondents believed that cholera was related to air, 33 (35%) respondents believed that cholera was due to bewitched. On the other hand, about 12 (13%) respondents believed that cholera occurred when poisons were put into wells, 8 (8%) respondents did not relate cholera with beliefs and 11 (11%) of the respondents had no response.
42
Cholera is a poison which is put into well
Figure 4. 5: Beliefs towards Cholera Outbreak
Source: Field Survey (2017)
The reasons given by respondents revealed that due to their traditional beliefs which they had, the cholera was not a disease; instead, its outbreak and deaths were associated with sorcery. They associated to someone who wants to kill the people of the certain village, family or destroy a certain clan by bewitched them. As well, during the interview with an old woman the following comment was noted:
It is impossible for more than one member of the family from the same condition and place to die of cholera. The woman believes that it is caused by kidumu, meaning that someone puts poison in the gallon and sprays it by combining with air. As a result, the people start to vomit and diarrhea eventually they die”.
On the other hand, the results from the survey were not far from the focus group discussion in Kamasi village, where two participants commented that:
“Cholera is caused by someone who puts poison into the well, and then when people fetch the water and use it, they become sick and die from vomiting and diarrhea”. Also, it is associated with the Health workers who put chlorine into wells to kill bacteria. Community members believe that it is a poison which destructs their reproductive system, especially to men.
43 Likewise, the second participant said:
“Cholera is caused by air, meaning that, the bad wind passes within the community as a result people start to become sick and die after a short time”.
These entail that, in the three villages, the majority of the people believe that the outbreak of cholera was associated with air issues related to witchcrafts and poisons being put into wells. This is not far from the other studies conducted by Ujah et al., (2015), Merten et al.,
(2013) and HRC, (2010) who found also that, an outbreak of cholera was associated with bad air, the anger of God, black magic, and witchcraft. For instance, in Congo (DRC), the study by Merten et al., (2013) found that 59.0% of the people believed in sorcery and witchcraft as the source of cholera.
4.2.3 Causes of Cholera outbreak
The results on the causes of cholera revealed that 16 (17%) respondents had the view that cholera was caused by drinking un-boiled water, 27 (29%) respondents argued that it was due to defecation out of the toilet, while, 25 (26%) respondents noted that it was caused by not washing hands after coming from the toilet. In addition 12 (13%) respondents said that it was caused by eating uncovered food which is cold, 6 (6%) respondents said it was due to the absence of latrines, 4 (4%) respondents said that it was due to poor hygiene and sanitation, and 5 (5%) respondent did not respond. Table 4.3 below is summarizes these results.
These variations of the results were due to various activities being conducted around the lake including fishing, showering, washing utensils, washing clothes and defecation.
44 Table 4. 3: Causes of cholera outbreak
Causes of cholera Frequency, (N) Percentage, (%) Drinking un-boiled water 16 17 Undergoing defecation out of toilet 27 29 Do not wash hands after coming from toilet 25 26 Eating uncovered food which is cold 12 13 The absence of pit latrine 6 6 Poor hygiene and sanitation 4 4 No response 5 5 Total 95 100
Source: Field Survey (2017)
On the other hand, the results revealed that Kerewe norms prohibit the father and his daughter-in-law to share the same latrine. This was found during the interview with the
District Health Officer (DHO) who commented that:
“It is strictly not allowed for the father and his daughter-in-law to share one toilet because it is a shame according to their culture”.
Also during the interviews, one of the oldest man commented that:
” They cannot share one toilet in order to avoid transmission of diseases from the toilet to the person, like chango diseases (stomach ache), and also they could not share the toilet by fearing to be bewitched by wizards”.
The findings revealed that in most cases cholera was caused by the people undergoing defecation out of the toilet, not washing hands after visiting the toilet, unsafe drinking water, poor hygiene, and sanitation. This implies that in the three studied villages, there were poor sanitation and hygiene and hence leading to the outbreak of cholera. The study tallies with other studies by Ghose (2011), Rosewell et al., (2012) and Merten et al.,
(2013) who also revealed that cholera outbreak was due to environmental factors such as unsafe drinking water, poor hygiene, poor hand washing and lack of sanitation.
45 4.2.4 Cholera Patients’ Caring
The respondents were asked on how they caring the person who suffer from cholera. The findings show that 41 (43%) respondents took their patients to hospitals, 30 (32%) respondents treat patients with traditional medicine, 9 (9%) respondents took their patients to traditional healers, 5 (5%) respondents gave first aid to their patients by providing Oral rehydration salts, and 10 (11%) respondents had no response.
Treating the patients with traditional medicine and sending them to traditional healers are the causal factor for the spread of cholera within the society because they caring and treated them without use protected gears such as gloves to avoid contamination as the result made cholera to spread easier to other community
Table 4. 4: Caring Cholera Patient
Place where patients were treated Frequency, (N) Percentage, (%) Take him/her to hospital 41 43 Traditional medicine 30 32 Traditional healer 9 9 Provide oral rehydration salt as the first Aid 5 5 No response 10 11 Total 95 100
Source: Field Survey (2017)
The results on the use of traditional medicine and traditional healers, both with 41% in caring patients with cholera had a minor difference with 43% of the patients taken to hospitals. This implies that in both villages, people still believe in traditional ways of treating patients with cholera rather than hospitals. This could result from the traditional beliefs and norms with the perception that outbreak of cholera was not due to poor hygiene and sanitation, but being witched. This corresponds with the study done by Ujah
46 et al., (2015) in Nigeria, who found that acceptance of treatment of cholera patients has been challenged due to cultural beliefs.
4.2.5 Place and Burying of the Deceased Person from Cholera
According to a questionnaire on the burial system of deceased person, respondents were asked whether the Kerewe traditions allow the deceased person as a result of cholera being buried away from home. Responses were limited to “yes” or “no”. Also, respondents were asked about a person who was involved in the burial of the deceased person. The following were the findings obtained from the study area.
