Health Promotion International Advance Access originally published online on November 1, 2004
Health Promotion International 2004 19(4):445-452; doi:10.1093/heapro/dah406
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HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 4 © Oxford University Press 2004; All rights reserved.
The effect of health education interventions on child malaria treatment-seeking practices among mothers in rural refugee villages in Belize, Central America
Department of Human Performance and Health Promotion, 2000 Lakeshore Drive, University of New Orleans, New Orleans, LA 70148, USA
Address for correspondence: Lorelei Cropley, Department of Human Performance and Health Promotion, 2000 Lakeshore Drive, University of New Orleans, New Orleans, LA 70148 USA E-mail: lcropley{at}uno.edu
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This paper reports on a study conducted to examine the effect of health education interventions on mothers' treatment-seeking behaviors for their children's malaria fevers. The study used a quasi-experimental post-test community-based design with an intervention and control group. A post-intervention survey was conducted to assess knowledge, attitudes and child fever and malaria treatment-seeking behaviors and access and exposure to health messages. Survey results indicated that some health education interventions, especially interpersonal communication, appeared to have a positive impact on fever and malaria beliefs and attitudes and on positive treatment-seeking behaviors. While some interventions appeared to have a positive impact on fever and malaria beliefs and attitudes and on positive treatment-seeking behaviors, limitations in the study design made assigning specific effects to the interventions difficult. However, health education interventions remain a valuable tool in addressing malaria in children.
Key words: health promotion; health education; malaria; community health worker; maternal child health
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Belize, Central-America experiences endemic malaria with an increasing rate of new malaria cases since 1990, especially in children 12 years and younger (PAHO, 1998
). This increase in children is of concern since malaria is most severe among those with little or no immunity, such as infants and children, who no longer have maternal immunity protection and have not reached full immunologic maturity [Bremen and Campbell, 1988; World Health Organization (WHO), 2000]. An important aspect of malaria in children is that the classic symptoms of fever and chills may not be seen, but instead may present with a variety of non-specific symptoms (Gilles and Warell, 1993).
Effective malaria programs involve multiple interventions aimed at disease prevention and control, with an increasing emphasis on health education (WHO, 2000). Community-based health workers (CHWS) have been identified as effective in delivering messages on specific control, treatment and prevention behaviors (Moir et al., 1985; Kaseje et al., 1987; Godoy, 1988; Ruebush and Godoy, 1992; Pagnoni et al., 1997). Belize's Vector Control Programme (VCP), uses CHWs called Voluntary Collaborators (VCs), to provide malaria services such as surveillance and treatment of malaria cases with the administration of chloroquine and primaquine to confirmed and suspected cases (PAHO, 1995; Yacoob, 1996).
Understanding mothers' treatment-seeking behaviors is important because they are an important factor in the outcome of malaria infection in children (Ayalde and Olivar, 1990). Using Green and Kreuter's framework (Green and Kreuter's, 1999), factors that influence a mother's treatment-seeking behaviors for her child can be classified as predisposing, enabling and reinforcing. Predisposing factors include knowledge, beliefs and perceptions of an illness and its manifestations, including severity of symptoms, episode duration, susceptibility, treatment sources, disease seasonality and causation. Examples of enabling factors are access to and cost of health services. Reinforcing factors can include perceived success of the treatment and receipt of medicine or treatment (MacCormack and Lwihula, 1983; Stock, 1983; Campion and Gabriel, 1985; Bremen and Campbell, 1988; Deming et al., 1989; Lipowsky et al., 1992; Aikins et al., 1993; Csete, 1993; Jayawardene, 1993; Aikins et al., 1994; Klein et al., 1995; Mwenesi et al., 1995; Tanner and Vlassoff, 1998). Demographic characteristics such as maternal education and child's gender and age can also influence mother's treatment-seeking behaviors (Campion and Gabriel, 1985; Csete, 1993; Jayawardene, 1993).
To address these issues, the Belize VCP program developed a series of health education interventions to target refugee mothers of young children who had probable malaria cases. Mothers of young children living in refugee communities were targeted for intervention because these communities had the highest levels of malaria incidence in Belize (Yacoob, 1996). The program outcome objective was that, at the end of the study, 80% of mothers with children five years old or younger would seek malaria treatment from an appropriate source within 48 hours of the first recognition of a fever indicative of a malaria infection, regardless of beliefs of causation.
