DEC.1998.Tanner.socsciMed.treatment-Seeking Behaviour for Malaria a Typology Based on Endemicity and Gender

8/14/2019 DEC.1998.Tanner.socsciMed.treatment-Seeking Behaviour for Malaria a Typology Based on Endemicity and Gender

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Pergamon Soc. Sci. Med. Vol. 46, Nos 4-5, pp. 523-532, 1998 1997 ElsevierScience Ltd. All rights reservedPII: S0277-9536(97)00195-0 Printed in Great Britain0277-9536/97 $19.00 + 0.00

T R E A T M E N T - S E E K I N G B E H A V I O U R F O R M A L A R IA : AT Y P O L O G Y B A S E D O N E N D E M I C I T Y A N D G E N D E R

MARCEL TANNER'* and CAROL VLASSOFF2'Swiss Tropical Institute, Socinstrasse 57, P.O. Box CH-4002 Basel, Switzerland and ~UNDP/WorldBank/WHO Special Programme for Research and Training in Tropical Diseases, Av. Appia, CH-1211Geneva 27, Switzerland

Abstract--A main component of current malaria control strategies to reduce malaria-related mortalityand severe morbidity is early diagnosis and treatment at peripheral health services such as village healthposts and dispensaries. This strategy has been promoted mainly by sensitising the population withregard to the available service offered and by providing classical biomedical descriptions of symptomsand signs of malaria. This strategy represents important challenges for successful implementation andmaintenance. Early treatment depends upon prompt recognition of symptoms and signs of malaria inthe household, i.e. mainly by women. Early treatment also requires that appropriate health services andmedication are accessible and used. In this paper we argue that the success of malaria control dependsupon 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 consequentlyoutlines 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 thecontrol of other communicable diseases. 1997 Elsevier Science Ltd. All rights reservedK e y w o r d s - - t r e a tm e n t - s e e k i n g , malaria, gender, epidemiology, household, community

INTRODUCTIONAND CONTEXTMalaria is the most important parasitic disease andremains of highest public health importance. Thestatistics are frightening with an estimated 300-500million people infected of which 2 to 3 million dieevery year (WHO, 1995a). The global impact o fmalaria is estimated at 35 million DALYs (disabil-ity adjus ted life-years) (World Bank, 1993), i.e. anannual loss of 35 million future life-years due topremature mortality and disability. Notably, 90%of the world's malaria burden is found in sub-Saharan Africa. The control of malaria remains oneof the wor ld's greatest public health challenges, par-ticularly as we are still waiting for an efficaciousand applicable vaccine (Tanner e t a l . , 1995).Moreover, some of the established tools such asanti-malarial drugs and insecticides are showingreduced efficacy in most endemic areas owing to thedevelopment of resistance among parasites and vec-tors. The 1993 Global Conference on Malaria re-iterated these points and outlined concepts andstrategies for each of the eight major endemic set-tings and malaria paradigms (WHO, 1993).Emphasis was placed on tailoring malaria controlto the local situation, i.e. considering the social,ecological and political context of a given area andits overall health and development plans. In this*Author for correspondence..

respect the household was identified and promotedas a promising and m ain target of the interventions(World Bank, 1993).

A main component of current malaria controlstrategies to reduce malaria-related mortality andsevere morbidity is early diagnosis and treatment atperipheral health services such as village healthposts an d dispensaries (WHO, 1993). This is pro-moted mainly by sensitising the population withregard to the available service offer and by provid-ing classical biomedical descriptions of symptomsand signs of malaria. This strategy, while positive inits recognition of the importance of community-based approaches to disease control, has been lesssuccessful in terms of implementation and sustain-ability. The reasons stem from the failure to incor-porate an interdisciplinary perspective in the designof malaria control strategies and from insufficientconsideration of the social and cultural context ofinfection and disease.The importance of social, cultural and economicfactors in malaria control for successful treatmentand health promoti onal interventions has beenemphasised an d illustrated frequently (reviewed inGomes, 1993; Agyepong, 1992a,b; Mwenesi, 1993b;McCombie, 1996; Agyepong e t a l . , 1995). Since thekey to effective malaria control is early detectionand treatment, an understa nding of the health andhelp-seeking behaviour of a population in relation

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524 Ma rcel Tann er and Caro l Vlassofft o t h e v a r i o u s h e a l t h s e r v i c e o p t i o n s ( i n c l u d i n g t r a -d i t i o n a l h e a l e r s , g o v e r n m e n t a l , n o n - g o v e r n m e n t a lo r g a n i s a t i o n s a n d p r i v a t e p r o v i d e r s ) , a s w e l l a s t h ep r e d i s p o s i n g , e n a b l i n g a n d p r o v i d e r f a c t o r s i n a n yg ive n se t t i n g ( r e v ie we d in P h i l l i p s , 1990), i s e s se n t i a l .

T h e n e e d t o t a k e s o c i a l a n d e c o n o m i c c o n s i d e r -a t i o n s i n t o a c c o u n t i s a l s o m e n t i o n e d f r e q u e n t l y i ng e n e r al d e s c r i p t i o n s o f m a l a r i a c o n t r o l p o l ic i es a n dc o n c e p t s . Y e t t h e l a c k o f c o n c r e t e e x p e r i e n c e s f r o me n d e m i c a r e a s i l lu s t r a ti n g h o w t h e " t a i l o r i n g o fs t r a t e g i e s " t o l o c a l s i t u a t i o n s a c t u a l l y t a k e s p l a c ea n d r e n d e r s m a l a r i a c o n t r o l e f f ec t iv e a t t h e c o m m u -n i t y l e v el m a k e s t h i s k i n d o f a s s e r t i o n l i t t l e m o r et h a n r h e t o r i c . T h e r e c e n t i n t r o d u c t i o n o f w e l l v a l i -d a t e d g u i d e l i n e s f o r t h e r a p i d a s s e s s m e n t o f s o c i a l ,e c o n o m i c a n d c u l t u r a l as p e c t s o f m a l a r i a( A g y e p o n g e t a l . , 1 9 9 5 ) r e p r e s e n t s a n i m p o r t a n tc o n t r i b u t i o n i n d e s c r i b i n g t o o l s t o c o l l e c t i n f o r -m a t i o n o n i s s u e s r e l a t i n g t o c o m m u n i t y - b a s e d m a -l a r i a c o n t r o l a n d i t s a d a p t a t i o n t o d i s t i n c t s o c i o -e c o l o g i c a l s e t t in g s . T h e m e t h o d s d e s c r i b e d a s s u m e ,b u t d o n o t c l e a r ly s p e ll o u t , a n u m b e r o f a s s u m p -t i o n s r e g a r d i n g g e n d e r r e l a t i o n s i n t h e c o m m u n i t y ,s u c h a s t h e f a ct t h a t w o m e n a r e t h e m a i n c a r e g iv e r si n t h e fa m i l y a n d t h a t h e a l t h i n f o r m a t i o n s h o u l d b ef o c u s e d o n w o m e n a n d m o t h e r s . I n t hi s p a p e r , w ef o c u s s p e c i f ic a l ly o n t h e i m p o r t a n c e o f g e n d e r r e -l a t i o n s f o r m a l a r i a c o n t ro l , a n d a r g u e t h a t a nu n d e r s t a n d i n g o f g e n d e r d i ff e r e n c es i n t h e d e t e r m i -n a n t s a n d c o n s e q u en c e s o f m a l a r i a , a n d o f g e n d e rr e l a t i o n s w i t h i n t h e h o u s e h o l d a n d c o m m u n i t y , a r ek e y s t o e n s u r i n g e f f ec t iv e m a l a r i a c o n t r o l a t c o r n -

m u n i t y l e v e l . B a s e d o n t h e g e n d e r f r a m e w o r k f o rt r o p i c a l d i s e a s e s p r o p o s e d b y R a t h g e b e r a n dV l a s s o f f ( 1 99 3 ), t h i s p a p e r c o m b i n e s a n u n d e r s t a n d -i n g o f g e n d e r i s s u e s r e l a t i n g t o h e a l t h a n d h e l p -s e e ki n g b e h a v i o u r w i t h e p i d e m i o l o g i c a l k n o w l e d g ec o n c e r n i n g m a l a r i a .

E P I D E M I O L O G I C A L A S P EC T ST h e e n d e m i c i t y o f m a l a r i a r a n g e s f r o m a r e a s o f

h i g h , p e r e n n i a l t r a n s m i s s i o n t o a r e a s w h e r e m a l a r i ao c c u r s i n e p i d e m i c p a t t e r n s a t i r r e g u l a r i n t e r v a l s .T h e p r e s e n t p a p e r d o e s n o t r e v is i t t h e b a s i c s o f m a -l a r ia e p i d e m i o l o g y , b u t e m p h a s i s es t h o s e e p i d e m i o -l o g i c a l c o n d i t i o n s t h a t a r e p a r t i c u l a r l y r e l e v a n t t od i s e as e c o n t r o l a t t h e c o m m u n i t y a n d h o u s e h o l dl e v e l s . T h e s e i n c l u d e t h e d i s t r i b u t i o n o f r i s k s f o rd i s e as e a n d t h e p e r ce i v e d a n d m e a s u r e d b u r d e n o fd i s e as e b e tw e e n a r e a s o f h i g h a n d l o w e n d e m i c i ty .A c o m p r e h e n s i v e e p i d e m i o l o g i c a l a s s e s sm e n t o f t h ed i s t r i b u t i o n o f m a l a r i a i n a c o m m u n i t y i m p l i e sse ve n l e ve l s , a s f o l lows :1 . l e v el a n d d i s t r i b u t i o n o f r i s k s o f a c q u i r i n g i n f e c -

t i on ;2 . l e v el a n d d i s t r i b u t i o n o f r i s k s o f d e v e l o p i n g

d i se a se ;3 . l e v el a n d d i s t r i b u t i o n o f r i s k s o f d e v e l o p i n g

s e v e r e d i s e a s e a n d d e a t h ;4 . p r e v a le n c e a n d d i s t r i b u t i o n o f p e r c e p t i o n a n dk n o w l e d g e o f m a l a r i a - r e l a te d m o r b i d i t y a s a

h e a l th p r o b l e m a t i n d i v id u a l a n d h o u s e h o l dleve l ;

