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MALARIA: Obstacles and Opportunities 12 Social and Behavioral Aspects of Malaria WHERE WE WANT TO BE IN THE YEAR 2010 There is widespread recognition that understanding the human response to malaria and to control programs is crucial to the success of all malaria control strategies. Because of an improved understanding of the way people perceive malaria, many social and behavioral barriers to the acceptance and use of prevention measures will be addressed in the design of malaria control programs. Similarly, a better grasp of health-seeking and treatment behavior will lead to more effective health communication strategies for malaria and the promotion of early and effective treatment of clinical cases of malaria, especially among young children. Community representatives will be active participants in the planning and implementation of malaria prevention and control programs. Many communities, particularly those in semiurban areas, will develop innovative ways of reducing larval development sites and at a minimal cost to outside resources, whether governmental or nongovernmental. WHERE WE ARE TODAY With the spread of insecticide-resistant vectors and chloroquine-resistant Plasmodium falciparum, malaria control program planners in many
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MALARIA: Obstacles and Opportunities parts of the world are finding that available control measures are either too expensive, not efficacious, or efficacious only under certain conditions. Obtaining high rates of acceptance and use of such interventions, especially those that are marginally efficacious, is crucial to the success of control efforts. Human behavior and social organization—one side of malaria's host-vector-parasite triangle—are clearly vital determinants for the success of control programs. Unfortunately, we do not know enough about how humans respond to malaria to be able to build strong multidisciplinary control programs. Historically, social scientists have had little or no role in the design and evaluation of malaria control programs. In modern malaria control programs, there is a clear need for applied social science research and the participation of social scientists. The choice of control methods appropriate for a specific community or region requires an understanding of how factors such as deforestation and the movement of populations from one region to another affect the local epidemiology of malaria. Many of these factors have their roots in social and economic change. It is the behavior of individuals and groups that determines how or whether efforts to prevent or treat malaria will be successful. To attain high rates of acceptance or use of a given control method, attention must be paid to a number of important considerations: (1) local perceptions of malaria and its causes, (2) the manner in which people decide whether a given treatment or preventive measure is efficacious, (3) patterns of treatment-seeking behavior during episodes of malaria, and (4) the role that the community as a whole plays in planning, implementing, and evaluating the control program. Social science research has often been criticized as anecdotal, unfocused on practical outcomes, and overly academic. These characterizations have little validity today. New research approaches to the social sciences that focus on participatory activities and multidisciplinary problem solving, combined with the adoption of formal and survey research methodologies, have narrowed the gap between the social and natural sciences. Factors Favoring Malaria Transmission The constancy of endemic malaria in certain parts of the world, and the resurgence of the disease in areas where eradication efforts were undertaken, are in large measure due to the interplay of broad social, cultural, and economic factors. Three such factors—agricultural development, population movement, and urbanization—are particularly important determinants of patterns of malaria transmission.
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MALARIA: Obstacles and Opportunities Agricultural Development The link between farming and malaria has a long history. In West Africa some 2,000 years ago, the advent of iron tools and higher-yield crops made the rain forest worth exploiting for agriculture (Livingstone, 1958). The Bantus of the central Benue River valley (what is now Nigeria) were perhaps the first to use iron tools to clear forests for farming. Their “slash-and-burn” and “slash-and-mulch” agricultural techniques may have set the stage for much of the current experience with malaria on the African continent. Anopheles gambiae mosquitoes account for most of the malaria transmission in Africa south of the Sahara. These insects do not breed in full shade, and it was only after tropical rain forests began to be cleared for crop production that sunlight-exposed pools of standing water, ideal sites for larval development for An. gambiae, were created (Coluzzi et al., 1985). Forest clearing also causes soil erosion, which in river valleys can attract mosquitoes to newly formed swamps (Laderman, 1975). The formation of small towns facilitates malaria transmission as a consequence of farming, which concentrates populations in relatively confined areas. Towns are often located near water supplies or, through change and disruption of the local environment, promote other potential larval development sites. A burrow pit dug at the edge of a village to collect material for construction often fills with water and serves as an ideal haven for mosquito larvae (Bruce-Chwatt and de Zulueta, 1980). It is no accident that most malaria occurs in rural agricultural communities. Agricultural settlement often brings changes in water use, alters the concentration of domesticated and wild animals, and causes deforestation, all of which can boost the number of larval development sites and increase human-mosquito contact. Irrigation practices that use canals or pumps to periodically flood fields for crops such as rice have a great impact on mosquito breeding. One type of livestock may attract a particular species of Anopheles but not another. The form of ownership of agricultural land and the type of labor utilized, such as sharecropping, also can affect the spread of and exposure to malaria parasites. Finally, the use of certain chemicals to increase crop production may have an indirect impact on the spread of malaria. High-yield varieties of crops require significant quantities of pesticides and fertilizers. Several studies have cited the use of pesticides in agriculture as a principal contributor to mosquito resistance to DDT in Central America, India, and other regions (Chapin and Wasserstrom, 1981, 1983). Other evidence suggests that DDT resistance can also be caused by antimosquito spraying (Curtis, 1981; Chapin and Wasserstrom, 1983).