4.2.5.1 Burial Place of the Deceased Person from Cholera
The results presented in Figure 4.12 show that 37 (39%) respondents said that, their traditions allowed for the dead to be buried away from their families, while 58 (61%) respondents said that their traditions did not allow a dead person being buried away from their family compounds.
Figure 4. 6: Respondents’ View on Burial Place for the Deceased Person
Source: Field Survey (2017)
47 This implies that the majority of people were not ready to bury their household members away from their home due to their traditional culture. It was believed that burying away the dead was felt as throwing and separating him or her from the family. Furthermore, it was reported that, if it happened the dead person has been buried away from the family, the sands of the grave were taken and be buried within home compounds. This was done as a sign or symbol of returning the dead person back to their homes (Litaka) to avoid other members to die one after another.
The burring of cholera patient should be taken with care. During the burial people should wear gloves and should be under the guidance of professional Health workers in order to avoid cholera to spread to other members of the communities. The study by Kabita (2010) in Zambia revealed that Cholera outbreaks occurred in several villages following funerals of cholera patients in the Region of Biombo due to negative attitudes towards cholera prevention from cholera corpses.
4.2.5.2 Burial Ceremony and Peoples’ Involvement
The results in Table 4.5 show that 70 (74%) respondents said that health practitioners were involved during the burying the deceased persons as the result of cholera. Also, 24 (25%) respondents said that the deceased persons were buried by community members and 1
(1%) respondents did not respond.
Table 4. 5: People Involved in the funeral of Deceased Person From Cholera
People involved Frequency, (N) Percentage, (%) Health practitioners 70 74 Community member 24 25 No response 1 1 Total 95 100
Source: Field Survey (2017)
48 In most cases the dead bodies of those died from cholera were buried by health practitioners. This could be according to the rules and regulation of health services in
Tanzania, to avoid the spread of the disease to more community members. Likewise, in
Zambia, the Ministry of Health (MOH) of Zambia had mandated that, the bodies of persons dying of cholera be disinfected before burial because many people did not care when burying a cholera case since cholera outbreaks were occurring in several villages following funerals of cholera patients (Kabita, 2010).
Those who prepare the body of a cholera patient for burial can be exposed to higher concentration of cholera vibrio. Also, it is important that these people are not responsible for the preparation of funeral food since this may increase the risk of transmission of infection. Furthermore, funeral may bring people into infected area from which they can carry the cholera organism elsewhere. It is necessary to limit funeral gatherings (WHO,
1993).
In Tanzania, the Government restricts and prohibits the community and political gathering or any meeting if there is an outbreak of cholera.
4.3 Awareness of Hygiene and Sanitation and its Contribution to the Cholera
Outbreak
This section responds to the second research question and objective which sought to the examiner awareness of hygiene and sanitation and its contribution to the outbreak of cholera. The data for this objective were collected through questionnaire, in-depth interview and focus group discussion where respondents were asked of hygiene and sanitation towards the outbreak of the disease include respondents‟ aware on the activities resulting in cholera, use of latrines and their types. Also, respondents were asked the time
49 taken to clean the latrines as well as washing hands after visiting the toilet. On the other hand they were asked about places of getting food and boiling drinking water.
4.3.1 Activities Resulting in Cholera Outbreak
Respondents were asked about the activities resulted in to the outbreak of cholera. The findings demonstrate that 14 (15%) respondents said that people used to take shower at the lake, 29 (31%) respondents reported that people were sharing one dish to wash hands when they were eating, while, 15 (16%) respondents argued that were washing utensils and clothes at the lake. On other hand, about 18 (19%) respondents reported that they were eating by sharing one plate, 10 (10%) respondents said there was no relation to cholera, and 9 (9%) respondents did not respond.
Table 4. 6: Activities Resulting to Cholera Outbreak
Activities Frequency, (N) Percentage, (%) Shower at the lake 14 15 Washing hands on one dish 29 31 Washing utensils and clothes at the lake 15 16 Eating by using one plate 18 19 Not related 10 10 No response 9 9 Total 95 100
Source: Field Survey (2017)
When people probed were about the above practices, responses were to maintain culture and traditions as a symbol of respect, love, and unity among Kerewe tribe. As well, it was said that even in burial ceremony, people were washing their hands in one dish and eat together due to their traditions and customs, as a symbol of love within the society.
50 The results indicated that if intervention would not be taken, prevalence of cholera could not stop. These calls for different planners and stakeholders to alter these cultural practices, unless otherwise cholera will not come to an end. The results are similar with other scholars who revealed that, cholera was resulting from drinking water from the lake or streams, washing hands in one dish, feasting in funerals and in traditional marriage ceremonies (Pan African Medical Journal, 2013; Opare et al., 2012).
4.3.2 Latrine and its Cleanliness at the Study Area
Respondents were asked about the types of latrines that they were using. As well, the researcher was interested to know whether the communities were cleaning and covering their latrines. The following were the results obtained from the study area.
4.3.2.1 Latrine in the Study Area
As for latrines in the area, respondents were asked whether they had toilets/ latrines.
Answers were limited to “Yes” or “No”. The results as shown in Figure 4.6 indicated that
57 (60%) respondents had latrine while, 38 (40%) respondents did not have. However, it was found that most of the latrines were of poor quality. The absence of quality toilets as well as their use can be the multiple factors for the altering of the diseases. (See Plate 4.1).
51
Figure 4. 7: Latrine in the Study Area
Source: Field Survey (2017)
Plate 4. 1: Poor Latrine Found at Kamasi Village
Source: Field Survey (2017)
52 Despite the high percentage of latrines in the study area, still, it was revealed that the majority of people were not using them. Cultural beliefs and perceptions were the main reasons for these latrines not to be used and hence contribute to the outbreak of cholera.
