Dengue and Educational Campaigns in
Maputo, Mozambique
Carolien van Klompenburg
International Development Studies
Dengue and Educational Campaigns in Maputo,
Mozambique
MSc International Development Studies 2018-2019
Graduate School of Social Sciences
Carolien van Klompenburg
12273163
June 2019
Word Count: 19675
Supervisor
Dr. Tatiana Acevedo Guerrero
UNESCO-IHE Institute for Water Education
Second reader
Dr. Rivke Jaffe
University of Amsterdam
Abstract
With increasing rates of urbanization in Mozambique, larger populations can be put at risk of contracting dengue. This is a main reason for why action needs to be taken, as the increasing population will move into already dense areas, leading to a greater population which is exposed to various health risks such as malaria,. As dengue is under-reported, misdiagnosed, and prevalent in societies around the world, it is important to examine the knowledge and practices in various parts of the world. The need to raise awareness, discuss the mis-diagnosis, highlight the testing for dengue, and general awareness about the Aedes aegypti is essential to tackling the greater issue of dengue. The research question which will be explored is “How can
urban awareness campaigns impact the knowledge and practices surrounding mosquito borne diseases, specifically dengue, in Maputo?”. Through exploring this question, it is possible to
determine what knowledge is present in Maputo, what the practices surrounding mosquitoes are, and how educational campaigns can have an influential role in changing the knowledge and practices. The research has been supported by existing literature and interviews conducted in the field. Overall it could be seen that while there was knowledge surrounding mosquitoes and their habits, the greatest challenge as perceived by the local population was Malaria. In addition to this, dengue was often a disease which was completely unknown by the general population. In conclusion it could be seen that education campaigns are an effective method of conveying information to the population; however, they need to be continuous so that all generations are aware of the importance of their actions and implications actions have on their health. This research can be grounds for changes in policies and practices in Mozambique with regards to their public health campaigns.
Key words: Mozambique, Maputo, Dengue, Education Campaigns, Vector Borne Diseases,
Acknowledgements
I would like to thank all of the individuals who helped me throughout this research process. First of all, I would like to thank Dr. Tatiana Acevedo Guerrero for being my supervisor, guiding me during my fieldwork, and pushing me with my academic knowledge and skills. In addition to that, I am grateful that she brought me in contact with Dr Sandra Manuel and Dr Margarida Paulo, from the Anthropology department of Universidade Eduardo Mondlane, who helped me find a local research assistant. Through their help, I was able to conduct my interviews and gather relevant data which helped me come to the conclusions in this text.
I would also like to thank the University Of Amsterdam, and the structure of their International Development Studies Master. Without the requirement of going to the field, I would not have been able to learn the valuable lessons I have learned during my fieldwork and grow further as an individual.
Finally, I would like to thank my family and friends who supported me throughout my time in the field and writing process. Without your support I would not have been able to produce this thesis.
Table of Contents
ABSTRACT ... I ACKNOWLEDGEMENTS ... III LIST OF FIGURES ... VIII LIST OF TABLES ... VIII ABBREVIATIONS ... IX 1. INTRODUCTION ... 1 1.1 BACKGROUND ... 1 1.2 PROBLEM STATEMENT ... 3 1.3 RESEARCH QUESTIONS ... 4 1.4 RESEARCH OBJECTIVES ... 4 2. LITERATURE REVIEW ... 6 2.1POLITICAL ECOLOGY ... 6
2.2AEDES AEGYPTI MOSQUITO ... 8
2.3DENGUE ... 8
2.4URBAN FRONTIER ... 11
2.5EDUCATIONAL CAMPAIGNS ... 15
2.5.1WHAT ARE THEY? ... 15
2.5.3MOZAMBIQUE ... 16 2.6CONCEPTUAL FRAMEWORK ... 19 3. METHODOLOGY ... 20 3.1RESEARCH DESIGN ... 20 3.2METHODS ... 21 3.2.1RESEARCH LOCATION ... 21
3.2.2DATA GATHERING METHODS ... 23
3.2.3DATA ANALYSIS ... 23
3.3LIMITATIONS ... 25
3.4ETHICAL PROCEDURES ... 26
4. HISTORY OF MOZAMBIQUE AND THE DEVELOPMENT OF CITIES ... 28
4.1HISTORY ... 28
4.2THE PROCESS OF URBANIZATION IN MOZAMBIQUE ... 31
4.3.URBANIZATION AND MOSQUITOES ... 37
5.1KNOWLEDGE ABOUT DENGUE ... 41
5.2PRACTICES SURROUNDING MOSQUITOES ... 42
6. AWARENESS CAMPAIGNS IN MOZAMBIQUE ... 46
6.1CAMPAIGNS ... 46
6.2RECOMMENDATIONS FOR THE FUTURE ... 48
7. DISCUSSION ... 50
8. CONCLUSION ... 55
WORKS CITED ... 58
APPENDICES ... 64
APPENDIX A:CREDENTIALS FOR WORKING IN MAPUTO ... 64
APPENDIX B:GENERAL QUESTIONNAIRE LIST ... 65
APPENDIX C:QUESTIONNAIRE FOR ORGANISATIONS, OFFICIALS, AND HEALTH WORKERS ... 66
APPENDIX D:INTERVIEW TRANSCRIPTS ... 68
INTERVIEW 1–RETIRED MAN ... 68
INTERVIEW 2–NEIGHBOURHOOD BOSS ... 69
INTERVIEW 3–DOMESTIC WORKER ... 71
INTERVIEW 4–GRANDMOTHER ... 72
INTERVIEW 5–NEIGHBOURHOOD BOSS ... 74
INTERVIEW 6–MAFALALA HEALTH AGENT ... 76
INTERVIEW 7–PROFESSOR ... 78
INTERVIEW 8–PUBLIC HEALTH PROFESSIONAL ... 80
INTERVIEW 9–MEDICINE TECHNICIAN ... 85
INTERVIEW 10–ANAESTHETIST ... 88
INTERVIEW 11–HEALTH TECHNICIAN ... 90
INTERVIEW 12–TEACHER ... 92
List of Figures
FIGURE 1(EUROPEAN COMMISSION HUMAN HEALTH SETTLEMENT,2018).THIS FIGURE DEPICTS THE URBAN GROWTH WHEN FIRST PHOTOGRAPHED BY NASA IN 1975.JUST AS OTHER COUNTRIES IN AFRICA,
MOZAMBIQUE’S URBANIZATION STARTED TAKING PLACE IN THE 1960S. ... 13
FIGURE 2(EUROPEAN COMMISSION HUMAN HEALTH SETTLEMENT,2018).WHAT THIS FIGURE DEPICTS IS THE URBAN GROWTH EXPERIENCED SINCE 1975 TILL 1990.THE URBAN SPACE HAS SPRAWLED OUT FURTHER INLAND AND EXPANDED GREATLY SINCE 1975 WHICH IS DEPICTED IN AN ORANGE COLOR. ... 13
FIGURE 3(EUROPEAN COMMISSION HUMAN HEALTH SETTLEMENT,2018).THE ADDITIONAL URBAN GROWTH IS REPRESENTED IN A LIGHT ORANGE COLOR. ... 14
FIGURE 4(EUROPEAN COMMISSION HUMAN HEALTH SETTLEMENT,2018).THE FINAL PICTURE TAKEN BY NASA IN THIS SERIES WAS TAKEN IN 2014.THE URBAN SPRAWL IS SHOWN IN YELLOW, AND ONCE AGAIN HAS MOVED FURTHER INLAND.THIS FINAL IMAGE ALSO CLEARLY SHOWS THE GROWTH OVER THE YEARS WHERE RED IS THE 1975’S LEVEL, ORANGE FROM THE 1990’S, LIGHT ORANGE 2000’S AND FINALLY 2014 IN YELLOW. ... 14
