To emphasize the tight link between social perception and social vulnerability of children aged 5 to 15 to malaria in relation to LLIN, the first section of this part will be devoted to representations of the bed nets in the different study areas. These data and some other data, though not specific to the 5-15-year-olds, will provide contextual factors related to the complex socio-cultural processes leading to social (section 2) and domestic (section 3) practices and organizations related to LLINs that affect children over 5 years old in Madagascar. In addition, global data on LLIN use were included to provide the reader a better understanding.
Representations of bed nets: levers and obstacles
Mosquito net adoption: a "fombandrazana" or tradition in some areas
In 4 of the 10 areas, the use of mosquito nets is common practice (Antsohihy, Mananjary, Farafangana, Sambava); however, their use is not systematically linked to the fight against malaria. Historically, mosquito nets are valuable objects: older people report that their parents already slept under mosquito nets (Antsohihy). However, in earlier times, mosquito nets were mainly reserved for adults. The idea has often been evoked that during the colonial era, mosquito nets were perceived as a high-class object—a sign of wealth—and therefore appreciated by the population (Antsohihy, Mananjary, Farafangana, Sambava). The main reason for using the mosquito net was the comfort provided by the object during sleep: preventing nuisances caused by insects and preserving the couple's privacy. In Mananjary and Farafangana, nets are intrinsically part of the kits offered on the occasion of weddings or births; thus, it is part of the family tradition in these regions. Before the circulation of information about malaria, such nets were sewn and used for the prestige they conferred upon to newlyweds and future parents. At the birth of a child, the net was required to protect the child from insect bites. This habit has been maintained through the present day, making marriage or childbirth key moments in the mosquito net use. Participants typically date their first use of nets to the time of their marriage. Even after the introduction of free LLIN distribution, the tradition of providing nets to newlyweds has continued, but the traditional bed net has been replaced by the LLIN. Today, free net distributions have democratized access to nets: wealth level no longer affects whether people have a net.
When the bed net provides information about the marital status of its user in the East Coast region
In community representations, the custom of including the net in the wedding trousseau (Mananjary and Farafangana) led to an association between net use and marital status. Even today, the use of LLINs is a symbol of this status.
“The use of mosquito nets is truly a tradition for us. Our ancestors used them. We can only be delighted that you have decided to give us free nets. It truly is a tradition for us. When we get married, we must have a mosquito net” [Man, 40, Farafangana].
The mosquito net represents the idea of death: highlands and western region
In the highlands (Moramanga, Ankazobe) and the west coast (Morondava), people install the bodies of deceased under mosquito nets during the 3 days of the funeral rites to avoid contact between the body and environmental elements (insects were mentioned, especially flies, which participate in the decomposition of the body). This painful event imprints a macabre image associated with the use of a mosquito net, sleeping under a net sparks fears of the anguish of dying. White mosquito nets are culturally used for the dead. Thus, many respondents in these areas expressed an aversion to nets of this color.
“Personally, the disadvantage of the mosquito net is that when you sleep inside one, you look like a corpse” [Man, 32, Morondava].
LLINs as a medicine and means of protection
Despite having specific representations in different regions, the LLIN is generally perceived positively, and the fact that they are now free is highly appreciated. The insecticide with which LLINs are impregnated is commonly called "fanafody" or "medicine" in the different areas surveyed. This reference to medicine in speeches has a rather positive connotation and is used in its protective sense: bringing well-being and health. The insecticide is also considered to be effective at eliminating insects.
“The mosquito net is one of the objects one should now own, such as mattresses, cushions, and kitchen utensils for the newlyweds (...) Before, it was just a fashion, now it's a medicine, it's impregnated. It's medicine for health” [Woman, 52, Mananjary].
The messages of awareness disseminated around the LLIN distributions are known and easily recited by the majority of the interlocutors, in particular its role as a barrier against mosquito bites and the importance of sleeping under one, especially for pregnant women and infants. However, the link between mosquitoes and malaria or "tazomoka," literally translated as mosquito fever, is not spontaneously evoked in the speeches (unless the link between mosquito and fever or disease was already suggested by the question). During the Photovoice, many participants captured their LLINs in response to the question "how can one protect against mosquito-borne disease," demonstrating that they were cognizant of the link between disease and LLINs. In addition, fever and malaria are widely confused, the word "tazo" is mostly used to refer to malaria, while the same word is used to describe a febrile state.
