Subscribers may have not seen the following paper on patterns of
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International Health and Infectious Diseases Study Group Newsletter.
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PATTERNS OF TREATMENT FOR MALARIA IN AFRICA
Department of Anthropology
Case Western Reserve University
IHIDSG NEWSLETTER Vol 1 (ns) No. 3 (February 1996)
International Health and Infectious Disease Study Group (IHIDSG)
Society for Medical Anthropology, American Anthropological
Association. Contact: Johannes Sommerfield <jsommerf at hiid.harvard.edu>
Malaria remains one of the most important causes of childhood
mortality in sub-Saharan Africa, and represents a significant risk
to non-immune adults such as travelers and migrants. It is
estimated that 40% of fevers are due to malaria (Brinkman and
Brinkman, 1991). A large proportion of malaria cases are treated
outside of the official health care system (Foster, 1991, Greenberg
et.al., 1989, Breman and Cambell, 1988). Research on treatment
seeking for malaria is important to plan appropriate interventions.
In some cultures, "malaria" is recognized as a distinct disease,
and knowledge of symptoms and transmission through mosquito bites
is high. In others, "malaria" is recognized as a distinct disease,
but in the absence of understanding of the etiology and
transmission. Accurate knowledge of etiology and transmission is
often unrelated to appropriate treatment. Antimalarials have come
into common use in many areas where mosquito transmission is not
In many cultures there is no general term or illness concept that
approximates malaria. In addition, there is variation within
cultures, illustrated by the concept of "nyongo" in Zimbabwe. There
was no agreement among respondents about whether "nyongo" was
equivalent to malaria. Some recognized both terms and said that
"nyongo" was not the same as malaria. However, a majority said the
symptoms of "nyongo" were headache and fever and that it was caused
by mosquito bites (Vundule and Mharakurwa, 1992).
Among the Dangbe of Ghana, the closest approximation of malaria is
"asra", which translates best as fever and is believed to be caused
by prolonged contact with heat. Mosquito transmission is not
recognized, although many use modern antimalarials for treatment.
A self diagnosis of "asra" was closely related to malaria. In one
village, 71% of those who believed they had "asra" were positive
for malaria (Agyepong, 1990, 1992). Still, 47% of those who did
not think they had asra were also positive, indicating that even
when a broad term is used, malaria cases may be missed.
Community surveys have shown that a high proportion of presumed
malaria cases receive some type of treatment. Figures range from
84% in Guinea (Dabis et.al., 1989) to 95% in Tanzania (Neuvians
et.al., 1988) with most over 90%. Many cases receive multiple
treatments, with patients consulting a variety of sources for a
single episode of illness.
A number of studies suggest that the majority of people recognize
the value of modern drugs in the treatment of malaria or perceive
the value of antimalarials in promoting health even when the drugs
are not associated with malaria (Allen et.al., 1990). In Tanzania,
during a program to provide chloroquine for prophylaxis in
children, mothers recognized the efficacy of the drug in reducing
fever and began diverting the supplies to other household members
who were ill with fevers (MacCormack and Lwihula, 1983).
The typical first response to malaria is self treatment. On
average, about half of patients purchase drugs from pharmacies,
shops or drug vendors. A number of studies note that underdosing
is common. A common behavior is to stop taking medication when
symptoms are relieved and save tablets for future attacks or
friends and family. In Kenya, 18% of the households surveyed had
antimalarials in the home, but none had a full course (Mwenesi,
The number who seek care from health centers, hospitals, and
village health workers varies greatly. Use of the official sector
is usually higher in urban areas, where there is more access to
modern medical facilities. In a survey in Nigeria, 25% of urban
people sought care at a health center versus only 18% in rural
areas (Odebiyi, 1992). In Guinea, overall use of health centers
was much higher, with 69% of urban residents and 33% of rural
residents using health centers (Glik, 1989).
In an urban survey in Cameroon, self treatment with antimalarials
purchased in shops was judged the least expensive option when fees
and transportation costs were included. Treatment at a dispensary
cost 2.6 times as much as self treatment, and hospital treatment
was 10 times higher than self treatment (Lewis et.al, 1992). Drug
shortages in the public sector are also common in many areas,
resulting in the need to purchase medication from private sources.
In Zambia, health workers responded to a short supply by reducing
the amounts given to patients for presumptive treatment (Makabulo,
In estimating rates of treatment from various sources, it is
important to distinguish between hypothetical and actual behavior.
The design of questionnaires and construction of questions has an
influence on responses. For instance, in a study in Kenya, 28%
mentioned a health unit in response to the question: "How can
malaria be treated?", while only 19% said they went to health units
to treat their family. An even greater difference was seen with
respect to buying drugs from a shop. Only 31% mentioned this a
general option, but 75% said that this is what they did to treat
cases in their family (Ongore et.al.,1989).
It appears that traditional healers are rarely consulted regarding
the treatment of malaria, although people sometimes use home herbal
remedies to reduce fever. In many cases, traditional healers do
not claim to cure malaria, and in others people already know how to
treat malaria with traditional or modern medicines (Bledsoe and
Goubad, 1985, Makabulo, 1991). In a study in Kenya, traditional
healers were not an important source of treatment for uncomplicated
malaria in children. However, traditional healers were likely to
be consulted for convulsions, splenomegaly and anemia, which were
not associated with malaria by the people (Mwenesi, et.al., 1995).