On the other hand, the study found that people constructed latrines to avoid penalties from the government officials. These cultural practices if not intervened could promote the spread and outbreak of cholera. Naveen et al., (2012) argued that social factors are obstacles in prevention and control of communicable diseases. The study by Hewlett, B.S and Hewlett, B.L (2008) ascertained that understanding of human culture leads to successful control of the outbreak.
4.3.2.2 Types of Latrines in the Study Area
The study discovered that people had different kinds of latrines. About 7 (7%) respondents had pit latrines, 12 (13%) respondents had flashing latrines (see Plate 4.2b).
Likewise, 46 (48%) respondents had traditional latrines known as “Magobole” (see Plate
4.2 a). However, the results indicated that 30 (32%) of respondents had no latrines (Figure
4.7). This means that they don‟t have a permanent place, and hence they go anywhere, including in the lake, bushes, around the big stones, and in farm plots.
53
Figure 4. 8: Kinds of a Latrine in the Study Area
Source: Field Survey (2017)
The implications of these results is that traditional latrines (48%) and absence of latrines
(32%) were dominant, leading to poor hygiene and sanitation in the study area.
Furthermore, the majority of the respondents perceived the construction of improved latrines to be very expensive compared to traditional ones. This likens with Wasonga et al., (2014), in Kisumu who revealed that the cost of constructing latrine was too much and thus people resorted to “cat method” (meaning to go around the bushes or farms with a hoe and dig a small hole for defecation then after, covering it with a soil). During the interview with Health Officer, it was found that the claims came as the results of their cultural practices, which ignore using one toilet. In addition, increased number of traditional latrines resulted from the government initiatives that, every family should have a toilet. Therefore, people found the simplest way to avoid fines and other penalties was the construction of tradition toilets.
54
a). Traditional Latrine (Magobole) b). Flashing latrine type
Plate 4. 2: Kinds of Latrines in the Study Area
Source: Field Survey (2017)
4.3.2.3 Latrine Cleanliness Timetable
Respondents were also asked as to when they cleaned their latrines. The answers were limited to “every day”, “when I get time”, “not cleaning at all” and “not sure”. The results shows that, 10 (11%) respondents were cleaning their latrines every day, 40 (42%) respondents said that they cleaned their latrine once they got time, 25 (26%) respondents did not clean at all, while 15 (16%) respondents were not sure, and 5 (5%) respondents did not respond at all. The results are as summarized in figure 4.9 below.
55
Figure 4. 9: Latrine Cleanliness Timetable
Source: Field Survey (2017)
Respondents were further probed on the challenges, and it was revealed that the quality and nature of latrines were among the factors hindering the cleanness being done regularly. Most of the latrines (“magobole”) were lacking smooth floor as they were covered with pieces of woods (see Plate 4.3) and thatched with grasses as walls. Although toilets were built away from the houses, still they could easily spread the diseases due to the low quality of building. That is, they easily allowed contamination of flies from the toilets to the utensils and uncovered food in the houses, hence outbreak of cholera. Also, due to the nature of those toilets, it was really difficult to be easily cleaned.
56
Plate 4. 3: Traditional Latrines, Wooded Floor and Grass Thatched Walls Source: Field survey (2017)
4.3.2.4 Covering Latrine with a Lead/ Stopper
Furthermore, respondents were asked whether they covered their latrine to avoid flies and other insects from getting out. The responses were limited to “yes” or “no”. The results indicated that 6 (6%) respondents were covering their toilets while 89 (94%) respondents were not. This implies that most of the latrines in both villages were not covered and hence allowed flies and other insects to pollute the food and fruits and then resulting to cholera outbreak. Therefore, education on the importance of covering the toilets should be provided so as to avoid the contamination of flies from toilets.
57
Figure 4. 10: Responses on Covering Latrines
Source: Field Survey (2017)
Few people who covered their latrines were using local tools which could be dangerous for them to get diseases such as cholera and other related diseases. Therefore, education should be provided on hygiene and sanitation so that they can use modern equipments for their health protection.
58
Uncovered latrine Woman demonstrates how they cover the latrines
Plate 4. 4: Covering of Latrines Source: Field Survey (2017)
4.3.2.5 Washing Hands with Soap after Visiting the Latrine
The findings presented in Figure 4.11 show that 19 (20%) respondents were washing their hands after attending to toilets, 76 (80%) respondents were not washing their hands. It was further revealed that the majority of people do not put water in their toilets. In addition, some people felt shy from touching the faeces/stool when washing instead they uses papers and grasses.
59
Figure 4. 11: Washing Hands after Visiting the Latrines
Source: Field Survey (2017)
During a focus group discussion at Galu, one of the respondents said that:
“Most of the people do not put water in the toilets, instead they use papers and grasses. The reason behind is that people think that when they use water they are going to touch stools”.
This indicates that there was lack of awareness on the proper use of the toilets and the importance of washing hands after visiting latrines. This is caused by high illiteracy rate associated with tradition and custom in these communities. A similar study conducted by
Wasonga et al., (2014) in Kisumu (Kenya) also revealed that hand washing with soap after visiting the latrine was hindered by cultural beliefs and taboos. Hand washing with soap as well as provision of water and soap next to the latrine encourages good hygiene behaviours as much as it is hard to sustain such behaviours within everyday settings
(Davis et al., 2011).
60 4.3.3 Source of Water
Source of water for domestic purposes indicated on Figure 4.12 presents the results within the area. Respondents were asked the sources of water for different uses including the domestic uses. The results indicated that 51 (54%) respondents fetched water from the lake, 9 (9%) respondents fetched water from shallow wells, 32 (34%) respondents fetched water from wells and 3 (3%) respondents used harvested rainwater.