T a b l e 1 . E p i d e m i o l o g i c a l f e a t u r e s i m p o r t a n t f o r u n d e r s t a n d i n g h e a l t h a n d h e l p - s e e k i n g b e h a v i o u r i n a r e a s o f d i f f e r e n t m a l a r i a e n d e m i c i t yF e a t u r e s H i g h e n d e m i c i t y ; h i g h s e a s o n a l o r L o w e n d e m i c i t y ; l o w t r a n s m i s s i o n ,

p e r e n n i a l t r a n s m i s s io n s i t u a ti o n o f " u n s t a b l e " m a l a r i aL e v e l a n d d i s t r i b u t i o n o f r i s k s o fa c q u i r i n g i n f e c t i o n

L e v e l a n d d i s t r i b u t i o n o f r i s k s o fd e v e l o p i n g d i s e a s e

L e v e l a n d d i s t r i b u t i o n o f r i s k s o fd e v e l o p i n g s e v e r e d i s e a s e a n d d e a t h

P r e v a l e n c e a n d d i s t r i b u t i o n o f p e r c e p t i o na n d k n o w l e d g e o f m a l a r i a - re l a t e dm o r b i d i t y a s a h e a l t h p r o b l e mP r e v a l e n c e a n d d i s t r i b u t i o n o f p e r c e p t i o na n d k n o w l e d g e o f m a l a r ia - r e la t e d d e a t ha s a h e a l t h p r o b l e mD i s t r i b u t i o n a n d l e v el o f s o c i a l b u r d e n o fm a l a r i a m o r b i d i t y a n d d e a t hD i s t r i b u t i o n a n d l e v e l o f e c o n o m i cb u r d e n o f m a l a r i a m o r b i d it y a n d d e a t h

W h o l e p o p u l a t i o n , b u t p a r t l y d e c re a s i n gw i t h a g e

M a i n l y c h i l d re n , a g e g r o u p d e p e n d e n t o nt h e d y n a m i c s o f d e v e l o p i n g s e m i -i m m u n i t y ; t h e h i g h e r t h e e n d e m i c i t y t h ey o u n g e r t h e c h i l d r e nP r e g n a n t w o m e nM a i n l y c h i l d re n , a g e g r o u p d e p e n d e n t o nt h e d y n a m i c s o f d e v e l o p i n g s e m i -i m m u n i t y ; t h e h i g h e r t h e e n d e m i c i t y t h ey o u n g e r t h e c h i l d r e nP r e g n a n t w o m e nW h o l e p o p u l a t i o n , b u t m o t h e r s a n dc a r e t a k e r s m o s t c o n c e r n e d

W h o l e p o p u l a t io n , b u t m o t h e r s a n dc a r e t a k e r s m o s t c o n c e r n ed

F e m a l e s i n h o u s e h o l d s w i t h c h i l d r e n

F e m a l e s i n h o u s e h o l d s w i t h c h i l d r e n

W h o l e p o p u l a t i o n ; o f t e n n o a g e e f fe c t,b u t p o s s i b i l i t y o f d i f f e r e n t ia l s d u e t os o c i a l s t a t u s a n d o c c u p a t i o nW h o l e p o p u l a t i o n , n o m a j o r a g ed i f f e r en t i a l s , bu t pos s ib i l i t y o f d i f f e r en t i a l sd u e t o s o c i a l s t a t u s a n d o c c u p a t i o n

P r e g n a n t w o m e nW h o l e p o p u l a t i o n , n o m a j o r a g ed i f f e r en t i a l s , bu t poss ib i l i t y o f d i f f e r en t i a l sd u e t o s o c i a l s t a t u s a n d o c c u p a t i o n

P r e g n a n t w o m e nW h o l e p o p u l a t i o n , b u t m o t h e r s a n dc a r e t a k e r s m o s t c o n c e r n e d

W h o l e p o p u l a t i o n , b u t m o t h e r s a n dc a r e t a k e r s m o s t c o n c e r n e d

H o u s e h o l d s w i t h a f f e c te d i n d i v i d u a l s

F e m a l e s i n h o u s e h o l d s w i t h a f f ec t e di n d i v i d u a l s


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Treatment-seeking beha viour for malaria 5255 . p r e v a le n c e a n d d i s t r i b u t i o n o f p e r c e p t i o n a n d

k n o w l e d g e o f m a l a r i a - r e l a t e d d e a t h a s a h e a l t hp r o b l e m a t i n d i v i d u a l a n d h o u s e h o l d l ev e l;

6 . l e v el a n d d i s t r i b u t i o n o f t h e s o c ia l b u r d e n o f m a -l a r i a m o r b i d i t y a n d d e a t h ; a n d

7 . l e ve l a n d d i s t r i b u t i o n o f th e e c o n o m i c b u r d e n o fm a l a r i a m o r b i d i t y a n d d e a t h .

T h e s e l e v e ls a r e r e fl e c t ed in T a b l e 1 a n d c o n -s i d e r e d i n t h e p r e s e n t a n a l y s i s . T h e f i rs t t h r e e l e v e lsr e p r e s e n t c l a s s i c a l e p i d e m i o l o g i c a i v a r i a b l e s b a s e do n q u a n t i t a t i v e m e a s u r e m e n t s u s e d, f o r e x a m p l e , t op r o v i d e h e a l t h s t a t u s a n d h e a l t h i m p a c t i n f o r -m a t i o n . M o s t o f t h e e p i d e m i o l o g i c al a p p r a i s a l s o fm a l a r i a p r o v i d e t h e se d a t a o n t h e l ev e l a n d d i s t ri -b u t i o n o f r i s k s o f i n f e c t i o n , d i s e a s e a n d p o s s i b l yd e a t h . H o w e v e r , a c o m p r e h e n s i v e h e a l t h i n f o r -m a t i o n s y s t e m t h a t c a n a d e q u a t e l y a d d r e s s h e a l t hp l a n n i n g n e e d s s h o u l d a l so i n c l u d e h e a l t h b e h a v i o u ra n d h e a l t h m a n a g e m e n t i n f o r m a t i o n , p r o v i d i n g t h ee p i d e m i o l o g i c a l b a s i s to u n d e r s t a n d h e a l t h c a r e a n ds e r v ic e u t i l i s a t i o n p a t t e r n s ( T a n n e r , 1 98 8; L o r e n z e ta l . , 1 99 5) . L e v e l s 4 - 7 d e a l w i t h t h e s e p a r a m e t e r s i na n e p i d e m i o l o g i c a l p e r s p e c t iv e b y c a l li n g fo r q u a n t i -t a t i v e o r s e m i - q u a n t i t a t i v e a ss e s s m e n t s o f th e p r e v a -l e nc e a n d d i s t r i b u t i o n o f k n o w l e d g e o f m a l a r i a a s ad i s e as e a n d t h e p e r c e p t i o n o f m a l a r i a a s a p r o b l e ma f f ec t i n g i n d i v i d u a l s a n d c o m m u n i t i e s . T h e s e e p i d e -m i o l o g i c a l c o m p o n e n t s t e n d t o b e c o n s i d e re d b ye p i d e m i o l o g i s t s a s s u f fi c ie n t o n t h e i r o w n t o p r o v i d et h e n e c e s s a r y b a c k g r o u n d f o r d i s e as e c o n t ro l .

M e a s u r e m e n t s o f t h e p re v a l en c e , m a g n i t u d e a n dd i s t r i b u t i o n o f k n o w l e d g e a b o u t m a l a r i a a n d p e r -c e p t i o n o f m a l a r i a a s a p r o b l e m a f fe c ti n g in d i v i d -u a l s a n d c o m m u n i t i e s c a n r ef le c t m a l a r i a e n d e m i c i tyi n a c o m m u n i t y ( D e g r ~ m o n t e t a l . , 1 9 8 7 ; T a n n e ra n d d e S a v i g n y , 1 9 8 7 ; T a n n e r e t a l . , 1991) . Suche p i d e m i o l o g i c a l l y e s t a b l i s h e d p r e v a l e n c e f ig u r e s,h e l p f u l t o a s s e s s l e v e l s o f e n d e m i c i t y a n d g e n e r a lk n o w l e d g e a b o u t t h e d is e a s e , d o n o t n e c e s s a r i l y ,h o w e v e r , i m p l y a n y c o n s e q u e n c e s i n h e a l t h a n dh e l p - se e k i n g b e h a v i o u r s . T h e e p i d e m i o l o g i c a l d a t al i n k in g h e a l th s t a t u s a n d h e a l t h i m p a c t i n f o r m a t i o nw i t h h e a l t h b e h a v i o u r a n d h e a l t h m a n a g e m e n t i n -f o r m a t i o n a r e s t i ll v e r y s c a rc e . C o n s e q u e n t l y ,d e s p i t e t h e f a c t t h a t t h e e p i d e m i o l o g i c a l v a r i a b l e sg e n e r a t e d t h r o u g h l e v el s 4 - 7 ( T a b l e 1 ) r e fl e c t as o c i a l s c ie n c e p e r s p e c t i v e , t h e y m a y b e i n e f fe c t u a l i nt e r m s o f d i s ea s e c o n tr o l , i f th e y a r e n o t c o m p l e m e n -t e d b y a n u n d e r s t a n d i n g o f t h e s o c i o c u i tu r a l c o n -t e x t , e s p e c ia l l y i n r e l a t i o n t o g e n d e r d y n a m i c s , i na n y e n d e m i c a r e a . W e t h e r e f o r e r e m a i n u n c e r t a i nc o n c e r n i n g t h e c o n t r i b u t i o n o f l e ve ls 4 - 7 t o h e a l t h -s e e k in g b e h a v i o u r a n d h e a l t h o u t co m e s , a n d t h e a d -d i t i o n a l c o n t r i b u t i o n o f t h e c o m b i n a t i o n o f l e v e l s1 - 3 w i t h t h e s e f a c t o r s . S u c h q u e s t i o n s n e e d t o b ea d d r e s s e d b y f u t u r e e p i d e m i o l o g i c a l s t u d i e s .

