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Social Sciences Master Dissertations

2017

The contribution of socio-cultural

practices to the outbreak of cholera in

Tanzania: A case study of Ukerewe district

Massawe, Ester G.

The University of Dodoma

Massawe, E. G. (2017). The contribution of socio-cultural practices to the outbreak of cholera in

Tanzania: A case study of Ukerewe district. Dodoma: The University of Dodoma

http://hdl.handle.net/20.500.12661/768

Downloaded from UDOM Institutional Repository at The University of Dodoma, an open access institutional repository.

THE CONTRIBUTION OF SOCIO-CULTURAL PRACTICES TO

THE OUTBREAK OF CHOLERA IN TANZANIA:

A CASE STUDY OF UKEREWE DISTRICT

ESTER G. MASSAWE

MASTER OF ARTS IN SOCIOLOGY

THE UNIVERSITY OF DODOMA

JULY, 2017

THE CONTRIBUTION OF SOCIO-CULTURAL PRACTICES TO

THE OUTBREAK OF CHOLERA IN TANZANIA:

A CASE STUDY OF UKEREWE DISTRICT

By

Ester G. Massawe

A Dissertation Submitted in Partial Fulfilment of the Requirements for the Degree of

Master of Arts in Sociology of the University of Dodoma

The University of Dodoma

July, 2017

i

CERTIFICATION

The undersigned certifies that he has read and hereby recommends for acceptance by the

University of Dodoma a Dissertation entitled: “The Contribution of Socio-Cultural

Practices to the Outbreak of Cholera in Tanzania: A Case Study of Ukerewe District” in

partial fulfilment of the requirements for the Degree of Master of Arts in Sociology of the

University of Dodoma.

…………………

Dr. I. Kombo

(SUPERVISOR)

Date………… …..

ii

DECLARATION

AND

COPYRIGHT

I, Ester G. Massawe declare that this dissertation is my own original work and that it has

not been presented and will not be presented to any other university for a similar or any

other degree award.

Signature………………………….

No part of this dissertation may be reproduced, stored in any retrieval system, or

transmitted in any form or by any means without prior written permission of the author or

the University of Dodoma.

iii

ACKNOWLEDGEMENTS

To begin with, I would like to thank God, for his power, strength, and protection he has

given me, especially during the time of writing this dissertation.

Also, I express my sincere gratitude to my supervisor, Dr. I. Kombo, who has been

generous in giving feedback and intelligent insights in a very friendly manner. I am very

much touched by his patience and compassion which he exercised tirelessly from day one

until the end of my Master's journey. Without his contributions, this study could have not

been successfully accomplished. I would also like to thank my colleagues in Master of

Arts in Sociology Programme of 2015/2017, my fellow Master's students of different

Programs and all other people who have played a role in this study.

Furthermore, I wish to acknowledge all my lecturers from the College of Humanities and

Social Sciences at the University of Dodoma for their academic support and cemented

foundation of this work. I would also like to appreciate my Head of Department of

Sociology and Anthropology, Dr. N. Ishengoma and all members of the Department for

their encouragement, assistance and contribution in materials for this report. May the

Almighty God bless you all.

Above all, I am honestly thankful to my beloved daughter, Caroline for her tolerance and

prayers to the successful completion of my study. Special thanks are also extended to my

parents and my young brother Alex, for their prayers, moral support, encouragement, and

cooperation during my studies.

In addition, I would like to extend my special thanks to my research assistants, Belina

Seleman and Sophia Minja for enhancing data collection activities. Thanks are also due to

all research participants for their willingness in providing relevant information with a

maximum cooperation which helped me to complete this study.

iv

Last but not least, I would like to show appreciation to the District Health Officer, Health

Workers, Government Officers at Ilangala ward and all community members of Ilangala

ward for their contribution in the accomplishment of this study.

v

DEDICATION

This dissertation is dedicated to my beloved parents Mr. and Mrs. Boniphace O. Ungando

for their supports since I was young up to this stage. May the grace of God be upon you

and have a long life.

vi

ABSTRACT

This study aimed at exploring the contribution of socio-cultural practices to the outbreak

of Cholera. The study involved three villages of Kaseni, Galu, and Kamasi in Ilangala

ward within Ukerewe District. Data were collected through social survey, in-depth

interview, focus group discussion and documentary review. Both purposeful and simple

random sampling procedures were used for sample selection. About 119 respondents were

involved in this study. Statistical Package for Social Science (SPSS version 20) and

Microsoft Excel were applied to analyze the data and then presented through tables,

figures, plates, and texts. The research divulged that the objective of this study was to

exploring the contribution of socio- cultural factors practices to the Outbreak of Cholera.

The specific objectives of this study were to identify socio-cultural practices that

contribute to the outbreak of Cholera. The second was to examine awareness of hygiene

and sanitation and its contribution to Cholera outbreak, and the last one, is to identify the

ways of preventing Cholera outbreak.

The findings revealed that the main cause of the cholera outbreak in Ukerewe was

undergoing defecation out of toilets, not washing hands after visiting latrine, drinking

unboiled water, eating uncovered and cold food, poor hygiene, and sanitation including

the absence of the pit latrines. Find also revealed ways of preventing cholera outbreak

including thorough provision of education is highly encouraged, improving existing

physical infrastructure, enforcement of laws on hygiene and sanitation to curb the situation

and to end the cholera history in Ukerewe. Hence the study suggested that intersectoral

collaborations among institutions, like Government Ministries, departments, and NGOs on

preventing and controlling the outbreak of cholera are essential.

vii

TABLE OF CONTENTS

CERTIFICATION ................................................................................................................ i

DECLARATION AND COPYRIGHT ...............................................................................ii

ACKNOWLEDGEMENTS ............................................................................................... iii

DEDICATION ..................................................................................................................... v

ABSTRACT ........................................................................................................................ vi

TABLE OF CONTENTS ...................................................................................................vii

LIST OF TABLES .............................................................................................................xii

LIST OF FIGURES ......................................................................................................... xiii

LIST OF PLATES ............................................................................................................ xiv

LIST OF ABREVIATIONS AND ACRONYMS ............................................................. xv

CHAPTER ONE ................................................................................................................ 1

INTRODUCTION AND BACKGROUND TO THE STUDY ........................................... 1

1.1 Introduction .................................................................................................................... 1

1.2 Background to the Study ................................................................................................ 2

1.3 Statement of the Problem ............................................................................................... 5

1.4 Research Objectives ....................................................................................................... 6

1.4.1 General Objectives ...................................................................................................... 6

1.4.2 Specific Objectives ..................................................................................................... 6

1.5 Research Questions ..................................................................................................... 6

1.6 Significance of the Study ............................................................................................... 7

1.7 Conclusion ..................................................................................................................... 7

CHAPTER TWO ............................................................................................................... 8

LITERATURE REVIEW .................................................................................................... 8

2.1 Introduction .................................................................................................................... 8

2.2 Definition of Key Terms ................................................................................................ 8

2.2.1 Socio-Cultural Practices .............................................................................................. 8

2.2.2 Concept of Cholera ..................................................................................................... 8

2.3 Theoretical Literature Review ....................................................................................... 9

2.3.1 The Social Construction of Reality ............................................................................. 9

2.3.2 Structural Functionalism Theory .............................................................................. 10

viii

2.4 Empirical Literature Reviews ................................................................................... 11

2.4.1 Outbreak of Cholera in Latin America ..................................................................... 11

2.4.2 The State of Cholera in Bolivia and Peru ................................................................. 12

2.4.3 Situation of Cholera Outbreak in Brazil ................................................................... 12

2.4.4 Outbreak of Cholera in Asia ..................................................................................... 13

2.4.4.1 State of Cholera Outbreak in Pakistan ................................................................... 13

2.4.4.2 State of Cholera Outbreak in India ........................................................................ 13

2.4.4.3 State of Cholera Outbreak in Haiti ......................................................................... 14

2.4.5 Outbreak of Cholera in Sub-Saharan Africa ............................................................. 14

2.4.5.1 Cholera Outbreak in Guinea-Bissau ...................................................................... 15

2.4.5.2 Congo (DRC) Cholera Outbreak Situation ............................................................ 16

2.4.5.3 Cholera Outbreak in Burkina Faso ......................................................................... 16

2.4.5.4 Cholera Outbreak in Papua New Guinea ............................................................... 16

2.4.5.5 Cholera Outbreak in Tanzania ............................................................................... 17

2.5 Identification of Knowledge Gap ................................................................................. 18

2.6 Conceptual Framework ................................................................................................ 19

2.7 Conclusion ................................................................................................................... 20

CHAPTER THREE ......................................................................................................... 21

RESEARCH METHODOLOGY ....................................................................................... 21

3.1 Introduction .................................................................................................................. 21

3.2 Research Design ........................................................................................................... 21

3.3 Research Approach ...................................................................................................... 21

3.4 Description of the Study Area ...................................................................................... 22

3.4.1 Selection of the Study Area ...................................................................................... 22

3.4.2 Location of the Study Area ....................................................................................... 23

3.4.3 Climate ...................................................................................................................... 24

3.4.4 Economic Activities .................................................................................................. 25

3.5 Target Population ......................................................................................................... 25

3.5.1 Study Population ....................................................................................................... 25

3.6 Sampling Techniques and Sample Size ....................................................................... 25

3.6.1 Sampling Procedures ................................................................................................. 26

3.6.2 Sampling Frame ........................................................................................................ 26

3.6.3 Sampling Size ........................................................................................................... 26

ix

3.6.4 Size Distribution ....................................................................................................... 27

3.7 Types of Data ............................................................................................................... 28

3.7.1 Primary Data ............................................................................................................. 28

3.7.2 Secondary Data ......................................................................................................... 28

3.8 Methods of Data Collection ......................................................................................... 29

3.8.1 Social Survey ............................................................................................................ 29

3.8.2 In-depth Interview ..................................................................................................... 30

3.8.3 Focus Group Discussion ........................................................................................... 30

3.8.4 Documentary Review ................................................................................................ 31

3.9 Data Analysis Procedures ............................................................................................ 31

3.10 Reliability and validity ............................................................................................... 31

3.10.1 Validity .................................................................................................................... 31

3.10.2 Reliability ................................................................................................................ 32

3.11 Ethical Consideration ................................................................................................. 32

3.12 Conclusion ................................................................................................................. 33

CHAPTER FOUR ............................................................................................................ 34

DATA PRESENTATION, ANALYSIS AND DISCUSSION OF THE FINDINGS ....... 34

4.0 Introduction .................................................................................................................. 34

4.1 Demographic Information of Respondents .................................................................. 34

4.1.1 Respondents‟ Villages ............................................................................................... 35

4.1.2 Sex of the Respondents ............................................................................................. 36

4.1.3 The Age of Respondents ........................................................................................... 37

4.1.4 The Occupation of the Respondents ......................................................................... 38

4.1.5 Respondents‟ Education Level .................................................................................. 39

4.2 Socio-Cultural Practices that Contributing to the Outbreak of Cholera ...................... 40

4.2.1 Socio- Cultural Norms towards Outbreak of Cholera ............................................... 40

4.2.2 Beliefs towards Cholera Outbreak ............................................................................ 42

4.2.3 Causes of Cholera outbreak ...................................................................................... 44

4.2.4 Cholera Patients‟ Caring ........................................................................................... 46

4.2.5 Place and Burying of the Deceased Person from Cholera ........................................ 47

4.2.5.1 Burial Place of the Deceased Person from Cholera ............................................... 47

4.2.5.2 Burial Ceremony and Peoples‟ Involvement ......................................................... 48

x

4.3 Awareness of Hygiene and Sanitation and its Contribution to the Cholera Outbreak

49

4.3.1 Activities Resulting in Cholera Outbreak ................................................................. 50

4.3.2 Latrine and its Cleanliness at the Study Area ........................................................... 51

4.3.2.1 Latrine in the Study Area ....................................................................................... 51

4.3.2.2 Types of Latrines in the Study Area ...................................................................... 53

4.3.2.3 Latrine Cleanliness Timetable ............................................................................... 55

4.3.2.4 Covering Latrine with a Lead/ Stopper .................................................................. 57

4.3.2.5 Washing Hands with Soap after Visiting the Latrine ............................................ 59

4.3.3 Source of Water ........................................................................................................ 61

4.3.4 The Places of Getting Foods ..................................................................................... 62

4.3.5 Boiling Water for Drinking ....................................................................................... 64

4.4 Ways of Preventing Cholera Outbreak in Ukerewe ..................................................... 65

4.4.1 Community‟s Perceptions towards being Free from Cholera ................................... 66

4.4.2 Educating the Community on Outbreak of Cholera .................................................. 67

4.4.3 Improving the Existing Physical Infrastructure ........................................................ 68

4.4.4 Enforcement of Laws on Hygiene and Sanitation .................................................... 70

4.4.5 The Motivation of Workers ....................................................................................... 72

4.4.6 Conclusion ................................................................................................................ 74

CHAPTER FIVE .............................................................................................................. 75

SUMMARY, CONCLUSION AND RECOMMENDATIONS OF THE STUDY ........... 75

5.1 Introduction .................................................................................................................. 75

5.2 Summary of the Findings ............................................................................................. 75

5.2.1 The Socio-cultural Practices for Cholera Outbreak ................................................. 75

5.2.2 Awareness of Hygiene and Sanitation ...................................................................... 76

5.2.3 Ways of Preventing the Outbreak of Cholera ........................................................... 77

5.3 Conclusion ................................................................................................................... 78

5.4 Recommendations of the Study ................................................................................... 78

5.4.1 Recommendations to the Government and Institutions ............................................ 78

5.4.2 Recommendations to the Community level .............................................................. 79

5.4.3 Recommendations to the Health Workers ................................................................ 79

5.4.4 Recommendations to the NGO‟s .............................................................................. 80

5.5 Areas for further research ............................................................................................ 80

xi

REFERENCES ................................................................................................................... 81

APPENDICES ................................................................................................................... 89

xii

LIST OF TABLES

Table 3. 1: Cholera Outbreak in Mwanza Region- 2015/2016 .......................................... 23

Table 3. 2: Number of Households .................................................................................... 27

Table 4. 1: Gender of the Respondents .............................................................................. 36

Table 4. 2: Socio-Cultural Norms towards the Outbreak of Cholera ................................. 41

Table 4. 3: Causes of cholera outbreak .............................................................................. 45

Table 4. 4: Caring Cholera Patient ..................................................................................... 46

Table 4. 5: People Involved in the funeral of Deceased Person From Cholera ................. 48

Table 4. 6: Activities Resulting to Cholera Outbreak ........................................................ 50

Table 4. 7: Respondents‟ Perceptions Towards Free From Cholera .................................. 66

xiii

LIST OF FIGURES

Figure 2. 1: Conceptual Framework .................................................................................. 20

