ARTICLE IN PRESS

Social Science & Medicine 59 (2004) 501–523

Review
A critical review of behavioral issues related to
malaria control in sub-Saharan Africa:
what contributions have social scientists made?
Holly Ann Williamsa,*, Caroline O.H. Jonesb
a
Malaria Epidemiology Branch, Centers for Disease Control and Prevention, Mail Stop F-22, 4770 Buford Hwy NE,
Atlanta, GA 30345, USA
b
DFID Malaria Knowledge Programme, London School of Hygiene and Tropical Medicine, London, UK

Abstract

In 1996, Social Science & Medicine published a review of treatment seeking for malaria (McCombie, 1996). Since
that time, a significant amount of socio-behavioral research on the home management of malaria has been undertaken.
In addition, recent initiatives such as Roll Back Malaria have emphasized the importance of social science
inputs to malaria research and control. However, there has been a growing feeling that the potential contributions
that social science could and should be making to malaria research and control have yet to be fully realized. To
address these issues, this paper critically reviews and synthesizes the literature (published, unpublished and
technical reports) pertaining to the home management of illness episodes of malaria in sub-Saharan Africa
from 1996 to the end of 2000, and draws conclusions about the use of social science in malaria research and
control.
The results suggest that while we have amassed increasing quantities of descriptive data on treatment
seeking behavior, we still have little understanding of the rationale of drug use from the patient perspective
and, perhaps more importantly, barely any information on the rationale of provider behaviors. However, the
results underline the dynamic and iterative nature of treatment seeking with multiple sources of care frequently
being employed during a single illness episode; and highlight the importance in decision making of gender, socio-
economic and cultural position of individuals within households and communities. Furthermore, the impact
of political, structural and environmental factors on treatment seeking behaviors is starting to be recognised. Programs
to address these issues may be beyond single sector (malaria control programme) interventions, but social science
practice in malaria control needs to reflect a realistic appraisal of the complexities that govern human behavior and
include critical appraisal and proposals for practical action. Major concerns arising from the review were the lack
of evidence of ‘social scientist’ involvement (particularly few from endemic countries) in much of the published
research; and concerns with methodological rigor. To increase the effective use of social science, we should focus
on a new orientation for field research (including increased methodological rigor), address the gaps in research
knowledge, strengthen the relationship between research, policy and practice; and concentrate on capacity
strengthening and advocacy.
r 2003 Elsevier Ltd. All rights reserved.

Keywords: Malaria; Social science; Treatment seeking; Malaria control; Sub-Saharan Africa

*Corresponding author. Tel.: +1-770-488-7764; fax: +1-770-488-7761.

E-mail addresses: hbw2@cdc.gov (H.A. Williams).

0277-9536/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2003.11.010
 ARTICLE IN PRESS
502 H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
Background and objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Treatment-seeking behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Recognition of illness signs and symptoms . . . . . . . . . . . . . . . . . . . . . . . . 504
Sources of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
Patterns of treatment seeking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Decision-making processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
Delays in seeking treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
Factors influencing choice of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Seasonality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Age, gender and social equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Household social organization and locus of decision making . . . . . . . . . . . . . . . 509
Drug use: consumer and provider behavior . . . . . . . . . . . . . . . . . . . . . . . . . . 510
Drug use by consumers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510
Delivery of drugs by providers—what are they doing? . . . . . . . . . . . . . . . . . . 510
Involvement of social scientists in the social science research . . . . . . . . . . . . . . . . . 510
Discussion of results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
Quantification of drug intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
Recognition of uncomplicated and severe malaria . . . . . . . . . . . . . . . . . . . . . 512
Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
Methodological rigor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
How have we moved on? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
Changing our approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
The primacy of context in understanding treatment-seeking behaviors . . . . . . . . . . . . 514
What are the factors constraining the contributions of social scientists in malaria control? . . 515
Effective use of social science? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
New orientation for fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
New areas for research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
Research, policy & practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Capacity strengthening & advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518

Introduction factors, together with the failure of earlier vertical,

Over recent years, there has been a dramatic increase
in global attention to malaria. Programmes such as the
Multilateral Initiative on Malaria (MIM) and Roll Back
Malaria (RBM) have been established and international
donor agencies (both private and public) have con-
tributed millions of dollars to malaria research and
control. This renewed interest has arisen at a time when
the concepts of decentralized health care and the role of
community participation have become central tenets of
disease prevention and treatment strategies. These
top-down malaria eradication programs, have contrib-
uted to the current emphasis on community-based
strategies for malaria control. The success of such
strategies relies on an understanding of human beha-
viors and the socio-cultural, political, economic and
environmental contexts that influence those behaviors.
Contributions from social science are now identified as
critical to malaria control (WHO/AFRO, 1998; Well-
come Trust/MIM, 1997; World Health Organization,
1997)—understanding treatment-seeking behaviors,
willingness to accept and pay for preventive and curative
 ARTICLE IN PRESS
H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
services, local illness classifications, and the determi-
nants of behavior relating to changing national malaria-
treatment policies are all examples of areas in which
social science contributions are needed. Consequently,
programs such as RBM and MIM have emphasized the
importance of social science inputs in helping them to
realize their goal of improved malaria control.
However, among social scientists and others working
in applied malaria research, there has been a growing
feeling that, despite international recognition of the role
human behavior plays in malaria, the potential con-
tributions that social science could and should be
making to malaria control have yet to be fully realized.
To explore why this gap exists, it is necessary to
understand what research has been done and what, if
any, impact the research has had in the field of malaria
control. This paper critically reviews and synthesizes
literature pertaining to treatment-seeking behaviors and
the management of malaria illness episodes in sub-
Saharan Africa, and examines the contributions that
social scientists have made to this knowledge. A
subsequent paper will concentrate on the literature
pertaining to preventive activities, particularly insecti-
cide-treated materials. These papers link to an interna-
tional alliance1 whose goals are to enhance the capacity
of social science in the field of malaria control and to
1
These papers are part of a multi-step research plan that has
been designed by the authors, as well as other members of the
international alliance, the ‘‘Partnership for Social Sciences in
Malaria Control,’’ which held its organizational meeting in
London, January 2001. The Partnership is envisioned as ‘‘an
alliance of individuals representing specific skills and expertise
within specified institutions.’’ Members of the Steering Com-
mittee of the Partnership include representatives from the
following institutions: Centers for Disease Control and
Prevention (CDC), London School of Hygiene and Tropical
Medicine (LSHTM), University of Nairobi, University of Mali,
The CHANGE Project, Multilateral Initiative on Malaria
(MIM), UNDP/World Bank/WHO/Special Programme on
Tropical Disease Research (TDR) (Social, Economic and
Behavioral Unit, Intervention Development and Implementa-
tion Research Unit, and Research Capacity Strengthening
Unit), Environmental Health Project (EHP), USAID African
Bureau, WHO/AFRO, Department for International Develop-
ment (DFID), The Maria Consortium, Mozambique National
Institute of Health, Ghana Health Services, Gates Malaria
Programme [LSHTM], Roll Back Malaria/WHO Geneva,
Malaria Foundation International, and the Danish Bilharziasis
Laboratory (DBL). In addition to the papers, other activities in
which the Partnership are engaged include: (a) updating the
literature base used for this paper, as well as maintaining a
‘‘Clearinghouse for Social Science and Malaria Literature,’’ (b)
developing a web–based searchable format for disseminating
the literature data base, (c) developing a participatory network
of social scientists that reside or work in Africa, and (d) refining
a research agenda for social scientists involved in malaria
activities for the next decade.
503
better integrate social science efforts with other scien-
tists, malaria control programs, and policy makers, in
order to design more appropriate, effective, and
sustainable intervention programs.
Background and objectives
In the early 1990s, the World Health Organization
(WHO) commissioned a review of literature on treat-
ment-seeking behaviors for malaria by McCombie
(1994, 1996). The results of this review showed that a
great deal had been learned about malaria treatment-
seeking behaviors, but several gaps in knowledge and
understanding remained, including: (a) quantification of
actual drug intake, (b) understanding how people
differentiated between uncomplicated and severe malar-
ia, and (c) knowledge on how provider behaviors’
impacted treatment seeking behaviors. McCombie
(1996) also noted concerns about a lack of clarity in
commonly used terms, such as the difference between
self and home treatments or what is meant by time to
‘‘appropriate treatment.’’ In addition, she pointed to a
lack of methodological rigor, noting that few studies
were comparable as there was minimal description
of how data were collected or what type of analysis
was used.
McCombie’s (1996) findings have been widely cited
and, since the review, there has been a marked increase
in the number of published papers discussing behavioral
issues related to malaria control. However, there has
been no concerted effort to summarize the knowledge or
critically examine the lessons learnt from the findings.
This paper attempts to fill this gap.2 In doing so, it
addresses the following areas: (a) what new knowledge
or complimentary knowledge has been generated since
McCombie’s review, (b) have the gaps in knowledge as
identified by McCombie been addressed, (c) has
methodological rigor increased, and (d) has the knowl-
edge been applied programmatically and, if not, why
not? The paper will also focus on identifying factors that
have constrained social scientists’ contributions to
malaria control, suggest new areas of research, and
highlight approaches to utilizing the results of applied
social science research, to improve malaria control.
Throughout this process, we sought to answer the
question, ‘‘what should the thrust of social science
research and activities related to malaria control be for
the next decade?’’ This review is written primarily from
2
This paper is an adaptation of a paper given by the authors
as an invited plenary session at a meeting convened by the
WHO/TDR Task Force on Home Management of Malaria
entitled, ‘‘Strategy Meeting to Define Outstanding Research
Issues in the Home Management for Malaria,’’ held in Kilifi,
Kenya, May 2000.
 ARTICLE IN PRESS
504 H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
the perspective of medical anthropology, although the
discussion points and recommendations have applica-
tion to a wider social science audience.
Methods
The review included published and unpublished
literature and technical reports pertaining to sub-
Saharan Africa, covering the time period 1994 to the
end of 2002. Although efforts were made to access all
pertinent literature, the authors acknowledge that, most
likely, there are missing papers relevant to this review,
particularly in the gray literature (technical reports,
unpublished papers), which were difficult to access. The
literature reviewed for this paper is part of a citation
database created by the authors and colleagues from
The Partnership for Social Sciences in Malaria Control
(PSSMC). The citation database consists of over 500
entries of published and unpublished literature, techni-
cal reports, and oral/poster presentations from regional,
national and international meetings on malaria. This
citation database is currently archived at the CDC and
LSHTM, with satellite centers under development in
sub-Saharan Africa, as well as http://www.malaria.org/.
Due to constraints of time and space, the oral and poster
presentations were not included in this review.
Working with medical librarians at the CDC and the
LSHTM, the authors designed various search strategies
to review the social science, epidemiology, health
education and communication, tropical medicine/infec-
tious diseases, and policy literature. Computerized
databases from the United States and the United
Kingdom were searched on a biweekly basis, including
Bath Information and Data Service (BIDS), CINAHL,
Dissertation Abstracts, Medline, PsycINFO, Social
Citation Index, Social SciSearch, and Sociological
Abstracts. Library searches of more difficult-to-access
African journals were done by both authors, at the
libraries of CDC, LSHTM, and the University of
London. During field trips to Africa, the authors also
searched archival materials in various sites, including,
for example, the libraries of the National Institute for
Medical Research and the Tanzanian Essential Health
Interventions Project, both located in Dar es Salaam,
Tanzania.
Agencies that participated in international malaria
control activities (either as programmatic partners or
funding agencies) were contacted to obtain copies of any
related technical reports or unpublished papers. In
addition, the authors searched the archives of the
UNDP/World Bank/WHO Special Programme for
Research and Training in Tropical Diseases (TDR) at
the World Health Organization (WHO). As well,
individuals known personally by the authors and/or
colleagues of the authors were contacted to ask if they
had any additional work that they could contribute,
particularly unpublished papers. Papers were considered
appropriate for this review if they were concerned with
aspects of human behavior related to the recognition,
diagnosis and management of malaria (as defined bio-
medically or in local terms). This included papers about
perceived quality of care, as well as papers that discussed
policy implications of malaria control. Three areas of
literature were excluded from the review—travel pro-
phylaxis, historical commentaries, and economic aspects
of malaria control. However, economic papers that
discussed the effect of cost on treatment-seeking
behaviors were included.
Results
We reviewed 117 published papers (including 87
research reports, one policy paper, two editorials, nine
letters to the editor, eight brief commentaries, five
abstracts, and five reviews), 15 unpublished and 32
technical reports for this paper, for a total of 164
documents.3 (See Appendix A for a list of journals in
which social science literature was found.)
Treatment-seeking behaviors
Factors relating to treatment-seeking behaviors were
examined from the perspectives of both the patient/care
givers and the providers, including use of alternative
providers, patterns of treatment seeking, delays in care,
drug use practices (actual dosage patterns and delivery
of drugs by providers), and cognitive processes that
guide the decision making related to choices for care.
Recognition of illness signs and symptoms
Although there was a wide array of perceived
etiologies for malaria, the symptom complex that
corresponds to the biomedical notion of uncomplicated
malaria was widely recognized as a commonplace febrile
illness that could be treated in the home first, often by
tepid sponging, domestically produced herbal prepara-
tions, and/or the administration of pharmaceuticals
(most commonly used were antimalarials, antipyretics
and/or analgesics) (see Table 1 for references). Gener-
ally, absence of fever, ability to eat and play indicated
that children were better (Williams et al., 1999). A study
in Kenya found that, if fever returned within 1 week,
then the mothers perceived that the treatment had not
worked but if fever recurred after 2 weeks, then it was
considered to be a separate disease episode (Marsh &
Mutemi, 1997). Mothers were found to be well attuned
3
For purposes of this paper, only key references will be cited.
However, a complete listing of all reviewed papers can be
obtained from the authors.
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Table 1
Recognition of illness

