Community Understanding of Malaria, and Treatment-Seeking Behaviour, in a Holoendemic Area of Southeastern Tanzania

One of the main components of WHO’s current malaria control strategy centres on early recognition and prompt treatment. Rapid identification of malaria and adequate treatment are essential for preventing irreversible complications and most deaths can be avoided. But even in areas with good access to health care, it is common for malaria patients to present at the health facility late or not at all. The overall goal of the study was to investigate community understanding of malaria, and treatment-seeking, and the way in which this can contribute to delay in attending a health facility in order to formulate recommendations for tackling this problem. The study was set in Ifakara (Kilombero District) in southeastern Tanzania, a semi-rural town with a large and well equipped District Hospital and other, private and public health facilities and pharmacies. Antimalarials, mainly chloroquine and other drugs are also widely available over-the-counter in the numerous small shops throughout the community. Beside the biomedical resources, traditional medicine is well represented in the community. Many different types of traditional healers offer their services to the public. Malaria in the study area is holoendemic and perennial, which presents a huge health burden for the population, in particular to children under the age of five years. Resistance to chloroquine was found to be high. The ethnographic fieldwork was conducted in a two year field study carried out between April 1995 and March 1997. Additional information has been recorded in a second, short field visit of one month in September 1997 in the context of a study on the impact of cost-sharing on the community, requested by the St. Francis Designated District Hospital. The investigation strategy was that of triangulation, using a combination of qualitative and quantitative methods. The population was found to be very well informed about malaria as it is biomedically defined. However, one of the major findings was that the local knowledge is the result of an interplay between biomedical and traditional concepts and logics, a process which is referred to as ‘medical syncretism’. Analysing the amalgamation of the two types of knowledge contributed to the understanding of cultural logics underlying treatment-seeking behaviour for malaria. The study of medical syncretism reveals most clearly that even if health messages are well understood by the population, the meaning given to them may considerably differ from what health promoters intended to convey. This amalgamation and its consequences for treatment and delay was seen as relevant for all three forms of malaria (uncomplicated, severe, and recurrent malaria). For example, in the case of uncomplicated malaria, it was found that cultural logics derived from notions on witchcraft could lead people to misinterpret repeated vomiting as a sign of relief, rather than as a manifestation indicating an evolution from uncomplicated to severe malaria. For severe malaria, the local illness term degedege was identified to come closest to biomedically defined cerebral malaria. However, while informants clearly recognised the link between degedege and malaria, they did not treat the two forms in the same way; for degedege, people used primarily traditional practices, including assistance by ‘knowledgeable women, while for malaria, they preferred biomedical treatments by far. Based on this finding, the role of knowledge about aetiology for treatment-seeking is discussed. It is argued that knowledge which is present in the cultural repertoire (‘recipe knowledge’) and is automatically evoked for action (non-reasoned action) plays an important role in treatment-seeking, especially for treatments in an early phase of illness. Reasoned action was found to set in when something unexpected occurs, for example when symptoms inexplicably aggravate or persist despite treatment. The study showed how in the local illness model, biomedical ideas about malaria are complemented with the logics of witchcraft. The analysis of the resulting knowledge permitted us to explain the logics which guide people in their labyrinthic treatment-seeking paths, including biomedical and traditional health services for the same illness episode. In a second focus, the study emphasised the relevance of economic constraints for treatment-seeking. Cognitive aspects were linked with social and economic aspects. It was observed that perception about illness aetiology determined the implication of the social network for illness management and the social pressure on covering treatment costs of the sick individual. In contrast to illnesses attributed to witchcraft or spirits, for illnesses which belonged to the ‘natural’ order, such as malaria, and required hospital intervention, support networks for coping viiwith treatment costs, if any, were found to be small. Women who could not count on male support were identified to be at a particular risk for delaying treatment for their children because of economic reasons. It was found that women had adopted different coping strategies for covering treatment costs, but besides delay, they frequently had negative long-term implications for their and their children’s well-being. A particular high risk for delay was found to result from a negative interaction of gender, seasonality and illness factors. The findings from this study contributed to a rethinking of the traditional - modern dichotomy in socio-cultural malaria research. They further challenged the common view that traditional treatments are an important source of delay for malaria treatments and called for the need to increasingly focus research on delay and application on socio-economic perspectives. Direct implications of the study for further research and recommendations for action were extensively discussed