Figure 3. 1: Location of the Study Area ............................................................................. 24

Figure 4. 1: The Respondents‟ Village .............................................................................. 35

Figure 4. 2: The Age of Respondents ................................................................................ 37

Figure 4. 3: The Occupation of the Respondents ............................................................... 38

Figure 4. 4: Education Level .............................................................................................. 39

Figure 4. 5: Beliefs towards Cholera Outbreak .................................................................. 43

Figure 4. 6: Respondents‟ View on Burial Place for the Deceased Person ....................... 47

Figure 4. 7: Latrine in the Study Area ............................................................................... 52

Figure 4. 8: Kinds of a Latrine in the Study Area .............................................................. 54

Figure 4. 9: Latrine Cleanliness Timetable ........................................................................ 56

Figure 4. 10: Responses on Covering Latrines .................................................................. 58

Figure 4. 11: Washing Hands after Visiting the Latrines .................................................. 60

Figure 4. 12: Source of Water for the Domestic Purpose ................................................. 61

Figure 4. 13: Boiling Water for Drinking .......................................................................... 64

Figure 4. 14: Awareness through Education ...................................................................... 67

Figure 4. 15: Enforcement of the Laws on Hygiene and Sanitation .................................. 71

Figure 4. 16: The Motivation of Worker on Cholera Outbreak ......................................... 73

xiv

LIST OF PLATES

Plate 4. 1: Poor Latrine Found at Kamasi Village ............................................................. 52

Plate 4. 2: Kinds of Latrines in the Study Area ................................................................. 55

Plate 4. 3: Traditional Latrines, Wooded Floor and Grass Thatched Walls ...................... 57

Plate 4. 4: Covering of Latrines ......................................................................................... 59

xv

LIST OF ABREVIATIONS AND ACRONYMS

CBOs Community Based Organizations

CCHP Council Comprehensive Health Plan

CDC Centre for Disease Control

CFR Case Fatality Rate

CTC Cholera Treatment Center

DEWS Disease Early Warning System

DHO District Health Officer

DNO District Nurse Officer

DRC Democratic Republic of Congo

EPOA Emergency Plan of Action

FGD Focus Group Discussion

MOH Ministry of Health

NGOs Non-Governmental Organizations

SPSS Statistical Package for Social Sciences

UDC Ukerewe District Council

UN United Nations

UNICEF United Nations Children‟s Fund

URT United Republic of Tanzania

WHO World Health Organization

1

CHAPTER ONE

INTRODUCTION AND BACKGROUND TO THE STUDY

1.1 Introduction

This chapter provides background information about the contribution of socio-cultural

practices to the outbreak of cholera in Ukerewe District. It focuses on the measures and

interventions of the plight of this epidemic disease. Besides that, this chapter scans the

global picture of the prevailing situation, that is, the cholera outbreak in different countries

and the strategies in place, to address the phenomenon.

Cholera is an infectious disease that causes severe watery diarrhea which can lead to

dehydration and even death if untreated (Cook-Gordon, 2009). According to Center for

Disease Control (2014), Cholera is an acute diarrheal illness caused by infection of the

intestine with the bacterium Vibrio-Cholerae. The disease is transmitted through ingestion

of food or water substances contaminated with a bacterium, and it is closely associated

with poor sanitation and overcrowding. Tanzania like any other developing countries faces

a number of developmental challenges. Among such challenges, disease stands out as the

major problem. Other challenges include inadequate access to safe and clean water,

hygiene, sanitation and sewage systems, which have contributed to the prevalence of the

waterborne infections, including cholera (Kandachar et al., 2011)

According to the United Nations (2005), about 1.1 billion people lack access to improved

water sources, which has resulted in 1.8 million deaths as a result of water-borne related

diseases. Again, about 2.8 million cases of cholera occur annually worldwide, the

incidence being 2 cases per 1000 people at risk (Kosek, 2003).To date, the world is

experiencing several large outbreaks of the disease, specifically in developing countries.

This preliminary chapter provides the background information to the outbreak of cholera.

2

The chapter thus, presents a statement of the problem, research objectives, research

questions and winds up with the significance of the study.

1.2 Background to the Study

In the industrialized countries such as Europe, North America, and the Western Pacific,

cholera is largely eliminated as a result of improved water and sewage treatment

infrastructure as well as improved housing conditions which have limited the survival of

cholera causative agents (Prüss-Üstün and Corvalán, 2006).

Countries in Southern Asia and sub-Saharan Africa have the highest incidences of

contracting the disease which kills approximately 91,000 people annually. The mortality

rate varies from 0.1% in developed countries compared to 15.2% in developing countries

(CDC, 2014). Many people still die of the disease notably in Sub-Saharan Africa and

Hispaniola, clearly showing that cholera remains a significant public health problem

(WHO, 2015).

Again, Prüss-Üstün and Corvalán, (2006) have asserted that Water-related diarrheal

diseases, including cholera, are widespread in areas where water resources are scarce and

the majority of diarrheal diseases can be attributed to environmental factors such as unsafe

drinking water, poor hygiene and lack of sanitation. In other studies such as Mpazi and

Kagoma, (2005), Traerup et al., (2010), it is said that the spread of cholera has been

related to floods caused by heavy monsoons which then contaminate drinking water with

the bacterium. In droughts, the bacterium can grow more easily in stagnating water in

ponds and rivers. Cholera has been found to vary with climate fluctuations over long time

periods (Pascual, 2002)

3

Singh (2001) noted that cholera is associated temperatures and rainfall anomalies with

diarrhea and cholera, and these stress the role of climate variability in transmission of

diarrheal diseases.

While Kosek, (2003) have associated cholera with the prevailing poverty, which is a

phenomenon common in all developing countries. In these countries, cholera has remained

to be a significant health and economic burden both to the government and the

households. For example, Peru experienced cholera outbreak in 1990. Cholera was spread

throughout the Latin America in 1991(Nicki, 2010). Other countries in which cholera has

been endemic include India, Pakistan, Bangladesh, Afghanistan, South East Asia, Middle

East and South America as it is localized. Also, cholera has been endemic in Gulf Coast

such as Florida, Alabama, Mississippi and Louisiana of the USA, all of which are

developing countries (Kotloff et al., 2013).

Elsewhere, in Haiti, the prevalence of cholera is associated with the poverty of the

country, which has resulted in the inadequate supply of clean and safe water, inadequate

housing and unsanitary conditions (WHO, 2011). Cholera outbreaks were intensified in

January, 2010 in Haiti as a result of the earthquake, which destroyed the few existing

infrastructure. With repeatedly occurring of hurricanes and earthquakes, cholera remains

endemic in the country, where only a quarter of the population is said to have access to

decent toilets and safe water (UNICEF, 2016).

In Sub-Saharan Africa, cholera has become endemic since 1970 and remains a recurring

cause of large, deadly, multinational epidemics in West, Central, and East Africa (Griffith

et al., 2006). In 2012, twenty-five (25) African nations reported a total of 94,553 cholera

cases, with large epidemics in the Democratic Republic of Congo, Sierra Leone, Ghana,

Guinea, Uganda, and Niger (WHO, 2013). However, the sub-Saharan Africa takes lead in

4

cholera outbreaks due to a large number of people who lack improved water sources

(61%) and covered with poor sanitary services (UNICEF, 2012).

Similarly, East African countries have experienced outbreaks of cholera in various areas,

such as Kenya since 26, December 2014, in Nairobi. Recently, cholera cases (893 cases)

have been reported in Mandera (EPoA, 2016). In Uganda, outbreaks are reported in

Kayunga District (21 cases with 8 deaths), and in Sironko District (70 cases with 7 deaths)

and this is due to heavy rainfall experienced in the areas (WHO, 2016).

In most cases, cultural factors such as gender inequality, myths, beliefs, taboos, and

attitudes are all known to be closely associated with the outbreak and spread of cholera in

various localities (WHO, 2002). The greatest burden of health risks is borne by the poor

populations in poor countries, and by the disadvantaged in all societies with little

education, and with low-status occupations but strictly abiding by their cultural life.

Therefore, people‟s cultural practices reflect the pattern of diseases and the ways in which

they respond to the situations (Lubos et al., 2013).

In Tanzania, cholera remains endemic both in rural and urban areas. Cholera cases are

repeatedly reported to hit most of the regions of the country, with nine of the regions being

dominant in reporting the outbreaks. The regions include Dar es Salaam, Dodoma,

Kigoma, Lindi, Mbeya, Morogoro, Mtwara, Pwani, and Tanga (WHO, 2008). Recent

reports indicate that there has been an ongoing outbreak of cholera in Morogoro, Dar es

Salaam, Tanga, Arusha, Singida, Mwanza and Zanzibar, which informs that much is to be

done to combat the outbreaks. For example, as of 20th

April 2016, a total of 25,276 cases

including 390 deaths had been reported national wide. Tanzania mainland alone, reporting

20,961 cases with 329 deaths and the remaining deaths and cases are from Zanzibar (URT,

2016).

5

1.3 Statement of the Problem

Cholera is a public health problem and epidemic in Tanzania (Hounmanou et al., 2016).

The cholera outbreaks have been responding adequately: Cumulatively, 8,185 cholera

cases (both Mainland and Zanzibar) and 116 deaths have been recorded (as of November

9, 2015). Over 50% of the cases were reported from Dar es Salaam and Mwanza (URT,

2015). Recently, (as for 20th April 2016) a total of 25,176 cases, including 390 deaths had

been reported from 23 regions (URT, 2016). Out of all cases, Ukerewe District recorded

988 cases including 18 deaths, constituting to 4.6% of all deaths in the country (Wang et

al., 2016)

Cholera outbreak is said to be contributed by several factors including contaminated water

and food substances, areas surrounded by water bodies like lakes, ponds, and swampy are

risk areas for cholera (WHO, 2008). The WHO (2016) argues that the spread of cholera

was due to a limited access to safe water and sanitation, low coverage to improved

latrines, myths and misconceptions on hygienic practices.

There were efforts taken by the government through different institutions, NGOs,

International organization like WHO, UNICEF, to fight against cholera outbreak including

the establishment of the Multisectoral National Cholera Task Force which provides

oversight and coordination responding to the outbreak (WHO, 2016). Despite the

collaborative initiatives in controlling and eradicating cholera, the epidemic is still

persisting in various parts of Tanzania including Ukerewe.

Different studies have been done on cholera outbreak such as a study by WHO (2008)

which focused on causes of cholera outbreak, WHO (2016) on effective means of

combating cholera, Figueroa et al.,(2010) on cultural practices, Mpanzi and Kagoma,

(2005) on hygienic practices, and lastly a study by Traerup et al., (2010) which focused on

6

climate change. From the above studies, there is partial documentation of the findings on

socio-cultural practices to the outbreak of cholera.

Therefore, from these studies, little is documented on socio-cultural practices in relation

to the outbreak of cholera. Limited application of social theories is another gap, which cast

a shadow on the cultural aspects of life. Differently from (WHO 2002) where cultural

zone were mentioned but it relay only on cultural factors that associated to the outbreak of

cholera, rather than socio-cultural practices that contribute to the disease. This research,

therefore, was set to fill the aforesaid knowledge gap. That is, this study aimed at

exploring the contribution of socio-cultural practices to the outbreak and spread of cholera

in Ukerewe District in Tanzania.

1.4 Research Objectives

1.4.1 General Objectives

The objective of this study was to explore the contribution of socio-cultural practices to

the outbreak of cholera.

1.4.2 Specific Objectives

i) To identify socio-cultural factors that contribute to the outbreak of Cholera.

ii) To examine the awareness of hygiene and sanitation and its contribution to

cholera outbreak.

iii) To identify the ways of preventing cholera outbreak.

1.5 Research Questions

i) How do social-cultural practices contribute to the outbreak of cholera in

Ukerewe District?

ii) To what extent is the awareness of hygiene and sanitation a factor toward the

outbreak of Cholera in Ukerewe District?

7

iii) How can cholera outbreak be prevented in Ukerewe District?

1.6 Significance of the Study

This is a community-based study, which aimed at obtaining information from the society

and the health practitioners. The information obtained from this study could contribute to

the knowledge on the socio-cultural practices and the outbreak of cholera in Ukerewe

District, Tanzania, and Worldwide. Again, the knowledge obtained could help policy,

decision makers and other partners to plan and design appropriate and effective

interventions that will trigger efforts towards eradicating the epidemic to the vulnerable

population in Ukerewe District and Tanzania at large. Moreover, the study findings may

be applicable for academic purposes and grounds for establishing further investigation on

the phenomenon under study.

1.7 Conclusion

In summary, this chapter has put the study problem in context. It has also outlined the

background to the study from global to local contexts, highlighting the policy-practice

dimensions to the contribution of socio-cultural practices to the outbreak of cholera.

Besides, the chapter has scanned the global picture of the prevailing situation that is the

cholera outbreak in different countries and the strategies in place, to address the

phenomenon. The chapter further has stated the problem and rationale for the study, and

then it has outlined the significance of the study. The next chapter (Chapter Two) focuses

on reviewing the relevant literatures about cholera cases.

8

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This chapter presents an overview of literature related to socio-cultural practices and the

outbreak of cholera. The chapter starts with the definition of key terms, theoretical and

empirical review related to the outbreak and spread of cholera. The chapter also presents a

theory which guides the inquiry, identification of knowledge gaps and conceptual

framework and winds up with chapter conclusion.

2.2 Definition of Key Terms

2.2.1 Socio-Cultural Practices

The term „socio-cultural practices‟ refers to a combination of material artifacts and non-

material formations that guide human behavior, whose reflection is contained within

human consciousness (Berger and Luckmann 1967). The products manifest subjective

meanings or intentionally of those who produced them. Culture encompasses beliefs,

attitudes, perceptions, norms (rules), customs, traditions, values, ideologies, and religions

that govern people‟s ways of life.

2.2.2 Concept of Cholera

Cholera represents the archetypal disease in the context of small-intestinal secretory

(watery) diarrhea. Cholera is caused by eating or drinking substances contaminated with

bacteria called Vibrio cholerae, a comma-shaped bacteria which is not invasive and exerts

its effects by means of an enterotoxin. If untreated, the disease results in about 20% - 80%

mortality. The cholera outbreak is mainly appearing in the area associated with poverty,

overcrowding and low socioeconomic status (Cook-Gordon, 2009).

9

2.3 Theoretical Literature Review

The study was guided by two theories namely, the Social Construction of Reality theory

and the Structural Functionalism Theory.

2.3.1 The Social Construction of Reality

The Social Construction of Reality theory asserts that reality is socially constructed

(Berger, and Luckmann, 1967). The theory seeks to explain knowledge creation processes

through which reality on a particular phenomenon is created through social interactions

and socialization process. From this assumption, the validity of the constructed reality

needs a contextual understanding from which the meaning of peoples‟ actions influences

their attitudes and practices. Hence, people‟s decision to act on a phenomenon is guided

by the reflection of the existing social realities. In this study, therefore, this theory was

valuable because it addresses issues regarding knowledge creation process, the creation of

reality through social interactions and socialization which are key functions of socio-

cultural practices.

