Recommendation IV: Sustainable Malaria Control Requires a Community-Based Approach

Recognizing the Social and Environmental Factors That Influence Behavior

Malaria is a behavioral as well as a medical problem. Social, cultural, and economic factors must be understood and incorporated into the design and implementation of malaria control programs. A top-down approach alone will not work. Rather, a community-based strategy must be employed recognizing that individuals are already making decisions for themselves and their families regarding malaria prevention and control, and only programs that are consistent with their interests will ultimately be sustainable.

It is also apparent that social and economic factors influence people's decisions regarding where they live and where they will situate their dwellings; such decisions in turn affect exposure to malaria. The economic benefit derived from locating homes near swamps (for fish and pasture land) that are known to be malarious, for example, may outweigh the perceived loss from contracting malaria. It appears that in cases where agricultural workers contract malaria, short-term productivity is not lost perhaps because of substitution by other community members to complete the required task (Mwabu). Malaria is likely, however, to have a long-term impact on household and community productivity:

Malaria morbidity reduces a household's ability to accumulate human and health capital because it interferes with schooling of children...Thus, although the short-run agricultural production of a household may not be affected by malaria because of the phenomenon of intrahousehold reallocation of labor in the event of a malaria attack, long-run labor productivity is in all probability impaired. It is this impairment of future labor productivity that could detain a malaria-endemic community in the initial stages of growth where increases in incomes have a negligible or no effect on malaria prevalence. (Mwabu)

Therefore, in developing a community-based approach, it is important first to determine local priorities and understandings of disease causation. "The majority of a community may not see health, as medically understood, as a priority. One should therefore not assume that people are ready and waiting to participate in malaria control activities" (Kaseje). Much of the population of Africa is more concerned with assuring the day-to-day necessities for survival such as collection of water, food, and fuel for cooking. In addition, malaria in some areas "is so common as to be perceived as being the 'norm' and not a condition that warrants expenditure of limited resources" (Etkin). Finally regarding disease causation, "while mosquitoes are generally considered to be a nuisance, their relation to disease may not be appreciated" by affected individuals (Etkin).

Practices and perceptions can be assumed to be neither known, nor uniform across the continent. It is recommended, therefore, that participant observation be conducted for affected communities in order to incorporate local understandings of health into project design. This end can be achieved quickly and at low cost by employing rapid assessment techniques that can be carried out, for example, by local health workers or students (Etkin).

Essential components for establishing a community-based approach include (Kaseje):

• Identifying, developing, and supporting current and potential leadership at all levels (community, district, national, and international).
• Providing existing health workers and those in related sectors with orientation to malaria control.
• Establishing a collaborative network of interested government sectors, NGOs, and districts to enable sharing of approaches.
• Developing appropriate organizational mechanisms for collaboration and for fostering political commitment and will.

In brief, the following conclusions and recommendations can be stated:

1. Community characteristics (demography, social and political structures, epidemiology, habitat, priorities) all affect the role any community might play, and must be assessed before any control program can be designed and implemented. The specifics will vary across communities and even within communities; they cannot be assumed to be homogeneous.
2. A community must play an active role in formulating, implementing, and evaluating strategies for control.
3. Where feasible, all critical variables relating to a specific community must be factored into the development of any control strategies.
4. Communities must determine their own priorities, needs, and capabilities. Any project should capitalize on those priorities and capabilities.
5. Local resources should be used, developed, and refined where possible in order to ensure local sustainability in any control project.
6. Functioning community structures, e.g., women's groups, schools, religious groups, traditional healers, should be used for the coordination of control activities.
   • Since women are frequently the primary health providers in the home, they should be utilized accordingly in control programs.
   • Traditional healers, as respected community members who are consulted for health matters, should be used in developing prevention and control strategies.
7. Communities also need to be informed about the effects of development on malaria. Often, small development projects, such as a series of small irrigation schemes, can have a pronounced adverse effect on malaria transmission within a community. That community must also be prepared to prevent or mitigate any adverse effects.
8. Community participation can be enhanced by income-generating activities. In some cases, a community needs to perceive an economic (or some other tangible) benefit to carry out a project.
9. A community's perception of a project as its own is also critical for success.
   • Community members must see themselves as the principal beneficiaries of and actors in programs (Mululebwe).
   • For example, the community participates both financially and physically in the Gezira scheme (Blue Nile Health Project) in the Sudan regarding activities in water supply, construction of latrines, garbage collection (El Gaddal).
10. Education may be a particularly important component at this level, where Environmental Impact Assessments may be less feasible for small-scale, community-level projects.
    • Health education messages should specifically target high-risk groups, such as pregnant women, children, and migrant workers.
    • Weaknesses or shortcomings (in areas where improvements seem essential for successful malaria control) may be remedied through education and communication, particularly through community leaders and existing structures such as schools.
11. Intersectoral cooperation needs to be encouraged at the community level as well. Groups should cooperate to convey health messages to the community regarding health and development.
12. Coordination with the national or district government may also be necessary in order to obtain the support critical to the success of a project.

In sum:

The public particularly has a contribution to make in the management or proper use of amenities for housing, water supply, and sanitation. Further, sustained good management by the community requires some commitment on its part and comes when members are involved in decisionmaking and implementation in the provision of the desired facilities. Local knowledge, values, and practices may determine acceptability of facilities meant to help the community. Continued interaction and communication with the beneficiaries of social projects are thus important (Laing).