Social and cultural aspects of 'malaria' and its control in central Côte d'Ivoire

Malaria is a devastating vector-borne disease that primarily occurs in the developing world. Over two billion people are at risk of malaria and, in 2001, an estimated 1.2 million people died from the disease [1]. There were an estimated 515 million clinical episodes due to an infection with Plasmodium falciparum in 2002 [2]. African governments spend more than 1% of their gross domestic product (GDP) to combat malaria and the estimated annual direct and indirect costs attributable to malaria in sub-Saharan Africa are in excess of US$12 billion [3].

In Côte d'Ivoire, malaria remains of the most pressing public health issues. Due to the climatic and geographic conditions, the disease is endemic in all parts of the country and transmission occurs all year round. Malaria accounts for more than 40% of in-patient and out-patient attendances in health care delivery structures and an estimated 20% of in-patient mortality [4]. Recent studies carried out in central Côte d'Ivoire showed that high malaria transmission rates in the face of limited personal protection result in a significant number of work days lost among rural farmers and have a negative impact on livelihood and economic revenues [5, 6]. Studies also identified a need for improving malaria control measures by taking into account local beliefs and practices. This issue underscores the growing body of literature on social and cultural aspects of malaria [7‐10]. Indeed, previous work has shown the relevance of people's illness classification, the recognition of symptoms, as well as explanation of causes and help-seeking behaviour for improvements in malaria control. For example, a deeper understanding of illness experiences at a household level can enhance appropriate home management of malaria and more effective use of insecticide-treated nets (ITNs) [11].

It is also important to note that people's experience and management of malaria, for example the use of ITNs, is influenced by socioeconomic factors [12]. Malaria is both a main cause and consequence of poverty [13‐17]. People suffering from frequent episodes of clinical malaria are economically less productive, and poor people are more likely to fall ill from malaria. Moreover a study in western Côte d'Ivoire has shown that the poorest people are least likely to benefit from health interventions and adequate service delivery [18].

Here, results from a household-based survey, carried out in two rural communities living in central Côte d'Ivoire, are reported. The study complements recent investigations in the same region, focusing on agricultural, biomedical and entomological issues of malaria [5, 6, 19]. The following four questions governed the research. First, does the disease 'malaria' correspond to an illness recognized by the villagers? Second, are villagers aware of a link between malaria-related illness and mosquitoes? Third, what are the main determinants of villagers' help-seeking? Fourth and finally, do villagers know and use methods to prevent malaria?

The present study aimed to enrich an existing database on clinical and entomological findings of malaria in two rural communities in central Côte d'Ivoire [5, 6, 19] with people's knowledge, attitudes, practices and beliefs and the socioeconomic status of a random sample of household heads. It is important to note that studies in sub-Saharan Africa have shown a variety of taxonomies relating to 'malaria'. As found in the present study, the local term djèkouadjo is used to refer to one or several symptoms which, taken together, approximate a clinical diagnosis of malaria. In this case, malaria was not seen as a new illness introduced by the formal health system as described by Adongo and colleagues [27]. Usually there is an adequate knowledge of symptoms caused by malaria in endemic areas, and people are well aware of the clinical manifestations of the disease [28].

The knowledge of symptoms and causes of malaria in the current study area was found to be sound. For example, white palms (symptom for anaemia), and yellow eyes and yellow urine (symptoms for jaundice) were recognized as symptoms of malaria by household heads and key informants. Similar findings have been reported before from Ghana [27‐29], Mali [30] and Uganda [31].

However, the respondents in this study also believed in 'natural' (e.g. sun, sweet and fatty diet) and 'mystic' (e.g. God and ancestors) causes for malaria. These findings are similar to observations made elsewhere [10, 27, 32‐35]. Belief in witchcraft was not necessarily seen as opposed to belief in natural cause. Both beliefs complemented each other [36]. This is illustrated by the treatment of complicated malaria which, when not cured rapidly with the first-line treatment, was attributed to supernatural causes.

Several studies in sub-Saharan Africa have demonstrated such a dichotomy in knowledge between folk and biomedical interpretations of malaria in terms of causal processes [10, 11, 37‐39]. A possible explanation for multiple aetiologies is that people receive information on malaria, mosquitoes and bed net usage, but have not yet been able to link this biomedical information with their cultural knowledge. Although malaria education and bed net promotion may not change community knowledge rapidly [27], it was found that interviewees who attained a higher educational level clearly associated malaria transmission with mosquitoes. Education campaigns thus influenced local knowledge. Interviewees in Zatta had a somewhat better knowledge on how malaria is transmitted, when compared to Adibrobo, possibly due to the community-awareness campaign for the promotion of ITNs, which had been carried out prior to the cross-sectional survey reported here.