“If we don't sleep under an insecticide-treated net, we will be bitten by mosquitoes and will get the tazomoka” [Man, 40, Farafangana].
“The reason I use a mosquito net is because it protects against mosquitoes; they can't get in. Because if a person gets bitten, it causes "tazo," doesn't it?” [Woman, 56, Ankazobe].
Social organizations and practices related to LLINs
LLINs: inconsistent use not always related to malaria protection
The consistent use of LLIN over time at the household level assures the protection of the whole family, including children, against mosquito bites and reduces the risk of malaria [1]. Attitudes towards the use of LLINs varied across the survey areas. This variability can be explained by the greater or lesser prevalence of mosquitoes and (to a lesser extent) by the importance of malaria in the area under consideration. The use of mosquito nets is always justified first and foremost by the discomfort caused by mosquitoes, and malaria prevention comes second. This order of priority was found in all 10 study areas.
“Why sleep under a mosquito net? Because you won't be bothered by mosquitoes, you will be able to sleep peacefully. There are so many things that can disturb one at night, such as cockroaches and centipedes. Mosquito nets truly protect us from many insects” [Man, 50, Farafangana].
As this excerpt indicates, LLINs are used to protect against insect-related nuisances. In addition to the presence of mosquitoes, it appears that many factors can promote or limit the use of mosquito nets, including temperature (heat, cold), wind, brightness, and privacy preservation. The number and characteristics of nets owned also influence their use. Attention is given to the fabric quality, size, shape, color, odor, and mesh size. In general, mosquito nets are preferred to soft, fine clothes, which are rectangular in shape and large enough to cover groups of sleepers. These are usually blue or some other colored (white is considered too messy or to refer to the representations described above), with fine mesh sizes. Intermittent use of LLINs is the rule and is specifically determined by the level of comfort or discomfort felt during its use.
A distribution based on the size of the household and not on its composition (age and gender of its members)
Our data showed that the LLIN distribution strategy and its implementation in the real world determine the final availability of LLINs in households. An insufficient number of LLINs for all family members leaves some beds uncovered by LLINs and leads to practices that often compromise LLIN use among children over five.
Appreciation for the free LLIN distribution policy differs from one area to another. In 6 of the 10 zones surveyed, both mass and continuous distributions seem to follow the Ministry's recommendations, and there were very few complaints about the distribution procedure. Instead, the complaints received are related to the inadequacy of the nets received—not because of an anomaly in the distribution but because the share per household is calculated on the number of members of the household and not on the number of beds. In fact, as we will discuss further, starting with children of a certain age, a "fady" (forbidden action or taboo) governs the organization of sleeping arrangements within a household. Beginning at age six to eight years old, male and female siblings can no longer share the same sleeping space, which leads to an increase in the number of LLINs required to cover the household sleeping spaces. In 3 of the 10 zones (Antsohihy, Ambovombe and Sambava), the insufficient number of LLINs is exacerbated by the presence of LLIN distribution anomalies. In these zones, several respondents complained that they did not receive LLINs or received insufficient numbers of LLINs (less than the expected number of 2 LLINs per household). In Antsohihy, some households possessed 3 LLINs while several had not received any. In Ambovombe, among those who received some, the number never exceeded 2 even for households comprising 8 or 9 people. The CHWs explain this situation by shortage of LLIN stocks. Other considerations may have limited the distribution of LLINs, as illustrated by the following health workers’ verbatim reports.
“The problem is that routine distribution was suspended ‘from above’ (from the District Health Service) on the pretext that the population received too many during the campaigns and that those given mosquito nets may be neglected” [Physician, Ankazobe].
“In any case, pregnant women, whether or not they receive a malaria prevention kit, it doesn't matter !! They already benefit from other offers. It's not just mosquito nets and IPT (intermittent preventive treatment)!! ... First, they always benefit from all kinds of awareness measures. Second, if they visit an HIV/AIDS testing center, they will be screened. They also benefit from syphilis screening” [District Health Service Manager, Brickaville].
When LLIN is lacking in a household, resourceful practices are used to acquire them, such as asking neighbors who received more than one LLIN or buying them at the market. However, our data did not allow us to clarify the uncertainty about the type (LLIN or other) or number (sufficient or not for the family) of purchased LLINs, nor about the exact reasons for distribution failures.