P e r c e p t io n s o f i l ln e ss , k n o w l e d g e a n d u n d e r s t a n d -i n g o f i l ln e s s a r e s o c i a l l y a n d c u l t u r a l l y c o n s t r u c t e d ,a s a r e a c t i o n s t a k e n w i t h r e g a r d t o t r e a t m e n t . I n a l l

o f t h e s e a r e a s , i m p o r t a n t g e n d e r d i f f e r e n c e s e x i s t( M e c h a n ic , 1964 , 1976; N a th a n so n , 1975 ;M a c I n t y r e , 1 99 3; V l a s s o f f a n d B o n i l l a , 1 9 9 4) . T h u s ,c o r r e l a t io n s b e t w e e n t h e m e a s u r e d r is k o f d i s e as ea n d t h e l e v el a n d d i s t r i b u t i o n o f p e r c ei v e d c o n c e r nd o n o t d i r e c t l y t r a n s l a t e i n t o a n e f f e c ti v e h e a l t h -s e e k i n g b e h a v i o u r .

S t u d i es h a v e s h o w n t h a t i n a n a r e a o f lo w m a -l a r i a e n d e m i c i ty w h e r e t h e p o p u l a t i o n h a s n o td e v e l o p e d s o m e d e g r e e o f i m m u n i t y , t h e r i s k s o fi n f e c t i o n , d i s e a s e , s e v e r e d i s e a s e a n d , p o s s i b l y ,d e a t h a r e d i r e c tl y r e l a t e d t o e x p o s u r e ( M o l i n e a u x e ta l . , 1 98 8). A n y o n e e x p o s e d m a y d e v e l o p d i s e as e .E x p o s u r e i s , h o w e v e r , n o t n o r m a l l y d i s t r i b u t e d i na n y e n d e m i c a r e a . E x p o s u r e i s a l w a y s c lu s t e r e d a s ar e s u lt o f m o s q u i t o p o p u l a t i o n d y n a m i c s a n d , m o r ei m p o r t a n t l y , o f h u m a n f a c t o r s su c h a s ty p e o fh o u s e s ( w a l l a n d r o o f t y p e s , p o s i t i o n o f f ir e p l a ce s )a n d b e h a v i o u r a l f a c t o r s r a n g i n g f r o m d a i l y a c t iv i -t ie s c o n t r i b u t i n g t o e x p o s u r e t o t h e u s e o f p r e v e n -t i v e t o o l s l i k e m o s q u i t o c o i l s a n d n e t s ( S m i t h e t a l . ,1 9 9 5 ) . C l e a r l y , e v e n c o m m u n i t i e s o f l o w e n d e m i c i t ym a y s h o w a h i g h d e g r e e o f h e t e r o g e n e i t y w i t hr e g a r d t o t h e d i s t r i b u t i o n o f m a l a r i a m o r b i d i t y a n dd e a t h . F o r e x a m p l e , w o m e n a n d c h i l d r e n o f t e n f a c ea h i g h e r r i s k o f i n c r e a s e d m o r b i d i t y a n d m o r t a l i t yb e c a u s e o f t h e i r l a c k o f a c c e s s to e f fe c ti v e t r e a t m e n ta n d o f t en , l a c k o f r e a d y c a s h t o p u r c h a s e p r e v e n t iv et o o l s s u c h a s b e d n e t s o r m o s q u i t o c o i l s o r t o v i s i th e a l t h s e r v i c e s ( E t t l i n g e t a l . , 1989; Be l jaev e t a l . ,1 9 8 6 ; O k o n o f u a e t a l . , 1992 ; Agye pong , 1992a ) .

A c l u s t e r e d d i s t r i b u t i o n o f e x p o s u r e t o i n f e c t i o ni m p l i e s t h a t t h e p r e v a le n c e o f t h e p e r c e p t i o n o f m a -l a r i a a s a p r o b l e m a s w e l l a s t h e l e v e l o f k n o w l e d g ea b o u t m a l a r i a a ls o s h o w a s u b s t a n t i a l v a r i a t io n a n dc l u s te r in g i n a n y c o m m u n i t y . L o w s o c ia l s t a tu s c a na m p l i f y t h e m a g n i t u d e o f t h e s e h e t e r o g e n e i t i e s . I tf o l lo w s t h a t t h e m a j o r r i s k a n d b u r d e n o f d i se a s ea r e c o n c e n t r a t e d i n t h e p o o r e s t s e g m e n t o f a p o p u -l a t i o n , o f t e n o f a l o w s o c i a l c la s s , t h a t a l w a y s h a sh i g h p r o p o r t i o n o f w o m e n a n d c h i l d r en . B o n i l laa n d R o d r i g u e z (1 9 9 3 ) re p o r t e d t h i s u n e q u a l d i s t r i -b u t i o n o f s o c ia l a n d e c o n o m i c b u r d e n o f m a l a r i a i nt h e i r an a l y s is o f C o l o m b i a n c o m m u n i t i e s .

T h e d i f f e re n t i a l s i n m a l a r i a r i s k a n d l e v el s o fk n o w l e d g e o f r i s k s a n d d i s e a s e b u r d e n a r e e v e nm o r e m a r k e d i n a r e a s o f h i g h e n d e m i c i t y , w h e r ec h i l d r e n a r e t h o s e s u f f e r i n g m o s t a n d m o t h e r s / c a r e -t a k e r s a r e c o n s t a n t l y c o n f r o n t e d w i t h d i s e a s e a n dd e a t h a n d f o r c e d t o r e ly o n w h a t e v e r m e t h o d s o fp r e v e n t i o n a n d t r e a t m e n t a r e a v a i la b l e t o t h e m .T h e c o m b i n a t i o n o f t h e s e e p i d e m i o l o g i c al , s o c ia la n d e c o n o m i c r i s k d i f f e r en t i a l s m e a n s t h a t c h i l d r e na n d w o m e n i n a r e a s o f h i g h m a l a r i a t r a n s m i s s io na r e i n e v i ta b l y t h e m o s t d i s a d v a n t a g e d p o p u l a t i o ns e c t o r . I n a d d i t i o n , i t i s w e l l d o c u m e n t e d t h a t p r e g -n a n c y a f f e c t s t h e r i s k o f m a l a r i a b y a l t e r i n g t e m p o r -a r i l y t h e i m m u n e s t a t u s ( r e v i e w e d i n R e u b e n , 1 99 3;B r a b in , 1994; M e ne n de z , 1995), f u r the r i nd ic a t in g


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526 Ma rcel Tan ner and Carol Vlassofft h e n e e d f o r a g e n d e r - s e n s i t i v e a p p r o a c h t o p r e v e n -t i o n a n d c o n t r o l .

A r e v ie w o f th e s c h e m a t i c a n d d e l i b e r a t e l y s i m p l i -f ie d c o m p a r i s o n s i n T a b l e 1 s h o w s h o w i n c r ea s i n ge n d e m i c i t y o f m a l a r i a i n a n y g i v en s e t t in g c a n l e a dt o g e n d e r d i f fe r e n c es a m o n g t h o s e c o n c e r n e d w i t hr e g a r d t o t h e r i s k o f b e c o m i n g i n f e c t e d , d e v e l o p i n gd i s e a s e a n d r e c e iv i n g a d e q u a t e a n d e f fe c ti v e t r e a t -m e n t i n t i m e . H i g h e r l e v e l s o f e n d e m i c i t y m a y s h i f tt h e d i s t r i b u t i o n a n d m a g n i t u d e o f b u r d e n a n d c o n -c e r n t o c h i l d r e n a n d t h e i r m o t h e r s / c a r e t a k e r s . M o s tr o u t i n e l y c o l l e c t e d h e a l t h i n f o r m a t i o n c o n s i s t s o fh e a l t h s t a t u s a n d i m p a c t d a t a a n d r e p r e s e n t s h i g h l ya g g r e g a t e d s t a t i s t i c s ( f o r v i l l a g e s , d i s t r i c t s , r e g i o n s )t h a t a r e n o t b r o k e n d o w n b y s e x . A s a r e s u l t , t h ee x c e s s r i s k s e x p e r i e n c e d b y s u b g r o u p s ( a g e , s e x ,s o c i al a n d e c o n o m i c s t a tu s ) o f a p o p u l a t i o n , p a r -t i c u l a r l y w h e n t h e r i s k s a r e h i g h l y a g g r e g a t e d , a r en o t r e v e a l e d .

