Data and social beliefs of malaria and prevention methods amongst itinerant Nomadic Arabs, Fulanis and Dagazada teams in Chad: a combined methodology examine | Malaria Journal


Survey results

Between 2 February and 28 March 2021, 78 households spread over 40 nomad camps in Dourbali (n = 11 Arab camps, n = 6 Fulani camps), Massenya (n = 6 Arab camps) and Massaguet (n = 17 Dazagada camps) were surveyed. Most interviewees were female (70.5%) and married (97.4%). Respondents’ mean age was 38.1 years (95% CI 36.7–39.5) and there were significant differences between nomadic groups, with respondents from Daza group being older. The mean household size was 8.4 (95% CI 7.7–9.0), with no significant difference between nomadic groups. Households surveyed had an average of 2.5 children under 5 years (95% CI 2.1–2.9) (Table 1). Proportion of respondents by marital status varied significantly by nomadic groups with monogamy more represented in Arab and Daza groups whereas polygamy more represented in Fulani group.

Table 1 Socio-demographic characteristics of the survey participants, frequency (%)

Knowledge of malaria

All respondents (78) had ever heard of malaria and the majority believed malaria is more frequent in the rainy season (80.8% reporting increased number of cases in July–September, and 38.5% in June and October). The knowledge of the period of high incidence of cases of malaria varies significantly by nomad groups; respondents from Arab and Fulani groups frequently mentioned the rainy season while those from Daza groups did less often. Regarding groups vulnerable to malaria, respondents most frequently mentioned children under 5 years, pregnant women and adults (84.6%, 64.1% and 74.4%), with those mentioning children under 5 years and adults varying significantly by nomadic groups (Table 2).

Table 2 Knowledge of respondents regarding malaria transmission

Concerning the causes of malaria transmission, responses varied between nomad groups. Most mentioned mosquitoes (including 63.6% respondents from the Arab group), in addition to environmental causes of malaria such as rainfall (73.1%) and heat or sun (50%). Muscle pain, fever, and nausea or vomiting were the most frequently mentioned symptoms of malaria, reported by 87.2%, 69.2% and 73.1% of all respondents, respectively.

Knowledge of malaria preventive methods

Most respondents believed malaria can be prevented. As preventive methods, LLIN, SMC, IPT, and traditional methods were mentioned by 88.5%, 23.1%, 17.9% and 10.3% of respondents, respectively. While mosquito nets were the most widely-known method, 94.9% of respondents reported using a mosquito net recently after 7 PM, with respondents from Arab and Daza groups more likely to report this method than respondents from Fulani groups. Most respondents from Fulani group (54.5%) mentioned IPT among preventive methods; almost none of the respondents across the three groups correctly identified the target group for IPT, however. Concerning SMC, 55.1% of respondents identified children under 5 years as the target of SMC but just 11.5% and 15.6% of respondent were able to mention the correct number of SMC cycles and the correct dosing of SMC medicines, respectively (Table 3).

Table 3 Knowledge and attitudes of respondents regarding malaria preventive methods

Reported use of malaria preventive methods

Mosquito nets were the most widely-reported preventive method used among participants. Nearly 75% reported owning at least one mosquito net, and 42.3% reported owning at least one LLIN. Also, nearly 60% of respondents declared they had slept under mosquito net the last night previous to survey. Mosquito net ownership and usage varied between nomad groups; the Daza group had the lowest proportion who reported owning (41.2%) and using (5.9%) a mosquito net. LLINs were followed by SMC as the next-most common method; 33.3% of households received a visit by SMC community distributors in 2020. Coverage of SMC and IPT treatment depended on the clinic catchment area where nomad groups reside. The coverage of SMC and IPT were higher among Arab and Fulani groups surveyed in Dourbali and Massenya districts than Daza groups surveyed in Massaguet district. Respondents from Fulani communities reported the highest percentage of household visits by SMC distributors. Of all mothers interviewed, just 12.8% said they received at least one IPT dose during their last pregnancy. This percentage was particularly low in Dazagada communities (see Table 4).

