Acta Tropica, 56(1994)327 339 327

© 1994 Elsevier Science B.V.

ACTROP 00366

Vector control at the household level: an analysis o f

its impact on w o m e n

Peter J. Winch a'*, Linda S. Lloyd b, Laura Hoemeke", Elli LeontsinP

aCenterfor International Community-Based Health Research, Department of International Health,
The Johns Hopkins University, School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore,
MD 21205, USA, bpublie Health Consultant, 4435 Nobel Drive, San Diego, CA 92122, USA
Received 16 November 1993; accepted 14 December 1993

The home is the setting where many vector-borne diseases are transmitted. Strategies for their control
consequently have to involve the active participation of householders. In this paper we propose that low
rates of participation in control activities frequently are related to the negative impact they have on
women's power and authority within the domestic domain. This can arise from intrusion into domestic
space by male vector control personnel, reorganization of the domestic environment as part of control
activities, and promulgation of the idea that disease originates from within the home. In addition, women
may need to make significant investments of both time and money in order to carry out the recommended
control measures. Very little is known about the impact of vector control measures on women. This subject
will assume increasing relevance as planners seek to involve householders, rather than the personnel of
vertically-organized control programmes, in the implementation of vector control measures.

Key words: Vector control; Women; Housing; Social and economic factors; Malaria; Chagas' disease;
Dengue

Introduction

F o r m a n y diseases t r a n s m i t t e d b y insect vectors, the h o m e is the setting for some

o r all o f the steps in the t r a n s m i s s i o n cycle, including the d e v e l o p m e n t o f the larval
f o r m s o f the insect, c o n t a c t between insects a n d b o t h p e o p l e a n d d o m e s t i c animals,
a n d the diagnosis a n d t r e a t m e n t o f the resulting disease. It is n o t surprising, therefore,
t h a t strategies for c o n t r o l l i n g these diseases m u s t frequently be i m p l e m e n t e d at the
h o u s e h o l d level a n d involve the active p a r t i c i p a t i o n o f h o u s e h o l d m e m b e r s . Such
strategies include h o u s i n g i m p r o v e m e n t to c o n t r o l the t r i a t o m i d bugs t r a n s m i t t i n g
C h a g a s ' disease, c o n t r o l o f the h a b i t a t s o f m o s q u i t o larvae such as pit latrines for
Culex species a n d w a t e r s t o r a g e c o n t a i n e r s for Aedes aegypti, a p p l i c a t i o n o f residu-
ally acting insecticides to h o u s e walls, use o f i n s e c t i c i d e - i m p r e g n a t e d c u r t a i n s a n d
m o s q u i t o nets; i n s t a l l a t i o n o f screening o n w i n d o w s a n d p r o m o t i o n o f early diagnosis
a n d t r e a t m e n t . A l t h o u g h such efforts are ostensibly for the benefit o f the h o u s e h o l d -
ers, this benefit m a y n o t be very a p p a r e n t to them. Several e x p l a n a t i o n s have been

*Corresponding author. Tel: 410-955-9853/9854. Fax: 410-955-7159. Internet: winch@jhuhyg.sph.jhu.edu.

SSDI 0001-706X(94)E0099-8
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advanced as to why there has been only modest success in generating participation
in vector-borne disease control programmes, lack of knowledge about the diseases
being arguably the most frequent. In a report on the control of Chagas' disease, we
find the statement 'The poor education of an unstable and unsettled population
contributes to the perpetuation of confused beliefs about the vector and disease
transmission and to a lack of self-confidence in the people's ability to control
transmission; this produces passive and negative attitudes towards control activities'
(WHO, 1992). Other studies have pointed to low perceived priority of a given
disease (Gordon et al., 1990), lack of communication between programme planners
and householders due to differences between local and biomedical definitions of
diseases (Helitzer-Allen, 1989; Kendall et al., 1991; Winch et al., 1991; Agyepong,
1992), apathy on the part of residents caused by distrust in government services and
programmes (Rajagopalan and Panicker, 1984; Lloyd, 1991), limited opportunities
for participation (Manderson et al., 1992), and low efficacy and high cost, both
perceived and actual, of the recommended interventions. As a result, householders
deny entry to health ministry personnel who come to spray the walls, check for
mosquito breeding or see if nets are being used. They may also display little interest
in opening windows so that insecticide will enter when it is sprayed from a truck
passing in front of the house, re-impregnating nets with insecticide or controlling
the domestic habitats of mosquito larvae. We believe that a further reason for lack
of acceptance of these measures is their impact on women and their power and
authority within the domestic domain, and it is this point that we will elaborate
throughout the remainder of the paper.