Further research is needed to answer the question of what
proportion of malaria cases get appropriate treatment and identify
the best strategies to improve the situation. It is important to
understand local disease categories and illness terms, and examine
the relationship between self-diagnosed malaria and true malaria in
each setting. It is especially important to investigate the
response to symptoms of severe malaria such as convulsions, which
may not be related to the same term used to approximate malaria.
There is a need for detailed studies of drug use and dosage
patterns, with information on the specific drugs used, considering
resistance patterns in a particular area. Underdosing is common,
and the clinical and epidemiological impact of this behavior
pattern needs to be studied. Hypothetical questions about
treatment seeking (i.e., "how can you treat", "how do you treat")
have a role in rapid assessment and developing appropriate
questions and preliminary models of treatment seeking behavior.
They may also be of value in showing differences between groups in
a single study. However, they are of limited usefullness in
estimating rates of actual treatments. Whenever possible, studies
should focus on actions taken for recent cases. Retrospective
studies also have limitations in that severe cases and cases that
were treated are more likely to be recalled. Innovative methods
such as prospective surveys and diary keeping can increase our
understanding of typical responses to malaria.
This research was supported by the World Health Organization
through the UNDP/World Bank/WHO Special Programme for Research and
Training in Tropical Diseases (TDR).
Agyepong, I.A. (1992) "Malaria: Ethnomedical perceptions and
practice in an Adangbe farming community and implications for
control" Social Science and Medicine 35(2):131-7.
Agyepong, I.A. (1990) Sociocultural and clinical factors affecting
the transmission of malaria: A study among adolescent girls in
rural Ghana. WHO/TDR final report, S20/181/53.
Allen, S.J., Snow, R.W., Menon, A., and B.M. Greenwood (1990)
"Compliance with malaria chemoprophylaxis over a 5 year period
among children in a rural area of the Gambia" Journal of Tropical
Medicine and Hygiene 93(5):313-22.
Bledsoe, C.H. and M.F. Goubaud (1985) "The Reinterpretation of
Western Pharmaceuticals among the Mende of Sierra Leone" Social
Science and Medicine 21(3):275-282.
Breman, J.G. and C.C. Campbell (1988) "Combating severe malaria in
African children" Bulletin of the World Health Organization
Brinkman, U. and A. Brinkman (1991) "Malaria and health in Africa:
The present situation and epidemiological trends" Tropical Medicine
and Parasitology 42(3):204-13.
Dabis, F., Breman, J. G., Roisin, A. J., Haba, F., and the ACSI
CCCD Team (1989) "Monitoring selective components of primary health
care: Methodology and community assessment of vaccination,
diarrhoea, and malaria practices in Conakry, Guinea" Bulletin of
the World Health Organization 67(6):675-84.
Foster, S. (1991) "The distribution and use of antimalarial drugs
- not a pretty picture". In Malaria: Waiting for the Vaccine. Ed.
G.A.T. Targett, Chichester: John Wiley and Sons, p. 123-40.
Glik, D.C., Ward, W.B., Gordon, A., and F. Haba (1989) "Malaria
treatment among mothers in Guinea" Journal of Health and Social
Greenberg, A.E., Ntumbanzondo, M.N., Ntula, N., Mawa, L., Howell,
J., and F. Davachi (1989) "Hospital based surveillance of
malaria-related paediatric morbidity and mortality in Kinshasa,
Zaire" Bulletin of the World Health Organization 67(2):189-96.
Louis, J.P., Trebucq, A., Gelas, H., Fondjo, E., Manga, L., Toto,
T.C., and P. Carnevale (1992) "Le paludisme-maladie dans le ville
de Yaounde (Cameroun)" Bull. Soc. Path. Ex. 85:26-38.
Neuvians, D., Mtango, F.D.E., and A.A. Kielman (1988) "The burden
of disease among preschool children from rural Tanzania" Tropical
Medicine and Parasitology 39(1):9-13.
MacCormack, C.P. and G. Lwihula (1983) "Failure to participate in
a malaria chemosuppression programme: North Mara, Tanzania" Journal
of Tropical Medicine and Hygiene 86(3):99-107.
Makubalo, E.L. (1991) Malaria and chloroquine use in Northern
Zambia. Ph.D. thesis, London School of Hygiene and Tropical
Mwenesi, Halima et.al., 1995 Child malaria treatment practices
among mothers in Kenya Social Science and Medicine 40(9):1271-77.
Mwenesi, H.A. (1993) Mother's definition and treatment of childhood
malaria on the Kenyan coast. Final report, WHO/TDR/SER.
Ongore, D., Kamuni, F., Knight, R., and A. Minawa (1989) "A study
of knowledge, attitudes and practices (KAP) of a rural community on
malaria and the mosquito vector" East African Medical Journal
Vundule, C. and S. Mharakurwa (1992) Reasons for the compliance and
non-compliance of rural communities with the malaria control
program in Gokwe district, Zimbabwe. WHO/TDR report, S20/181/75.
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