Findings from qualitative data analysis and a review of personnel training needs were used to develop health education messages, select message delivery channels and develop and implement interventions consisting of training workshops and dissemination of education materials. To convey a revised definition of fever, the message developed for use in the interventions was that mothers with children five years old or younger would seek malaria treatment from an appropriate source within 48 hours of the first recognition of her child's fever as calentura, fiebre or mal de ojo, with at least one additional symptom, regardless of causation beliefs.
A combination of channels was selected to increase message exposure and enhance retention. Interpersonal channels, such as VCs and VCP and District Health Team personnel working in target communities, were selected to put health messages in a more familiar context, to allow for discussion and clarification and to provide support for action. Community channels, such as clinics, were selected to reinforce and expand upon the interpersonal messages.
Three types of education materials were used to communicate the message: a pamphlet, a poster and a malaria post sign (see Figures 1–3). These were revisions of pre-existing materials to include aspects of the revised program message. Development of the materials included extensive review and pre-testing with gatekeepers followed by pre-testing with the target population. Following development of the materials, workshops were conducted for district health team members, VCP personnel and VCs living in intervention villages. At the workshop conclusion, trained personnel were expected to address local beliefs and use local terminology and disease concepts in providing health education messages at the village level through one-on-one discussions, informal group meetings and material dissemination. To monitor implementation, monthly reports and observation records were collected and reviewed, communities were visited weekly to observe health education performance; VC homes and key life path points such as community centers and schools were observed for the presence of materials.
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The purpose of this study was to assess the effect of health education interventions on child malaria treatment-seeking practices among rural refugee mothers in Belize, Central America.
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MATERIALS AND METHODS |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Program outcome evaluation was conducted using a post-intervention survey six months after the interventions were completed to assess levels of knowledge, attitudes and child fever and malaria treatment-seeking behaviors and access and exposure to health messages. The survey used a quasi-experimental post-test community-based design with an intervention and control group.
The survey was conducted on mothers with children between six months and five years old residing in rural refugee communities. Eight non-equivalent rural refugee communities in the Cayo district were selected; four were intervention villages and four were used as controls. Villages were selected on the basis of: (1) high malaria transmission, (2) current inclusion in VCP activities, including the VC program, (3) ethnic and linguistic representation of the larger population to be served by the VCP and (4) documented childhood morbidity from malaria. Efforts were made to match the control and intervention villages as closely as possible in terms of age, ethnicity, malaria incidence, size and location.
The sample size was selected by using a hypothesis testing formula to compare binomial proportions using a one-tailed test (Rosner, 1986). This formula yielded a sample size of 75 households per village. In cases of villages with less than 75 households, all households were sampled. The total number of households sampled using this formula was 402.
Survey questionnaires developed for other malaria projects were collected, reviewed and modified for use with input from VCP and Ministry of Health personnel. Following the development process, the questionnaire was translated into Spanish then pilot tested among VCs and CHWs working in rural refugee villages. This was followed by a two-part pilot testing process where the questionnaire was tested during interviewer training, then field-tested in a refugee village not included in the survey.
CHWs were selected and were trained as survey interviewers during a three-day workshop, where the survey rationale and points crucial to survey success were explained and survey interview skills taught. After several practice sessions with the questionnaire, participants practiced interviews in a village not selected for the survey.
Keeping in mind the inherent threats to validity of a large-scale household survey, such as reliance on respondent memory, willingness to answer honestly to the interviewer, reported versus actual behaviors, and, in the case of interviewing of mothers regarding their child, proxy reporting (Kroeger, 1983), maximum control was exerted over the data collection process. Interviewers were observed unobtrusively while they conducted survey interviews to ensure their interview effectiveness. When the interview was completed, interviewers returned questionnaires to the supervisor for review of completion errors and accuracy. If errors were found, the interviewer made corrections and returned to the household if necessary. Other strategies used to overcome self-reported behavior bias were third party reports of the actual behavior, use of indirect measurement procedures, and careful question construction, using open-ended questions with details only respondents practicing the behavior would know.
EPI Info Version 6 (Dean et al., 1996) was used for data analysis. Frequency distributions of all relevant variables were generated, then 
2 and Fisher's exact tests conducted to test for significance. Results were considered significant at p < 0.05.