A n a l y s i n g th e e p i d e m i o l o g y o f m a l a r ia a n d c o m -b i n i n g t h e a v a i l a b l e q u a n t i ta t i v e a n d q u a l i t a t iv e i n -f o r m a t i o n r e v ea l s h o w w o m e n a n d c h i l d r e n a r ef a c i n g h i g h e r r i s k s o f i n f e c t i o n , d i s e a s e a n d d e a t h i nm o s t e n d e m i c s e t t i n g s . Y e t a s t h e e v i d e n c e p r o v i d e di n T a b l e 2 s h o w s , w o m e n i n m o s t s o c i e t i e s t e n d t ob e t h e o n e s t h a t a r e o f t e n p o o r l y i n f o r m e d a b o u td i s e a s e ri s k s a n d p o s s i b i l i t i e s f o r p r e v e n t i o n a n dc u r e ( R a t h g e b e r a n d V l a s s o f f , 1 9 9 3 ; V l a s s o f f e t a l . ,1 9 9 5 ) . O n t h e o t h e r h a n d , w o m e n c a r r y t h e m a j o rs h a r e o f r e s p o n s i b i l i t y f o r t h e w e l l - b e i n g o f t h eh o u s e h o l d i n m o s t s o c i e t ie s . T h i s r e s p o n s i b i l i t y i sr a r e ly m a t c h e d b y a u t o n o m y t o m a k e d e c i s i o n s o rb y a c c e s s t o t h e n e c e s s a r y r e s o u r c e s . W o m e n m a yh a v e t o a s k p e r m i ss i o n f r om o t h e r s - - h u s b a n d s ,m o t h e r s - i n - l a w , s e n i o r h o u s e h o l d m a l e s - - b e f o r eb e i n g p e r m i t t e d t o s e e k c a r e . I n s o m e c u l t u r e s ,w o m e n c a n n o t v i s i t h e a l t h c e n t r e s ( o r e ls e w h e r e )u n a c c o m p a n i e d , a n d t h e l a ck o f a m a l e c h a p e r o n em a y m a k e i t i m p o s s i b l e f o r w o m e n t o a c t u p o nt h e i r d e s i r e t o g o f o r t r e a t m e n t ( V l a s s o f f e t a l . ,1 9 9 5 ; K h a t t a b , 1 9 9 3 ) . C o n s e q u e n t l y , w o m e n ' s u s eo f h e a l t h s e r v i ce s a n d p r e v e n t i v e m e a s u r e s a g a i n s tm a l a r i a i s o f t e n p r o b l e m a t i c . I n a d d i t i o n , r e s e a r c hh a s s h o w n t h a t h e a l t h s e r v i ce s a r e o f t e n i n s e n s i t i v et o w o m e n a n d t e n d t o b l a m e t h e m w h e n t h e y co m el a t e f o r t r e a t m e n t ( K h a t t a b , 1 99 3; T h e P r e v e n t i o no f M a t e r n a l M o r t a l i t y N e t w o r k , 1 99 2; W y s s a n dN a n d j i n g a r , 1 9 9 5 ; L u l e a n d S s e m b a t i y a , 1 9 9 5 ;F o n n a n d X a b a , 1 9 9 5 ) .

S o c i a l a n d b e h a v i o u r a l f a c t o r s s u c h a s a c c e s s i b i l -i t y , p e r c e i v e d q u a l i t y o f s e r v i c e s ( i n c l u d i n g s o c i a ld i s t a n c e b e t w e e n u s e r s a n d p r o v i d e r s ) , a n d s o c i a la n d e c o n o m i c s t a t u s o f t h e i n d i v i d u a l c o n c e r n e d ,a f fe c t t h e s t e p s f r o m c o n c e r n a b o u t a n i l ln e s s t o t h ede c i s ion to s e e k he lp ( M wa bu , 1986 ; P h i l l i p s , 1990 ;M c P a k e , 1 99 3; R a t h g e b e r a n d V l a s s o ff , 19 93 ;K w a w u , 1 9 9 4 ; V l a ss o ff , 1 9 9 4 ; F o n n a n d X a b a ,1995). B a s e d on T a b le 1 , i t c a n be se e n tha t g e nd e rr e l a t i o n s i n a g i v e n a r e a p r o v i d e a n e n t r y p o i n t f o ra c o m p r e h e n s i v e u n d e r s t a n d i n g o f t h e e p i d e m i o l o g y

o f m a l a r i a i n a f fe c te d p o p u l a t io n s , a n d h e l p t o r e n -d e r a n y m a l a r i a c o n t r o l s t r a t e g y m o r e s u c c e s s f u l .W e t h e r e fo r e p r o p o s e t h e f o l lo w i n g t y p o l o g y t or e c o n c i l e t h e e p i d e m i o l o g i c a l f e a t u r e s w i t h g e n d e rv a r i a b l e s .

THE TYPOLOGYW h i l e e p i d e m i o l o g i c a l f a c to r s g o v e r n t h e u n d e r -

s t a n d i n g o f d i s e a s e t r a n s m i s s i o n , a g e n d e r - s e n s i t i v ea p p r o a c h t o m a l a r i a c o n t r o l n e e d s t o b a s e i t s e lf o nt h e a n a l y s i s o f t h e g e n d e r c o n s t r u c t s i n a g i v e ne n d e m i c s e t t i n g . T h e w o r d " g e n d e r " i s u s e d t od e s c r ib e c h a ra c t e ri s t ic s o f m e n a n d w o m e n t h a t a r es o c i a l l y c o n s t r u c t e d , i n c o n t r a s t t o t h o s e t h a t a r eb i o l o g i c a ll y d e t e r m i n e d . P e o p l e a r e b o r n m a l e o rf e m a l e b u t l e a r n t o b e g i r ls o r b o y s w h o g r o w i n t ow o m e n a n d m e n . T h e y a r e t a u g h t w h a t t h e a p p r o -p r i a t e a t t i t u d e s , r o l e s a n d b e h a v i o u r a r e f o r t h e ma n d h o w t h e y s h o u l d r e l a t e t o o t h e r s . T h i s l e a r n e db e h a v i o u r i s w h a t m a k e s u p g e n d e r i d e n t i t y a n dd e t e r m i n e s g e n d e r r o l e s . G e n d e r r o l e s c h a n g e o v e rt i m e a n d o v e r a n i n d i v i d u a l ' s l i fe s t a g es . I n p r a c t i -c a l l y a l l c u l t u r e s w o m e n h a v e a l o w e r s t a t u s t h a nm e n . A g e n d e r a n a l y s i s r e v e a l s t h e p o w e r r e l a t i o n sb e t w e e n m e n a n d w o m e n i n w h i c h w o m e n a r eu s u a l l y s u b o r d i n a t e . I t a l s o e x a m i n e s p o w e r r e -l a t i o n s b e t w e e n p e o p l e o f t h e s a m e s ex , b u t h a v i n gd i f f e re n t s o c i a l s t a t u s o r o t h e r a t t r i b u t e s .

T h i s i s i l l u s t r a t e d b y a g e n d e r f r a m e w o r k p r o -p o s e d b y R a t h g e b e r a n d V l a s s o f f ( 1 99 3 ), F i g . 1 .T h e f r a m e w o r k c o n s i st s o f t h r e e m a i n c o m p o n e n t s :( 1 ) p e r s o n a l f a c t o r s d i s t i n c t f o r e a c h i n d i v i d u a l b u ta c o n s e q u e n c e o f t h e s o c i o c u l t u r a l e n v i r o n m e n t , ( 2 )s o c i a l a n d r e p r o d u c t i v e a c t i v it i e s, a n d ( 3 ) e c o n o m i ca n d p r o d u c t i v e a c t i v i t i es . E a c h o f t h e t h r e e a r e a s i sb r o k e n d o w n i n t o c o m p o n e n t s . T o t a k e t h ee x a m p l e o f m a l a r i a , a g e n d e r a p p r o a c h e x a m i n e sb o t h f e m a l e a n d m a l e r o le s in t e r m s o f e x p o s u r ew i t h i n t h e w o r k p l a c e a n d t h e h o m e , r e s p o n s i b i l i t yf o r s a n i t a t i o n a n d c l e a n li n e s s , r e s p o n s i b i l i t y fo r c a r -i n g f o r o t h e r s s u f f e r i n g f r o m m a l a r i a , a c c e s s t o a n du s e o f h e a l t h c a r e f a c i l it i e s, a n d f a c t o r s i n f l u e n c i n gu t i l is a t i o n s u ch a s t h e p r o v i d e r - p a t i e n t r e l a ti o n s h i p .

T a b l e 2 , b a s e d o n t h e g e n d e r f r a m e w o r k , p r o -v i d e s t h e k e y t o t h i s d i s c u s s i o n . E v i d e n c e i s b a s e do n t h e a v a i l a b l e i n f o r m a t i o n o r p u b l i s h e d l i t e r a tu r ea n d / o r a " b e s t g u e s s " h y p o t h e s i s t h a t i s u s e d t op r o d u c e a s e m i - q u a n t it a t iv e r a ti n g o f t h e p r o b -a b i l i t y t h a t t h e a v a i l a b l e e v i d e n c e a n d / o r c o n f i r -m a t i o n o f t h e h y p o t h e s i s a f f e ct s t h e r i s k o f i n f e c t i o n( T a b l e 2 , c o l u m n A ) , t h e r i s k o f d e v e l o p i n g d i s e a s e( T a b l e 2, c o l u m n B ) a n d t h e p r o b a b i l i t y o f a n i n d i -v i d u a l r e c e iv i n g e ff e ct iv e t r e a t m e n t ( T a b l e 2 , c o l u m nC ).

