epi.2004.williams.socscimed.a critical review of behavioral issues related to malaria control in ssa...

8/14/2019 EPI.2004.Williams.socsciMed.a Critical Review of Behavioral Issues Related to Malaria Control in SSA What Contrib

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ARTICLE IN PRESS

Social Science & Medicine 59 (2004) 501523

Review

A critical review of behavioral issues related to

malaria control in sub-Saharan Africa:

what contributions have social scientists made?

Holly Ann Williamsa,*, Caroline O.H. Jonesb

aMalaria Epidemiology Branch, Centers for Disease Control and Prevention, Mail Stop F-22, 4770 Buford Hwy NE,

Atlanta, GA 30345, USAbDFID Malaria Knowledge Programme, London School of Hygiene and Tropical Medicine, London, UK

Abstract

In 1996, Social Science & Medicine published a review of treatment seeking for malaria (McCombie, 1996). Since

that time, a significant amount of socio-behavioral research on the home management of malaria has been undertaken.

In addition, recent initiatives such as Roll Back Malaria have emphasized the importance of social science

inputs to malaria research and control. However, there has been a growing feeling that the potential contributions

that social science could and should be making to malaria research and control have yet to be fully realized. To

address these issues, this paper critically reviews and synthesizes the literature (published, unpublished and

technical reports) pertaining to the home management of illness episodes of malaria in sub-Saharan Africa

from 1996 to the end of 2000, and draws conclusions about the use of social science in malaria research and

control.

The results suggest that while we have amassed increasing quantities of descriptive data on treatmentseeking behavior, we still have little understanding of the rationale of drug use from the patient perspective

and, perhaps more importantly, barely any information on the rationale of provider behaviors. However, the

results underline the dynamic and iterative nature of treatment seeking with multiple sources of care frequently

being employed during a single illness episode; and highlight the importance in decision making of gender, socio-

economic and cultural position of individuals within households and communities. Furthermore, the impact

of political, structural and environmental factors on treatment seeking behaviors is starting to be recognised. Programs

to address these issues may be beyond single sector (malaria control programme) interventions, but social science

practice in malaria control needs to reflect a realistic appraisal of the complexities that govern human behavior and

include critical appraisal and proposals for practical action. Major concerns arising from the review were the lack

of evidence of social scientist involvement (particularly few from endemic countries) in much of the published

research; and concerns with methodological rigor. To increase the effective use of social science, we should focus

on a new orientation for field research (including increased methodological rigor), address the gaps in researchknowledge, strengthen the relationship between research, policy and practice; and concentrate on capacity

strengthening and advocacy.

r 2003 Elsevier Ltd. All rights reserved.

Keywords: Malaria; Social science; Treatment seeking; Malaria control; Sub-Saharan Africa

*Corresponding author. Tel.: +1-770-488-7764; fax: +1-770-488-7761.

E-mail addresses:[email protected] (H.A. Williams).

0277-9536/$- see front matterr 2003 Elsevier Ltd. All rights reserved.

doi:10.1016/j.socscimed.2003.11.010


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services, local illness classifications, and the determi-

nants of behavior relating to changing national malaria-

treatment policies are all examples of areas in which

social science contributions are needed. Consequently,

programs such as RBM and MIM have emphasized the

importance of social science inputs in helping them to

realize their goal of improved malaria control.However, among social scientists and others working

in applied malaria research, there has been a growing

feeling that, despite international recognition of the role

human behavior plays in malaria, the potential con-

tributions that social science could and should be

making to malaria control have yet to be fully realized.

To explore why this gap exists, it is necessary to

understand what research has been done and what, if

any, impact the research has had in the field of malaria

control. This paper critically reviews and synthesizes

literature pertaining to treatment-seeking behaviors and

the management of malaria illness episodes in sub-Saharan Africa, and examines the contributions that

social scientists have made to this knowledge. A

subsequent paper will concentrate on the literature

pertaining to preventive activities, particularly insecti-

cide-treated materials. These papers link to an interna-

tional alliance1 whose goals are to enhance the capacity

of social science in the field of malaria control and to

better integrate social science efforts with other scien-

tists, malaria control programs, and policy makers, in

order to design more appropriate, effective, and

sustainable intervention programs.

Background and objectives

In the early 1990s, the World Health Organization

(WHO) commissioned a review of literature on treat-

ment-seeking behaviors for malaria by McCombie

(1994, 1996). The results of this review showed that a

great deal had been learned about malaria treatment-

seeking behaviors, but several gaps in knowledge and

understanding remained, including: (a) quantification of

actual drug intake, (b) understanding how people

differentiated between uncomplicated and severe malar-

ia, and (c) knowledge on how provider behaviors

impacted treatment seeking behaviors. McCombie(1996) also noted concerns about a lack of clarity in

commonly used terms, such as the difference between

self and home treatments or what is meant by time to

appropriate treatment. In addition, she pointed to a

lack of methodological rigor, noting that few studies

were comparable as there was minimal description

of how data were collected or what type of analysis

was used.

McCombies (1996) findings have been widely cited

and, since the review, there has been a marked increase

in the number of published papers discussing behavioral

issues related to malaria control. However, there hasbeen no concerted effort to summarize the knowledge or

critically examine the lessons learnt from the findings.

This paper attempts to fill this gap.2 In doing so, it

addresses the following areas: (a) what new knowledge

or complimentary knowledge has been generated since

McCombies review, (b) have the gaps in knowledge as

identified by McCombie been addressed, (c) has

methodological rigor increased, and (d) has the knowl-

edge been applied programmatically and, if not, why

not? The paper will also focus on identifying factors that

have constrained social scientists contributions to

malaria control, suggest new areas of research, and

highlight approaches to utilizing the results of applied

social science research, to improve malaria control.

Throughout this process, we sought to answer the

question, what should the thrust of social science

research and activities related to malaria control be for

the next decade? This review is written primarily from

ARTICLE IN PRESS

1These papers are part of a multi-step research plan that has

been designed by the authors, as well as other members of the

international alliance, the Partnership for Social Sciences in

Malaria Control, which held its organizational meeting inLondon, January 2001. The Partnership is envisioned as an

alliance of individuals representing specific skills and expertise

within specified institutions. Members of the Steering Com-

mittee of the Partnership include representatives from the

following institutions: Centers for Disease Control and

Prevention (CDC), London School of Hygiene and Tropical

Medicine (LSHTM), University of Nairobi, University of Mali,

The CHANGE Project, Multilateral Initiative on Malaria

(MIM), UNDP/World Bank/WHO/Special Programme on

Tropical Disease Research (TDR) (Social, Economic and

Behavioral Unit, Intervention Development and Implementa-

tion Research Unit, and Research Capacity Strengthening

Unit), Environmental Health Project (EHP), USAID African

Bureau, WHO/AFRO, Department for International Develop-

ment (DFID), The Maria Consortium, Mozambique National

Institute of Health, Ghana Health Services, Gates Malaria

Programme [LSHTM], Roll Back Malaria/WHO Geneva,

Malaria Foundation International, and the Danish Bilharziasis

Laboratory (DBL). In addition to the papers, other activities in

which the Partnership are engaged include: (a) updating the

literature base used for this paper, as well as maintaining a

Clearinghouse for Social Science and Malaria Literature, (b)

developing a webbased searchable format for disseminating

the literature data base, (c) developing a participatory network

of social scientists that reside or work in Africa, and (d) refining

a research agenda for social scientists involved in malaria

activities for the next decade.

2This paper is an adaptation of a paper given by the authors

as an invited plenary session at a meeting convened by the

WHO/TDR Task Force on Home Management of Malaria

entitled, Strategy Meeting to Define Outstanding Research

Issues in the Home Management for Malaria, held in Kilifi,

Kenya, May 2000.

H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501523 503


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the perspective of medical anthropology, although the

discussion points and recommendations have applica-

tion to a wider social science audience.

Methods

The review included published and unpublished

literature and technical reports pertaining to sub-

Saharan Africa, covering the time period 1994 to the

end of 2002. Although efforts were made to access all

pertinent literature, the authors acknowledge that, most

likely, there are missing papers relevant to this review,

particularly in the gray literature (technical reports,

unpublished papers), which were difficult to access. The

literature reviewed for this paper is part of a citation

database created by the authors and colleagues from

The Partnership for Social Sciences in Malaria Control

(PSSMC). The citation database consists of over 500entries of published and unpublished literature, techni-

cal reports, and oral/poster presentations from regional,

national and international meetings on malaria. This

citation database is currently archived at the CDC and

LSHTM, with satellite centers under development in

sub-Saharan Africa, as well as http://www.malaria.org/.

