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Pergamon Soc. Sci. Med. Vol. 46, Nos 4-5, pp.

523-532, 1998
© 1997ElsevierScienceLtd. All rights reserved
PII: S0277-9536(97)00195-0 Printed in Great Britain
0277-9536/97$19.00+ 0.00




'Swiss Tropical Institute, Socinstrasse 57, P.O. Box CH-4002 Basel, Switzerland and ~UNDP/World
Bank/WHO Special Programme for Research and Training in Tropical Diseases, Av. Appia, CH-1211
Geneva 27, Switzerland

Abstract--A main component of current malaria control strategies to reduce malaria-related mortality
and severe morbidity is early diagnosis and treatment at peripheral health services such as village health
posts and dispensaries. This strategy has been promoted mainly by sensitising the population with
regard to the available service offered and by providing classical biomedical descriptions of symptoms
and signs of malaria. This strategy represents important challenges for successful implementation and
maintenance. Early treatment depends upon prompt recognition of symptoms and signs of malaria in
the household, i.e. mainly by women. Early treatment also requires that appropriate health services and
medication are accessible and used. In this paper we argue that the success of malaria control depends
upon an approach that is gender-sensitiveand takes into account the level of endemicity in a given set-
ting. The level of endemicity determines which group of the population is at highest risk for infection,
morbidity and mortality, and is strongly related to gender considerations. The paper develops a typol-
ogy that combines the key factors of gender variables with epidemiological features. It consequently
outlines an approach to community-based, effective malaria control tailored to a given endemic setting.
Finally, we suggest that the proposed framework could be validated for its potential application to the
control of other communicable diseases. © 1997 Elsevier Science Ltd. All rights reserved

Key words--treatment-seeking, malaria, gender, epidemiology, household, community

INTRODUCTIONAND CONTEXT respect the household was identified and promoted

Malaria is the most important parasitic disease and as a promising and main target of the interventions
remains of highest public health importance. The (World Bank, 1993).
statistics are frightening with an estimated 300-500 A main component of current malaria control
million people infected of which 2 to 3 million die strategies to reduce malaria-related mortality and
every year (WHO, 1995a). The global impact of severe morbidity is early diagnosis and treatment at
malaria is estimated at 35 million DALYs (disabil- peripheral health services such as village health
ity adjusted life-years) (World Bank, 1993), i.e. an posts and dispensaries (WHO, 1993). This is pro-
annual loss of 35 million future life-years due to moted mainly by sensitising the population with
premature mortality and disability. Notably, 90% regard to the available service offer and by provid-
of the world's malaria burden is found in sub- ing classical biomedical descriptions of symptoms
Saharan Africa. The control of malaria remains one and signs of malaria. This strategy, while positive in
of the world's greatest public health challenges, par- its recognition of the importance of community-
ticularly as we are still waiting for an efficacious based approaches to disease control, has been less
and applicable vaccine (Tanner et al., 1995). successful in terms of implementation and sustain-
Moreover, some of the established tools such as ability. The reasons stem from the failure to incor-
anti-malarial drugs and insecticides are showing porate an interdisciplinary perspective in the design
reduced efficacy in most endemic areas owing to the of malaria control strategies and from insufficient
development of resistance among parasites and vec- consideration of the social and cultural context of
tors. The 1993 Global Conference on Malaria re- infection and disease.
iterated these points and outlined concepts and The importance of social, cultural and economic
strategies for each of the eight major endemic set- factors in malaria control for successful treatment
tings and malaria paradigms (WHO, 1993). and health promotional interventions has been
Emphasis was placed on tailoring malaria control emphasised and illustrated frequently (reviewed in
to the local situation, i.e. considering the social, Gomes, 1993; Agyepong, 1992a,b; Mwenesi, 1993b;
ecological and political context of a given area and McCombie, 1996; Agyepong et al., 1995). Since the
its overall health and development plans. In this key to effective malaria control is early detection
and treatment, an understanding of the health and
*Author for correspondence.. help-seeking behaviour of a population in relation