Uncomplicated malaria: Serious illness: fever with Convulsions: a primary

common, minor & mild febrile
illness, treated in home often
with tepid sponging, domestic
herbal preparations &/or use
of drugs in the home
vomiting, cough or diarrhea, symptom differentiating severe
high fever or persistent fever illness from ‘‘normal’’ malaria
with headache with ‘supernatural’ or
‘spiritual’ force involved

East Adome et al., 1997, 1998;
Africa Baume, 1998; Ellman &
Shayo, 1997; Jenkins, 1998;
Kengeya-Kayondo et al., 1994;
Klaver, 1993; Molyneux et al.,
2002; Mwenesi, 1994; Mwenesi
et al., 1995; Nyamongo, 2002;
Reynolds-Whyte & Birungi,
2000; Ruebush et al., 1995;
Shafritz & Helitzer-Allen,
1996; Tarimo et al., 1998,
2000; Williams & Mungai,
1999; Winch et al., 2000b.
West Adongo & Hudelson, 1995;
Africa Agyepong & Manderson,
1994; Agyepong, 1995; Ahorlu
et al., 1997; Isah, Isah, & Ogie,
1995; Jenkins, 1998; Ortega &
Binka, 1994; Thera et al., 2000.
Southern Baume et al., 2000; Douglass,
Africa 1998; Jenkins, 1998; Williams
et al., 1999.
Baume, 1998; Jenkins, 1998;
Molyneux et al., 2002; Shafritz
& Helitzer-Allen, 1996;
Tarimo et al., 1998.
Agyepong, 1995; Agyepong &
Manderson, 1994; Jenkins,
1998; Ortega & Binka, 1994.
Baume et al., 2000; Baume &
Macwan’gi, 1998; Govere
et al., 2000; Jenkins, 1998.
Alilio et al., 1998; Hausmann-
Muela & Muela, 1998;
Kengeya-Kayondo et al., 1994;
Makemba et al., 1996;
Mwenesi et al., 1995;
Nyamongo, 1999a; Oberlander
& Elverdan, 2000; Tarimo
et al., 1998.
Adongo & Hudelson, 1995;
Ahorlu et al., 1977; Maynard
Tucker, 2000; Ortega & Binka,
1994.
Baume et al., 2000; Baume &
Macwan’gi, 1998; Jenkins,
1998.

to the state of their children and signs that the illness had
worsened or symptoms that were perceived as severe or
out of the ordinary signaled a need for different actions.
A combination of fever with vomiting, cough or
diarrhea, or simply a persistent fever with headache
that had not responded to treatment, were frequently
mentioned as signs of serious illness that required advice
from outside the home, most often from the nearest or
most affordable health facility (or biomedical provider)
(see Table 1 for references). High fevers were frequently
viewed as serious, necessitating a visit to a health care
facility (hospital or clinic), whenever possible. Findings
from a few studies indicated that the ability to link
certain symptoms with severity of illness was signifi-
cantly associated with higher levels of education
(Tarimo, Lwihula, Minjas, & Bygbjerg, 2000; Tarimo,
Urassa, & Msamanga, 1998), while in other studies
educational level was not related to judgment of severity
(Slutsker, Chitsulo, Macheso, & Steketee, 1994). Con-
vulsions were almost universally recognized as being a
primary symptom differentiating severe illness from
‘‘normal’’ malaria. The appearance of convulsions
frequently led to the perception that some form of
‘supernatural’ or ‘spiritual’ force was, or had become,
involved in the illness process and any cure necessitated
the involvement of a ‘traditional healer’ of some kind
(see Tables 1 and 2 for references).
Sources of care
There were inter-country, urban/rural and district
level variations in the type and quantity of sources of
care available to the review populations (Alilio &
Tembele, 1994; Dawson, 1996; Molyneux, Mung’ala-
Odera, Harpham, & Snow, 1999) but, to a greater or
lesser degree, each functioned within a pluralistic health
system. Although patients and care givers were often
reluctant to discuss use of alternate providers and home/
self treatments due to fear of bullying, accusations, or
belittling from health care staff (Oketch-Rabah, Oduol,
Oluka, & Nyamwaya, 1998; Williams et al., 1999;
Williams & Mungai, 1999), the reality was that, in
addition to the public health system, other sources of
drugs, biomedical and non-biomedical health care
existed. For example, the majority of studies reported
that pharmaceutical drugs (antipyretics and anti-malar-
ial drugs) were available and purchased from licensed
drug shops, non-licensed shops (e.g. grocers), informal
‘table top’ drug sellers, as well as from private and non-
governmental organization (NGO) clinics and hospitals
(see Table 3 for references). Use of these sources of care
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506 H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523

Table 2
Treatment for convulsions

Primary use of traditional healers Biomedicine and traditional healers

East Africa Hausmann Muela & Muela, 1998; Makemba Alilio et al., 1998; Alilio & Tembele, 1994;
et al., 1996; Mwenesi et al., 1995; Snow et al., Jenkins, 1998; Molyneux, Mung’ala-Odera,
1998. Harpham & Snow, 2000; Molyneux et al., 2002;
Winch et al., 2000a.
West Africa Adongo & Hudelson, 1995; Maynard-Tucker, Jenkins, 1998; Sommerfeld et al., 2001.
2000; Ortega & Binka, 1994.
Southern Africa Baume & Macwan’gi, 1998; Baume et al., 2000;
Jenkins, 1998.