Housing, households and the domestic domain

In the tropical disease literature, a distinction is rarely made between the terms
'housing', 'household' and 'domestic domain'. Most of what has been written is
about housing, or the physical condition of the buildings in which people live and
its impact on disease transmission. This has been a particular focus in the literature
on Chagas' disease (e.g., Dias and Dias, 1982).
When we move beyond the physical characteristics of a house to considering the
people who live in it, the concept of household enters in. While it is common in a
household census to use a uniform definition such as 'all of those who eat from the
same pot' or 'everyone who is related to the head of the household', in reality
multiple definitions exist, even within the same community. This is far from just an
academic question. For example, a group of eight people who consider themselves
a household may own two mosquito nets. Two of the household members spend
most or all of their time working in the capital city. When they go to the city to
work, they may take the two nets with them, leaving the rest to go without. Although
an outsider might conclude from the absence of nets in the house that no action is
being taken to prevent malaria in this household, household members may feel that
nets are being used within the household, although not within the house. In the
words of Segalen (1986:22) 'Rather than the size, it is the structure of the domestic
group that is significant, for it reveals a certain form of organization governing the
transmission of practices and cultural values, and linking family and work, family
and power, and family and possessions.'
The domestic or private domain has been defined as 'activities performed within
the localized family unit' (Sanday, 1974), and it can be seen in the context of the
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physical setting of the home, and the symbolic setting of familial and intimate
relationships. It is a sphere of life that 'encompasses the household and the world
where private, moral sanctions hold sway,' differing from the public domain, which
'refers to institutions of the state and society outside of the household, such as
political and economic organization' (Berman et al., 1994).
Public health policies originate, by necessity, in the public domain, since it is only
possible to detect epidemiologic trends and opportunities for disease control and
prevention when examining data aggregated across a population. The implementa-
tion of these policies, however, largely occurs within the domestic domain, as stated
by Mosley (1989): 'In reality, diseases occur and interventions must operate -
under social conditions beyond the control of the biomedical scientist. Therefore,
most health interventions are fundamentally social interventions.' As a result, plan-
ners often have little control over the implementation of their policies. Two tactics
have been used to gain this control. The first has been to change the location of
events such as childbirth, illness recognition and treatment and health education
from the home to a public location such as a clinic, hospital or school. The second
has been to try to influence events in the home, either through providing health
education aimed at modifying preventive and curative behaviors, or by sending
extension workers such as primary health care workers, midwives and spraymen
into people's houses.
The difficulties associated with the first tactic are well recognized, but poorly
understood. One factor is people's reluctance to involve outsiders in private matters.
Kendall (1990), writing about the household treatment of diarrhea by mothers in
Honduras, describes how diarrhea is initially treated as a routine occurrence that is
treated within the home and viewed as transitory. 'If the episode continues, however,
a transition is made from an occurrence which exists within the domestic environ-
ment, controlled by parents and caretakers, to an episode which becomes public ...
One reason parents postpone visits to clinics or healers may be that the visit is an
admission of public concern for domestic matters.' People may also hesitate to seek
treatment in the public domain for conditions that are socially unacceptable or
scandalous. For example, Muhondwa (1983) found that people in coastal Tanzania
with hydrocoele secondary to lymphatic filariasis delayed treatment and led restricted
lives. In the same area it has also been reported recently that some people do not
bring their mosquito nets to be re-impregnated with insecticide because their unclean
condition is shameful and might suggest to others that the inside of their house is
also very unclean (Ahmed Makemba, personal communication).
Vector-borne disease control programmes most commonly take the second tactic,
that of entering the house and changing its physical characteristics through rebuilding
or plastering walls, application of insecticides, installation of screens or insecticide-
impregnated curtains, and promoting the modification of practices for storing and
disposing of water, waste management or insect control. We propose that local
responses to this second tactic should be interpreted by examining how the control
programme articulates with the domestic domain.