FIGURE 5MAP OF MOZAMBIQUE ... 22
FIGURE 6GOOGLE MAPS VIEW OF MAFALALA,2019 ... 33
FIGURE 7GOOGLE EARTH VIEW OF MAFALALA, OUTLINED IN GREEN.(BAYONA,2018), ... 34
FIGURE 8CORRUGATED IRON SHEETS WHICH MAKE UP A WALL WHICH DIVIDES THE PRIVATE SPACE OF A HOME AND A PATHWAY IN MAFALALA. ... 35
FIGURE 9IRON SHEETS FIXATED TO POLES SEVERAL LAYERS HIGH.THIS ONCE AGAIN DEPICTS HOW THESE SHEETS CAN BE USED TO CREATE A DIVISION BETWEEN THE PRIVATE AND PUBLIC SPACE.THE SHEETS ARE UPHELD WITH A FEW SCREWS AND NAILS. ... 36
FIGURE 10EXAMPLE OF WATER STORAGE NEXT TO A HOUSEHOLD, USING OPEN TUBS, SPARE WATER BOTTLES, AND SMALLER CLOSED CONTAINERS TO SAVE WATER WHICH CAN BE USED IN AND AROUND THE HOUSEHOLD ... 45
List of Tables
TABLE 1LIST OF KEY TERMS, DEFINITIONS, FREQUENCY USED WHEN CODING AND IN HOW MANY DIFFERENT FILES THE NODE COULD BE FOUND. ... 24Abbreviations
WHO World Health Organization
DHF Dengue Hemorrhagic Fever
DSS Dengue Shock Syndrome
NASA National Aeronautics and Space Administration
USAID United Stated Agency for International Development
LLINs Long lasting insecticidal nets
IRS Indoor spraying campaigns
ITNs Insecticide-treated nets
HDI Human Development Index
ANC African National Congress
MNR Mozambique National Resistance
IMF International Monetary Fund
1. Introduction
1.1 Background
Dengue is a vector borne disease which can impact over 2.5 to 4 billion people worldwide, putting 40-60% of the world population at risk (Jaenisch, et al., 2014). According to the World Health Organization (WHO), the cases of dengue have increased in the past decades and is found in tropical and sub-tropical climates worldwide, in urban and semi-urban areas (WHO, 2018). The Aedes aegypti mosquito is the main carrier of this disease and thrives in urban and urbanizing areas.1 There are 4 serotypes, or strains, of the virus known as
DEN-1, DEN-2, DEN-3 and DEN-4, as well as a more severe form of dengue known as Dengue Hemorrhagic Fever (DHF) (WHO, 2018). For the four serotypes the classical symptoms are fevers, sore muscles and joints, and occasional nausea and rashes (Hopp & Foley, 2003). The symptoms of DHF include sudden fevers, and hemorrhages, which lead to extreme fluid loss, which then in turn leads to shock (Hopp & Foley, 2003). If an individual has been infected with one of the serotypes the chances of contracting DHF are higher, where the fatality rate of DHF is roughly 5% (Hopp & Foley, 2003).
Dengue is a growing threat to many parts of the world, as climates shift due to enhanced global climate change. The Aedes aegypti originated in Africa, but has spread to more than 120 countries worldwide, allowing for 390 – 500 million cases of dengue per year (Abílio, et al., 2018). In Africa, cases of dengue have been reported since the 1960s sporadically or in large epidemic outbreaks, across 22 different countries (Amarasinghe, Kuritsky, Letson, & Margolis, 2011). The first official recorded epidemic outbreak was reported in Durban, South Africa in 1926 where DEN-1 and DEN-2 were found (Cornet, 1993). A large issue is the accurate reporting on dengue, as cases go undiagnosed or are often misdiagnosed as malaria due to the similarity in symptoms (Amarasinghe, Kuritsky, Letson, & Margolis, 2011).2 The WHO has
stated that insufficient data on dengue has made it a challenge to estimate the burden which dengue brings to households and communities (WHO, 2012). Due to the rapid urbanization which has taken place in Africa since the 1950s and the increased number of informal settlements, available habitats for the Aedes aegypti has grown (Were, 2012). This species of
1 The Aedes aegypti is not the only species which thrives in urban areas, as Aedes albopictus is another species
which thrives in the urban space (Abílio, et al., 2018). The Aedes albopictus carries at least 22 viruses which can affect humans, including dengue (Abílio, et al., 2018).
2 It is worth noting that malaria, another vector-borne disease present in Africa, is transmitted by a different
mosquito species, namely the female Anopheles. This disease has similar symptoms such as fevers, headaches, and chills, which appear roughly after 10-15 days after being bitten by a mosquito (WHO, 2018).
mosquitoes thrives in the urban space and the private household, where the female will lay its eggs on household objects or abandoned trash laying nearby with stagnant pools of water (Nading, 2014). The Aedes aegypti needs limited access to water, therefore any volume of free-standing water can become a breeding space creating a serious threat to the local population.
The last major outbreak of dengue in Mozambique was reported in October 1984 till March 1985 in the city of Pemba, in the north of the country (Cornet, 1993). However, reports of dengue have continued to this day, which highlights the importance for this work that needs to be done in this field. The most recent outbreak of dengue took place in 2014, where over 100 confirmed cases were reported. This was followed by an endemic circulation of DEN-2 in 2015-2016 infecting 21 people (Abílio, et al., 2018). This shows that the disease and the health threat are still present, infecting various people across the country, and highlights the need for more research studies, awareness campaigns and education programs. The informal settlements throughout the country, and the informal water storage methods used in these dense urban areas, are the main contributors to creating habitats and breeding sites for mosquitoes. Urbanization is a major contributing factor for increased numbers of dengue, as the “accumulation of nonbiodegradable, human-made containers in and around living areas has provided the aquatic environment required by these mosquitoes” (Amarasinghe, Kuritsky, Letson, & Margolis, 2011, p. 1352). The limited access to drainage and sanitation infrastructure is an additional challenge in low-income neighborhoods, as neighborhoods grew rapidly and these services were not implemented in these areas (Bayona, 2018).