Table 3
Patterns of resort to care for uncomplicated malaria

Use of Pharmaceuticals (Purchase of Private sector: closer Private sector: friendly,

antimalarials or use of drugs left-over with regular supply of negotiated charges and
from previous illness episodes) before drugs offered credit
visiting health facility

East Africa Adome et al., 1998; Allilio et al., 1997; Alilio & Tembele, 1994; Armstrong-Schellenberg
Ellman & Shayo, 1997; Fraser-Hunt & Ellman & Shayo, 1997; et al., 2001; Baume,
Lyimo, 1998; Geissler et al., 1998; Gilson Floyd, 1996; Marsh & 1998; Geissler et al.,
et al., 1994; Kengeya-Kayondo et al., Mutemi, 1997; 1998; Jenkins, 1998;
1994; Klaver, 1993; Lubanga, Norman, Molyneux et al., 2002; Klaver, 1993; Reynolds-
Ewbank, & Karamagi, 1997; Massele Mulemi, 1998; Ongore & Whyte & Birungi, 2000.
et al., 1998; Molyneux et al., 2000; Nyabola, 1996; World
Molyneux et al., 2002; Mwenesi, 1994; Bank/WHO/UNICEF,
Ndyomugyenyi et al., 1998; Nyamongo, 1999b.
2002; Oketch-Rabah et al., 1998;
Reynolds-Whyte & Birungi, 2000;
Ruebush et al., 1995; Shafritz & Helitzer-
Allen, 1996; Van der Geest, 1999; WHO/
TDR, 1999; Winch et al., 2000b.
West Africa Adongo & Hudelson, 1995; Adome et al., Goel, Ross-Degnan, Adongo & Hudelson,
1996; Adome et al., 1997; Agyepong & Berman, & Soumerai, 1995; Agyepong &
Manderson, 1994; Agyepong, 1995; 1996; Standing, 1996. Manderson, 1994;
Biritwum & Welbeck, 2000; Isah et al., Jenkins, 1998.
1995; Ortega & Binka, 1994; Thera et al.,
2000; Watling, 1995.
Southern Africa Baume et al., 2000; Baume & Macwan’gi, Baume et al., 2000; Jenkins, 1998.
1998; Douglass, 1998; Slutsker et al., Baume & Macwan’gi,
1994; Van Geldermalsen & Munochiveyi, 1998; Douglass, 1998;
1995; Watling, 1995. Franco et al., 1997;
Standing, 1996; World
Bank/WHO/UNICEF,
1999b.

was high and driven by practical concerns: greater ease
of access due to longer and more flexible operating
hours and larger number of facilities to choose from,
dependable and adequate levels of supplies and drugs,
staff comprised of known local community members
(often relatives, sometimes even children) and, in some
instances, perceived cheaper costs (see Table 3 for
references). In addition, many studies reported the
existence of a series of ‘traditional healers’, who were
perceived to have familiarity with a wide range of
clinical, emotional, and spiritual problems. The ‘tradi-
tional healers’ ranged from spiritual and ‘demon’ healers
through wound healers and bone setters to ‘old women’,
who were not considered as ‘traditional healers’ by the
community but who were known to have the knowledge
of experience and were used for advice (see Table 4). For
example, in Tanzania, certain grandmothers or ‘‘bibis’’
were respected sources of care and advice: they did not
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Table 4
Range of ‘Healers’: familiar with variety of clinical, spiritual & emotional problems & used for advice

East Africa Alilio & Tembele, 1994; Baume, 1998; Ellman & Shayo, 1997; Gessler et al., 1995a, b; Hausmann-
Muela & Muela, 1998; Jenkins, 1998; Khayundi, 2000; Makemba et al., 1996; Maynard-Tucker,
2000; Molyneux et al., 2000, 2002; Winch et al., 2000a.
West Africa Agyepong 1995; Clark et al., 1999; Maynard-Tucker, 2000; Ortega & Binka, 1994.
Southern Africa Baume et al., 2000; Baume & Macwan’gi, 1998; Winston, Patel, Musonza, & Nyathi, 1995.

charge for services and they were accessible day and
night (Hausmann-Muela & Muela, 1998).
Patterns of treatment seeking
Comparisons of patterns of treatment seeking be-
tween studies were hampered by variations in definitions
of terms such as ‘home treatment’ and ‘time to
treatment,’ as well as by variations in data collection
and analytical techniques. However, while there was no
single pattern of treatment seeking (either within or
between communities), as mentioned earlier, generally
the first response to the recognition of febrile illness was
some form of ‘home treatment.’ In addition to tepid
sponging and/or use of local herbs, drugs were
frequently purchased from informal sources, such as
shops, chemists, itinerant vendors, and even other
households (Foster, 1995; McCombie, 1996). In fact,
drugs were often purchased and used before seeking care
at a health care facility (see Table 2 for references). In
most cases, drug sellers (drug shops, general shops
stocking drugs and itinerant vendors) were closer than
the nearest public health facility and, unlike the public
health facilities, they had a reliable supply of drugs (see
Table 3 for references). In addition, drug sellers also
responded to community pressure (e.g., offering certain
tablets or injections perceived to be ‘‘strong’’), were
perceived as friendly, and negotiated charges and
offered credit when purchasing drugs, which was seen
as a definite benefit (see Table 3 for references). Left-
over drugs from previous illness episodes were also
administered when another family member became
ill, particularly in poorer communities (Adongo &
Hudelson, 1995; Agyepong, 1995; Baume & Macwan’gi,
1998; Biritwum & Welbeck, 2000; Dondi, Danda, &
Kangere, 1998; Douglass, 1998; Francis, 1997; Ruebush,
Kern, Campbell, & Oloo, 1995; Shafritz & Helitzer-
Allen, 1996). The use of health-care facilities as the first
choice for treatment was found only in a small minority
of the studies. Factors influencing this pattern of
treatment seeking included situations in which antima-
larials were difficult to obtain outside the health-care
facilities and/or these public facilities were the closest
and most reliable source of inexpensive or free
antimalarials (Baume, Helitzer-Allen, & Kachur, 2000;
Clarke, Rowley, Bogh, Walraven, & Lindsay, 1999). In
addition, in one study in an area of unstable transmis-
sion, health facilities were used initially in preference to
home treatment (Lindblade, O’Neill, Mathanga, Ka-
tungu, & Wilson, 2000). In this study, hospital care was
favored as provision of care was perceived to be of good
quality, drugs were available on site, services were
provided at very low cost, and the facility could treat
severe cases of malaria. Most studies reported simulta-
neous use of several strategies (see Table 5 for
references). In addition to biomedicine, people sought
local solutions to problems and used familiar sources of
treatment (such as herbs) (Oketch-Rabah et al., 1998).
However, home management or self treatment should
not be thought of as a default response to lack of
adequate health-care services, for it occurred in areas
even where biomedical and traditional services were
widely available, accessible, and known to local com-
munities (Hausmann-Muela & Muela, 1998).
If the home-treatment strategies were perceived as
non-effective or as failing (i.e., there was no improve-
ment within 48 h or additional symptoms appeared),
then help was generally sought from a more ‘qualified’
provider of health care. These providers were frequently
bio-medical health-care providers (either in the public,
NGO or private health-care system), but some studies
found that care outside the home was also sought from
‘traditional healers.’ As noted earlier, use of traditional
healers frequently overlapped with seeking care from a
health-care facility and it was commonplace to use a
combination of modern and traditional medicines (see
Table 5 for references). Often, traditional healers would
refer clients to health-care facilities if the malady was
perceived to be more amenable to conventional therapy,
if physical symptoms worsened, or if there was a
perception that the traditional remedy had failed
(Gessler et al., 1995a; Makemba et al., 1996). However,
the appearance of convulsions (a manifestation often
viewed as unrelated to malaria) frequently leads to a
significant alteration in perceptions about the disease
and precipitated a change in treatment actions. Some
studies suggested that, once convulsions appeared,
traditional healers were the primary source of treatment
but others found that traditional healers were employed
in addition to biomedical interventions (see Table 2 for
references).
Literature focusing on malaria treatment-seeking
behaviors during pregnancy is scanty (Helitzer-Allen,
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508 H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523

Table 5
Strategies for treatment

Combination of modern and traditional & simultaneous use of several strategies (trail & error, no clear
hierarchy of use)

East Africa Alilio & Tembele, 1994; Baume, 1998; Geissler et al., 2000; Hausmann-Muela et al., 1998; Jenkins, 1998;
Kenyan Medical Research Institute, 1995; Khayundi, 2000; Molyneux et al., 2000, 2002; Munguti, 1997;
Oberlander & Elverdan, 2000; Oketch-Rabah et al., 1998; Winch et al., 2000a.
West Africa Agyepong, 1995; Agyepong & Manderson, 1994; Ahorlu et al., 1997; Jenkins, 1998; Ortega & Binka, 1994;
Sommerfeld et al., 2001; Thera et al., 2000.
Southern Africa Baume et al., 2000; Baume & Macwan’gi, 1998; Jenkins, 1998.

