Category Archives: Social Factors

Questions Raised on Indigenous Medicine in Ghana

Azusa Sato raises an important question in a research article on health service choices by Ghanaians – why do individuals turn to traditional medicine only as a second recourse?

In general, Sato’s review of literature on health care choices cite the maxim that indigenous medicine is easily accessible, affordable, available and acceptable. The irony in this study is that indigenous medicine is a more popular second choice than first.  Sato shows that “The most common acute complaint was ‘fever, headache and hot body’ (334/460, or 72.6%),” which people may interpret as possible malaria in a local context.  Interestingly, only 45 respondents used indigenous medicines first whether they sought acute care from outside or found/made it at home.

When a second or additional recourse was added, the number using indigenous medicine rose to 103 people for acute illnesses. Respondents who chose indigenous medicine at some point overwhelmingly had a favorable opinion (77%) of this form of medicine.

dscn3872sm.jpgGhana has a dynamic health system that is attempting to bring more people into the orthodox care orbit.  The national health insurance scheme to which over 60-70% of people subscribe, make care seeking at orthodox health facility (either public or private) more attractive and affordable.  Ghana is also working on expanding primary health care through establishing community health compounds – a local building donated by the community and staffed by government trained community health officers. Although these measures are a ways from attaining universality, they may in part explain a tendency to choosing orthodox care first.

Another interesting irony of Ghana’s pharmacy system is the the health authorities have actually approved some indigenous malaria medicines (see picture). These are sold alongside Coartem and artesunate-amodiquine in licensed shops and pharmacies.

Pharmacy stocks and consumer care seeking choices support Sato’s recommendations for seeking more evidence to develop an integrated system of care in Ghana.  With global health funding in seeming decline, any effort to find additional efficacious local resources to expand malaria treatment are most welcome.

Lesson on World AIDS Day – don’t forget human behavior

This morning’s Washington Post featured a story concerning another setback in HIV/AIDS prevention research. The article stated that, “The abrupt closure last week of one part of a complicated study called VOICE marked the third time in eight months that anti­retroviral drugs did not prevent infection in those assigned to use them.” Ironically, the interventions had proven effective in smaller scale trials.  What happened during scale up?

logo-wad.jpgThe two research interventions focused on either having women insert a vaginal gel daily or people taking pills. One explanation offered for the failure the second time around was as follows:

The answers may lie in subtle differences between the groups being studied and the designs of the experiments. For example, the volunteers in Partners PrEP (pre-exposure prophylaxis study) were long-term couples in which one person was infected and the other not. It’s possible they may have been more motivated to take the pills every day. In CAPRISA (the South African PrEP study), the women inserted the vaginal gel before and after sexual intercourse rather than every day — a targeted approach that may have helped them stick to the program.

Such differences in the social and behavioral context of research make all the difference – basic research on drug effectiveness cannot be divorced from the people who receive the medications. The Post contacted experts who offered the following opinions about why there were problems.

  • The daily regimen just probably was not acceptable; if the gel were being used according to instructions some differences between groups should have emerged.
  • Other studies of vaginal microb­icides and pre-exposure prophylaxis have shown that few people use prevention tools as regularly as they say they do, but the more “adherent” people are, the more protection they get.
  • What we have to face up to is that everything in HIV prevention is based in human behavior.

The article concluded by saying, “What seems clear is that this strategy, once viewed as the easiest and most certain, is going to require a lot of fine-tuning even if it works.”

With malaria interventions, similar lessons apply. ACTs do not protect is people do not adhere to the 3-day regimen. LLINs do not protect if people use them to cover their vegetable gardens. IPTp is not effective unless pregnant women attend antenatal care regularly. Rapid diagnostic tests are wasted if health workers do not believe in their efficacy.

Often we wait until problems of non- or inappropriate utilization of health interventions occur before we start looking at social and behavioral factors. The Post quoted one epidemiologist who said, “People are upset. It’s a big head-scratcher as to why it didn’t work.” Researchers should be embarrassed to admit such, as this means they did not do adequate formative research in advance to understand the social and cultural context into which they were introducing their innovations.

Certainly similar mistakes have been made in malaria research and intervention, but now with international donor funding severely threatened, we cannot waste resources pushing interventions that are not socially and culturally acceptable.

What’s in a Lifestyle?

The coverage has started of the big UN focus on non-communicable diseases (NCDs).  BBC leads with a headline that states, “WHO targets non-communicable ‘lifestyle’ diseases.” Lifestyle is a facile term that may lead one to think that people have certain diseases because of choices in their lifestyle.

Is poverty a lifestyle? We doubt whether people chose poverty.

NCDs, like almost all diseases, have a ‘behavioral component’ in their etiology, but we need to be careful not to blame the victim whose health related behavior may be confined by culture, poverty or a political system.  Behavior also therefore is not a simple matter of ‘lifestyle.’

So, if we are getting into the issue of behavior as a factor in the spread of disease, we need to be careful about making black and white distinctions between communicable and non-communicable.  Malaria, a communicable disease (with a vector) arises not from simple lifestyle choices to avoid sleeping under an insecticide treated – the factors influencing behavior are complex. Furthermore, communicable diseases have non-communicable consequences – witness the challenges of chronic anemia and neurological consequences of malaria.

In the push for a new theme for the decade we need to avoid compartmentalization and remember the universal goals that launched primary health care in 1978.  Our goal should not be to focus on or un-neglect a class of diseases, but to ensure all people, especially those living in poverty, have equitable access to whatever care and prevention they need.