524 Marcel Tanner and Carol Vlassoff

to the various health service options (including tra- munity level. Based on the gender framework for
ditional healers, governmental, non-governmental tropical diseases proposed by Rathgeber and
organisations and private providers), as well as the Vlassoff (1993), this paper combines an understand-
predisposing, enabling and provider factors in any ing of gender issues relating to health and help-
given setting (reviewed in Phillips, 1990), is essential. seeking behaviour with epidemiological knowledge
The need to take social and economic consider- concerning malaria.
ations into account is also mentioned frequently in
general descriptions of malaria control policies and EPIDEMIOLOGICAL ASPECTS
concepts. Yet the lack of concrete experiences from
endemic areas illustrating how the "tailoring of The endemicity of malaria ranges from areas of
strategies" to local situations actually takes place high, perennial transmission to areas where malaria
and renders malaria control effective at the commu- occurs in epidemic patterns at irregular intervals.
nity level makes this kind of assertion little more The present paper does not revisit the basics of ma-
than rhetoric. The recent introduction of well vali- laria epidemiology, but emphasises those epidemio-
dated guidelines for the rapid assessment of social, logical conditions that are particularly relevant to
economic and cultural aspects of malaria disease control at the community and household
(Agyepong et al., 1995) represents an important levels. These include the distribution of risks for
contribution in describing tools to collect infor- disease and the perceived and measured burden of
mation on issues relating to community-based ma- disease between areas of high and low endemicity.
laria control and its adaptation to distinct socio- A comprehensive epidemiological assessment of the
ecological settings. The methods described assume, distribution of malaria in a community implies
but do not clearly spell out, a number of assump- seven levels, as follows:
tions regarding gender relations in the community, 1. level and distribution of risks of acquiring infec-
such as the fact that women are the main caregivers tion;
in the family and that health information should be 2. level and distribution of risks of developing
focused on women and mothers. In this paper, we disease;
focus specifically on the importance of gender re- 3. level and distribution of risks of developing
lations for malaria control, and argue that an severe disease and death;
understanding of gender differences in the determi- 4. prevalence and distribution of perception and
nants and consequences of malaria, and of gender knowledge of malaria-related morbidity as a
relations within the household and community, are health problem at individual and household
keys to ensuring effective malaria control at corn- level;

Table 1. Epidemiological features important for understanding health and help-seeking behaviour in areas of different malaria endemicity
Features High endemicity; high seasonal or Low endemicity; low transmission,
perennial transmission situation of "unstable" malaria

Level and distribution of risks of Whole population, but partly decreasing Whole population; often no age effect,
acquiring infection with age but possibility of differentials due to
social status and occupation

Level and distribution of risks of Mainly children, age group dependent on Whole population, no major age
developing disease the dynamics of developing semi- differentials, but possibility of differentials
immunity; the higher the endemicity the due to social status and occupation
younger the children

Pregnant women Pregnant women

Level and distribution of risks of Mainly children, age group dependent on Whole population, no major age
developing severe disease and death the dynamics of developing semi- differentials, but possibility of differentials
immunity; the higher the endemicity the due to social status and occupation
younger the children

Pregnant women Pregnant women

Prevalence and distribution of perception Whole population, but mothers and Whole population, but mothers and
and knowledge of malaria-related caretakers most concerned caretakers most concerned
morbidity as a health problem

Prevalence and distribution of perception Whole population, but mothers and Whole population, but mothers and
and knowledge of malaria-related death caretakers most concerned caretakers most concerned
as a health problem

Distribution and level of social burden of Females in households with children Households with affected individuals
malaria morbidity and death

Distribution and level of economic Females in households with children Females in households with affected
burden of malaria morbidity and death individuals
Treatment-seeking behaviour for malaria 525