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MALARIA: Obstacles and Opportunities Type I and Type II Farming Systems For the purpose of discussing the interaction between agriculture and malaria, farming systems can be divided into two primary types: type I systems, typically smallholder-subsistence or “minifundia” cash-crop businesses, in which land-use rights are held by the farmers working the land; and larger, type II systems, in which the land is not owned by the people who farm it and frequent use is made of migrant or wage laborers. This distinction is similar to that drawn by Bruce-Chwatt (1987) between “rural areas” and “development projects.” In type II farming, changes in land tenure often occur as land is consolidated into larger parcels. Plantations and capital-intensive agro-industry are two common type II farming arrangements. Poor sanitary conditions among farm workers in type II farming systems favor the transmission of malaria and other diseases that can decimate a work force and make it necessary to import more laborers. For example, the importation of African slaves into Mexico and the establishment of sugarcane plantations there created conditions favorable for P. falciparum, to which many Africans already had some natural immunity (Friedlander, 1969). This resulted in an increase in the already high mortality rate among the indigenous Indian workers and a corresponding increased demand for African slaves. In the early 1900s, the Italian physician Antonio Celli observed that in southern Europe malaria tended to disproportionately affect the poor or landless, especially those who were seasonal laborers on large farms (Celli, 1900; Chapin and Wasserstrom, 1981). Celli reasoned that transmission depended on the flow of nonimmune persons into malarious zones just before the annual peak of the Anopheles population. Packard (1984), in a study of colonial Swaziland, has shown how changes in land ownership and labor utilization can increase malaria transmission. Much of the country's best land was given to European colonial miners, farmers, and land speculators. That, combined with the thinning of cattle herds by an epidemic of rinderpest in 1886 and the decline in traditional Swazi raiding activities, turned the native population from essentially self-sufficient food producers into agricultural wage laborers. Under this arrangement, it was more difficult to cope with drought, and years of drought became years of famine. The occurrence of major epidemics of malaria in Swaziland in 1923, 1932, 1939, 1942, and 1946 appears to be related not only to the rainfall in the year of the epidemic but also to famine conditions in the preceding year. This suggests that sound land reform and agricultural policies, as well as public health measures, can play an important role in malaria control.
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MALARIA: Obstacles and Opportunities Type II farms are also distinguished by their large-scale use of water. Irrigation is common to almost all forms of type II farming systems. Studies of irrigation projects in India have linked increases in mosquito populations to higher subsoil water tables and to the creation of small side channels suitable for larval development when the canal is refilled (Covell, 1946; Hyma and Ramesh, 1980). Large dams, which often accompany irrigation projects, create additional opportunities for malaria to gain a foothold. Mosquitoes can breed in the reservoir itself, especially if its edges are not kept clean of vegetation. Seepage from the dam and pooling also can occur, providing new larval development sites. Finally, all large dam projects require that considerable numbers of construction workers be brought to the dam site (Covell, 1946; Hyma and Ramesh, 1980). When nonimmune workers are exposed to malaria, or when malaria is introduced by workers from endemic regions, epidemic malaria may result. Economic development programs that incorporate dam construction, irrigation, or “green revolution” technologies—also typical of type II farming—likely will change malaria epidemiology. Any development project that alters preexisting relationships between humans and their environment should be evaluated within an ecological framework (Hughes and Hunter, 1970). Careful planning before such projects are undertaken can reduce or eliminate the potential for malaria transmission. Human Population Movements The importance of human population movements to malaria control cannot be overemphasized. In fact, such shifts may contribute to the spread of chloroquine-resistant P. falciparum. In many African countries, for example, people move from permanent settlements to rural farms during the early months of the wet season, when cultivation, planting, and weeding are carried out (Prothero, 1961). A variation on this pattern is the seasonal movement of pastoralists tending their livestock between mountain and lowland pastures. Religious pilgrimage, need for employment, drought, famine, war, resettlement, and tourism all contribute to the ebb and flow of populations and the spread of malaria. Population movement increases malaria transmission in four principal ways. First, such movement often introduces nonimmune people into endemic areas or infected people into malaria-free regions. For example, the higher incidence of malaria among Afghan refugees living in Pakistan than among the indigenous population reflects the Afghans' lower level of preexisting immunity (Suleman, 1988). Second, the living conditions of migrants differ markedly from those of settled populations, resulting in greater exposure to infected mosquitoes.