It can be regarded that socio-cultural practices are the ones that guide lifestyle of the

people in a society but may contribute to the outbreak of cholera. Health is as well socially

constructed through socialization, the definition of health, disease and even treatment.

Thus this theory held strength to be used in this study.

According to Ritzer (1999), the constructed and shared meanings are internalized by

individuals to consolidate it as the social reality. As for Durkheim (1961), the human

being is viewed as products of society, shaped by the shared norms and values, whereas

societies are human products and human beings are social products, who create meanings

and reality through the socialization process. As for Furst et al. (1996), the reasons for

acting in a certain manner are socially constructed. As far as this study is concerned,

10

internalized meanings derived from norms, values, and perceptions that govern the

interaction of the people were important in trying to understand the disease itself,

transmission mode and even carrying of the patient. It was therefore important to examine

how these factors can be associated with the spread of cholera.

Although the theory gives a clear stipulation of how reality is constructed, it does not

pinpoint the contribution of institutions in the society in both reality construction and

equilibrium maintenance. Therefore in order to accomplish this theory, the structural

functionalism theory was also employed in this study.

2.3.2 Structural Functionalism Theory

Structural functionalism theory has its origin from the English philosopher, Herbert

Spencer‟s conceptualization of a social organism in the 1850s (Longhofer and Winchester,

2016). The theory describes society as a complex system whose parts work together to

promote solidarity and stability. It asserts that human life is guided by social structures,

with relatively stable patterns of social behaviour (Longhofer and Winchester, 2016).

According to Zuberi (2015), actors continually act to adjust their behaviour to reflect the

existing social structures. In this light, sociological explanation of complex phenomenon

like cholera in the society needs socialization in order to understand people's life, since

individuals live in a pre-structured world (Andrews and Ritzer, 2007). Thus, structural

functionalism theory is suitable for providing a sociological explanation for a social

phenomenon in the society with complex structures and social relations as it is in Ukerewe

District (Ritzer, 1999).

This theory was thought to be important in this study because it shows the way different

institutions in the society work together in order to maintain stability and equilibrium of

the society. Among these institutions are education, family, and cultural practices. If all

11

these institutions collaborate and work together, the society will be free from cholera.

Nevertheless, if one of the institutions fails to work properly, it affects other institutions

hence leading to an outbreak of cholera within the community. In this study it was thought

that socio-cultural practice as one of the institutions does not work properly, that‟s why

the study was trying to examine its contribution to the outbreak of cholera in Ukerewe

District.

2.4 Empirical Literature Reviews

2.4.1 Outbreak of Cholera in Latin America

Cholera outbreak has been occurring in the societies as the result of insufficient safe and

clean water, inadequate hygiene and sanitation ranging from improper waste disposal,

food handling, processing, and preservation, poor housing, improper and inadequate

sewerage systems (Pascual 2002; Mpazi and Kagoma, 2005; Prüss-Üstün and Corvalán,

2006; WHO, 2009). However, cholera infection has been perceived differently across the

societies and nations, where, a person‟s perceived risk of contracting an illness and the

severity of its consequences are likely to trigger healthy practices (Becker, 1981).

In Latin America, certain cultural practices encourage people to leave food that had been

cooked permanently open, especially during funerals and pilgrimages to religious

sanctuaries (Kumate et al., 1998). Again, water for domestic use is preserved in

containers that promote contamination, making the risk of contracting cholera by drinking

stored water 2 to 3 times higher than by drinking water from streams or rivers. This

practice provides room for contamination as flies will settle on the food and increase the

risk of infection if such food is eaten (Wasonga, et al., 2014)

12

2.4.2 The State of Cholera in Bolivia and Peru

According to Balderston et al., (2002) the Andean Indians prefer using the coca leaf

despite its great chance of causing lung cancer. Culturally, coca leaf is used as a medium

of exchange as well as a means of communicating with the supernatural world as well as a

bonding mechanism for the promotion of kinship ties and cultural royalties. Even though

the leaf affects the health of the Andean Indians, it is continuously used for cultural

purposes. Moreover, Rogers (1995) explains the outbreak of diarrhea among the Peruvian

villagers, and he argued that boiling water was associated with caring for the sick person

or a symbol that there is someone sick in the household. So, the community members were

not allowed to boil water by their customs, boiling of water was a taboo. Any community

member attempting to boil water was violating the taboo, regarded as deviant and

subjected to sanctions such as isolation. Thus, any intervention introduced in the area

failed to combat diarrhea diseases as a result of cultural practices of the local communities

(Figueroa and Kincaid, 2010).

2.4.3 Situation of Cholera Outbreak in Brazil

In Brazil, the dominant belief was in water treatment whereby it was conceived as

unnecessary practice and that it was associated with the intoxication of drinking water

(Quick et al., 1996). With such a misconception, water treatment for prevention of

diarrheal diseases could not be effective, hence, a frequent outbreak of epidemics.

Moreover, Ritter and Tondo, (2014) added that the boiling of water as an alternative to the

use of chlorine was not practiced because it is expensive and time-consuming.

Although access to safe water and sanitation in Brazil has made important advances in the

last decades, gastrointestinal infections remain a public health concern in Brazil from 2000

to 2013. The Brazilian Ministry of Health reported an average of 665 foodborne outbreaks

13

per year (Brazilian MOH 2014). According to Marcynuk et al (2013) due to the effort

made by the government from the last nine years, Brazil has reported non-imported cases.

2.4.4 Outbreak of Cholera in Asia

2.4.4.1 State of Cholera Outbreak in Pakistan

Nielsen et al. (2003) narrated that in Pakistan, water-borne infections have been recurring

in the local communities as a result of people‟s attitudes towards hygiene practices. For

example, in Punjab area of Pakistan, hygiene practices were related to the wife‟s

perception of her “social status” rather than a measure to prevent diseases. Floods in

Pakistan have affected millions of people and greatly increased the risk of diseases

outbreak. The operations guidance was developed in order to strengthen surveillance using

the Disease Early Warning System (DEWS) and allow a coordinated approach to disease

outbreak preparedness and response in the floods affected the population. The DEWS

system has been functioning in Pakistan since 2005 (Rahim et al.,2010)

Pakistan is a developing country, currently facing the double burden of disease with

infectious diseases contributing to 26% of the total disease burden. The outbreak of

cholera is attributed to poor environment and sanitation condition and consumption of

contaminated water and food due to natural calamities which have displaced a large

population. These have become a major cause of morbidity and mortality in Pakistan

(Noor et al., 2010, WHO 2011).

2.4.4.2 State of Cholera Outbreak in India

Naveen et al., (2012) argued that the Indian tradition, do not allow people of the scheduled

caste hamlet to collect water from the other hamlet even in the case of a crisis such as

cholera outbreak. Scheduled Caste community believed that the outbreak was due to the

wrath of the goddess, and a sacrificial goat was offered to appease her. This suggests that

14

these social factors are obstacles in prevention and control of communicable diseases.

Poor sanitation and poor personal hygiene were not regarded as determining factors for the

outbreak.

2.4.4.3 State of Cholera Outbreak in Haiti

In Haiti, during a cholera outbreak in 2010 following the powerful earthquake which

devastated the country, people believed that cholera was brought by foreigners in order to

use or to harm their citizens (HRC, 2010). Some people believed that cholera was a

deliberate infection spread through a magic „cholera powder‟ ("kolera poud") prepared by

Voodoo priests and transmitted by Voodoo worshippers. Such believes made the natives

to be reluctant with the real causes of cholera, making it persistent.

After the earthquake in Haiti 2010, International Medical Corps made more effort on

combating the outbreak by progressing out a network of cholera treatment centers (CTCs)

and mobile medical units in Haiti‟s villages and affected areas. Furthermore, International

Medical Corps made the Ministry of Health (MoH) together with local doctors, nurses and

community health workers central to its cholera reaction and be a part of the country‟s

long-term infrastructure to prevent and treat cholera in Haiti (Tu et al., 2009).

2.4.5 Outbreak of Cholera in Sub-Saharan Africa

Cook-Gordon (2009) argues that in middle of the 1990s epidemics of cholera in Africa

was partly associated with mass refugee‟s movements in central Africa, but also in Eastern

and Southern regions. Cook-Gordon (2009) asserted that in 1994, the largest proportion of

all cholera cases were in Africa, while forty-two percent (42%) of all cholera deaths were

witnessed in Africa South of Sahara. These were due to the explosive epidemic and

genocide in Rwanda. Refugees who were displaced to the eastern region of the

Democratic Republic of Congo (DRC) reported 70,000 cases of cholera and 12,000

15

deaths. Between 2001 and 2009, African countries accounted for 93% - 98% of all

reported cholera cases worldwide. In 2009, several countries in Africa experienced large

cholera outbreaks.

A total of 217,333 cholera cases were reported from Africa in 2009 (WHO, 2009).

Cholera was viewed as an important cause of epidemics in Western Kenya and Zimbabwe

resulting from drinking water from the lake or streams, feasting in funerals and in

traditional marriage ceremonies (WHO, 2002).

2.4.5.1 Cholera Outbreak in Guinea-Bissau

The study conducted by Einarsdóttir et al., (2001) show that, in Africa, cholera outbreaks

have been associated with the impacts of evil spirits to the society. Owing to these, the

villagers believed that local ceremonial practices such as offerings to the spirits can help to

remedy the situation. In such local ceremonials, chickens and alcohol are placed at entry

points to the village, around the village, and in every house, with the intention of

preventing cholera as it has been evidenced in some local communities in Guinea-Bissau.

Furthermore, according to Einarsdóttir et al., (2001), other local practices include the

designation of religious leaders of the area or women and men with special religious status

to go to the most important shrines with offerings and requests for intervention from the

gods. Also, women gather at the shrine of the deity, with offerings, dance naked in the

night, seeking help from the gods. Older women would sleep at the shrine until the

epidemic was over.

In Guinea-Bissau, the attack during the funerals was higher in villages where bodies were

not disinfected, and that eating at a funeral with a non-disinfected corpse is recognized

risk factor for cholera (Onyango et al., 2013). The burial of cholera victims without

disinfection and feasting at these funerals definitely fuelled the spike in cases. People have

16

their own ways of viewing, explaining and responding to epidemics depending on their

cultural practices. Khan et al, (1981) had previously suggested that the only effective

means to control cholera outbreak is to protect water supply and the prevention of using

contaminated water. In addition, in African settings, particularly in densely population

areas, another control measure can be through chlorination of water.

2.4.5.2 Congo (DRC) Cholera Outbreak Situation

According to Hewlett and Hewlett (2008), when a person dies in Congo following cholera

outbreak, the traditional healers conclude that the death is due to poisoning by sorcery. To

avoid more outbreaks and deaths, offerings and sacrifices in terms of food and drinks need

to be prepared and shared with relatives while a special ritual is performed. Understanding

of human culture leads to successful control of outbreak, as the case of Ebola in Congo in

2003 (Hewlett and Hewlett, 2008). In most cases, a wide belief on outbreak is that external

interventions culminate the epidemics. Outbreaks and deaths are traditionally associated

with not sharing, that is they are not shared with neighbour‟s families.

2.4.5.3 Cholera Outbreak in Burkina Faso

In Burkina Faso, one of the reasons mothers followed the hygiene advice provided at

health education sessions may have been “they were wanting to be modern rather than

believing in germ” (Curtis et al., 1995). In some Muslim communities, the practices of

rinsing the mouth with water before prayers are considered as a risk factor for cholera

(Birmingham et al., 1997). However, mouth rinsing and religion are not related to the

disease. It is the use of contaminated water for rinsing the mouth that causes the disease.

2.4.5.4 Cholera Outbreak in Papua New Guinea

In Papua New Guinea, cholera was believed to be a disease that „jumps‟ from one person

to another (WASH news Asia & Pacific, 2009). From such beliefs, no one takes trouble

17

when one dies by the roadside on that basis. Even the nurses at the hospital did not want to

have physical contact like handshakes with other nurses working in the cholera treatment

center, during the cholera outbreak in 2009. This misconception has resulted into a regular

outbreak of the disease in this community and other communities in cholera epidemic

regions.

2.4.5.5 Cholera Outbreak in Tanzania

Tanzania, like any other developing countries faces a number of developmental

challenges. Among such challenges, disease stands out as the major problem. Other

challenges include inadequate access to safe and clean water, hygiene, sanitation and

sewage systems, which have contributed to the prevalence of the waterborne infections,

including cholera. According to UN (2005), about 1.1 billion people lack access to

improved water sources, which have resulted in 1.8 million deaths as a result of water-

borne related diseases. Again, about 2.8 million cases of cholera occur annually

worldwide, the incidence being 2 cases per 1000 people at risk (Kosek, 2003).

Mpazi and Kagoma (2005), indicated that Cholera outbreaks are a result of many factors

ranging from improper waste disposal, food handling, processing and preservation and

poor housing. He further added that improper and inadequate sewerage systems, water

shortages, geographical and socio-economic backgrounds of the people are the

contributory factors. With this pattern of conceptualization, lacking access to improved

drinking water sources without access to improved sanitation is the globally recognized

cause of cholera (Water Aid, 2012).

Traerup et al., (2010) added that health impacts of climate change in Tanzania noted that

climate change is the results of variability in temperatures and changes in the patterns of

rainfall which entails serious consequences for human health, including the risk of

18

diarrheal diseases. Indeed, there is a strong evidence that temperature and rainfall patterns

affect the disease pattern that has a link with the incidence of cholera.

According to WHO (1998), the first major outbreak of cholera in Tanzania occurred in

1992 and led to 18,526 cases with 2,173 deaths. In 1997, Tanzania had an alarming

outbreak which started in Dar es Salaam with 40,249 cases including 2,231 deaths as a

result of El Nino phenomenon (WHO, 1998). To date, there have been a series of cholera

outbreak in which the government has been responding adequately.

2.5 Identification of Knowledge Gap

From the reviewed literature, the spread of cholera in the developing countries was due to

changing in temperatures which influence patterns of rainfall, scarcity of water resources,

and floods caused by heavy rainfall that contaminates drinking water. Also inadequate

health education program measures, inadequate infrastructure for a sewage system and

contacting disinfected corpses have been other factors. However, all the findings are

capable of being quantified. For instance, the study by Mpazi and Kagoma (2005)

indicated that the outbreak of cholera was culminated by inadequate hygienic practices

concerning cholera by the community due to misconceptions on the transmissibility of

cholera, that it cannot be transmitted through young children stool.