The power and authority of women in the domestic domain

Throughout the world, women tend to have more power and authority in the
domestic domain than in the public domain. Conversely, men have more power in
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the public domain. Sanday (1974:190) quotes M.G. Smith's (1960) definition of
power as 'the ability to act effectively on persons or things, to take or secure
favorable decisions which are not of right allocated to the individuals or their roles'
and authority as 'the right to make a particular decision and to command obedience.'
Although women may possess a great deal of power in the public domain by virtue
of working outside the home or by maintaining contacts with other people, their
authority, or recognized power, is often largely restricted to the domestic domain.
Public health interventions may have a positive or negative impact on female
power and authority in the domestic domain. The physical characteristics of the
house itself can be directly linked to the status and authority of a woman in many
societies. Any intervention that improves the physical condition of the house or its
surroundings may therefore result in increased status for the women living in it.
Children are the 'pride and joy', as well as ultimate responsibility of the mother
within many societies. Thus the women who, as a result of a public health interven-
tion, have healthy, well-fed children may acquire increased status.
Development programmes that seek to empower women and to improve their
status within society often begin with income-generating activities that theoretically
give women more economic power within society, in the public domain. Similarly,
vector control interventions, such as the community-based malaria control pro-
gramme in Pondicherry, India described by Rajagopalan and Panicker (1984), which
involve income generation, may have a positive impact on female status if women
share in the new income that is generated.
The negative impact on female power and authority within the domestic domain
may be reflected in low levels of participation in vector control activities. The effect
of vector control interventions on gender roles and mechanisms through which
interventions may change or shift the existing power relationships within the house-
hold are issues that have received little attention. In a study in Tanzania, it was
found that the roles of men and women were such that women were unable to
change their behaviour without the support of both the household and the com-
munity, even if they were responsible for the behaviour (McCauley et al., 1992).
We will now describe various ways in which vector-borne disease control programmes
interact with the domestic domain generally, and women specifically, and how this
interaction can result in lack of acceptance of, or participation in, vector control
activities.

Factors affecting acceptance of control measures

Objection to intrusion into domestic space

Interaction between vector control personnel with householders is initiated when

permission to enter the premise to carry out spraying or inspection procedures is
requested; routine inspections generally occur during the day when men are away
at work and women are home. The delivery of health education messages at the
time of the visit increases the intensity of contact between the women and vector
control personnel because such messages may contradict current household practices
or suggest that not enough is being done to maintain 'hygienic' conditions in and
around the house.
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There are many references in articles examining community responses to vector-

borne disease control programmes to householders objecting to the intrusion of
either employees or insecticides into domestic space. Knudsen (1992), for example,
in describing community reactions to dengue control programmes, states that there
is 'a general sociological aversion on the part of householders to premise inspections
which is related to a general ignorance regarding the disease and its control among
those at greatest risk in developing countries.' Similarly, Coimbra (1988:257) reports
that in the Brazilian Amazon,

'... malaria control programmes are constantly confronting cultural and social forces that
hamper the execution of certain measures. People's refusal to have their houses sprayed
with DDT, for example, is a problem constantly faced by public health teams in Amazonia.
In some areas the refusal rate reaches about 10% of the total number of houses to be
sprayed. Often the people allow the malaria spraying in their homes, after the public health
team leaves they replaster their houses or vigorously wash all the walls, alleging that the
insecticide stains the paint or spoils the wood used for house building... Other problems
faced by SUCAM teams are locked houses, and medical certificates indicating an allergy
to insecticides. These are provided by physicians to serve as justification for refusing
malaria spraying.'