Due to constraints of time and space, the oral and poster

presentations were not included in this review.

Working with medical librarians at the CDC and the

LSHTM, the authors designed various search strategies

to review the social science, epidemiology, health

education and communication, tropical medicine/infec-

tious diseases, and policy literature. Computerized

databases from the United States and the United

Kingdom were searched on a biweekly basis, including

Bath Information and Data Service (BIDS), CINAHL,

Dissertation Abstracts, Medline, PsycINFO, Social

Citation Index, Social SciSearch, and Sociological

Abstracts. Library searches of more difficult-to-access

African journals were done by both authors, at the

libraries of CDC, LSHTM, and the University of

London. During field trips to Africa, the authors also

searched archival materials in various sites, including,

for example, the libraries of the National Institute for

Medical Research and the Tanzanian Essential HealthInterventions Project, both located in Dar es Salaam,

Tanzania.

Agencies that participated in international malaria

control activities (either as programmatic partners or

funding agencies) were contacted to obtain copies of any

related technical reports or unpublished papers. In

addition, the authors searched the archives of the

UNDP/World Bank/WHO Special Programme for

Research and Training in Tropical Diseases (TDR) at

the World Health Organization (WHO). As well,

individuals known personally by the authors and/or

colleagues of the authors were contacted to ask if they

had any additional work that they could contribute,

particularly unpublished papers. Papers were considered

appropriate for this review if they were concerned with

aspects of human behavior related to the recognition,

diagnosis and management of malaria (as defined bio-

medically or in local terms). This included papers about

perceived quality of care, as well as papers that discussedpolicy implications of malaria control. Three areas of

literature were excluded from the reviewtravel pro-

phylaxis, historical commentaries, and economic aspects

of malaria control. However, economic papers that

discussed the effect of cost on treatment-seeking

behaviors were included.

Results

We reviewed 117 published papers (including 87

research reports, one policy paper, two editorials, nineletters to the editor, eight brief commentaries, five

abstracts, and five reviews), 15 unpublished and 32

technical reports for this paper, for a total of 164

documents.3 (See Appendix A for a list of journals in

which social science literature was found.)

Treatment-seeking behaviors

Factors relating to treatment-seeking behaviors were

examined from the perspectives of both the patient/care

givers and the providers, including use of alternative

providers, patterns of treatment seeking, delays in care,

drug use practices (actual dosage patterns and delivery

of drugs by providers), and cognitive processes that

guide the decision making related to choices for care.

Recognition of illness signs and symptoms

Although there was a wide array of perceived

etiologies for malaria, the symptom complex that

corresponds to the biomedical notion of uncomplicated

malaria was widely recognized as a commonplace febrile

illness that could be treated in the home first, often by

tepid sponging, domestically produced herbal prepara-

tions, and/or the administration of pharmaceuticals

(most commonly used were antimalarials, antipyreticsand/or analgesics) (see Table 1 for references). Gener-

ally, absence of fever, ability to eat and play indicated

that children were better (Williams et al., 1999). A study

in Kenya found that, if fever returned within 1 week,

then the mothers perceived that the treatment had not

worked but if fever recurred after 2 weeks, then it was

considered to be a separate disease episode (Marsh &

Mutemi, 1997). Mothers were found to be well attuned

ARTICLE IN PRESS

3For purposes of this paper, only key references will be cited.

However, a complete listing of all reviewed papers can be

obtained from the authors.

H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501523504
http://www.malaria.org/http://www.malaria.org/http://www.malaria.org/


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to the state of their children and signs that the illness had

worsened or symptoms that were perceived as severe or

out of the ordinary signaled a need for different actions.

A combination of fever with vomiting, cough or

diarrhea, or simply a persistent fever with headache

that had not responded to treatment, were frequently

mentioned as signs of serious illness that required advice

from outside the home, most often from the nearest or

most affordable health facility (or biomedical provider)

(see Table 1 for references). High fevers were frequently

viewed as serious, necessitating a visit to a health care

facility (hospital or clinic), whenever possible. Findings

from a few studies indicated that the ability to linkcertain symptoms with severity of illness was signifi-

cantly associated with higher levels of education

(Tarimo, Lwihula, Minjas, & Bygbjerg, 2000; Tarimo,

Urassa, & Msamanga, 1998), while in other studies

educational level was not related to judgment of severity

(Slutsker, Chitsulo, Macheso, & Steketee, 1994). Con-

vulsions were almost universally recognized as being a

primary symptom differentiating severe illness from

normal malaria. The appearance of convulsions

frequently led to the perception that some form of

supernatural or spiritual force was, or had become,

involved in the illness process and any cure necessitated

the involvement of a traditional healer of some kind

(see Tables 1 and 2 for references).

Sources of care

There were inter-country, urban/rural and district

level variations in the type and quantity of sources of

care available to the review populations (Alilio &

Tembele, 1994; Dawson, 1996; Molyneux, Mungala-

Odera, Harpham, & Snow, 1999) but, to a greater or

lesser degree, each functioned within a pluralistic health

system. Although patients and care givers were often

reluctant to discuss use of alternate providers and home/

self treatments due to fear of bullying, accusations, orbelittling from health care staff (Oketch-Rabah, Oduol,

Oluka, & Nyamwaya, 1998; Williams et al., 1999;

Williams & Mungai, 1999), the reality was that, in

addition to the public health system, other sources of

drugs, biomedical and non-biomedical health care

existed. For example, the majority of studies reported

that pharmaceutical drugs (antipyretics and anti-malar-

ial drugs) were available and purchased from licensed

drug shops, non-licensed shops (e.g. grocers), informal

table top drug sellers, as well as from private and non-

governmental organization (NGO) clinics and hospitals

(see Table 3 for references). Use of these sources of care

ARTICLE IN PRESS

Table 1

Recognition of illness

Uncomplicated malaria:

common, minor & mild febrile

illness, treated in home often

with tepid sponging, domestic

herbal preparations &/or useof drugs in the home

Serious illness: fever with

vomiting, cough or diarrhea,

high fever or persistent fever

with headache

Convulsions: a primary

symptom differentiating severe

illness from normal malaria

with supernatural or

spiritual force involved

East

Africa

Adome et al., 1997, 1998;

Baume, 1998; Ellman &

Shayo, 1997; Jenkins, 1998;

Kengeya-Kayondo et al., 1994;

Klaver, 1993; Molyneux et al.,

2002; Mwenesi, 1994; Mwenesi

et al., 1995; Nyamongo, 2002;

Reynolds-Whyte & Birungi,

2000; Ruebush et al., 1995;

Shafritz & Helitzer-Allen,

1996; Tarimo et al., 1998,

2000; Williams & Mungai,1999; Winch et al., 2000b.

Baume, 1998; Jenkins, 1998;

Molyneux et al., 2002; Shafritz

& Helitzer-Allen, 1996;

Tarimo et al., 1998.

Alilio et al., 1998; Hausmann-

Muela & Muela, 1998;

Kengeya-Kayondo et al., 1994;

Makemba et al., 1996;

Mwenesi et al., 1995;

Nyamongo, 1999a; Oberlander

& Elverdan, 2000; Tarimo

et al., 1998.

West

Africa

Adongo & Hudelson, 1995;

Agyepong & Manderson,

1994; Agyepong, 1995; Ahorlu

et al., 1997; Isah, Isah, & Ogie,

1995; Jenkins, 1998; Ortega &

Binka, 1994; Thera et al., 2000.

Agyepong, 1995; Agyepong &

Manderson, 1994; Jenkins,

1998; Ortega & Binka, 1994.


Ahorlu et al., 1977; Maynard

Tucker, 2000; Ortega & Binka,

1994.

Southern

Africa

Baume et al., 2000; Douglass,

1998; Jenkins, 1998; Williams

et al., 1999.

Baume et al., 2000; Baume &

Macwangi, 1998; Govere

et al., 2000; Jenkins, 1998.

Baume et al., 2000; Baume &

Macwangi, 1998; Jenkins,

1998.



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was high and driven by practical concerns: greater ease

of access due to longer and more flexible operating

hours and larger number of facilities to choose from,

dependable and adequate levels of supplies and drugs,

staff comprised of known local community members

(often relatives, sometimes even children) and, in some

instances, perceived cheaper costs (see Table 3 for

references). In addition, many studies reported the

existence of a series of traditional healers, who were

perceived to have familiarity with a wide range of

clinical, emotional, and spiritual problems. The tradi-

tional healers ranged from spiritual and demon healers

through wound healers and bone setters to old women,

who were not considered as traditional healers by the

community but who were known to have the knowledge

of experience and were used for advice (see Table 4). For

example, in Tanzania, certain grandmothers or bibis

were respected sources of care and advice: they did not

ARTICLE IN PRESS

Table 2

Treatment for convulsions

Primary use of traditional healers Biomedicine and traditional healers

East Africa Hausmann Muela & Muela, 1998; Makemba

et al., 1996; Mwenesi et al., 1995; Snow et al.,

1998.