Mozambique has also been highlighted as one of the most vulnerable countries in Africa to climate change, and in in the top 5 worldwide (Boyce, 2017, p. 79). Mozambique’s vulnerability is linked to its geographic location in southern Africa and placement next to the Indian Ocean, placing it at a greater risk than other countries in Africa. Due to this, it can be expected that due to increased tropical storms, floods and droughts the people of Mozambique will face various challenges such as food insecurity, social unrest, alongside the daily struggle to make ends meet (Boyce, 2017). These possible challenges will become increasingly burdensome due to the limited preventative action, which is being taken by the government, in addition the limited infrastructure which is present in Mozambique
In the case of Maputo, the Aedes aegypti has been able to thrive in the urban areas. The mosquito has been present in various different neighborhoods, such as Polana Cimento, Alto Maé, Chamanculo, Mafalala, Polana Caniço, and Moagoanine (Bayona, 2018). Within these specific neighborhoods, the mosquito is able to thrive due to the methods used to store water,
meaning that the spread of dengue is also prevalent. The ability of the Aedes aegypti to thrive in the urban space means that the densely populated neighborhoods create the ideal habitat for its life cycle with places to breed and lay its larvae, and the ability to mature and repeat the process.
1.2 Problem Statement
As dengue is under-reported, misdiagnosed, and prevalent in societies around the world, it is important to examine the knowledge and practices in various parts of the world. The need to raise awareness, discuss the misdiagnosis, highlight the need to test for dengue in hospitals, and general understanding about the Aedes aegypti is essential to tackling the greater issue of dengue.
With increasing rates of urbanization, larger populations can be put at risk of contracting dengue. This is one of the main reasons for why action needs to be taken, as the inevitable increasing population will move into already dense areas, leading to a greater number of people who are exposed to various health risks.
Through raising the awareness about Aedes aegypti and working to minimize their breeding space, it is possible to limit the population which is exposed to dengue. By educating the population about the life cycle, habitat and habits of the mosquitoes it is possible to minimize the exposure to diseases carried by them. By stressing the importance of limiting pools of stagnant water near the household, which can be found by plant pots, trash, and old tires amounts other objects, this then leads to less breeding sites for the mosquitoes. While this is the ideal situation, it should be noted that in less economically developed regions or areas, infrastructure can be limited, run down, or non-existent. This can lead to the accumulation of waste, water, and other challenges to health. In these specific contexts it is important to highlight the importance of hygiene and the appropriate means of disposing of waste, as this can have significant impacts on the greater health of the population.
An additional challenge is the limited knowledge about dengue. This is mainly in the local context, where dengue is considered to be a synonym for malaria, or even considered unimportant. This thus calls for the need to raise the general awareness about dengue and the health risks and implications it can have.
The limited diagnostic testing at hospitals, and therefore also the misdiagnosis of dengue, is a frequent and serious issue. The limited diagnostic testing means that there is inaccurate or insufficient data regarding the exposure of dengue to a population, number of
cases per year, and cases which are treated. By increasing the testing for dengue, making testing more affordable, and accurately reporting the cases of dengue, it is possible to accurately analyze the impact dengue truly has on the population.
The lack of testing also results in cases being misdiagnosed, and thus patients being treated for other diseases which they might not have. As dengue has very similar symptoms to malaria, over “70% of febrile illnesses are treated as presumptive malaria, often without proper medical examination and a laboratory diagnosis” (Amarasinghe, Kuritsky, Letson, & Margolis, 2011, p. 1351). This approach is not effective, as treatments for malaria are not effective if the patient has dengue. While there is no vaccine for dengue, an increase in the accurate portrayal of the frequency of this disease could lead to more medical research and changes in this regard.
1.3 Research Questions
These questions are in relation to educational awareness campaigns and the urban nature of Maputo. The main research question is:
How can urban awareness campaigns impact the knowledge and practices surrounding mosquito borne diseases, specifically dengue, in Maputo?
This question will then aim to also answer sub-questions such as
I. What types of processes have contributed to the resurgence of dengue in Mozambique?
II. What are the practices surrounding mosquitoes in Mozambique?
III. How can educational campaigns impact the knowledge surrounding dengue in Mozambique?
Through these questions the aim is to analyze how effective educational campaigns have been and can be in Maputo. By examining past campaigns, it is possible to identify strengths and weakness within the campaigns. In doing so, it opens up the possibility to give recommendations and improvements for future programs and campaigns, leading to increased effectiveness.
1.4 Research Objectives
The aim of this research is to understand how and if awareness campaigns are effective methods of portraying information regarding dengue. In light of the fact that the knowledge
about dengue remains limited in the Global South, and specifically Mozambique, the aim of the research was to use the data gathered to acquire the relevant knowledge surrounding dengue. These conclusions could possibly be generalized to a greater context of the Global South. Through a political ecological lens, an analysis on the knowledge, practices, and campaigns surrounding dengue, mosquitoes, and public health, it is possible to answer the research question “How can urban awareness campaigns impact the knowledge and practices surrounding mosquito borne diseases, specifically dengue, in Maputo?”.
2. Literature review
In this literature review there will be a discussion surrounding the political ecology approach that states that the environment is intertwined with the socio-economic and pollical processes. This will be used as a theoretical lens throughout the research. Furthermore, literature surrounding four main topics will be introduced and discussed: Aedes aegypti mosquitoes, dengue, the urban frontier (urbanization), and educational campaigns in the context of public health.
2.1 Political Ecology
Instead of seeing water as an external resource, alternative approaches like political ecology see water as a socio-nature. This means that water is studied as a historical-geographical process in which society and nature are inseparable, mutually produced, and transformable (Robbins, 2004). Political ecological analyses processes of environmental change as deeply interrelated to socio-economic and political dynamics. Works drawing from political ecology emphasize the impact of environmental dynamics on social relations and seriously question how the physical properties of water may be sources of unpredictability, unruliness and resist human intentions (Acevedo Guerrero, 2018). As an alternative to the hydrological cycle, political ecology proposes the concept of hydro-social cycle, which emphasizes that water is deeply political and social (Linton & Budds, 2014).
An analysis of water policies based on a political ecological approach considers power relations. This means that, while water implies a series of connections between individuals and between social and natural systems, it also implies segregations as it reflects wider tensions in society and cannot be separated from processes of race, ethnicity/religion identity and class formation (Anand, 2017) (Gandy, 2014) (von Schnitzler, 2016). Besides, the use, management, governance and knowledge of water and sanitation services and resources is deeply gendered (Zwarteveen, Ahmed, & Guatam, 2012). It is important to stress that processes of water exclusion and stratification are always contested. Residents of the informal settlements in the urban South rework unequal power relations by contesting their lack of access to infrastructure through mobilization, sabotage, and through formal complaints in state or utility offices (McFarlane & Silver, 2017). Water can be mobilized by exerting pressure on the water utility’s engineers, asking (or paying them) them to fix a connection or alter a water meter; or exerting pressure on politicians, for example, by negotiating the family or community’s future votes (Anand, 2011) (Anand, 2017) (Gandy, 2008). Also, some residents are able to survive in the
city despite the absence of municipal water pressure and sanitation, by using pumps and other equipment to build clandestine water connections and temporary pit-latrines (Anand, 2017) (McFarlane, Desai, & Graham, 2014). Women living in informal settlements recur to everyday practices such as staying back from work to access water, walking miles in search of sanitation, and procuring water from illegal and informal sources (Sultana, 2011) (Truelove, 2011).
