Malaria is linked to All Aspects of Life

Temesgen Afeta

The meaning community members give to malaria and their perception about its causes, prevention and treatment are changing overtime. ?The meaning changes are connected to the family and community livelihood, physical health, economy and history, social support and network, institution, culture and gender roles of the Gibe River stream community. Health facility success for malaria prevention and treatment is linked to the meaning communities give to disease and death; their causes, treatment options available and level of family income. Women and men actions in malaria prevention and treatment are also linked with their awareness level about malaria prevention and its causes. That is the actions of women and men in malaria intervention depend upon information, communication and education the family members received. There is also interconnection between using available health services and husband and wife negotiations on types, place and time of treatment complied by physicians’ orders. Families treatment seeking and prevention practices are linked with social network in which neighbors provide emotional, social, spiritual, economic and emotional support to the malaria sick person and his/her families or the families whose members have died due to malaria(T. Afeta, 2013). ?

Family members’ sickness by malaria coincides with land cultivation, crop harvesting and children school attendance seasons. Malaria sickness is also linked with the history of each family and its health background. Because, the society in this particular localities have been facing malaria from one generation to the other. There is also a link between human ecology: people, female anopheles mosquito and malaria causing parasites as both survive and breed in the same geographical areas and under the same climatic conditions. As the malaria parasites survive and breed by infecting both human body and anopheles mosquito, the incidence of malaria outbreak is related to topography, temperature and water where they survive and breed.

The malaria treatment and prevention are provided within such ecological contexts, cultural and socio economic conditions.? People keep living in such ecological areas where Long-lasting insecticidal nets (LLINs) and Indoor Residual Spraying (IRS) are used to avoid mosquito and human body contact and environment management to reduce mosquito breeding. Such malaria prevention goes together with malaria sick person treatment in the existing healing system, so that mosquito can’t get or access the parasite infected human body. Health care services for malaria treatment are linked with the availability of health facilities, transport and road access to travel for treatment. ?

Malaria is related to gender and age as pregnant women and children are more vulnerable and affected than adult men and non pregnant women. Malaria is related to women burden and family poverty as many children become orphan when one or two parents die of malaria or when the bread winners get sick for long time or die or unable to engage in productive activities and produce enough food for the family. Malaria disease burden and its control action links are extended out from family environment to health post; health post to health center and health center to Wereda/District/ health office; this keeps on to national and international levels.? Families are connected to health posts for treatment or the health extension visits households to provide information, skills and support in LLIN use, using medicine as prescribed by physicians, not plastering the sprayed houses and draining water collected. The sickness records of individuals due to malaria and rapid diagnostic test results and treatment are kept at health posts and connected through reports to health center and Wereda Offices then to regional and national, even to international levels (T. Afeta, 2013).

Such recording and interconnected information sharing are stated as part of “malaria surveillance systems in the control phase”?(WHO Malaria Report, 2012, P. 10)?through which?malaria case registers are kept with diagnostic tests performed at health facilities; data were sent to district and higher levels. District health facilities periodically?(weekly or monthly) summarize?malaria?cases and deaths to see trends; assess the impacts of malaria control actions already taken and spot health facility catchments and villages that need priorities and urgent actions. Malaria cases and deaths are assessed to identify malaria incidence, the population affected and the sources of infection. Malaria incidences are analyzed from daily or weekly graphs to spot the trends, village and cases that require attention?(WHO Malaria Report, 2012). The link between the sick person and health facilities is critical, though there must be people who instantly take him/her for treatment along with uninterrupted supply of health service provision from health care systems. Malaria disease intervention needs consistent attention from health service providers and families; instant response to treatment, information sharing and continuous availability of services in which health facilities and families of malaria sick person roles are critical(T. Afeta, 2013). ??

The emergence of new concepts and meanings in malaria intervention

New concepts and meanings emerge along with the introduction of new health services and utilization of modern health services, treatment and? disease prevention, for example when supplying LLIN, spraying houses, RDT services and medicine. There are newly rising concepts and terminologies (rhetoric) to which community members are getting familiar along with the introduction of new health services more effectively addressing malaria prevention and treatment needs. The emerging meanings and languages are used to convey information and education between family members and health professionals as well as naming emerging services like Agobara or Saphana siree(LLIN), bifa chemicala ( IRS), nano qulqulesssuu(environmental management), maree hawassa(community conversation on malaria) and halamijessa(community conversation facilitator). With regard to treatment, the newly emerging words are mana yala(health service facility), dhiga sakata’amu(testing for malaria? by laboratory or by RDT), marfee waranachuu(taking injection) and qoricha liqimsa ( taking quinine). Learning these words by the community members and health care providers are important as they the two to effectively delver health care by the providers and accept health services by health service users. These health concepts help health care providers and service seekers to exchange information and message about malaria prevention, treatment and evaluate the impacts of malaria intervention. ?

