Review
A critical review of behavioral issues related to malaria control in sub-Saharan Africa:: what contributions have social scientists made?

https://doi.org/10.1016/j.socscimed.2003.11.010Get rights and content

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 To address these issues, this paper critically reviews and synthesizes the literature (published, unpublished and technical reports) pertaining to the home management of illness episodes of malaria in sub-Saharan Africa from 1996 to the end of 2000, and draws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 treatment seeking 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 research knowledge, strengthen the relationship between research, policy and practice; and concentrate on capacity strengthening and advocacy.

Introduction

Over recent years, there has been a dramatic increase in global attention to malaria. Programmes such as the Multilateral Initiative on Malaria (MIM) and Roll Back Malaria (RBM) have been established and international donor agencies (both private and public) have contributed millions of dollars to malaria research and control. This renewed interest has arisen at a time when the concepts of decentralized health care and the role of community participation have become central tenets of disease prevention and treatment strategies. These factors, together with the failure of earlier vertical, top-down malaria eradication programs, have contributed to the current emphasis on community-based strategies for malaria control. The success of such strategies relies on an understanding of human behaviors and the socio-cultural, political, economic and environmental contexts that influence those behaviors. Contributions from social science are now identified as critical to malaria control (WHO/AFRO, 1998; Wellcome Trust/MIM, 1997; World Health Organization, 1997)—understanding treatment-seeking behaviors, willingness to accept and pay for preventive and curative services, local illness classifications, and the determinants 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 contributions 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 insecticide-treated materials. These papers link to an international 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 scientists, malaria control programs, and policy makers, in order to design more appropriate, effective, and sustainable intervention programs.

Section snippets

Background and objectives

In the early 1990s, the World Health Organization (WHO) commissioned a review of literature on treatment-seeking behaviors for malaria by McCombie (1994), McCombie (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 malaria, and (c) knowledge

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

Results

We reviewed 117 published papers (including 87 research reports, one policy paper, two editorials, nine letters 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

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

Acknowledgements

The authors wish to thank the core members of the Partnership for Social Sciences in Malaria Control for their continued support and insightful comments during this review, Ms. Onnalee Henneberry, reference librarian at the Centers for Disease Control and Prevention (CDC), and the various donors that made this collaborative project a reality: CDC, The CHANGE Project, US Agency for International Development (USAID)/African Bureau, and the Department for International Development (DFID), through

References (163)

  • L Gilson et al.

    Community satisfaction with primary health care servicesAn evaluation undertaken in the Morogoro region of Tanzania

    Social Science & Medicine

    (1994)
  • P Goel et al.

    Retail pharmacies in developing countriesA behavior and intervention framework

    Social Science & Medicine

    (1996)
  • J Kengeya-Kayondo et al.

    Recognition, treatment seeking behavior and perception of cause of malaria among rural women in Uganda

    Acta Tropica

    (1994)
  • G Kidane et al.

    Teaching mothers to provide home treatment of malaria in Tigray, EthiopiaA randomised trial

    Lancet

    (2000)
  • P Kofoed et al.

    Diagnosis of fever in Africa. Letter to the Editor

    Lancet

    (1998)
  • R Lubanga et al.

    Material diagnosis and treatment of children's fever in an endemic malaria zone of UgandaImplications for the malaria control programme

    Acta Tropica

    (1997)
  • S McCombie

    Treatment seeking for malariaA review of recent research

    Social Science & Medicine

    (1996)
  • F Moerman et al.

    The contribution of health-care services to a sound and sustainable malaria-control policy

    The Lancet Infectious Diseases

    (2003)
  • O.R Adome et al.

    Popular pills. A community drug use in Uganda

    (1996)
  • Adome, O. R., Reynolds-Whyte, S., Ortenblad, L., Ezati, E., Nsabagasani, X., Owor, J., & Turinde, A. K. (1997). The...
  • Adome, O. R., Whyte, S. R., Ortenblad, L., Ezati, E., Nsabagasani, X., Owor, J., & Turinde, A. K. (1998). The community...
  • Adongo, P., & Hudelson, P. (1995). The management of malaria in young children in northern Ghana: A report of a rapid...
  • A Ager et al.

