How cultural norms deny women access to malaria care

Some cultural practices in Nigeria have been identified as hindrance to medical care, especially for women. In addition to other norms, some of the affected women, including pregnant ones, who spoke to Daily Trust, said they must get the approval of their husbands before accessing hospitals for malaria treatment. “We are farmers and there is […]

Some cultural practices in Nigeria have been identified as hindrance to medical care, especially for women. In addition to other norms, some of the affected women, including pregnant ones, who spoke to Daily Trust, said they must get the approval of their husbands before accessing hospitals for malaria treatment.

“We are farmers and there is a lot of work to do, so to secure permission from my husband to go to the hospital because of malaria is not easy,” Angbada, 41, said as she emphasized that she needed her husband’s permission to access malaria care services. 

She said the symptoms could get worse before she would be allowed to seek medical attention.

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“We usually take agbo (herbal mixtures) when we have fever. It is when we become seriously ill that we go to the hospital or buy drugs. I had fever and body pains last year and my husband allowed me to go to a chemist, where I was given drugs, but I didn’t feel better,” she added.

She was only permitted to visit a hospital after some weeks when her condition became worse.

“I was shocked to discover that it was malaria all along,” she said.

The mother of four, who lives at Daki-Biyu, a suburb of the Jabi area of Abuja, said hers was not the only home where women would need permission from their husbands to seek medical attention.

“Our husbands’ view about malaria determines the level their wives and children access medical services. I would have gone to the hospital immediately I fell sick but I had to respect my husband’s decision on it too because in our culture, he has the final say,” she added.

Also, Rafat, a 35-year-old mother of three at Mabushi, also in the Federal Capital Territory, said she had fever during her last pregnancy, which she suspected was malaria, but could not access treatment because her husband would not grant her permission.

He, however, bought her anti-malaria drugs from a patent medicine store near their house.

“He kept complaining that there was no money for me to go to the hospital. I told him I learnt that malaria drugs were free in some hospitals for pregnant women, but he said the hospital may come up with other expenses for tests and drugs. I could not disobey him and I also don’t have money to go there myself,” Rafat said.

Another woman who lives at Masaka in Nasarawa State but asked not to be named, said that while her husband granted her permission to go to hospital a number of  times during her last pregnancy, he didn’t allow her to attend a primary healthcare centre in her area to get malaria drugs.

“He said that since I was not sick, there was no reason for me to go to the health facility. When I said it was to protect me from malaria, he said I could take herbal mixtures or drugs from patent medicine stores,” she said.

A medical professional who identified herself as Mrs Olushola said many women did not come to her primary healthcare  facility for malaria services, even during free medical outreach campaigns, because they couldn’t secure permission from their husbands.

She said some women were not serious about accessing services for malaria in health facilities.

 

“Some women also attribute symptoms of malaria to witchcraft attack. They go to prayer houses rather than seek medical care. Some of them either engage in self-medication or take herbal medicines. It is when it gets worse that we see them,” Mrs Olushola said.

Malaria is a life-threatening disease caused by plasmodium parasites that are transmitted to people through the bites of female anopheles mosquitoes carrying the parasites. Symptoms include fever, headache, vomiting, diarrhoea, profuse sweating and anaemia.

According to the World Health Organisation (WHO) Malaria Report, 2020, nearly 61million malaria cases occur in Nigeria annually.

The Minister of Health, Dr Osagie Ehanire, said Nigeria accounted for 27 per cent of global malaria cases and 23 per cent of global malaria deaths.

Despite the huge burden of malaria in the country, cultural norms abound, which hamper women’s rights to access malaria services. Some of these norms place the decision concerning a woman’s health on men. There is also a taboo on materials such as mosquito nets, as well as beliefs that malaria is a spiritual disease that requires traditional medicine and prayers, among other issues.

Some communities have  cultural taboos against sleeping under white insecticide nets. When such nets are donated during free medical outreaches, residents use them for fishing. Women and children in such communities are often at high risk of malaria.

The 2018 Nigeria Demographic and Health Survey (NDHS) found that only about 44 per cent of married women in Nigeria are likely to make decisions about their healthcare.

According to the NDHS, more than half of women (52 per cent) report at least one problem of accessing healthcare for themselves.

Eleven per cent is concerned about getting permission to go for treatment. Rural women are more likely to report at least one problem of accessing healthcare than urban women (60 per cent versus 42 per cent), the report stated.

Dr Godwin Ntadom, the Chief Epidemiologist of the Federation, said varying beliefs in different parts of Nigeria affected malaria outcomes.

Some communities in Benue State believe that it is only dead bodies that should be covered with white cloths, including insecticide-treated nets.

“Some other communities in the state also believe that malaria is caused by witchcraft.

“They say that when you encounter an old woman holding a knife at night you will become ill with malaria. In the eastern part of the country, they associate malaria to eating too much oil, local pear and working too hard.

“Some communities in the south-western part of the country also believe in similar superstitions and also associate staying in the sun to malaria,” he said.

The medical expert said another norm involved actions taken by parents when malaria becomes severe.

“When some parents see their children convulsing or twitching, they think it is a spiritual attack, so rather than go to hospital they go to herbalists or churches, delaying the commencement of treatment,” he said.

Dr Ntadom said a belief that all fevers in children were caused by tooth eruption has led to many mothers not seeking treatment.