The emerging concepts and meanings are used by family members for example taking injection or using quinine, exchange information between neighbors on malaria through community conversation. This implies, there are concepts and knowledge of medical services that family members and communities have to know to apply malaria prevention and treatment promoted by health care providers. There are also emerging concepts and meanings regarding gender in the community in the context of promoting equality of women and men to health care services that includes walqixuma dubaritii (women equality), hirmana dubartoota( women participation), loogu dhiisuu ( non-discrimination) and others. Not only words, but meanings and how and in what context they are transferred to local people and used in the family also come out newly along with such newly emerging concepts. There are also discourses about malaria at community level. The community leaders, the religious leaders and community administrators take malaria issue as one of their top agendas and discuss on their meetings and discussing as part of community matters that need continuity.???? ?????????

Tools for identifying malaria, the types of medicine ordered by physicians to cure the sick person from malaria and the knowledge and the meaning about the causes, prevention and treatment of malaria has changed in the community in the past years. Some years back, malaria is identified by community members using eye observation ?and body contact to the sick person and noticing the severity of the disease from fever, sweating and shivering, loss of appetite, what the sick person say and his/her body position like inability to move, lying on bed and expressing serious pain noises. However, since recent years, RDT is used for identifying malaria sickness though the knowledge of family members remains significant to complement these scientific methods.

The pattern of relationship between family members and neighbors in relation to malaria prevention and treatment has been changing overtime. The types of relationship and joint actions between treatment seekers and healers have been changing along with the changes in the mode and types of treatment of malaria sick person and preventing the disease. Previously healing knowledge and skills depend on customary practice transferred form generation within the community while the health services is open, mainly from outside that include trained professionals from various disciplines in which local, regional, national and international bodies have part. In the previous times, in some cases, there is discouraging or prohibiting visits to malaria sick families or contact to the sick person. The collective reaction to malaria is people’s gathering at one place, slaughtering bull and praying. This is considered as cure for the sick person or prevents malaria. The fear of getting malaria through body contact with sick person is currently changed and people carry the sick person to health services without fear of body contact, discuss about LLIN use, IRS and sharing information on treatment availability. Treatment and prevention seeking through consulting traditional local healers is changed to getting advice from health professionals, health extension workers and community leaders with some kind of health information.

?Meaning and Practice Changes in Malaria Intervention

The fining of the study indicates language (rhetoric) and discourses about malaria and its outbreak, sickness, severity and beliefs about the causes and treatment seeking and practice has been changing over time (T. Afeta, 2013). There are a number of changes in community perceptions and beliefs about malaria; definition and knowledge about its causes, ways of identifying malaria disease as well as taking treatment and prevention actions. One noticeable change is community definition of malaria changes from naming malaria as?Golfa?in the past is currently changed to calling the disease as?Busa?(malaria); from believing? its cause as eating maize, contacting the sick person vomit, sleeping with the sick person to currently accepting mosquito bites as the cause of malaria; from identifying malaria? by looking or touching the sick person with fever and shaking to the current rapid diagnostic testing (RDT); from garlic, green paper and herbs customary healing to using modern medicine prescribed by physician. The trend indicates, communities are increasingly becoming familiar with terminologies like anopheles mosquito, LLIN and its management, IRS and avoiding plastering the sprayed rooms, names of medicines used for treatment like chlorophyll for vivax treatment and – for plasmodium?Falciparum.