Positive treatment-seeking behaviors for fever was defined by three variables: treatment sought: (1) from an appropriate source, (2) within 48 hours of onset and (3) for fevers with at least one additional symptom. Fevers called fiebre, calentura or those caused by mal de ojo were used in analysis since they met the definition of possible malaria fevers. Exposure to interpersonal communication was measured by responses to three questions: (1) whether the respondent had heard about malaria recently, (2) use calentura to describe fever as a malaria symptom and (3) a question regarding malaria transmission. The total number of questionnaires used in analysis was 400, 223 from intervention villages and 177 from control villages.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Villages were similar in population composition and malaria incidence. There was no significant difference between intervention and control groups in terms of ethnicity as determined by reported country of origin (see Tables 1 and 2).
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Of the 400 respondents, 50.5% (n = 202) reported fever in at least one child five years old or younger within the previous 3 months and, of these 37% (n = 148) reported her child's fever accompanied by at least one additional symptom. Of the 148 fever cases, 85 mothers reported fever in more than one child, resulting in an actual fever incidence of 58.5% (n = 234). Of the 400 respondents, 18.3% (n = 73) reported malaria in at least one child five years old or younger within the previous three months. Of these, 14 reported malaria in more than one child, resulting in an actual malaria incidence of 24% (n = 97). No significant difference was found for either fever or malaria incidence for the intervention and control groups. The most common malaria symptoms cited by mothers were fever (94%), chills (76%), headache (63%), vomiting (49%), anorexia (33%), weakness (25%), sweating (24%), body/back ache (8%), bone pain; anemia (3% each), convulsions; cough; frequent crying; flu (1% each).
Of the 148 mothers who reported a case of fever within the last three months, 75.6% (n = 65) of mothers in intervention villages met the criteria for positive treatment-seeking behaviors as opposed to 22.6% (n = 14) in control villages. Of the mothers who reported a case of malaria within the last three months, 84.1% (n = 37) of those in intervention villages met the criteria for performing positive treatment-seeking behaviors for malaria, as opposed to 37.9% (n = 11) for those in control villages. These results were significant for both fever (2 40.67, p < 0.0001) and malaria (2 16.54, p < 0.0001).
Mothers who lived in intervention villages had significantly higher levels of exposure to the poster (2 23.09, p < 0.0001), malaria post sign (2 95.26, p < 0.0001) and the pamphlet (2 12.92, p < 0.001). A statistically significant difference was found between positive treatment-seeking behaviors for fever and exposure to the malaria post sign (2 24.91, p < 0.0001), and exposure to the poster (2 8.45, p < 0.01) but not for exposure to the pamphlet. There was a significant difference between positive treatment-seeking behaviors for malaria and exposure to the sign (2 4.91, p < 0.027) but not for exposure to either the malaria poster or the pamphlet.
Mothers living in intervention villages were significantly more likely to have heard about malaria recently (2 75.2 1, p < 0.0001), to report calentura as a malaria symptom (2 50.91, p < 0.0001), to know that malaria can be spread to others (2 8.03, p < 0.01) and that it is spread by a mosquito (2 14.11, p = 0.0001) than those in control villages. There was no significant difference between the control and intervention groups in recognizing fiebre as a symptom. Interpersonal communication had a significant association with positive treatment-seeking behaviors for both fever (2 34.66, p < 0.0001) and malaria (2 5.32, p < 0.05).
Results were significant for positive treatment-seeking behaviors for fevers accompanied by chills (2 5.66, p < 0.05) but not for fevers accompanied by convulsions. However, the number of fever cases with convulsions was very small (n = 5).
Results showed no difference among age groups, school attendance or child's gender and positive treatment-seeking behavior for malaria or fever.
Of the 382 respondents who believed that treatment for malaria is available, 254 (66.5%) knew treatment was available from a VC. However, only 24.3% (n = 36) sought treatment from a VC for a child with fever and 57.5% (n = 42) for a child with malaria. No significant difference was found for mothers in intervention groups in using a VC as a treatment source for a child with fever or malaria. Of the cases where treatment-seeking from an appropriate source was delayed for more than three days or never initiated, 63% of fever cases and of 42% malaria cases were treated at home as a first resort. Treatment at home consisted of palliative measures to reduce pain and fever through use of modern medicines (e.g. aspirin), traditional medicines (e.g. herbs) and traditional methods such as using cool cloths on the forehead.
