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

TREATMENT-SEEKING BEHAVIOUR FOR MALARIA: A

TYPOLOGY BASED ON ENDEMICITY A N D G E N D E R

MARCEL TANNER'* and CAROL VLASSOFF 2

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

523
524 Marcel Tanner and Carol Vlassoff

to the various health service options (including tra-
ditional healers, governmental, non-governmental
organisations and private providers), as well as the
predisposing, enabling and provider factors in any
given setting (reviewed in Phillips, 1990), is essential.
The need to take social and economic consider-
ations into account is also mentioned frequently in
general descriptions of malaria control policies and
concepts. Yet the lack of concrete experiences from
endemic areas illustrating how the "tailoring of
strategies" to local situations actually takes place
and renders malaria control effective at the commu-
nity level makes this kind of assertion little more
than rhetoric. The recent introduction of well vali-
dated guidelines for the rapid assessment of social,
economic and cultural aspects of malaria
(Agyepong et al., 1995) represents an important
contribution in describing tools to collect infor-
mation on issues relating to community-based ma-
laria control and its adaptation to distinct socio-
ecological settings. The methods described assume,
but do not clearly spell out, a number of assump-
tions regarding gender relations in the community,
such as the fact that women are the main caregivers
in the family and that health information should be
focused on women and mothers. In this paper, we
focus specifically on the importance of gender re-
lations for malaria control, and argue that an
understanding of gender differences in the determi-
nants and consequences of malaria, and of gender
relations within the household and community, are
keys to ensuring effective malaria control at corn-
munity level. Based on the gender framework for
tropical diseases proposed by Rathgeber and
Vlassoff (1993), this paper combines an understand-
ing of gender issues relating to health and help-
seeking behaviour with epidemiological knowledge
concerning malaria.
EPIDEMIOLOGICAL ASPECTS
The endemicity of malaria ranges from areas of
high, perennial transmission to areas where malaria
occurs in epidemic patterns at irregular intervals.
The present paper does not revisit the basics of ma-
laria epidemiology, but emphasises those epidemio-
logical conditions that are particularly relevant to
disease control at the community and household
levels. These include the distribution of risks for
disease and the perceived and measured burden of
disease between areas of high and low endemicity.
A comprehensive epidemiological assessment of the
distribution of malaria in a community implies
seven levels, as follows:
1. level and distribution of risks of acquiring infec-
tion;
2. level and distribution of risks of developing
disease;
3. level and distribution of risks of developing
severe disease and death;
4. prevalence and distribution of perception and
knowledge of malaria-related morbidity as a
health problem at individual and household
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
5. prevalence and distribution of perception and
knowledge of malaria-related death as a health
problem at individual and household level;
6. level and distribution of the social burden of ma-
laria morbidity and death; and
7. level and distribution of the economic burden of
malaria morbidity and death.
These levels are reflected in Table 1 and con-
sidered in the present analysis. The first three levels
represent classical epidemiologicai variables based
on quantitative measurements used, for example, to
provide health status and health impact infor-
mation. Most of the epidemiological appraisals of
malaria provide these data on the level and distri-
bution of risks of infection, disease and possibly
death. However, a comprehensive health infor-
mation system that can adequately address health
planning needs should also include health behaviour
and health management information, providing the
epidemiological basis to understand health care and
service utilisation patterns (Tanner, 1988; Lorenz et
al., 1995). Levels 4-7 deal with these parameters in
an epidemiological perspective by calling for quanti-
tative or semi-quantitative assessments of the preva-
lence and distribution of knowledge of malaria as a
disease and the perception of malaria as a problem
affecting individuals and communities. These epide-
miological components tend to be considered by
epidemiologists as sufficient on their own to provide
the necessary background for disease control.
Measurements of the prevalence, magnitude and
distribution of knowledge about malaria and per-
ception of malaria as a problem affecting individ-
uals and communities can reflect malaria endemicity