Through this theoretical lens, it is possible to look at scale, region, place, and landscape through a critical analysis (Neumann, 2011). Landscape is a relevant concept within political ecology, as the division and use of landscapes can be unequal, landscapes can change over time, and can have a colonial narrative. Landscapes are prone to change, natural and due to human impacts, which does not match the human embodied experience (Nading, 2014, p. 174).
It is important to note that visualizations within the field of political ecology remain under-explored (vonHedemann, Butterwoth, Robbins, Landau, & Morin, 2015). While geographic information system technology could be an effective means of collecting and analyzing data, however it has not been a preferred or popular method. Through mapping tools, various kinds of politics emerge, as it can show ethnographic data, political divisions, racial and economic differences, and so on (vonHedemann, Butterwoth, Robbins, Landau, & Morin, 2015). Through visualizing different aspects of political ecology, it is possible to identify different factors which can contribute to the inequality seen in specific areas.
Political ecology refers to how the material and the social, mediated by political economic structures are dialectically produced in nature (Nading, 2014, p. 10). The power relations in the case of Mozambique, can be seen in the urban landscape and the inequalities which, in part, have been shaped by the historical context. These inequalities can further be based on class, ethnicity, gender, and age, and are relevant when looking at dengue. The socio-economic status has a role in determining who is more susceptible to contracting dengue. As individuals who live in houses with glazed windows, piped water, and insect screening can reduce their contact with the relevant vectors (Banu, Hu, Hurst, & Tong, 2011). The housing type can thus have an impact, as dense urban dwellings can have open spaces where discarded items can be filled with water and create mosquito breeding sites (Banu, Hu, Hurst, & Tong, 2011). This socio-economic status can also have greater implications when it comes to seeking aid or medical attention. Since patients often need to pay for their consultations, laboratory tests, and drugs, it can call for an individual to seek medical attention at a later date or increase self-medication (Amexo, Tolhurst, Barnish, & Bates, 2004).
2.2 Aedes aegypti mosquito
The Aedes aegypti mosquito is the carrier of vector borne diseases such as Zika, dengue and chikungunya. The mosquito will be discussed in terms of its habitat, and when it is most active and the implications of its activity.
This mosquito has colonized all parts of the household and city, as it thrives in urban areas. The Aedes aegypti “breeds most often in household water supplies, both formal (sinks, barrels, buckets) and impromptu (crooks of trees, garbage, coconut shells)” (Nading, 2012, p. 573). Due to this, it has been a challenge to fight this mosquito in urban areas. Studies have also revealed that this species of mosquitoes prefers a warmer temperature when breeding, which takes place in various urban households and informal settlements (Overgaard, et al., 2017). It should be noted that the optimum breeding water temperature lies between 20 – 30 °C, and Bayona (2018) shows that stored water in neighborhoods in Maputo averages between 25.45 – 29.76°C making those areas optimal for Aedes aegypti to lay its larvae (Bayona, 2018). Due to the urban context of Maputo, it can be seen that the characteristics of water storage tools and the increased temperatures of water, there is sufficient breeding grounds for the Aedes
aegypti.
What is notable about this species is that it feeds during the day, specifically two hours after sunrise or before sunset (World Mosquito Program, 2012). This thus leaves those in the households to be more vulnerable to bites and diseases as individuals tend to be in the household at these times. Research by Nading (2012) shows that in most cases, this leaves more women exposed to the Aedes aegypti, due to the fact that women will most likely be doing the cooking, cleaning, and daily household chores (Nading, 2012) during these times. The Aedes aegypti feeds on and acquires vital nutrients from human blood and this is an essential part of the life cycle. This life cycle can be as short as 8 to 10 days, developing from the egg to larva, to pupa, to adult (Nading, 2014, p. 5). In this process excess trash or weed patches are an ideal place for pupa to dry their wings while maturing into adult mosquitoes and offer spaces to breed and hide.
2.3 Dengue
Within this research the main focus will be on dengue, therefore there will be a short discussion on the implications of contracting dengue, and why it is often misdiagnosed as other diseases (Higa, et al., 2015). It is worth noting that there are two severe strands of the disease namely DHF and dengue shock syndrome (DSS) in severe cases (Lam, 2013). There are 4
serotypes of dengue, all spread by the Ae. aegypti, which can lead to fevers and joint pains as symptoms. Dengue can be characterized as “a febrile illness with two or more of the following myalgia, arthralgia, headache, retro-orbital pain, rash, leukopenia and/or hemorrhagic manifestations, plus supportive serology or occurrence at the same location and time as other confirmed cases of dengue fever” (McArthur, Sztein, & Edelman, 2013, p. 934). Once one of the serotypes has been contracted, it increases the chances of contracting the more severe DHF. DHF symptoms often present themselves after high-fevers subside and can lead to internal plasma leakage, which can cause death (Nading, 2014, p. 8). The immune systems failure to recognize a new serotype leads to breeding of viral cells without immune intervention, and thus infecting the host at a quicker pace. This is thus a challenge and a threat, as “dengue makes you sick the first time, but kills you the second” (Nading, 2014, p. 12). As individuals might not get tested for dengue, it is possible that many cases and fatalities go unreported.
Dengue is prevalent in various parts of the world mainly in tropical and sub-tropical regions. This places 2.5 billion people at risk annually around the world, mainly in developing counties in Asia-Pacific, the Americas, the Middle East, and Africa (Lam, 2013). Data on dengue in Africa is under-reported, however it can be contracted in 35 different countries across the continent (Amarasinghe, Kuritsky, Letson, & Margolis, 2011). It should also be noted that the Aedes aegypti can be found in an additional 13 countries but have not yet had any reports of dengue (Amarasinghe, Kuritsky, Letson, & Margolis, 2011). This could be a result of limited testing for dengue in these various countries.
According to Amarasinghe, Kuritsky, Letson, and Margolis (2011), dengue is underrecognized and under reported in Africa due to the low awareness amongst health care providers, the confusion of simmilar sympotoms of other diseases and viruses, and the lack of testing and survaillance of dengue. The overdiagnosis of malaria, is at a 61% rate, as malaria is the most common febrile illness in Africa (Amarasinghe, Kuritsky, Letson, & Margolis, 2011). The similar symptoms lead to the prescription for medicines for malaria, rather than conducting tests to determine what could be the cause of the symptoms. Most cases of dengue are reported by travelers who have left the region and are showing the symptoms of dengue. In the cases of travelers, there is also a high misdiagnosis frequency of dengue with malaria (Amarasinghe, Kuritsky, Letson, & Margolis, 2011). This misdiagnosis can be caused by various reasons, such as high patient-to-clinician workload, variation in the health worker’s training and skills, slide preparation, conditions of the microscope, and quality of the laboratory (Stoler, al Dashti, Anto, Fobil, & Awandare, 2014). The main reason for the misdiagnosis of dengue would be the lack of testing, in addition to the other reasons listed. Through limited
testing, and the prescription of drugs intended for a different disease, this misdiagnosis and mistreatment can lead to a threat in the future, where the population can become resistant to the malaria drugs.