Table 4 Coverage of malaria preventive methodsTable 5 Treatment seeking behaviour

Treatment-seeking behaviour

When asked about their first recourse for malaria treatment, 41% and 50% of respondents mentioned health facilities and informal drug sellers respectively. Preferences for service delivery method varied between nomadic groups. Informal drug sellers were the most frequently-reported malaria treatment options among Daza respondents (94.1% of respondents). Regarding preferred health service provider for malaria treatment, 20.5% of respondents mentioned a preference for a nurse or midwife and 53.8% of respondents mentioned local drug seller; this preference varied between nomadic groups. Cost of health care and the severity of sickness were the main reasons for the choice of health service provider; these reasons were mentioned by 67.9% and 26.9% of respondents respectively. In addition, 78.5% of respondents expressed a positive opinion of services provided by these sources mentioned. Meanwhile, the household member responsible for decision-making on malaria treatment was most commonly a male head of household, with the exception of the Daza, among whom 55.9% of respondents mentioned a female head of household (See Table 5).

Mothers’ and camp leaders’ perceptions of malaria and control interventions

In all three FGDs most women were aged over 30 years and had no formal education: 41% of mothers had no education and 32% had a Koranic education. More than half of the mothers had at least one child under 5 years (55%), and just over a third had their last pregnancy less than 1 year prior (36%). Only four women out of 22 had attended ANC during their last pregnancy (Table 6). Interviews were held with leaders of each of the six camps visited for FGD; all were male and aged over 30 years.

Table 6 Socio-demographic characteristics of mother who participated in each FGD

Four overarching themes around the social representation of malaria and malaria risk, perspectives on malaria prevention and malaria treatment practices among nomadic groups were identified (Additional File 1: Table S7).

Social representation of malaria risk

Perception of malaria risk among nomadic groups

Nomadic leaders and mothers expressed consistent views on the risk of malaria among their groups. Firstly, they were certain that malaria is a disease that “attacks everyone”, from young to old and men and women. They used the expression ‘big and small’ affected by malaria to imply that the disease affects everyone without exception. Mothers in all three discussions and all the leaders interviewed mentioned that malaria was the biggest health challenge in their community.

Lastly, both leaders and mothers explained how their nomadic lifestyle put them in contact with mosquitoes and, therefore, at risk of malaria. For example, the leaders reported that “flies and mosquitoes… hunt north”, which implies that when mosquito density is high in their temporary settlement in the south this compels nomads to move to the north of the country; it is an obligation to travel. Leaders also made a connection between the nomads’ temporary huts, often adjacent to their animal compounds, which are usually dark enclosed spaces. They believed that because mosquitoes are attracted to dark places and the heat and odor of animals, this put them at risk of mosquito bites and therefore malaria. The quotes below illustrate the social representation of risk; see Additional File 2: additional quotes in Box S1.1.

“We think malaria attacks everyone big and small. Malaria bothers everyone” (FGD Arab Dourbali)

“In the rainy season, flies and mosquitoes drive us for the north” (KII Daza Massaguet 2)

“We move with these diseases [malaria]. They abuse during all times of the year”. (KII Arab Dourbali).

Social representation of malaria

Diverse local explanations for cause of malaria

Most of the nomadic women participating in FGDs and the leaders interviewed were aware of established biomedical causes of malaria; for example, the mothers associated malaria with mosquitoes and leaders linked it to the rainy season. However, a plethora of other causes were mentioned; some believed that malaria was due to nomads’ living conditions, including poor nourishment, hunger and food insecurity. Others mentioned physical exertion due to the nomadic lifestyle that involved long walks during transhumance; this was particularly the case for Arab and Daza groups and less for Fulani in the process of adopting a sedentary lifestyle. Others attributed the cause of malaria to the physical environment such as the presence of moisture or rainwater, cold or plenty of sun. The cold was more often mentioned by the Fulani group, who also describe using blankets as prevention against malaria. Leaders indicated “… cool water in the rainy season”, and “the humidity” brings malaria. Contrary to the leaders, mothers believed malaria is caused by heat or ‘abundant sun’. Mothers from Fulani and Arab groups also referred to religious causes such as acts of God.

“It is God who makes malaria rife [Laughs]” FGD Fulani Korbol

“Malaria is permanent during the rainy season. So it is the humidity that brings malaria” KII Fulani Korbol

“We are in the sun, we have no food. If we were in the shade, we are not going to suffer from malaria. Also, there are mosquitoes too” FGD Arab Dourbali

“We go south where there is water, the sun is also abundant, we are tired, this is what gives disease” FGD Daza Massaguet

“There are also mosquitoes which cause malaria despite the fact that we sleep under mosquito nets” FGD Fulani Korbol.