in a community (Degr~mont et al., 1987; Tanner
and de Savigny, 1987; Tanner et al., 1991). Such
epidemiologically established prevalence figures,
helpful to assess levels of endemicity and general
knowledge about the disease, do not necessarily,
however, imply any consequences in health and
help-seeking behaviours. The epidemiological data
linking health status and health impact information
with health behaviour and health management in-
formation are still very scarce. Consequently,
despite the fact that the epidemiological variables
generated through levels 4-7 (Table 1) reflect a
social science perspective, they may be ineffectual in
terms of disease control, if they are not complemen-
ted by an understanding of the sociocuitural con-
text, especially in relation to gender dynamics, in
any endemic area. We therefore remain uncertain
concerning the contribution of levels 4-7 to health-
seeking behaviour and health outcomes, and the ad-
ditional contribution of the combination of levels
1-3 with these factors. Such questions need to be
addressed by future epidemiological studies.
Perceptions of illness, knowledge and understand-
ing of illness are socially and culturally constructed,
as are actions taken with regard to treatment. In all
525
of these areas, important gender differences exist
(Mechanic, 1964, 1976; Nathanson, 1975;
MacIntyre, 1993; Vlassoff and Bonilla, 1994). Thus,
correlations between the measured risk of disease
and the level and distribution of perceived concern
do not directly translate into an effective health-
seeking behaviour.
Studies have shown that in an area of low ma-
laria endemicity where the population has not
developed some degree of immunity, the risks of
infection, disease, severe disease and, possibly,
death are directly related to exposure (Molineaux et
al., 1988). Anyone exposed may develop disease.
Exposure is, however, not normally distributed in
any endemic area. Exposure is always clustered as a
result of mosquito population dynamics and, more
importantly, of human factors such as type of
houses (wall and roof types, position of fireplaces)
and behavioural factors ranging from daily activi-
ties contributing to exposure to the use of preven-
tive tools like mosquito coils and nets (Smith et al.,
1995). Clearly, even communities of low endemicity
may show a high degree of heterogeneity with
regard to the distribution of malaria morbidity and
death. For example, women and children often face
a higher risk of increased morbidity and mortality
because of their lack of access to effective treatment
and often, lack of ready cash to purchase preventive
tools such as bednets or mosquito coils or to visit
health services (Ettling et al., 1989; Beljaev et al.,
1986; Okonofua et al., 1992; Agyepong, 1992a).
A clustered distribution of exposure to infection
implies that the prevalence of the perception of ma-
laria as a problem as well as the level of knowledge
about malaria also show a substantial variation and
clustering in any community. Low social status can
amplify the magnitude of these heterogeneities. It
follows that the major risk and burden of disease
are concentrated in the poorest segment of a popu-
lation, often of a low social class, that always has
high proportion of women and children. Bonilla
and Rodriguez (1993) reported this unequal distri-
bution of social and economic burden of malaria in
their analysis of Colombian communities.
The differentials in malaria risk and levels of
knowledge of risks and disease burden are even
more marked in areas of high endemicity, where
children are those suffering most and mothers/care-
takers are constantly confronted with disease and
death and forced to rely on whatever methods of
prevention and treatment are available to them.
The combination of these epidemiological, social
and economic risk differentials means that children
and women in areas of high malaria transmission
are inevitably the most disadvantaged population
sector. In addition, it is well documented that preg-
nancy affects the risk of malaria by altering tempor-
arily the immune status (reviewed in Reuben, 1993;
Brabin, 1994; Menendez, 1995), further indicating
526 Marcel Tanner and Carol Vlassoff
the need for a gender-sensitive approach to preven-
tion and control.
A review of the schematic and deliberately simpli-
fied comparisons in Table 1 shows how increasing
endemicity of malaria in any given setting can lead
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
the distribution and magnitude of burden and con-
cern to children and their mothers/caretakers. Most
routinely collected health information consists of
health status and impact data and represents highly
aggregated statistics (for villages, districts, regions)
that are not broken down by sex. As a result, the
excess risks experienced by subgroups (age, sex,
social and economic status) of a population, par-