Along with using new health terminologies, households experiencing malaria sickness see when their own role combined with the action of physicians and used modern health post and health center treatments are curing them from malaria in practice. There is also role shifts in malaria prevention and treatment practices overtime. In previous times, the communities overlook their roles and the contribution of some other forces in prevention and curing the person.? They believed some evil, wrong did or God punishment is making them sick. That is some power either make them cured or die; or prevents them from disease. They overlook their own action and actions of others doing something in their actions exactly like what physicians and health care systems are doing with families care givers. Now they have realized they are contributing even play significant roles in their own health in which their interaction and relationship with health facilities and professionals are indispensable. They are changed from only believing God punishment and wrong did makes people get sick and praying alone make people be cured to getting treatment cures people and not getting treatment makes people die. They know and are sure getting health service cures them, and not getting treatment makes people die. At present they are realizing the importance of their own actions for their own health both for getting treatment and cure as well as preventing disease and death. In the past, the belief and decisions about once being healthy and death is something out of their control. Such notion is getting less importance while they are getting more and more dependable on the decisiveness of their roles in their own health; their own action significantly contribute to prevent or cure them from disease. They also understood their own carelessness and reluctance to immediately and continuously respond to own health leads to sickness and death (T. Afeta, 2013).

Along with the expansion of health facilities, educating own children; emerging and improvement in relationship between health service providers and families, the transformation in health knowledge, beliefs and action is noticeable.? That is a change from depending on beliefs that one can be prevented, cured or die to individuals, family and physicians actions determine prevention, cure and death of a person? and from depending on something external bodies for own health to understanding self-significance about own health. Knowledge, beliefs and actions and relationship between families and health service delivery systems are increasingly changing and new actions are emerging from time to time to empower families and individuals to be more competent and responsible for their own health through disease prevention and treatment (T. Afeta, 2013). Community conversation on malaria, establishing community support groups and training community conversation facilitators through C-Change projects are some (CARE Ethiopia unpublished report, 2012) examples of emerging community empowerment for own health. One focus group participant stated such changes are mainly due to increasing community children education who now becoming physicians, health extension workers, and development agents and teaches. ???

Furthermore, Gibe River Stream communities have been facing malaria burden through the generation along which they have been taking steadily improving measures from one generation to the other. The belief about malaria cause as Gods punishment for wrong did or eating corn at its early stage (Asheetii), contacting or sleeping with the sick person has changed to accepting its causes due to mosquito bites. They believed as Golfa was transmitting from one person to the other; because, when one person got sick in the family or neighborhood, two or more persons got sick next. However, they haven’t or couldn’t realize mesquite was infected when biting the person sick with Golfa and then transmit the disease when biting other people. Such changes and malaria prevention actions promoted by health care systems are becoming the point of discussions on community formal meetings and the interactions of grassroots experts with community, teacher with students, prayers with religious leaders as well as family members with their neighbors. The dialogue was mainly on action and the role of individuals, families and physicians as determining prevention and cure from malaria; pulling and pushing people to understand their own importance and take actions for their own health.? The discourse was not to make them believe that something external bodies help them to be healthy and safe from disease and death.? It was to make them realize their essential and persisting role from within the community complementing health services provided by health extension and health centers and other modern health facilities (T. Afeta, 2013).

Malaria Causalities Passing from Generation to Generation

?Family history reveals experiencing malaria causalities and challenges in underlying treatment; loses of life and burdens passing from one generation to the other. The families and communities in the Gibe River Stream have practicing trials of treating malaria sick person and prevention; steady treatment improvement, language and meaning changes on malaria for generation. They have been going through one generation to the other by taking malaria prevention measures, providing treatment when someone got sick; giving different meanings for malaria and its causes.

Within this malaria, mosquito and human relationship legacy, the communities in Gibe River Stream valley have developed the kind of practices and knowledge to prevent the disease and use various treatments to cure malaria sickness. They consult healers that give explanation about the disease, its causes and treatment recommendations. The knowledge of study participant women about sickness, healthiness and symptoms of disease is part of such preventive and treatment history in which women have been playing crucial roles in managing the health of family and contributing to neighborhood health. Health of family in which women play key roles is the most constantly and entirely monitored, the most regularly watched and instantly noticed and the most immediately reacted. Because, ensuring the health of a person through preventive and treatment is the major goal of human survival and this burden is essential family functions that link families to any health service providers be it modern or the traditional once. Beyond the health of their family members, people are concerned about the health of their neighbors, relatives, friends and the whole community members in general. In the study community, people salute each other during the first morning contact represent by inquires about the health and security of the contacted person, his family, resources and environment(T. Afeta, 2013).?? ?