Manifestation and symptoms of malaria are well known

While some nomads generally knew the biomedical causes of malaria and its manifestations and symptoms, some also mentioned local explanations. In all three nomadic groups, anorexia (refusal of food), fever, chills, stomach aches and nausea were commonly described as manifestations and symptoms of malaria.

In addition to describing malaria manifestations and symptoms, mothers also described malaria fever in great detail. For example, women mentioned that fever is intermittent, ‘accompanied by the refusal of breast milk’ and that fever can also be ‘followed by a cold’. Mothers were quite specific in describing a pattern of feeling well in the morning followed by’suffering’ in the evening and recognized the ‘rhythm of a sick day and a healthy day’ as malaria. These words effectively designate discontinuous recurring fevers as malaria.

“In the morning, she is better, however in the evening, she goes to bed due to the pain. It is in this rhythm of a sick day and another healthy day that we say it is malaria. Also, a persistent cold reaches the sick person in the chest. Even being in hospital, this cold persists” FGD Fulani Korbol.

“The body hurts, the head also hurts, the person has the chills and she also vomits” FGD Daza Massaguet

“Malaria that tires people out. It creates stomach aches, headaches. It can kill too” KII Arab Dourbali

“The fever that makes one think of malaria is that which is accompanied by the refusal of breast milk. When the child refuses to breastfeed” FGD Arab Dourbali.

Perspectives on malaria prevention

Knowledge of intermittent preventive treatment (IPT) varied among nomadic women

Many nomadic women seemed unaware of IPT for preventing malaria in pregnancy. Several claimed they had ‘not heard of it’. However, others who claimed they had ‘heard about it’ described following a nurse or doctor’s direction in relation to antenatal care and IPT. The few participants who were familiar with IPT said that it protects pregnant women and their children against malaria by reducing the frequency of episodes of the disease.

“We have not heard of it and no one has provided such treatment” FGD Arab Dourbali

“I respect the appointment of the month that the nurse gives me during ANC [antenatal care] and IPT. What the nurse says there for the pregnant woman to do” FGD Fulani Korbol

“The advantage of these drugs is that they protect pregnant women and their children against malaria” FGD Fulani Korbol

“This is to reduce the frequency of illness” FGD Daza Massaguet

Seasonal Malaria Chemoprevention (SMC) is not commonly known or used by nomadic groups

Nomadic women did not seem to be familiar with SMC; many said they ‘had not heard’ of SMC. Some women from Arab and Daza groups who had, explained that even when their nomadic group was present in an SMC-eligible district, their camps were excluded and did not receive visits from community distributor to administer the SMC doses. Nomadic leaders from Dourbali said even when health facilities are aware of their presence in the catchment area “they didn’t come to us”, which seemed to indicate a feeling of exclusion or discrimination against nomadic groups.

“We have not heard of this drug. We did not hear anything” FGD Arab Dourbali

“We have not heard of it except the mosquito net that we heard about. Perhaps by going to the doctor [clinician] in Massaguet we will obtain” FGD Daza Massaguet

“No! They don’t come. We heard about it, but they didn’t come to us” KII Arab Dourbali

Insecticide treated nets widely known but not freely available

The mosquito net appeared to be the most popular and widely-known malaria prevention method among all three nomadic groups. However, women in all three groups mentioned that they had too few nets for everyone in their household, or that they were not in good condition, for example several mentioned that ‘they are torn’. Except for nomads adopting a sedentary lifestyle (the Fulani group in Korbol), women’s reports suggest that insecticide treated nets are not provided for free and that they have to buy them from the market. The leaders emphasized how their nomadic groups feel excluded from health interventions, as one Daza leader expressed “why is the state just watching us but not stepping in to help us”. However, the discussions with mothers suggested that it is common for nomads to renew the mosquito nets at the start of the rainy season. All participants stated a preference for spacious mosquito nets impregnated with insecticide.