Alilio et al., 1998; Alilio & Tembele, 1994;

Jenkins, 1998; Molyneux, Mungala-Odera,

Harpham & Snow, 2000; Molyneux et al., 2002;Winch et al., 2000a.

West Africa Adongo & Hudelson, 1995; Maynard-Tucker,

2000; Ortega & Binka, 1994.

Jenkins, 1998; Sommerfeld et al., 2001.

Southern Africa Baume & Macwangi, 1998; Baume et al., 2000;

Jenkins, 1998.

Table 3

Patterns of resort to care for uncomplicated malaria

Use of Pharmaceuticals (Purchase of

antimalarials or use of drugs left-over

from previous illness episodes) before

visiting health facility

Private sector: closer

with regular supply of

drugs

Private sector: friendly,

negotiated charges and

offered credit

East Africa Adome et al., 1998; Allilio et al., 1997;

Ellman & Shayo, 1997; Fraser-Hunt &

Lyimo, 1998; Geissler et al., 1998; Gilson

et al., 1994; Kengeya-Kayondo et al.,

1994; Klaver, 1993; Lubanga, Norman,

Ewbank, & Karamagi, 1997; Massele

et al., 1998; Molyneux et al., 2000;

Molyneux et al., 2002; Mwenesi, 1994;

Ndyomugyenyi et al., 1998; Nyamongo,

2002; Oketch-Rabah et al., 1998;

Reynolds-Whyte & Birungi, 2000;

Ruebush et al., 1995; Shafritz & Helitzer-

Allen, 1996; Van der Geest, 1999; WHO/TDR, 1999; Winch et al., 2000b.

Alilio & Tembele, 1994;

Ellman & Shayo, 1997;

Floyd, 1996; Marsh &

Mutemi, 1997;

Molyneux et al., 2002;

Mulemi, 1998; Ongore &

Nyabola, 1996; World

Bank/WHO/UNICEF,

1999b.

Armstrong-Schellenberg

et al., 2001; Baume,

1998; Geissler et al.,

1998; Jenkins, 1998;

Klaver, 1993; Reynolds-

Whyte & Birungi, 2000.

West Africa Adongo & Hudelson, 1995; Adome et al.,

1996; Adome et al., 1997; Agyepong &

Manderson, 1994; Agyepong, 1995;

Biritwum & Welbeck, 2000; Isah et al.,

1995; Ortega & Binka, 1994; Thera et al.,

2000; Watling, 1995.

Goel, Ross-Degnan,

Berman, & Soumerai,

1996; Standing, 1996.

Adongo & Hudelson,

1995; Agyepong &

Manderson, 1994;

Jenkins, 1998.

Southern Africa Baume et al., 2000; Baume & Macwangi,

1998; Douglass, 1998; Slutsker et al.,

1994; Van Geldermalsen & Munochiveyi,

1995; Watling, 1995.

Baume et al., 2000;

Baume & Macwangi,

1998; Douglass, 1998;

Franco et al., 1997;

Standing, 1996; World

Bank/WHO/UNICEF,

1999b.

Jenkins, 1998.



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charge for services and they were accessible day and

night (Hausmann-Muela & Muela, 1998).

Patterns of treatment seeking

Comparisons of patterns of treatment seeking be-

tween studies were hampered by variations in definitions

of terms such as home treatment and time to

treatment, as well as by variations in data collection

and analytical techniques. However, while there was nosingle pattern of treatment seeking (either within or

between communities), as mentioned earlier, generally

the first response to the recognition of febrile illness was

some form of home treatment. In addition to tepid

sponging and/or use of local herbs, drugs were

frequently purchased from informal sources, such as

shops, chemists, itinerant vendors, and even other

households (Foster, 1995; McCombie, 1996). In fact,

drugs were often purchased and used before seeking care

at a health care facility (see Table 2 for references). In

most cases, drug sellers (drug shops, general shops

stocking drugs and itinerant vendors) were closer than

the nearest public health facility and, unlike the public

health facilities, they had a reliable supply of drugs (see

Table 3 for references). In addition, drug sellers also

responded to community pressure (e.g., offering certain

tablets or injections perceived to be strong), were

perceived as friendly, and negotiated charges and

offered credit when purchasing drugs, which was seen

as a definite benefit (see Table 3 for references). Left-

over drugs from previous illness episodes were also

administered when another family member became

ill, particularly in poorer communities (Adongo &

Hudelson, 1995; Agyepong, 1995; Baume & Macwangi,

1998; Biritwum & Welbeck, 2000; Dondi, Danda, &Kangere, 1998; Douglass, 1998; Francis, 1997; Ruebush,

Kern, Campbell, & Oloo, 1995; Shafritz & Helitzer-

Allen, 1996). The use of health-care facilities as the first

choice for treatment was found only in a small minority

of the studies. Factors influencing this pattern of

treatment seeking included situations in which antima-

larials were difficult to obtain outside the health-care

facilities and/or these public facilities were the closest

and most reliable source of inexpensive or free

antimalarials (Baume, Helitzer-Allen, & Kachur, 2000;

Clarke, Rowley, Bogh, Walraven, & Lindsay, 1999). In

addition, in one study in an area of unstable transmis-

sion, health facilities were used initially in preference to

home treatment (Lindblade, ONeill, Mathanga, Ka-

tungu, & Wilson, 2000). In this study, hospital care was

favored as provision of care was perceived to be of good

quality, drugs were available on site, services were

provided at very low cost, and the facility could treat

severe cases of malaria. Most studies reported simulta-

neous use of several strategies (see Table 5 for

references). In addition to biomedicine, people soughtlocal solutions to problems and used familiar sources of

treatment (such as herbs) (Oketch-Rabah et al., 1998).

However, home management or self treatment should

not be thought of as a default response to lack of

adequate health-care services, for it occurred in areas

even where biomedical and traditional services were

widely available, accessible, and known to local com-

munities (Hausmann-Muela & Muela, 1998).

If the home-treatment strategies were perceived as

non-effective or as failing (i.e., there was no improve-

ment within 48 h or additional symptoms appeared),

then help was generally sought from a more qualified

provider of health care. These providers were frequently

bio-medical health-care providers (either in the public,

NGO or private health-care system), but some studies

found that care outside the home was also sought from

traditional healers. As noted earlier, use of traditional

healers frequently overlapped with seeking care from a

health-care facility and it was commonplace to use a

combination of modern and traditional medicines (see

Table 5 for references). Often, traditional healers would

refer clients to health-care facilities if the malady was

perceived to be more amenable to conventional therapy,

if physical symptoms worsened, or if there was a

perception that the traditional remedy had failed(Gessler et al., 1995a; Makemba et al., 1996). However,

the appearance of convulsions (a manifestation often

viewed as unrelated to malaria) frequently leads to a

significant alteration in perceptions about the disease

and precipitated a change in treatment actions. Some

studies suggested that, once convulsions appeared,

traditional healers were the primary source of treatment

but others found that traditional healers were employed

in addition to biomedical interventions (see Table 2 for

references).

Literature focusing on malaria treatment-seeking

behaviors during pregnancy is scanty (Helitzer-Allen,

ARTICLE IN PRESS

Table 4

Range of Healers: familiar with variety of clinical, spiritual & emotional problems & used for advice

East Africa Alilio & Tembele, 1994; Baume, 1998; Ellman & Shayo, 1997; Gessler et al., 1995a, b; Hausmann-

Muela & Muela, 1998; Jenkins, 1998; Khayundi, 2000; Makemba et al., 1996; Maynard-Tucker,

2000; Molyneux et al., 2000, 2002; Winch et al., 2000a.

West Africa Agyepong 1995; Clark et al., 1999; Maynard-Tucker, 2000; Ortega & Binka, 1994.

Southern Africa Baume et al., 2000; Baume & Macwangi, 1998; Winston, Patel, Musonza, & Nyathi, 1995.



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Macheso, Wirima, & Kendall, 1994; Khayundi, 2000;

Ndyomugyenyi, Neema, & Magnussen, 1998; Schultz

et al., 1994b; Standing, 1996; UNICEF, 2000). The

major findings included low antenatal clinic attendance

and low and inconsistent use of malaria chemoprophy-laxis among pregnant women (Khayundi, 2000; Lemar-

deley et al., 1997; Massele, Mpundu, & Hamudu, 1997;

Mnyika, Kabalimu, & Lugoe, 1995; Mnyika, Kabalimu,

& Mbaruku, 1998; Phillips-Howard, 1999).