ticularly when the risks are highly aggregated, are
not revealed.
Analysing the epidemiology of malaria and com-
bining the available quantitative and qualitative in-
formation reveals how women and children are
facing higher risks of infection, disease and death in
most endemic settings. Yet as the evidence provided
in Table 2 shows, women in most societies tend to
be the ones that are often poorly informed about
disease risks and possibilities for prevention and
cure (Rathgeber and Vlassoff, 1993; Vlassoff et al.,
1995). On the other hand, women carry the major
share of responsibility for the well-being of the
household in most societies. This responsibility is
rarely matched by autonomy to make decisions or
by access to the necessary resources. Women may
have to ask permission from others--husbands,
mothers-in-law, senior household males--before
being permitted to seek care. In some cultures,
women cannot visit health centres (or elsewhere)
unaccompanied, and the lack of a male chaperone
may make it impossible for women to act upon
their desire to go for treatment (Vlassoff et al.,
1995; Khattab, 1993). Consequently, women's use
of health services and preventive measures against
malaria is often problematic. In addition, research
has shown that health services are often insensitive
to women and tend to blame them when they come
late for treatment (Khattab, 1993; The Prevention
of Maternal Mortality Network, 1992; Wyss and
Nandjingar, 1995; Lule and Ssembatiya, 1995;
Fonn and Xaba, 1995).
Social and behavioural factors such as accessibil-
ity, perceived quality of services (including social
distance between users and providers), and social
and economic status of the individual concerned,
affect the steps from concern about an illness to the
decision to seek help (Mwabu, 1986; Phillips, 1990;
McPake, 1993; Rathgeber and Vlassoff, 1993;
Kwawu, 1994; Vlassoff, 1994; Fonn and Xaba,
1995). Based on Table 1, it can be seen that gender
relations in a given area provide an entry point for
a comprehensive understanding of the epidemiology
of malaria in affected populations, and help to ren-
der any malaria control strategy more successful.
We therefore propose the following typology to
reconcile the epidemiological features with gender
variables.
THE TYPOLOGY
While epidemiological factors govern the under-
standing of disease transmission, a gender-sensitive
approach to malaria control needs to base itself on
the analysis of the gender constructs in a given
endemic setting. The word "gender" is used to
describe characteristics of men and women that are
socially constructed, in contrast to those that are
biologically determined. People are born male or
female but learn to be girls or boys who grow into
women and men. They are taught what the appro-
priate attitudes, roles and behaviour are for them
and how they should relate to others. This learned
behaviour is what makes up gender identity and
determines gender roles. Gender roles change over
time and over an individual's life stages. In practi-
cally all cultures women have a lower status than
men. A gender analysis reveals the power relations
between men and women in which women are
usually subordinate. It also examines power re-
lations between people of the same sex, but having
different social status or other attributes.
This is illustrated by a gender framework pro-
posed by Rathgeber and Vlassoff (1993), Fig. 1.
The framework consists of three main components:
(1) personal factors distinct for each individual but
a consequence of the sociocultural environment, (2)
social and reproductive activities, and (3) economic
and productive activities. Each of the three areas is
broken down into components. To take the
example of malaria, a gender approach examines
both female and male roles in terms of exposure
within the workplace and the home, responsibility
for sanitation and cleanliness, responsibility for car-
ing for others suffering from malaria, access to and
use of health care facilities, and factors influencing
utilisation such as the provider-patient relationship.
Table 2, based on the gender framework, pro-
vides the key to this discussion. Evidence is based
on the available information or published literature
and/or a "best guess" hypothesis that is used to
produce a semi-quantitative rating of the prob-
ability that the available evidence and/or confir-
mation of the hypothesis affects the risk of infection
(Table 2, column A), the risk of developing disease
(Table 2, column B) and the probability of an indi-
vidual receiving effective treatment (Table 2, column
C).
Despite the importance of malaria as a public
health problem, there is relatively little literature on
malaria that takes into account the possible influ-
ence of gender factors and gender relations.
Consequently, the relationships presented for each
 Treatment-seeking behaviour for malaria 527