The Causalities of Malaria on Women of Local Community

As it infects at least one family member during cultivation of land and harvesting seasons, malaria is unique for Gibe River stream women and community who never be free from the fear of malaria when rain starts and go. The duration of malaria outbreak coincidences with most important farm pick seasons like seeding and harvesting. People worry their members may get sick or when some feels discomfort, he/she might be caught by malaria. The bread winners both women and men lost life or on bed for long or get impaired during pick farming seasons. ?Hence, malaria threatens food security of the family or the family experience hunger, even disintegration; when father or mother or both die children are separated to get care form relatives. Serious malaria sickness, especially when husband gravely sick for many days impaired, cured or die or when referred for further treatment the head of the families are unable to engage fulltime on farm and produce enough grain to feed his/her own families. These have serious implication on family livelihood and children who could not get adequate care and attention from parents (T. Afeta, 2013).?

Malaria also infects more than one family member at once; this increase the burden of women to care for more than one family member at once. All family members (constituting five persons nationally, the average household size is 4.7 persons [MOH, 2010) at risk and there is a time when all family members get sick at once.?All age groups and all family members are at risk from birth to death and this makes population residing in malaria endemic unique. Sickness of many family members increases women care giving burden. For example, according to the study participants, Dambi Dima Kebele has recent experience, when all family members have died in some households and in many families few people recovered while many died and in others when children lost father, mother and siblings(T. Afeta, 2013).

The other complexity of malaria disease burden that when malaria infects more than one family members, their sickness can be at various stages: hence what they need, especially children at different age for treatment, food, cleaning and support varies, though all can be dependent on care givers in some way. In such case, women (when not infected) jump from caring for one sick person to the other; from farming to caring for many sick family members and from domestic work to cooking. Malaria is also unique for women as it infects many neighborhoods at once. During malaria outbreak, as many or sometimes all family members in neighbors get sick, people couldn’t get the person who provides care at home by cooking food, caring for children, cleaning, carrying to treatment, looking after livestock and looking for farm. Furthermore, malaria mainly affects children and pregnant women who normally need especial care even when they are free of malaria; otherwise their life is most threatened. When the mother is infected by malaria; the burden comes to husband. He is unable to get the one who play the role of mother or forced to do both what mother and men do, otherwise children couldn’t get food, hygiene, health care and all caring that the mother provides(T. Afeta, 2013).

Malaria prevention and treatment is integral part of family health

That is malaria prevention and treatments for the sick person are an integral part of family health in which the care for the sick person is mainly accepted as the practice of women domestic roles. Disease prevention and treatment for all diseases at home are mainly carried out by women. Caring for the sick person is also believed to be part of domestic works and labeled as the duty of women. Hence caring for malaria sick person is integral part of the duty of women. Providing care, reminding and giving medicine on time, cook especial food preferred by the sick person, cleaning and providing physical, psychological and social supports are sick person caring mainly performed by women. Women provide psychological support to make the sick person feel strong, capable and recover so that take medicine, eat food, make physical exercise, stand, walk, sleep, seat, go to toilet, bed and come to the ground. Women are the main actors of social support connecting the sick person to information and health care as well as relatives, neighbors, community members and health services that involve and contribute for curing the sick person. Malaria sick mother is the one who cares for herself and for the other malaria sick children and family members, especially when the disease starts and at early stage of recovery.? The sick mother keeps working until she gets unable to control self and cook and caring for children, even before totally being recovered. Compared to men, she is the one who lately go to bed when she gets sick, working until she gets seriously sick, caring the disease and working. The mother starts early or soon to care for malaria sick family members immediately after she gets recovered until the sick person get totally cured. She is the one who work while she is sick (T. Afeta, 2013).

Multi stakeholders and multi-level role in malaria prevention and treatment

Malaria control and prevention is not only the role of individuals or groups in the family. It is complemented by the knowledge of experts, physicians, care givers and malaria sick person her/himself. It fundamentally starts from the existence of the diseases, primarily spotted by sick person, involves health care professionals in identifying the disease, its causes and cures. Factories producing drugs, insecticides and LLIN; donors providing fund for drug and insecticide purchase; international and national policy makers; regional offices distributing drugs, insect sides to intermediary offices supplying the medicine to grassroots, the agencies mainly dealing with financial, policy and make decisions on quality of treatment. The grassroots dispatch the medicine for health service providers and health posts from which the malaria sick person directly get the medicine and treatment (T. Afeta, 2013).

