Use of insecticide-impregnated bed nets in Gambian primary health care: economic aspects.

Village-wide use of permethrin-impregnated bed nets, compared with placebo-treated nets, has reduced clinical attacks of malaria by 63% in the Gambia. Costs were calculated for nets made by local tailors and for their treatment with insecticide in the villages, as well as for targeted chemoprophylaxis and back-up treatment for fever, in a comprehensive malaria control strategy through primary health care. The villagers' preferences for bed net fabrics and willingness to pay for them, and their preferences for various items of expenditure by ranked order, age group, and sex are given. Ethnic differences in the use of bed nets are also discussed.

Technology and women's health in developing countries.

In developing countries is medical technology transfer reaching women? Do women control new technologies or are they only passive recipients? What is the impact of these new technologies on women's health and welfare? To answer these questions this article explores concepts of health, technologies, and women, then gives findings from an extensive literature search on contraception, childbirth, immunization, essential drugs, oral rehydration therapy, water, sanitation, and breast-feeding. The article concludes with recommendations on pre-project planning studies, monitoring, and evaluation.

PIP: This article is concerned with access to and control of medical technologies by women in developing countries and the impact of technologies transferred in the development process on the health of women. An extensive literature search assesses whether the literature is adequate to guide planners wishing to enhance the health of Third World women, and evaluates whether the conceptual models being used to interpret reports and studies are the most comprehensive, constructive and valid approaches with efficient use of resources and social justice. Women need to be "mainstreamed" into all development projects; special women's projects continue to focus on low-skill, low-technology, low-income activities, which do not enhance the general status of women nor result in improved health. Mainstreaming of women is important in all health projects since women are the producers of environmental hygiene and providers of health care. Suggestions for monitoring improvement in women's health and development projects include 1) numbers of women health workers trained by grade of job; 2) the time-saving potential of improved technologies through women's time budgets; 3) technology transfers to document women's control of the technology 5 years after the end of the project; 4) the range of medical technologies being offered, compared with user preference; 5) the proportion of women trained to maintain health-related technologies; 6) the proportion of self-help appropriate technologies compared with specialist technologies, and 7) when medical technologies/practices are not widely used, are programs redesigned to be more culturally and gender appropriate and economically feasible?

Health and the social power of women.

The relationship between women's social status and the survival chances of their children is explained and illustrated with examples. When women (and girls) have low status, relatively little social investment is made in them, and this is reflected in girls' and boys' differential mortality rates. Several health-related social investment indicators are given, and matched against children's mortality patterns by ecological regions of Africa and Asia. The cultural propensity to invest in girls (nutrition, education, etc.) and their resultant survival chances, are explained by ecology which in past centuries has largely determined agricultural economies that either had a high demand for female labour or did not. In the former, women are more likely to control the wealth they produce and use it for transactions that put others in their social debt, thus growing in social power. Policy implications of planning and implementing primary health care in these different types of societies are explored.

The human host as active agent in malaria epidemiology.

The literature on malaria epidemiology tends to view the human host as a passive or constant factor. However, for at least 2000 years people have been an active factor, causing vast changes in epidemiological patterns. They have cut forest and increased the breeding area of An. gambiae, or changed salinity in rice swamps causing a different change in the dominant vector. Human activity not only increases risk, but influences control by killing mosquito larvae, killing adult mosquitos or preventing mosquitos from feeding. For example, people prefer chloroquine or other anti-malarials to traditional herbal remedies that do not kill parasites, and in some areas introduce larvivorous fish into swamp rice fields and cattle ponds. Bed nets impregnated with residual insecticide simultaneously prevent mosquitos from feeding on people and kill adult mosquitos. Preferences and practices in bed net use in the Gambia are described.

Gambian cultural preferences in the use of insecticide-impregnated bed nets.

In field trials of permethrin-treated bed nets in a large Mandinka village, 95% of people were already sleeping under locally-made nets. They lasted about 6 years and cost about US$9.00 ($1.50 per year). Two permethrin dips per year added a further $0.60 per year (1985 prices). Non-immune children slept in beds shared with adults, and people wanted nets for many reasons, not just malaria protection. Fifty-eight per cent of people preferred opaque sheeting to open netting; sheeting gave more privacy, lasted longer, gave better protection from very small insects, dust, rats, etc. White was the colour preferred by 90% of interviewees. Comparing Mandinka with Wolof and Fula, there were ethnic differences in net owning and the proportion of children sleeping in beds with a mattress.

Lay concepts affecting utilization of family planning services in Jamaica.