Ask and ye shall receive – though not always a valid answer

child-interview-2-sm.jpgObinna Onwujekwe and colleagues have documented a major problems with health seeking behavior surveys – people do not always give valid responses. This is not to say that people lie, but the interview situation can be a complex social interaction in which things are not always as they seem. In Onwujekwe’s study while respondents indicated that their preferred source of care for malaria illness were public and private clinics, their main actual source of care for recent malaria episodes were the patent medicine dealers.

Perceptions of what are ideal and expected behaviors often differ from what people actually do. For example with guinea worm 75% of residents in rural southwestern Nigeria said that clinics offered the best treatment for the disease. Examination of clinic records during the same time found that only about 3% of actual sufferers attended a clinic.

When asked why, villagers complained that guinea worm could not be cured with western medicine and that treatment which included bandaging the open ulcer agnered the worm and made the disease worse. In fact a fair number of people who were treated at clinic actually attended for another reason, and the health worker just happened to notice the guinea worm ulcer.

Another issue is gender. in Onwujekwe’s survey a majority of the respondents were female. Women in health surveys have been found to give ‘don’t know’ responses more often than men. The interview is a formal social situation with a visitor to the home. Sometimes women may not feel comfortable giving opinions on behalf of their households.

The key lesson from these experiences is that while we urgently need data on whether people are actually gaining universal access to malaria treatment services, we need to take caution in how we approach interviewees and how they believe they should answer us. Interview techniques that set people at ease and find several different ays to ask the same question about treatment choices can help improve data collection. Only with valid responses, will we learn if our services are reaching people and where improvements are needed.

What are the indicators to monitor toward MDGs

There is hope among world leaders that the Millennium Development Goal of reducing malaria deaths to near zero is now likely to happen. Ray Chambers, the UN Special Envoy for Malaria is quoted as saying …

“Today, enough nets are in place to protect 75 percent of those at risk, and we will reach universal coverage by December 31, 2010, an astounding testimony to the power and efficacy of the unified global campaign. These nets have reached nearly 500 million people in the last two years alone, and their impact on saving lives is profound – current levels of intervention are saving 200,000 lives per year. We are on track to meet the Secretary-General’s goal of ending malaria deaths by 2015, and our work won’t be finished until we do.”

Having nets ‘in place’ and having nets used are two different indicators of success. ‘Nets in place’ will not achieve the MDG for malaria unless nets are used. Numerous surveys have been mentioned in our previous postings showing that even when nets are ‘in place’ in homes, they are not always used by the most vulnerable members of the household.

Another concern is that even if nets are ‘in place’ by the end of 2010, we may not achieve the MDG of near zero malaria deaths. LLINs are known to wear out after 2-3 years of normal use. Unless there are plans for net massive replacement efforts around 2013, we may see slippage in attaining and sustaining the goal.

A major weakness of past public health programming has been providing people with technologically sound and useful interventions without taking into full account the social, cultural and behavioral factors that influence acceptance and use of the interventions.  In order to continue to save lives with nets and other malaria interventions, we must strengthen the social and behavioral components of programming now and not wait until 2015 to see if we actually saved lives or not.

Malaria, Sex and Gender

Women and men have different health and disease experiences according to an article this morning in the Baltimore Sun. The article stresses that, “A rapidly growing body of research shows men and women are biologically different in ways that have nothing to do with the obvious physical features and lots to do with which diseases strike and how successfully or not the body fights them off.”

Some of the highlighted examples include …

  • Women’s bodies have been shown to generate a stronger antibody response to the H1N1 vaccine than men’s
  • Autism is four times more common in males
  • Lupus and irritable bowel syndrome predominantly afflict females

The Sun article states that like many innovative thoughts and practices, “… for the most part, the idea that males and females are very different patients hasn’t made its way into the doctor’s office.” Fortunately the Society for Women’s Health Research is trying to address these issues.

We might ask, is there evidence that malaria affects men and women differently? Such differences may be biological – sex-related; while other differences may be social – gender-related.

Among travelers, Schlagenhauf and colleagues found that, “Women are proportionately less likely to have febrile illnesses (OR, 0.15; 95% CI, 0.10-0.21) [and] vector-borne diseases, such as malaria (OR, 0.46; 95% CI, 0.41-0.51).”  Munga and Gideon learned that a greater proportion of women in rural Tanzania reported malaria episodes compared to men, while the opposite was true in urban areas. They surmise that social or gender roles may actually increase the exposure to mosquitoes in each setting.

In Yemen El-Taiar and colleagues observed that women were less likely to associate malaria with mosquitoes and that “different beliefs and roles identified between men and women need to be taken into account in health promotion messages.” In many places women have less access to formal education than men.

atiamkpat-community-2-nets-sm.jpg“Some research suggests that gender may influence the use of ITNs within households, as different roles dictate different sleeping patterns for men and women,” as Toe and colleagues summarized from the literature. Ahmed et al. in Bangladesh observed a “gender divide in knowledge and health-seeking behaviour was observed disfavouring women,” with malaria-like symptoms.

Other studies have shown that pregnant women attract more malaria-bearing mosquitoes, a biological issue in Sudan and The Gambia. Intra-household gender issues have been found to influence equitable use of bednets.

We welcome readers to contribute other examples of the gender and human biological factors that may influence malaria and its control. The key lesson is that unless we plan for both sets of influences, our tools may not be fully effective or equitably utilized in order to achieve universal coverage and mortality reduction.