5. prevalence and distribution of perception and of these areas, important gender differences exist
knowledge of malaria-related death as a health (Mechanic, 1964, 1976; Nathanson, 1975;
problem at individual and household level; MacIntyre, 1993; Vlassoff and Bonilla, 1994). Thus,
6. level and distribution of the social burden of ma- correlations between the measured risk of disease
laria morbidity and death; and and the level and distribution of perceived concern
7. level and distribution of the economic burden of do not directly translate into an effective health-
malaria morbidity and death. seeking behaviour.
These levels are reflected in Table 1 and con- Studies have shown that in an area of low ma-
sidered in the present analysis. The first three levels laria endemicity where the population has not
represent classical epidemiologicai variables based developed some degree of immunity, the risks of
on quantitative measurements used, for example, to infection, disease, severe disease and, possibly,
provide health status and health impact infor- death are directly related to exposure (Molineaux et
mation. Most of the epidemiological appraisals of al., 1988). Anyone exposed may develop disease.
malaria provide these data on the level and distri- Exposure is, however, not normally distributed in
bution of risks of infection, disease and possibly any endemic area. Exposure is always clustered as a
death. However, a comprehensive health infor- result of mosquito population dynamics and, more
mation system that can adequately address health importantly, of human factors such as type of
planning needs should also include health behaviour houses (wall and roof types, position of fireplaces)
and health management information, providing the and behavioural factors ranging from daily activi-
epidemiological basis to understand health care and ties contributing to exposure to the use of preven-
service utilisation patterns (Tanner, 1988; Lorenz et tive tools like mosquito coils and nets (Smith et al.,
al., 1995). Levels 4-7 deal with these parameters in 1995). Clearly, even communities of low endemicity
an epidemiological perspective by calling for quanti- may show a high degree of heterogeneity with
tative or semi-quantitative assessments of the preva- regard to the distribution of malaria morbidity and
lence and distribution of knowledge of malaria as a death. For example, women and children often face
disease and the perception of malaria as a problem a higher risk of increased morbidity and mortality
affecting individuals and communities. These epide- because of their lack of access to effective treatment
miological components tend to be considered by and often, lack of ready cash to purchase preventive
epidemiologists as sufficient on their own to provide tools such as bednets or mosquito coils or to visit
the necessary background for disease control. health services (Ettling et al., 1989; Beljaev et al.,
Measurements of the prevalence, magnitude and 1986; Okonofua et al., 1992; Agyepong, 1992a).
distribution of knowledge about malaria and per- A clustered distribution of exposure to infection
ception of malaria as a problem affecting individ- implies that the prevalence of the perception of ma-
uals and communities can reflect malaria endemicity laria as a problem as well as the level of knowledge
in a community (Degr~mont et al., 1987; Tanner about malaria also show a substantial variation and
and de Savigny, 1987; Tanner et al., 1991). Such clustering in any community. Low social status can
epidemiologically established prevalence figures, amplify the magnitude of these heterogeneities. It
helpful to assess levels of endemicity and general follows that the major risk and burden of disease
knowledge about the disease, do not necessarily, are concentrated in the poorest segment of a popu-
however, imply any consequences in health and lation, often of a low social class, that always has
help-seeking behaviours. The epidemiological data high proportion of women and children. Bonilla
linking health status and health impact information and Rodriguez (1993) reported this unequal distri-
with health behaviour and health management in- bution of social and economic burden of malaria in
formation are still very scarce. Consequently, their analysis of Colombian communities.
despite the fact that the epidemiological variables The differentials in malaria risk and levels of
generated through levels 4-7 (Table 1) reflect a knowledge of risks and disease burden are even
social science perspective, they may be ineffectual in more marked in areas of high endemicity, where
terms of disease control, if they are not complemen- children are those suffering most and mothers/care-
ted by an understanding of the sociocuitural con- takers are constantly confronted with disease and
text, especially in relation to gender dynamics, in death and forced to rely on whatever methods of
any endemic area. We therefore remain uncertain prevention and treatment are available to them.
concerning the contribution of levels 4-7 to health- The combination of these epidemiological, social
seeking behaviour and health outcomes, and the ad- and economic risk differentials means that children
ditional contribution of the combination of levels and women in areas of high malaria transmission
1-3 with these factors. Such questions need to be are inevitably the most disadvantaged population
addressed by future epidemiological studies. sector. In addition, it is well documented that preg-
Perceptions of illness, knowledge and understand- nancy affects the risk of malaria by altering tempor-
ing of illness are socially and culturally constructed, arily the immune status (reviewed in Reuben, 1993;
as are actions taken with regard to treatment. In all Brabin, 1994; Menendez, 1995), further indicating
526 Marcel Tanner and Carol Vlassoff