Moreover, the research by Traerup et al. (2010) shows that the spread of cholera is due to

increased temperature and changes in patterns of rainfall due to changes in climate. Again,

the study conducted by Cowman (2015), indicated that the spread of cholera was due to

differing climatic conditions, open defecation, in access to improved sanitation, improved

water sources, poverty and level of education.

For that reason, from the studies above, little is explained on socio-cultural practices in

relation to the outbreak of cholera in Tanzania. Limited application of social theories is

19

another gap, which cast a shadow on the cultural aspects of life. This study aims to fill the

abovementioned knowledge gap.

2.6 Conceptual Framework

This study conceptualizes that there are interrelations between factors in relation to the

outbreak of cholera. These factors include the personal factor (Age, Sex, Occupation, and

Education) as the independent variables. Cultural factors (Attitudes, Norms, and Customs)

and other factors including the institutional factors (community awareness, health

programs, and legal and policy framework) as intervening variables and the outbreak of

cholera which is a dependent variable. The personal factors and cultural factors

(independent variables) under certain condition (intervening factors) have an influence on

the prevalence of cholera (dependent variable).

The framework has been used to show the interrelation among the variables because they

are more than two. The study has independent, intervening and dependent variables.

Independent variables includes age, education, sex, and occupation, where by intervening

variables comprises health programs, legal and policy framework, and community

awareness, attitude, norms, customs, perception, beliefs, and taboos. Lastly was dependent

variable which stands for the outbreak of cholera.

In connection to the study, factors like age, education, sex, and occupation influence the

actors such as health programs, legal and policy framework, and community awareness

regarding to outbreak of cholera. Therefore, the community seems to influence the

outbreak of cholera, since people‟s attitudes, perceptions, customs, norms, beliefs, and

taboos are socially constructed to the reality which will contribute to have or to be free

from cholera outbreak. So, people‟s mindset has to be changed positively towards the

outbreak of cholera in order the community to be free from cholera.

20

Figure 2. 1: Conceptual Framework

Source: Researcher (2017)

2.7 Conclusion

This chapter has focused on the connected literature, introduction of it, definition of key

terms, theoretical literature review, conceptual framework, empirical review, research gap

as well as a conclusion. The subsequent chapter( chapter three) present the research

methodology, focusing on the research design, research approach, description of the study

area, target population, sampling techniques and sample size. Also, types of data, methods

of data collection, data analysis and interpretation, reliability and validity are in order.

INDEPENDENT

VARIABLES

INTERVENING

VARIABLES

DEPENDENT

VARIABLE

Personal Factors

Age

Education

Sex

Occupation

Institutional factors

Health programs

Legal and policy

framework

Community

awareness

Attitudes

Norms

Customs

Perception

Beliefs

Taboos

Outbreak of

cholera

21

CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Introduction

This chapter provides details on how information was extracted from various sources and

the methodology used to carry out the research. Therefore, the chapter comprises of

research design, research approach, description of the study area and its selection criteria,

targeted population, sampling techniques and sample size, types of data, methods of data

collection, data analysis procedure, and ends up with reliability and validity.

A methodology is a general approach of studying a research topic in a certain area (Seale,

2004). In this study, methodology was prepared to get data which explore the contribution

of socio-cultural practices to the outbreak of cholera in Ukerewe District.

3.2 Research Design

The study used a cross-sectional research design. The design was used in collecting a wide

range of information from the population with relatively homogeneous characteristics

(similar cultural practices) for establishing explanatory and descriptive associations

(Creswell, 2007). Cross-sectional research design has the potential of communicating the

findings in narration basing on perceptions, experiences, and attitudes (Marshall et al,

2014). Furthermore, the design assumed to give an understanding of contribution of socio-

cultural practices to the outbreak of cholera within the study area.

3.3 Research Approach

The study used a combined or mixed approach (qualitative and quantitative), with the

qualitative approach being dominant. Qualitative approach dominated the study as the

researcher aimed to examine the socio-cultural practices towards the outbreak of cholera.

According to Creswell (2003), combined approach is appropriate when the researcher

22

intends to collect both qualitative and quantitative data. The analysis offers a better and

detailed understanding of human behaviour and its contribution to cholera outbreak

through social cultural practices.

3.4 Description of the Study Area

Ukerewe is one of the seven Districts forming Mwanza region in Tanzania. The District is

composed of islands in Lake Victoria, located between Longitudes 31 degrees and 30‟ and

32 degrees 5‟ East and Latitude 1 degree 30‟ and 2 degrees 20‟south. The District has a

total area of 6,400 km2, of which 640 km

2 is an island surface and 5760 km

2 is occupied by

water bodies. Other Districts in Mwanza region are Ilemela, Nyamagana, Magu,

Sengerema, and Buchosa. The District has 38 islands, Ukerewe being the biggest island.

Out of 38 islands, only 15 are permanently inhabited due to the nature of the environment

to support permanent settlement. The rest are only inhabitable seasonally due to fishing

activities. Therefore, people are migrating from one place to another following the season

of the environment to engage in their activities. According to the 2012 population census,

Ukerewe District had 345,147 people, 169,279 males and 175,868 females (URT, 2012).

3.4.1 Selection of the Study Area

This study was conducted in Ukerewe District, Mwanza region. The District was selected

being among the Districts in Mwanza region with regular outbreaks of cholera (Table.

3.1). At the regional level, the data obtained from Mwanza Region Health Officer

indicated that cholera cases were 2,311. The data are demonstrating that forty-two point

seven percent (42.7 %) equivalent to 988 cases was in Ukerewe District. Total death cases

were 39 at the regional level, with 46.1% of cases being from Ukerewe District. On the

other hand, within Ukerewe District, the most affected ward was Ilangala. Similarly,

within Ilangala ward the most affected villages were Galu, Kaseni, and Kamasi. It is in

this situation of frequently recurring cholera outbreaks that these villages were selected for

23

the study. As well, little has been explained on cultural practices towards the outbreak of

the disease.

Table 3. 1: Cholera Outbreak in Mwanza Region- 2015/2016

District name Cumulative Cases Cumulative deaths CFR %

Ukerewe 988 18 1.7%

Ilemela 575 7 2.9%

Nyamagana 251 3 3.0%

Sengerema 282 7 2.9%

Magu 140 3 1.7%

Misungwi 2 0 3.6%

Kwimba 17 0 0.0%

Buchosa 56 1 1.8%

Total 2311 39 1.7%

CFR=Case Fatality Rate

Source: Regional Health Office (2017).

3.4.2 Location of the Study Area

Ukerewe District is divided into four divisions, namely, Mumbuga, Mumlambo, Ilangala,

and Ukara. There are 24 wards which are subdivided into 74 villages. Nansio being the

Districts headquarter and the main gateway into and out of Ukerewe.

24

3.3.2 Location of the Study Are

Figure 3. 1: Location of the Study Area

Source: Developed by the Researcher (2017).

3.4.3 Climate

Ukerewe is characterized by two agro-ecological zones namely, the Eastern and Western

zone with an annual average temperature of 24.5oC. The eastern zone enjoys a four humid

months period (October to May) while the western zone has a longer growing humid

period of five to six months (September to July), hence the western zone experiences more

rainfall (1800mm) than the eastern zone (900mm). Also, the District has two different

agricultural zones, with different planting seasons.

25

3.4.4 Economic Activities

The main economic activities include fishing and small-scale agriculture. Fishing is the

dominant attracting fortune-seekers from the neighboring Districts (CCHP, 2016). The

major crops cultivated in Ukerewe District include cassava, rice, sweet potatoes, and

maize on peasantry basis. Cassava is the staple food for the natives. The peasants also

keep livestock in small scales such as cattle and poultry. The prominent tribes in Ukerewe

District are the Kerewe, Kara, and Jita (CCHP, 2016).

3.5 Target Population

The target population refers to the part of the population in research‟s mind and control

(Kothari, 2004). In this study, the target population included the selected households (aged

18 years and above) from three villages in Ilangala ward and the health workers. The

selection based on the fact that respondents had a wide knowledge and experience

regarding the socio-cultural practices and the outbreak of cholera, and hence they were

expected to provide accurate information.

3.5.1 Study Population

Population refers to all elements under study (Singh, 2006). Similarly, Mugenda and

Mugenda (1999) explain population as a set of individuals, cases or objects with some

common observable characteristics. It also refers to all members or individuals or group or

other elements that a researcher hopes to represent in the study (Vans, 1990). Population

for this study was drawn from the households in Ilangala ward, and health workers and

VEOs from Ukerewe District.

3.6 Sampling Techniques and Sample Size

Sampling design refers to research plan that shows the way respondents or subjects were

selected for the study (Kothari, 2004). Sampling technique refers to the processes used in

26

selecting a number of individuals from a population (Cohen et al, 2000). The reason for

using sampling techniques in qualitative and quantitative research was to get respondents

who would be able to give information and explanations on socio-cultural practices within

the study area.

3.6.1 Sampling Procedures

The respondents were selected using area sampling and purposive sampling. Area

sampling often is used when the total geographical area of interest happens to be big,

whereas, a purposive sampling is employed when the universe happens to be small and a

known characteristic needs to be studied intensively (Kothari, 2004). Purposive sampling

method was used to select the key informants including health workers, and government

officials (VEOs) so that they can able to give an explanation and information about society

which they are serving on the knowledge on socio-cultural factors and its contribution to

the cholera outbreak.

3.6.2 Sampling Frame

The sampling frame is the source list from which the sample is drawn. It includes the

number of all items in the population (Kothari, 2004). The sampling frame for this study

was households from three villages of Ilangala ward. In addition, key informants were

obtained from the health officers, health workers and Village Executive Officers (VEOs)

in the respective villages.

3.6.3 Sampling Size

The sample size under this study was drawn from 1900 households in the three villages

(Galu 469, Kamasi 842, and Kaseni 589) (URT, 2013). The sample size was determined

using a formula by Yamane (1967); n= N/[1+N(e)2]

27

Where n –is the sample size; N -is the sampling frame; e - is the sampling error

n= 1900/[1+1900(0.1)2]= 95

This study covered, with a total number of 119 participants, whereby it includes a sample

size of 95 households, 6 Key Informants, and three focus group discussion of 18

participants who were involved from three villages.

3.6.4 Size Distribution

The sample size of 95 respondents was distributed using proportionate sampling. The

number of respondents in each village was proportioned based on its population size. The

formula by Israel formula (2009) was used in equation

n= (P*N)/P Whereas

P =Total households in three villages.

N=Total sample size.

n=Sample proportional.

p=number of households in one village.

Table 3. 2: Number of Households

Village name Number of households

Number of households to be surveyed

(n=N*p/P)

Kamasi 842 42

Galu 469 24

Kaseni 589 29

Total 1900 95

Source: URT (2013).

28

3.7 Types of Data

The study used both primary and secondary data. Primary data were collected through

questionnaires, in-depth interviews and focus group discussions, while the secondary data

were collected from relevant sources such as books, journals, manuscripts, District health

reports, and internets.

3.7.1 Primary Data

Primary data are those collected afresh and for the first time, and thus happen to be

original in character (Kothari, 2004). In this study, the primary data were collected

through questionnaires, in-depth interviews and focus group discussions. For example

during the interview with one of the health worker asked about the effective use of water

guard to the community members and replayed that

“Use of water guards failed due to local communities associated it with the sexual

reproductive system, arguing that, water guards affect reproductive organs and in

particular male organ”.

Also in focus group discussion one of respondent said that, they do not want to boil water

because boiled water had artificial test compared to un-boiled.

Primary data collection helped the researcher to get information related to socio-cultural

practices and cholera outbreak.

3.7.2 Secondary Data

The secondary data are those data that had already been collected by someone which

supplement the primary data (Kothari, 2005). Therefore in this study, the secondary data

were collected from relevant sources such as books, journals, manuscripts, District health

reports, and internets so as to extract information related to cholera and socio-cultural

practices.

29

For example URT (2015) reported that cholera outbreaks have been responding

adequately: Cumulatively, 8,185 cholera cases (both Mainland and Zanzibar) and 116

deaths have been recorded (as of November 9, 2015). Over 50% of the cases were

reported from Dar es Salaam and Mwanza (URT, 2015). Recently, (as for 20th April

2016) a total of 25,176 cases, including 390 deaths had been reported from 23 regions

(URT 2016)

Furthermore WHO (2016) argue that the spread of cholera was due to a limited access to

safe water and sanitation, low coverage to improved latrines, myths and misconceptions

on hygienic practices.

3.8 Methods of Data Collection

According to Kombo and Tromp (2006), data collection refers to gathering information

aimed at providing some facts. The case study research design allows the researcher to use

different methods of data collection including an in-depth interview, questionnaire,

documentary review and focus group discussion. Primary data of this study were collected

through key informants‟ interviews, questionnaires survey, and focus group discussion.

Secondary data were collected through review of related literature, books, and journals.

3.8.1 Social Survey

The study used social survey to collect data, in which questionnaires consisting of both

closed and open-ended questions were administered to the respondents. The survey is an

appropriate means by which quantitative data were gathered; given that the researcher has

a prior knowledge of a range of responses likely to be obtained (Kothari, 2004). If the

survey is well planned and conducted, the results are always reliable and representative of

a much wider population (McNabb, 2002). Questionnaires were administered to the ninety

five (95) selected households in the study area after obtaining their informed consent.

30

However, questionnaires were administered in Swahili for the purpose of reducing the risk

of misunderstanding and misconceptions.

3.8.2 In-depth Interview

This method of data collection was involved during the interview with the key informants.

Mugenda and Mugenda (1999) explains in-depth interview as a detailed process consisting

of dialogue or verbal responses between two persons or between several persons, by using

a checklist as a tool. In this study, in-depth interviews were conducted from six key

informants including health officers, a health worker at the village, Village Executive

Officers (VEOs) and the researcher. Duration of one session was fifteen minutes. And the

data was taken through a tape recorder to make the important information to be noted

easier. The checklist was used in guiding the interview (see Appendix II).

3.8.3 Focus Group Discussion

McNabb (2002) defines focus group discussion (FGD) as the organized group of resource

persons to discuss issues of interest to the researcher from required data that can be

assembled. Focus group discussion (FGD) is a convenient method for gathering

information quickly and in identifying and exploring beliefs, ideas, and opinions from

groups (Kombo and Tromp, 2006).

The discussion guide was used as data collection tool. FGDs were conducted to

community members and health providers. Three FGDs were conducted one from each

village, even though two FDGs in two villages were for female only while the other group

discussion was for males only in the third village. Each group consisted of six participants.

Male were guided by their fellow man, a research assistant in order for them to be free to

discuss issues on cholera outbreak. The groups of female were guided by the researcher

herself. The data were obtained through tape recorder and each FDG take a half an hour

31

during the discussion. This data collection method was employed to supplement

information gathered from the questionnaires.