For all respondents, a clinic or hospital was within two hours distance, and a VC was within half an hour distance from the respondent's home. The majority of respondents pay nothing for VC, government clinic or hospital services, which are provided without charge by the government. Private doctors, clinics and hospitals are more expensive and there were reports of charges as high as 30 US dollars per visit. For the most part, treatment was with oral chloroquine and primaquine, although some respondents reported receiving antibiotics and i.v. fluids from private treatment sources.
Of the 73 malaria cases, 25 (34%) respondents reported that the fever recurred. Of the 25 cases of malaria with recurrence, 19 (76%) mothers returned to the official source for treatment; the other six (24%) gave other treatment.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Results indicated that, while some interventions appeared to have a positive impact on fever and malaria beliefs and attitudes and treatment-seeking behaviors, limitations in the study design made assigning effects to the interventions difficult. While the program objective "at the end of this study, 80% mothers with children five years old or younger would seek malaria treatment from an appropriate source within 48 hours of the first recognition of a fever, identified locally as calentura, fiebre or mal de ojo, with at least one additional symptom, regardless of beliefs of causation" was not attained, correct treatment-seeking behavior was significantly greater in intervention villages than in control villages. This may be because only mothers who received the intervention were given specific messages that classic malaria symptoms (chills, fever) may not be present in young children and that all children with fiebre, calentura or ojo fevers with one additional symptom should be examined by a health practitioner.
It was apparent that some mothers in control villages were exposed to the health education materials due to their use of treatment sources outside of their community where education materials were distributed and displayed. Despite this access, there were significant differences between intervention and control in exposure to the materials, especially the malaria post sign. The strong relationship between exposure to the sign and the intervention group may be attributable to material distribution; while pamphlets or posters could be viewed at a clinic or hospital, signs were distributed only to VCs in intervention villages for display outside their houses.
Due in part to study design flaws, there was not convincing evidence that the educational materials positively influenced treatment-seeking behaviors. Out of the three education materials, the malaria post sign and the poster were significantly related to positive treatment-seeking behaviors, but the true effects are indeterminable. Mothers who visited the VCs homes for treatment were more likely to have seen the sign or poster, making it difficult to determine which came first: exposure to the materials then positive treatment-seeking behavior or positive treatment-seeking behavior with subsequent exposure to the materials. In addition, exposure to these materials would most likely have occurred in intervention villages where mothers also received other interventions such as inter-personal communication.
The health education intervention with the greatest effect appeared to be interpersonal communication. The finding that interpersonal communication, which was associated with positive treatment-seeking behaviors for both fever and malaria, had an even stronger association for fever may be because the message on calentura focused on fever rather than malaria behavior. The interpersonal communication effects may also be seen in the significantly higher reporting of calentura as a malaria symptom by the intervention group. Still another finding that supports the influence of interpersonal communication on the intervention group was the knowledge by intervention group mothers that malaria can be spread to another person by a mosquito. This message was given as a rationale for encouraging early treatment. Therefore, interpersonal communication appeared to be the important factor in behavior change, with the educational materials reinforcing and increasing the quality of the relationship. This reflects Green and Kreuter's framework of the factors that influence behavior (1999).
The results did not support literature findings that that maternal age or education level or child's gender are significant determinants of a mother's treatment-seeking behavior for malaria or fever.
On some topics, respondents' disease knowledge was notable, whether from program efforts or from another source. Most knew at least one correct malaria symptom and some recognized intermittent fever as a malaria symptom. In addition, information about the curative properties of chloroquine, and occasionally primaquine, had reached some individuals although not always in helpful ways. For example, some respondents sought chloroquine from pharmacies or the clinic and then self-administered the drug in inappropriate dosages.
Based on the literature findings, a significant relationship between fever accompanied by convulsions, a symptom that could be considered as serious, and positive treatment-seeking behavior was expected. Results for this relationship were not significant, but this may not be accurate since the number of fever cases with convulsions was very small. In addition, an association between type of symptoms and treatment-seeking behaviors was supported by results that showed that when a fever was accompanied by chills, a symptom usually recognized as a sign of malaria, mothers were more likely to perform positive treatment-seeking, regardless of the intervention.
