ReviewA critical review of behavioral issues related to malaria control in sub-Saharan Africa:: what contributions have social scientists made?
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
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 someHave Gaps in Knowledge & Previous Calls to Action Been Addressed?
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
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