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sexual d'Nision of labouravaileble substitute labour when il lexposure to infection in workplace~w ~m ~ potlass ~ s~ s s sto~use o f servicesopportunity costs o f acffon (t ime,


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Treatment-seeking behav iour for malaria 529w h i c h a h o u s e h o l d e x i s ts a n d i n w h i c h d e c i s i o n s a r em a d e . T h e s e f a c t o r s c h a ll e n g e m a l a r i a c o n t r o l a tt h e c o n c e p t u a l l e v e l b y q u e s t i o n i n g m a i n l y : ( I ) t h et a r g e t g r o u p s a n d c o m m u n i c a t i o n c h a n n e l s , p a r t i c u -l a r ly w i th r e g a r d t o h e a l t h e d u c a t i o n a n d s o c ia lm a r k e t i n g f o r s e rv i c e s a n d p r e v e n t i o n , a n d ( 2 ) t h eo r g a n i s a t i o n a l a n d c o n t r a c t u a l o r g a n i s a t i o n o f d is -e a s e c o n t r o l a t l o c a l a n d n a t i o n a l l e v e l . W i t h r e g a r dt o t h e l a t t e r , t h e o v e r a l l s o c i a l d e v e l o p m e n t p o l i c i e sa n d a p p r o a c h e s a r e a l s o i m p o r t a n t i n t h e c o n t e x t o fe a r l y t r e a t m e n t f o r m a l a r i a . T h i s r e f e r s t o t h e t y p ea n d m o d e o f c o s t - re c o v e r y s ys t em s , t h e c r e a t i o n o fe m p l o y m e n t a n d t r a i n i n g / e d u c a t i o n o p p o r t u n i t i e s ,a n d t o t h e c o n d i t i o n a l i t i e s n e g o t i a t e d f o r b i - a n dm u l t i l a t e r a l ly f u n d e d m a l a r i a c o n t r o l p r o j ec t s . T h er e v i e w o f t h e G l o b a l M a l a r i a C o n t r o l S t r a t e g y( W H O , 1 99 3), a s w e ll a s o f n a t i o n a l c o n t r o l p r o -g r a m m e s , s h o w s t h a t t h e m i c r o c l im a t e t h a t g o v e r n sd e c i s i o n - m a k i n g ( T a b l e 2 , I I a n d I I I ) i s o f t e n n o ta d d r e s s e d a t t h e s t r a t e g i c a n d o p e r a t i o n a l l e v e l s .T h i s m a y e x p l a i n w h y e v e n t h o s e m a l a r i a c o n t r o lp r o g r a m m e s t h a t a r e c o n c e p t u a l l y a p p r o p r i a t e f a i lt o be e f f e c tive .

D I SC U SSI O NA i m i n g a t r e n d e r i n g m a l a r i a c o n t r o l m o r e e f f e c -

t iv e a n d a s s u r in g e a r l y r e c o g n i ti o n a n d t r e a t m e n t o fm a l a r i a e p i s o d e s , t h i s b r i e f r e v i e w p r o v i d e s a t y p o l -o g y t h a t c o m b i n e s e p i d e m i o l o g i c a l f e a tu r e s o f m a -l a r i a w i t h t h e k e y g e n d e r v a r i a b l e s t h a t d e t e r m i n et h e r i s k o f i n f e ct i o n , d is e a s e a n d t h e p r o b a b i l i t y o fs e e k i n g t r e a t m e n t a t d i f f e r e n t l e v e l s o f c a r e . T h ea n a l y s i s s h o w s t h a t , i r r e s p e c t iv e o f t h e l e v el o f m a -

l a r i a e n d e m i c i t y , b u t m o r e d i s t i n c t l y a t h i g h e r e n d e -m i c i t y l e v el s , w o m e n a n d c h i l d r e n r e p r e s e n t h i g hr i s k g r o u p s a n d k e y p l a y e r s i n d i s e as e c o n t r o l .W h i l e t h e ir p o s i t i o n a s h i g h r i s k p o p u l a t i o n s , t a r g e tg r o u p s a n d b e n e f ic i a ri e s o f c o n t r o l h a s n e v e r b e e nq u e s t i o n e d , t h e i r r o l e i n m a l a r i a c o n t r o l a c t i v i t i e st h e m s e l v e s h a s b e e n n e g l e c t e d . I t f o l l o w s t h a tw o m e n a n d c h i l d r e n m u s t b e c o n s i d e re d n o t o n l y a st a r g e t s i n t h e d e s i g n o f c o n t r o l s t r a t e g i e s , b u t t h a tt h e s o c i a l , c u l t u r a l a n d e c o n o m i c f a c t o r s t h a t d e f i n et h e g e n d e r c o n t e x t i n w h i c h t h e y l i v e , a n d t h e i r p o -t e n t i a l r o l e i n a n y c o n t r o l s t r a t e g y , m u s t a l s o b er e c o g n i s e d .

F o u r l e ve l s r e q u i r e d i s c u s s i o n w i t h r e g a r d t o t h ed e s i g n o f c o n t r o l s t r a t e g i e s : (1 ) t h e p e r s o n a l l e v elg o v e r n e d b y t h e p a t t e r n s o f p e r c e p t io n o f m a l a r i ad i s e a s e a n d i t s s y m p t o m s a n d s i g ns , (2 ) th e h o u s e -h o l d l e ve l w i t h t h e i n t e r p l a y o f t h e s o c i a l a n d r e p r o -d u c t i v e a c t iv i t i e s t h a t g o v e r n t h e d e c i s i o n - m a k i n g ,a n d ( 3 ) t h e c o m m u n i t y a n d ( 4 ) t h e s e r v ic e s l e v elw i t h t h e s o c i a l a n d e c o n o m i c f e a t u r e s t h a t d e t e r -m i n e t h e m i c r o c l i m a t e in c l u d i n g t h e p o w e r r e l a t i o n -s h i p s i n w h i c h h e a l t h a n d h e l p - s e e k i n g d e c i s i o n s a r er e a c h e d . T a b l e 3 th e r e f o r e p r o v i d e s a t y p o l o g y t h a ta i m s a t w e i g h i n g t o w h a t e x t e n t e a c h f a c t o r o f t h eg e n d e r c o m p o n e n t s o u t l i n e d i n T a b l e 2 n e e d s t o b ec o n s i d e r e d i n t h e d e s i g n o f m a l a r i a c o n t r o l s t r a t -e g i e s fr o m t h e i n d i v i d u a l t o t h e s e r v ic e s l e ve l .

W e r e c o g n i s e t h a t t h e t y p o l o g y i s a n o v e r s i m p l i f i-c a t i o n o f c o m p l e x i n t e r r e l a t i o n s h i p s b e t w e e n a n da m o n g t h e i n d i c a t o r s o f g e n d e r , e n d e m i c i t y a n dl e v e l s o f i n t e r v e n t i o n , a n d o v e r l o o k s m a n y s u b t l e -t i e s w i t h i n e a c h o f t h e s e a r e a s a s w e l l . T h i s o v e r s i m -p l i f i c a t io n is d u e l a r g e l y t o t h e l a c k o f d a t a

Table 3. Typolo gy of malaria c ontrol strategies emphasising early reco gnition and treatment in relation to the gender variables (seeTable 2) to be considered

Gender variables and key factors (based on Table 2) PersonalLevel of Intervention of malari a control ~

Household Comm unit y Services

I Per s onal fac to r s1 Knowl edge abo ut disease/illness + + + b + + +2 Beliefs abo ut disease/illness + + + + + +3 User/pro vider relationship + + + + + +

+ + ++ + ++ + +

II Social and reproduct ive act ivi t ies1 Roles in healt h at hous ehol d level + + + + + + +2 Cult ural nor ms affecting exposur e + + + + + + + +3 Avail able sup por t networ ks + + + 4- + + +4 Decis ion- maki ng at hous ehol d level + + + + + + + + +5 Use of services + + + + + + + + + +6 Quali ty of health services ++ + + + ++ + + +7 Socia l sti gma + + + + + + +II I Economic~product ive act ivi t ies1 Divis ion of labo ur + + + + + + +2 Subs titu tion of labo ur + + + + + + +3 Exposur e to infecti on + + + + + + + + +4 Opp ort uni ty costs + + + + + + + +5 Econo mic policies in relation to accessibility of services/care 0 + + + + + +6 Avai labi lity of cash + + + + + +aLevel to which the control approaches targeted an d/or activities are based.bSemi-quantitative rating to what extent factors need to be considered in the design of a control strategy:+ + + = strong consideration always required+ = consideration required+ + = consideration import ant0 = fact or not assessed to be instr ument al.


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530 Marcel Tanner and Carol Vlassoffa va i l a b l e on ge nde r d i f f e r e nc e s i n t he de t e r mi na n t sa nd c onse qu e nc e s o f ma l a r ia , a nd o f t he i r i n t e r-r e l a t i onsh i ps w i t h t he o t he r f a c t o r s p r e se n t e d . T h i se mpha s i se s t he ne e d f o r mor e a t t e n t i on t o t he sed i f f e r e n t c o m p o n e n t s t h r o u g h m u l t i d i s c i p l i n a r ya ppr oa c he s us i ng a ge nde r - se ns i t i ve " l e ns" .

Table 3 indica tes tha t the household leve l i s them o s t i m p o r t a n t a r e a f o r m a l a ri a - re l a te d i n te r v e n-t i ons, e spe c i a ll y f o r t he p r ov i s i on o f i n f o r m a t i on i na gender - sens i t ive way. This fo l lows logica l ly f romou r d i s c us s ion o f ge nde r pow e r r e l a ti ons be c a uset he se t a ke p l a c e w i th i n t he c on t e x t o f t he hou se ho l da nd i t i s l a r ge l y t h i s c on t e x t t ha t de t e r mi ne s w ha ta c t i on w i l l be t a ke n . D e s i gn i ng ma l a r i a p r e ve n t i oni n f o r ma t i on t o me e t t he se ne e ds i s a ne w c ha l l e ngef o r m o s t d i s e a s e c o n t r o l p r o g r a m m e s t h a t t e n d t or e ly o n t r a d i t io n a l m e a n s o f h e a l th c o m m u n i c a t i o nsuc h a s pos t e r s , c l i n i c t a l ks a nd oc c a s i ona l r a d i o o rte levis ion messages . Di f fe rent ski l l s f rom thoseusua l l y a va i l a b l e w i t h i n he a l t h e duc a t i on s e c t i ons o fmi n i s t ri e s o f he a l th m a y a l so be r e qu i r e d a n d c on -s i de r a b l e r e t r a i n i ng ma y be ne c e s sa r y . Whi l e t h i sm a y s e e m a s o m e w h a t d a u n t i n g t a sk , t h e b e n e fi ts o fb r i n g i n g m a l a r i a i n f o r m a t i o n t o t h o s e m o s t a f fe c te da r e m a n y a n d t h e p o t e n t i a l f o r s p i n o f f s i n t o o t h e ra r e a s o f h e a l t h a n d d e v e l o p m e n t e n o r m o u s .