3.8.4 Documentary Review

Documentary review refers to analyzing the contents of documentary materials such as

books, magazines, newspapers, internet, and the contents of all other verbal materials in

either spoken or printed (Kothari, 2004). Information related to cholera outbreak were

collected to enrich the study findings.

3.9 Data Analysis Procedures

According to Kothari (2004), data analysis implies editing, classifying, and tabulating the

collected data so that they are amenable to analysis. In this study, both qualitative and

quantitative data were collected. The data were verified, compiled, coded, and

summarized before carrying out statistical analysis based on objectives stated. Statistical

Package for Social Science (SPSS) version 20 was employed as a tool for data coding and

analysis for qualitative and analyzing quantitative data and socio-demographic data such

as age and sex (Kothari, 2004).

3.10 Reliability and validity

3.10.1 Validity

According to Hedberg and Harper (1991), validity is commonly used in determining

whatever the findings are accurate from the standpoint of the researcher, participants or

the reader of an account. It is used to judge whatever the researcher accurately describes

the phenomena which are intended to describe (Bryman, 2001). To ensure validity, the

researcher conducted a pilot study in which focus group discussion guide, interview

guides and questionnaires were tested to eliminate the language ambiguity and to make

32

questions clear so that every respondent can be able to understand it clearly. The pilot

study was conducted at Ilangala village, in Ilangala ward.

3.10.2 Reliability

Reliability is a measure of the degree to which research instruments yield same results or

data after repeated trial (Mugenda and Mugenda, 1999). A reliable instrument measures

data in a consistent and accurate manner rather than randomly. In order to make the

instrument reliable, the researcher provided clear instruction for the instrument and

clarified them in order to remove ambiguous instructions. Moreover, to ensure reliability,

multiple methods of data collection were employed. These methods included focus group

discussion, in-depth interview, and questionnaires. Moreover, the appropriateness of the

research instruments was checked after the pilot study and solicited the required

information. Some of the items which were found to be not necessary for the study were

removed and the important ones were modified.

3.11 Ethical Consideration

Protection of human rights was ensured by the researcher. Mugenda and Mugenda, (1999)

asserted that respondents should be protected by keeping the information given

confidential, especially if confidentiality has been promised. The data obtained were only

accessed by the researcher and the respondent participated in the research voluntarily.

The first thing was to respect his or her informants and understand their rights, needs,

values, and desires. Secondly, the research objectives were verbally articulated to the

respondents before the study took place. The researcher obtained the introduction letter

from the University of Dodoma. The letter was presented to the District Executive

Director for permit approval in data collection. The researcher administered questionnaires

to the respondents, conducted focus group discussions, and interviews with the key

33

informants. The respondents were ensured that the information obtained will be

confidential.

3.12 Conclusion

Briefly, this chapter has presented the entire research process. It has explained the study

location and its characteristics, research approach and design, sample and sampling

techniques (purposive and simple random sampling), the study population, methods of

data collection (primary and secondary data), issues of reliability and validity. Moreover,

it has explained the methods used in data analysis and it have ended up with issues of

ethical consideration during the research process. The following chapter (Chapter Four)

deals with data presentation, analysis and discussion of the findings.

34

CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND DISCUSSION OF THE FINDINGS

4.0 Introduction

This chapter presents the research findings. These are based on primary and secondary

data which were collected in Ilangala ward. To be able to elucidate these results clearly,

results were presented and discussed in three sub-sections. The first part presents

respondents‟ general information. The second and the third part present and discuss the

findings on the contribution of socio-cultural practices to the outbreak of cholera in

Ilangala ward. The data are presented by using frequencies, percentages, tables, graphs,

plates, and charts.

Data were collected from Galu, Kamasi, and Kaseni village in Ilangala ward. About 119

respondents where involved in this study; whereby ninety-five (95) were the number of

household, 6 respondents were key informants and three groups consisting 18 respondents

during the focus group discussions. Focus group discussions were organized and covered

six participants from each village. Key informants were three Village Executive Officers,

that is one from each village and three health practitioners in Ukerewe District. The data

obtained through questionnaires were encoded in Statistical Package for Social Sciences

(SPSS) and Microsoft Excel for analysis and interpretation.

4.1 Demographic Information of Respondents

This part presents respondent‟s demographic characteristics. These include age, sex,

education, and occupation. The purpose of presenting these characteristics was to make a

connection between them and the contribution of socio-cultural practices to the outbreak

of cholera among the community living in Ukerewe District.

35

4.1.1 Respondents’ Villages

Household interviews were carried out in three villages of Ukerewe District. A total of 95

households were interviewed (Figure1). Villages were selected from Ilangala ward

because it was highly affected by cholera outbreak than other wards. This was due to the

nature of the environment, migration, interaction among people and fishing activities

(UDC 2016). From these for examples villages, the researcher was able to identify the

socio-cultural practices which influence the outbreak of cholera among the Kerewe

people.

Figure 4. 1: The Respondents’ Village

Source: Field Survey (2017)

36

Respondents included men and women above 18 years from the three villages of Ilangala

Ward. The data shows that the respondent from three villages is as follows: Galu has 24

(25%), Kaseni 29 (31%) and Kamasi has 42 (44%). Kamasi had more respondents because

it is a camp place for fishing activities. Structured questionnaires were used to solicit

responses from participants on the contribution of socio-cultural practices to the outbreak

of cholera.

4.1.2 Sex of the Respondents

The data show that 48 (51%) of the respondents were males while 47 (49%) were

females.The males dominated compared to females because of the nature of the

environment depends on fishing activities and small-scale agriculture.

Table 4. 1: Gender of the Respondents

Sex Frequency (N) Percentage (%)

Male 48 51

Female 47 49

Total 95 100

Source: Field Survey (2017)

These data shows that the total number of males was greater than that of females. This was

caused by the nature of the environment and economic activities carried around the study

area. That is it was found that males were the ones who engaged mostly in fishing

activities and small scale agriculture than females. However, the socio-cultural practices it

involved both, males and females and affect the whole community. When cholera

outbreak occurs it affects all members of the community. It includes children, youth(boys

and girls), males, females, and elders This is not far from a study done by Ujah at el

(2015) argues that both gender and age groups were affected by cholera outbreak.

37

4.1.3 The Age of Respondents

Figure 4.2 presents the data about the age of the respondents. The data indicated that 13

(14%) of the respondents aged between 18- 29 years. As well, 35 (37%) of the

respondents aged between 30-45 years, while 38 (40%) of the respondents were 46-60

years of age, and lastly 9(9%) of the respondents were 61 and above years old. As the

figure displays, the data show that the majority of respondents ranged between 46 to

60years.

Figure 4. 2: The Age of Respondents

Source: Field Survey (2017)

This entails that in both villages the communities were dominated by the energetic groups,

with the age between 30- 60 years old involved in both small scale agriculture and fishing

activities. Therefore due to the outbreak of cholera caused death to a large number of

people especially energetic group hence the country lacks the manpower that will work for

their country and bring development in their family level and the nation at large. This is

corresponding to URT, (1977) both, 18-60 years are energetic and working age group

class in the country.

38

4.1.4 The Occupation of the Respondents

With regarded to the aspect of occupation, the data showed that the majority of

respondents in the study area about 36 (38%) respondents were fishermen. The other

group 35 (36%) of the respondents were a peasant, while 13 (14%) respondents were

business and few of the respondents 11 (11%) were employed by the government offices

or institutions.

Source: Field Survey (2017)

Figure 4. 3: The Occupation of the Respondents

The data indicate the main occupation in the study area were farming and fishing activities

followed by business in fishing sector and small retail shops. This corresponds with URT

(1999a) that, majority of the Tanzanian population, mainly smallholder farmers living in

villages depend almost entirely on land resources through agriculture and fishing

activities.

39

4.1.5 Respondents’ Education Level

Figure 4.4 shows the data about education level of the respondents. 48 (51%) of the

respondents had primary education, 16 (17%) of the respondents had secondary education,

19 (20%) of the respondents had informal education (didn‟t attend the school) while, only

12 (12%) of the respondents had college or university education.

Source: Field Survey (2017)

Figure 4. 4: Education Level

The data indicated that the majority of respondents in the three villages had attended at

least primary education. These results are not far from the study by Kashikila (2013) who

revealed that 88.5% of the respondents had primary education and were engaging in

fishing activities and small-scale agriculture. Consequently the people with low level of

education, most of them they are living in hardship and poor condition hence easier for

them to get conterminated disease including cholera. Also is difficult for them to change

their beliefs and customs and attitude as the result can accelerate to the high increase of

cholera outbreak compares to the people who are highly educated, it is easy for them to

40

change their attitude for their benefit of their health. This result joins the study conducted

by Katega (2007), who argues that education determines person‟s level of understanding

to interact with his or her surrounding environments.

4.2 Socio-Cultural Practices that Contributing to the Outbreak of Cholera

This section is a response to the first research objective and question which sought to

investigate the socio-cultural practices that are responsible for the outbreak of cholera in

Ukerewe District. In addition the researcher wanted to examine as to how these socio-

cultural practices contributed to this deadly disease.

The data to attain this objective were collected through Questionnaire, In-depth interview

and Focus group discussion; whereby respondents were asked identify different norms that

contribute to the outbreak of cholera, how they cared cholera patients, and beliefs towards

cholera outbreak.

4.2.1 Socio- Cultural Norms towards Outbreak of Cholera

The findings with regard to this objective have shown that 16 (16%) respondents argued

that, bearing mothers should take shower to the lake, 28 (29%) respondents had norms of

eating together using one plate, 17 (18%) respondents had norms of washing hand in one

bowl, 11 (12%) respondents had norms of drinking “hands washed water” as a sign of

reconciliation. Likewise, 9 (10%) respondents had norms of not sharing one toilet, 5 (5%)

respondents had norms of drinking using one cup and, 9 (9%) respondents did not respond

(see Table 4.2). This is in line with Berger and Luckmann, (1967) who argue that every

society has its own norms, beliefs, customs which guide them in their social and cultural

life activities.

41

Table 4. 2: Socio-Cultural Norms towards the Outbreak of Cholera

Norms guides the socio-cultural Frequency (N) Percentage (%)

Shower of bearing mother to water lake 16 17

Eating together by using one plate 28 29

Washing hands in one bowl 17 18

Drinking of washed water as a

reconciliation 11 12

No sharing toilet 9 10

Use of one cup in drinking 5 5

No response 9 9

Total 95 100

Source: Field Survey (2017)

Moreover, the respondents were probed as to why they preferred to eat together using one

plate and washing hands in one bowl. Among the reasons given were to: maintain unity,

love, and sharing among themselves which is grounded in the traditions and customs of

African societies. As well, they believed that their children and future generation would

learn to avoid jealous and separation. During the interview with key informants, the

finding revealed that Kerewe tribes were very strictly to their norms, as stated by one of

the Village Executive Officers from Kaseni saying:

“Kerewe tribe follow their norms strictly, they must eat together outside to

the house as a sign of love, unity and sharing among them in order sustain

the good norms to the next generation of their tribe”.

As well, during the focus group discussion in Galu village, it was revealed that drinking of

washed hand water was a sign of reconciliation between two parties that are in conflicts.

This was said by an older man saying:

“ if there is a misunderstanding within the family, the sign of reconciliation is

to put water in a dish, and everyone should wash his/her hand and after that

those who are in quarreling are supposed to drink the water in order to

purify their heart and showing love to each other”.

42

The study shows that if these different norms to the society like the Kerewe remain

unchecked, they could be one of the causes towards the outbreak of cholera. These results

correspond with other studies whereby WHO, (2002) found that cultural factors such as

gender inequality, myths, beliefs, taboos, and attitudes are all known to be closely

associated with the outbreak and spread of cholera in various localities. In Peru, the study

by Figueroa and Kincaid (2010) revealed that interventions to combat cholera failed as a

result of cultural practices of the local communities. A similar study by Nielsen et al.,

(2003) in Punjab area (Pakstan), revealed that water borne infections were recurring in the

local communities due to people‟s attitudes towards hygiene practices.

4.2.2 Beliefs towards Cholera Outbreak

The respondents were asked about their beliefs towards the outbreak of cholera. The data

from Figure 4.5 shows that people within the society had different beliefs on cholera

outbreak. The results revealed that, 31 (33%) respondents believed that cholera was

related to air, 33 (35%) respondents believed that cholera was due to bewitched. On the

other hand, about 12 (13%) respondents believed that cholera occurred when poisons

were put into wells, 8 (8%) respondents did not relate cholera with beliefs and 11 (11%)

of the respondents had no response.

43

Figure 4. 5: Beliefs towards Cholera Outbreak

Source: Field Survey (2017)

The reasons given by respondents revealed that due to their traditional beliefs which they

had, the cholera was not a disease; instead, its outbreak and deaths were associated with

sorcery. They associated to someone who wants to kill the people of the certain village,

family or destroy a certain clan by bewitched them. As well, during the interview with an

old woman the following comment was noted:

It is impossible for more than one member of the family from the same

condition and place to die of cholera. The woman believes that it is caused by

kidumu, meaning that someone puts poison in the gallon and sprays it by

combining with air. As a result, the people start to vomit and diarrhea

eventually they die”.

On the other hand, the results from the survey were not far from the focus group

discussion in Kamasi village, where two participants commented that:

“Cholera is caused by someone who puts poison into the well, and then when

people fetch the water and use it, they become sick and die from vomiting and

diarrhea”. Also, it is associated with the Health workers who put chlorine

into wells to kill bacteria. Community members believe that it is a poison

which destructs their reproductive system, especially to men.

Cholera is a

poison which

is put into

well

44

Likewise, the second participant said:

“Cholera is caused by air, meaning that, the bad wind passes within the

community as a result people start to become sick and die after a short time”.

These entail that, in the three villages, the majority of the people believe that the outbreak

of cholera was associated with air issues related to witchcrafts and poisons being put into

wells. This is not far from the other studies conducted by Ujah et al., (2015), Merten et al.,

(2013) and HRC, (2010) who found also that, an outbreak of cholera was associated with

bad air, the anger of God, black magic, and witchcraft. For instance, in Congo (DRC), the

study by Merten et al., (2013) found that 59.0% of the people believed in sorcery and

witchcraft as the source of cholera.

4.2.3 Causes of Cholera outbreak

The results on the causes of cholera revealed that 16 (17%) respondents had the view that

cholera was caused by drinking un-boiled water, 27 (29%) respondents argued that it

was due to defecation out of the toilet, while, 25 (26%) respondents noted that it was

caused by not washing hands after coming from the toilet. In addition 12 (13%)

respondents said that it was caused by eating uncovered food which is cold, 6 (6%)

respondents said it was due to the absence of latrines, 4 (4%) respondents said that it was

due to poor hygiene and sanitation, and 5 (5%) respondent did not respond. Table 4.3

below is summarizes these results.