the need for a gender-sensitive approach to preven- of malaria in affected populations, and help to ren-
tion and control. der any malaria control strategy more successful.
A review of the schematic and deliberately simpli- We therefore propose the following typology to
fied comparisons in Table 1 shows how increasing reconcile the epidemiological features with gender
endemicity of malaria in any given setting can lead variables.
to gender differences among those concerned with
regard to the risk of becoming infected, developing
disease and receiving adequate and effective treat-
ment in time. Higher levels of endemicity may shift While epidemiological factors govern the under-
the distribution and magnitude of burden and con- standing of disease transmission, a gender-sensitive
cern to children and their mothers/caretakers. Most approach to malaria control needs to base itself on
routinely collected health information consists of the analysis of the gender constructs in a given
health status and impact data and represents highly endemic setting. The word "gender" is used to
aggregated statistics (for villages, districts, regions) describe characteristics of men and women that are
that are not broken down by sex. As a result, the socially constructed, in contrast to those that are
excess risks experienced by subgroups (age, sex, biologically determined. People are born male or
social and economic status) of a population, par- female but learn to be girls or boys who grow into
ticularly when the risks are highly aggregated, are women and men. They are taught what the appro-
not revealed. priate attitudes, roles and behaviour are for them
Analysing the epidemiology of malaria and com- and how they should relate to others. This learned
bining the available quantitative and qualitative in- behaviour is what makes up gender identity and
formation reveals how women and children are determines gender roles. Gender roles change over
facing higher risks of infection, disease and death in time and over an individual's life stages. In practi-
most endemic settings. Yet as the evidence provided cally all cultures women have a lower status than
in Table 2 shows, women in most societies tend to men. A gender analysis reveals the power relations
be the ones that are often poorly informed about between men and women in which women are
disease risks and possibilities for prevention and usually subordinate. It also examines power re-
cure (Rathgeber and Vlassoff, 1993; Vlassoff et al., lations between people of the same sex, but having
1995). On the other hand, women carry the major different social status or other attributes.
share of responsibility for the well-being of the This is illustrated by a gender framework pro-
household in most societies. This responsibility is posed by Rathgeber and Vlassoff (1993), Fig. 1.
rarely matched by autonomy to make decisions or The framework consists of three main components:
by access to the necessary resources. Women may (1) personal factors distinct for each individual but
have to ask permission from others--husbands, a consequence of the sociocultural environment, (2)
mothers-in-law, senior household males--before social and reproductive activities, and (3) economic
being permitted to seek care. In some cultures, and productive activities. Each of the three areas is
women cannot visit health centres (or elsewhere) broken down into components. To take the
unaccompanied, and the lack of a male chaperone example of malaria, a gender approach examines
may make it impossible for women to act upon both female and male roles in terms of exposure
their desire to go for treatment (Vlassoff et al., within the workplace and the home, responsibility
1995; Khattab, 1993). Consequently, women's use for sanitation and cleanliness, responsibility for car-
of health services and preventive measures against ing for others suffering from malaria, access to and
malaria is often problematic. In addition, research use of health care facilities, and factors influencing
has shown that health services are often insensitive utilisation such as the provider-patient relationship.
to women and tend to blame them when they come Table 2, based on the gender framework, pro-
late for treatment (Khattab, 1993; The Prevention vides the key to this discussion. Evidence is based
of Maternal Mortality Network, 1992; Wyss and on the available information or published literature
Nandjingar, 1995; Lule and Ssembatiya, 1995; and/or a "best guess" hypothesis that is used to
Fonn and Xaba, 1995). produce a semi-quantitative rating of the prob-
Social and behavioural factors such as accessibil- ability that the available evidence and/or confir-
ity, perceived quality of services (including social mation of the hypothesis affects the risk of infection
distance between users and providers), and social (Table 2, column A), the risk of developing disease
and economic status of the individual concerned, (Table 2, column B) and the probability of an indi-
affect the steps from concern about an illness to the vidual receiving effective treatment (Table 2, column
decision to seek help (Mwabu, 1986; Phillips, 1990; C).
McPake, 1993; Rathgeber and Vlassoff, 1993; Despite the importance of malaria as a public
Kwawu, 1994; Vlassoff, 1994; Fonn and Xaba, health problem, there is relatively little literature on
1995). Based on Table 1, it can be seen that gender malaria that takes into account the possible influ-
relations in a given area provide an entry point for ence of gender factors and gender relations.
a comprehensive understanding of the epidemiology Consequently, the relationships presented for each
Treatment-seeking behaviour for malaria 527