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+ + + + + + + + + + + +++ + +

+ +
+ + +

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

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'13
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08 ~ -~_o ~.~
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~.~ ~ ~, ~ ~ "'.~ o ~--
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ei ,= ~ . ~ o ~ ~ o ~ ~ ~

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

which a household exists and in which decisions are
made. These factors challenge malaria control at
the conceptual level by questioning mainly: (I) the
target groups and communication channels, particu-
larly with regard to health education and social
marketing for services and prevention, and (2) the
organisational and contractual organisation of dis-
ease control at local and national level. With regard
to the latter, the overall social development policies
and approaches are also important in the context of
early treatment for malaria. This refers to the type
and mode of cost-recovery systems, the creation of
employment and training/education opportunities,
and to the conditionalities negotiated for bi- and
multilaterally funded malaria control projects. The
review of the Global Malaria Control Strategy
(WHO, 1993), as well as of national control pro-
grammes, shows that the microclimate that governs
decision-making (Table 2, II and III) is often not
addressed at the strategic and operational levels.
This may explain why even those malaria control
programmes that are conceptually appropriate fail
to be effective.
DISCUSSION
Aiming at rendering malaria control more effec-
tive and assuring early recognition and treatment of
malaria episodes, this brief review provides a typol-
ogy that combines epidemiological features of ma-
laria with the key gender variables that determine
the risk of infection, disease and the probability of
seeking treatment at different levels of care. The
analysis shows that, irrespective of the level of ma-
laria endemicity, but more distinctly at higher ende-
micity levels, women and children represent high
risk groups and key players in disease control.
While their position as high risk populations, target
groups and beneficiaries of control has never been
questioned, their role in malaria control activities
themselves has been neglected. It follows that
women and children must be considered not only as
targets in the design of control strategies, but that
the social, cultural and economic factors that define
the gender context in which they live, and their po-
tential role in any control strategy, must also be
recognised.
Four levels require discussion with regard to the
design of control strategies: (1) the personal level
governed by the patterns of perception of malaria
disease and its symptoms and signs, (2) the house-
hold level with the interplay of the social and repro-
ductive activities that govern the decision-making,
and (3) the community and (4) the services level
with the social and economic features that deter-
mine the microclimate including the power relation-
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
considered in the design of malaria control strat-
egies from the individual to the services level.
We recognise that the typology is an oversimplifi-
cation of complex interrelationships between and
among the indicators of gender, endemicity and
levels of intervention, and overlooks many subtle-
ties within each of these areas as well. This oversim-
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
and consequences of malaria, and of their inter-
relationships with the other factors presented. This
emphasises the need for more attention to these
different components through multidisciplinary
approaches using a gender-sensitive "lens".
Table 3 indicates that the household level is the
most important area for malaria-related interven-
tions, especially for the provision of information in
a gender-sensitive way. This follows logically from
our discussion of gender power relations because
these take place within the context of the household
and it is largely this context that determines what
action will be taken. Designing malaria prevention
information to meet these needs is a new challenge
for most disease control programmes that tend to
rely on traditional means of health communication
such as posters, clinic talks and occasional radio or
television messages. Different skills from those
usually available within health education sections of
ministries of health may also be required and con-
siderable retraining may be necessary. While this
may seem a somewhat daunting task, the benefits of
bringing malaria information to those most affected
are many and the potential for spinoffs into other
areas of health and development enormous.
The proposed typology of analysis of the gender
variables in relation to epidemiological features and
control strategies may be applied not only for the
case of malaria, but could serve for a gender-sensi-
tive analysis of other communicable diseases control
strategies and integrated health intervention pro-
grammes that will improve health and thus ensure
sustainable health development. The outcomes of
such an analysis will probably vary considerably for
different diseases. For example, in Table 3, with the
exception of exposure and opportunity cost factors
(items III-3 and III-4), the community appears to
be less critical than personal or household factors
in the selection of malaria control strategies.
However, if we were to consider other diseases of a
highly contagious nature, or where vectors are key
parts of the transmission cycle, the community will
be an extremely important point of intervention.
Continuing with the typology, carefully conceived