In general, the interlinked bodies working on malaria can be divided into four major categories: the sick person whose life is threatened by malaria; families and health care professionals directly providing care and treatment for the sick person; institutions formulating health polices, decide on purchase, supply and control quality of medicine as well as donors and medicine producers that generate resources for malaria prevention and treatment. Though the role of the sick person, professionals’ knowledge, factories producing malaria drugs and insect sides as well as the roles of those delivering the medicine to people are most important, malaria intervention requires the involvement of different professionals and organizations and passes a number of steps. Treatment, drug use and production are also guided by polices (WHO Malaria report, 2012), laws, cultural values and attitudes.???

Malaria is the disease of poverty

Malaria is the disease of poverty as it is related to low level of education, lack of awareness, and income and resource constraints at government, international, community and household levels. Its outbreak brings poverty to children, family, and the community. Because, children dropout and leave school, die, or become impaired, mother or father die and children become orphan; the family lost bread winner or the women become widowed and take the responsibility of caring for many children without husband.

Malaria has intra-generation and inter - generation effects

In upper Gibe River community, malaria has inter-generational effects as it is connected with the ecology of the area and putting the settlers at risk from one generation to the other. These people neither move to other place and the malaria never be eliminated. It is usual for their forefathers, fathers and generation feel fear of malaria sickness or deaths expected twice a year, especially when farmers are shortage of manpower and time to work to ensure their families yearly livelihood. Their forefathers and father is caught by malaria and their father and then children and so on. This also passes debilitating generational effects that pass from one generation to the other.

Malaria and Women ?

Malaria is related to reproductive health and age. The pregnant women mainly affected by malaria compared to non-pregnant women and children compared to adult persons (MOH, 2010, WHO,2012). High fertility and uncontrolled pregnancy put women the most at risk to malaria in their life courses. Starting from the time when the woman (conceived) is in her mother’s womb and before reaching five years, then when she becomes pregnant and inter into old age, women are more exposed to the risk of malaria compared to men in their life courses. The women risk increases along with frequency of getting pregnant; if she gets pregnant nine times in life, her risk increase nine times more than men or the women who has not get pregnant. Hence, when living in malaria endemic areas, woman is at risk, fear or feels insecure for self, family and neighbor in her /his life course compared to the people living in malaria risk free areas or not making travel to malaria risk regions. In most cases, most population in malaria endemic areas either can’t move away from the regions where malaria is risk or malaria can’t be eliminated. They rather developed their own survival mechanisms that incorporate tolerating malaria risks that cost life, resources and longtime effects on one hand, taking actions of prevention and treatment dynamics either in traditional or modern prevention and treatment actions.

Malaria is unique for women in that in malaria endemic areas it becomes sever in their life courses several times that are when they are in their mother’s womb, when they are under five, when they get pregnant and when they get older age. Repeated pregnancy makes women in repeated severity risk. Malaria is different for women also when caring for the sick persons at home, as it infects many family members and increases her burden tremendously. Its prevention is also different for women as the duty of managing bed net, house utensils and arranging home for the spray are mainly the responsibility of women.?

Men leave the decision as to what types of food to prepare (the size, thickness and quantity of Injera to be baked, the amount of onion to be chopped, the thickness of wat to be prepared; how to make washed clothes neat and clean houses), which type of firewood and water to be fetched, when and how to clean rooms and wash clothes for women. The men hold the decision about selling cows and grains, the amount and the types of expenses to do for treatment. In both cases the men are benefiting. Since, the women have knowledge, skills and experiences, the men leave the later one for the women decision and choice. Their decision and action are punished or rewarded by the social values and women decide and do the best due to fear of social punishment hence, men benefit from the best action women take in domestic works. Women decision fear of social punishment is benefiting men. Secondly, decisions over the resource use; expenses and managing money benefits men as they directly use or allocate money according to their priorities and interest. Women quality and uniqueness to overcome or withstand social and cultural pressures? through demonstrating their competency, quality work and endurance are significantly contributing to their swift response to treatment, consistent use of prevention devices, accomplishing wider range of and long times of work in domestic and farm activities, consistent and? covering a number of care for malaria sick through cleaning, food provision and medicine provision is critical for ensuring family health and the health of the general population in general.? From this one can realize, women have the power and their voice influence and change the minds of men, if they are listened and the situation is facilitated to make them speak, act and decide especially in group.