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MALARIA: Obstacles and Opportunities Housing, if available, is crowded, of poor quality, and often located adjacent to Anopheles breeding sites. Third, the type of work performed by migrants and the conditions under which they work often result in greater exposure to malaria-infected mosquitoes. Much of the work, especially if it is illegal (for example, gem mining, gold prospecting, and drug smuggling), is performed at night, when Anopheles mosquitoes are most likely to be biting. In addition, since employment for migrants is usually seasonal or temporary, there are periods when no funds are available for malaria treatment. Finally, migrant populations rarely are served by government malaria control programs. Even if they are served, most control methods, such as residual application of insecticides to walls of houses, chloroquine prophylaxis for pregnant women, and screening of houses, may be difficult or impossible to implement. For example, gold miners who work along the Madeira River in the Brazilian Amazon live in temporary shelters without walls. The absence of walls makes insecticide spraying impractical and allows mosquitoes to enter freely at night (Coimbra, 1988). The illegal status of some migrants further complicates efforts at malaria control. During the 1960s, for example, Mozambican laborers were hired to work on sugar estates in Swaziland. When the use of Mozambican laborers instead of indigenous Swazi workers became a political issue, the government of Swaziland imposed restrictions on the use of foreign labor, but Mozambicans continued to migrate and work illegally in the country. Swaziland health authorities had difficulty detecting cases of malaria among these migrants because of their illegal status and the sugar industry's lack of cooperation (Packard, 1986). Most studies of the dynamics of malaria transmission treat human populations as though they are static. Even research that examines the effects of population movement, such as the Garki project (Molineaux and Gramiccia, 1980), fails to assess such shifts or to adequately distinguish between them. Urbanization Diseases transmitted by insect vectors continue to be thought of primarily as illnesses of rural areas. While the insect vectors for some diseases, such as onchocerciasis (river blindness) and African trypanosomiasis (sleeping sickness), are exclusively rural, some of the mosquito vectors that carry malaria, Bancroftian filariasis (elephantiasis), Japanese encephalitis, and dengue hemorrhagic fever have become well adapted to city life (Bang and Shah, 1988; Dunn, 1988). In general, urban areas have higher population densities, which allow for increased rates of disease transmission, large numbers of larval development sites due to water storage practices, and limited methods for disposal of wastewater and refuse.