Figure 4. 12: Source of Water for the Domestic Purpose
Source: Field Survey (2017)
The majority of the people in these communities depend on the lake and wells as the main sources of water for domestic uses. However, many human activities carried out in the lake have caused pollution of the water leading to the eruption of waterborne diseases including cholera. In contrast, some of the community members did not agree that water from the lake can be spoiled or polluted. This was revealed during the focus group discussion in Kamasi village, one woman said:
61 “Water from the lake cannot be polluted by anything, even if you put a poison or any kind of rubbish water cannot be polluted” (enanza tekolwa bulogo– Maji ya ziwa hayachafuliwi na kitu chochote).
It was in this respect, everyone was aware that lake water cannot be polluted by anything and believed that, water from the lake was medicine. As well, when conducting the focus group discussion in Kaseni Village, an old man said:
“Water from the lake is a medicine; when you are not feeling good, you may go to stretch your body at the lake, three times a day, and you will recover your normal condition”.
This corresponds to the study done by Opare et al., (2012) who ascertained that contamination of lake water was due to different activities done by human being within the lake. Water supply by human waste was said to be responsible for the cholera outbreak in Ghana and open land river defecation increased the odds of cholera risk.
4.3.4 The Places of Getting Foods
Places of getting food were associated with the spread of cholera. The researcher was interested to know where people get their food. The Findings presented in Table 4.6 show that 40 (42%) respondents said that they preferred to get food from food vendors (mama lishe), 10 (11%), respondents got food from cafeteria. Also 27 (28%) respondents prepared their own food, 3 (3%) respondents got food from hotels, and 15 (16%) respondents got food from camps (fish camps) which prepared by someone.
62 Table 4.6: The Places of Getting Foods
Places Frequency, (N) Percentage, (%) Food vendors (Mama Lishe ) 40 42 Cafeteria 10 11 Home 27 28 Hotels 3 3 At camps (fishermen) 15 16 Total 95 100
Source: Field Survey (2017)
The results imply that the majority of the people were engaging in fishing activities and most of them were fishermen who spent most of their time in these activities, and hence got food from food vendors (mamalishe) and at camps. Also, some of them were not residents but came purposely in the area for fishing activities and other business.
These places were not conducive and attractive for getting food. They were lacking toilets, poor places of food preparations, and as well, food vendors lack personal cleanness. Some reasons were given as to why many people preferred to get food from mama lishe. Among them were: nature of economic and social activities around Lake Victoria including fishing and cheap prices of the food. But the problem with these places of getting food was poor hygiene and sanitation, that is why was simple for them to acquire the diseases such as cholera. This corresponds with the study by Kabita (2010) in Zambia, which revealed that many people in the affected area had a poor practice of not treating drinking water, shared traditionally brewed drinks and did not practice good environmental hygiene. Traore et al (2012) argue that eating cooked food or uncooked food led to the cholera outbreak in a community. Not far from the study conducted by Merten et al (2013) who said that the majority of the community members considered insufficient hygiene and
63 sanitation levels as the key cause of cholera through ingestion of contaminated water and food.
4.3.5 Boiling Water for Drinking
Respondents were asked whether they boiled water for drinking. Answers were limited to
“yes” or “no”. The results presented in Figure 4.13 revealed that 39 (36%) respondents were boiling water for drinking, while 61 (64%) respondents were not.
Figure 4. 13: Boiling Water for Drinking
Source: Field Survey (2017)
Respondents were probed as to why many people did not boil water. Among the reasons given were: boiled water had artificial taste compared to un-boiled. Another reason was said that the majority of the respondents did not boil water for drinking because they lack energy such as firewood, due to the nature of the environment which is surrounded by water, and therefore, it was difficult for them to get enough firewood for boiling water and cooking food.
64 On the other hand, during the interview one fisherman said:
Most of the fishermen did not use hot water as they have medicine obtained from traditional healer which helps them in fishing activities. It was believed that the use of boiled water could reduce the power of the medicine leading to sickness. This makes them use cold water and not boiled water.
Through government initiatives, communities were advised to treat drinking water using the approved chemicals like water-guards. Due to poor perceptions resulted from traditional beliefs, this initiative also failed. During the interview with one of the health worker said:
“Use of water guards failed due to local communities associated it with the sexual reproductive system, arguing that,waterguards affects reproductive organs and in particular male organs (hupunguza nguvu za kiume)”.
This implies that, with such misconceptions, water treatment for prevention of cholera diseases could not be effective. This indicates that fight against cholera could not be effectively managed if, poor perceptions and traditional beliefs are not well intervened.
This corresponds with the study by Rogers (1995), in Peru who explained that, the outbreak of diarrhea among the Peruvian villagers occurred because people did not use boiled water due to their different beliefs, whereby boiling water was associated with caring for the sick person or a symbol that there is someone sick in the household.
Likewise, in Brazil, the dominant belief in water treatment as unnecessary practice and that it was associated with the intoxication of drinking water (Quick et al., 1996).
4.4 Ways of Preventing Cholera Outbreak in Ukerewe
This part presents the results of the third objective which required to identify the ways used to prevent cholera outbreak and the community perceptions towards free from cholera. The ways to prevent cholera outbreak suggested by the community include: educating the community on cholera outbreak, improving the existing physical
65 infrastructure owned by the government, enforcement of laws related to hygiene and sanitation and provision of motivation to extension health workers.
4.4.1 Community’s Perceptions towards being Free from Cholera
Respondents were asked whether it was possible for the community to be free from cholera. Answers were limited to “strongly agree”, “agree”, “neutral”, “disagree” and
“strongly disagree”. The results show that 29 (30%) of the respondents strongly agreed,
45 (47%) respondents agreed, 10 (11%) respondents were neutral, while 11 (12%) respondents disagreed, and no respondents strong disagreed.