Macheso, Wirima, & Kendall, 1994; Khayundi, 2000;
Ndyomugyenyi, Neema, & Magnussen, 1998; Schultz
et al., 1994b; Standing, 1996; UNICEF, 2000). The
major findings included low antenatal clinic attendance
and low and inconsistent use of malaria chemoprophy-
laxis among pregnant women (Khayundi, 2000; Lemar-
deley et al., 1997; Massele, Mpundu, & Hamudu, 1997;
Mnyika, Kabalimu, & Lugoe, 1995; Mnyika, Kabalimu,
& Mbaruku, 1998; Phillips-Howard, 1999).
Decision-making processes
The literature reviewed demonstrated that people are
not passive recipients of care. Decisions about choices of
providers and which drugs to use are made system-
atically, based on prior illness and treatment experi-
ences, local beliefs about how illnesses should be treated,
understandings of illness etiologies, recognition of
constellations of symptoms, influence of social net-
works, and a realistic appraisal of available options
(Beckerleg, 1994; Geissler, Nokes, Prince, & Aagaard-
Hansen, 1998; Gilson, Alilio, & Heggenhougen, 1994;
Janzen, 1978; Molyneux, Murira, Masha, & Snow, 2002;
Oberlander & Elverdan, 2000; Ofori-Adjei & Arhinful,
1996; Oketch-Rabah et al., 1998). Williams et al. (1999)
also found that a new drug (in this case, sulfadoxine-
pyrimethamine introduced in an area that had used
chloroquine almost exclusively) could be accepted and
used based on its demonstrated clinical efficacy.
Decisions about choice and sequencing of treatments
were often based more on perceived effectiveness of a
medication or treatment for a particular constellation of
symptoms in a particular illness episode, rather than a
belief in their relationship to a specific cause of the
illness (Ager, Carr, Maclachland, & Kaneka-Chilongo,
1996; Hausmann-Muela & Muela, 1998; Klaver, 1993;
Mogensen, 1998). That is, in many of the communities
studied, uncomplicated malaria was frequently viewed
as a mild childhood illness, the treatment for which was
not necessarily malaria specific, but rather reflected a
more generalized pattern of the management of mild
febrile symptoms with diagnosis altering in response to
symptom variation and treatment outcomes. In addi-
tion, even where the biomedical model of causation for
malaria is well known, it is unlikely to be the only factor
affecting treatment decision making (see Table 1 for
references). For example, regardless of the level of
acceptance of the biomedical etiology of ‘degedege’ (a
locally construed symptom complex mirroring cerebral
malaria), Tanzanian women readily used local remedies,
such as herbal baths and teas, when degedege was
suspected. These practices were guided mostly by years
of experience and local knowledge passed from one
generation of women to the next (Hausmann-Muela,
Muela, & Tanner, 1998; Oberlander & Elverdan, 2000).
Essentially, as symptoms alter, beliefs and explanations
shift and alternate types of treatments are employed
until an outcome (recovery or death) is reached
(Hausmann-Muela, Muela, & Tanner, 1998; Oberlander
& Elverdan, 2000). Various terms have been used
to describe this type of treatment-seeking behavior,
including: ‘‘trial and error’’ (Alilio & Tembele, 1994),
‘‘nomadic’’ (Baume, 1998), and ‘‘try and see’’ (Kenyan
Medical Research Institute, 1995; Marsh & Mutemi,
1997).
Delays in seeking treatment
McCombie (1996) noted that ‘‘delays in treatment-
seeking behaviors’’ were actually studies of time before
presentation to a health facility, not time to any
treatment. In the literature we reviewed, there were
few definitions for ‘delay in treatment,’4 but there were
very few situations in which mothers or caregivers did
nothing (Biritwum & Welbeck, 2000). Fevers were
treated promptly, often with chloroquine (Agyepong &
Manderson, 1994; Lindblade et al., 2000; Slutsker et al.,
1994; Thera et al., 2000; Warhurst, 1998). Most initial
actions occurred between a few hours of symptom
recognition and 48 h, with delays in treatment seeking
over 48 h associated with increased distance from the
clinic (Lindblade et al., 2000; Slutsker et al., 1994;
4
One of the few definitions was given by Lindblade et al.
(2000), who defined delay as treatment that occurs ‘‘...o1 day
between onset of symptoms and first treatment’’ (p. 867).
 ARTICLE IN PRESS
H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
Tarimo et al., 1998; Thera et al., 2000; Watling, 1995).
In a study of treatment seeking in an area of unstable
transmission (Lindblade et al., 2000), neither demo-
graphic nor socioeconomic status was associated with
receiving prompt, effective treatment. Rather, the most
important predictor for seeking rapid treatment at a
health facility was perceived severity of illness.
In a study of childhood deaths, findings from verbal
autopsies indicated that 93% ðn ¼ 125Þ of the children
who died had been seen in a health-care center or
hospital within 2 weeks of their deaths. Matching
surviving controls with the deceased children showed
that the elapsed time between disease onset to first
consultation was shorter for those who died than those
who survived (Sodeman, Jakobsen, Molbak, Alvarenga,
& Aaby, 1997).
Factors influencing choice of care
Reasons for not seeking treatment immediately from
outside the household, in spite of recognizing symptoms
that corresponded to the biomedical notion of malaria,
included: lack of money, illness starting at night, beliefs
that the symptom complex could be successfully treated
at home, and cultural differentiations about the
seriousness of different types of the same symptom
complex (Kengeya-Kayondo et al., 1994; Thera et al.,
2000).
Furthermore, although several studies found that
health workers were perceived as knowing the best (or
‘proper’) treatment or providing the best advice
(Agyepong & Manderson, 1994; Baume, 1998; Baume
et al., 2000; Jenkins, 1998; Shafritz & Herlitzer-Allen,
1996; Tarimo et al., 1998; World Bank/WHO/UNICEF,
1999a) and, once consulted, doctors are most influential
in terms of decision making about the illness, there were
many studies describing wide dissatisfaction with public
facilities. The key issues (mentioned in the majority of
the studied reviewed) contributing to this dissatisfaction
were: consistent lack of drugs and equipment, poor staff
attitudes, cost (direct and indirect) and accessibility
(distance and limited opening hours) (see Table 6 for
references).
In addition to dissatisfaction with public health
facilities, several studies pointed to other factors, which
were found to influence choice of care.
Seasonality
Seasonality influenced access to care in a variety of
ways. Ability to access clinics during rainy seasons was
often hampered by poor or absent roads (Nyamongo,
1999b). During periods of cultivation, farming demands
often made it impossible to attend clinics, including
antenatal care (Khayundi, 2000; Schultz et al., 1994b),
and may restrict the ability to monitor the progress of
the illness (Dawson, 1996). Disposable income was also
509
limited during periods of hunger or cultivation, thus
limiting the ability to pay clinic fees (Hausmann-Muela
et al., 1998).
Age, gender and social equity
Most treatment-seeking studies focus on children
under the age of 5, although a few studies are now
beginning to look at treatment seeking in other age
groups (Agyepong & Manderson, 1994; Geissler et al.,
1998; Krause & Sauerborn, 2000; Lindblade et al.,
2000). The influences of gender and age are beginning to
be recognized in terms broader than physiological
vulnerability. A few papers recognized social, cultural
and economic factors relating to distribution of power
and resources as variables that create a different type of
vulnerability that limits the ability to seek care or have
necessary access to information and resources (Gheb-
reyesus, Alemayehu, Bosman, Witten, & Teklehaima-
not, 1996; Khayundi, 2000; Mulemi, 1998; Munguti,
1998b; Oberlander & Elverdan, 2000; Tanner & Vlass-
off, 1998; Vlassoff & Bonilla, 1994). In some studies, it
was difficult for women to access health care due to the
possible perception of sexual disloyalty if the woman
received care from a male health-care worker and, in
other studies, social pressure constrained women’s
abilities to express their needs and admit to feeling ill
for fear of being thought ‘weak’ (Francis, 1997;
Ghebreyesus et al., 1996; WHO/RBM, 1999). However,
the influence of power as it shapes the ability to seek
treatment is rarely a leading theme in the literature.
Social equity is also related to educational opportu-
nities, with African women generally having lower levels
of education than African men (Munguti, 1998b). Lower
educational levels have been significantly associated with
lower levels of malaria knowledge, fewer antenatal visits
and hospital deliveries, and lower frequencies of clinic
visits (Carme, Plassart, Senga, & Nzingoula, 1994;
Macheso et al., 1994; Mwenesi, Harpham, & Snow,
1995; Schultz et al., 1994b; Slutsker et al., 1994; Tarimo
et al., 2000; Watling, 1995). Poverty, in general, has been
identified as a major constraint for access and use of
health care facilities (Biritwum & Welbeck, 2000; Kager,
2002; Macheso et al., 1994; Moerman et al., 2003).
Household social organization and locus of decision
making
In spite of women often being the first to recognize
illness and having the responsibility for illness manage-
ment, they may be prevented from seeking appropriate
treatment as ultimate decision-making responsibility
and control of finances may lie outside of their social
purview (Alilio, Eversole, & Bammek, 1998; Heggen-
hougen, Hackethal, & Vivek, 2003; Molyneux et al.,
2002; Mwenesi, Harpham, & Snow, 1995; Oberlander &
Elverdan, 2000; Tanner & Vlassoff, 1998). Other factors
included heavy workloads that preclude women from
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510 H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523