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MALARIA: Obstacles and Opportunities Anopheles stephensi is the most important vector of urban malaria on the Indian subcontinent. Nowhere else in the world is there a malaria vector so well adapted to urban life. It breeds in wells, cisterns, fountains, ornamental tanks, barrels, and buckets (Bang and Shah, 1988). During the initial planning of the Indian National Malaria Eradication Program (NMEP), cities and towns with a population of more than 40,000 were considered to have little malaria transmission or to be malaria free (Sharma and Mehrotra, 1986), and malaria control in these communities was turned over to the local government. The result was a precipitous drop in malaria transmission in rural areas with no corresponding drop in urban areas. The proportion of malaria cases occurring in urban areas increased in many parts of India. In the state of Tamil Nadu, for example, 50 percent of malaria cases reported in 1961 were from urban areas; by 1963, this proportion had increased to 95 percent (Sharma and Mehrotra, 1986). The presence of pockets of urban malaria in India was an important contributor to the dramatic resurgence of the disease in the late 1960s. An in-depth evaluation of the NMEP concluded that the absence of control strategies for urban malaria was the program's most important failure (Sharma and Mehrotra, 1986). At least one other Anopheles species, An. arabiensis, found in Nigeria, seems to be adapting to living in town or city centers (World Health Organization, 1988). In most of Africa, Latin America, and Asia, however, malaria vectors are primarily confined to rural areas. In these regions, malaria is an important urban disease only in peripherally located communities that are similar in some respects to rural sites. In a study of malaria transmission and urbanization in Brazzaville, Congo, human settlement was initially found to favor the spread of An. gambiae, but subsequent increases in population density tended to eliminate larval development sites as open spaces were gradually built up and standing water became too contaminated for Anopheles larvae to survive in (Trape and Zoulani, 1987). Since Anopheles species breed in fairly clean collections of standing water, such as rice paddies, swamps, and lakes, an increase in fecal or other contamination ruins their suitability for larval development. Malaria, therefore, is more of a problem in semiurban than in truly urban areas. The proportion of people living in urban and semiurban areas is expanding rapidly. In 1950, almost 30 percent of the world's 2.5 billion inhabitants lived in urban areas. By the year 2000, half of the world's projected 6.2 billion people will live in urban settings, many of them in slums and squatter settlements (World Health Organization, 1988). Although most anopheline mosquitoes do not thrive in urban areas, the fact than an increasing share of the world's population will reside in urban or semiurban locales provides impetus for increased malaria control in those areas. Finally, it should be pointed out that the social and economic factors
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MALARIA: Obstacles and Opportunities that contribute to the appearance of urban malaria are similar to those involved in producing malaria in rural populations and in migrants. The recently settled, low-income neighborhoods on the periphery of urban areas where malaria commonly occurs are usually populated by migrants from rural sites or refugees from war, famine, or changing patterns of land tenure. Many work part of the year in the city as wage laborers and then return to the country. Implications for Malaria Control Programs An understanding of the social and behavioral factors that favor malaria transmission may not appear to have any practical implications for malaria control programs. It is difficult to see how these programs can have any impact on processes such as urbanization, deforestation, and migration. Nevertheless, awareness of which of these factors are important in a given area can help in the choice of appropriate control measures and in decisions about how these measures will be implemented. In choosing control measures, it is important to consider factors such as human population movements, which can make measures such as residual spraying with insecticides to kill mosquitoes both ineffective and difficult to implement because people may not have a permanent home. On the other hand, slight improvements in socioeconomic conditions may make marginally efficacious technologies far more efficacious. In a study in Muheza, Tanzania, it was found that slight improvements in housing conditions significantly improved the efficacy of insecticide-impregnated bednets (Lyimo et al., in press). Understanding social and behavioral factors which influence transmission can also be helpful to policymakers charged with choosing among malaria control options. For example, the distinction between type I and type II farming systems, even though it is not always clear-cut, can indicate which groups should be involved in control activities. Migrant laborers working in rice production—a type II farming arrangement —may have no control at all over the presence of larval development sites in the field or around housing facilities. In this case, only the landowner or the company can take the appropriate control steps. Acceptance and Usage of Control Methods Most malaria control programs are still planned and implemented on the assumption that the major barrier to the adoption of control interventions is lack of knowledge. Posters, pamphlets, radio advertisements, and health education campaigns are all intended to provide information that will change behavior.