Two aspects of these citations deserve comment. First, it is stated that the objection
comes from 'householders' or from 'people'. Since the level of analysis for these
studies has typically been the community, it is rarely stated whether men or women
are the ones objecting. As women are more likely to be at home during the day
when the vector control teams pass by, it stands to reason that they are frequently
the source of the objections. Second, the analysis focuses on the action the vector
control team is perceived to be doing. Here 'doing' refers to the effect of their action
on the physical state of the world. In the first excerpt, the objection is said to arise
from ignorance of the disease vector, and by extension, failure to understand what
the vector control employees are doing or why they are doing it. In the second
excerpt, the objection is said to arise from the physical effects of the insecticide: it
stains the paint or spoils the wood.
Potential explanations for women's objections to what is being 'done' can be
found in considering women's multiple roles as producers of food, protectors of
health and homemakers. As health providers, women may be concerned that chemi-
cals with strong odors could cause asthma or aggravate allergies. As producers of
food, women may seek to avoid death of poultry or domestic animals due to contact
with an insecticide, and as homemakers women might suspect that the chemicals
could harm pets or decorative plants, or cause irreversible damage to wood or
painted surfaces. In a study of community responses to D D T house spraying in
Thailand, Hongvivatana et al. (1982) noted that potential harmful effects of D D T
on children and pregnant women, death of domestic animals, especially cats, and
the unpleasant appearance of D D T residues on the walls were the main reasons that
householders did not allow all or part of their homes to be sprayed by malaria
control workers.
Alternatively, objections may be based not only on what vector control teams are
'doing', but also on what they are 'saying'. Here by 'saying' we mean that 'their
behaviour, like all social behaviour, is coded so that it makes statements about what
the social situation is and where the actor is positioned in the social situation.'
(Leach, 1982:177) The intrusion of foreign people, foreign technologies or foreign
332

ideologies m a y be making a number of statements regarding relations between the

domestic and public domains, and about the power and authority of women.
Entry into homes by male strangers to carry out vector control activities not only
extends the power of a public institution, the ministry of health, into the domestic
domain, but also extends male power into a space where the power and authority
of women are greatest. Since the vast majority of vector control employees worldwide
are men, and they frequently are in uniform, while the householders present during
the day usually are women and children, there may be very real security concerns
on the part of the residents, as the value of objects in the house can become public.
Hongvivatana et al. (1982) note in their study in Thailand that 'stealing food,
agricultural products and clothes was c o m m o n ' on the part of the vector control
employees and was greatly resented. In some cases the vector control employee
himself may turn out to be a thief who has stolen a uniform and is using it to enter
houses. The presence of a male stranger m a y also raise doubts regarding the propriety
of female behavior, as shown in this quote from an ethnography on Indian women
living in purdah:

'They used to be considerate to us, and take into account that we pirzade women live in
purdah. For several years they used to send quite young boys to each house to spray with
DDT. That was good for us. But last year, they sent an adult man - and of course we
couldn't let him come in as none of our men were at home. That is very cruel of the
government. Do they want us all to catch malaria?' (Jeffery, 1979).

W h a t is being said depends not only on the person or technology being introduced,
but also on the time of the day and the part of the house into which it is introduced.
For diseases such as malaria, Chagas' disease and filariasis, much of the transmission
occurs at night when people are sleeping due to the biting patterns of the insects
and, in the case of Bancroftian filariasis, on the nocturnal periodicity in the blood
of the infective form of the parasite found in m a n y areas. This means that control
measures need to be applied in the bedroom, and that data collection activities such
as capturing mosquitoes and obtaining blood samples for filariasis must be carried
out at night. Marsden and Penna (1982) note that the G6mez-Nufiez trap used for
detecting the reinfestation of a house by Chagas' disease vectors, is placed vertically
over the principal bed, and that 'every time the husband and wife wake up it is
above their bed.'
Anthropological studies about how the space inside a home is organized can help
us to predict how these control and evaluation measures will be interpreted by
householders, especially women. Leach (1982:209) notes that 'different kinds of
space are differentiated as 'private' or 'public' in several cross-cutting ways.., the
underlying basis of such differentiation relates to eating/defecation, clean/dirty,
cooked/uncooked, sexual relations/asexual relations, inside/outside, etc.' That being
said, the most private part of the house is usually the master bedroom. If letting a
vector control employee into the home makes women uncomfortable, allowing him
into the master bedroom will cause the most discomfort. This may result in vector
control employees only being allowed to apply insecticide or inspect for mosquito
larvae or triatomid bugs outside of the home or in parts of the home that are
considered to be less private, such as a r o o m where guests stay or the kitchen area.
The presence of a new technology in the house, even if it has been brought there
by the householder, m a y be seen as a violation of domestic space. Just as an animal
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marks out its territory, the presence of a G6mez-Nufiez trap (for Chagas' disease
vectors) or insecticides on the wall can serve as a reminder that vector control
employees either have been in the house or may come again in the future. For
example, someone m a y not purchase a mosquito net, thinking that in the future
someone m a y want to enter the house to see if it is hung up properly or to ask if it
is being used (Ahmed Makemba, personal communication). Furthermore, the new
technology m a y be one that women are unfamiliar with, leading to a feeling of lack
of power over an object located inside an area they have authority over.
Insecticides, aimed at both larval and adult forms of insect vectors, are the
technology most frequently employed in vector control. When homeowners refuse
to allow vector control staff to put larvicides such as temephos into their water
containers, they may be confronted by laws that mandate compliance with vector
control measures. The power of the female responsible for the household conse-
quently is lessened as she has no control over what she may consider to be a harmful
substance and its application within her domestic space. The only means to resist
this would be to empty the container and fill it with fresh water; however, this is
not always an option in areas where water is difficult or expensive to obtain.
Finally, vector-borne disease control programmes frequently introduce a distinct,
and typically male, ideology into the domestic domain, the ideology of war. Coimbra
(1988), notes that vector control personnel in Brazil wear khaki-colored uniforms,
drive black and white vehicles that are the colours associated with police cars and
commonly use terms such as campaign, combat and weapons. He goes on to state
that 'I would presume that no one is willing to allow a 'battle' to take place in one's
home, especially if one does not share the same set of values and ideology as the
'warriors', and even if they assure one that the war is being fought for one's benefit.'