Decision-making processes

The literature reviewed demonstrated that people are

not passive recipients of care. Decisions about choices of

providers and which drugs to use are made system-

atically, based on prior illness and treatment experi-

ences, local beliefs about how illnesses should be treated,

understandings of illness etiologies, recognition of

constellations of symptoms, influence of social net-

works, and a realistic appraisal of available options

(Beckerleg, 1994; Geissler, Nokes, Prince, & Aagaard-

Hansen, 1998; Gilson, Alilio, & Heggenhougen, 1994;

Janzen, 1978; Molyneux, Murira, Masha, & Snow, 2002;

Oberlander & Elverdan, 2000; Ofori-Adjei & Arhinful,

1996; Oketch-Rabah et al., 1998). Williams et al. (1999)

also found that a new drug (in this case, sulfadoxine-

pyrimethamine introduced in an area that had used

chloroquine almost exclusively) could be accepted and

used based on its demonstrated clinical efficacy.

Decisions about choice and sequencing of treatments

were often based more on perceived effectiveness of amedication or treatment for a particular constellation of

symptoms in a particular illness episode, rather than a

belief in their relationship to a specific cause of the

illness (Ager, Carr, Maclachland, & Kaneka-Chilongo,

1996; Hausmann-Muela & Muela, 1998; Klaver, 1993;

Mogensen, 1998). That is, in many of the communities

studied, uncomplicated malaria was frequently viewed

as a mild childhood illness, the treatment for which was

not necessarily malaria specific, but rather reflected a

more generalized pattern of the management of mild

febrile symptoms with diagnosis altering in response to

symptom variation and treatment outcomes. In addi-

tion, even where the biomedical model of causation for

malaria is well known, it is unlikely to be the only factor

affecting treatment decision making (see Table 1 for

references). For example, regardless of the level of

acceptance of the biomedical etiology of degedege (alocally construed symptom complex mirroring cerebral

malaria), Tanzanian women readily used local remedies,

such as herbal baths and teas, when degedege was

suspected. These practices were guided mostly by years

of experience and local knowledge passed from one

generation of women to the next (Hausmann-Muela,

Muela, & Tanner, 1998; Oberlander & Elverdan, 2000).

Essentially, as symptoms alter, beliefs and explanations

shift and alternate types of treatments are employed

until an outcome (recovery or death) is reached

(Hausmann-Muela, Muela, & Tanner, 1998; Oberlander

& Elverdan, 2000). Various terms have been used

to describe this type of treatment-seeking behavior,

including: trial and error (Alilio & Tembele, 1994),

nomadic (Baume, 1998), and try and see (Kenyan

Medical Research Institute, 1995; Marsh & Mutemi,

1997).

Delays in seeking treatment

McCombie (1996) noted that delays in treatment-

seeking behaviors were actually studies of time before

presentation to a health facility, not time to any

treatment. In the literature we reviewed, there were

few definitions for delay in treatment,4 but there were

very few situations in which mothers or caregivers didnothing (Biritwum & Welbeck, 2000). Fevers were

treated promptly, often with chloroquine (Agyepong &

Manderson, 1994; Lindblade et al., 2000; Slutsker et al.,

1994; Thera et al., 2000; Warhurst, 1998). Most initial

actions occurred between a few hours of symptom

recognition and 48 h, with delays in treatment seeking

over 48 h associated with increased distance from the

clinic (Lindblade et al., 2000; Slutsker et al., 1994;

ARTICLE IN PRESS

Table 5

Strategies for treatment

Combination of modern and traditional & simultaneous use of several strategies (trail & error, no clear

hierarchy of use)

East Africa Alilio & Tembele, 1994; Baume, 1998; Geissler et al., 2000; Hausmann-Muela et al., 1998; Jenkins, 1998;

Kenyan Medical Research Institute, 1995; Khayundi, 2000; Molyneux et al., 2000, 2002; Munguti, 1997;Oberlander & Elverdan, 2000; Oketch-Rabah et al., 1998; Winch et al., 2000a.

West Africa Agyepong, 1995; Agyepong & Manderson, 1994; Ahorlu et al., 1997; Jenkins, 1998; Ortega & Binka, 1994;

Sommerfeld et al., 2001; Thera et al., 2000.

Southern Africa Baume et al., 2000; Baume & Macwangi, 1998; Jenkins, 1998.

4One of the few definitions was given by Lindblade et al.

(2000), who defined delay as treatment that occurs ...o1 day

between onset of symptoms and first treatment (p. 867).



9/23

Tarimo et al., 1998; Thera et al., 2000; Watling, 1995).

In a study of treatment seeking in an area of unstable

transmission (Lindblade et al., 2000), neither demo-

graphic nor socioeconomic status was associated with

receiving prompt, effective treatment. Rather, the most

important predictor for seeking rapid treatment at a

health facility was perceived severity of illness.In a study of childhood deaths, findings from verbal

autopsies indicated that 93% n 125 of the children

who died had been seen in a health-care center or

hospital within 2 weeks of their deaths. Matching

surviving controls with the deceased children showed

that the elapsed time between disease onset to first

consultation was shorter for those who died than those

who survived (Sodeman, Jakobsen, Molbak, Alvarenga,

& Aaby, 1997).

Factors influencing choice of care

Reasons for not seeking treatment immediately from

outside the household, in spite of recognizing symptoms

that corresponded to the biomedical notion of malaria,

included: lack of money, illness starting at night, beliefs

that the symptom complex could be successfully treated

at home, and cultural differentiations about the

seriousness of different types of the same symptom

complex (Kengeya-Kayondo et al., 1994; Thera et al.,

2000).

Furthermore, although several studies found that

health workers were perceived as knowing the best (or

proper) treatment or providing the best advice

(Agyepong & Manderson, 1994; Baume, 1998; Baume

et al., 2000; Jenkins, 1998; Shafritz & Herlitzer-Allen,

1996; Tarimo et al., 1998; World Bank/WHO/UNICEF,

1999a) and, once consulted, doctors are most influential

in terms of decision making about the illness, there were

many studies describing wide dissatisfaction with public

facilities. The key issues (mentioned in the majority of

the studied reviewed) contributing to this dissatisfaction

were: consistent lack of drugs and equipment, poor staff

attitudes, cost (direct and indirect) and accessibility

(distance and limited opening hours) (see Table 6 for

references).

In addition to dissatisfaction with public healthfacilities, several studies pointed to other factors, which

were found to influence choice of care.

Seasonality

Seasonality influenced access to care in a variety of

ways. Ability to access clinics during rainy seasons was

often hampered by poor or absent roads (Nyamongo,

1999b). During periods of cultivation, farming demands

often made it impossible to attend clinics, including

antenatal care (Khayundi, 2000; Schultz et al., 1994b),

and may restrict the ability to monitor the progress of

the illness (Dawson, 1996). Disposable income was also

limited during periods of hunger or cultivation, thus

limiting the ability to pay clinic fees (Hausmann-Muela

et al., 1998).

Age, gender and social equity

Most treatment-seeking studies focus on children

under the age of 5, although a few studies are nowbeginning to look at treatment seeking in other age

groups (Agyepong & Manderson, 1994; Geissler et al.,

1998; Krause & Sauerborn, 2000; Lindblade et al.,

2000). The influences of gender and age are beginning to

be recognized in terms broader than physiological

vulnerability. A few papers recognized social, cultural

and economic factors relating to distribution of power

and resources as variables that create a different type of

vulnerability that limits the ability to seek care or have

necessary access to information and resources (Gheb-

reyesus, Alemayehu, Bosman, Witten, & Teklehaima-

not, 1996; Khayundi, 2000; Mulemi, 1998; Munguti,1998b; Oberlander & Elverdan, 2000; Tanner & Vlass-

off, 1998; Vlassoff & Bonilla, 1994). In some studies, it

was difficult for women to access health care due to the

possible perception of sexual disloyalty if the woman

received care from a male health-care worker and, in

other studies, social pressure constrained womens

abilities to express their needs and admit to feeling ill

for fear of being thought weak (Francis, 1997;

Ghebreyesus et al., 1996; WHO/RBM, 1999). However,

the influence of power as it shapes the ability to seek

treatment is rarely a leading theme in the literature.