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MALARIA: Obstacles and Opportunities Although there is an awareness that other cultural, behavioral, and operational factors may also be acting as barriers to adoption of interventions, they tend to receive less attention for several reasons. First, program planners seldom have the training in qualitative research techniques necessary to investigate these factors. Second, the tremendous diversity in culture and community structure observed in many malarious regions, even between adjacent villages, has led program planners to believe that a serious consideration of these variables would entail the development of a unique control program for each village. This is clearly not a task that can be undertaken with the limited resources of most ministries of health. Coping with this diversity becomes much less of a challenge when it is realized that certain features of the ways in which people adapt to malaria, including the models used to explain malaria, its causes, and treatments, are found in a broad range of different cultures. As a result, it is possible to describe a set of barriers to the success of control efforts which have been documented in many different parts of the world. Perceptions of Cerebral Malaria A major objective of many malaria control programs is to decrease mortality from cerebral malaria. Unfortunately, because of its sudden onset and the presence of neurological symptoms such as convulsions, cerebral malaria is often perceived as a nonmalarious condition. Ramakrishna and Brieger (1987) quote a mother in western Nigeria as saying, “Yesterday I thought my child was having malaria, but today when the convulsion started, I knew it was another disease. ” This “other disease,” which corresponded clinically to cerebral malaria, was identified by the mother to be ile tutu or “cold earth,” a nonmalarious condition. The acute mental changes associated with cerebral malaria lead many to believe that it is due to supernatural rather than natural causes. Both Helitzer-Allen (1989) in Malawi and Fivawo (1986) in Tanzania describe a type of fever accompanied by convulsions that is attributed to spirits or witchcraft. The results of such perceptions are twofold. First, cerebral malaria, while seen as dangerous, is not thought to be controllable through vector control or chemotherapy. At the same time, non-cerebral malaria is not seen as an important health threat. Causes of Malaria Even among those who view mosquitoes as central to malaria, the presence of mosquitoes may be considered neither sufficient nor necessary for disease transmission. In one survey in the Philippines, 93 percent of respondents agreed that mosquitoes transmit malaria, yet almost half also
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MALARIA: Obstacles and Opportunities said the disease could be caused by “germs” in contaminated water, and nearly 30 percent blamed the disease on “microorganisms” (Lariosa, 1986). About 70 percent of respondents believed that malaria was communicable by close contact with a patient. Some of the reasons that education about the cause-and-effect relationship between mosquitoes and malaria is usually not successful have been listed by Gramiccia (1981). Perhaps the most important is the fact that many mosquito bites may not result in malaria, yet one can get malaria after a few bites or even without being bitten recently, depending on the mosquito species that is biting, the percentage of mosquitoes infected, and the possibility of malaria relapse or recrudescence. Furthermore, someone who installs screens on the house, uses mosquito nets, and eliminates larval development sites around the house may get malaria, while someone who takes none of these precautions may not. There are many similarities between the explanatory models for the causes of malaria found in different cultures because they are based on observations of similar phenomena. These phenomena include the association of malaria with rain (which increases the number of vector breeding sites), with humidity and heat (which affect mosquito longevity), and with agricultural work (which increases exposure to mosquitoes and often is more intensive during or after the rainy season). Helitzer-Allen (1989) describes a folk belief for malaria and malaria-like conditions in Malawi. The term malungo, which literally means fever and is used to denote malaria, was found to have seven separate subcategories of the disease, each with its own etiology, symptoms, and treatment. They included, by etiology, malungo due to mosquitoes; getting wet in the rain or getting cold; hard work; spirits or witchcraft; other airborne methods; dirty water or food; and kulipuka, a form of malungo in children associated with blisters in the parents. In the Gambia, MacCormack and Snow (1986) had remarkably similar findings. In the village of Katchang, malaria was thought to be caused not only by mosquitoes but also by getting wet in the rain or getting cold; hard work; eating maize, kucha, or fruit of ningkong at the end of the rains; not having enough to eat; and lack of sleep due to nuisance mosquitoes. The significance of perceptions that there are many causes of malaria is that people may feel that there is no way to control malaria. Mosquitoes can be avoided, but it is difficult to avoid hard work, getting wet or cold, or eating “contaminated” food. As a result, people are unwilling to participate in time-consuming malaria control activities. Participants in a study in Liberia, for example, felt that exposure to malaria 's causative agents was inevitable, that contracting malaria was determined largely by fate, and that the chance of contracting the illness was unpredictable (Jackson, 1985). An additional consequence of the perception that mosquitoes are not