Knowledge that treatment was available from a VC was high, but this knowledge was often not enough to influence a mother to take her child to a VC for treatment. Despite this, VCs still can contribute to message dissemination by acting as translators of the health education message, and bridge the gap between health professionals and lay-people. Their role in the health care infrastructure needs to be strengthened, since even though VCs provide almost the same treatment available by private sources who charge a fee, they remain under-utilized. This under-utilization may reflect a lack of credibility in the VCP, perceptions that VCs are connected with the government (especially by refugees who are in the country illegally), preference for "western" medicine, and perceptions that fee-based services have greater value than those provided at no cost.
An important reinforcing factor is the perception that the treatment is effective. Despite a third of respondents reporting that the malaria fever recurred, the majority of mothers returned to the official source for treatment, which appeared to reflect a continued faith in treatment. Perception of the VCP is also an important reinforcing factor. Throughout the study, the VCP suffered program delivery challenges that may influence perceptions. The staff was under-trained in many areas and often provided conflicting information regarding malaria treatment. During the course of the study, problems materialized as the VCP went through some abrupt and major changes, including replacement of the VCP director, two changes in the treatment regimen, and a promise then retraction of residual spraying activities.
Specific immediate recommendations were made to: (1) integrate results into the VCP, (2) provide the intervention to the control group, (3) conduct the study among different populations in Belize to reflect their cultural differences and (4) develop maintenance messages to ensure that mothers practicing positive treatment-seeking behaviors do not regress into previous behavior patterns. In addition, while this study focused on mothers, the message should be delivered to other traditional advisors and influential community change-agents such as family members, friends, traditional healers, and informal and formal village leaders. This improves the likelihood that the message will be integrated into community belief systems. Because intervention effects were confounded in two particular areas (1) behavior change may have been due to activities by other projects or to changing rates regardless of program efforts and (2) the multiple components of the interventions made identifying individual effects methodologically and conceptually difficult, an improved study design should be considered to exert more control over these effects.
On a wider scale, prior to future design of health education messages, malaria control programs should make an attempt to understand local fever and malaria knowledge, attitudes, perceptions and treatment behaviors and apply this understanding to the development of health education messages. To achieve this, personnel may need to be trained in formative research. Another recommendation, given the level of mothers' malaria and fever knowledge, is to consider teaching mothers to provide home treatment of malaria, a strategy already being used quite effectively to reduce child mortality from malaria in Ethiopia (Kidane and Morrow, 2000).
The scope of malaria control is changing worldwide. With less emphasis being placed on insecticide use, increased community participation in malaria control and prevention measures will be of higher importance. With greater emphasis being placed on community control and prevention, health education based on understanding community and individual behaviors, attitudes and knowledge pertaining to malaria is moving to the forefront as a measure necessary for malaria control.
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REFERENCES |
|---|
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Aikins, M. K., Pickering, H. and Greenwood, B. M. (1994) Attitudes to malaria, traditional practices and bednets (mosquito nets) as vector control measures: a comparative study in five west African countries. Journal of Tropical Medicine and Hygiene, 97, 81–86.
Aikins, M. K., Pickering, H., Alonso, P. I., D'Alessandro, A., Lindsay, S. W., Todd, J., et al. (1993) A malaria control trial using insecticide-treated bed nets and targeted chemoprophylaxis in a rural area of The Gambia, West Africa. 4. Perceptions of the causes of malaria and of its treatment and prevention in the study area. Transactions of the Royal Society of Tropical Medicine and Hygiene; 87, 25–30.
Ayalde, J. and Olivar, M. (1990) Malaria. VBC Tropical Disease Paper No. 1, WHO, Geneva.
Bremen, J. G. and Campbell, C. C. (1988) Combating severe malaria in African children. WHO Bulletin, 66, 611–620.
Campion, P. D. and Gabriel, J. (1985) Illness behavior in mothers with young children. Social Science and Medicine, 20, 325–330.
Csete, J. (1993) Health-seeking behavior of Rwandan woman. Social Science and Medicine, 37, 1285–1292.
Dean, A. G., Dean, J. A., Coulombier, D., Brendel, K. A., Smith, D. C., Burton, A. H. et al. (1996) Epi Info, Version 6.04a, a word processing, database, and statistics program for public health on IBM-compatible microcomputers. Centers for Disease Control and Prevention, Atlanta.