Table 4. 7: Respondents’ Perceptions Towards being Free From Cholera
Responses Frequency, ( N) Percentage, (%) Strong agree 29 30 Agree 45 47 Neutral 10 11 Disagree 11 12 Strong disagree 0 0 Total 95 100
Source: Field Survey (2017)
The results imply that the majority (77%) of respondents combined of strongly agree with
30% and agree with 47% of the community in both villages had agreed that, it was possible for the society to be free from cholera. This was similar to the studies conducted by Vicari et al., (2013), and Ivers et al., (2013) that, willingness to participate is high in a population that has received awareness on cholera. This indicates that, if education campaign will be effectively provided to the community, the society will be ready to change their attitudes, traditional culture, and perceptions towards cholera outbreak.
66 4.4.2 Educating the Community on Outbreak of Cholera
Education through workshops, training, and awareness campaigns, seminars, meetings and through mass media on cholera outbreak will be the ways in preventing outbreak suggested by the community. The findings presented in Figure 4.14 revealed that, 17
(18%) respondents suggested training, 33 (35%) respondents said education campaign should be given to the community, 18 (19%) respondents suggested education should be given through workshops, 13 (14 %) respondents suggested that seminars on the outbreak of cholera should be provided to the community, 4 (4%) respondents said meetings were important and should be conducted in educating people, 10 (10%) respondents suggested mass media should be used in educating people on the outbreak of cholera in Ukerewe.
This was supported by extension health worker during the interview when she said:
“The campaign was the most attractive way of the people to listen and discuss themselves, this changes them slowly especially for the youths and men”.
Figure 4. 14: Awareness through Education
Source: Field Survey (2017)
67 Likewise, Wasonga et al., (2014) found that the use of mass media and community health volunteers were the probable means of message diffusion into the community. Chanda
(2017) in Zambia added that the supervisors should support them to conduct outreach sessions where they conduct Information, Education, and communication on personal hygiene practices, maintenance of environmental sanitation and healthy lifestyles. Also,
Vicari et al, (2013) in his study said that through education they can promote effective use of vaccine program and policies to control the cholera epidemic. Even in Zanzibar education is needed due to frequently occurring of cholera outbreak.
4.4.3 Improving the Existing Physical Infrastructure
As well, ways towards prevention of cholera in the study area were to improve the existing physical infrastructure owned by the government. The results indicated that, 15 (16%) respondents said that the government has to extend health services through construction of new health centers, 5 (5%) respondents suggest the improvement of water services to the community through providing safe and clean water, by use of tape water connections. In addition, about 34 (36%) respondents stated that the, government has to increase the number of boats especially in islands in order to improve transportation for sick people to the hospital, 19 (20%) respondents suggested that ambulances should be added from 1 to
3, and 22 (23%) respondents were of the idea that improvement should be made in the provision of enough tools and equipment for health activities.
68 Table 4.9: Improvement of Infrastructure
Types of the infrastructure Frequency, Percentage, (N) (%) Construction of health centers 15 16 Providing water services 5 5 Provide more boats 34 36 Provide more ambulances 19 20 Proving tools and equipment for health services 22 23 Total 95 100
Source: Field Survey (2017)
The findings show that many respondents suggested that the government should provide more boats 34 (36%). This idea was suggested by many respondents compared to others infrastructures mentioned.
The reasons behind which caused the respondents‟ demands on boats were due to the fact that the area is surrounded by water and many areas are islands, as a result, the residences prefer more transport of boats in order to move from one place to another for their daily activities. Also, the majority of peoples depend on fishing activities to run their daily lives.
However, they also suggested on building updated hospitals with full equipment which is scientific with enough staff in order to reduce the number of deaths to the community members when cholera outbreak occurs.
Also, boats will help them to reach earlier to the hospital and save the life of their relatives because it will be easier for them to get health services at the right time without delaying to the hospital.
69 From the interviews, Village Executive Officer Kamasi commented that:
The majority of the residences depend on fishing activities, for their income generations; so, the boats were most wanted at these areas. Also it will be easier for a sick person to reach at the right time to the hospital in order to get health services in Bomani hospital at Ukerewe District.
The good infrastructures help to prevent cholera whereby the residences are supported and guided on.
4.4.4 Enforcement of Laws on Hygiene and Sanitation
The findings show that 16 (17%) respondents had the view that, supervision of rules and regulations should be in place. While 14 (15%) respondents noted that, people should be encouraged to keep the environment clean. Also, 23 (24%) respondents suggested that emphasize should be on building improved latrines for every family. While 17 (18%) respondents noted that the government should enforce the existing rules and laws. In addition, 14 (15%) respondents said that the government should impose punishment for people who do not clean their environment. Eleven respondents which equals to11% of the respondents said that unlawful people to be imprisoned in order to bring the disciplines and to avoid cholera outbreak.
This has been a practice in Zanzibar, whereby the cholera patients were quarantined in prison Island. This has assisted in reducing the problem in Zanzibar (Elizabeth, 2017)
70
Figure 4. 15: Enforcement of the Laws on Hygiene and Sanitation Source: Field Survey (2017)
The data above demonstrate that the respondents who said that there should be emphasize on building the latrines were the majority of the all residences.
The logic behind on building the latrines are as follows: the majority of people do not want to share the latrines due to their customs, beliefs, attitudes and their taboos that prohibit them to share one latrine because they afraid to bewitched. They do prefer to go to bushes, lakes, and holes. This was caused by poor awareness of residences at the
Ukerewe.
From the focus group discussion one of the respondents said that the majority didn‟t believe that:
„The cholera outbreak is caused by poor hygiene and sanitation whereby the people do not keep their environment clean and others they do not want to leave their traditions and customs which affect their life”.
71 The enforcement of the laws is very important in making the people change and follows the rules and regulations so as to avoid bad and do well (Gimpelson et al.,2009).