“They only seek help when the disease has become severe. The culture of ‘mixing or counting medicines’ according to one’s resources is another challenge. This means that when a mother takes a child to a chemist, the patent medicine vendor gives her medicines according to the money she has,” he added.

The programme manager, Benue State Malaria Elimination Programme, Mrs Susan Abege, said cultural norms against white mosquito nets in the affected Benue communities had reduced due to increased awareness.

She said the state was able to tackle it through creating awareness that the nets were meant for the living, not the dead. She added that people came to realise that the net was the only way out because mosquitoes were no longer dying from insecticides.

Dr Bolatito Aiyenigba, the deputy project director, Malaria and Tuberculosis, Breakthrough ACTION-Nigeria, said another obstacle was that some cultures in the country did not encourage women to use clinics.

She said, “Women who visit health facilities are seen as weak. These women prefer to suffer in silence till their symptoms become severe.”

In addition, rural women who attend to their farms in the morning may miss out on treatment while the clinics, especially antenatal, are open in the morning.

“By the time they come back home, the clinic is closed, so they find alternative sources of care, such as herbs and going to traditional birth attendants who do not give medication to prevent malaria during pregnancy,” she added.

She said some women from the Gbagyi ethnic group prioritised farming ahead of clinic.

She said that in some cultures, women are generally not empowered financially and in decision making, so they cannot transport themselves to health facilities for care. They may also need their husbands’ permission.

Mrs Olufunmilayo Sanni-Adeniyi, the director and head of the Advocacy, Communication and Social Mobilisation (ACSM) of the National Malaria Elimination Programme (NMEP), said cultural norms could be religious or social. She confirmed widespread obstacles to women getting the right healthcare services. This includes women kept in purdah (who don’t go out).

“Pregnant women are supposed to register for antenatal care, and it is a problem if their husbands don’t allow them to go to health facilities.

“In some areas, there are beliefs that going to the hospital is a taboo. They prefer to go to traditional birth caregivers. It is only when they run into complications that they start running to the hospital. This sometimes leads to deaths.

“From our findings, we also learnt that some places in Benue State have norms around using the white insecticide net. So some women don’t sleep under the nets,” she said.

She said the National Malaria Elimination Programme was working towards scaling up its scope of intervention to address cultural norms and their impact.

“We are trying to reach all these people to enlighten them that these are all myths and that sleeping under insecticide nets protects them and their babies,” she added.

Implications of cultural norms on malaria prevention and control

Mrs Adeniyi said cultural norms led to increasing malaria cases.

She also said they affected women’s access to intermittent preventive treatment, which is necessary for women during pregnancy.

“For example, a pregnant woman who does not take intermittent preventive treatment and does not sleep under insecticide nets will, of course, come down with malaria; and if care is not taken, she might die.

“This is because when the woman has complications, it affects her and her baby. It also makes cases of malaria more prevalent,” she added.

Dr Aiyenigba of Breakthrough ACTION-Nigeria said malaria prevention and control among women was essential because it protects them and their babies.

She said the preventive measures include consistent use of mosquito bed nets all year round, prompt and regular antenatal care where medicine for prevention of malaria is given at least three times before delivery, prompt testing of fever to be sure it is malaria before taking anti-malaria medicine, completion of recommended course of treatment during any episode of confirmed malaria.

Ways to tackle cultural norms hampering access to malaria services

Dr Aiyenigba said cultural norms hampering women’s access to malaria services could be tackled by engaging all stakeholders – women groups, men’s groups, youth and traditional leaders.

“The value of the change is promoted and benefits accruing from modifying the norms widely disseminated. The use of trusted advocates can also be used to promote new norms,” she said.

She said that where feasible, use of social structures, such as dance troops, drama groups and the mass media, especially radio, in rural places, could also be utilised to communicate the message.

“Religious leaders are also proven agents of change. They can be engaged in promoting the positive behaviour that will empower women and improve their access to care,” she advised.

Aiyenigba added that the health system could also be adaptive to the culture.

“Where feasible, local women with the right qualification can be engaged to man the clinic and open in the evenings when women will be around. That way, utilisation and access are guaranteed,” she said.

She said Breakthrough ACTION-Nigeria was working in 11 states and the Federal Capital Territory to increase women’s knowledge and access to malaria prevention and care.

“We support women empowerment initiatives in five states, so the women have some financial power to transport themselves or their neighbours to the health facilities. We also have funding though the United States president’s malaria initiative to educate the populace, including women during mass distribution of mosquito bed nets,” she added.

Also, Dr Ntadom said efforts by the government to tackle the impact of cultural norms included making recommended anti-malarial medicines come in age specification and colour-coded packs.

“They are made available free or at highly subsidised costs. Awareness creation and sensitisation of communities are also important,” he said.

Mrs Sanni Adeniyi of the National Malaria Elimination Programme said cultural norms were among the reasons her organisation was taking advocacy messages to state governors, religious and traditional leaders, market women’s groups and civil society organisations.

She said, “When we get everyone on board, there will be less cultural norms hampering access to malaria services. Women will benefit a lot from attending antenatal care during pregnancy and sleeping under insecticide-treated nets.

“Right now, a lot of my staff members are in the streets doing advocacy. In fact, even ministers, governors, market women and medical professionals are involved.

“The essence is to prevent an increase in malaria cases because we are working towards a malaria-free Nigeria.”