Perceptions of risk, vulnerability, and disease prevention in rural Burkina Faso: Implications for community-based health care and insurance

Human Organization, Summer 2002 by Sommerfield, Johannes, Sanon, Mamadou, Kouyate, Bocar A, Sauerborn, Rainer

This paper examines local discourse on perceived risk and vulnerability among rural and semiurban populations in Kossi Prov-- ince in the northwest of Burkina Faso. Focus group data are presented to elucidate this discourse in a number of risk domains. Local notions of disease prevention are exemplified with respect to malaria, diarrhea, and vaccine-preventable diseases. Quan-- titative measures on perceived severity and perceived personal vulnerability, assessed using culturally adapted scaling methods and relating to a list of selected risks, are presented. Implications of the complex local discourse on uncertainty and vulnerability with respect to community-centered development efforts such as community-based health care and insurance are explored.

Key words: risk, vulnerability, perceptions, West Africa, Burkina Faso

Research in public health, and notably epidemiology, is predicated largely upon the concept of risk (Backett, Davies, and Petros-Barvazian 1984; Gordis 1988). In the public health sciences, the concept has impor-- tant implications for health policy, health resource alloca-- tion, and health communication. Community-based health care (CBHC) and community-based health insurance (CBI) are important policy concepts for the development of sus-- tainable rural health care systems in developing countries. CBHC and CBI are built upon the need to create and sustain community action, and community perceptions, attitudes, and practices toward risk and vulnerability are of interest to ap-- plied medical anthropologists and public health profession-- als alike.

Risk perception research has figured prominently in an-- thropology as well as public health (Cashdan 1990; Fischoff, Bostrum, and Quadrel 1997; Johnson and Covello 1987; Kaufert and O'Neill 1993; Krimsky and Golding 1992). Ten years after Mary Douglas's (1992) pioneering work on risk perception (cf. Tansey and O'Riordan 1999), the social sci-- ences have rediscovered and redefined risk research. Extend-- ing beyond an individualistic and psychometric paradigm (Slovic 1987), social scientists have stressed that risk behav-- iors and perceptions can neither be understood nor analyzed outside the social and cultural contexts in which they evolve (Frankenberg 1993; Hayes 1991; Lupton 1993; Kane 1993; Petersen and Lupton 1996).

Anthropology's interest in situating risk in its social and cultural context and reconstructing risk discourses from the meanings of groups and communities "at risk" has recently been challenged by medical anthropologists working from a critical or critical interpretive perspective. They have problematized individualist approaches to risk perception and behavior, pointing instead to the role of macrolevel factors and structural forces, such as poverty and gender inequality, as enhancers of risk for exposure to HIV (Farmer 1992). Criti-- cal anthropologists contextualize microlevel ethnographic data in the wider socioeconomic complex. The possibil-- ity of individual behavior change is often limited, par-- ticularly if one disease is singled out in disease control. Rather than studying individual risk perceptions and behaviors, these critical medical anthropologists have opted to study agencies of power and locate risk in the living conditions in which it occurs (e.g., Connors 1992; Gifford 1986; Kane 1993).

This kind of research expands the narrow concept of risk by looking at the larger framework of vulnerability, clarify-- ing which social processes lead to the existence and persis-- tence of local representations of, and attitudes toward, uncertainty (Farmer 1992; cf. Delor and Hubert 2000). An-- thropological risk research has often been disease-specific, related to perceptions of AIDS, malaria, or tuberculosis, for example. Rarely has it dealt with risks and vulnerabilities across a number of domains such as health, agriculture, eco-- nomics, and the environment.

Our research explored perceptions and valuations of risk and vulnerability in the domains of health, health care, eco-- nomics, climate, and agriculture. In addition, we investigated whether people perceived prevention approaches to these vulnerabilities. Finally, we investigated the degree of per-- ceived severity and vulnerability in relation to a selected number of risks.

Most inhabitants in the rural northwest of Burkina Faso lead lives of constant vulnerability to agroclimatic shocks, food insecurity, and illness. Their relatively isolated location, endemic poverty, and lack of effective social services, including water and sanitation, health care, and educational facilities, challenge communities on a daily and constant basis. How do people make sense of this situation? How do they experience and cope with their harsh environment? Do they perceive risks as international organizations, health plan-- ners, development economists, or agricultural agents usually frame them (USAID 1998; World Food Program 1998; Min-- istry of Economy and Finance 2000; Ministere de la Sante 2000)? Can strategies be conceived that reduce vulnerabili-- ties to financial risks associated with illness through, for ex-- ample, community-based insurance?