Maternal health that constitutes gender is the core for global and national health (Oromia Health Bureau (2011). Maternal health and associated gender issue is being addressed by national polices for example: the Ethiopian Constitution (1994) and intentional human rights proclamation (Universal Declarations, 1948); the Labor proclamations, family law and other policies. To implement policies on women, the ministry of women and children is established and its structures are extended from Federal to Wereda levels. There is high media coverage regarding gender and it also mainstreamed in many government, NGOs and UN organizations. However, according to the Ethiopian Demographic and health survey, the Ethiopian women are far behind in education, employment, holding higher positions while they are higher in illiteracy rate, burdened by domestic chores?

?Health system, which is either educating or learning health profession, working in health at senior management and policy making level, health care delivery systems starting from referral hospital to Wereda level are male dominated starting from households to organizations employing persons and providing training. The unpublished data at regional and federal levels shows that the number of men professionals by large exceeds the number women (unpublished data, Oromia Health Bureau, 2013 and Ministry of Health, 2013).? Professionals giving service and making health policies are mainly males. Health promotion and education are planned, implemented, supervised and evaluated in male dominated health systems, culture, education, training and movement.?Gender is fixed into the economy, the family, the politics, medical and legal system; influence how men and women are treated in all life including health and illness; being born or dying (Lorber, 1997:3) states cited in Encyclopedia of Public Health, 2002).??At all positions in informal or formal it is not women who make decisions. Consistent to this, The?Millennium Development Goals Report 2013(2013) states that “whether in the public or private sphere, from the highest levels of government decision-making to households, women continue to be denied equal opportunity with men to participate in decisions that affect their lives” (MDG Report 2013, 2013).?In government offices responsible to materialize? affirmative measures ( the Ethiopian Constitution,1994) to ensure women equality and mainstreaming gender in government sector,? for example? Ministry of Health and Women Affairs office, the number of male employed, especially at senior position is exceedingly high compared to women. Though the number of women is at least equal with men worldwide, women has not been at the position of secretary general of the United Nations, the body first proclaimed equal rights of all people without discrimination of any kind.?? ??

Though few women come to high position, they are influenced by men in many several dimensions, their boss may be male, advisor may be men, the majorities of partner organization heads may be men; women may be only one in vertical or horizontal directions to be at post in one organization. Budget allocation and activity implementation might be directed by men, though the women may have high positions. The structure is established by men, policies and mainstreaming programs for women health are mostly formulated, managed, directed and executed by men. According to MDG 2013 report, though the study conducted in 51 countries reveals increasing women’s enrolment in tertiary education since recent years, it doesn’t attained great opportunities for women in the labor market. Gender wage gaps and women hold less managerial positions compared that ranges from 10 per cent to 43 per cent in private sectors many (The Millennium Development Goals Report 2013, 2013).

At community level, health extension workers are women but in many cases Kebele/community administration chairman and the majorities of Kebele cabinet members are men and Wereda Health heads and health staff are men. These men have the position of women inculcated in their mind by the way their fathers, teachers and the society have been treating women and may refer their religion, history, and existing gender related prevailing attitude to treat health extension workers. Hence, male dominated health system makes the realization of the right of women challenging.? It doesn’t go beyond paper and media talks; this is why women remain at less position in all aspects of life staring from family to education and employment institution and decision making. Employment and education inequalities are impacting women health and decision making power and possession of resources that they can allocate for their own that of their family health including malaria interventions.

Community integrated response to malaria intervention??

Unpublished data from C-Change project implemented reveals that community members exchange information about malaria through religious prayers, social and cultural gathering, farm activities and any other social contacts during which the community discuss about its concerns and priorities related to health and security of its members. Communities have a number of occasions during which its groups organize a meeting to address its functions like solidarity and administration like Jige community cooperation during farming and harvesting, Afosha community members’ voluntary meeting, Kebele/community administration meetings to discuss and decided on administrative issues and implement government policies. Malaria discussion was mainstreamed along with such community contacts and the trained community leaders and community conversation facilitators facilitate community discussion and transferring messages on malaria prevention and treatment. Prevention of diseases fundamentally presupposes the willingness and participation of diverse community members.