An additional reason for the misdiagnosis of dengue is due to the difficulty in clinically distinguishing between dengue and the family of bacteria it belongs to,3 and the cross-reactivity
within this family (Stoler, al Dashti, Anto, Fobil, & Awandare, 2014). This cross-reactivity has been seen between dengue, chikungunya, and leptospirosis, causing obstacles to clinics using commercial serology kits and rapid diagnostic tests (Stoler, al Dashti, Anto, Fobil, & Awandare, 2014).
The rate of unplanned urbanization in Mozambique has also created artificial breeding sites for mosquitoes, putting a larger number of the population at risk of contracting dengue (Abílio, et al., 2018). Recent research into Mozambique and dengue, has highlighted the abundance of the Aedes aegypti in Mozambique, and the increased risk and exposure to dengue this has created for the entire population. Findings from the research show that the Aedes
aegypti can be found in all regions of the country and suggests that control programs should
focus on the storage and disposal of water and storage containers, and that vector monitoring programs should expand to other species (Abílio, et al., 2018). While the vector can be found throughout the country the recent outbreaks have been limited to the north of the country (Higa, et al., 2015).
While there are no vaccines or drugs available to help treat dengue, researchers have been in the process of developing a vaccine. The Pediatric Dengue Vaccine Initiative (PDVI) aims to accelerate the development, evaluation, and introduction of dengue vaccines (Beatty, et al., 2011). A reason to why there is no vaccine or drug available is because there is still limited understanding about the dengue virus and its impact on our immune system (McArthur, Sztein, & Edelman, 2013). Another reason is the need for the vaccine to be tetravalent that provides long lasting immunity for all four serotypes of dengue, while the relationship and reactogenicity with other vaccines for the flavivirus vaccines, such as yellow fever and Japanese encephalitis, needs to be investigated (McArthur, Sztein, & Edelman, 2013). In addition to development costs, the cost of the vaccine and the private market will have an impact on the availability if a vaccine is produced. While governments are willing to pay between 0.50 - 1.00 USD per dose, launching the vaccine on the private market could sell the
3 Dengue is part of the Flaviviridae family, which includes yellow fever, hepatitis C, West Nile virus, and viruses
drug at thirty times the price (McArthur, Sztein, & Edelman, 2013). This drastic difference in potential price calls for a relevant discussion to the price at which the potential vaccine could be sold. In addition to this, the minimal knowledge regarding the prevalence and frequency of dengue does not accurately represent the threats it can pose to society which in turn limits research. As medical research is often politicized, the increase in testing and data can allow for more research to be done in this field.
Some scholars have also stated that the genetic makeup of an individual can have an impact on contracting dengue. It is stated that Caucasians are more susceptible to dengue, while Africans are genetically less susceptible, which could be another factor to the limited reporting and rarity of dengue and DHF in Africa (Fagbami & Onoja, 2018).
In addition to this, enhanced climate change will also prove to be another challenge when combatting dengue, as “projected climate change will affect the biology and ecology of vectors and consequently the risk of vector-borne disease transmission” (Banu, Hu, Hurst, & Tong, 2011). As temperatures, rainfall, and humidity are essential factors for the life cycles, growth and distribution of mosquitoes and potentials dengue outbreaks, the changing of regional temperatures and climates could lead to dengue spreading globally. The potential increases of drought can lead to more storage of water within the household which can potentially become a breeding site for the Aedes aegypti, while increased rainfall and flooding can also lead to more breeding sites as more larval habitats remain flooded to support the life cycle (Banu, Hu, Hurst, & Tong, 2011).
2.4 Urban Frontier
As has been mentioned before the Aedes aegypti is thriving in the urban household due to water storage methods in response to intermittent (irregular) water supply. In Mozambique, the urban settlements have developed rapidly since 1975. Considering the Aedes aegypti are endemic and prefer artificial water containers to lay its eggs and offspring, this makes it a challenge to fight the mosquito (Higa, et al., 2015). It is important to note how water is stored in low income areas and informal settlements, as this is a major contribution to the spread of vector borne diseases.
Urbanization is an important concept within this framework, as it is a contributing factor to the spread of the Aedes aegypti and dengue. Urbanization can be defined as “the increasing concentration of people (relative to a base population) in urban style settlements at densities that are higher than in the areas surrounding them” (Gregory, 2009, pp. 792-794) This can be
expanded on further by looking at the consequences of urbanization, as underdevelopment and squatter settlements can be seen as products of increased populations (Gregory, 2009). It has been well documented that there has been an increased urban sprawl towards urban centers in Africa.
The concept ‘urban frontier’ is based on the definition of both words. The urban refers to the “in, relating to, or characteristic of a town or city”, while frontier refers to “the extreme limit of settled land beyond which lies wilderness” (Oxford Dictionaries, 2019) (Oxford Dictionaries, 2019). Through combining the two terms, the urban frontier sees “the inner-city population as a natural element of their physical surroundings” (Smith, 1996, p. 17). This thus means that the city is the space in which wilderness lies, as mosquitoes have managed to thrive in the urban settlements. The urban frontier in this context is the dense urban spaces in which the mosquitoes thrive. Due to the history of Maputo, rapid urban expansion in lower income neighborhoods is prevalent and leads to a greater urban density. This urban density leads to multiple households in a single plot, where families share and divide the limited space available (Bayona, 2018). Moreover, the urban density and the limited services provided by the municipality means that there are minimal water and waste services. This can lead to the rapid spread of diseases and create various breeding sites for mosquitoes which in turn can infect the densely populated area. An increasing dense urban population can lead to the “accumulation of nonbiodegradable, human-made containers in and around living areas has provided the aquatic environment required by these mosquitoes” (Amarasinghe, Kuritsky, Letson, & Margolis, 2011, p. 1352).
The local context is of importance when looking at the urban ecology, because “limited sanitation infrastructure, multiple rainy seasons, pervasive household water storage, and virtually no public awareness of dengue transmission, presents a similarly prime environment for breeding of Aedes aegypti, the primary vector for yellow fever and dengue fever, as observed around the world” (Stoler, al Dashti, Anto, Fobil, & Awandare, 2014, p. 59).
As can be seen in the figures below, Maputo experienced rapid urbanization from 1975 onwards. Figures 1 – 4, on the following pages (13 – 14), which show National Aeronautics and Space Administration’s (NASA) satellite images which have tracked the urban growth in Maputo from 1975 till 2014 (European Commission Human Health Settlement, 2018). These images show the extension of the urban into the periphery while also displaying the increasing density in the urban areas.
Figure 1 (European Commission Human Health Settlement, 2018). This figure depicts the urban growth when first photographed by NASA in 1975. Just as other countries in Africa, Mozambique’s urbanization started taking place in the 1960s.