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MALARIA: Obstacles and Opportunities the only cause of malaria is that people may feel that methods of treatment such as chloroquine do not work for all forms of malaria. In Malawi, Helitzer-Allen (1989) found that only malungo attributed to mosquitoes or to airborne dissemination was thought to be treatable with chloroquine. This had the effect of decreasing chemoprophylaxis compliance by pregnant women who underestimated the range of illness episodes that it would be able to prevent. Water and Mosquitoes Just as mosquitoes are not believed by many cultures to be the only source of malaria parasites, neither is standing water, such as swamps and drainage ditches, thought to be the exclusive locus of larval development. Indigenous populations commonly believe that mosquitoes originate from almost anywhere in the environment, that the number of potential larval development areas is unlimited, and that mosquitoes are therefore uncontrollable. This view can limit interest in time-consuming mosquito control measures. Subjects interviewed in Mexico and Honduras expressed the belief that mosquitoes are generated not only by humidity, wind, and rain, but also by plants, mud, earth or waste, and “dirtiness.” In Mexico, study participants claimed to have witnessed mosquitoes emerging from leaves (Center for International Community-Based Health Research, 1988; Winch et al., undated); in Honduras, where significant unfamiliarity with mosquito larval stages was found, participants claimed to have witnessed young mosquitoes immediately stretching their wings and flying after hatching (Leontsini, undated). Distinguishing Malaria from Other Diseases In regions of the world where malaria is endemic, there is almost always a term that corresponds to clinical malaria. However, there is not always agreement among the patients' perceptions of malaria symptoms, the definition of malaria used in a local health clinic, and the definition used by parasitologists (Jackson, 1985). The result frequently is nosological fusion, a phenomenon in which there is a failure to distinguish between what are biomedically two or more discrete diseases (Young, 1979). Nosological fusion can affect, in three ways, whether a person feels that a control measure is efficacious. First, if an illness is incorrectly diagnosed as malaria, the patient may conclude that preventive measures taken, such as the use of impregnated bednets, do not prevent malaria. Alternatively, the patient may conclude that an antimalarial medication is ineffective when in fact the drug is inappropriate for whatever disease is present.
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MALARIA: Obstacles and Opportunities Finally, nosological fusion can make local treatments seem effective when they are not. For example, if a viral infection is diagnosed incorrectly as malaria and the patient takes a local remedy and becomes well, the patient may conclude that the treatment is efficacious against malaria when it is not; the viral infection has merely been resolved by the patient's own immune system. Drug Side Effects and Beliefs About Drug Action Drug side effects and beliefs about drug action are important determinants of the acceptance of malaria prophylaxis and treatment. When studied, acceptance has usually been found to be low. In one study of compliance with chloroquine prophylaxis among pregnant women in Africa south of the Sahara, rates of compliance ranged from a low of 2 percent in Zaire to a high of 18 percent in the Central African Republic (Breman and Campbell, 1988). The most common side effect of chloroquine is pruritus (itching). In Saradidi, Kenya, itching due to chloroquine use was reported in about 20 percent of adults (Spencer et al., 1987), and 10 percent of women interviewed stated that they had not taken the chloroquine because of fear of itching (Kaseje et al., 1987). Interestingly, a study of compliance with chloroquine prophylaxis among pregnant women in Malawi found that those who complained about side effects felt that these side effects indicated that the drug was working; side effects were considered more beneficial than harmful (Helitzer-Allen, 1989). Chloroquine's bitter taste may or may not be a barrier to compliance. In the Saradidi studies and a study conducted in North Mara, Tanzania (MacCormack and Lwihula, 1983), bitterness was not reported as a major barrier to compliance. These findings appeared to be confirmed by the Malawi study, in which women infrequently reported side effects and 99 percent said that chloroquine was not bad for pregnant women. In key informant interviews, however, virtually all participants expressed the view that chloroquine was bad for pregnant women and, because of its bitter taste, was considered to be an abortifacient. A nonbitter formulation, together with improved health education that addressed these perceptions, significantly raised compliance rates (Helitzer-Allen, 1989). Logistical and Organizational Problems Many times the failure to achieve a high rate of usage of a malaria control technology is due neither to side effects nor to beliefs but simply to the fact that the technology is unavailable or if it is available, people are unaware that it exists.