+ + + + + + + + + + + + + +
o + + + + + + + + + + + +++ + +
+ + + + + + + + + + + +++ + +

+ +
+ + +

¢~ 0 0 + + ~ + + O 0 + +

+ + +
+ + + + + + +
+ + o + o + + + o + +++ + +
,,,1= ~ 0~ ,=

":2. ~. "~ o o
N -'~
O~ =
0 o
~.~ "~ -
-~ ~I~ ~.~
~- m ~'"

~-.~ 'o.~
.~-~ 8 ~ o
-~ o ~ ~ ~ ~ ~
08 ~ -~_o ~.~
~,,, ~o,

r~ ~1"~ "~. 0

.~ ~ ~ ~ 00~
= o~ o ~ .~ ~ . . ~
~. ..~ & ~.-~ .~8.~$$
~.~ ~ ~, ~ ~ "'.~ o ~--
~.-.,~ ~,
~-..g ~o~ -~ - ' ~ ~

o: ~ ~ - ~ ~ - -

~.~- .-'~'=~'~" ~ "c ~'~'~'~'~ ~--'~

,~, l,r,,l ~. "~ L~
~' ,~

~ ~ r~ o m o o
ei ,= ~ . ~ o ~ ~ o ~ ~ ~

"7,~ o

- a ,~ & ~,
~ o o ~ o .~ o
-o .~' ~ ~ ~ ~- .~

. o
e,i ~r~+ II ~ o
.. o
~ < Z + + + o
528 Marcel Tanner and Carol Vlassoff

Gender variables \

Economic/Productive Activities
sexual d'Nision of labour
availeble substitute labour when ill
exposure to infection in workplace
~ w ~ m ~ potlass ~ s~sss
to~use of services
opportunity costs of acffon (time,
<#stance, cost of drugs, etc.)
available cash

Social/Reproductive Activities
health roles of woman in household
cultural norms affecting exposure
available support networks
decision making power wtthinhousehold
decision making power withln community
utillsetion of t i s s ~ ~ s
quality of health services
suc~ ~ m a
Nature of
Personal Factors
~-~om~ge about dsease
be//efs and fears alx~.'t d/sease

Fig. 1. Gender framework for tropical diseases research (Rathgeber and Vlassoff, 1993).

key factor in Table 2 are based on available litera- ers have observed, for example, that while women
ture concerning malaria in particular as well as recognise early signs such as fever and chills to be
plausible hypotheses and findings of studies of the malaria, they attribute convulsions to spiritual
relevance of gender to other diseases and con- intervention (Mwenesi, 1993b; Kikwawila Study
ditions. Group, 1995). Hence women in Kenya and
Table 2 reveals how a gender perspective can Tanzania sought different kinds of treatment for
affect malaria infection, disease and health-seeking malaria, in which case they visited modern health
behaviour at many levels. Virtually all key elements services, and convulsions, for which they visited tra-
of the gender framework--including personal fac- ditional healers.
tors, social and reproductive activities, and econ- Recognition of malaria based on local concepts
omic considerations--are relevant to malaria forms the framework through which people con-
infection, disease and treatment. Early recognition sider seeking help and care. It is at this stage that
of symptoms and signs leading to a decision to seek decision-making within the household occurs, and it
effective treatment is dependent on all gender vari- is here that gender relations play a crucial role
ables, including the responsibility and power to (Table 2, II). We have listed some of the most im-
make decisions, as well as access to resources. The portant factors that may influence the process of
semi-quantitative assessment of the magnitude of decision-making. The review of these seven factors
each key factor in relation to malaria infection and shows that six out of the seven factors (i.e. I1-2 to
disease shows that each factor may influence the 11-7) are of high relevance and determine, each one
probability of an individual receiving effective treat- independently of the other factors (but often highly
ment. Combining this finding with the analysis of interrelated), whether people, even when a malaria
the risk groups in Table 1, it is evident that women episode is recognised, will/can seek care. As we
and their children are at greatest risk in both high have seen, although women are usually the centre
and low endemic areas. of reference for illness within the household, gender
The strategy of early and effective malaria treat- power relationships within the household may inhi-
ment depends mainly on behaviour at the individual bit their ability to seek care or to have the necessary
and household levels. It starts with the early recog- access to information and resources.
nition of symptoms and signs that are interpreted Finally, Table 2 highlights the various economic/
as a malaria episode. Such an episode, however, is productive factors that determine the probability of
culturally and socially defined and may not corre- seeking care (Table 2, III). Again, they are crucial
spond to the biomedical definition of symptoms but operate less directly on health-seeking beha-
and signs in many endemic areas. Several research- viour. They rather determine the microclimate in
Treatment-seeking behaviour for malaria 529