These variations of the results were due to various activities being conducted around the

lake including fishing, showering, washing utensils, washing clothes and defecation.

45

Table 4. 3: Causes of cholera outbreak

Causes of cholera Frequency, (N) Percentage, (%)

Drinking un-boiled water 16 17

Undergoing defecation out of toilet 27 29

Do not wash hands after coming from toilet 25 26

Eating uncovered food which is cold 12 13

The absence of pit latrine 6 6

Poor hygiene and sanitation 4 4

No response 5 5

Total 95 100

Source: Field Survey (2017)

On the other hand, the results revealed that Kerewe norms prohibit the father and his

daughter-in-law to share the same latrine. This was found during the interview with the

District Health Officer (DHO) who commented that:

“It is strictly not allowed for the father and his daughter-in-law to share one

toilet because it is a shame according to their culture”.

Also during the interviews, one of the oldest man commented that:

” They cannot share one toilet in order to avoid transmission of diseases from

the toilet to the person, like chango diseases (stomach ache), and also they

could not share the toilet by fearing to be bewitched by wizards”.

The findings revealed that in most cases cholera was caused by the people undergoing

defecation out of the toilet, not washing hands after visiting the toilet, unsafe drinking

water, poor hygiene, and sanitation. This implies that in the three studied villages, there

were poor sanitation and hygiene and hence leading to the outbreak of cholera. The study

tallies with other studies by Ghose (2011), Rosewell et al., (2012) and Merten et al.,

(2013) who also revealed that cholera outbreak was due to environmental factors such as

unsafe drinking water, poor hygiene, poor hand washing and lack of sanitation.

46

4.2.4 Cholera Patients’ Caring

The respondents were asked on how they caring the person who suffer from cholera. The

findings show that 41 (43%) respondents took their patients to hospitals, 30 (32%)

respondents treat patients with traditional medicine, 9 (9%) respondents took their patients

to traditional healers, 5 (5%) respondents gave first aid to their patients by providing Oral

rehydration salts, and 10 (11%) respondents had no response.

Treating the patients with traditional medicine and sending them to traditional healers are

the causal factor for the spread of cholera within the society because they caring and

treated them without use protected gears such as gloves to avoid contamination as the

result made cholera to spread easier to other community

Table 4. 4: Caring Cholera Patient

Place where patients were treated Frequency, (N) Percentage, (%)

Take him/her to hospital 41 43

Traditional medicine 30 32

Traditional healer 9 9

Provide oral rehydration salt as the first Aid 5 5

No response 10 11

Total 95 100

Source: Field Survey (2017)

The results on the use of traditional medicine and traditional healers, both with 41% in

caring patients with cholera had a minor difference with 43% of the patients taken to

hospitals. This implies that in both villages, people still believe in traditional ways of

treating patients with cholera rather than hospitals. This could result from the traditional

beliefs and norms with the perception that outbreak of cholera was not due to poor

hygiene and sanitation, but being witched. This corresponds with the study done by Ujah

47

et al., (2015) in Nigeria, who found that acceptance of treatment of cholera patients has

been challenged due to cultural beliefs.

4.2.5 Place and Burying of the Deceased Person from Cholera

According to a questionnaire on the burial system of deceased person, respondents were

asked whether the Kerewe traditions allow the deceased person as a result of cholera being

buried away from home. Responses were limited to “yes” or “no”. Also, respondents

were asked about a person who was involved in the burial of the deceased person. The

following were the findings obtained from the study area.

4.2.5.1 Burial Place of the Deceased Person from Cholera

The results presented in Figure 4.12 show that 37 (39%) respondents said that, their

traditions allowed for the dead to be buried away from their families, while 58 (61%)

respondents said that their traditions did not allow a dead person being buried away from

their family compounds.

Figure 4. 6: Respondents’ View on Burial Place for the Deceased Person

Source: Field Survey (2017)

48

This implies that the majority of people were not ready to bury their household members

away from their home due to their traditional culture. It was believed that burying away

the dead was felt as throwing and separating him or her from the family. Furthermore, it

was reported that, if it happened the dead person has been buried away from the family,

the sands of the grave were taken and be buried within home compounds. This was done

as a sign or symbol of returning the dead person back to their homes (Litaka) to avoid

other members to die one after another.

The burring of cholera patient should be taken with care. During the burial people should

wear gloves and should be under the guidance of professional Health workers in order to

avoid cholera to spread to other members of the communities. The study by Kabita (2010)

in Zambia revealed that Cholera outbreaks occurred in several villages following funerals

of cholera patients in the Region of Biombo due to negative attitudes towards cholera

prevention from cholera corpses.

4.2.5.2 Burial Ceremony and Peoples’ Involvement

The results in Table 4.5 show that 70 (74%) respondents said that health practitioners were

involved during the burying the deceased persons as the result of cholera. Also, 24 (25%)

respondents said that the deceased persons were buried by community members and 1

(1%) respondents did not respond.

Table 4. 5: People Involved in the funeral of Deceased Person From Cholera

People involved Frequency, (N) Percentage, (%)

Health practitioners 70 74

Community member 24 25

No response 1 1

Total 95 100

Source: Field Survey (2017)

49

In most cases the dead bodies of those died from cholera were buried by health

practitioners. This could be according to the rules and regulation of health services in

Tanzania, to avoid the spread of the disease to more community members. Likewise, in

Zambia, the Ministry of Health (MOH) of Zambia had mandated that, the bodies of

persons dying of cholera be disinfected before burial because many people did not care

when burying a cholera case since cholera outbreaks were occurring in several villages

following funerals of cholera patients (Kabita, 2010).

Those who prepare the body of a cholera patient for burial can be exposed to higher

concentration of cholera vibrio. Also, it is important that these people are not responsible

for the preparation of funeral food since this may increase the risk of transmission of

infection. Furthermore, funeral may bring people into infected area from which they can

carry the cholera organism elsewhere. It is necessary to limit funeral gatherings (WHO,

1993).

In Tanzania, the Government restricts and prohibits the community and political

gathering or any meeting if there is an outbreak of cholera.

4.3 Awareness of Hygiene and Sanitation and its Contribution to the Cholera

Outbreak

This section responds to the second research question and objective which sought to the

examiner awareness of hygiene and sanitation and its contribution to the outbreak of

cholera. The data for this objective were collected through questionnaire, in-depth

interview and focus group discussion where respondents were asked of hygiene and

sanitation towards the outbreak of the disease include respondents‟ aware on the activities

resulting in cholera, use of latrines and their types. Also, respondents were asked the time

50

taken to clean the latrines as well as washing hands after visiting the toilet. On the other

hand they were asked about places of getting food and boiling drinking water.

4.3.1 Activities Resulting in Cholera Outbreak

Respondents were asked about the activities resulted in to the outbreak of cholera. The

findings demonstrate that 14 (15%) respondents said that people used to take shower at the

lake, 29 (31%) respondents reported that people were sharing one dish to wash hands

when they were eating, while, 15 (16%) respondents argued that were washing utensils

and clothes at the lake. On other hand, about 18 (19%) respondents reported that they were

eating by sharing one plate, 10 (10%) respondents said there was no relation to cholera,

and 9 (9%) respondents did not respond.

Table 4. 6: Activities Resulting to Cholera Outbreak

Activities Frequency, (N) Percentage, (%)

Shower at the lake 14 15

Washing hands on one dish 29 31

Washing utensils and clothes at the lake 15 16

Eating by using one plate 18 19

Not related 10 10

No response 9 9

Total 95 100

Source: Field Survey (2017)

When people probed were about the above practices, responses were to maintain culture

and traditions as a symbol of respect, love, and unity among Kerewe tribe. As well, it was

said that even in burial ceremony, people were washing their hands in one dish and eat

together due to their traditions and customs, as a symbol of love within the society.

51

The results indicated that if intervention would not be taken, prevalence of cholera could

not stop. These calls for different planners and stakeholders to alter these cultural

practices, unless otherwise cholera will not come to an end. The results are similar with

other scholars who revealed that, cholera was resulting from drinking water from the lake

or streams, washing hands in one dish, feasting in funerals and in traditional marriage

ceremonies (Pan African Medical Journal, 2013; Opare et al., 2012).

4.3.2 Latrine and its Cleanliness at the Study Area

Respondents were asked about the types of latrines that they were using. As well, the

researcher was interested to know whether the communities were cleaning and covering

their latrines. The following were the results obtained from the study area.

4.3.2.1 Latrine in the Study Area

As for latrines in the area, respondents were asked whether they had toilets/ latrines.

Answers were limited to “Yes” or “No”. The results as shown in Figure 4.6 indicated that

57 (60%) respondents had latrine while, 38 (40%) respondents did not have. However, it

was found that most of the latrines were of poor quality. The absence of quality toilets as

well as their use can be the multiple factors for the altering of the diseases. (See Plate 4.1).

52

Figure 4. 7: Latrine in the Study Area

Source: Field Survey (2017)

Plate 4. 1: Poor Latrine Found at Kamasi Village

Source: Field Survey (2017)

53

Despite the high percentage of latrines in the study area, still, it was revealed that the

majority of people were not using them. Cultural beliefs and perceptions were the main

reasons for these latrines not to be used and hence contribute to the outbreak of cholera.

On the other hand, the study found that people constructed latrines to avoid penalties from

the government officials. These cultural practices if not intervened could promote the

spread and outbreak of cholera. Naveen et al., (2012) argued that social factors are

obstacles in prevention and control of communicable diseases. The study by Hewlett, B.S

and Hewlett, B.L (2008) ascertained that understanding of human culture leads to

successful control of the outbreak.

4.3.2.2 Types of Latrines in the Study Area

The study discovered that people had different kinds of latrines. About 7 (7%)

respondents had pit latrines, 12 (13%) respondents had flashing latrines (see Plate 4.2b).

Likewise, 46 (48%) respondents had traditional latrines known as “Magobole” (see Plate

4.2 a). However, the results indicated that 30 (32%) of respondents had no latrines (Figure

4.7). This means that they don‟t have a permanent place, and hence they go anywhere,

including in the lake, bushes, around the big stones, and in farm plots.

54

Figure 4. 8: Kinds of a Latrine in the Study Area

Source: Field Survey (2017)

The implications of these results is that traditional latrines (48%) and absence of latrines

(32%) were dominant, leading to poor hygiene and sanitation in the study area.

Furthermore, the majority of the respondents perceived the construction of improved

latrines to be very expensive compared to traditional ones. This likens with Wasonga et

al., (2014), in Kisumu who revealed that the cost of constructing latrine was too much

and thus people resorted to “cat method” (meaning to go around the bushes or farms with

a hoe and dig a small hole for defecation then after, covering it with a soil). During the

interview with Health Officer, it was found that the claims came as the results of their

cultural practices, which ignore using one toilet. In addition, increased number of

traditional latrines resulted from the government initiatives that, every family should have

a toilet. Therefore, people found the simplest way to avoid fines and other penalties was

the construction of tradition toilets.

55

Plate 4. 2: Kinds of Latrines in the Study Area

Source: Field Survey (2017)

4.3.2.3 Latrine Cleanliness Timetable

Respondents were also asked as to when they cleaned their latrines. The answers were

limited to “every day”, “when I get time”, “not cleaning at all” and “not sure”. The

results shows that, 10 (11%) respondents were cleaning their latrines every day, 40 (42%)

respondents said that they cleaned their latrine once they got time, 25 (26%) respondents

did not clean at all, while 15 (16%) respondents were not sure, and 5 (5%) respondents

did not respond at all. The results are as summarized in figure 4.9 below.

a). Traditional Latrine (Magobole) b). Flashing latrine type

56

Figure 4. 9: Latrine Cleanliness Timetable

Source: Field Survey (2017)

Respondents were further probed on the challenges, and it was revealed that the quality

and nature of latrines were among the factors hindering the cleanness being done

regularly. Most of the latrines (“magobole”) were lacking smooth floor as they were

covered with pieces of woods (see Plate 4.3) and thatched with grasses as walls. Although

toilets were built away from the houses, still they could easily spread the diseases due to

the low quality of building. That is, they easily allowed contamination of flies from the

toilets to the utensils and uncovered food in the houses, hence outbreak of cholera. Also,

due to the nature of those toilets, it was really difficult to be easily cleaned.

57

Plate 4. 3: Traditional Latrines, Wooded Floor and Grass Thatched Walls

Source: Field survey (2017)

4.3.2.4 Covering Latrine with a Lead/ Stopper

Furthermore, respondents were asked whether they covered their latrine to avoid flies and

other insects from getting out. The responses were limited to “yes” or “no”. The results

indicated that 6 (6%) respondents were covering their toilets while 89 (94%) respondents

were not. This implies that most of the latrines in both villages were not covered and

hence allowed flies and other insects to pollute the food and fruits and then resulting to

cholera outbreak. Therefore, education on the importance of covering the toilets should be

provided so as to avoid the contamination of flies from toilets.

58

Figure 4. 10: Responses on Covering Latrines

Source: Field Survey (2017)

Few people who covered their latrines were using local tools which could be dangerous

for them to get diseases such as cholera and other related diseases. Therefore, education

should be provided on hygiene and sanitation so that they can use modern equipments for

their health protection.

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Plate 4. 4: Covering of Latrines

Source: Field Survey (2017)

4.3.2.5 Washing Hands with Soap after Visiting the Latrine

The findings presented in Figure 4.11 show that 19 (20%) respondents were washing their

hands after attending to toilets, 76 (80%) respondents were not washing their hands. It was

further revealed that the majority of people do not put water in their toilets. In addition,

some people felt shy from touching the faeces/stool when washing instead they uses

papers and grasses.

Uncovered latrine Woman demonstrates how they cover

the latrines

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Figure 4. 11: Washing Hands after Visiting the Latrines

Source: Field Survey (2017)

During a focus group discussion at Galu, one of the respondents said that:

“Most of the people do not put water in the toilets, instead they use papers

and grasses. The reason behind is that people think that when they use water

they are going to touch stools”.

This indicates that there was lack of awareness on the proper use of the toilets and the

importance of washing hands after visiting latrines. This is caused by high illiteracy rate

associated with tradition and custom in these communities. A similar study conducted by

Wasonga et al., (2014) in Kisumu (Kenya) also revealed that hand washing with soap after

visiting the latrine was hindered by cultural beliefs and taboos. Hand washing with soap as

well as provision of water and soap next to the latrine encourages good hygiene

behaviours as much as it is hard to sustain such behaviours within everyday settings

(Davis et al., 2011).

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4.3.3 Source of Water

Source of water for domestic purposes indicated on Figure 4.12 presents the results within

the area. Respondents were asked the sources of water for different uses including the

domestic uses. The results indicated that 51 (54%) respondents fetched water from the

lake, 9 (9%) respondents fetched water from shallow wells, 32 (34%) respondents fetched

water from wells and 3 (3%) respondents used harvested rainwater.