Two hundred and sixty-eight Jamaican women were interviewed and asked about their views on various types of contraceptives. During the interviews they were given an outline of a woman's body and asked to draw the female reproductive system. Worries about altered menstruation, irreversible sterility and other consequences of contraception contributed to underutilization of services. Recommendations for improved services and public education are made.

Lay concepts affecting utilization of family planning services in Jamaica

Two hundred and sixty-eight women were interviewed and asked about their views on various types of contraceptives. During the interviews they were given an outline of a woman's body and asked to draw the female reproductive system. Worries about altered menstruation, irreversible sterility and other consequences of contraception contributed to underutilization of services. Recommendations for improved services and public education are made (AU)

Primary health care in Sierra Leone.

Two pilot primary health care programmes are compared. One is primarily concerned with covering the national population by the year 2000; the other is more concerned with community participation and culturally-appropriate health care organisation. Strengths and weaknesses of the two pilot programmes are assessed in relation to national financial constraints, epidemiological patterns, and the socio-cultural structure of rural chiefdoms. The comparison concludes with specific recommendations for a national programme which incorporates the best of both pilot programmes.

Human ecology and behaviour in malaria control in tropical Africa.

Since about 250 BC, human modification of African environments has created increasingly favourable breeding conditions for Anopheles gambiae. Subsequent adaptations to the increased malaria risk are briefly described and reference is made to Macdonald's mathematical model for the disease. Since values for the variables in that model are high in tropical Africa, there is little possibility that simple, inexpensive, self-help primary health care initiatives can control malaria in the region. However, in combination with more substantial public health initiatives, simple primary health care activities might be done by communities to (1) prevent mosquitos from feeding on people, (2) prevent or reduce mosquito breeding, (3) destroy adult mosquitos, and (4) eliminate malaria parasites from human hosts. Lay methods of protection and self-care are examined and some topics for further research are indicated. Culturally appropriate health education methods are also suggested.

Failure to participate in a malaria chemosuppression programme: North Mara, Tanzania.

A malaria prophylaxis programme for 100 000 children in one rural district of Tanzania was carried out under the very favourable conditions of 1) a government genuinely committed to rural public health, 2) a well organized system of village government for distribution of the drug to children, and 3) free chloroquine supplied without interruption by WHO to the project area. The project failed to suppress malaria for a combination of the following reasons. Small delays in distribution because of poor communication, vehicle breakdowns, bad roads, key people being away or too busy resulted in the drug not being available for ingestion at regular intervals. A few children from families with marginal social status were excluded by local leaders. Some people were not convinced that regular chloroquine taking might prevent children's malaria and therefore saved it to treat fever in all family members. Various survey techniques were used to discover why children might refuse to swallow tablets, and as many as 28% of children complained of vomiting, as many as 56% complained of itching, and other unfavourable qualities of chloroquine were indicated.

Community participation in primary health care.

PIP: The advantages of a community participation approach in primary health care (PHC) are as follows: a community participation approach is a cost effective way to extend a health care system to the geographical and social periphery of a country; communities that begin to understand their health status objectively rather than fatalistically may be moved to take a series of preventive measures; communities that invest labor, time, money, and materials in health promoting activities are more committed to the use and maintenance of the things they produce, such as water supplies; health education is most effective in the context of village activities; and community health workers, if they are well chosen, have the confidence of the people. An error made in early efforts at community participation was to assume that villages were uniformly free from internal exploitation. Some are cohesive moral communities, but in other there is grievous exploitation of landless laborers by landowners and shopkeepers. Villages may be divided by caste or ethnic origin. Political organization of villages may be democratic or they may be governed in an authoritarian manner. In politically unstable countries where the central government has a rather tenuous control over the rural periphery, genuine community initiatives may be viewed as threatening and may not receive official encouragement. Social groups within communities may be tremendous assets. In planning the community participation aspects of primary health care, the collaboration of an anthropologist or rural sociologist with field experience is recommended. Promoting community participation is a skill which must be taught to community health workers, and backed up with support services. The genuine commitment of medical staff to community self help is crucial to the motivation process. Motivation within the community quickly breaks down if materials, expertise, and salaries fail to arrive when promised. Community activities are most successfully promoted with reference to the people's own ideas of purity/pollution, cleanliness/dirtiness, and health/illness. Guidelines for successful community participation include: projects undertaken should be ones that the community has identified as a priority; demonstrations and activities to promote health might be linked with agricultural initiatives, adult literacy campaigns, or programs from other sectors; and it is necessary to make sure the community fully understands all the costs in labor, time, money, and materials. If projects or longterm community health programs fail, a quick, simple analysis should be made of constraints that may be operating. Some points to be covered are suggested.^ieng