Reorganization of the domestic environment

Because the organization of the domestic environment is frequently a female respon-

sibility, strategies requiring changes or reorganization to this environment m a y lead
to loss or gain of female authority over it. In Chagas' disease control programmes
the central component is the elimination of the vector from the house and peri-
domestic areas. The actions recommended are often hygiene-related in that women
are encouraged to sweep all areas of the house, including dark corners, walls and
behind wall decorations, to shake and air piles of clothing and other stored items
and to remove animals from the house. In such cases, women m a y feel that their
authority has been undermined as their rationale for placing the items or animals
where they are is shown to be flawed or even wrong.
Where possible, housing improvements are undertaken as a means to permanently
eliminate the triatomid bugs from the house and to minimize reinfestation. The
housing improvements require re-plastering and re-roofing of the house along with
improvements in the peri-domestic buildings. While the construction of the house is
typically a male responsibility, the organization and maintenance of the inside of
the home is a female responsibility. Bricefio-Ledn (1986), when examining the effects
of social conditions and attitudes on participation in a Chagas' disease p r o g r a m m e
in Venezuela, found that women did not play an important role in the household
decision to participate in the housing improvement programme. Their role was,
however, pivotal in whether the work on the house was completed or not.
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Areas within the house previously used for crops or animals may become allocated
for another use, in which case additional space must be found for the items
no longer allowed in the house. An example of this is a housing improvement
programme in Paraguay, where improvements to the house and peri-domestic
buildings resulted in a change in the status of the room being used as a kitchen.
After plastering the walls, the room appeared too attractive for use as a kitchen, so
it became a formal part of the house and was used as a bedroom. The homeowners
then had to build another, detached kitchen (Nilsa Zacarias-Bemitez, unpublished
observation).
In Aedes aegypti and dengue control programmes, women are instructed to reorga-
nize their backyards by eliminating small containers, bottles or tires, or keeping
them under cover so that rain water cannot collect in them. They also are encouraged
to maintain water storage containers inverted when empty, or covered when in use
(Lloyd et al., 1992; Leontsini et al., 1993). These instructions may represent a
challenge to female authority similar to that found with Chagas' disease control
measures.
In malaria control programmes, the use of bed nets also requires changes in the
organization of domestic space. These changes come about when the family decides
how the bed net should be used and who should sleep under it. This may even entail
the purchase of a new bed, finding a location for the new bed and deciding who
will get to sleep in the bed. Changes in established sleeping patterns may upset the
recognized power relationships that determined the original sleeping patterns. By
examining sleeping patterns and reasons why people sleep under a net, interventions
will be better able to address those issues (MacCormack and Snow, 1986).

