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