T h e p r o p o s e d t y p o l o g y o f a n al y s is o f t h e g e n d e rva r i a b l e s i n r e l a t i on t o e p i de mi o l og i c a l f e a t u r e s a ndc o n t r o l s t r a t e g i e s m a y b e a p p l i e d n o t o n l y f o r t h ec a se o f ma l a r i a , bu t c ou l d s e r ve f o r a ge nde r - se ns i-t ive a na l ys i s o f o t he r c om mu ni c a b l e d i s e a se s c on t r o ls t r a t e g i e s a nd i n t e g r a t e d he a l t h i n t e r ve n t i on p r o -g r a m m e s t h a t w i l l i m p r o v e h e a l t h a n d t h u s e n s u r es u s t a i n a b l e h e a l t h d e v e l o p m e n t . T h e o u t c o m e s o fsuc h a n a na l ys i s w i l l p r oba b l y va r y c ons i de r a b l y f o rdi f fe rent d i seases . Fo r example , in Tab le 3 , wi th thee x c e p t io n o f e x p o s u r e a n d o p p o r t u n i t y c o s t f a c to r s( i t e m s I I I - 3 a n d I I I - 4 ) , t h e c o m m u n i t y a p p e a r s t obe l e s s c r i t i c a l t ha n pe r sona l o r house ho l d f a c t o r si n t he s e l e ct i on o f ma l a r i a c on t r o l s t ra t e g ie s .H ow e ve r , i f w e w e r e t o c ons i de r o t he r d i s ea se s o f ah i gh l y c on t a g i ous na t u r e , o r w he r e ve c t o r s a r e ke ypa r t s o f t he t r a nsmi s s i on c yc l e , t he c om m un i t y w il lb e a n e x t re m e l y i m p o r t a n t p o i n t o f i n te r v e n ti o n .

Con t i nu i ng w i t h t he t ypo l ogy , c a r e f u l l y c onc e i ve da n d a p p r o p r i a t e c o m m u n i c a t i o n s a i m e d m a i n l y a tt he house ho l d l e ve l shou l d a l so a f f e c t t he pe r sona lsphere , i f i t is t ru ly gender - sens i tive . C ur re nt hea l the d u c a t i o n a p p r o a c h e s , a n d p a r t l y a l s o t h e d e s i g n o fsoc i a l ma r ke t i ng t o p r omot e p r e ve n t i ve t oo l s suc has insec t ic ide t r ea ted mosqui to ne ts , do not suf f i -c i e n t l y a ddr e s s t he s t r ong l y ge nde r - r e l a t e d d i f f e r e n -t i a l s t ha t ope r a t e a t t he house ho l d l e ve l a ndde t e r mi ne t he he a l t h a nd w e l l -be i ng o f c omm uni t i e s .T h e i n f o r m a t i o n s h o u l d b e t a i l o r e d t o t y p i c a lhouse ho l d de c i s i on - ma k i ng s t r uc t u r e s , t a k i ng i n t oa c c oun t w ho i s l i ke l y t o r e c e i ve t he i n f o r ma t i on a ndt o p a s s i t o n w i t h i n t h e h o u s e h o l d , a n d w h o i sl i ke l y t o use i t . H e a l t h i n f o r ma t i on c a n a l so be t a r -ge t e d f o r d i f f e re n t pos s i b le t ype s o f r e l a t ionsh i ps

w i t h i n house ho l ds a nd c ommuni t i e s i n a n i n t e r e s t -i ng a nd a t t r a c t i ve w a y .

A n e x a m p l e o f a S o u t h A f r i c a n h e al th e d u c a t i o nini t ia t ive may he lp to i l lus t ra te th i s point . "SoulC i t y" i s a mul t i me d i a p r o j e c t i nvo l v i ng t e l e v i s i on ,r a d i o a nd book l e t s t ha t p r ov i de soc i a l l y r e l e va n the a l t h i n f o r ma t i on t o t he i r a ud i e nc e w h i c h i nc l ude st he ma j o r i t y o f the na t i ona l popu l a t i on . I t is r oo t e di n a p o o r t o w n s h i p o r s h a n t y t o w n s e t t i n g a n d b u i l ta r o un d t he e xpe r ie nc e s o f s t a f f a t t he l oc a l he a l t hc e n t r e . H e a l t h e duc a t i on t ha t i s t r u l y ge nde r - se ns i -t i ve i s p r ov i de d i n a n e n t e r t a i n i ng w a y t h r ough t heuse o f s cr i p ts t ha t a r e de ve l ope d i n a poo rJ o h a n n e s b u r g s l u m c o m m u n i t y a n d a d j u s t e da c c or d i n g t o t he f e e d ba c k r e ce ive d. T h e r a d i os c r i p t s a r e p r o d u c e d i n E n g l i s h a n d p r o v i d e d t o t h em a j o r l a n g u a g e r a d i o b r o a d c a s t i n g n e t w o r k s i n t h ec oun t r y f o r t he i r t r a ns l a t i on a nd use . T he book l e t si l l u s t r a t e i n s i mpl e l a ngua ge a nd p i c t o r i a l l y t he ke yhea l th and soc ia l i ssues dea l t wi th in the s tor ies . Ane x t e r na l e va l ua t i on o f t he p r o j e c t ha s show n i t t obe w e ll r e c e i ve d a nd ve r y w i de i n t e rms o f t he a ud i -e nc e r e a c he d : 8 .1 mi l l i on pe op l e , i nc l ud i ng 47% ofb l a c k S o u t h A f r i c a n s o v e r t h e a g e o f 1 5 . N o t o n l yha ve t he me ssa ge s be e n w e l l unde r s t ood by t hev i e w e r s bu t t he y w e r e a l so i mpor t a n t i n sha p i ngb e h a v i o u r i n u p t o 8 7 % o f t h o s e in t e rv i e w ed( CA S E , 1995) .

Table 3 a l so indica tes tha t the hea l th se rvicesp l a y a n i mpor t a n t r o l e i n i n f l ue nc i ng ge nde r - r e l a t e df a c t o r s r e ga r d i ng ma l a r i a . T he se i n f l ue nc e pe r sona lf a c t o r s mos t s i gn i f i c a n t l y be c a use o f t he i r r o l e i nhe a l t h e duc a t i on a nd i n t he i r d i r e c t r e l a t i onsh i pw i t h pa t i e n t s , bu t t he y a l so i n f l ue nc e soc i a l a nde c onomi c f a c t o r s be c a use t he i r qua l i t y a nd a c c e s s i -bi l i ty (in te rms of d is tance , co s t and sens i t iv i ty tot he ne e ds o f pa t i e n t s ) i n fl ue nc e pe op l e ' s u se o f s e r-v ic es . H e a l t h p l a n ne r s a nd t r a ine r s o f me d i c a l pe r -sonne l shou l d be s e ns i t i s e d t o a ddr e s s mor ec onc r e t e l y t he i ssue s o f qua l it y o f c a r e t h a t - -a l t h o u g h g e n e r a l l y a c c e p t e d a s c r u c i a l - - a r e n o taddressed wi th suf f ic ient gender - sens i t iv i ty . Tra iningpr ogr a mme s f o r he a l t h p r o f e s s i ona l s f r e que n t l yi g n o r e t h e c o n s u m e r p e r s p e c t i v e a n d f o c u s m o r e o ntechnica l cura t ive and, to a lesse r extent , prevent ivea spe c t s o f he a l th p r ov i s i on . Ca r e e r pa t hs i n t hehe a l t h f i e l d do no t p r ov i de i nc e n t i ve s f o r t he k i ndo f c o m m u n i t y d i a l o g u e t h a t w o u l d g r e a t ly e n h a n c et he he a l t h p r ov i de r ' s c ompe t e nc e a nd e f f e c t i ve ne s s .T he i n i ti a ti ve s o f t he W or l d H e a l t h O r ga n i sa t i ona n d n o n - g o v e r n m e n t a l o r g a n i s a t i o n s t o i m p r o v ew ome n ' s he a l t h a nd e f f e c t i ve use r - p r ov i de r i n t e r -a c t i ons , pa r t i c u l a r l y w i t h r e ga r d t o f e ma l e c l i e n t s ,a re concre te s teps towards address ing these i ssuesa n d r e n d e r i n g h e a l t h p r o m o t i o n a n d h e a l t h c a r ede l ivery acceptable and e f fec t ive (WHO, 1995b,c ) .