Changing perceptions of the origin of disease

The health education components of dengue and Chagas' disease control pro-
grammes promote the idea that the disease originates from within the home and,
therefore, the specific actions needed to prevent transmission are the householders'
responsibility. Research on local perceptions of disease transmission and causation
show, however, that people frequently believe illnesses to come from outside the
home. Illness is seen as being introduced into the home by men or children who are
exposed to pathogens at work or school, or by insects coming into the house from
outside. Marsden and Penna (1982) state that when houses are reinfested by tria-
tomid bugs, 'most householders thought that the bugs actively flew into houses from
the surrounding bush.' In a study on the ecology of dengue transmission in Venezuela,
Ruiz and Gonzfilez-T611ez (1992) report that more than 54% of respondents believed
there were no mosquito breeding places in their houses, and that mosquitos come
from outside. Similarly, G o r d o n et al. (1990), in a study in the Dominican Republic,
note that 'Folk explanations of environmental problems could make it particularly
difficult to accept the idea that mosquitos come from one's home.' In an Aedes
aegypti control programme carried out in M6rida, Mexico, respondents stated that
mosquitoes came from dirty standing water, overgrown vegetation and garbage.
Female respondents also stated that the mosquitoes found inside the home were
'family' mosquitoes and did not cause illnesses (Lloyd 1991; Winch et al., 1991).
The house is typically viewed as a clean and healthy environment, a haven from
disease. Health education messages often link lack of hygiene within the domestic
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environment to the transmission of disease. The message that disease transmission

is occurring within the home may indirectly imply that the domestic environment is
unhealthy, and call into question the woman's ability to preserve health by maintain-
ing the household free of disease.

Economic impact of vector control activities

A number of articles have pointed out the scarcity of careful assessments of the
economic impact of tropical diseases on the household (e.g., Popkin, 1982; Shepard
et al., 1991). Days of work lost (Shepard et al., 1991), change in the intensity of
performing a work task and shifting from highly demanding activities to less demand-
ing and less productive activities due to tropical disease morbidity (Parker, 1992)
and intrahousehold substitutions of male disabled labor with female healthy labor
(Popkin, 1982) have been considered.
The economic impact of vector control methods on the household has received
even less attention. Recent studies have documented that people take a number of
measures to combat mosquitoes, and in so doing incur significant expenses. Zandu
et al. (1991), in a survey of 420 households in Kinshasa, Zaire found that 85.6% of
families used mosquito coils, 55.5% insecticide sprays and 38.6% mosquito nets, and
that families spent a median sum of U.S. $5.00 per year in total on mosquito control.
In a similar household survey in Yaound6, Cameroon, Desfontaine et al. (1988)
found that 48% of families used mosquito nets, 39.5% used insecticide sprays and
36.7% used mosquito coils, resulting in a median sum of 117 ECU/year being spent
on mosquito control. Such a level of expenditure may represent 5% or more of the
household's annual cash income. In an environment where no regular or reliable
water supply exists, emptying of water from containers to prevent mosquito breeding
and comply with disease prevention measures may result in a larger water bill.
Women might resent the fact that they were made to empty the water and, should
the water supply be unexpectedly cut, they would then have to buy water to fulfill
their immediate needs. In the case of Chagas' disease, both men and women may
incur significant expenses, related to the improvement of housing. Finally, medical
treatments for vector-borne diseases represent an additional economic burden,
although in some cases it is small in comparison with the indirect costs of the disease
such as loss of income due to days lost from work (Shepard et al., 1991).
The economic impact of successful tropical disease control on women and house-
holds, however, should be viewed more globally and with long term impact in mind.
Reduction in morbidity among women might allow more time for productive activity
and hence further economic benefits. Investment in water supply and sanitation may
have an impact on a wide range of diseases, including lymphatic filariasis, dengue,
schistosomiasis and diarrheal diseases. Finally, investment in more effective control
measures such as insecticide-impregnated mosquito nets and control of mosquito
larval production sites may allow householders to spend less on mosquito coils and
insecticide aerosol sprays (Desfontaine et al., 1988; Zandu et al., 1992). Briscoe
(1984) has attempted to estimate the long term economic impacts of water and
sanitation measures on families, and shown that we usually limit ourselves to short
term outcomes without taking into consideration the long term outcomes.
336