Social equity is also related to educational opportu-

nities, with African women generally having lower levels

of education than African men (Munguti, 1998b). Lower

educational levels have been significantly associated with

lower levels of malaria knowledge, fewer antenatal visits

and hospital deliveries, and lower frequencies of clinic

visits (Carme, Plassart, Senga, & Nzingoula, 1994;

Macheso et al., 1994; Mwenesi, Harpham, & Snow,

1995; Schultz et al., 1994b; Slutsker et al., 1994; Tarimo

et al., 2000; Watling, 1995). Poverty, in general, has been

identified as a major constraint for access and use of

health care facilities (Biritwum & Welbeck, 2000; Kager,

2002; Macheso et al., 1994; Moerman et al., 2003).

Household social organization and locus of decision

making

In spite of women often being the first to recognize

illness and having the responsibility for illness manage-

ment, they may be prevented from seeking appropriate

treatment as ultimate decision-making responsibility

and control of finances may lie outside of their social

purview (Alilio, Eversole, & Bammek, 1998; Heggen-

hougen, Hackethal, & Vivek, 2003; Molyneux et al.,

2002; Mwenesi, Harpham, & Snow, 1995; Oberlander &

Elverdan, 2000; Tanner & Vlassoff, 1998). Other factors

included heavy workloads that preclude women from

ARTICLE IN PRESS



10/23

seeking treatment for themselves or their children

(Dawson, 1996; Ghebreyesus et al., 1996).

Drug use: consumer and provider behavior

Drug use by consumers

Findings about reported drug-use patterns indicatedthat polypharmacy practices were common and Western

pharmaceuticals were often given concurrently with

herbal preparations (see Table 7 for references). Drugs

were sold both to adults and children (Geissler et al.,

1998; Maende & Prince, 1998). Caregivers frequently

reported using antipyretics/analgesics as a first-line

treatment for malaria (see Table 7 for references).

Inappropriate drug dosages and/or incorrect timing of

dosages were frequently reported, particularly for

smaller children (see Table 7 for references). Findings

from a nationwide knowledge, attitude, and practice

(KAP) study in Malawi indicated that less than 30% of

people were estimated to have received appropriate

antimalarial doses (Macheso et al., 1994). In one

qualitative study in western Kenya, pregnant women

could not distinguish between routine medications given

in antenatal clinic, such as vitamins, from antimalarials

(Williams & Mungai, 1999). Although some work is

beginning to focus on descriptions of community druguse patterns (Adome et al., 1998; Geissler et al., 1998;

Massele, Nsimba, Warsame, & Tomson, 1998) few

studies were found that attempted to quantify actual

drug use. Two studies assessed self-reported drug use,

combined with blood levels of antimalarials (Kenyan

Medical Research Institute, 1995; Verhoef et al., 1999).

Delivery of drugs by providerswhat are they doing?

Most treatment-seeking studies examine the behaviors

of mothers or care givers in terms of appropriate

management of malaria. However, the quality of health-

care services needs to be examined as well. In spite of

ARTICLE IN PRESS

Table 6

Reasons for non-use of health facilities

No drugs (&/or

equipment)

Too far, closed, or

queues

Cost (treatment, loss of

income, transport, etc.)

Rude health

workers

East Africa Ahmed, Urassa, Gherardi,

& Game, 1996; Alilio &Tembele, 1994; Alilioet al.,

1998; Geissler et al., 1998;

Gilson et al., 1994;

Jenkins, 1998; Massele

et al., 1998;

Ndyomugyenyi et al.,

1998; Nsimba et al., 1999;

Nyamongo, 2002; Oketch-

Rabah et al., 1998; Osei &

Commey, 1994; Ruebush

et al., 1995; Shafritz &

Helitzer-Allen, 1996;

World Bank/WHO/

UNICEF/KenyanMinistry of Health, 1998.

Geissler et al., 1998;

Gilson et al., 1994;Jenkins, 1998;

Lindblade et al.,

2000; Maende &

Prince, 1998;

Munguti, 1998a;

Ndyomugyenyi

et al., 1998; Oketch-

Rabah et al., 1998;

Ruebush et al.,

1995; Shafritz &

Helitzer-Allen,

1996; Tarimo et al.,

2000.

Geissler et al., 2000;

Jenkins, 1998; Lindbladeet al., 2000;

Ndyomugyenyi et al.,

1998; Williams & Mungai,

1999.

Dondi et al., 1998;

Gilson et al., 1994;Mwenesi, 1993;

Nyamongo, 1999b;

Ruebush et al.,

1995; Shafritz &

Helitzer-Allen,

1996; Williams &

Mungai, 1999.

West Africa Jenkins, 1998; Osei &

Commey, 1994; Standing,

1996.

Adongo &

Hudelson, 1995;

Agyepong, 1995;

Ahorlu et al., 1997;

Jenkins, 1998;

Maynard-Tucker,

2000; Ortega &

Binka, 1994.

Adongo & Hudelson,

1995; Agyepong, 1995;

Ahorlu et al., 1997;

Jenkins, 1998; Maynard-

Tucker, 2000; Ortega &

Binka, 1994.

Maynard-Tucker,

2000.

Southern

Africa

Baume et al., 2000; Baume

& Macwangi, 1998;

Douglass, 1998; Franco

et al., 1997; Jenkins, 1998;Standing, 1996; Williams

et al., 1999; World Bank/

WHO/UNICEF, 1999a.

Baume et al., 2000;

Douglass, 1998;

Jenkins, 1998;

Schultz et al.,1994b.

Baume et al., 2000;

Douglass, 1998; Jenkins,

1998; Macheso et al., 1994;

Schultz et al., 1994.

Douglass, 1998;

Williams et al.,

1999.



11/23

repeated calls for rational drug use of antimalarials, little

emphasis has been given to examining how providers

prescribe antimalarials. While provider behavior was

rarely the main focus in the reviewed studies, many of

the studies reported either anecdotal or observed poor

practice at both public and private health facilities (see

Table 6 for references). These included: lack of counsel-

ing, poor diagnosis, rude treatment of patients and

caregivers, as well as over prescription of drugs,

incorrect dosage and poor explanation of drug. Delays

in initiation of treatment at health-care facilities and

delays in diagnosis by hospital laboratories were also

noted in studies examining malaria-related deaths

(Durrheim, Frieremans, Kruger, Mabuza, & de Bruyn,

1999; Sodeman et al., 1997).

Data from the qualitative component of a rapid

assessment for district-based malaria prevention duringpregnancy (Williams & Mungai, 1999) indicated little

consistency among health-care workers in what was

prescribed for pregnant women experiencing malaria.

Not only were there differences among health-care

workers in the same center, differences also existed

across centers. Actual practice differed markedly from

what was supposed to be practiced as per national

treatment guidelines.

There is a growing recognition that even when formal

providers have correct knowledge about drug dosages

and therapeutic management, knowledge does not

predict behavior (Brugha & Zwi, 1998; Ofori-Adjei &

Arhinful, 1996). In a study from Ghana examining the

effect of training on the clinical management of malaria

by medical assistants (Ofori-Adjei & Arhinful, 1996),

findings showed that gains in knowledge following

training deteriorated within 1 year. Common practices

like polypharmacy, high use of injectables and poor

recording were identified. These practices were found to

be rooted in a sociocultural basethat of responding to

the social expectations of the community, which

demanded injectable medications and wanted prompt

treatment. Prescriptive practices were driven more by

these community expectations of how a health-care

worker should perform, than by the knowledge gained

in the in-service training.

Inappropriate prescribing practices also extended to

the private sector. Informal drug sellers generally lacked

pharmaceutical or health training of any sort, yetdispensing of inappropriate dosages and offering advice

was commonly practiced by these vendors (Djimde et al.,

1998; Kofoed, Dias, Lopes, & Rombo, 1998; Krause

et al., 1998; Massele et al., 1998; Mwenesi, 1994; Oketch-

Rabah et al., 1998; Ongore & Nyabola, 1996). Drugs

that were sold did not necessarily correspond to national

malaria treatment policies (Feller-Dansokho, Diop, &

Badiane, 1995). Even when sanctioned providers

offered correct dosing regimens and used drugs recom-

mended by national policies, consumers opted to buy

non-recommended treatments for malaria and reported

giving sub-optimal doses when using recommended

ARTICLE IN PRESS

Table 7

Drug use

Pharmaceuticals &

herbs

Antipyretics/analgesics as first-

line treatment for malaria

Inappropriate dosage/

timing of intake

Poor provider

practice

East Africa Hall, 2000; Massele

et al., 1998;Molyneux et al.,

1999; Oketch-

Rabah et al., 1998;

Ongore & Nyabola,

1996; Snow et al.,

1998.