Table 6
Reasons for non-use of health facilities

No drugs (&/or Too far, closed, or Cost (treatment, loss of Rude health
equipment) queues income, transport, etc.) workers

East Africa Ahmed, Urassa, Gherardi, Geissler et al., 1998; Geissler et al., 2000; Dondi et al., 1998;
& Game, 1996; Alilio & Gilson et al., 1994; Jenkins, 1998; Lindblade Gilson et al., 1994;
Tembele, 1994; Alilio et al., Jenkins, 1998; et al., 2000; Mwenesi, 1993;
1998; Geissler et al., 1998; Lindblade et al., Ndyomugyenyi et al., Nyamongo, 1999b;
Gilson et al., 1994; 2000; Maende & 1998; Williams & Mungai, Ruebush et al.,
Jenkins, 1998; Massele Prince, 1998; 1999. 1995; Shafritz &
et al., 1998; Munguti, 1998a; Helitzer-Allen,
Ndyomugyenyi et al., Ndyomugyenyi 1996; Williams &
1998; Nsimba et al., 1999; et al., 1998; Oketch- Mungai, 1999.
Nyamongo, 2002; Oketch- Rabah et al., 1998;
Rabah et al., 1998; Osei & Ruebush et al.,
Commey, 1994; Ruebush 1995; Shafritz &
et al., 1995; Shafritz & Helitzer-Allen,
Helitzer-Allen, 1996; 1996; Tarimo et al.,
World Bank/WHO/ 2000.
UNICEF/Kenyan
Ministry of Health, 1998.
West Africa Jenkins, 1998; Osei & Adongo & Adongo & Hudelson, Maynard-Tucker,
Commey, 1994; Standing, Hudelson, 1995; 1995; Agyepong, 1995; 2000.
1996. Agyepong, 1995; Ahorlu et al., 1997;
Ahorlu et al., 1997; Jenkins, 1998; Maynard-
Jenkins, 1998; Tucker, 2000; Ortega &
Maynard-Tucker, Binka, 1994.
2000; Ortega &
Binka, 1994.
Southern Baume et al., 2000; Baume Baume et al., 2000; Baume et al., 2000; Douglass, 1998;
Africa & Macwan’gi, 1998; Douglass, 1998; Douglass, 1998; Jenkins, Williams et al.,
Douglass, 1998; Franco Jenkins, 1998; 1998; Macheso et al., 1994; 1999.
et al., 1997; Jenkins, 1998; Schultz et al., Schultz et al., 1994.
Standing, 1996; Williams 1994b.
et al., 1999; World Bank/
WHO/UNICEF, 1999a.

seeking treatment for themselves or their children
(Dawson, 1996; Ghebreyesus et al., 1996).
Drug use: consumer and provider behavior
Drug use by consumers
Findings about reported drug-use patterns indicated
that polypharmacy practices were common and Western
pharmaceuticals were often given concurrently with
herbal preparations (see Table 7 for references). Drugs
were sold both to adults and children (Geissler et al.,
1998; Maende & Prince, 1998). Caregivers frequently
reported using antipyretics/analgesics as a first-line
treatment for malaria (see Table 7 for references).
Inappropriate drug dosages and/or incorrect timing of
dosages were frequently reported, particularly for
smaller children (see Table 7 for references). Findings
from a nationwide knowledge, attitude, and practice
(KAP) study in Malawi indicated that less than 30% of
people were estimated to have received appropriate
antimalarial doses (Macheso et al., 1994). In one
qualitative study in western Kenya, pregnant women
could not distinguish between routine medications given
in antenatal clinic, such as vitamins, from antimalarials
(Williams & Mungai, 1999). Although some work is
beginning to focus on descriptions of community drug
use patterns (Adome et al., 1998; Geissler et al., 1998;
Massele, Nsimba, Warsame, & Tomson, 1998) few
studies were found that attempted to quantify actual
drug use. Two studies assessed self-reported drug use,
combined with blood levels of antimalarials (Kenyan
Medical Research Institute, 1995; Verhoef et al., 1999).
Delivery of drugs by providers—what are they doing?
Most treatment-seeking studies examine the behaviors
of mothers or care givers in terms of ‘‘appropriate’’
management of malaria. However, the quality of health-
care services needs to be examined as well. In spite of
 ARTICLE IN PRESS
H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523 511

Table 7
Drug use

Pharmaceuticals & Antipyretics/analgesics as first- Inappropriate dosage/ Poor provider

herbs line treatment for malaria timing of intake practice

East Africa Hall, 2000; Massele Adome et al., 1998; Baume,
et al., 1998; 1998; Dondi et al., 1998;
Molyneux et al., Douglass, 1998; Geissler et al.,
1999; Oketch- 1998; Jenkins, 1998; Klaver,
Rabah et al., 1998; 1993; Marsh & Mutemi, 1997;
Ongore & Nyabola, Molyneux et al., 2000; Mulemi,
1996; Snow et al., 1998; Reynolds-Whyte &
1998. Birungi, 2000; Shafritz &
Helitzer-Allen, 1996; Tarimo
et al., 2000.
West Africa Sesay & Adongo & Hudelson, 1995;
Wijeyaratne, 1994; Agyepong, 1995; Douglass,
Thera et al., 2000. 1998; Jenkins, 1998; Watling,
1995.
Southern Africa Baume & Macwan’gi, 1998;
Baume et al., 2000; Douglass,
1998; Jenkins, 1998; Slutsker
et al., 1994.
Baume, 1998;
Dondi et al., 1998;
Floyd, 1996; Gilson
et al., 1994.
Krause et al., 1998; Agyepong, 1995;
Krause & Sauerborn, Douglass, 1998;
2000; Osei & Commey, Standing, 1996.
1994; Thera et al., 2000.
Baume et al., 2000; Baume &
Slutsker et al., 1994. Macwan’gi, 1998;
Baume et al., 2000;
Franco, Daminsoni,
& Francisco, 1996;
Franco et al., 1997;
Standing, 1996.