Some practices particularly expose young people to malaria
In coastal areas (Antsohihy, Mananjary, Brickaville, Farafangana, Sambava), during periods of high heat (October to April), many people refuse to use mosquito nets because they are too hot. In addition, while the sleeping time usually spans from approximately 8 p.m. to 5 a.m., in the summer, people wait for the heat to drop and go to bed after 9 p.m. Sociability practices such as parties with friends and family discussions, specifically called "débat" in Ambovombe, extend this time of exposure to mosquitoes to an undefined length. However, during this time of year, mosquitoes are present in high densities. Thus, even people who protect themselves during sleep are still subject to mosquito bites because they are exposed longer before going to bed.
"We ... we always do it like this [she hits her arm with a cloth] we use this cloth to repel mosquitoes when we want to talk in the evening with the neighbors, [she mimes hitting herself] like this, so that the mosquitoes do not bite us. When we get ready to sleep, we put the net down and go to bed” [Woman, 36, Ambovombe].
Very young children, who are perceived as vulnerable, are put under nets early on and are therefore better protected from exposure to mosquito bites. In contrast, children over five years of age and adolescents take advantage of this time to play outdoors (Ambovombe, Antsohihy, Mananjary, Morondava, Farafangana). Thus, this group of children runs a higher risk of mosquito bites.
Domestic organizations and practices related to LLINs
Organization of the sleeping space
The characteristics of the houses control the organization of the domestic sleeping spaces. Although the study areas are mostly in rural areas (9/10), they differ in terms of spatial distribution and building materials. Everywhere, however, the houses tend to consist of a single living room (on average 9 m²), which is transformed into a sleeping area for the night. The kitchen and showers are located outside. This leads to a particular spatial distribution of sleeping spaces: if a bed[1] is available, the parents and children under 5 years of age sleep in the bed under mosquito nets. The rest of the family (those beyond this age) sleep on the floor or on a sofa, usually without a mosquito net (Brickaville, Ankazobe, Ambovombe, Mananjary, Farafangana, Sambava).
“Here, they have only one room, and most of the time, each family has many children, some of whom sleep on the floor. Only those who sleep on the bed have a mosquito net and are protected; those on the floor do not” [ Health worker, Brickaville].
When there is no bed in the sleeping space and everyone sleeps on the floor, the mosquito net can cover up to 5 people (Ambovombe, Mananjary, Farafangana). Because the houses are small, they do not allow large households to deploy enough nets so that each person can sleep two-to-a-net, as recommended. However, even without a bed, children up to 5 years old typically sleep with their parents.
The mother of the family, responsible for the LLIN
Mothers are responsible for the acquisition, installation and maintenance of LLINs in a household (purchasing, washing, designating who sleeps under a net, etc.). These tasks devolve to those tasked with tidying or furnishing the interior of the house and are generally part of a more global representation of the role of women in the home. Additionally, the deployment of mosquito nets before bedtime is the mother's responsibility, both for the couple's bed and for the children's bed. For this reason, some men in Ankazobe, for example, did not feel concerned about net awareness.
Prioritizing pregnant women and children under 5 years of age in the use of LLINs
In all the study zones, the vulnerability of pregnant women and children under 5 years of age to malaria is unanimously acknowledged by the different categories of respondents. This perception echoes the awareness messages on malaria. According to the villagers interviewed, the injunction: "It is necessary to sleep under a mosquito net" applies particularly to children under 5 years old and the pregnant women. Beyond the age of 5, some respondents say that children are no longer at risk of malaria (Moramanga, Fianarantsoa).
“Our child always slept under a mosquito net until he was 5 years old. Beyond the age of five, there is no more risk of the tazomoka” [Woman, 30, Moramanga].
Some households without children under 5 and pregnant women question the value of continuing to sleep under LLINs (Mananjary, Antsohihy, Moramanga). In 8 out of the 10 zones surveyed, it was observed that if a household has too few mosquito nets, the pregnant woman or the woman with the infant should benefit first, followed by parental couples with or without children under 5 years old, and last, by children over 5 years old. It seems that the head of the family is much more likely to sleep under LLINs than are children over 5 years of age. The man often sleeps where the woman does. The only exception to this rule is the "mifana" period in Ambovombe (the confinement period after childbirth), where for 3 months, the man cannot share the same bed (and therefore the net) with the mother and the newborn. Moreover, according to our interviews, malaria is considered less virulent for men than for women (Farafangana). Men are "resistant, immunized" against malaria, and men's skin is thicker and therefore impenetrable to mosquito bites (Ambovombe, Farafangana, Sambava, Morondava). In Farafangana, it was noted that men acquire their "immunity" through physical strength due to heavy work in the fields. Therefore, for groups perceived as not at risk, even the availability of a LLIN for all members of the household does not necessarily lead to their regular use.