4.4.5 The Motivation of Workers
Motivation to workers was mentioned by key informants as one of the measures towards preventing cholera in Ukerewe. The findings indicated that 30% of the key informants had the view that, incentives like hardship allowances should be provided to workers as motivation, 21% of the key informants indicated that, promotions were very important to workers due to nature of the environments and in curbing the problem of cholera. Twenty percent (20%) of the key informants had the view on improving good governance, and in particular when a worker at the community level was attending patients, officials at the higher level had to appreciate and not discouraging them through intimidation. Fifteen percent (15%) of the key informants said the government should provide protective gears for health workers when attending the patients, particularly during the outbreak of cholera. In addition, 14% of the key informants said the government and the community at village level should build and create a conducive environment. Conducive environment for health worker includes having a separate place for the identified cholera patients, who could be treated separately to avoid direct contacts with other patients.
72
Source: Field Survey (2017)
Figure 4. 16: The Motivation of Worker on Cholera Outbreak
The motivation to workers as one of the ways to curb cholera outbreak was also mentioned by the respondents. They viewed that health workers should be well motivated since the environment are not conducive. The environment has poor social services and transport facilities.
The interview that was conducted with DHO commented that:
The motivations for workers are the most needed in order to improve the effectiveness of the work to the workers.
These results imply that poor and absence of incentives could lower the working morale for workers, particularly on the health sector. Also, the absence of protective gears could increase the widespread of cholera among the community especially those who are attending the patients. Chanda (2017) argues that, in the rural areas, incentives should be provided to the frontline health care workers consisting of the community-based workers, the enrolled Nurses and Midwives.
73 4.4.6 Conclusion
By summing up, chapter four has presented, analyzed and discussed the research results based on the intention of the investigation, specific objectives and research questions presented in chapter one. Moreover, the chapter has presented the basic research assumptions against the key findings emerged from the study to see how the findings supported the assumptions. The chapter in additional, has described the theory of the contribution of socio-cultural practices to the outbreak of cholera as a synthesis of key issues emanated from the study findings. The subsequent chapter is on the summary, conclusions, and recommendations of the study.
74 CHAPTER FIVE
SUMMARY, CONCLUSION AND RECOMMENDATIONS OF THE STUDY
5.1 Introduction
This chapter presents the summary of the study findings based on the specific objectives, conclusion and the recommendations on the contribution of socio-cultural practices to the outbreak of cholera in Ilangala ward in Ukerewe District. Finally, the study suggests areas for further studies.
5.2 Summary of the Findings
The study focused on exploring the contribution of socio-cultural practices to the outbreak of cholera in Ukerewe District. The study was conducted in Galu, Kaseni and Kamasi villages in Ilangala ward. Specifically, the study identified the socio-cultural factors that contribute the outbreak of cholera, examined the community awareness of hygiene and sanitation and its contribution to the outbreak of cholera. Finally, the study identified ways towards the prevention of cholera outbreak within the community. It was in this line, the study came up with the following findings.
5.2.1 The Socio-cultural Practices for Cholera Outbreak
The study revealed and identified different norms and socio-cultural practices within
Kerewe societies. The socio-cultural norms which influence the outbreak of cholera included, eating together using one plate (29%), washing hands in one bowl (18%), and bearing mothers were found to take shower in the lake. Other revealed norms which contributed to the outbreak and spread of the cholera were: drinking of hands washed water as a sign of reconciliation, no sharing of the toilet among the family members and drinking by use of the same or one cup.
75 The results also revealed that 35% of the people believed that, cholera was due to witchcraft, 33% of the people associated cholera with air. Other people within the community believed that cholera occurrence was due to poison being put into water sources including shallow wells. The main cause of the cholera outbreak in Ukerewe was undergoing defecation out of toilets, not washing hands after visiting latrine, drinking unboiled water, eating uncovered and cold food, poor hygiene, and sanitation including the absence of the pit latrines.
Other socio-cultural practices were traditional and culture during the funeral and burial ceremonies. Sixty-one percent (61%) of the people said that tradition and culture of their tribe do not allow the deceased person to be buried away from the homestead. It was believed that burying away a deceased person, could lead to curse, hence leading to the death of one after another among the family members. To avoid the curse, the sand from the grave were taken and be reburied within the home compound (Litaka). The study discovered that 41% of the cholera patients were not taken to hospital for treatment (32 % were treated with traditional medicine and 9% were taken to witchdoctors) believing that, patients could be bewitched. Different beliefs within the society were the factors contributing to the outbreak and spread of cholera in the study area.
5.2.2 Awareness of Hygiene and Sanitation
The results revealed that these are poor hygiene and sanitation in Ukerewe and another parts of Tanzania. Forty percent (40%) of families were found having no latrines.
Furthermore, the study found that most of the latrines (48%) were traditional latrines
(magobole). Despite the presence of the traditional latrines, most of them were not used due to cultural beliefs and poor perceptions, like not sharing the same latrine. Likewise, the study found that most of the families did not clean their latrines. Only 11% of the respondents were cleaning their toilets daily while others were not. As well, the majority
76 of the people (94%) were not covering their latrines, and 80% of them were not washing their hands after visiting the latrines. The main sources of water for different domestic uses in the study area were water from the lake (54%), wells (34%) and others like rain harvesting water and from shallow wells. In the study area, it was found that 64% of the families did not boil water for drinking, which could lead to the outbreak and spread of cholera. However, boiled water was perceived to lack taste.
5.2.3 Ways of Preventing the Outbreak of Cholera
The results from the study unveiled that, the majority (77%) of the respondents agreed that it was possible for the community to be free from a cholera outbreak. This could be possible when education is provided to the community to change their attitudes, tradition and culture, and poor perceptions towards cholera outbreak. Provision of education should be through training, education campaign, workshops, seminars, meetings and mass media.