repeated calls for rational drug use of antimalarials, little
emphasis has been given to examining how providers
prescribe antimalarials. While provider behavior was
rarely the main focus in the reviewed studies, many of
the studies reported either anecdotal or observed poor
practice at both public and private health facilities (see
Table 6 for references). These included: lack of counsel-
ing, poor diagnosis, rude treatment of patients and
caregivers, as well as over prescription of drugs,
incorrect dosage and poor explanation of drug. Delays
in initiation of treatment at health-care facilities and
delays in diagnosis by hospital laboratories were also
noted in studies examining malaria-related deaths
(Durrheim, Frieremans, Kruger, Mabuza, & de Bruyn,
1999; Sodeman et al., 1997).
Data from the qualitative component of a rapid
assessment for district-based malaria prevention during
pregnancy (Williams & Mungai, 1999) indicated little
consistency among health-care workers in what was
prescribed for pregnant women experiencing malaria.
Not only were there differences among health-care
workers in the same center, differences also existed
across centers. Actual practice differed markedly from
what was supposed to be practiced as per national
treatment guidelines.
There is a growing recognition that even when formal
providers have correct knowledge about drug dosages
and therapeutic management, knowledge does not
predict behavior (Brugha & Zwi, 1998; Ofori-Adjei &
Arhinful, 1996). In a study from Ghana examining the
effect of training on the clinical management of malaria
by medical assistants (Ofori-Adjei & Arhinful, 1996),
findings showed that gains in knowledge following
training deteriorated within 1 year. Common practices
like polypharmacy, high use of injectables and poor
recording were identified. These practices were found to
be rooted in a sociocultural base—that of responding to
the social expectations of the community, which
demanded injectable medications and wanted prompt
treatment. Prescriptive practices were driven more by
these community expectations of how a health-care
worker should perform, than by the knowledge gained
in the in-service training.
Inappropriate prescribing practices also extended to
the private sector. Informal drug sellers generally lacked
pharmaceutical or health training of any sort, yet
dispensing of inappropriate dosages and offering advice
was commonly practiced by these vendors (Djimde et al.,
1998; Kofoed, Dias, Lopes, & Rombo, 1998; Krause
et al., 1998; Massele et al., 1998; Mwenesi, 1994; Oketch-
Rabah et al., 1998; Ongore & Nyabola, 1996). Drugs
that were sold did not necessarily correspond to national
malaria treatment policies (Feller-Dansokho, Diop, &
Badiane, 1995). Even when ‘sanctioned’ providers
offered correct dosing regimens and used drugs recom-
mended by national policies, consumers opted to buy
non-recommended treatments for malaria and reported
giving sub-optimal doses when using recommended
 ARTICLE IN PRESS
512 H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
anti-malarials (Djimde et al., 1998). Shopkeeper training
in proper dispensing of anti-malarials appears to hold
promise as an intervention addressing the urgent need
for better dispensing practices (Marsh et al., 1999; Van
der Geest, 1999). As well, some novel approaches in
malaria education programs are beginning to target
school children as agents of change for the community
(Brooker et al., 2000; Bundy, Lwin, Osika, McLaughlin,
& Panneborg, 2000; Geissler et al., 1998). There was
little mention of drug regulation or enforcement of laws
pertaining to sales of supposedly regulated prescription
drugs (Alilio et al., 1997; Geissler et al., 1998; Oketch-
Rabah et al., 1998; Ongore & Nyabola, 1998). In
addition, findings from a study of illness episodes among
primary school children in Western Kenya indicated
that children purchased drugs from shops near their
schools, where young children served as the ‘‘shop-
keepers’’ (Geissler et al., 1998; Maende & Prince, 1998).
Involvement of social scientists in the social science
research
We were interested in knowing how much of the
research on aspects of malaria control related to human
behavior included contributions by a trained social
scientist. To give a rough estimation, the papers were
coded as to whether the authorship included a trained
social scientist (identified by degree, institutional affilia-
tion or personal contact). If the status of the author/s
could not be determined, it was coded as unknown. Out
of these papers, we could only identify a social scientist
in 37 of the 87 of the research papers (43%). However,
social scientists were included as authors or contributors
to 20/35 of the technical papers (64.5%) and 13/15
(86.7%) of the unpublished papers. Of all the published
papers (research and other categories, n ¼ 116), social
scientists were the sole or primary author in 29% ðn ¼
34Þ of the documents.
Discussion of results
Have Gaps in Knowledge & Previous Calls to Action
Been Addressed?
The results of the current review suggest that, since the
McCombie (1996) review, we have amassed increasing
quantities of descriptive data on treatment-seeking
behavior. These data, to a large extent, echo the findings
of the McCombie review. That is, choice of treatment is
affected by a number of factors, multiple resorts to care
are often used, and the use of modern medicines in some
form is usually high. We do have some additional
understanding of the different treatments people employ
based on how they differentiate uncomplicated and
severe malaria and there is more information about how
provider behaviors’ impact treatment-seeking behaviors
(Durrheim, Frieremans, Kruger, Mabuza, & de Bruyn,
1999). However, to a large extent, the gaps identified by
McCombie (1996), and the methodological issues raised,
remain unaddressed.
Quantification of drug intake
Quantification of drug intake continues to be ignored.
With one or two notable recent exceptions (Massele
et al., 1997; Oketch-Rabah et al., 1998), there are still
limited data on actual drug intake and the reasoning
that drives behaviors surrounding the use of anti-
malarials (Hausmann-Muela & Muela, 1998; Molyneux
et al., 2002). A limitation of the existing data is that it is
based mostly on self-report obtained through question-
naire surveys. Self-report data can be biased with recall
difficulties, an inability of caregivers to differentiate
drugs, as well as confusion about dosing when giving
multiple drugs. Not only do we not fully understand
drug use from the consumer or patient perspective, we
also continue to operate on assumptions that providers,
given the right information, will practice rational drug
use based on clinical or scientific rationality—this
assumption needs to be tested (Trostle, 1996). A recent
informal consultation on the use of antimalarial drugs
by WHO suggests that operational research is needed to
determine ways of improving prescribing practices
involving drug vendors and other informal sector
providers (World Health Organization, 2001). Expand-
ing the argument further, we need to examine carefully
what can realistically be considered rational antimalarial
drug use, given the extremes of poverty facing patients,
consumers, and even Ministries of Health throughout
sub-Saharan Africa.
Recognition of uncomplicated and severe malaria
In regard to understanding how people differentiate
between uncomplicated and severe malaria, we now
know that in many places people are able to distinguish
between uncomplicated and severe disease. The progres-
sion from mild to severe disease is of major public health
significance, but clinicians and researchers from all
public health disciplines have been challenged by their
limited understanding of why some cases proceed to
severe disease and others do not. Obviously, biomedical
and epidemiology factors, such as levels of transmission
and degree of parasitemia, levels of acquired immunity
and how that immunity is affected by other factors such
as concurrent disease, malnutrition, etc.,5 are critical to
this process, but it is also influenced by choices made
regarding type and timing of treatment. An implication
is often made that, by delaying biomedical treatment,
5
Discussion of the numerous physiological factors that affect
progression of disease is beyond the scope of this paper.
 ARTICLE IN PRESS
H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
severe disease may be the fault of the mother or
caregiver. However, the extent to which caregiver
recognition, early treatment, use of herbal versus
western medicines, etc., contributes has still not been
carefully studied to date. Some of the results from this
review suggest that use of herbal and traditional
medicines does not unduly delay the seeking of
biomedical care (Alilio & Tembele, 1994; Baume et al.,
2000; Baume & Macwan’gi, 1998; Heggenhougen et al.,
2003; Jenkins, 1998). On the other hand, we still have a
limited understanding of what happens in severe disease
at the household level. Studies of drug intake and severe
disease are prime examples of areas in malaria control in
which the joint efforts of social scientists, epidemiolo-
gists and clinicians are needed. Scientists from the
various disciplines should be working together in order
to identify possible avenues for intervention. Social
science research alone cannot provide the answer
to these questions, but the contextual information
that it offers can greatly enhance our understanding of
the human processes that affect the progression of
disease.
Terminology
Terminology is still vague and we have a limited
understanding as to what is included in definitions of
home versus self-treatment (an exception is Geissler
et al., 1998), or what constitutes ‘‘rational drug use.’’
Furthermore, what is meant by ‘‘prompt treatment’’ is
not usually defined. These problems with definition not
only lessen our ability to interpret research findings but
also make cross-study comparisons extremely difficult.
Methodological rigor
As well as concerns with terminology, the McCombie
review in 1996 (and more recently in 2002) also strongly
recommended that there needed to be improvements in
methodological rigor; yet this area remains problematic.
There were limited descriptions of methods, confusion
with terms relating to methods applied, lack of attention
to ethical review, and few details of analysis, other than
mentioning which software package was used. In
research papers, results were woven into discussion of
results and recommendations. The lack of information
presented makes it exceedingly difficult to judge the
rigor that might have been applied to the study and
contributes to the difficulties encountered in any cross-
comparison of studies. There is also concern that few
studies used more than one method of data collection.
Triangulation was rarely used, except in studies that
were completed by trained anthropologists or other
social scientists.
In addition to greater rigor, to provide the type of
contextual information needed to tackle, for example,
the issues of severe malaria and actual drug intake, there
is a need for a change in methodological approaches.
513
Knowledge, Attitudes and Practices (KAP) surveys and
rapid assessments provide data on what people say they
do, which may vary considerably from actual behavior.
In order to collect the type of data that will provide us
with a better understanding of actual behaviors and the
factors affecting behaviors, longer periods of ethno-
graphic fieldwork are essential. This type of methodol-
ogy is usually only seen during doctoral level fieldwork,
but such fieldwork needs to be central to the develop-
ment of multi-disciplinary operational research.
How have we moved on?
At the time of the McCombie (1996) review, much of
the social science input to malaria control was largely
focused on answering the question of why local people
did not adhere to suggested control measures or
biomedical treatments. A commonly held view in public
health was that people’s knowledge was inadequate;
thus, people acted in ways contrary to what was
expected from the biomedical world. KAP surveys were
commonly employed to contrast what was known or
understood locally with what should be known in order