Figure 4. 12: Source of Water for the Domestic Purpose

Source: Field Survey (2017)

The majority of the people in these communities depend on the lake and wells as the main

sources of water for domestic uses. However, many human activities carried out in the

lake have caused pollution of the water leading to the eruption of waterborne diseases

including cholera. In contrast, some of the community members did not agree that water

from the lake can be spoiled or polluted. This was revealed during the focus group

discussion in Kamasi village, one woman said:

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“Water from the lake cannot be polluted by anything, even if you put a poison

or any kind of rubbish water cannot be polluted” (enanza tekolwa bulogo–

Maji ya ziwa hayachafuliwi na kitu chochote).

It was in this respect, everyone was aware that lake water cannot be polluted by anything

and believed that, water from the lake was medicine. As well, when conducting the focus

group discussion in Kaseni Village, an old man said:

“Water from the lake is a medicine; when you are not feeling good, you may

go to stretch your body at the lake, three times a day, and you will recover

your normal condition”.

This corresponds to the study done by Opare et al., (2012) who ascertained that

contamination of lake water was due to different activities done by human being within

the lake. Water supply by human waste was said to be responsible for the cholera

outbreak in Ghana and open land river defecation increased the odds of cholera risk.

4.3.4 The Places of Getting Foods

Places of getting food were associated with the spread of cholera. The researcher was

interested to know where people get their food. The Findings presented in Table 4.6 show

that 40 (42%) respondents said that they preferred to get food from food vendors (mama

lishe), 10 (11%), respondents got food from cafeteria. Also 27 (28%) respondents

prepared their own food, 3 (3%) respondents got food from hotels, and 15 (16%)

respondents got food from camps (fish camps) which prepared by someone.

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Table 4.6: The Places of Getting Foods

Places Frequency, (N) Percentage, (%)

Food vendors (Mama Lishe ) 40 42

Cafeteria 10 11

Home 27 28

Hotels 3 3

At camps (fishermen) 15 16

Total 95 100

Source: Field Survey (2017)

The results imply that the majority of the people were engaging in fishing activities and

most of them were fishermen who spent most of their time in these activities, and hence

got food from food vendors (mamalishe) and at camps. Also, some of them were not

residents but came purposely in the area for fishing activities and other business.

These places were not conducive and attractive for getting food. They were lacking toilets,

poor places of food preparations, and as well, food vendors lack personal cleanness. Some

reasons were given as to why many people preferred to get food from mama lishe. Among

them were: nature of economic and social activities around Lake Victoria including

fishing and cheap prices of the food. But the problem with these places of getting food

was poor hygiene and sanitation, that is why was simple for them to acquire the diseases

such as cholera. This corresponds with the study by Kabita (2010) in Zambia, which

revealed that many people in the affected area had a poor practice of not treating drinking

water, shared traditionally brewed drinks and did not practice good environmental

hygiene. Traore et al (2012) argue that eating cooked food or uncooked food led to the

cholera outbreak in a community. Not far from the study conducted by Merten et al (2013)

who said that the majority of the community members considered insufficient hygiene and

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sanitation levels as the key cause of cholera through ingestion of contaminated water and

food.

4.3.5 Boiling Water for Drinking

Respondents were asked whether they boiled water for drinking. Answers were limited to

“yes” or “no”. The results presented in Figure 4.13 revealed that 39 (36%) respondents

were boiling water for drinking, while 61 (64%) respondents were not.

Figure 4. 13: Boiling Water for Drinking

Source: Field Survey (2017)

Respondents were probed as to why many people did not boil water. Among the reasons

given were: boiled water had artificial taste compared to un-boiled. Another reason was

said that the majority of the respondents did not boil water for drinking because they lack

energy such as firewood, due to the nature of the environment which is surrounded by

water, and therefore, it was difficult for them to get enough firewood for boiling water

and cooking food.

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On the other hand, during the interview one fisherman said:

Most of the fishermen did not use hot water as they have medicine obtained

from traditional healer which helps them in fishing activities. It was believed

that the use of boiled water could reduce the power of the medicine leading to

sickness. This makes them use cold water and not boiled water.

Through government initiatives, communities were advised to treat drinking water using

the approved chemicals like water-guards. Due to poor perceptions resulted from

traditional beliefs, this initiative also failed. During the interview with one of the health

worker said:

“Use of water guards failed due to local communities associated it with the

sexual reproductive system, arguing that,waterguards affects reproductive

organs and in particular male organs (hupunguza nguvu za kiume)”.

This implies that, with such misconceptions, water treatment for prevention of cholera

diseases could not be effective. This indicates that fight against cholera could not be

effectively managed if, poor perceptions and traditional beliefs are not well intervened.

This corresponds with the study by Rogers (1995), in Peru who explained that, the

outbreak of diarrhea among the Peruvian villagers occurred because people did not use

boiled water due to their different beliefs, whereby boiling water was associated with

caring for the sick person or a symbol that there is someone sick in the household.

Likewise, in Brazil, the dominant belief in water treatment as unnecessary practice and

that it was associated with the intoxication of drinking water (Quick et al., 1996).

4.4 Ways of Preventing Cholera Outbreak in Ukerewe

This part presents the results of the third objective which required to identify the ways

used to prevent cholera outbreak and the community perceptions towards free from

cholera. The ways to prevent cholera outbreak suggested by the community include:

educating the community on cholera outbreak, improving the existing physical

66

infrastructure owned by the government, enforcement of laws related to hygiene and

sanitation and provision of motivation to extension health workers.

4.4.1 Community’s Perceptions towards being Free from Cholera

Respondents were asked whether it was possible for the community to be free from

cholera. Answers were limited to “strongly agree”, “agree”, “neutral”, “disagree” and

“strongly disagree”. The results show that 29 (30%) of the respondents strongly agreed,

45 (47%) respondents agreed, 10 (11%) respondents were neutral, while 11 (12%)

respondents disagreed, and no respondents strong disagreed.

Table 4. 7: Respondents’ Perceptions Towards being Free From Cholera

Responses Frequency, ( N) Percentage, (%)

Strong agree 29 30

Agree 45 47

Neutral 10 11

Disagree 11 12

Strong disagree 0 0

Total 95 100

Source: Field Survey (2017)

The results imply that the majority (77%) of respondents combined of strongly agree with

30% and agree with 47% of the community in both villages had agreed that, it was

possible for the society to be free from cholera. This was similar to the studies conducted

by Vicari et al., (2013), and Ivers et al., (2013) that, willingness to participate is high in a

population that has received awareness on cholera. This indicates that, if education

campaign will be effectively provided to the community, the society will be ready to

change their attitudes, traditional culture, and perceptions towards cholera outbreak.

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4.4.2 Educating the Community on Outbreak of Cholera

Education through workshops, training, and awareness campaigns, seminars, meetings and

through mass media on cholera outbreak will be the ways in preventing outbreak

suggested by the community. The findings presented in Figure 4.14 revealed that, 17

(18%) respondents suggested training, 33 (35%) respondents said education campaign

should be given to the community, 18 (19%) respondents suggested education should be

given through workshops, 13 (14 %) respondents suggested that seminars on the outbreak

of cholera should be provided to the community, 4 (4%) respondents said meetings were

important and should be conducted in educating people, 10 (10%) respondents suggested

mass media should be used in educating people on the outbreak of cholera in Ukerewe.

This was supported by extension health worker during the interview when she said:

“The campaign was the most attractive way of the people to listen and

discuss themselves, this changes them slowly especially for the youths

and men”.

Figure 4. 14: Awareness through Education

Source: Field Survey (2017)

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Likewise, Wasonga et al., (2014) found that the use of mass media and community health

volunteers were the probable means of message diffusion into the community. Chanda

(2017) in Zambia added that the supervisors should support them to conduct outreach

sessions where they conduct Information, Education, and communication on personal

hygiene practices, maintenance of environmental sanitation and healthy lifestyles. Also,

Vicari et al, (2013) in his study said that through education they can promote effective use

of vaccine program and policies to control the cholera epidemic. Even in Zanzibar

education is needed due to frequently occurring of cholera outbreak.

4.4.3 Improving the Existing Physical Infrastructure

As well, ways towards prevention of cholera in the study area were to improve the existing

physical infrastructure owned by the government. The results indicated that, 15 (16%)

respondents said that the government has to extend health services through construction of

new health centers, 5 (5%) respondents suggest the improvement of water services to the

community through providing safe and clean water, by use of tape water connections. In

addition, about 34 (36%) respondents stated that the, government has to increase the

number of boats especially in islands in order to improve transportation for sick people to

the hospital, 19 (20%) respondents suggested that ambulances should be added from 1 to

3, and 22 (23%) respondents were of the idea that improvement should be made in the

provision of enough tools and equipment for health activities.

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Table 4.9: Improvement of Infrastructure

Types of the infrastructure Frequency,

(N)

Percentage,

(%)

Construction of health centers 15 16

Providing water services 5 5

Provide more boats 34 36

Provide more ambulances 19 20

Proving tools and equipment for health services 22 23

Total 95 100

Source: Field Survey (2017)

The findings show that many respondents suggested that the government should provide

more boats 34 (36%). This idea was suggested by many respondents compared to others

infrastructures mentioned.

The reasons behind which caused the respondents‟ demands on boats were due to the fact

that the area is surrounded by water and many areas are islands, as a result, the residences

prefer more transport of boats in order to move from one place to another for their daily

activities. Also, the majority of peoples depend on fishing activities to run their daily lives.

However, they also suggested on building updated hospitals with full equipment which is

scientific with enough staff in order to reduce the number of deaths to the community

members when cholera outbreak occurs.

Also, boats will help them to reach earlier to the hospital and save the life of their relatives

because it will be easier for them to get health services at the right time without delaying

to the hospital.

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From the interviews, Village Executive Officer Kamasi commented that:

The majority of the residences depend on fishing activities, for their income

generations; so, the boats were most wanted at these areas. Also it will be

easier for a sick person to reach at the right time to the hospital in order to

get health services in Bomani hospital at Ukerewe District.

The good infrastructures help to prevent cholera whereby the residences are supported and

guided on.

4.4.4 Enforcement of Laws on Hygiene and Sanitation

The findings show that 16 (17%) respondents had the view that, supervision of rules and

regulations should be in place. While 14 (15%) respondents noted that, people should be

encouraged to keep the environment clean. Also, 23 (24%) respondents suggested that

emphasize should be on building improved latrines for every family. While 17 (18%)

respondents noted that the government should enforce the existing rules and laws. In

addition, 14 (15%) respondents said that the government should impose punishment for

people who do not clean their environment. Eleven respondents which equals to11% of

the respondents said that unlawful people to be imprisoned in order to bring the

disciplines and to avoid cholera outbreak.

This has been a practice in Zanzibar, whereby the cholera patients were quarantined in

prison Island. This has assisted in reducing the problem in Zanzibar (Elizabeth, 2017)

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Figure 4. 15: Enforcement of the Laws on Hygiene and Sanitation

Source: Field Survey (2017)

The data above demonstrate that the respondents who said that there should be emphasize

on building the latrines were the majority of the all residences.

The logic behind on building the latrines are as follows: the majority of people do not

want to share the latrines due to their customs, beliefs, attitudes and their taboos that

prohibit them to share one latrine because they afraid to bewitched. They do prefer to go

to bushes, lakes, and holes. This was caused by poor awareness of residences at the

Ukerewe.

From the focus group discussion one of the respondents said that the majority didn‟t

believe that:

„The cholera outbreak is caused by poor hygiene and sanitation whereby the

people do not keep their environment clean and others they do not want to

leave their traditions and customs which affect their life”.

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The enforcement of the laws is very important in making the people change and follows

the rules and regulations so as to avoid bad and do well (Gimpelson et al.,2009).

4.4.5 The Motivation of Workers

Motivation to workers was mentioned by key informants as one of the measures towards

preventing cholera in Ukerewe. The findings indicated that 30% of the key informants

had the view that, incentives like hardship allowances should be provided to workers as

motivation, 21% of the key informants indicated that, promotions were very important to

workers due to nature of the environments and in curbing the problem of cholera. Twenty

percent (20%) of the key informants had the view on improving good governance, and in

particular when a worker at the community level was attending patients, officials at the

higher level had to appreciate and not discouraging them through intimidation. Fifteen

percent (15%) of the key informants said the government should provide protective gears

for health workers when attending the patients, particularly during the outbreak of

cholera. In addition, 14% of the key informants said the government and the community

at village level should build and create a conducive environment. Conducive environment

for health worker includes having a separate place for the identified cholera patients, who

could be treated separately to avoid direct contacts with other patients.

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Source: Field Survey (2017)

Figure 4. 16: The Motivation of Worker on Cholera Outbreak

The motivation to workers as one of the ways to curb cholera outbreak was also

mentioned by the respondents. They viewed that health workers should be well motivated

since the environment are not conducive. The environment has poor social services and

transport facilities.

The interview that was conducted with DHO commented that:

The motivations for workers are the most needed in order to improve the

effectiveness of the work to the workers.

These results imply that poor and absence of incentives could lower the working morale

for workers, particularly on the health sector. Also, the absence of protective gears could

increase the widespread of cholera among the community especially those who are

attending the patients. Chanda (2017) argues that, in the rural areas, incentives should be

provided to the frontline health care workers consisting of the community-based workers,

the enrolled Nurses and Midwives.

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4.4.6 Conclusion

By summing up, chapter four has presented, analyzed and discussed the research results

based on the intention of the investigation, specific objectives and research questions

presented in chapter one. Moreover, the chapter has presented the basic research

assumptions against the key findings emerged from the study to see how the findings

supported the assumptions. The chapter in additional, has described the theory of the

contribution of socio-cultural practices to the outbreak of cholera as a synthesis of key

issues emanated from the study findings. The subsequent chapter is on the summary,

conclusions, and recommendations of the study.

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CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS OF THE STUDY

5.1 Introduction

This chapter presents the summary of the study findings based on the specific objectives,

conclusion and the recommendations on the contribution of socio-cultural practices to the

outbreak of cholera in Ilangala ward in Ukerewe District. Finally, the study suggests areas

for further studies.

5.2 Summary of the Findings

The study focused on exploring the contribution of socio-cultural practices to the outbreak

of cholera in Ukerewe District. The study was conducted in Galu, Kaseni and Kamasi

villages in Ilangala ward. Specifically, the study identified the socio-cultural factors that

contribute the outbreak of cholera, examined the community awareness of hygiene and

sanitation and its contribution to the outbreak of cholera. Finally, the study identified ways

towards the prevention of cholera outbreak within the community. It was in this line, the

study came up with the following findings.