“Sometimes, the mosquito net is not sufficient. The husband and his wife are fighting over the mosquito net. Find us mosquito nets. We get it with our own money” FGD Arab Dourbali

“We heard about it but we didn’t receive it. Nomads have nothing. We pay for our mosquito nets, our medicines and our food.” KII Arab Dourbali

“We buy it and several of us sleep in it, it rips apart. Anyway, at the start of the rainy season we buy more. […]. Two people can sleep there, a mother and her children can sleep there as well as a father” FGD Daza Massaguet.

“LLINs are very large and several people can sleep in a single net. In addition, mosquitoes cannot get in because there are products that drive them away” FGD Fulani Korbol.

Various uses for mosquito nets

Most nomadic women recognized that mosquito nets are intended for use by children and pregnant women for protection from mosquito bites, and that use is recommended during the rainy season. However, several women mentioned various uses for mosquito nets including protection from other insect bites. Some Fulani women indicated that the nets ‘do not protect us [children and mother] against malaria’ and requested blankets instead.

“First, it is the children who have to sleep under a mosquito net. Adults can protect themselves in other ways” FGD Arab Dourbali

“Mosquito nets are primarily intended for our children but also for pregnant women” FGD Fulani Korbol

“During the mosquito season, as soon as it gets dark, we use it. We use the mosquito net during the rainy season when there are mosquitoes” FGD Daza Massaguet

“We use the mosquito net against mosquitoes also bees whose bite hurts. One of the obligations to use the mosquito net” FGD Arab Dourbali

“The mosquito nets we are given protect our children and ourselves against mosquitoes. But, they do not protect us against malaria. Bring us blankets” FGD Fulani Korbol.

Malaria treatment practices in nomadic households

Treatment strategies for malaria are driven by financial considerations

Three remedies for treatment were mentioned by the nomads: modern medicine, traditional medicine and street drugs. Health facilities were often mentioned despite complaints about financial barriers to access. The Arab groups particularly mentioned that ‘without money, no one will take care of us’. On the contrary, the Fulani who live a more sedentary lifestyle have the possibility of being treated on credit at public health centre.

“We go to the nearest hospital to us, either N’Djamena, Dagana or Bachom, we take the vehicle to go there” FGD Daza Massaguet

“Even when we don’t have the money, we go to the hospital for treatment on credit” FGD Fulani Korbol

“We go to hospitals. The latter also do not process it for free. Without money, nobody will take care of us” FGD Arab Dourbali.

The head of household as the key decision maker for curative treatments and prevention methods

The head of household is typically responsible for decision-making for malaria treatments or the purchase of mosquito nets. In addition, male heads of household are usually responsible for providing the necessary funds to pay for prevention methods and treatment. In the absence of a male head of household, responsibility typically falls on the camp leader. As far as it concerns mothers, they are responsible to ‘take care of … child’ by giving drugs or using nets and sometimes helping their husband financially.

“It was the husband who bought the mosquito net” FGD Arab Dourbali

“It is the child’s father who is involved in the care decision, in case of his absence, it is the camp leader. It is the mother who should take care of it when it comes to a child” FGD Daza Massaguet.

“The father of the child has to bring the child to the hospital and pay the bills; (Laughs) It’s the man who takes charge when the child gets sick.” FGD Fulani Korbol.

Local treatment practice against malaria

Nomad women and leaders mentioned hospitals as a source of treatment. However, recourse to traditional medicine, street drug sellers and self-medication are also quite common for Arab and Daza groups. Both leaders and women claimed to use products found in their environment such as ‘koulkul tree leaves’, ‘camel urine’ and ‘beef urine’ or ‘milk butter’; this is particularly highlighted in Arab and Daza groups, while the Fulani group of Korbol, who are in the process of shifting to a more sedentary lifestyle, mentioned visiting the health centre. To manage the symptoms of malaria, Daza women ‘soak some cloth in water and put on the child’ to reduce fever and ‘cover him’ in case of shivering.

“We go to the seller along the street and also to the well-built hospitals” FGD Arab Dourbali

“We soak some cloth in water and we put on the child. In case of shivering, we cover him, if we have tablets such as paracetamol and nivaquine we also give it” FGD Daza Massaguet

“We have no other recourse other than hospitals. Otherwise, we also use “koulkoul” tree leaves and camel urine” KII Arab Dourbali.

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