Figure 2 (European Commission Human Health Settlement, 2018). What this figure depicts is the urban growth experienced since 1975 till 1990. The urban space has sprawled out further inland and expanded greatly since 1975 which is depicted in an orange color.
Figure 3 (European Commission Human Health Settlement, 2018). The additional urban growth is represented in a light orange color.
Figure 4 (European Commission Human Health Settlement, 2018). The final picture taken by NASA in this series was taken in 2014. The urban sprawl is shown in yellow, and once again has moved further inland. This final image also clearly shows the growth over the years where red is the 1975’s level, orange from the 1990’s, light orange 2000’s and finally 2014 in yellow.
2.5 Educational Campaigns
2.5.1 What are they?
Through the exploration of educational programs and awareness campaigns in the context of public health, it is important to first define and understand what these campaigns are. First there will be a short analysis into educational programs, which will be followed by an analysis into awareness projects, finally there will be an exploration into the impact on public health and the necessity for specific dengue campaigns. Then there will be a focus on existing campaigns in Mozambique, focusing on public health to explore what methods have been used in general. The method of comparison between the programs and campaigns will be mentioned in further detail in the Methodology section (pages 20 – 27), where this section will focus on the campaigns, programs, and organizations.
Educational campaigns can be defined as “a connected series of operations designs to bring a particular result” in this case focusing on bringing “the knowledge and development” gained (Merriam-Webster, 2019) (Merriam-Webster, 2019). Therefore, an educational campaign is focused on bringing to light new information about a relevant topic, in order to educate the audience. When looking at an awareness campaigns, this is focused on bringing to light “knowledge and understanding that something is happening or exists” (Merriam-Webster, 2019). In this we can see that educational campaigns and awareness campaigns are quite similar in nature but have slightly different focuses. In this research, they will be used side-by-side and interchangeably, as the greater focus of the research is on knowledge and practices surrounding dengue.
The literature on such campaigns and their impact on public health is varied. For the impacts to have a positive effect, some scholarly sources state that campaigns need to be personalized to the local area, while also requiring active participation from the target audience and its community leaders (Espinoza-Gómez, Hernández-Suárez, & Coll-Cárdenas, 2002). In this specific research they stated that preventative measures for dengue should be based on the community involvement, with programs that involve house-to-house visits, involvement of natural leaders of the community, use marketing strategies, together with a quantitative evaluations of the program (Espinoza-Gómez, Hernández-Suárez, & Coll-Cárdenas, 2002). Through public campaigns, which focus on the community involvement “public education campaigns can have beneficial effects on vector control … by teaching and motivating the public on how to manage habitats in order to prevent immature mosquitoes from completing their development” (Bartlett-Healy, et al., 2011, p. 1359). In this research project, the
interactive level was taken to elementary and secondary schools, where teachers were given relevant material to present and teach lessons while summer projects were set up for students in grades 3 – 5. The adult campaign consisted of brochures (on spring cleanup, a quick guide to reducing biting mosquitoes, the Asian tiger mosquito, and canine heart worm) in English and Spanish, with educational website links (Bartlett-Healy, et al., 2011).
A study about the impacts and effectiveness of public service announcements stated that public health agendas which used public service announcements significantly raised the care seeking attitudes in the population (Corrigan, PsyD, Powell, MS, & Al-Khouja, 2015). From this initial brief exploration, it can be seen that awareness campaigns can be effective in various different approaches and styles. Through a deeper analysis into campaigns and their methods, it is possible to understand and analyze the impacts they can have on local populations.
Finally, the need for such campaigns is essential and critical as dengue is a continuous and amplifying problem in the Global South. Growing cases of dengue, increasing urban populations and urbanization, and changing climates and climate zone are reasons for setting up campaigns surrounding dengue. It is estimated that there are 50 – 100 million cases of dengue annually worldwide, leading to over 20,000 deaths per year (Suaya, Shepard, & Beatty, 2006). This is sufficient evidence that awareness campaigns need to be created or adapted to discuss the Aedes aegypti mosquito, dengue, and water storage methods.
2.5.3 Mozambique
While Mozambique has various campaigns surrounding mosquitoes and public health, these are mainly focused on combatting malaria and a different species of mosquitoes namely the Anopheles gambiae. Seeing that this species of mosquito is most active at night, bites can be prevented by sleeping under long lasting insecticidal nets (LLINs) (Arroz, et al., 2018). However, the Aedes aegypti is active during different hours of the day, and therefore, there is a need for a different approach to combat the spread of the diseases that these mosquitoes carry. In the past, there have been various campaigns in Mozambique about mosquito awareness, water storage methods, and health related topics.
The United States Agency for International Development (USAID) has had projects in Mozambique with regards to malaria and HIV/AIDS awareness and diagnostic testing (USAID, 2018). This involved building health facilities and improving basic access to health in the rural spaces of Mozambique. Through these facilities there has also been a distribution
of over 1,000,000 LLINs to help combat malaria (USAID, 2018). In addition to this, USAID has provided one third of the antiretroviral drugs for those infected with HIV/AIDS, provides rapid and mobile test kits, and funded the first nationwide campaigns on preventing HIV (USAID, 2018). Through these programs, USAID has managed to make a substantial impact on the public health in Mozambique. In addition to this, there have been multiple campaigns by various actors to help combat malaria throughout Mozambique. This is often done through the handing out of LLINs to the population, or indoor spraying campaigns (IRS). The Mozambican government started a large-scale campaign in 2017, where “16 million insecticide-treated mosquito nets (ITNs), reached 97% of households nationwide (WHO, 2018).
While there have been multiple campaigns and programs throughout Mozambique, long-term partnerships are often scraped for short-term ‘easy-wins’ programs by the government (Boyce, 2017). The need for development is clear, however donors have become “uncomfortable with the relatively blunt conditionality” of relationships with the government and the political nature of the country (Boyce, 2017). Due to the political nature of Mozambique and the possible instability which it causes, it can be seen that organizations are proceeding with caution before starting programs. Uneven distribution of national resources in Mozambique impact medical care, while also being impacted by spatial relations and practices (McKay, 2018). Small public health centers are often also centers for projects run by NGOs and international agencies, which allow for important resources to become available. International flows of knowledge and funding leads to several well-funded public spaces, while other public services are under-resourced and struggling (McKay, 2018). The medical possibilities available are also dependent on relations outside of clinical spaces, as the “conditions under which medical goods enable health and recovery … include not just economic possibilities or medical resources … but also practices of reciprocity that extended between households, through gendered family and friend relationships, and across the city” (McKay, 2018, p. 535). This shows that, in addition to possible limited access to health care, an additional boundary is created due to unequal gender relations. The relationships which are formed in social settings, thus contribute to the access and availability of health care. The relationship between genders is relevant because the women are more exposed to dengue as it is their role to take care of the household and are thus more exposed to dengue (Nading, 2012). The health services offered in Mozambique post-independence led to the abolishment of fees, centralized pharmaceutical procurement and dispensation, and opening hospitals to the public, however most services remained in the urban centers (McKay, 2018).