A taboo on sharing the same sleeping space for children of the opposite sex
When a child reaches the age of 6, he or she leaves the parents' bed for another in the family home. The primary reason given for this separation is that by this age, children are old enough to no longer need to sleep under a mosquito net. Indeed, before this age, they are still perceived to be highly vulnerable to malaria; therefore, they must sleep with their parents under mosquito nets.
“I am the one who sleeps under a net, even though I have three children, the last of whom is 6 years old. Because the children are already grown up, they do not sleep under a net. I was told at the hospital that pregnant women are the ones who should sleep under a net” [Young woman, 26, Antsohihy].
From a certain age, a "fady" or taboo governs the distribution of beds within a household. Male and female siblings can no longer share the same sleeping space. Same-gender siblings, however, may share a sleeping space until one of them is married. The age at which the taboo begins to apply varies according to the zone: it is 8 years in Antsohihy, Fianarantsoa and Moramanga, and ranges from 10 to 13 years in Ankazobe, Brickaville, Ambovombe, Farafangana, Manajary and Sambava. A single mother can sleep with her son until he is 6 years old and with her daughter until she is 14 years old.
“We have three mosquito nets and there are six of us. This is not enough, because some of my children are grown up and cannot sleep in the same bed because they are siblings” [Man, 51, Ankazobe].
In Ambovombe, Farafangana, and Mananjary, this separation of children's beds sometimes means leaving the parental home. Indeed, the parents build a house for each child near the parental house and install them in it. In Mananjary, separation from the family home takes place at the age of 14 and is similar to an initiation to adult life. The separated children still share the family meal before they have found their "suitors." Once married, a girl moves to the home of her husband's family, while a young man will build a more suitable home not far from his parents' home. The LLIN is not being used during the entire period before marriage.
Refusal of unmarried young men to sleep under a net
In Mananjary and Farafangana, the association of the net with marriage, as described above, leads young unmarried men to avoid using LLINs. From the age of 10 until marriage, boys, who by then sleep outside the parental home, refuse to sleep under the net for fear of being considered married. The presence of a mosquito net in the home could signify to those around him that he has already acquired a wife.
“Young unmarried men do not want to sleep under mosquito nets too much. They say it is married people who sleep under nets. Men who are not yet married and who are looking for a companion do not sleep under a mosquito net” [Woman, 17, rural Farafangana].
Furthermore, the role attributed to women in the procurement, maintenance and installation of a mosquito net reinforces this perception. If a mosquito net is rolled out in a house, it is because a woman has installed it for the boy, thus inducing him to become part of a couple. In addition, men's sense of 'immunity' to malaria and resistance to mosquito bites reinforces the idea that the use of a net is not necessary.
According to one of our interlocutors, the association between net use and marriage is promulgated by his church and parallels "good fatherhood," which involves taking care of the family and putting a net in the home.
“It is a man's role when he gets married to equip the house. After he considers himself an adult, he is no longer a child who does not care whether or not he sleeps under a net. The mosquito net is part of the necessary equipment for the house. At the church they explain to us that marriage is sacred, and as he becomes an adult, the man has to take care of the house. The mosquito net is one of those things to have. It used to be a matter of fashion to have a mosquito net. Now it is a medicine, it is for health” [Man, 35-year-old Mananjary].
Fear of death prevents the use of LLINs
As described above, mosquito nets are equated with the death veil in the highland (Moramanga and Ankazobe) and western coastal (Morondava) regions. The fear of LLINs generated by this association of the object with the event of death deprives part of the community of LLIN protection. At least two population groups are victims of this fear: children old enough to understand the concept of death (approximately those over 5 years old) and the Sakalava ethnic groups, including their children.
“The only problem [regarding the use of mosquito nets] is getting children into them. They get scared and escape from the bed (...) They equate the net with a death veil. However, this mostly happened the first time they slept under it; when we explained to them that it protects them against mosquitoes, they understood” [Man, 48, Ankazobe].
“Some people do not like to use the net because it makes them think they are dead. They still take the free mosquito nets, but then they sell them; they do not just want to sleep under them because they think it makes them look like corpses” [Women, 45, Morondava].
[1] A bed here is defined as a sleeping surface raised from the ground, whether it has a mattress or not, of any kind and regardless of its material of manufacture (wood, bamboo, metal, etc.) or quality of finish.