Treatment-seeking did neither differ between ethnic and religious groups, nor by education level. The first step of treatment-seeking was typically based on self-medication, and often included the combined use of traditional medicine (herbal tea, bathing or enema) and modern drugs (pharmaceutics, including analgesics and antimalarials). Seeking professional medical advice and treatment was delayed until it became clear that the illness could not be adequately managed at home. Almost two-third of the interviewees seemed to be "traditionalist", i.e. using traditional medicine, rather than "modernist" (one-third). Similar findings have recently been reported for north-eastern Nigeria [40]. The preference towards folk treatment rather than formal health services might be explained by the fact that health care sought by traditional healers is usually quite inexpensive [10]. In addition, traditional treatment is often provided through more flexible services and pricing systems, which are readily adapted to the clients' ability to pay [41]. As observed in different African settings, the use of preventive methods is dependent on people's socioeconomic status, which was proxied by using a household asset-based index [18, 23, 24]. Previous work has revealed that the poorest people are the least likely to benefit from health interventions and adequate service delivery as shown in studies carried out in Tanzania [15] and Côte d'Ivoire [18].

Surprisingly, there was no correlation between the perceived causes and the choice of treatment. Even when interviewees believed in the established biomedical aetiology of malaria, they used traditional medicine, sometimes unaccompanied by modern medicine. At the same time interviewees who thought djèkouadjo to be caused exclusively by the sun, or sorcerers, also used modern treatment. Sick people generally used both treatment types during one episode of malaria regardless of the perceived causes. This flexibility may be due to their intimacy with the disease and their confidence in their ability to self-medicate at little expenses. Malaria and the management of the disease appear to be part of people's everyday life. This may explain why the awareness of various modern and traditional treatments for malaria was elevated, similar to observations made elsewhere [35]. It follows that the use of multiple modalities of care-seeking behaviour was a common feature in both villages, which correlates with findings of previous studies in other African settings [10, 28, 42, 43].

An important factor governing malaria mortality and morbidity in endemic settings is the lack or insufficient attention given to preventive measures with proven efficacy [7]. This might be due to prevailing folk perceptions of the disease and perceived low efficacies of preventive tools or inaccessibility due to high costs or other reasons. In this study, among interviewees who related the cause of malaria to mosquitoes, only few protected their houses with wire screening on doors and windows. Bed nets were used only by a small fraction of the population. Bed net usage was limited due to perceived high costs and discomfort when sleeping under a net. Subsidizing of bed nets is a common request by rural communities [44]. In the 1990s, low coverage of bed nets and other personal protective measures at the household level was common [29, 45‐48]. Often, bed nets are regarded as a tool primarily to combat the nuisance of mosquitoes [49], and are, therefore, used by adults rather than by children [27]. In this study, the use of ITNs and the relatively more expensive insecticide spray (when used continuously) was linearly and significantly linked to socioeconomic status, hence in contrast to recent findings reported from Gabon [12]. The difference between the poorest and the least poor concerning bed net usage has been reported before [16‐18]. A common explanation is that poorer populations have less access to effective means of prevention and treatment because they have lower purchasing power and flexibility [16‐18, 44]. The low fraction of households using bed nets calls for continued health education, and improving access to this preventive tool at no or low costs, so that the poorest population segments can purchase and protect themselves with bed nets.

Findings reported here from a rural part in central Côte d'Ivoire suggest that even people with sound knowledge of causes and symptoms of malaria continue to use traditional treatments, while those with folk beliefs also rely on modern treatment. Although socioeconomic status and education attainment are important drivers of the epidemiology and control of malaria, the study revealed that more complex mechanisms are waxing and waning the decision-making process of people who live in malaria-endemic countries.

A better understanding of the social dynamics regulating access to household resources might help to explain differences in decision-making for malaria prevention and treatment. Obrist and colleagues [50] have pointed out that knowledge of malaria alone is not enough. Access to different resources such as financial or social capital significantly influences health-seeking practices. It is concluded that equitable access to resources at household, community and health system levels are essential. Innovative and community-based approaches are warranted that match health care services with poor people's needs and resources. At the same time, the health care delivery system needs to align its services accordingly, for instance, by making vouchers available for low socioeconomic status groups or by offering free or subsidized prevention and treatment services.