Women's allocation of time to vector control activities

'Time is money' has even been found written on the kangas women wear in East
Africa, although women's time frequently is not remunerated. Preventive measures
for vector-borne diseases may result in smaller expenditures of time and effort over
the long term, but they almost always result in increased time and effort for women
over the short term. Activities such as installing bed nets, curtains or window and
door screens and plastering walls all require a considerable investment of women's
time.
For vector control to be effective, it is often necessary for the entire house lot to
be 'controlled' in some manner. For effective Aedes aegypti control, tyres and cans
containing water must be controlled, whether they are right beside the house, or at
some distance from it. The household area may originally be thought of by the
householder as limited to the house and its immediate surroundings. This area may
be kept meticulously clean, with large pieces of refuse being disposed of at the very
back of the lot, and small pieces of debris being swept out beyond an invisible line
demarcating the boundary of the household area (Arnold, 1990). Vector control
workers promote the idea that householders are responsible for the entire property
lot, including the area used for dumping household refuse. This translates into more
time and effort for cleaning this expanded area, including sweeping, filling in puddles,
eliminating cans, bottles and tires, covering standing water and developing alternate
refuse disposal strategies.
Leslie (1989) has extensively looked at the time that women have to allocate to
child survival interventions, including administration of oral rehydration therapy
( O R T ) distribution to sick children and preparation of more appropriate weaning
foods. Similar studies need to be conducted in the context of tropical diseases and
the time allocation requirements that they demand.

An agenda for future research

Responsibility for the implementation of strategies to control vector-borne diseases

has traditionally been assigned to the personnel of vertically organized vector control
programmes. Such personnel have entered homes and applied residually acting
insecticide to walls to control malaria and Chagas' disease vectors or have inspected
and eliminated the container habitats of Aedes aegypti. The impracticality of such
approaches when they are facing decreasing acceptance on the part of communities,
coupled with increasing fiscal austerity, has led to an examination of the potential
role the householder might play in disease vector control.
Vector control measures carried out by householders undoubtedly provide benefit
in terms of reduction in mosquito nuisance, but their actual contribution to disease
prevention may be negligible if high levels of coverage are not achieved. An under-
standing of the factors that affect usage is necessary in order to assess whether
sufficiently high levels of usage of interventions, such as insecticide-impregnated
mosquito nets, can be achieved.
The implementation of vector control measures at the household level is frequently
the responsibility of women. It should be kept in mind that women are at the same
time responsible for the implementation of other disease prevention measures mostly
 337

related to their roles as mothers, e.g., the Child Survival technologies. Bolton et al.
(1989) have pointed out women's multiple roles as spouses, child bearers, providers
as well as recipients of household health interventions and income generators. Vector
control interventions thus will have to compete with a series of other tasks for
women's attention. How well vector control interventions compete will depend on
a number of factors, including their perceptions of the biting insects and the diseases
they transmit, the relative effectiveness of different control measures and the amount
of disposable income at the household level. It will also depend on the effect both
past and current control programmes and interventions have on them in terms of
their power and authority within the household, their economic position and the
total work load placed on them. Very little is known about this now. Therefore,
there is a need to pursue a research agenda on vector control, women and the
domestic domain.
The first step in such an initiative should be to recognize the household and the
domestic domain as a distinct subject for research separate from the house and its
physical characteristics. This has seldom been done. Berman et al. (1994) note that
'it is curious that so little work in international health has utilized this understanding
of the household ... this also may be due to methodological inadequacies which
force the household to be defined only as a physical setting in which these behaviours
take place.' A multi-disciplinary approach will be needed, including household
economics, cultural anthropology, geography and vector ecology. An explicit focus
should be to study how women divide a house and its surrounding area into different
zones according to the degree to which it is public or private, the uses for each zone
and the people who are permitted in it. Appropriate control measures should be
developed for each zone. In the future we may need to provide the householder with
a range of control options and allow them to choose where in the house each is to
be applied. They may choose, for example, to use insecticide-impregnated curtains
in the bedroom and then spray the walls of the other rooms with insecticide.
In conclusion, we believe that future research will need to explore the following
areas in order to improve the acceptability and, thus, the efficacy of vector control
programmes:
(1) Factors that affect the selection and usage of various vector control measures
at the household level;
(2) Women's responses to vector control programmes and factors that influence
these responses;
(3) The influence of vector control programmes on interpersonal relationships within
the household; and
(4) How utilization of and access to different zones within the house and surrounding
area by various household members and strangers influence the selection of
vector control measures by householders.

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