which a household exists and in which decisions are laria endemicity, but more distinctly at higher ende-
made. These factors challenge malaria control at micity levels, women and children represent high
the conceptual level by questioning mainly: (I) the risk groups and key players in disease control.
target groups and communication channels, particu- While their position as high risk populations, target
larly with regard to health education and social groups and beneficiaries of control has never been
marketing for services and prevention, and (2) the questioned, their role in malaria control activities
organisational and contractual organisation of dis- themselves has been neglected. It follows that
ease control at local and national level. With regard women and children must be considered not only as
to the latter, the overall social development policies targets in the design of control strategies, but that
and approaches are also important in the context of the social, cultural and economic factors that define
early treatment for malaria. This refers to the type the gender context in which they live, and their po-
and mode of cost-recovery systems, the creation of tential role in any control strategy, must also be
employment and training/education opportunities, recognised.
and to the conditionalities negotiated for bi- and Four levels require discussion with regard to the
multilaterally funded malaria control projects. The design of control strategies: (1) the personal level
review of the Global Malaria Control Strategy governed by the patterns of perception of malaria
(WHO, 1993), as well as of national control pro- disease and its symptoms and signs, (2) the house-
grammes, shows that the microclimate that governs hold level with the interplay of the social and repro-
decision-making (Table 2, II and III) is often not ductive activities that govern the decision-making,
addressed at the strategic and operational levels. and (3) the community and (4) the services level
This may explain why even those malaria control with the social and economic features that deter-
programmes that are conceptually appropriate fail mine the microclimate including the power relation-
to be effective. ships in which health and help-seeking decisions are
reached. Table 3 therefore provides a typology that
aims at weighing to what extent each factor of the
gender components outlined in Table 2 needs to be
Aiming at rendering malaria control more effec- considered in the design of malaria control strat-
tive and assuring early recognition and treatment of egies from the individual to the services level.
malaria episodes, this brief review provides a typol- We recognise that the typology is an oversimplifi-
ogy that combines epidemiological features of ma- cation of complex interrelationships between and
laria with the key gender variables that determine among the indicators of gender, endemicity and
the risk of infection, disease and the probability of levels of intervention, and overlooks many subtle-
seeking treatment at different levels of care. The ties within each of these areas as well. This oversim-
analysis shows that, irrespective of the level of ma- plification is due largely to the lack of data

Table 3. Typology o f malaria control strategies emphasising early recognition and treatment in relation to the gender variables (see
Table 2) to be considered

Level o f Intervention o f malaria control ~

Gender variables and key factors (based on Table 2) Personal Household Community Services

I Personal factors
1 Knowledge about disease/illness + + +b + + + + + +
2 Beliefs about disease/illness + + + + + + + + +
3 User/provider relationship + + + + + + + + +

II Social and reproductive activities

1 Roles in health at household level + + + + + + +
2 Cultural norms affecting exposure + + + + + + + +
3 Available support networks + + + 4- + + +
4 Decision-making at household level + + + + + + + + +
5 Use o f services + + + + + + + + + +
6 Quality of health services ++ + + + ++ + + +
7 Social stigma + + + + + + +