In te res t ingly , the communi ty i t se l f , which i s of tenre fe r red to as the d es i red rec ipient of hea l th in te r -ve n t i ons , a ppe a r s i n T a b l e 3 t o be t he l e a s t i mpor t -a n t i n t e r ve n t i on p o i n t i n t e rms o f t he po t e n t i a l f o r


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Trea tmen t - seek in g b eh av io u r fo r mala r ia 531s u c c e ss f u l d i s e a se c o n t r o l s t ra t e g ie s . C o m m u n i t i e sa r e , a f te r a ll , c o m p o s e d o f i n d i v i d u a l s a n d h o u s e -h o l d s w h o s e v a l u e s a n d b e h a v i o u r a r e r e p r o d u c e dt o a g r e a t e x te n t a t t h e w i d e r c o m m u n i t y l e ve l . A so u t l i n e d e a r l i e r , t h e d i s t i n c t f e a t u r e s o f i n d i v i d u a l sa n d h o u s e h o l d s w i t h r e g a r d t o t ra d i t i o n s , v a l u e sa n d s t a t u s , c r e a t e s i g n i f i c a n t d i f f e r e n t i a l s w i t hr e g a r d t o h e a l t h r i s k s , th e p e r c e p t i o n o f t h e s e r is k sa n d t h e m e a n s a n d s t r a te g i e s to c o p e . H e n c e i tw o u l d s e e m t h a t c u r r e n t a p p r o a c h e s t o d i s e a se c o n -t r o l s h o u l d r e t h i n k t h e r a t h e r v a g u e c o n c e p t o f" c o m m u n i t y p a r t i c i p a t i o n " a n d r e c og n i se th a t c o m -m u n i t ie s a re c o m p o s e d o f w o m e n a n d m e n w h or e l a t e t o e a c h o t h e r i n w a y s t h a t i m p a c t o n t h e i ru n d e r s t a n d i n g o f h e a lt h , t h e i r h e a l t h - r e l a t e d b e h a -v i o u r a n d u l t i m a t e l y t h e i r h e a l th .

U n d e r s t a n d i n g a n d r e l a t in g t o c l ie n t s i n th i s n e ww a y m a y s e e m a d a u n t i n g c h a l l e n g e f o r h e a l t h p r o -f e s s i o n a l s w h o , a l t h o u g h t h e y w o r k w i t h i n d i v i d u a l sa n d f a m i l ie s o n a d a i l y b a si s , a re n o t a d e q u a t e l yt r a i n e d i n t h e u n d e r s t a n d i n g o f t h e b r o a d e r s o c i a la n d c u l t u r a l c o n t e x t s f r o m w h i c h t h e i r p a t i e n t sc o m e . T h e l a t t e r i s t he d o m a i n o f t h e s o c i a l s ci e n ti s ta n d s o c ia l w o r k e r , a n d i t i s h e r e t h a t r e a l o p p o r t u -n i ti e s ex i s t f o r i n c r e a s e d c o l l a b o r a t i o n a n d i n t e r d is -c i p l i n a ry d i a l o g u e . C o m b i n i n g t h e s k il ls o fe p i d e m i o l o g y i n re l a t i o n to t h e u n d e r s t a n d i n g o fd i s e a s e w i t h t h e s o c i a l s c i e n c e a n a l y s i s o f r e l e v a n tg e n d e r f a c t o rs , a s d e m o n s t r a t e d i n t hi s p a p e r , c a na d v a n c e o u r t h e o r e t i c a l a n d p r a c t i c a l u n d e r s t a n d i n go f h o w h e a l t h a n d d i s e a s e a r e " e n g e n d e r e d " i n so -c i e t y a n d h o w t h i s f a c i l i t a t e s o r i n h i b i t s s u s t a i n a b l ed i s e a s e p r e v e n t i o n a n d c o n t r o l .

A c k n o w l e d g e m e n t s - - T h i s p ap er was wr i t ten d u r in g a sab -b a t ica l p e r io d o f o n e o f u s (MT) a t th e Au s t r a l ian C en t r efo r In te rn a t io n a l an d Tro p ica l Hea l th an d Nu t r i t io n( A C I T H N ) , U n i v e r s it y o f Q u e e n s l an d M e d i c a l S c h o o l ,Br isbane. We gratefu lly acknowledge the f ru i tfu l d iscus-s io n s o f d r a f t s o f th i s p ap er w i th P ro fesso r Len o reM a n d e r so n o f A C I T H N .

REFERENCESAg y ep o n g , I . A . (1 9 9 2 a) Malar ia : e th n o med ica l p ercep -t io n s an d p rac t ice in an Ad an g b e f a rmin g co mmu n i tyan d imp l ica t io n s fo r co n t ro l . S o c ia l S c i en ce & M ed ic in e35, 131.Agyepong, I . A. (1992b) Women and malar ia: social ,eco n o mic , cu l tu r a l an d b eh av io u ra l d e te rmin an ts o f ma-laria. In W o men a n d Tro p ica l Di sea ses , ed s P .Wijey ara tn e , E . R a th g eb er an d E . S t . On g e , p p . 1 7 6 -1 9 3 . In te rn a t io n a l D ev e lo p m en t R esearch C en t r e ,O t tawa .Ag y ep o n g , I . A . , Ary ee , B . , Dz ik u n u , H . an d Man d er so n ,L. (1995) T h e M a l a r i a M a n u a l . W H O , G e n e v a .Beljaev , A. E. , Sharma, G. K. , Brohult , J . A. and Haque,M. A . (1 9 8 6 ) S tu d ies o n th e d e tec t io n o f ma la r ia a tP r imary Hea l th C en t r es . Par t I I . Ag e an d sex co mp o -s i t io n o f p a t ien ts su b jec ted to b lo o d ex am in a t io n in p as -s ive case detec tion . In d ia n Jo u rn a l o f M a la r io lo g y 23, 19.Bonilla , E. and Rod r iguez, A. (1993) De term ining mala r iaeffects in rural Colombia. S o c ia l S c i en ce & M ed ic in e 37 ,

1109 .

Brabin, B. J.(1994) T h e R i s k s a n d S e v e r i t y o f M a l a r i a i nP r e g n a n t W o m e n . Ap p l ied F ie ld R esearch in Malar iaR ep o r t s , No . 1 , W HO , Gen ev a .C ASE (C o mmu n i ty Ag en cy fo r So c ia l En q u i ry ) (1 9 9 5 )" 'Le t t h e S ky t o b e t h e L imi t " . So u l C i ty Ev a lu a t io nR ep o r t , J an aca Ed u ca t io n , Jo h an n esb u rg .Degr+mont, A. A. , Burnier , E. , Lwihula, G. K. ,Ma y o m b an a , C h . , d e Sav ig n y, D . an d Tan n er , M. (1 98 7 )Lo n g i tu d in a l s tu d y o f th e h ea l th s ta tu s o f ch i ld r en in aru ra l Tan zan ian co mmu n i ty : co mmu n i ty -b ased c l in ica lexam inations , th e d iseases seen at v i l lage health postsan d th e p ercep t io n o f h ea l th p ro b lems b y th e p o p u -lat ion . Acta Tropica 44 , 175.Et t l in g , M. B . , Kro n g th o n g , T . , Krach ak t in , S . an dB u alo mb ai , P . ( 1 9 8 9 ) Ev a lu a t io n o f ma la r ia c l in ics inMaeso t , Th a i lan d : u se o f se ro lo g y to as sess co v erag e .Tra n sa c t io n s o f t h e Ro ya l S o c i e t y o f T ro p ica l M ed ic in ea n d H y g i e n e 83, 325.F o n n , S . a n d X a b a , M . ( 1 9 9 5 ) H e a l t h W o r k e r s f o rChange. W H O / T D R , G e ne v a.Gomes, M. (1993) Malar ia , special issue. S o c ia l S c i en ce &M ed ic in e 37, 1091.Kaseje, D. C. O. , Sempebwa, E. K. and Spencer , H.C . ( 1 9 8 7 ) M a l a r i a c h e m o p r o p hy l a x is t o p r e g n a ntw o m e n p r o v i d e d b y c o m m u n i t y h e a l t h w o r k e r s i nC era ted , Ken y a . I . R easo n s fo r n o n -accep tan ce . An n a l so f T ro p ica l M ed ic in e a n d Pa ra s i t o lo g y 81, 77-83 .K h a t t a b , H . ( 1 9 9 3 ) The S i len t Endurance: Socia lCo n d i t i o n s o f W o men ' s Rep ro d u c t i ve Hea l th i n Ru ra lEg yp t . U N I C E F , A m m a n .Kik wawi la S tu d y Gro u p (1 9 9 5 ) W H O / T D R W o r ks h op o nQu a l i t a t i ve Resea rch M eth o d s ; Rep o r t o n t h e F i e ldW o r k . So cia l an d Eco n o mic R esearch P ro jec t R ep o r t sn o . 1 4, W o r ld He a l th Org an isa t io n , Gen ev a .Kwawu , J . ( 1 9 9 4 ) Gen d er an d h o u seh o ld h ea l th seek in gb eh av io u r s , I n Gender, Heal th and Susta inableDeve lo p men t , Pro ceed in g s o f W o rksh o p in Na i ro b i , 5 -8October 1993, eds P. Wijeyaratne, L. J . Arsenault , J .Ha tch er -R o b er t s an d J . K i t t s , p p . 2 2 5 -2 2 9 .In te rn a t io n a l Dev e lo p men t R esearch C en t r e , O t tawa .Lo ren z , N . , K i l ima , P . , Tan n er , M . an d Garn e r , P . ( 19 9 5)Ob jec t iv es in h ea l th ca r e p lan n in g : t im e to g e t th emright . W o r l d H e a l t h F o r u m 16, 280.Lule, G. S. and Ssembatiya, M . (1995) In ten tion to deliveran d d e l iv ery o u tco me. In Th e Fema le C l i en t a n d t h eHeal th Provider , ed s J . Ha tch er R o b er t s an d C .Vlasso f f , p p . 7 9 -9 0 . I n te rn a t io n a l Dev e lo p men tR esearch C en t r e , O t tawa .Macln tyre, S . (1993) Gender d if ferences in the perceptionso f co mmo n co ld sy mp to ms . S o c ia l S c i en ce & M ed ic in e3 6 , 15.Mb ack e , C . an d Van d e Wal le , E . ( 1 9 8 7 ) S o c io -eco n o micFa c to rs a n d Access t o Hea l th S erv i ces a s Determin a n t s o fCh i ld M o r ta l i t y . I U S S P S e m i n a r o n M o r t a l i t y a n dSo c ie ty in su b -Sah aran A f r ica , IUSS P, Yao u n d e .McCombie, S . C . (1996) Treatment seeking for malar ia: areview of rec ent research. S o c ia l S c i en ce & M ed ic in e 43 ,933.M cPak e, B. (1993) Use r charges for health services indeveloping countr ies : a rev iew of the economic l i tera-ture. S o c ia l S c i en ce & M ed ic in e 3 6 , 1397.Mech an ic , D . (1 9 6 4 ) Th e inf lu ence o f mo th er s o n th e i rch i ld r en ' s a t t itu d es an d b eh av io u r s . Ped ia t r i cs 33, 444.Mechanic, D. (1976) Sex , i l lness , i l lness behaviour and theuse of h ealth services. S o c ia l S c i en ce & M ed ic in e 12(1B),207.Men en d ez , C . (1 9 9 5 ) Ma lar ia d u r in g p reg n an cy : a p r io r i tyarea o f mala r ia r esearch an d co n t ro l . Pa ra s i t o lo g yTo d a y 11, 178.Mo l in eau x , L . , Mu ir , D . A . , Sp en cer , H . C . an dWe rn sd o r f e r , W. H . (1 98 8 ) Th e ep id emio lo g y o f mala r iaand its measurements. In M a la r ia : p r in c ip l es a n dpract ice o f malario logy, Vol. 2 , eds W. H. Wernsdorfer