to have effective malaria control (Barrett, 1997; Man-
derson, 1998; Sommerfeld, 1998). Not surprisingly, the
findings of many of these surveys indicated that knowl-
edge by itself and/or attitudes did not necessarily predict
behaviors. While KAP surveys have provided much
useful information on describing reported treatment-
seeking behaviors, they were not sufficient to understand
the factors influencing those behaviors (Alilio et al.,
1998; Biritwum & Welbeck, 2000; Djimde et al., 1998;
Macheso et al., 1994; Mnyika et al., 1998; Schultz et al.,
1994a, b; Slutsker et al., 1994; Van Geldermalsen &
Munochiveyi, 1995).
Changing our approach
Since McCombie (1996), more attention has been
focused on addressing the issue of why people do what
they do and methods such as rapid ethnographic
assessment (REA) have become popular tools in applied
research.6 However, much of research reported to be
using REA, in fact falls short of the required standards
for this approach. For example, fieldwork completed in
only 2 or 3 weeks rather than 3 months and the use of
field staff who do not speak the local language or have
long-term familiarity of the area (Jenkins, 1998). Even
when applied correctly, one of the limitations of these
6
In this paper, rapid assessment refers to collection of data
over 2–3 weeks duration. We recognize that, in some situations,
rapid assessment has been defined as a period of up to 3
months, such as research commissioned by WHO/TDR
(Adongo & Hudelson, 1995); however, this appears to rarely
be the case.
 ARTICLE IN PRESS
514 H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
methods is that they can also miss sensitive and crucial
information and do not provide an in-depth under-
standing of the larger context in which behaviors occur
(Jenkins, 1996; Lambert, 1998; Manderson, 1998;
Manderson, Agyepong, Aryee, & Dzikunu, 1996;
Sommerfeld, 1998). On an encouraging note, results
from rapid ethnographic studies and recent, innovative
(and longer term) research focusing on understanding
behavioral patterns in the much broader context of
people’s everyday lives (Adongo & Hudelson, 1995;
Hausmann-Muela et al., 1998; Heggenhougen et al.,
2003; Jenkins, 1998; Kidane & Morrow, 2000; Mwenesi,
1994; Nyamongo, 1999b; Nyamongo, 2002; Reynolds-
Whyte & Birungi, 2000) have started to convince
researchers and implementers that the blocks to prompt
and effective treatment cannot simply be ascribed to a
lack of knowledge among community members. Social,
political and economic factors, such as poverty, access to
health facilities and treatment and the quality of services
received often play a much more prominent role as
determinates of treatment-seeking behavior. Most re-
cently, the results from in-depth ethnographic research
(Hausmann-Muela et al., 1998; Molyneux et al., 1999)
have highlighted the importance of gender and social or
economic position of the individual (or responsible care
giver) in the household on the decision-making processes
underpinning treatment-seeking behavior.
The primacy of context in understanding treatment-
seeking behaviors
There is now a greater awareness of the complexity of
treatment-seeking behaviors, including the recognition
that people are active decision-makers in their own care
and usually employ multiple sources of care. Decisions
about treatment seeking are not static but are dynamic
and iterative (Gilson et al., 1994; Oberlander &
Elverdan, 2000). ‘‘Rationale’’ drug use, as commonly
used in the global malaria community, implies a single
rationality based on biomedical standards. This con-
trasts a parallel rationality, which is framed by the need
to seek treatment in situations of limited resources
(drugs, access to health care, financial and educational).
This parallel rationality reflects not only the current
constraints in seeking biomedical treatment, but also a
familiarity and comfort with the local environment and
years of experience with treatment decisions based on a
system of trial and error that is passed on generation to
generation (Haaland, 1998). Diagnosing and treatment
decisions are not the purview of an elite class of health
professionals but, rather, represent shared experience
and knowledge well embedded in a local culture
(Geissler et al., 1998). In this context, treatment
decisions that arise may not necessarily be linear or
logical in biomedical terms, but systematic choices are
made nonetheless.
When people become ill, their primary goal is to find
prompt and effective treatment within the constraints
imposed by their environment. This goal is in agreement
with one of WHO’s central tenets of malaria control
(i.e., the need for prompt and effective treatment) but, in
the environment found in most countries in sub-Saharan
Africa, the pragmatic choice for prompt and effective
treatment (especially for uncomplicated malaria) cur-
rently lies outside the formal health sector. Here the
treatments are usually prompt but not always effective
by biomedical standards. In fact, the weakness of the
public health-care system in much of sub-Saharan
African makes the use of self and home treatments
indispensable (Adome, Reynolds-Whyte, & Hardon,
1996; Geissler et al., 1998). We should hardly be
surprised that people commonly self-treat and stop
taking medications when they feel better, and that there
are delays in seeking treatment from a health facility,
since these practices are also found in developed nations
and elsewhere throughout the world (Bedell et al., 2000;
Dempsey, Dracup, & Moser, 1995; DiMatteo &
DiNicola, 1994; DiMatteo, Lepper, & Croghan, 2000;
Fortney, Rost, & Zhang, 1998; MacGregor, 1997;
Wagner, Phillips, Radford, & Hornsby, 1995; Walker,
2001). In fact, in the US alone, 125,000 people are
estimated to die each year as a result of some form of
medication non-compliance (Walker, 2001). Cost, dis-
tance to health-care facilities, poor drug-use education,
and perceptions of the care expected from health-care
facilities are just some of the factors that influence
treatment-seeking behaviors, not only in sub-Saharan
Africa, but in the ‘‘developed’’ world as well (Bedell
et al., 2000; DiMatteo & DiNicola, 1994; DiMatteo
et al., 2000; Moran & Kim, 2001). As Paul Farmer has
frequently pointed out ‘‘...those least likely to comply
are those least able to comply’’ (p. 353) as, in many
settings, degree of compliance is limited by forces
external to the individual (Farmer, 1997).
Critics of antimalarial use in sub-Saharan Africa
should be aware that focusing on the issue of
‘‘compliance’’ in relation to malaria treatment, while
ignoring the large and critical literature on the issue that
exists in western Europe and America, could be
interpreted as establishing a different standard of
practice for Africans (Manderson, 1998). We are not
condoning these practices but, rather, raising the issues
that these practices are not unique to Africa and that the
concepts of ‘‘compliance’’ and ‘‘adherence’’ are imbued
with the notion that treatment failures are patient
failures. Social scientists working in malaria control
should not, therefore, be trying to provide an answer to
that most frequently asked question ‘‘how can we get
them to......’’ but, rather, we should be pressing to find
ways to increase people’s capacity to access and
complete effective treatments. A good example of this
is the recent concentration on developing the capacity of
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H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
shopkeepers (who commonly provide many anti-malar-
ial drugs) to give advice and correct treatment for
malaria in Kenya (Marsh et al., 1999). This initiative
arose from detailed ethnographic research that showed
that the majority of anti-malarial drugs used in a coastal
Kenyan community were being provided through shops
and not through health facilities (Mwenesi, 1993). The
public health intervention ‘shopkeeper training’ is
therefore based on ethnographic work that has
been used to inform the development of a program
that addresses the common goal of increasing the
likelihood of sick children receiving prompt and
effective treatment.
While we now have a better description of the factors
that influence the search for prompt and effective
treatment, what is not well understood or measured is
the relative weight or influence of the various factors
that drive people to seek care in particular situations or
contexts (Munguti, 1998a). In order to develop effective
interventions, it is necessary not only to understand the
context in which behavior takes place but also to
examine the relative weight of the various factors
influencing actions within that context. Little attention
has been paid to the dynamic nature of both behavior
and context that vary not only within and among
countries (e.g. in some regions of Ghana, most of first-
line treatment is provided by the private sector, whereas
in other regions of the same country the private sector
barely exists), but also change over time (Agyepong,
1995). For example, in the early 1960s in Uganda, the
main source of first-line health care was the formal
health sector. Today, the situation is very different as
most first-line treatments are provided by the informal
sector. This change has little to do with changes in
knowledge or belief about disease causation among the
population, but has a lot to do with the breakdown in
the formal health sector during the Amin years
(Reynolds-Whyte & Birungi, 2000). There is, therefore,
a need to recognize that factors within the local
environment, such as conflict, natural disasters, changes
in subsistence patterns, attitudes towards local and
national government and government structures and
organizations, go beyond what effective malaria-control
programs can influence on their own and may not be
amenable to single-sector interventions.
However, it remains to be seen to what extent
recommendations that fall outside the normally sanc-
tioned approaches for public health interventions will be
accepted by other research scientists, policy makers and
implementers. For example, in Uganda, intervention
plans were developed for shopkeeper training in three
districts but political resistance necessitated limiting the
training to only shop owners and implementing it in
only one district (Reynolds-Whyte & Birungi, 2000). In
spite of appearing to challenge conventional wisdom or
usual modes of action, Van der Geest (1999) urges
515
applied anthropologists to continue using cultural
knowledge to improve public-health efforts, even if it
means practicing against standard policy.
What are the factors constraining the contributions of
social scientists in malaria control?
Social science involvement in malaria control has
increased over the past decade, but much remains to be
done. Social scientists have contributed to infectious
disease control through focusing on illness etiologies
and, more recently, through helping to describe and
understand treatment-seeking behaviors. They are also
increasingly using this information to make suggestions
on possible points for intervention (Manderson et al.,
1996; Sommerfeld, 1998). But, based on the literature
from this review very little (with a couple of notable
exceptions: Helitzer-Allen et al., 1994; Kidane &
Morrow, 2000; Marsh et al., 1999; Pagnoni, Convelbo,
Tiendrebeogo, Cousens, & Esposito, 1997; Reynolds-
Whyte & Birungi, 2000) from this body of work has
actually been used in designing or testing interventions
(Manderson, 1998). It is unclear to what extent this is
due to a failure to communicate the results of research,
to the lack of importance that is often placed on this
type of work, or to the fact that many of the
recommendations either conflict with current policy or
lie outside the sole control of malaria-control programs.
From the results of this review, and our experiences
working in malaria research and control, factors that
constrain the contributions that social scientists could be
making to malaria control include: (a) the lack of
involvement of trained social scientists in malaria
control, (b) the lack of awareness by Ministries of
Health, malaria-control programs and many non-social
science researchers of the variety of disciplines within
social science and the expertise and assistance each could
offer, (c) the lack of awareness by social scientists