    Perceptions of tropical health risks in Mponda, MalawiAttributions of cause, suggested means of risk reduction and preferred treatment

    Psychology and Health

    (1996)
  • Agyepong, I. (1995). Improving malaria control in the context of health sector reform. Technical Report prepared for...
  • A.M Ahmed et al.

    Patients’ perception of public, voluntary and private dispensaries in rural areas of Tanzania

    East African Medical Journal

    (1996)
  • C Ahorlu et al.

    Malaria-related beliefs and behavior in southern GhanaImplications for treatment, prevention and control

    Tropical Medicine and International Health

    (1997)
  • M Alilio et al.

    A KAP study on malaria in ZanzibarImplications for prevention and control. A study conducted for UNICEF sub-office Zanzibar

    Evaluation and Program Planning

    (1998)
  • Alilio, M., Kamugisha, M., Msuya, F., Massaga, J., Salum, F., & Njunwa, K. (1997). Availability and utilization of...
  • Alilio, M., & Tembele, R. (1994). Kilombero District Health Support: Sociocultural assessment. Technical Report...
  • J Armstrong-Schellenberg et al.

    Effect of large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania

    Lancet

    (2001)
  • Baume, C. (1998). Care seeking for fever in Bungoma District, Kenya: Implications for malaria programs. Technical...
  • Baume, C., & Macwan’gi, M. (1998). Care-seeking for illnesses with fever or convulsions in Zambia. Technical Report...
  • S Beckerleg

    Medical pluralism and Islam in Swahili communities in Kenya

    Medical Anthropology Quarterly

    (1994)
  • S Bedell et al.

    Discrepancies in the use of medicationsTheir extent and predictors in an outpatient practice

    Archives of Internal Medicine

    (2000)
  • R.B Biritwum et al.

    Incidence and management of malaria in two communities of different socio-economic level, in Accra, Ghana

    Annals of Tropical Medicine & Parasitology

    (2000)
  • R Brugha et al.

    Improving the quality of private sector delivery of public health servicesChallenges and strategies

    Health Policy and Planning

    (1998)
  • B Carme et al.

    Cerebral malaria in African childrenSocioeconomic risk factors in Brazzaville, Congo

    American Journal of Tropical Medicine and Hygiene

    (1994)
  • Clarke, S., Rowley, J., Bogh, C., Walraven, G., & Lindsay, S. (1999). Home treatment of malaria in a rural area of The...
  • U D’Alessandro

    A rational approach to malaria control in pregnancy in sub-Saharan AfricaThe need for a link between scientific research and public health interventions

    Annals of Tropical Medicine & Parasitology

    (1999)
  • Dawson, S. (1996). A situation analysis and opportunities for malaria control support in Tanzania. Technical Report...
  • R DiMatteo et al.

    Enhancing patient adherence to medical recommendations

    Journal of the American Medical Association

    (1994)
  • R DiMatteo et al.

    Depression is a risk factor for noncompliance with medical treatment

    Archives of Internal Medicine

    (2000)
  • A Djimde et al.

    Use of antimalarial drugs in MaliPolicy versus reality

    American Journal of Tropical Medicine and Hygiene

    (1998)
  • Dondi, N., Danda, S., & Kangere, T. (1998). Information, education and communication assessment, Bungoma District....
  • Douglass, E. F. (1998). Trip Report: IEC support for malaria control in Eastern Province, Zambia. Trip Report prepared...
  • D Durrheim et al.

    Confidential inquiry into malaria deaths

    Bulletin of the World Health Organization

    (1999)
  • Durrheim, D., Williams, H. A., Barnes, K., Speare, R., & Sharp, B. (in press). Beyond evidence: a retrospective study...
  • Ellman, R., & Shayo, D. (1997). Attitudes to malaria and malaria treatment in the East Usambara mountains of Tanzania....
  • E Feller-Dansokho et al.

    Prescription and delivery of antimalarials in Dakar, Senegal

    Annals of Tropical Medicine & Parasitology

    (1995)
  • Floyd, K. (1996). A situation analysis and opportunities for malaria control and support in selected countries in...
  • Cited by (193)

    View all citing articles on Scopus
    View full text