Adome et al., 1998; Baume,

1998; Dondi et al., 1998;Douglass, 1998; Geissler et al.,

1998; Jenkins, 1998; Klaver,

1993; Marsh & Mutemi, 1997;

Molyneux et al., 2000; Mulemi,

1998; Reynolds-Whyte &

Birungi, 2000; Shafritz &

Helitzer-Allen, 1996; Tarimo

et al., 2000.

Baume, 1998;

Dondi et al., 1998;Floyd, 1996; Gilson

et al., 1994.

West Africa Sesay &

Wijeyaratne, 1994;

Thera et al., 2000.


Agyepong, 1995; Douglass,

1998; Jenkins, 1998; Watling,

1995.

Krause et al., 1998;

Krause & Sauerborn,

2000; Osei & Commey,

1994; Thera et al., 2000.

Agyepong, 1995;

Douglass, 1998;

Standing, 1996.

Southern Africa Baume & Macwangi, 1998;

Baume et al., 2000; Douglass,1998; Jenkins, 1998; Slutsker

et al., 1994.

Baume et al., 2000;

Slutsker et al., 1994.

Baume &

Macwangi, 1998;Baume et al., 2000;

Franco, Daminsoni,

& Francisco, 1996;

Franco et al., 1997;

Standing, 1996.



12/23

anti-malarials (Djimde et al., 1998). Shopkeeper training

in proper dispensing of anti-malarials appears to hold

promise as an intervention addressing the urgent need

for better dispensing practices (Marsh et al., 1999; Van

der Geest, 1999). As well, some novel approaches in

malaria education programs are beginning to target

school children as agents of change for the community(Brooker et al., 2000; Bundy, Lwin, Osika, McLaughlin,

& Panneborg, 2000; Geissler et al., 1998). There was

little mention of drug regulation or enforcement of laws

pertaining to sales of supposedly regulated prescription

drugs (Alilio et al., 1997; Geissler et al., 1998; Oketch-

Rabah et al., 1998; Ongore & Nyabola, 1998). In

addition, findings from a study of illness episodes among

primary school children in Western Kenya indicated

that children purchased drugs from shops near their

schools, where young children served as the shop-

keepers (Geissler et al., 1998; Maende & Prince, 1998).

Involvement of social scientists in the social science

research

We were interested in knowing how much of the

research on aspects of malaria control related to human

behavior included contributions by a trained social

scientist. To give a rough estimation, the papers were

coded as to whether the authorship included a trained

social scientist (identified by degree, institutional affilia-

tion or personal contact). If the status of the author/s

could not be determined, it was coded as unknown. Out

of these papers, we could only identify a social scientistin 37 of the 87 of the research papers (43%). However,

social scientists were included as authors or contributors

to 20/35 of the technical papers (64.5%) and 13/15

(86.7%) of the unpublished papers. Of all the published

papers (research and other categories, n 116), social

scientists were the sole or primary author in 29% n

34 of the documents.

Discussion of results

Have Gaps in Knowledge & Previous Calls to Action

Been Addressed?

The results of the current review suggest that, since the

McCombie (1996) review, we have amassed increasing

quantities of descriptive data on treatment-seeking

behavior. These data, to a large extent, echo the findings

of the McCombie review. That is, choice of treatment is

affected by a number of factors, multiple resorts to care

are often used, and the use of modern medicines in some

form is usually high. We do have some additional

understanding of the different treatments people employ

based on how they differentiate uncomplicated and

severe malaria and there is more information about how

provider behaviors impact treatment-seeking behaviors

(Durrheim, Frieremans, Kruger, Mabuza, & de Bruyn,

1999). However, to a large extent, the gaps identified by

McCombie (1996), and the methodological issues raised,

remain unaddressed.

Quantification of drug intake

Quantification of drug intake continues to be ignored.

With one or two notable recent exceptions (Massele

et al., 1997; Oketch-Rabah et al., 1998), there are still

limited data on actual drug intake and the reasoning

that drives behaviors surrounding the use of anti-

malarials (Hausmann-Muela & Muela, 1998; Molyneux

et al., 2002). A limitation of the existing data is that it is

based mostly on self-report obtained through question-

naire surveys. Self-report data can be biased with recall

difficulties, an inability of caregivers to differentiate

drugs, as well as confusion about dosing when givingmultiple drugs. Not only do we not fully understand

drug use from the consumer or patient perspective, we

also continue to operate on assumptions that providers,

given the right information, will practice rational drug

use based on clinical or scientific rationalitythis

assumption needs to be tested (Trostle, 1996). A recent

informal consultation on the use of antimalarial drugs

by WHO suggests that operational research is needed to

determine ways of improving prescribing practices

involving drug vendors and other informal sector

providers (World Health Organization, 2001). Expand-

ing the argument further, we need to examine carefully

what can realistically be considered rational antimalarial

drug use, given the extremes of poverty facing patients,

consumers, and even Ministries of Health throughout

sub-Saharan Africa.

Recognition of uncomplicated and severe malaria

In regard to understanding how people differentiate

between uncomplicated and severe malaria, we now

know that in many places people are able to distinguish

between uncomplicated and severe disease. The progres-

sion from mild to severe disease is of major public health

significance, but clinicians and researchers from all

public health disciplines have been challenged by theirlimited understanding of why some cases proceed to

severe disease and others do not. Obviously, biomedical

and epidemiology factors, such as levels of transmission

and degree of parasitemia, levels of acquired immunity

and how that immunity is affected by other factors such

as concurrent disease, malnutrition, etc.,5 are critical to

this process, but it is also influenced by choices made

regarding type and timing of treatment. An implication

is often made that, by delaying biomedical treatment,

ARTICLE IN PRESS

5Discussion of the numerous physiological factors that affect

progression of disease is beyond the scope of this paper.



13/23

severe disease may be the fault of the mother or

caregiver. However, the extent to which caregiver

recognition, early treatment, use of herbal versus

western medicines, etc., contributes has still not been

carefully studied to date. Some of the results from this

review suggest that use of herbal and traditional

medicines does not unduly delay the seeking ofbiomedical care (Alilio & Tembele, 1994; Baume et al.,

2000; Baume & Macwangi, 1998; Heggenhougen et al.,

2003; Jenkins, 1998). On the other hand, we still have a

limited understanding of what happens in severe disease

at the household level. Studies of drug intake and severe

disease are prime examples of areas in malaria control in

which the joint efforts of social scientists, epidemiolo-

gists and clinicians are needed. Scientists from the

various disciplines should be working together in order

to identify possible avenues for intervention. Social

science research alone cannot provide the answer

to these questions, but the contextual informationthat it offers can greatly enhance our understanding of

the human processes that affect the progression of

disease.

Terminology

Terminology is still vague and we have a limited

understanding as to what is included in definitions of

home versus self-treatment (an exception is Geissler

et al., 1998), or what constitutes rational drug use.

Furthermore, what is meant by prompt treatment is

not usually defined. These problems with definition not

only lessen our ability to interpret research findings but

also make cross-study comparisons extremely difficult.

Methodological rigor

As well as concerns with terminology, the McCombie

review in 1996 (and more recently in 2002) also strongly

recommended that there needed to be improvements in

methodological rigor; yet this area remains problematic.

There were limited descriptions of methods, confusion

with terms relating to methods applied, lack of attention

to ethical review, and few details of analysis, other than

mentioning which software package was used. In

research papers, results were woven into discussion of

results and recommendations. The lack of informationpresented makes it exceedingly difficult to judge the

rigor that might have been applied to the study and

contributes to the difficulties encountered in any cross-

comparison of studies. There is also concern that few

studies used more than one method of data collection.

Triangulation was rarely used, except in studies that

were completed by trained anthropologists or other

social scientists.

In addition to greater rigor, to provide the type of

contextual information needed to tackle, for example,

the issues of severe malaria and actual drug intake, there

is a need for a change in methodological approaches.

Knowledge, Attitudes and Practices (KAP) surveys and

rapid assessments provide data on what people say they

do, which may vary considerably from actual behavior.

In order to collect the type of data that will provide us

with a better understanding of actual behaviors and the

factors affecting behaviors, longer periods of ethno-

graphic fieldwork are essential. This type of methodol-ogy is usually only seen during doctoral level fieldwork,

but such fieldwork needs to be central to the develop-

ment of multi-disciplinary operational research.

How have we moved on?