themselves of the constraints faced by malaria-control
programs and the presentation of results that cannot be
easily interpreted or used by program personnel, and
finally, (d) the expectation that including a ‘social
scientist’ on a program will provide a ‘magic bullet’ to
fix all the problems (Williams et al., 2002). Contribu-
tions of trained social scientists were clearly identified in
less than half of the publications reviewed for this paper
(although we recognize that this might be a conservative
estimate). Whether the issue is that social scientists are
doing the work and not clearly identifying themselves or
their disciplinary background or whether they truly have
not been involved in conducting the behavioral research,
people from other disciplines appear to be taking the
lead in behavioral research related to malaria. One of
the consequences of having non-social scientists conduct
social science research is that those responsible for the
research often have limited or no training in social
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516 H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
science theory and methodology and, as mentioned
earlier, this can lead to poor-quality research. In
addition, attention to the complex array of factors that
influence the promotion, acceptability, and sustainabil-
ity of malaria-control activities in its widest sense
requires a level of methodological training that most
non-social scientists lack. This, in turn, may help to
perpetuate a perception that social science has little to
offer malaria control.
On the other hand, the reality for most national
malaria-control programs is that there are insufficient
funds to support a full-time social scientist or even to
occasionally commission a short-term social science
consultant. Moreover, programme personnel may not
recognize the specific expertise that social scientists can
offer to a malaria-control programme. Malaria-control
personnel may have a difficult time identifying social
science issues or research questions pertinent to their
particular program and are often unclear if specific
expertise is required or if a short course in qualitative
data collection and analysis is sufficient qualification for
a task or project.
Social scientists should work jointly at the country
level with malaria-control programs to increase qualita-
tive skills (particularly in relationship to qualitative data
analysis) for non-social scientists, and to develop an
understanding of issues or research questions that can be
addressed by non-social scientists who have received
some level of beginning training in social science versus
situations in which the expertise of fully trained social
scientists is needed. In addition, social scientists involved
in malaria research and control should be aware of
programmatic concerns, for which they could offer
assistance. They should work with program personnel,
not only to help identify their needs, but also to
present research results in such a way that the find-
ings are understandable, practical, and useful to
malaria-control programs, public health personnel and
communities.
Effective use of social science?
From the results of this review, it appears that, to
increase the effective use of social science in malaria
control, social scientists should focus on four principal
issues: (a) a new orientation for field research (and
increased rigor in methods), (b) addressing gaps in
research knowledge, (c) strengthening the relationship
between research, policy and practice, and (d) capacity
strengthening and advocacy.
New orientation for fieldwork
The primacy of context in understanding behaviors
has been described and we now need to move beyond
research that focuses on documenting behaviors (at
individual, community, health facility or governmental
level) into examining the larger contexts in which those
behaviors operate, investigating the relative ‘weights’ of
factors influencing behavior within specific contexts
(Heggenhougen et al., 2003). This type of research
requires a different orientation than has been customary
in the social science components of many malaria
research projects, which have traditionally allotted
minimal amounts of time for fieldwork, with the
expectation that tremendous amounts of useful data
could be gathered during that time (Heggenhougen et al.,
2003). Answering the more compelling questions con-
fronting malaria-control programmes now (such as how
changes in subsistence patterns impact on power
relationships and the ability to seek care or decision
making and treatment seeking within the household)
involves proper ethnographic fieldwork. Such fieldwork
requires significantly more than a brief 2-week field trip.
Moreover, rather than being an ‘‘added–on’’ component
after a study has been designed and funded, social
scientists should be contributing to the conceptualiza-
tion and design of the study from the beginning,
thus assuring that adequate time and funding are
requested.
New areas for research
As we have corroborated McCombie’s findings (1996)
and increased our understanding about treatment-
seeking behaviors, we have also recognized additional
areas that impact on the home management of malaria
and need research attention. For example, an area that
needs further exploration is in examining the array of
factors that influence provider behaviors in regard to
dispensing drugs. Much of the recent attention on
community and home management focuses on the
mother/care giver in terms of drug administration.7
While this is a critical component for understanding
drug use, it will not provide other essential informa-
tion—that of the provider’s behavior. Other areas in
malaria ‘home management’ that have received limited
research attention from social scientists include: (a)
quantifying drug intake (both at the home and with
prescriptions given from a health-care facility); (b)
investigating treatment-seeking behaviors in areas of
low endemicity and epidemic prone areas; (c) identifying
socially vulnerable populations, such as pregnant
7
There is a vast body of literature on drug-utilization
behaviors that is beyond the scope of this paper. Much of this
literature has an application wider than malaria control. For
readers interested in these issues, we refer them to a special issue
of Social Science and Medicine 42(8), 1996, which focuses on
the ‘‘Inappropriate Distribution of Medicines by Professionals
in Developing Countries,’’ and the Proceedings of the Workshop
on People and Medicines in East Africa, Mbale, Uganda,
November 16–20, 1998, published by the Danish Bilharziasis
Laboratory, 2000.
 ARTICLE IN PRESS
H.A. Williams, C.O.H. Jones / Social Science & Medicine 59 (2004) 501–523
adolescent girls who are often a difficult population to
reach, have low social status and higher rates of
illiteracy (D’Alessandro, 1999), or groups that are
barred from accessing malaria control activities due to
political constraints; (d) expanding on what is known
about social determinants of treatment-seeking beha-
viors during pregnancy, including willingness and ability
to engage in preventive and treatment activities and how
this is affected by household structure and concepts of
vulnerability and protection for mother and fetus; and
(e) examining treatment-seeking behaviors during com-
plex emergencies.
Research, policy & practice
In addition to developing a new orientation in
fieldwork and undertaking research in new areas, social
scientists working in public health (particularly applied
anthropologists) are in an ideal position to play a major
role in getting research results applied to policy and
policy into practice. Researchers need to place their
findings within the broader context, which requires an
understanding of how knowledge is used locally (Brugha
& Zwi, 1998). For this understanding to occur, social
scientists need to be committed to examining the
complex set of inter-relationships among stakeholders
that impact on the wider political and policy issues
surrounding malaria control in general. It is then
incumbent upon social scientists to interpret these
results to implementers and policy makers in a language
that is usable in programmatic ways (D’Alessandro,
1999; Robb, 1999). Shretta, Omumbo, Rapuoda, and
Snow (2000) recently attempted to do this with an
analysis of the recent antimalarial drug policy change in
Kenya. In association with two evaluations of combina-
tion antimalarial therapy (Interdisciplinary Monitoring
Programme for Antimalarial Combination Therapy in
Tanzania (IMPACT-TZ) and the South East Africa
Combination Antimalarial Therapy Evaluation (SEA-
CAT), one of the authors of this review (Williams) is
currently engaged in conducting multi-disciplinary case
studies of changes in national malaria-treatment guide-
lines (Durreheim, et al., in press; Williams & Trupin,
2002). This work should provide information about the
process of decision-making as it relates to national
policy changes and should help to inform the process for
subsequent policy changes. Moreover, attention needs to
be placed on what happens once guidelines are
changed—how do providers actually implement treat-
ment guidelines in practice? An important area of social
science inquiry that has not been adequately developed
is examining the factors influencing the development
and implementation of national malaria-treatment
guidelines from the provider perspective, including
the consequences of improper application of those
guidelines.
517
Capacity strengthening & advocacy
One of the clearest findings from this review was the
scarcity of social scientists from endemic countries
involved in malaria research and control. Concerns over
this situation have recently been expressed by MIM,
WHO/TDR and other international bodies involved in
malaria research and control. We need to be developing
training programs and joint practice models with other
disciplines to tackle the pressing issues facing malaria-
control programs now and for the future. These issues
relate not just to basic training but, perhaps more
importantly, to career development and recognition at
the Ministry level. Social scientists should also be
advocating for increased social science presence on
funding review boards (such as proposal reviews
through TDR/WHO or private funders, such as the
Wellcome Trust), as well as having a stronger presence
on editorial review panels for journals critical to malaria
control.
The voices of social scientists are starting to be heard.
Considerable progress has been made over the past few
years (Heggenhougen et al., 2003) but more is needed.
We are advocating for social science practice in malaria
control that reflects a realistic appraisal of the complex-
ities that govern human behavior and include critical
appraisal and practical action. However, to do so, we
need to be willing to challenge assumptions, ‘‘get our
hands dirty,’’ and advocate for the use of different
research methods that we feel can provide better data to
help answer the challenges of malaria control. The
‘‘Partnership for Social Sciences in Malaria Control’’
(see footnote 1) is a recently formed international
alliance that aims to assist in developing communication
and collaboration among social scientists and between
social scientists, other public health professionals and
malaria control programme personnel to ensure that the
contributions social scientists offer to malaria control
are appropriate, timely, and ultimately useful in meeting
the global goals of reducing the burden of malaria.
Acknowledgements
The authors wish to thank the core members of the
Partnership for Social Sciences in Malaria Control for
their continued support and insightful comments during
this review, Ms. Onnalee Henneberry, reference librarian
at the Centers for Disease Control and Prevention
(CDC), and the various donors that made this colla-
borative project a reality: CDC, The CHANGE Project,
US Agency for International Development (USAID)/
African Bureau, and the Department for International
Development (DFID), through the DFID Malaria
Knowledge Programme at London School of Hygiene
and Tropical Medicine (LSHTM). We would also like to
thank Ms. Paulyne Ngalame for her assistance and
 ARTICLE IN PRESS
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