5.2.1 The Socio-cultural Practices for Cholera Outbreak

The study revealed and identified different norms and socio-cultural practices within

Kerewe societies. The socio-cultural norms which influence the outbreak of cholera

included, eating together using one plate (29%), washing hands in one bowl (18%), and

bearing mothers were found to take shower in the lake. Other revealed norms which

contributed to the outbreak and spread of the cholera were: drinking of hands washed

water as a sign of reconciliation, no sharing of the toilet among the family members and

drinking by use of the same or one cup.

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The results also revealed that 35% of the people believed that, cholera was due to

witchcraft, 33% of the people associated cholera with air. Other people within the

community believed that cholera occurrence was due to poison being put into water

sources including shallow wells. The main cause of the cholera outbreak in Ukerewe was

undergoing defecation out of toilets, not washing hands after visiting latrine, drinking

unboiled water, eating uncovered and cold food, poor hygiene, and sanitation including

the absence of the pit latrines.

Other socio-cultural practices were traditional and culture during the funeral and burial

ceremonies. Sixty-one percent (61%) of the people said that tradition and culture of their

tribe do not allow the deceased person to be buried away from the homestead. It was

believed that burying away a deceased person, could lead to curse, hence leading to the

death of one after another among the family members. To avoid the curse, the sand from

the grave were taken and be reburied within the home compound (Litaka). The study

discovered that 41% of the cholera patients were not taken to hospital for treatment (32 %

were treated with traditional medicine and 9% were taken to witchdoctors) believing that,

patients could be bewitched. Different beliefs within the society were the factors

contributing to the outbreak and spread of cholera in the study area.

5.2.2 Awareness of Hygiene and Sanitation

The results revealed that these are poor hygiene and sanitation in Ukerewe and another

parts of Tanzania. Forty percent (40%) of families were found having no latrines.

Furthermore, the study found that most of the latrines (48%) were traditional latrines

(magobole). Despite the presence of the traditional latrines, most of them were not used

due to cultural beliefs and poor perceptions, like not sharing the same latrine. Likewise,

the study found that most of the families did not clean their latrines. Only 11% of the

respondents were cleaning their toilets daily while others were not. As well, the majority

77

of the people (94%) were not covering their latrines, and 80% of them were not washing

their hands after visiting the latrines. The main sources of water for different domestic

uses in the study area were water from the lake (54%), wells (34%) and others like rain

harvesting water and from shallow wells. In the study area, it was found that 64% of the

families did not boil water for drinking, which could lead to the outbreak and spread of

cholera. However, boiled water was perceived to lack taste.

5.2.3 Ways of Preventing the Outbreak of Cholera

The results from the study unveiled that, the majority (77%) of the respondents agreed that

it was possible for the community to be free from a cholera outbreak. This could be

possible when education is provided to the community to change their attitudes, tradition

and culture, and poor perceptions towards cholera outbreak. Provision of education should

be through training, education campaign, workshops, seminars, meetings and mass media.

Improvement of the existing health infrastructure through provision of more boats in

islands, ambulances, water services, construction of health centers, provision of gears and

equipment for health services. Another way of preventing cholera outbreak was

enforcement of the laws on hygiene and sanitation through effective supervision of rules

and regulation. These should be emphasized by building latrines for each family, keeping

the environment clean, initiating penalties and punishment for non-complaints and

unlawful people. The last identified way of preventing the outbreak of cholera was said to

be through motivating the workers, particularly at the village level. Motivation could be

incentives like hardship allowances, promotion, building conducive environment for

health workers and provision of protective gears.

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5.3 Conclusion

The study has revealed that socio-cultural practices have contributed to the outbreak of

cholera which led to the number of deaths in Ukerewe. Cholera in Galu, Kaseni, and

Kamasi occurs due to poor hygiene and sanitation associated with socio-cultural practices.

Many cases of cholera outbreak were due to poor sanitation, socio-cultural practices, and

beliefs within the community. This happens simply because the majority of people have

poor perceptions and beliefs on sharing latrines, drinking boiling water, burying a

deceased person away from home compound, poor perception on cholera disease, and

poor habit of putting water to the latrine and washing hand after visiting the latrines.

Changing of socio-cultural practices and beliefs through educating the community should

involve the community elders and the traditional healers (Community participation). The

government also should involve other sectors in education campaign against cholera

outbreak. Sectors like community development, social welfare, and health workers should

learn the socio-cultural practices such as norms, values, perceptions, attitudes, beliefs,

taboos, and traditions hence work together with the elders and traditional healers to

disseminate the knowledge on fighting against cholera outbreak within the community.

5.4 Recommendations of the Study

Based on the findings, the study has revealed that socio-cultural practices have contributed

to the outbreak of cholera in Ukerewe. However, in order for the community to be free

from cholera outbreak, the study suggests the following recommendations:

5.4.1 Recommendations to the Government and Institutions

i. Intersectoral collaborations among ministries, departments, and NGOs interested in

preventing and controlling the outbreak of cholera must be improved and strengthen

to combine other efforts in the fight against cholera outbreak.

79

ii. The government should improve infrastructures such as roads, health centers, builds

Cholera Treatment Centers (CTC) and sewage systems.

iii. Provide motivation for the workers especially those who are working in a hardship

condition.

iv. The government should effectively enforce laws and enact by-laws for non-

complaints in maintaining hygiene and sanitation.

v. Ministry of health should formulate teams and establish awareness campaign

program with the community members to educate and raise awareness on the

outbreak of cholera associated with socio-cultural practices.

5.4.2 Recommendations to the Community level

i. Members within the community including traditional healers, religious leaders,

headmen and village leaders should be involved in the teams for providing education

for fighting against cholera.

ii. To improve hygiene and sanitation within the compound especially concerning food

and water treatment (i.e. drinking safe water).

iii. To build improved and proper latrines and using them.

5.4.3 Recommendations to the Health Workers

To provide health services to the patients especially giving first priority to cholera

patients.

To provide education to the community members on how they can provide first

Aid to a cholera patient before sending to the hospital.

To educate the community members on how to treat water by using water guards.

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5.4.4 Recommendations to the NGO’s

To collaborate with ministries, departments and community members on

preventing and controlling the outbreak of cholera.

To provide support by building health centers and provides equipment for

protection to the health workers when providing services to a cholera patient or to

a person who has died of cholera.

5.5 Areas for further research

The study aimed to explore the contribution of socio-cultural practices to the outbreak of

cholera in Ukerewe District and it was conducted in three villages. Cholera is a serious

disease in Ukerewe District and in other rural villages around Lake Victoria. The findings

of this study have revealed the contribution of socio-cultural practices to the outbreak of

cholera. Further researches in socio-cultural practices should focus on improving

knowledge diffusion and bridge the gap between socio-cultural practices on other

transmitted diseases.

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APPENDICES

Appendix I: Questionnaires on the Contribution of Socio-Cultural Practices to the

Outbreak of Cholera

My name is Ester Massawe from the University of Dodoma pursuing Master of Arts in

Sociology. This questionnaire is about „The contribution of socio-cultural practices to the

outbreak of cholera in Tanzania: A case study of Ukerewe District”

It aims at collect data regarding The Contribution of Socio-Cultural Practices to the

Outbreak of Cholera; in order to fulfill the research project for the Master of Arts in

Sociology of the University of Dodoma (UDOM).

I would like to request your participation in filling this question.

Remember that all the information provided by you, are for the research purpose only and

also be assured that information will not be passed to anybody else and will be

confidential. You may express your views either in Swahili or English.

I would like to take this opportunity to express my gratitude and thanks for your

cooperation.

Faithfully Yours

_____________________

Ms. Massawe

90

Appendix II: Questionnaire for Social Survey

This research is under control of the University of Dodoma, with the purpose of exploring

the contribution of socio-cultural practices to the outbreak of cholera in Ukerewe District.

It is in this respect that I request your cooperation to fill the questionnaire. Your

information remains to be confidential and, be used only for this study and not otherwise.

You may express your views either in Swahili or English.

A: General Information

Ward name: ..................................................................................

Name of the Village.........................................................................

1. Sex of the respondent

a) Male............................................................................................

b) Female..........................................................................................

2. Age of the respondent

a) 18-29 years..................................................................................

b) 30-45 years....................................................................................

c) 46-60 years....................................................................................

d) 61 and above...............................................................................

3. Occupation of the respondent

a) Peasant........................................................................................

b) Fisherman.....................................................................................

c) Business......................................................................................

d) Civil servant...............................................................................

91

4. Level of Education of Respondent

a) Informal education......................................................................

b) Primary level...............................................................................

c) Secondary level...........................................................................

d) College / University.......................................................................

B: Socio- Cultural practices that contribute to the Outbreak of Cholera

5. Which socio-cultural norms influence the outbreak cholera in this area?

a) Shower of bearing mother to water lake………………….

b) Eating together by using one plate………………………..

c) Washing hands in one ball………………………………..

d) Drinking of washed water as reconciliation………………

e) No sharing toilet……………………………………………

f) Use of one cup in drinking…………………………………

6. What are your beliefs towards cholera outbreak? Please mention

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………

7. What activities are resulting to cholera outbreaks?

………………………………………………………………………………………………

……………………………………………………………………………………

8. What do you do when one of the household members suffer from cholera?

…………………………………………………………………………………………

…………………………………………………………………………………………

92

9. Does your tradition allow burying a deceased person away from the family compound?

a) Yes…………………………………………………………………………

b) No……………………………………………………………………………

10. If Not, please explain why?

………………………………………………………………………………………………

……………………………………………………………………………………

11. Who is involved in the funeral of a deceased person from cholera?

a) Health practitioners……………………………………………………

b) Community members…………………………………………………

c) Others specify…………………………………………………………

C: Awareness of hygiene and sanitation and its contribution to the Cholera

Outbreak

12. Do you have latrine at your compound?

a) Yes……………………………………………………………….

b) No…………………………………………………………………

13. Which Kinds of latrine do you use?

a) Pit latrine………………………………………………………….

b) Flashing latrine…………………………………………………...

c) Traditional latrine…………………………………………………

d) Others specify…………………………………………………….

93

14. What is the source of water you always use for domestic purpose?

a) From the lake……………………………………………………..

b) Shallow wells…………………………………………………….

c) Well………………………………………………………………

d) Rain harvested water……………………………………………

e) Other sources specify……………………………………………

15. Do you clean your latrine?

a) Yes………………………………………………………….

b) No…………………………………………………………..

16. If yes, at what time do you clean latrine?

a) Every day………………………………………………………

b) When I get time………………………………………………...

c) Not at all………………………………………………………..

d) Not sure………………………………………………………...

17. Do you always cover your latrine with a lead/ stopper?

a) Yes………………………………………………………………

b) No………………………………………………………………..

18. Do you always wash hands with soap after coming from the toilet?

a) Yes………………………………………………………………

b) No………………………………………………………………..

19. Where do you get food?

a) From food vendors (Mama lishe )………………………………

94

b) From cafeteria………………………………………………………

c) At home…………………………………………………………..

d) At camps (fishermen)……………………………………………

e) Others, specify……………………………………………………

20. Do you always boil water for drinking?

a) Yes………………………………………………………………..

b) No………………………………………………………………….

D: Ways in Preventing Cholera Outbreak

21. Do you agree that it is possible for the society to be free from cholera?

a) Strong disagree………………………………………………………

b) Disagree………………………………………………………………

c) Neutral………………………………………………………………

d) Agree…………………………………………………………………

e) Strong agree……………………………………………………………

22. Suggest ways of preventing outbreak of cholera in your village

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………

95

Appendix III: Interview Guide for Health Workers and Government Officials

This research is under control of the University of Dodoma, with the purpose of exploring

the contribution of socio-cultural practices to the outbreak of cholera in Ukerewe District.

It is in this respect, I require your cooperation to fill the questionnaire. Your information

remains to be confidential and, be used only for this study and not otherwise. You may

express your views either in Swahili or English.

A: Personal Information

Please put a tick ( ) in an appropriate box beside.

Name…………………………………………………… (If applicable)

1. Sex:

Male………………………………………………………

Female……………………………………………………………

2. Age……………………………………….

3. Position…………………………………

4. Address…………………………………..

Village……………………………………

Ward……………………………………...

5. Educational qualifications

a. Secondary level…………………………………………………………….

b. Diploma level……………………………………………………………...

c. Degree level……………………………………………………………….

d. Others (specify) ………………………………………………….

96

6. What is cholera………………………………………………………………

7. Why has cholera outbreak been repeatedly occurring in your locality?

…………………………………………………………………………………………

…………………………………………………………………………………………

8. Which socio-cultural practices do you think are the sources of cholera outbreak?

………………………………………………………………………………………………

……………………………………………………………………………………

9. Do you think that the community has received enough information and education on

hygiene and sanitation to be free from cholera?

a. Yes…………………………………………….…………………………….

b. No……………………………………………………………….................

10. Following the government efforts to combat and eradicate cholera, have you witnessed

any changes in behaviour among the community members?

a. If yes which changes……………………………………………………….

……………………………………………….………………………………..

If no why ………………………………….………………………………….

………….……………………………………………………………………..

11. When a cholera victim dies, does the society accept deceased household member to be

buried away from the family compound?

Yes…………………………………………………………….................

No …………………………………………………………………………

If no, how do they perceive it? ..............................................................................

12. What is your recommendation on combating and eradicating cholera outbreak in the

area? …………......................................................................................................

Thank you for your cooperation!

97

Appendix IV: Focus Group Discussion’s Guide

1. Why has cholera outbreak been repeatedly occurring in the society you live in?

2. Which kind of latrine is dominant in the community?

3. Which cultural practices do you think to contribute the outbreak of cholera?

4. Which beliefs are associated with the outbreak of cholera?

5. What are your perceptions towards lake water in relating to cholera outbreak?

6. What measures should be taken to combat and eradicate cholera outbreak?

Thank you for your cooperation

98

MATRIX TABLE FOR ERRORS CORRECTION OF A DISSERTATION TITLED

The Contribution of Socio-Cultural Practices to the Outbreak of Cholera in

Tanzania: A Case Study of Ukerewe District

BY

ESTER GASPER MASSAWE

S/N EXTERNAL EXAMINER

OBSERVATION

WHAT HAS BEEN DONE

1. The abstract has no findings Correction has been done accordingly

by putting the findings as directed by

external examiner

2. Page 36: on 4.1.2 the word Gender

should be replaced by the word Sex.

The word has been replaced

3. Page 66: on 4.4.1 addition of the

word being to the sentence and

omitting the word on to the sentence.

This was corrected as per external

examiners‟ suggestions.

4. Page 70: 4.4.4 the word emphasized

should be replaced by the word

encouraged.

The replacement was done as directed

by external examiner

5 Page 72: 4.4.5 the word witnessed

should be replaced by the word

mentioned.

6. Page 79: 5.4.1 (v) recommendations

to the government. Which sector of

the government should do this?

The government sector was mentioned

as suggested by external examiner