At the time of the McCombie (1996) review, much of

the social science input to malaria control was largely

focused on answering the question of why local people

did not adhere to suggested control measures or

biomedical treatments. A commonly held view in public

health was that peoples knowledge was inadequate;thus, people acted in ways contrary to what was

expected from the biomedical world. KAP surveys were

commonly employed to contrast what was known or

understood locally with what should be known in order

to have effective malaria control (Barrett, 1997; Man-

derson, 1998; Sommerfeld, 1998). Not surprisingly, the

findings of many of these surveys indicated that knowl-

edge by itself and/or attitudes did not necessarily predict

behaviors. While KAP surveys have provided much

useful information on describing reported treatment-

seeking behaviors, they were not sufficient to understand

the factors influencing those behaviors (Alilio et al.,1998; Biritwum & Welbeck, 2000; Djimde et al., 1998;

Macheso et al., 1994; Mnyika et al., 1998; Schultz et al.,

1994a, b; Slutsker et al., 1994; Van Geldermalsen &

Munochiveyi, 1995).

Changing our approach

Since McCombie (1996), more attention has been

focused on addressing the issue of why people do what

they do and methods such as rapid ethnographic

assessment (REA) have become popular tools in applied

research.6 However, much of research reported to be

using REA, in fact falls short of the required standards

for this approach. For example, fieldwork completed in

only 2 or 3 weeks rather than 3 months and the use of

field staff who do not speak the local language or have

long-term familiarity of the area (Jenkins, 1998). Even

when applied correctly, one of the limitations of these

ARTICLE IN PRESS

6 In this paper, rapid assessment refers to collection of data

over 23 weeks duration. We recognize that, in some situations,

rapid assessment has been defined as a period of up to 3

months, such as research commissioned by WHO/TDR

(Adongo & Hudelson, 1995); however, this appears to rarely

be the case.



14/23

methods is that they can also miss sensitive and crucial

information and do not provide an in-depth under-

standing of the larger context in which behaviors occur

(Jenkins, 1996; Lambert, 1998; Manderson, 1998;

Manderson, Agyepong, Aryee, & Dzikunu, 1996;

Sommerfeld, 1998). On an encouraging note, results

from rapid ethnographic studies and recent, innovative(and longer term) research focusing on understanding

behavioral patterns in the much broader context of

peoples everyday lives (Adongo & Hudelson, 1995;

Hausmann-Muela et al., 1998; Heggenhougen et al.,

2003; Jenkins, 1998; Kidane & Morrow, 2000; Mwenesi,

1994; Nyamongo, 1999b; Nyamongo, 2002; Reynolds-

Whyte & Birungi, 2000) have started to convince

researchers and implementers that the blocks to prompt

and effective treatment cannot simply be ascribed to a

lack of knowledge among community members. Social,

political and economic factors, such as poverty, access to

health facilities and treatment and the quality of servicesreceived often play a much more prominent role as

determinates of treatment-seeking behavior. Most re-

cently, the results from in-depth ethnographic research

(Hausmann-Muela et al., 1998; Molyneux et al., 1999)

have highlighted the importance of gender and social or

economic position of the individual (or responsible care

giver) in the household on the decision-making processes

underpinning treatment-seeking behavior.

The primacy of context in understanding treatment-

seeking behaviors

There is now a greater awareness of the complexity of

treatment-seeking behaviors, including the recognition

that people are active decision-makers in their own care

and usually employ multiple sources of care. Decisions

about treatment seeking are not static but are dynamic

and iterative (Gilson et al., 1994; Oberlander &

Elverdan, 2000). Rationale drug use, as commonly

used in the global malaria community, implies a single

rationality based on biomedical standards. This con-

trasts a parallel rationality, which is framed by the need

to seek treatment in situations of limited resources

(drugs, access to health care, financial and educational).

This parallel rationality reflects not only the currentconstraints in seeking biomedical treatment, but also a

familiarity and comfort with the local environment and

years of experience with treatment decisions based on a

system of trial and error that is passed on generation to

generation (Haaland, 1998). Diagnosing and treatment

decisions are not the purview of an elite class of health

professionals but, rather, represent shared experience

and knowledge well embedded in a local culture

(Geissler et al., 1998). In this context, treatment

decisions that arise may not necessarily be linear or

logical in biomedical terms, but systematic choices are

made nonetheless.

When people become ill, their primary goal is to find

prompt and effective treatment within the constraints

imposed by their environment. This goal is in agreement

with one of WHOs central tenets of malaria control

(i.e., the need for prompt and effective treatment) but, in

the environment found in most countries in sub-Saharan

Africa, the pragmatic choice for prompt and effectivetreatment (especially for uncomplicated malaria) cur-

rently lies outside the formal health sector. Here the

treatments are usually prompt but not always effective

by biomedical standards. In fact, the weakness of the

public health-care system in much of sub-Saharan

African makes the use of self and home treatments

indispensable (Adome, Reynolds-Whyte, & Hardon,

1996; Geissler et al., 1998). We should hardly be

surprised that people commonly self-treat and stop

taking medications when they feel better, and that there

are delays in seeking treatment from a health facility,

since these practices are also found in developed nationsand elsewhere throughout the world (Bedell et al., 2000;

Dempsey, Dracup, & Moser, 1995; DiMatteo &

DiNicola, 1994; DiMatteo, Lepper, & Croghan, 2000;

Fortney, Rost, & Zhang, 1998; MacGregor, 1997;

Wagner, Phillips, Radford, & Hornsby, 1995; Walker,

2001). In fact, in the US alone, 125,000 people are

estimated to die each year as a result of some form of

medication non-compliance (Walker, 2001). Cost, dis-

tance to health-care facilities, poor drug-use education,

and perceptions of the care expected from health-care

facilities are just some of the factors that influence

treatment-seeking behaviors, not only in sub-Saharan

Africa, but in the developed world as well (Bedell

et al., 2000; DiMatteo & DiNicola, 1994; DiMatteo

et al., 2000; Moran & Kim, 2001). As Paul Farmer has

frequently pointed out ...those least likely to comply

are those least able to comply (p. 353) as, in many

settings, degree of compliance is limited by forces

external to the individual (Farmer, 1997).

Critics of antimalarial use in sub-Saharan Africa

should be aware that focusing on the issue of

compliance in relation to malaria treatment, while

ignoring the large and critical literature on the issue that

exists in western Europe and America, could be

interpreted as establishing a different standard ofpractice for Africans (Manderson, 1998). We are not

condoning these practices but, rather, raising the issues

that these practices are not unique to Africa and that the

concepts of compliance and adherence are imbued

with the notion that treatment failures are patient

failures. Social scientists working in malaria control

should not, therefore, be trying to provide an answer to

that most frequently asked question how can we get

them to...... but, rather, we should be pressing to find

ways to increase peoples capacity to access and

complete effective treatments. A good example of this

is the recent concentration on developing the capacity of

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shopkeepers (who commonly provide many anti-malar-

ial drugs) to give advice and correct treatment for

malaria in Kenya (Marsh et al., 1999). This initiative

arose from detailed ethnographic research that showed

that the majority of anti-malarial drugs used in a coastal

Kenyan community were being provided through shops

and not through health facilities (Mwenesi, 1993). Thepublic health intervention shopkeeper training is

therefore based on ethnographic work that has

been used to inform the development of a program

that addresses the common goal of increasing the

likelihood of sick children receiving prompt and

effective treatment.

While we now have a better description of the factors

that influence the search for prompt and effective

treatment, what is not well understood or measured is

the relative weight or influence of the various factors

that drive people to seek care in particular situations or

contexts (Munguti, 1998a). In order to develop effectiveinterventions, it is necessary not only to understand the

context in which behavior takes place but also to

examine the relative weight of the various factors

influencing actions within that context. Little attention

has been paid to the dynamic nature of both behavior

and context that vary not only within and among

countries (e.g. in some regions of Ghana, most of first-

line treatment is provided by the private sector, whereas

in other regions of the same country the private sector

barely exists), but also change over time (Agyepong,

1995). For example, in the early 1960s in Uganda, the

main source of first-line health care was the formal

health sector. Today, the situation is very different as

most first-line treatments are provided by the informal

sector. This change has little to do with changes in

knowledge or belief about disease causation among the

population, but has a lot to do with the breakdown in

the formal health sector during the Amin years

(Reynolds-Whyte & Birungi, 2000). There is, therefore,

a need to recognize that factors within the local

environment, such as conflict, natural disasters, changes

in subsistence patterns, attitudes towards local and

national government and government structures and

organizations, go beyond what effective malaria-control

programs can influence on their own and may not beamenable to single-sector interventions.

However, it remains to be seen to what extent

recommendations that fall outside the normally sanc-

tioned approaches for public health interventions will be

accepted by other research scientists, policy makers and

implementers. For example, in Uganda, intervention

plans were developed for shopkeeper training in three

districts but political resistance necessitated limiting the

training to only shop owners and implementing it in

only one district (Reynolds-Whyte & Birungi, 2000). In

spite of appearing to challenge conventional wisdom or

usual modes of action, Van der Geest (1999) urges

applied anthropologists to continue using cultural

knowledge to improve public-health efforts, even if it

means practicing against standard policy.