People either become ok or get involved if they accept and think the action is their main concern and vital. Hence, the participation of women on the information exchange domains was low compared to men. That is on community conversation conducted for six months on malaria in the malariaous Kebeles, women represented less participants of malaria community conversation conducted for six months. The number of women is less not only on the training organized at Wereda levels on malaria, but also on CBOs, religious prayers and others discussions conducted on malaria actions at community levels. For example, during community members discussions conducted by CBO members, women represented only 34% the community members participated? on discussions on malaria actions, conducted in the community.

Out of the 20 malarious Kebeles selected from Ilu Galan and Bako Weredas for the first round community conversation. The community level leaders members male dominated and only the health extension workers and few teachers and manager women were there in the committee. In this regard, 140 members of community cabinet groups leading the community, women constitute 21 percent while men representing 79 percent of community leadership. Even of the total 30 women involved 20(66 percent) are health extension workers. On the average, women represent 2 of every seven cabinet members, and the majorities are health extension workers or dominated men.? There are no women CBO leader, no women Kebele chairperson, no women religious leader women and all these key position in the Kebeles are occupied by men. Except health extension works, very few women become teachers, managers and development agents. Out of community conversation facilitators trained to conduct community conversation in each of the 20 target Kebeles, women only represent 13 percent and men occupied 87 percent. Of the 20 Kebeles women are only from 4 Kebeles from 16 Kebeles on women participated in community conversation.

Gender role in community health

Women are fully committed in health care in which they involved and they also involve in many dimension of household care for malaria sick person. Women are consistent, passionate and whole hearted in caring for malaria sick person. They play the role of physician by primarily diagnosing; had it not been the women tested the sickness of the person at home no one comes for health services and women are primary healers through identifying the sick person and mediating the link of the persons to appropriate health services, family and neighborhood engagement? in community health care systems. They provide medicine (link medicine to the sick person), they make checkup regularly to see the intensity of sickness. They transport to health service and back to home, they pull resources by involving the family, the neighbors, community and relatives in the sick person treatment systems. They pull resources around the sick person.

Being women extension workers have an implication on their work and health services. Because, the work of women is mainly labeled as low or inferior to men, whatever educational level they attained or whatever position they hold; hence, they may not hear to the person whom they consider as less.? Furthermore, they label not only the women position, but all works and actions categorized as the role of women(the role, status, behavior, preference, perception and knowledge and relationship) or what they promote or give priority are labeled as inferior to what men possess; hence male dominated community cabinet give less attention to what the health extension workers give priority, reluctant to make health extension workers speak first, they are given chance to talk about health programs most of the time at last, or after all agendas were discussed; mainly after the meeting participants get fed up.

Always the health extension workers are the last invited to speak on the meeting, and sometimes, the Kebele leaders give priority to other issues, mainly political matters rather than what these young women were talking about. The women if they have some issues they repeatedly lobby the Kebele leaders to allow them to speak and it seems gender issues is expanding/transferring to the position and the role of health extension workers and the leaders have the tendency to see the role of health extension workers as that of the role of women or from women role the dimension of women’s positions.

That is when health extension workers are poisoned as women, and their health service, health promotion activities are understood as the role of women. Not only women work, but women cloths, women shoes, women associations, women sites, women hairs and so on. It mainly observed when women tend to wear men’s clothes, trousers which are exclusively considered as the cloth of men, though men don’t wear, the woman’s dress. This implies how women are moving to the clothes reserved for men while still men don’t feel conformable to wear the women? cloth styles as they contempt it, it is the women’s clothes.

Malaria prevention and treatment response in the family

The actions women take in reaction to sickness of family member depends upon the duration to which one stay sick, the types of disease and the type of family members who got sick, for example whether it is a child or an adult. Women are more attentive to the sickness of children compared to adults. Close health follow up on the health of young children is the universal phenomena: be it in the family or health services or health care settings. This is evident in giving priority for children under five during ITN use in household. ?When the disease is malaria, the person seeking early treatment can go by himself walking, he/she takes food; however, if stayed longer he needs cart or animal back and going sitting not standing; if stayed more longer he will be carried by people; shoulder lying on bed(neither stand nor sitting). The sick person goes to health service, if it is early, mostly on his foot moving by him/herself, if stayed longer without getting treatment not on foot, but sitting or others making a walk either by human or animal back or by vehicle, if still stay longer, neither walk, nor sits but lying by his back and carried by people, cart or vehicle and then the sick person get rescued.

?Temesgen Afeta(MSW)

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