El paludismo y otras penurias. Salud y desigualdades de género en Tanzania

A pesar de todos los esfuerzos realizados para controlar la malaria, esta enfermedad protozoaria sigue siendo uno de los principales azotes del continente africano. En los grupos más vulnerables a la enfermedad, particularmente los niños menores de cinco años, el tratamiento rápido con medicación adecuada es la única manera de prevenir la muerte u otras graves consecuencias de la enfermedad. Los datos de este artículo proceden de una etnografía médica realizada en Lipangalala, una comunidad tanzana que basa su economía en el cultivo del arroz, y donde la malaria es holoendémica. Lipangalala se distingue del panorama médico africano general por una larga historia de presencia biomédica. En la actualidad cuentan con un hospital bien equipado, la biomedicina es la primera opción para el tratamiento de la malaria, existe un buen conocimiento del problema fruto de numerosas campañas de salud y, sin embargo, el paludismo sigue siendo la primera causa de mortalidad infantil, con unas cifras muy por encima de lo que cabría esperar en estas condiciones. En Lipangalala, más que con las ‘creencias’ o la disponibilidad de recursos, la terapia antipalúdica tropezaba con la falta de dinero y las dificultades para conseguirlo. En este artículo nos enfocamos en la búsqueda de recursos para pagar el tratamiento,un proceso clave, aunque a menudo olvidado por los investigadores, para comprender el problema del acceso a la terapia en toda su dimensión. Concretamente presentamos los procesos de toma de decisiones, los itinerarios sociales – normativos y reales – que las madres de niños enfermos siguen para conseguir dinero del padre u otros parientes, las estrategias activadas para hacer frente a los costes del tratamiento, el contexto socio-económico y ecológico que condiciona estos procesos, y el papel determinante de las desigualdades de género. Contrariamente al objetivo dominante en las investigaciones actuales en salud pública, orientadas a dilucidar los factores determinantes del retraso terapéutico, aquí proponemos una perspectiva a la vez procesual y estructural, que permite articular y contextualizar los elementos en juego, así como reconstruir las espirales de vulnerabilidad en las que están inmersas las personas de Lipangalala

Malaria in pregnancy: what can the social sciences contribute?

Building on existing knowledge from social science work on malaria, the authors propose two models for studying social science aspects of malaria in pregnancy

Пойменные ценокомплексы Красноярского водохранилища в районе залива реки Убей

Текст работы публикуется с изъятиям

What Role Do Traditional Beliefs Play in Treatment Seeking and Delay for Buruli Ulcer Disease?–Insights from a Mixed Methods Study in Cameroon

Victims of Buruli ulcer disease (BUD) frequently report to specialized units at a late stage of the disease. This delay has been associated with local beliefs and a preference for traditional healing linked to a reportedly mystical origin of the disease. We assessed the role beliefs play in determining BUD sufferers' choice between traditional and biomedical treatments.Anthropological fieldwork was conducted in community and clinical settings in the region of Ayos and Akonolinga in Central Cameroon. The research design consisted of a mixed methods study, triangulating a qualitative strand based on ethnographic research and quantitative data obtained through a survey presented to all patients at the Ayos and Akonolinga hospitals (N = 79) at the time of study and in four endemic communities (N = 73) belonging to the hospitals' catchment area.The analysis of BUD sufferers' health-seeking behaviour showed extremely complex therapeutic itineraries, including various attempts and failures both in the biomedical and traditional fields. Contrary to expectations, nearly half of all hospital patients attributed their illness to mystical causes, while traditional healers admitted patients they perceived to be infected by natural causes. Moreover, both patients in hospitals and in communities often combined elements of both types of treatments. Ultimately, perceptions regarding the effectiveness of the treatment, the option for local treatment as a cost prevention strategy and the characteristics of the doctor-patient relationship were more determinant for treatment choice than beliefs.The ascription of delay and treatment choice to beliefs constitutes an over-simplification of BUD health-seeking behaviour and places the responsibility directly on the shoulders of BUD sufferers while potentially neglecting other structural elements. While more efficacious treatment in the biomedical sector is likely to reduce perceived mystical involvement in the disease, additional decentralization could constitute a key element to reduce delay and increase adherence to biomedical treatment

The community counts: a participatory approach to social audits

Community matters – community responds. Yet many health planners still consider people as passive recipients of programs. Social audits respond to the voice of different stakeholders, including intended beneficiaries, in order to improve health planning and service delivery. The introductory and concluding papers of a special supplement to BioMed Central, discusses the evolution of Centro de Investigación de Enfermedades Tropicales (CIET)’s social audit methods, the lessons learned, and the way forward to the next generation of social audits

“It Is Me Who Endures but My Family That Suffers”: Social Isolation as a Consequence of the Household Cost Burden of Buruli Ulcer Free of Charge Hospital Treatment

Despite free of charge biomedical treatment, the cost burden of Buruli ulcer disease (Bu) hospitalisation in Central Cameroon accounts for 25% of households' yearly earnings, surpassing the threshold of 10%, which is generally considered catastrophic for the household economy, and calling into question the sustainability of current Bu programmes. The high non-medical costs and productivity loss for Bu patients and their households make household involvement in the healing process unsustainable. 63% of households cease providing social and financial support for patients as a coping strategy, resulting in the patient's isolation at the hospital. Social isolation itself was cited by in-patients as the principal cause for abandonment of biomedical treatment. These findings demonstrate that further research and investment in Bu are urgently needed to evaluate new intervention strategies that are socially acceptable and appropriate in the local context