What are the factors constraining the contributions of

social scientists in malaria control?

Social science involvement in malaria control has

increased over the past decade, but much remains to be

done. Social scientists have contributed to infectious

disease control through focusing on illness etiologies

and, more recently, through helping to describe and

understand treatment-seeking behaviors. They are also

increasingly using this information to make suggestions

on possible points for intervention (Manderson et al.,

1996; Sommerfeld, 1998). But, based on the literature

from this review very little (with a couple of notable

exceptions: Helitzer-Allen et al., 1994; Kidane &

Morrow, 2000; Marsh et al., 1999; Pagnoni, Convelbo,Tiendrebeogo, Cousens, & Esposito, 1997; Reynolds-

Whyte & Birungi, 2000) from this body of work has

actually been used in designing or testing interventions

(Manderson, 1998). It is unclear to what extent this is

due to a failure to communicate the results of research,

to the lack of importance that is often placed on this

type of work, or to the fact that many of the

recommendations either conflict with current policy or

lie outside the sole control of malaria-control programs.

From the results of this review, and our experiences

working in malaria research and control, factors that

constrain the contributions that social scientists could be

making to malaria control include: (a) the lack of

involvement of trained social scientists in malaria

control, (b) the lack of awareness by Ministries of

Health, malaria-control programs and many non-social

science researchers of the variety of disciplines within

social science and the expertise and assistance each could

offer, (c) the lack of awareness by social scientists

themselves of the constraints faced by malaria-control

programs and the presentation of results that cannot be

easily interpreted or used by program personnel, and

finally, (d) the expectation that including a social

scientist on a program will provide a magic bullet to

fix all the problems (Williams et al., 2002). Contribu-tions of trained social scientists were clearly identified in

less than half of the publications reviewed for this paper

(although we recognize that this might be a conservative

estimate). Whether the issue is that social scientists are

doing the work and not clearly identifying themselves or

their disciplinary background or whether they truly have

not been involved in conducting the behavioral research,

people from other disciplines appear to be taking the

lead in behavioral research related to malaria. One of

the consequences of having non-social scientists conduct

social science research is that those responsible for the

research often have limited or no training in social

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science theory and methodology and, as mentioned

earlier, this can lead to poor-quality research. In

addition, attention to the complex array of factors that

influence the promotion, acceptability, and sustainabil-

ity of malaria-control activities in its widest sense

requires a level of methodological training that most

non-social scientists lack. This, in turn, may help toperpetuate a perception that social science has little to

offer malaria control.

On the other hand, the reality for most national

malaria-control programs is that there are insufficient

funds to support a full-time social scientist or even to

occasionally commission a short-term social science

consultant. Moreover, programme personnel may not

recognize the specific expertise that social scientists can

offer to a malaria-control programme. Malaria-control

personnel may have a difficult time identifying social

science issues or research questions pertinent to their

particular program and are often unclear if specificexpertise is required or if a short course in qualitative

data collection and analysis is sufficient qualification for

a task or project.

Social scientists should work jointly at the country

level with malaria-control programs to increase qualita-

tive skills (particularly in relationship to qualitative data

analysis) for non-social scientists, and to develop an

understanding of issues or research questions that can be

addressed by non-social scientists who have received

some level of beginning training in social science versus

situations in which the expertise of fully trained social

scientists is needed. In addition, social scientists involved

in malaria research and control should be aware of

programmatic concerns, for which they could offer

assistance. They should work with program personnel,

not only to help identify their needs, but also to

present research results in such a way that the find-

ings are understandable, practical, and useful to

malaria-control programs, public health personnel and

communities.

Effective use of social science?

From the results of this review, it appears that, to

increase the effective use of social science in malariacontrol, social scientists should focus on four principal

issues: (a) a new orientation for field research (and

increased rigor in methods), (b) addressing gaps in

research knowledge, (c) strengthening the relationship

between research, policy and practice, and (d) capacity

strengthening and advocacy.

New orientation for fieldwork

The primacy of context in understanding behaviors

has been described and we now need to move beyond

research that focuses on documenting behaviors (at

individual, community, health facility or governmental

level) into examining the larger contexts in which those

behaviors operate, investigating the relative weights of

factors influencing behavior within specific contexts

(Heggenhougen et al., 2003). This type of research

requires a different orientation than has been customary

in the social science components of many malaria

research projects, which have traditionally allottedminimal amounts of time for fieldwork, with the

expectation that tremendous amounts of useful data

could be gathered during that time (Heggenhougen et al.,

2003). Answering the more compelling questions con-

fronting malaria-control programmes now (such as how

changes in subsistence patterns impact on power

relationships and the ability to seek care or decision

making and treatment seeking within the household)

involves proper ethnographic fieldwork. Such fieldwork

requires significantly more than a brief 2-week field trip.

Moreover, rather than being an addedon component

after a study has been designed and funded, socialscientists should be contributing to the conceptualiza-

tion and design of the study from the beginning,

thus assuring that adequate time and funding are

requested.

New areas for research

As we have corroborated McCombies findings (1996)

and increased our understanding about treatment-

seeking behaviors, we have also recognized additional

areas that impact on the home management of malaria

and need research attention. For example, an area that

needs further exploration is in examining the array offactors that influence provider behaviors in regard to

dispensing drugs. Much of the recent attention on

community and home management focuses on the

mother/care giver in terms of drug administration.7

While this is a critical component for understanding

drug use, it will not provide other essential informa-

tionthat of the providers behavior. Other areas in

malaria home management that have received limited

research attention from social scientists include: (a)

quantifying drug intake (both at the home and with

prescriptions given from a health-care facility); (b)

investigating treatment-seeking behaviors in areas oflow endemicity and epidemic prone areas; (c) identifying

socially vulnerable populations, such as pregnant

ARTICLE IN PRESS

7There is a vast body of literature on drug-utilization

behaviors that is beyond the scope of this paper. Much of this

literature has an application wider than malaria control. For

readers interested in these issues, we refer them to a special issue

of Social Science and Medicine 42(8), 1996, which focuses on

the Inappropriate Distribution of Medicines by Professionals

in Developing Countries, and the Proceedings of the Workshop

on People and Medicines in East Africa, Mbale, Uganda,

November 1620, 1998, published by the Danish Bilharziasis

Laboratory, 2000.



17/23

adolescent girls who are often a difficult population to

reach, have low social status and higher rates of

illiteracy (DAlessandro, 1999), or groups that are

barred from accessing malaria control activities due to

political constraints; (d) expanding on what is known

about social determinants of treatment-seeking beha-

viors during pregnancy, including willingness and abilityto engage in preventive and treatment activities and how

this is affected by household structure and concepts of

vulnerability and protection for mother and fetus; and

(e) examining treatment-seeking behaviors during com-

plex emergencies.

Research, policy & practice

In addition to developing a new orientation in

fieldwork and undertaking research in new areas, social

scientists working in public health (particularly applied

anthropologists) are in an ideal position to play a majorrole in getting research results applied to policy and

policy into practice. Researchers need to place their

findings within the broader context, which requires an

understanding of how knowledge is used locally (Brugha

& Zwi, 1998). For this understanding to occur, social

scientists need to be committed to examining the

complex set of inter-relationships among stakeholders

that impact on the wider political and policy issues

surrounding malaria control in general. It is then

incumbent upon social scientists to interpret these

results to implementers and policy makers in a language

that is usable in programmatic ways (DAlessandro,

1999; Robb, 1999). Shretta, Omumbo, Rapuoda, and

Snow (2000) recently attempted to do this with an

analysis of the recent antimalarial drug policy change in

Kenya. In association with two evaluations of combina-

tion antimalarial therapy (Interdisciplinary Monitoring

Programme for Antimalarial Combination Therapy in

Tanzania (IMPACT-TZ) and the South East Africa

Combination Antimalarial Therapy Evaluation (SEA-

CAT), one of the authors of this review (Williams) is

currently engaged in conducting multi-disciplinary case

studies of changes in national malaria-treatment guide-

lines (Durreheim, et al., in press; Williams & Trupin,

2002). This work should provide information about theprocess of decision-making as it relates to national

policy changes and should help to inform the process for

subsequent policy changes. Moreover, attention needs to

be placed on what happens once guidelines are

changedhow do providers actually implement treat-

ment guidelines in practice? An important area of social

science inquiry that has not been adequately developed

is examining the factors influencing the development

epi.2004.williams.socscimed.a critical review of behavioral issues related to malaria control in ssa...

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