Improvement of the existing health infrastructure through provision of more boats in islands, ambulances, water services, construction of health centers, provision of gears and equipment for health services. Another way of preventing cholera outbreak was enforcement of the laws on hygiene and sanitation through effective supervision of rules and regulation. These should be emphasized by building latrines for each family, keeping the environment clean, initiating penalties and punishment for non-complaints and unlawful people. The last identified way of preventing the outbreak of cholera was said to be through motivating the workers, particularly at the village level. Motivation could be incentives like hardship allowances, promotion, building conducive environment for health workers and provision of protective gears.
77 5.3 Conclusion
The study has revealed that socio-cultural practices have contributed to the outbreak of cholera which led to the number of deaths in Ukerewe. Cholera in Galu, Kaseni, and
Kamasi occurs due to poor hygiene and sanitation associated with socio-cultural practices.
Many cases of cholera outbreak were due to poor sanitation, socio-cultural practices, and beliefs within the community. This happens simply because the majority of people have poor perceptions and beliefs on sharing latrines, drinking boiling water, burying a deceased person away from home compound, poor perception on cholera disease, and poor habit of putting water to the latrine and washing hand after visiting the latrines.
Changing of socio-cultural practices and beliefs through educating the community should involve the community elders and the traditional healers (Community participation). The government also should involve other sectors in education campaign against cholera outbreak. Sectors like community development, social welfare, and health workers should learn the socio-cultural practices such as norms, values, perceptions, attitudes, beliefs, taboos, and traditions hence work together with the elders and traditional healers to disseminate the knowledge on fighting against cholera outbreak within the community.
5.4 Recommendations of the Study
Based on the findings, the study has revealed that socio-cultural practices have contributed to the outbreak of cholera in Ukerewe. However, in order for the community to be free from cholera outbreak, the study suggests the following recommendations:
5.4.1 Recommendations to the Government and Institutions
i. Intersectoral collaborations among ministries, departments, and NGOs interested in
preventing and controlling the outbreak of cholera must be improved and strengthen
to combine other efforts in the fight against cholera outbreak.
78 ii. The government should improve infrastructures such as roads, health centers, builds
Cholera Treatment Centers (CTC) and sewage systems.
iii. Provide motivation for the workers especially those who are working in a hardship
condition.
iv. The government should effectively enforce laws and enact by-laws for non-
complaints in maintaining hygiene and sanitation.
v. Ministry of health should formulate teams and establish awareness campaign
program with the community members to educate and raise awareness on the
outbreak of cholera associated with socio-cultural practices.
5.4.2 Recommendations to the Community level
i. Members within the community including traditional healers, religious leaders,
headmen and village leaders should be involved in the teams for providing education
for fighting against cholera.
ii. To improve hygiene and sanitation within the compound especially concerning food
and water treatment (i.e. drinking safe water). iii. To build improved and proper latrines and using them.
5.4.3 Recommendations to the Health Workers
To provide health services to the patients especially giving first priority to cholera
patients.
To provide education to the community members on how they can provide first
Aid to a cholera patient before sending to the hospital.
To educate the community members on how to treat water by using water guards.
79 5.4.4 Recommendations to the NGO’s
To collaborate with ministries, departments and community members on
preventing and controlling the outbreak of cholera.
To provide support by building health centers and provides equipment for
protection to the health workers when providing services to a cholera patient or to
a person who has died of cholera.
5.5 Areas for further research
The study aimed to explore the contribution of socio-cultural practices to the outbreak of cholera in Ukerewe District and it was conducted in three villages. Cholera is a serious disease in Ukerewe District and in other rural villages around Lake Victoria. The findings of this study have revealed the contribution of socio-cultural practices to the outbreak of cholera. Further researches in socio-cultural practices should focus on improving knowledge diffusion and bridge the gap between socio-cultural practices on other transmitted diseases.
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88 APPENDICES
Appendix I: Questionnaires on the Contribution of Socio-Cultural Practices to the Outbreak of Cholera
My name is Ester Massawe from the University of Dodoma pursuing Master of Arts in
Sociology. This questionnaire is about „The contribution of socio-cultural practices to the outbreak of cholera in Tanzania: A case study of Ukerewe District”
It aims at collect data regarding The Contribution of Socio-Cultural Practices to the
Outbreak of Cholera; in order to fulfill the research project for the Master of Arts in
Sociology of the University of Dodoma (UDOM).
I would like to request your participation in filling this question.
Remember that all the information provided by you, are for the research purpose only and also be assured that information will not be passed to anybody else and will be confidential. You may express your views either in Swahili or English.
I would like to take this opportunity to express my gratitude and thanks for your cooperation.
Faithfully Yours
______
Ms. Massawe
89 Appendix II: Questionnaire for Social Survey
This research is under control of the University of Dodoma, with the purpose of exploring the contribution of socio-cultural practices to the outbreak of cholera in Ukerewe District.
It is in this respect that I request your cooperation to fill the questionnaire. Your information remains to be confidential and, be used only for this study and not otherwise.
You may express your views either in Swahili or English.
A: General Information
Ward name: ......
Name of the Village......
1. Sex of the respondent
a) Male......
b) Female......
2. Age of the respondent
a) 18-29 years......
b) 30-45 years......
c) 46-60 years......
d) 61 and above......
3. Occupation of the respondent
a) Peasant......
b) Fisherman......
c) Business......
d) Civil servant......
90 4. Level of Education of Respondent
a) Informal education......
b) Primary level......
c) Secondary level......
d) College / University......