and appropriate communications aimed mainly at
the household level should also affect the personal
sphere, if it is truly gender-sensitive. Current health
education approaches, and partly also the design of
social marketing to promote preventive tools such
as insecticide treated mosquito nets, do not suffi-
ciently address the strongly gender-related differen-
tials that operate at the household level and
determine the health and well-being of communities.
The information should be tailored to typical
household decision-making structures, taking into
account who is likely to receive the information and
to pass it on within the household, and who is
likely to use it. Health information can also be tar-
geted for different possible types of relationships
within households and communities in an interest-
ing and attractive way.
An example of a South African health education
initiative may help to illustrate this point. "Soul
City" is a multimedia project involving television,
radio and booklets that provide socially relevant
health information to their audience which includes
the majority of the national population. It is rooted
in a poor township or shantytown setting and built
around the experiences of staff at the local health
centre. Health education that is truly gender-sensi-
tive is provided in an entertaining way through the
use of scripts that are developed in a poor
Johannesburg slum community and adjusted
according to the feedback received. The radio
scripts are produced in English and provided to the
major language radio broadcasting networks in the
country for their translation and use. The booklets
illustrate in simple language and pictorially the key
health and social issues dealt with in the stories. An
external evaluation of the project has shown it to
be well received and very wide in terms of the audi-
ence reached: 8.1 million people, including 47% of
black South Africans over the age of 15. Not only
have the messages been well understood by the
viewers but they were also important in shaping
behaviour in up to 87% of those interviewed
(CASE, 1995).
Table 3 also indicates that the health services
play an important role in influencing gender-related
factors regarding malaria. These influence personal
factors most significantly because of their role in
health education and in their direct relationship
with patients, but they also influence social and
economic factors because their quality and accessi-
bility (in terms of distance, cost and sensitivity to
the needs of patients) influence people's use of ser-
vices. Health planners and trainers of medical per-
sonnel should be sensitised to address more
concretely the issues of quality of care that--
although generally accepted as crucial--are not
addressed with sufficient gender-sensitivity. Training
programmes for health professionals frequently
ignore the consumer perspective and focus more on
technical curative and, to a lesser extent, preventive
aspects of health provision. Career paths in the
health field do not provide incentives for the kind
of community dialogue that would greatly enhance
the health provider's competence and effectiveness.
The initiatives of the World Health Organisation
and non-governmental organisations to improve
women's health and effective user-provider inter-
actions, particularly with regard to female clients,
are concrete steps towards addressing these issues
and rendering health promotion and health care
delivery acceptable and effective (WHO, 1995b,c).
Interestingly, the community itself, which is often
referred to as the desired recipient of health inter-
ventions, appears in Table 3 to be the least import-
ant intervention point in terms of the potential for
 Treatment-seeking behaviour for malaria
successful disease control strategies. Communities
are, after all, composed of individuals and house-
holds whose values and behaviour are reproduced
to a great extent at the wider community level. As
outlined earlier, the distinct features of individuals
and households with regard to traditions, values
and status, create significant differentials with
regard to health risks, the perception of these risks
and the means and strategies to cope. Hence it
would seem that current approaches to disease con-
trol should rethink the rather vague concept o f
"community participation" and recognise that com-
munities are composed of women and men who
relate to each other in ways that impact on their
understanding of health, their health-related beha-
viour and ultimately their health.
Understanding and relating to clients in this new
way may seem a daunting challenge for health pro-
fessionals who, although they work with individuals
and families on a daily basis, are not adequately
trained in the understanding of the broader social
and cultural contexts from which their patients
come. The latter is the domain of the social scientist
and social worker, and it is here that real opportu-
nities exist for increased collaboration and interdis-
ciplinary dialogue. Combining the skills o f
epidemiology in relation to the understanding o f
disease with the social science analysis of relevant
gender factors, as demonstrated in this paper, can
advance our theoretical and practical understanding
of how health and disease are "engendered" in so-
ciety and how this facilitates or inhibits sustainable
disease prevention and control.
Acknowledgements--This paper was written during a sab-
batical period of one of us (MT) at the Australian Centre
for International and Tropical Health and Nutrition
(ACITHN), University of Queensland Medical School,
Brisbane. We gratefully acknowledge the fruitful discus-
sions of drafts of this paper with Professor Lenore
Manderson of ACITHN.
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