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MALARIA: Obstacles and Opportunities MacCormack and Lwihula (1983) show how a program aimed at controlling malaria in children through the use of prophylactic chloroquine failed because of a lack of sensitivity to a series of quite practical problems, including the exclusion of socially marginal families from the program and irregular drug supplies at the local level. While no single problem was insurmountable, together these difficulties threatened the success of an otherwise sound program. In Saradidi, Kenya, chloroquine prophylaxis was offered free of charge to pregnant women through village health helpers, yet only 29 percent of 357 pregnant women seen in antenatal clinics were taking the drug (Kaseje et al., 1987). Of those women not taking chloroquine, over half said they were unaware that the service was available. In a study of compliance with malaria chemosuppression regimes in Tanga Region, Tanzania, despite fears of drug side effects and abortifacient properties, the predominant problem was irregular drug supply. Ironically, even when chloroquine became available, it was often not taken because of fears that it might not be available for future needs; mothers were tempted to hoard the drug for use in future malaria episodes instead of using it prophylactically (Matola and Malle, 1985). Evaluation of the effects of operational and economic barriers to the use of malaria control technologies must take into account explanatory models about malaria and malaria-like illnesses and their causes. If a technology appears to address the problem as it is understood by the community, people may be willing to pay more or endure more inconvenience to obtain it. If, however, it does not appear to address the real problem as elaborated by these models, acceptance may remain low even if the technology is made more available and is less expensive. Lack of Community Participation Active community participation in the design and implementation of health and development projects can greatly increase the chances of success. Communities are rarely involved in real decision making and therefore feel that they have little stake in program outcome. Nichter (1984) points out that assumptions regarding what a community wants, needs, or will support are usually made by program planners rather than the community. Rajagopalan and Panicker (1984) state, “Many times such plans are forced upon the villagers and the latter acquiesce passively to their implementation, without participating in them. Their acquiescence is often mistaken for cooperation/participation. ” A malaria control program in which community participation was encouraged in the planning and implementation phases was carried out by the Vector Control Research Centre (VCRC) of Pondicherry, India (Rajagopalan
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MALARIA: Obstacles and Opportunities and Panicker, 1984). One of the program's initial findings was that the community's objectives did not coincide with those of disease control. To pursue both sets of objectives, a flexible integrated approach was undertaken. Rather than concentrate strictly on vector control, the VCRC first collaborated with community organizations on issues of concern to the community, including problems related to drinking water and electricity. Once these problems were resolved, attention was given to vector control. VCRC then proceeded to link vector control activities to economic rewards. In the study village, it was found that the presence of algae reduced the number of larval development sites. Since the algae could be used to make cardboard, there was a financial incentive for the villagers to grow, harvest, and sell the algae. A similar economics-based approach was used when it was discovered that the small pools in which mosquitoes thrived could be used to breed prawns. Even when attempts are made to involve communities actively in program activities, factionalism within communities may limit participation (Schwartz, 1981; Paul and Demarest, 1984; Twumasi and Freund, 1985). Allen and co-workers (1990) describe a malaria chemoprophylaxis program among children in the Gambia in which the drug was administered by village health workers (VHWs). Problems of drug supply and drug side effects had little effect on compliance; however, mothers were unwilling to have their children receive treatment from VHWs or to be cared for by traditional birth attendants if they came from a social or ethnic group different from that of the mother. Village health workers are often key to the successful operation of malaria control programs. In Latin America, for example, passive case detection networks made up of unpaid community volunteers were established in most countries in the late 1950s. The networks have become the principal tool for malaria surveillance and antimalarial drug treatment in many national malaria programs (Ruebush et al., 1990). Use of VHWs is not without problems, however. The integration of malaria control into larger national primary health care programs has meant that VHWs have much broader responsibility for health in general, leaving less time for them to address problems specific to malaria (Justice, 1986; Heggenhougen et al., 1987). Careful selection and training are key to ensuring an effective VHW work force. In a review of VHW activity in Honduras, worker selection was the single most important determinant of the sustainability of local malaria control efforts (Kendall, in press). Unfortunately, selection is often the responsibility of the lowest-level professional health worker, and selection criteria are often ill defined. A manual for the rapid assessment of social and cultural aspects of malaria is now being developed by a working