B: Socio- Cultural practices that contribute to the Outbreak of Cholera
5. Which socio-cultural norms influence the outbreak cholera in this area?
a) Shower of bearing mother to water lake………………….
b) Eating together by using one plate………………………..
c) Washing hands in one ball………………………………..
d) Drinking of washed water as reconciliation………………
e) No sharing toilet……………………………………………
f) Use of one cup in drinking…………………………………
6. What are your beliefs towards cholera outbreak? Please mention
……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………
7. What activities are resulting to cholera outbreaks?
……………………………………………………………………………………………… ……………………………………………………………………………………
8. What do you do when one of the household members suffer from cholera?
………………………………………………………………………………………… …………………………………………………………………………………………
91 9. Does your tradition allow burying a deceased person away from the family compound?
a) Yes…………………………………………………………………………
b) No……………………………………………………………………………
10. If Not, please explain why?
……………………………………………………………………………………………… ……………………………………………………………………………………
11. Who is involved in the funeral of a deceased person from cholera?
a) Health practitioners……………………………………………………
b) Community members…………………………………………………
c) Others specify…………………………………………………………
C: Awareness of hygiene and sanitation and its contribution to the Cholera
Outbreak
12. Do you have latrine at your compound?
a) Yes……………………………………………………………….
b) No…………………………………………………………………
13. Which Kinds of latrine do you use?
a) Pit latrine………………………………………………………….
b) Flashing latrine…………………………………………………...
c) Traditional latrine…………………………………………………
d) Others specify…………………………………………………….
92 14. What is the source of water you always use for domestic purpose?
a) From the lake……………………………………………………..
b) Shallow wells…………………………………………………….
c) Well………………………………………………………………
d) Rain harvested water……………………………………………
e) Other sources specify……………………………………………
15. Do you clean your latrine?
a) Yes………………………………………………………….
b) No…………………………………………………………..
16. If yes, at what time do you clean latrine?
a) Every day………………………………………………………
b) When I get time………………………………………………...
c) Not at all………………………………………………………..
d) Not sure………………………………………………………...
17. Do you always cover your latrine with a lead/ stopper?
a) Yes………………………………………………………………
b) No………………………………………………………………..
18. Do you always wash hands with soap after coming from the toilet?
a) Yes………………………………………………………………
b) No………………………………………………………………..
19. Where do you get food?
a) From food vendors (Mama lishe )………………………………
93 b) From cafeteria………………………………………………………
c) At home…………………………………………………………..
d) At camps (fishermen)……………………………………………
e) Others, specify……………………………………………………
20. Do you always boil water for drinking?
a) Yes………………………………………………………………..
b) No………………………………………………………………….
D: Ways in Preventing Cholera Outbreak
21. Do you agree that it is possible for the society to be free from cholera?
a) Strong disagree………………………………………………………
b) Disagree………………………………………………………………
c) Neutral………………………………………………………………
d) Agree…………………………………………………………………
e) Strong agree……………………………………………………………
22. Suggest ways of preventing outbreak of cholera in your village ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………
94 Appendix III: Interview Guide for Health Workers and Government Officials
This research is under control of the University of Dodoma, with the purpose of exploring the contribution of socio-cultural practices to the outbreak of cholera in Ukerewe District.
It is in this respect, I require your cooperation to fill the questionnaire. Your information remains to be confidential and, be used only for this study and not otherwise. You may express your views either in Swahili or English.
A: Personal Information
Please put a tick ( ) in an appropriate box beside.
Name…………………………………………………… (If applicable) 1. Sex: Male………………………………………………………
Female…………………………………………………………… 2. Age………………………………………. 3. Position………………………………… 4. Address………………………………….. Village…………………………………… Ward……………………………………...
5. Educational qualifications
a. Secondary level…………………………………………………………….
b. Diploma level……………………………………………………………...
c. Degree level……………………………………………………………….
d. Others (specify) ………………………………………………….
95 6. What is cholera………………………………………………………………
7. Why has cholera outbreak been repeatedly occurring in your locality? ………………………………………………………………………………………… ………………………………………………………………………………………… 8. Which socio-cultural practices do you think are the sources of cholera outbreak? ……………………………………………………………………………………………… ……………………………………………………………………………………
9. Do you think that the community has received enough information and education on hygiene and sanitation to be free from cholera? a. Yes…………………………………………….……………………………. b. No………………………………………………………………......
10. Following the government efforts to combat and eradicate cholera, have you witnessed any changes in behaviour among the community members? a. If yes which changes……………………………………………………….
……………………………………………….………………………………..
If no why ………………………………….………………………………….
………….……………………………………………………………………..
11. When a cholera victim dies, does the society accept deceased household member to be buried away from the family compound?
Yes……………………………………………………………......
No …………………………………………………………………………
If no, how do they perceive it? ......
12. What is your recommendation on combating and eradicating cholera outbreak in the area? …………......
Thank you for your cooperation!
96 Appendix IV: Focus Group Discussion’s Guide
1. Why has cholera outbreak been repeatedly occurring in the society you live in?
2. Which kind of latrine is dominant in the community?
3. Which cultural practices do you think to contribute the outbreak of cholera?
4. Which beliefs are associated with the outbreak of cholera?
5. What are your perceptions towards lake water in relating to cholera outbreak?
6. What measures should be taken to combat and eradicate cholera outbreak?
Thank you for your cooperation
97 MATRIX TABLE FOR ERRORS CORRECTION OF A DISSERTATION TITLED
The Contribution of Socio-Cultural Practices to the Outbreak of Cholera in Tanzania: A Case Study of Ukerewe District
BY
ESTER GASPER MASSAWE
S/N EXTERNAL EXAMINER WHAT HAS BEEN DONE OBSERVATION 1. The abstract has no findings Correction has been done accordingly by putting the findings as directed by external examiner 2. Page 36: on 4.1.2 the word Gender The word has been replaced should be replaced by the word Sex.
3. Page 66: on 4.4.1 addition of the This was corrected as per external word being to the sentence and examiners‟ suggestions. omitting the word on to the sentence. 4. Page 70: 4.4.4 the word emphasized The replacement was done as directed should be replaced by the word by external examiner encouraged.
5 Page 72: 4.4.5 the word witnessed should be replaced by the word mentioned. 6. Page 79: 5.4.1 (v) recommendations The government sector was mentioned to the government. Which sector of as suggested by external examiner the government should do this?
98