10/10

5 3 2 Ma rce l Tan n er an d C aro l V lasso f fan d I . M cGreg o r , p p 9 9 9 -1 0 89 . C h u rch i l l L iv in g s to n e ,Ed in b u rg h .Mw ab u , G . M . (1 9 8 6 ) Hea l th ca r e d ec is io n s a t th e h o u se-hold level: results of a rural hea lth survey in Keny a.S o c ia l S c i en ce & M ed ic in e 22, 315.Mwenesi , H. A. (1993b) M o th ers Def in i t i o n a n d Trea tmen to f Ch i ld h o o d M a la r ia o n t h e Ken ya n Co a s t . So cia l an dEco n o mic P ro jec t R ep o r t s No . 1 3, Sp ecia l P ro g ramm efo r R esearch an d Tra in in g in Tro p ica l D iseases (TDR ) ,W H O , G e n e v a .Nath a n so n , C . (1 9 7 5 ) I lln ess an d th e f emin in e ro le : atheoretical rev iew. S o c ia l S c i en ce & M ed ic in e 9, 57.Ok o n o fu a , F . E . , Fey ise tan , B . J . , Dav ies -Ad etu g b o , A .Sanusi, Y. O. (1992) Inf luence of socioe conom ic factorso n t h e t r e a t m e n t a n d p r e v e n ti o n o f m a l a r i a i n p r e g n a n tan d n o n -p reg an an t ad o lescen t g i r l s in N ig er ia . J o u r n a lo f T r o p ic a l M e d i c i n e a n d H y g i e n e 95, 309.Phillips, D. R. (1990) He a l th a n d Hea l th Ca re i n th e Th i rdW o r ld . L o n g m a n D e v e l o p m e n t S t u d i e s a n d J o h n W i l e ya n d S o n s , H o n g k o n g / N e w Y o r k .T h e P r e v e n t i o n o f M a t e r n a l M o r t a l i t y N e t w o r k ( 1 9 9 2 )Ba rr i er s t o t rea tm en t o f o b s t e t r i c emerg en c i es i n ru ra lco mmu n i t i es o f W es t A f r i ca . S tu d i es i n Fa mi l y P la n n in g2,3, 279-291 .R ash ed , S . F . , Do n g ie r , P . , Jo h n so n , H . , Gb ad u id i , C . C . ,Mo reau , R . an d C o l in , L . ( 19 9 6) Dete rmin a n ts d e l ' u t i l i-sa t io n d e mo u s t iq u a i r es imp reg n res au B en in .Un p u b l i sh ed p ap er p r esen ted a t 3 rd C an ad ianC o n feren ce in In te rn a t io n a l Hea l th , O t tawa .Rathgeber , E. and Vlassoff , C . (1993) Gender and tropicald iseases: a new research focus. S o c ia l S c i en ce &M e d i c i n e 37, 513.R eu b en , R . (1 9 9 3 ) W o m en an d mala r ia . Sp ec ia l ri sk s an dappropr iate contro l s trategy . S o c ia l S c i en ce & M ed ic in e37, 473.

Silva, K. T. (1988) M a l a r i a C o n t r o l t h ro u g h C o m m u n i t yAc t io n a t t h e Gra ss -Ro o t s : Exp er i en ce o f t h e S a rvo d a yaM a l a r i a C o n t r o l R e s e a r ch P r o j e c t i n S r i L a n k a f r o m1980 to 1986. S E R P r o j e c t R e p o r t s N o . 4 . W o r l dH e a l t h O r g a n i sa t i o n , G e n e v a .Smi th , T . , C h ar lwo o d , J . D . , Tak k en , W. , Tan n er , M. an dSpiegelha lter , D. (1995) Bayesian ma pping o f the den-s i t ies of malar ia vectors with in a s ingle v i l lage. A c t aTro p ica 59, 1.Tanner , M. (1988) Dis t r i c t - leve l Da ta Co l l ec t io n a n d Use .In d ep en d en t In te rn a t io n a l C o mmiss io n o n Hea l thR esearch fo r Dev e lo p men t , C o mmiss io n ed Pap er ,H a r v a r d S c h o o l o f P u b l ic H e a l t h , B o s to n .

Tan n er , M . an d d e Sav ig n y, D . (1 9 87 ) Mo n i to r in g o f co m-munity health s tatus: exper ience f rom a case s tudy inTan zan ia . Ac ta Tro p ica 4 4 , 261.Tan n er , M. , d e Sav ig n y , D . , May o mb an a , C . , Ha tz , C . ,B u rn ie r , E . , Tay ar i , S . an d Deg r rmo n t , A . A . (1 9 9 1 )Mo rb id i ty an d mo r ta l i ty a t K i lo mb ero , Tan zan ia . I nDisea se a n d M o r ta l i t y i n S u b -S a h a ra n A f r i ca , eds R. G.Feach em an d D . T . Jamiso n , p p . 2 8 6 -3 0 5 . Ox fo rdUn ivers i ty Press , Oxford .Tan n er , M. , Teu sch er , T . an d A lo n so , P . L . ( 1 9 9 5 )SPf6 6 - - th e f i r s t mala r ia v acc in e . Pa ra s i t o lo g y To d a y 11 ,10 .Traore, S . , Coulibaly , S . and Sid ibe, M. C. (1993)Co mp o r t emen t s e t co u t s l i d s a u p a lu d i sme ch ez l es

f e m m e s d e c a m p e m e n t s d e p d c he u r s d a ns l a z o n e d eS e l in g u e a u M a l i . SER Pro jec t R ep o r t s n o . 1 2 , Wo r ldHeal th Org an isa t io n , Gen ev a .Vlassoff, C . (1 994) Ge nde r inequali t ies in health in theTh i rd Wo r ld : u n ch ar ted g ro u n d . S o c ia l S c i en ce &M ed ic in e 39, 1249.Vlassoff , C . and Bonil la , E. (1994) Gender d if ferences intropical d iseases: what do we know? Jo u rn a l o f B io so c ia lS c i en ce 26, 37.Vlassoff , C . , Hardy, R. and Rathgeber , E. (1995) T o w a r d sthe H eal thy W om en Counsel ling Guide. W H O / T D R ,G e n e v a .Wo r ld B an k (1 9 9 3 ) W o r l d D e ve lo p m e nt R e p o r t 1 9 9 3 -In ves t i n g i n Hea l th . Ox fo rd Un iv er s i ty P ress, Ox fo rd .Wo r ld Hea l th Org an isa t io n (WHO) (1 9 9 3 ) Imp lemen ta t i o no f t h e Glo b a l M a la r ia Co n t ro l S t ra t eg y . R e p o r t o f aW H O s t u d y g r o u p o n t h e i m p l e m e n t a t i o n o f t h e g l o b a lp lan fo r ac t io n fo r mala r ia co n t ro l 1 9 9 3 -2 0 0 0 , WHOTech n ica l R ep o r t Ser ies 8 3 9 , WHO, Gen ev a .Wo r ld Hea l th Org an isa t io n (WHO) (1 9 9 5 a) C o n t r o l o fT r o p ic a l D i s e a s e s - - M a l a r i a C o n tr ol . W H O , G e n e v a .Wo r ld Hea l th Org an isa t io n (WHO) (1 9 9 5 b ) To wa rd s aHe al thy W om en Counsell ing Guide. W o r l d H e a l t hOrg an isa t io n , Gen ev a .W o r l d H e a l t h O r g a n i s a t i o n ( W H O ) ( 1 9 9 5 c ) H e a l t hW o r k e r s f o r C h a n g e - - A M a n u al . W o r l d H e a l t hOrg an isa t io n , Gen ev a .Wy ss , K . an d Nan d j in g ar , M. (1 9 9 5) P ro b lems o f u t i li z -a t io n o f n u t r i t io n a l r eh ab i l i t a t io n se rv ices b y mo th er s o fmaln o u r i sh ed ch i ld r en in N 'D jamen a (C h ad ) . I n T h eFema le C l i en t a n d t h e Hea l th Pro v id er , ed s J . Ha tch erRober ts and C. Vlassoff , pp . 138-153. In ternationalDev e lo p men t R esearch C en t r e , O t tawa .

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