While foreign aid has been flowing into the country since the 1980s, national organizations have had a secondary role as non-governmental organizations have been significant (McKay, 2016). The destruction of health infrastructure in the 1980’s intensified structural adjustment policies and wore out the public health system. While international organizations and agencies intervened while peace talks were taking place in the late 1980’s, they had become central in tackling issues on the ground, while also reinforcing existing inequalities (McKay, 2016). The flow if international aid led to government entities taking on new roles, which focuses more on managing funds and interventions than providing treatment (McKay, 2016). This created a dependency on international aid to help solve some of Mozambique’s health problems and infrastructure.
3. Methodology
3.1 Research Design
The purpose of this research was to analyze the knowledge and practices surrounding mosquitoes and dengue, and the impact educational campaigns can have on this. This research took place in Maputo, Mozambique and specifically looking at the barrio, or district, Mafalala. The objective is to contribute to the knowledge about dengue in dense urban areas. The urban context is of importance, as the Aedes aegypti mosquito is known to thrive in densely populated areas. This can all be linked to the political ecological contexts of the residents in Maputo, as their environment is linked to the socio-economic and political dynamics. Through qualitative research methods such as interviews and observations it was possible to analyze the local knowledge on dengue, practices surrounding mosquitoes, and the various campaigns which have been active in Maputo.
The main research question is supported by three sub-questions, which guide the research process. The fist sub-question which will be looked at is: What types of processes have
contributed to the resurgence of dengue in Mozambique?. This question will be tackled in
Chapter 4, which looks at how the historical processes and development of citied contributed to the presence of dengue. The urbanization process in Mozambique is an important factor to look at, due to the nature of the Aedes aegypti and their ability to thrive in the urban space. The second sub-question looks at exploring What are the practices surrounding mosquitoes in
Mozambique?. This question guides Chapter 5, and uses data gathered from the various
interviews as a basis. By using data collected, supported by literature where appropriate, the understanding of the local knowledge about dengue and practices surrounding mosquitoes becomes clear. Finally, the third sub-question is: How can educational campaigns impact the
knowledge surrounding dengue in Mozambique?. This will be looked at in Chapter 6, and uses
information gathered from the respondents. Once again, this to gain a deeper understanding of the local knowledge but also the local opinions of campaigns which have been active in their neighborhood. This also allows for some recommendations to be made for future campaigns in the region. Through these sub-questions, the main research question can be answered.
The epistemological position for this research is that the knowledge is present, but needs to be discovered still, through ethnographic approaches. While the ontological position is that it is best to understand the society trough examining the collective knowledge they have and the impact that their society has on them.
3.2 Methods
3.2.1 Research Location
Mozambique is located in south east Africa, with a population of over 27 million people and a tropical to subtropical climate. It borders South Africa, Swaziland, Zimbabwe, Zambia, Malawi, Tanzania and the Indian Ocean (The CIA World Factbook, 2019). This can be seen in Figure 5, on page 23. Due to its location it is at risk of droughts, cyclones, and floods throughout the country. The current environmental issues Mozambique is challenged with is the migration to urban centers, near Maputo and Inhambane in the south, Beira and Chimoio in the central provinces, and Nampula, Cidade de Nacala and Pemba in the northern provinces (The CIA World Factbook, 2019). Additionally, Mozambique was hit by Cyclone Idai on the 14th of March 2019, followed by Cyclone Kenneth on the 24th of April, which caused
widespread devastation in the country’s central provinces (OCHA, 2019).
To gain a deeper understanding of the population of Mozambique, some data will be used to help illustrate situation of Mozambique. The ranking on the Human Development Index (HDI) it is at 0.437, indicating it is in the low human development category as of 2017. The HDI looks at three indicators, namely ‘a long and healthy life’, ‘access to knowledge’, and ‘a decent standard of living’ (UNDP, 2017). The GINI coefficient measures “the extent to which the distribution of income (or, in some cases, consumption expenditure) among individuals or households within an economy deviates from a perfectly equal distribution.…Thus a Gini index of 0 represents perfect equality, while an index of 100 implies perfect inequality” (The World Bank, 2019). Mozambique is ranked 39th in the world, with a coefficient of 45.6 as of
2008 (The CIA World Factbook, 2019). Additionally, it was predicted that in 2015 46.1% of the population lived below the poverty line, based on national estimates (The CIA World Factbook, 2019).
The population in Mozambique faces various challenges such as access to water and electricity. This can be seen as in 2013 15.7 million in habitants did not have access to electricity, and 48.9% had access to water through “unprotected dug wells; unprotected springs; cart with small tank or drum; tanker truck; surface water, which includes rivers, dams, lakes, ponds, streams, canals or irrigation channels; or bottled water” (The CIA World Factbook, 2018).
Mafalala has been identified as the research location, based on previous research which has been conducted. It can be estimated that some 21 thousand inhabitants live in Mafalala, an informal settlement next to the country’s capital (Candiracci, n.d.). Mafalala has been identified
as the research location, as Bayona (2018) stated that this research site could identify various sites in which mosquitoes can breed.
3.2.2 Data Gathering Methods
The primary data was gathered through conducting a series of interviews. As there is limited information available on dengue in Mozambique, the interviews and research also focused on other campaigns which have focused on malaria, HIV/AIDs, oral hygiene and more. In doing this, it is possible to look the methods used by other campaigns and see what has been most effective. By interviewing community leaders (neighborhood bosses), teachers, religious leaders, nurses, and other relevant community members, it was possible to identify how key actors within the community could contribute to the awareness surrounding public health campaigns. The initial question guides can be seen in the appendix (pages 64 – 66), and most of the interviews were conducted by a local research assistant who spoke Portuguese and Changana (one of the local languages). In addition to this primary data, the supporting literature has been found through extensive online research and through access to the University of Amsterdam Library. The literary sources have been selected based on the relevance to the topic.
3.2.3 Data Analysis
The interviews which have been conducted and translated have also been analyzed accordingly. By using Nvivo for coding the 13 interviews, it was possible to find the common links and themes within the different interviews. The nodes which were created were ‘access to water’, ‘actors’, ‘campaigns’, ‘cleanliness’, ‘dengue’, ‘knowledge about diseases’, ‘mosquito prevention’, ‘power relationships’, and finally ‘trash’. All these nodes had clear definitions, to ensure that the process would have a valuable outcome, with some definitions taken from dictionaries while others were self-defined. In the table below, the definitions, frequency used, and in how many different interviews the node was selected. Through using these definitions, it was possible to describe and divide the data collected into manageable sections. In doing so, the relevant data has been selected and used throughout the analysis.
Name Definition Frequency files Access to Water Availability of water and storage methods used 16 6
Actors
Any relevant actor: - community leader - NGO - Government - Etc. 10 5 Campaigns
A connected series of operations designed to bring a particular result. Bringing the knowledge and information to a desired audience
51 12
Cleanliness
“The quality or state of being clean: the practice of keeping oneself or one’s
surroundings clean” Merriam-Webster
definition
9 5
Dengue Any mention of dengue or knowledge related
to it 25 9
Knowledge about diseases
Any knowledge or lack thereof about vector borne diseases and the consequences of these disease
29 10
Mosquito prevention
Any techniques used to prevent mosquitoes from entering the home, and methods used to prevent being bitten/stung.