II I Economic~productive activities
1 Division o f labour + + + + + + +
2 Substitution o f labour + + + + + + +
3 Exposure to infection + + + + + + + + +
4 Opportunity costs + + + + + + + +
5 Economic policies in relation to accessibility o f services/care 0 + + + + + +
6 Availability o f cash + + + + + +

aLevel to which the control approaches targeted and/or activities are based.
bSemi-quantitative rating to what extent factors need to be considered in the design o f a control strategy:
+ + + = strong consideration always required
+ = consideration required
+ + = consideration important
0 = factor not assessed to be instrumental.
530 Marcel Tanner and Carol Vlassoff

available on gender differences in the determinants within households and communities in an interest-
and consequences of malaria, and of their inter- ing and attractive way.
relationships with the other factors presented. This An example of a South African health education
emphasises the need for more attention to these initiative may help to illustrate this point. "Soul
different components through multidisciplinary City" is a multimedia project involving television,
approaches using a gender-sensitive "lens". radio and booklets that provide socially relevant
Table 3 indicates that the household level is the health information to their audience which includes
most important area for malaria-related interven- the majority of the national population. It is rooted
tions, especially for the provision of information in in a poor township or shantytown setting and built
a gender-sensitive way. This follows logically from around the experiences of staff at the local health
our discussion of gender power relations because centre. Health education that is truly gender-sensi-
these take place within the context of the household tive is provided in an entertaining way through the
and it is largely this context that determines what use of scripts that are developed in a poor
action will be taken. Designing malaria prevention Johannesburg slum community and adjusted
information to meet these needs is a new challenge according to the feedback received. The radio
for most disease control programmes that tend to scripts are produced in English and provided to the
rely on traditional means of health communication major language radio broadcasting networks in the
such as posters, clinic talks and occasional radio or country for their translation and use. The booklets
television messages. Different skills from those illustrate in simple language and pictorially the key
usually available within health education sections of health and social issues dealt with in the stories. An
ministries of health may also be required and con- external evaluation of the project has shown it to
siderable retraining may be necessary. While this be well received and very wide in terms of the audi-
may seem a somewhat daunting task, the benefits of ence reached: 8.1 million people, including 47% of
bringing malaria information to those most affected black South Africans over the age of 15. Not only
are many and the potential for spinoffs into other have the messages been well understood by the
areas of health and development enormous. viewers but they were also important in shaping
The proposed typology of analysis of the gender behaviour in up to 87% of those interviewed
variables in relation to epidemiological features and (CASE, 1995).
control strategies may be applied not only for the Table 3 also indicates that the health services
case of malaria, but could serve for a gender-sensi- play an important role in influencing gender-related
tive analysis of other communicable diseases control factors regarding malaria. These influence personal
strategies and integrated health intervention pro- factors most significantly because of their role in
grammes that will improve health and thus ensure health education and in their direct relationship
sustainable health development. The outcomes of with patients, but they also influence social and
such an analysis will probably vary considerably for economic factors because their quality and accessi-
different diseases. For example, in Table 3, with the bility (in terms of distance, cost and sensitivity to
exception of exposure and opportunity cost factors the needs of patients) influence people's use of ser-
(items III-3 and III-4), the community appears to vices. Health planners and trainers of medical per-
be less critical than personal or household factors sonnel should be sensitised to address more
in the selection of malaria control strategies. concretely the issues of quality of care that--
However, if we were to consider other diseases of a although generally accepted as crucial--are not
highly contagious nature, or where vectors are key addressed with sufficient gender-sensitivity. Training
parts of the transmission cycle, the community will programmes for health professionals frequently
be an extremely important point of intervention. ignore the consumer perspective and focus more on
Continuing with the typology, carefully conceived technical curative and, to a lesser extent, preventive
and appropriate communications aimed mainly at aspects of health provision. Career paths in the
the household level should also affect the personal health field do not provide incentives for the kind
sphere, if it is truly gender-sensitive. Current health of community dialogue that would greatly enhance
education approaches, and partly also the design of the health provider's competence and effectiveness.
social marketing to promote preventive tools such The initiatives of the World Health Organisation
as insecticide treated mosquito nets, do not suffi- and non-governmental organisations to improve
ciently address the strongly gender-related differen- women's health and effective user-provider inter-
tials that operate at the household level and actions, particularly with regard to female clients,
determine the health and well-being of communities. are concrete steps towards addressing these issues
The information should be tailored to typical and rendering health promotion and health care
household decision-making structures, taking into delivery acceptable and effective (WHO, 1995b,c).
account who is likely to receive the information and Interestingly, the community itself, which is often
to pass it on within the household, and who is referred to as the desired recipient of health inter-
likely to use it. Health information can also be tar- ventions, appears in Table 3 to be the least import-
geted for different possible types of relationships ant intervention point in terms of the potential for
Treatment-seeking behaviour for malaria 531

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