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MALARIA: Obstacles and Opportunities group of the United Nations Development Programme/World Bank/World Health Organization/Special Programme for Research and Training in Tropical Diseases/Social and Economic Research. RESEARCH AGENDA The application of social and behavioral science research on malaria (excluding questions of economics and management, which are dealt with in other chapters) should have two main objectives: to help researchers understand and reduce social and behavioral barriers that hinder the acceptance and use of preventive measures; and to promote early and effective treatment of clinical cases of malaria, especially among young children. Understanding Community Beliefs Communities often have conflicting beliefs about what causes malaria, where mosquitoes come from, and how best to prevent or treat the disease. For example, because chloroquine tablets are an effective treatment for certain types of malaria but have no demonstrable effect in young children with cerebral malaria, some may conclude that cerebral malaria is not, in fact, a type of malarial illness. Communities and malaria program planners may have widely different views about the nature of the malaria problem and the availability and efficacy of control options. RESEARCH FOCUS: In-depth studies of community beliefs, observations, and perceptions. Health-Seeking Behavior There have been few systematic studies of how episodes of malaria are recognized and treated at the household level. It is essential to know how people, especially mothers and caretakers of young children, make decisions about whether to administer home remedies, consult traditional healers or VHWs, or go to a clinic or hospital. Without information on health-seeking behavior, it will be difficult to develop an integrated strategy for reducing malaria mortality. RESEARCH FOCUS: Studies of health-seeking behaviors in malaria. One method that may be especially useful for analyzing health-seeking behavior is the ethnographic protocol. The protocol technique involves interviewing key informants, mothers of children under age three, and
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MALARIA: Obstacles and Opportunities health care providers. Relevant data are obtained through free listing of illnesses, narratives of past malaria episodes, hypothetical case scenarios, paired comparisons, severity ratings, and sorting tasks. RESEARCH FOCUS: Development of an ethnographic protocol on treatment-seeking behavior for episodes of malaria. Research Methods Most social science research on malaria is conducted with use of standardized survey instruments, often in the form of knowledge, attitude, and practice questionnaires. Although surveys can be useful when the variables being measured are well defined, such as socioeconomic and demographic data, they are of limited use for examining factors that influence the acceptance and use of malaria control methods. For example, in responding to a questionnaire, individuals may state that mosquitoes are the cause of malaria, but the fact that they believe mosquitoes are considered neither sufficient nor necessary for malaria transmission may be concealed. Multimethod qualitative techniques, which have been used by applied social scientists in research on nutrition and primary care health, need to be adapted to research on malaria. RESEARCH FOCUS: Development of a malaria rapid assessment procedures guide containing instructions for the use of social science methods, including key-informant interviewing, focus groups, and consensus modeling, as well as other social science data collection methods. Health Communications The need for research does not end once barriers to the acceptance and use of interventions have been documented. Research is also needed to determine the best strategy to provide convincing and persuasive means to involve communities in control activities. The traditional approach to malaria education has been to stress biological and medical facts. Mosquitoes are presented as the only route through which malaria parasites can be transferred to humans, and the life cycle of the mosquito is explained repeatedly. The importance of “nonscientific ” and traditional theories of illness causation to malaria control should not be underestimated, however, since they summarize the communities ' perception of the local epidemiology of malaria and their perception of risk.
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MALARIA: Obstacles and Opportunities RESEARCH FOCUS: Adoption and evaluation of contemporary health communication techniques that use qualitative and quantitative research intensively to define the audiences, behaviors, strategies, channels, and messages for malaria control programs. RESEARCH FOCUS: Exploration and evaluation of the applicability of contemporary learning models to bring about behavior change in populations at risk. RESEARCH FOCUS: Evaluation of the role of new channels, such as mass media, and traditional channels, such as theater, as vehicles for health communications on malaria. Community Participation Much of the research on community involvement in malaria control has focused on stable rural communities where residents had a significant degree of control over their immediate environment. In urban areas, in areas where agriculture dominates, or within communities whose populations migrate, community participation necessarily will take on a different look. It is often assumed that communities do not exist in urban and migrant settings, and approaches to malaria control in these areas accordingly have often been based on legislation (Bang and Shah, 1988). This strategy has had limited effectiveness, and new approaches will have to be developed for urban and migrant communities that are growing in both number and importance. RESEARCH FOCUS: Development and evaluation of participatory strategies in malaria control for urban and migrant communities. Community Involvement in Planning and Evaluation During the eradication era, intervention strategies were largely predetermined, and there was little room for local input into the decision-making process. Now that choices about what control technologies to use have become less clear-cut, community involvement has become critical. Consultations with the community can reveal whether a certain intervention will be accepted and, if so, to what extent. There may be no point in implementing interventions aimed at decreasing malaria transmission unless a high level of acceptance is expected. Unfortunately, little is known about methods of involving communities in decision making and program evaluation as these activities relate to malaria control.
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