16 8
Power Relationships any form of power relations between classes,
rich and poor, male and female, and ethnicity. 26 6
Solid Waste
Management (Trash)
The impact trash and rubbish have on the
mosquitoes around the home and
neighborhood.
2 2
3.3 Limitations
The fieldwork was done in Maputo from February 11th till March 22nd, 2019. In this
period, interviews were conducted in the field to obtain qualitative data on urban water storage methods, knowledge surrounding mosquito borne diseases and practices surrounding dengue. Through this process there are some limitations which should be highlighted, in relation to the validity of the research process and its outcomes.
This short period for research resulted in limited data. Due to this shortened process, it was not possible to expand the field to more neighborhoods, to have a more accurate response and sample of the population. Through the testimonies given by participants in the single research location, the analysis will focus on this region and make general assumptions based on the responses given and other research which has been conducted. Overall, the time needed to process and gain legal access to the research site took over 2 weeks, which resulted in a shortened period in which the research could be conducted. As there were only 7 weeks in the field, losing these two weeks led to the research being rushed.
As Mozambique is a Portuguese speaking country, the majority of the interviews were conducted in Portuguese. A smaller number of interviews were conducted in the local language Changana. This thus meant that the interviews which were conducted were subject to translation and the meaning of the questions or answers could have been slightly altered in this process. Moreover, personally I was not the individual transcribing, but a research assistant was. This calls to question the method of transcription and how the text was translated. The transcription was not word-for-word, meaning that the research assistant edited the true nature of the interview to make sentences and phrases more coherent. In addition to this, it has been brought to my attention that all of the interviews have been translated through Google Translate. Through using Google Translate for the translating of the interviews, the interviews have sections which are inaccurate, ungrammatical, and incoherent. This led to the adaptation of the text, when referenced and quoted in the analysis, to allow for the text to be more coherent. In general, the unprofessional translation of these interviews means that meaning and data could have been lost. The problems with translation is not new in research and has always created a barrier in gathering data, “in essence, both tasks of conducting interviews and translating interview data in multilingual/multicultural settings represent complex situations, in which not only the language, but also the culture has to be translated or interpreted and dealt with” (Filep, 2009).
Within Mozambique, any research project needs to go through a rigorous ethics committee, however, due to the limited time available for this research this procedure was not followed. In turn, this impacted on research process as I was only able to have contact with acquaintances. When approaching employees at the Ministry of Health, I needed to be careful with who I was able to contact to ensure that I would not run into legal problems further down the research process. The respondents I was able to contact were through connections from my supervisor, professors at the Eduardo Mondlane University, and personal connections. This limitation proved to be extra challenging to overcome as the relations took long to establish, and thus allowed for limited interaction with the individuals.
3.4 Ethical Procedures
When starting a research project, the ethical procedures and considerations are very important to keep in mind. In the case of this research project, there were some ethical procedures which were not followed. As was stated in the limitations section, the ethical process for conducting research in Mozambique was not followed. This was only brought to my attention after being in the field for 2 weeks and was informed that this process could not be started during the time I was present. The reason for not following the national ethical process, was due to the politicized and slow process through which a research project must go through. As this information was only relayed after arriving in Mozambique, I had no other option but to continue the process without the official authorization from the local government. If this issue had been brought to my attention when planning the research project, it would have been suggested to start the process, in hopes that official authorization would be granted.
On the other hand, this set back also led to more organization with regards to the other aspects of the research. As the data collected was through interviews, the voluntary participation, informed consent, and trust was of importance. For the few interviews with locals in the research site, their participation was asked for before the interviews began. This was often through a short dialogue about the topic of the research and assurance that the recording of the interview would only be used for the research analysis. It was discussed with the local research assistant that creating written informed consent forms would not be of value, as not all individuals in the research site are literate, and thus having them sign a form would be redundant as they could not read what they are signing for. Since the information shared does not cover any topics which are controversial or can place the respondent in danger, their occupation and age was asked for during the interviews.
For the interviews conducted with the medical practitioners, there were some other ethical considerations to keep in mind. While the details about patients were not asked for, the testimony about treating patients and the knowledge of patients was asked for. It was important that the medical practitioners did not break any doctor-patient confidentiality rules, and only discussed the case in broad terms. While it was possible to obtain written consent for these interviews, it was not done as the interviews were often set up through informal connections.
In general, when conducting the interviews, there were little ethical challenges encountered during the research period. The challenges which were faced were related to participation, but since the voluntary participation was essential, any participant who did not wish to participate could choose not to or choose to stop the interview at any point.
4. History of Mozambique and the Development of Cities
4.1 History
To better understand the current state of affairs in Mozambique, it is important to briefly explore the political history of the country. The Portuguese had been passing by Mozambique and Mozambique Island from the 1500s and set up the Estado da India in 1504, to establish a permanent foothold in the Indian Ocean. Over the years, forts and local trade in gold and ivory led to Mozambique becoming a trading hub between the Portuguese, the merchants from India, the Gulf, and Arabia (Newitt, 2017). In 1891 the frontiers of modern Mozambique were drawn by Britain and Portugal, starting off the Portuguese colonial rule in Portuguese East Africa. In the later years of colonial rule, nationalism rose, eventually leading to the formation of the Frelimo, Frente de Libertação de Moçambique (the Mozambique Liberation Front) in 1962 (Newitt, 2017). This group was created by exiles, and had a Marxist nature, and began a campaign in the north of the country. This resistance was met by Portuguese military power; however, the Frelimo controlled the northern part of the colony, and made its way further south by 1974 (Boyce, 2017). Resistance against Portuguese colonial rule was also taking place in Angola and Portuguese Guinea, when a military coup in Portugal in 1974 brought new changes for the colonies. The colonies were granted independence, and a provisional government was set up for the transition to a successful independence, of Portuguese and Frelimo members, and Portuguese East Africa (which was renamed Mozambique in July 1975) (Newitt, 2017) (Boyce, 2017). In this transition period, there was a deep distrust between the Frelimo and the Portuguese people and the Frelimo did not want to “have their hands tied” to any possible developments regarding the newly independent country and possible consequences the early decisions could have (Newitt, 2017, p. 153).
After the constitution was established and a leader, Samora Machel, was chosen, the Marxist nature of the party became evident, leading to the rapid departure of many Portuguese settlers (Boyce, 2017). In 1979, an economic plan was introduced with the aim to modernize the country. This modernization plan focused on industrializing the country and the creation of state farms, followed by the construction of communal co-operative villages, and finally the development of village agriculture. In addition to these policies, literacy campaigns and primary health care were introduced to limit small-pox and other transmittable diseases (Newitt, 2017). However, the Frelimo faced opposition and hostility from the regimes in South Africa and Rhodesia, as Mozambique hosted exiles from the Patriotic Front (Zambia),