Deming, M. S., Gayibor, A., Murphy, K., Jones, T. S. and Karsa, T. (1989) Home treatment of febrile children with anti-malarials in Togo. Bulletin of the World Health Organization, 67, 695–670.[ISI][Medline]
Gilles, H. M. and Warrel, D. A. (eds) (1993) Essential Malariology, 4th edition. Edward Arnold, London, 37–38.
Godoy, H. (1988) Knowledge, attitudes and treatment-seeking behavior for malaria in Guatemala. Final report TDR/SER/ID 850077. WHO, Geneva.
Green, L. W. and Kreuter, M. W. (1999) Health Promotion Planning: An Educational and Ecological Approach, 3rd edition. Mayfield, Mountain View, CA.
Jayawardene, R. (1993) Illness perception: social cost and coping strategies of malaria cases. Social Science and Medicine, 37, 1169–1176.
Kaseje, D. C. O., Spencer, H. C. and Sempebwa, E. K. (1987a) Characteristics and functions of community health workers in Saradidi, Kenya. Annals of Tropical Medicine and Parasitology. 81, Supplement, 56–66.
Kidane, G. and Morrow, R. H. (2000) Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomized trial. The Lancet, 356, 550–555.[CrossRef][ISI][Medline]
Klein, R. E., Weller, S. C, Zeissig, R., Richards, F. O and Ruebush, T. K. (1995) Knowledge, beliefs, and practices in relation to malaria transmission and vector control in Guatemala. American Journal of Tropical Medicine and Hygiene, 5, 383–388.
Kroeger, A. (1983) Health interview surveys in developing countries: a review of the methods and results. International Journal of Epidemiology, 12, 465–481.
Lipowsky, R., Kroeger, A. and Vazquez, M. L. (1992) Sociomedical aspects of malaria control in Columbia. Social Science and Medicine, 34, 625–637.
MacCormack, C. P. and Lwihula G. (1983) Failure to participate in a malaria chemosuppression programme: North Mara, Tanzania. Journal of Tropical Medicine and Hygiene, 86, 99–107.
Moir, J., Tulloch, J., Vrboca, H., Jolley, D., Heywood, P. and Alpers, M. P. (1985) The role of voluntary village aides in the control of malaria by presumptive treatment of fever. I. Selection, training, and practice. Papua New Guinea Medical Journal, 28, 57–266.
Mwenesi, H., Harpham, T. and Snow R. W. (1995) Child malaria treatment practices among mothers in Kenya. Social Science and Medicine, 40, 1271–1277.
Pagnoni, F., Convelbo, N., Tiendrebeogo, J., Cousens, S. and Esposito, F. (1997) A community-based programme to provide prompt and adequate treatment of presumptive malaria in children. Transactions of the Royal Society of Tropical Medicine and Hygiene, 91, 512–517.[CrossRef][ISI][Medline]
PAHO (1995). Regional Status Of Malaria In The Americas, 1994. Epidemiological Bulletin, 16. Retrieved August 2003 from http://www.paho.org/English/SHA/epibul_95-98/bc953rcg.htm.
PAHO (1998) Health Situation Analysis and Trends: Chapter Summary from Health in the Americas. August 2003. Http://www.paho.org/English/SHA/prflBEL.htm. Available from: Http://www.paho.org/English/SHA/prflBEL.htm (last accessed 8 April 2003).
Rosner, B. (1986) Fundamentals of Biostatistics, 2nd edition. PWS Publishers, Boston.
Ruebush, T. K.,II and Godoy, H. A. (1992) Community participation in malaria surveillance and treatment. I. The Volunteer Collaborator Network of Guatemala. American Journal of Tropical Medicine and Hygiene, 46, 248–260.
Stock, R. (1983) Distance and utilization of health services in rural Nigeria. Social Science and Medicine, 17, 563–570.
Tanner, M. and Vlassoff C. (1998) Treatment seeking behaviour for malaria: a typology based on endemicity and gender. Social Science and Medicine, 46, 523.
World Health Organization (2000). Expert Committee on Malaria. WHO Technical Report Series, 892, 1–74. Geneva, Switzerland.
Yacoob M. (1996) Community Participation and Vector-Borne Disease Control in Belize: An Assessment of Current and Potential Activities. Vector Biology & Control Project. USAID technical report (PN-ABM-168).
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