The central argument of the thesis is that self-care intervention alone cannot improve the role of men and women in malaria treatment and prevention. Social, economic, cultural, administrative and health infrastructure have to be considered also. Analysing gender dimensions in malaria is essential to strengthen home management. Multiple methods were used in eight villages of Laputta of moderate malaria endemicity, where the United Nations Development Programme assisted self-care intervention under the 'Human Development Initiative' was launched, to understand villager's knowledge and behaviour associated with malaria.
The research started with 11 in-depth interviews of personnel familiar with policy issues, integrated with the perspectives of 24 villagers (religious leaders, elders, teachers, health workers, drug sellers), 28 focus group discussions and field observations. The conceptualised gender framework for decision-making roles was investigated for 193 adults and 89 children who had experienced malaria, supplemented by 17 case histories. The associations between behaviour, knowledge and use of the manual and barriers to appropriate behaviour of 405 currently married couples with at least one child under ten years were ascertained by bivariate, stratified and multivariate analyses.
Important findings include:
• Approximately 70% of men and women knew that fever with chills and rigor could be due to malaria but very few were aware of diagnostic services. Self-medication, particularly with chloroquine, was widespread but under-dosing was common. Poor knowledge related to malaria transmission (42% of men, 36% of women) and high cost prevented purchasing of bed-nets.
• Despite the self-care training, poor knowledge scores for 33 questions (18 for men, 17 for women) (P = 0.001) favoured incorrect use of chloroquine, not using chloroquine to prevent and treat malaria in pregnant women, irregular use of bed-nets, not using personal protective measures against the vector and not giving priority to source reduction.
• Men often made decisions for the first action at home (52%) and administering chloroquine (43%) for simple malaria in adults, while joint decisions were common for the first action at home (69%) and to administer chloroquine (65%) to children, indicating an unmet requirement for training of men. Despite the self-care intervention, the majority perceived that their competencies in caring for a malaria patient did not improve (91% of men, 82% of women) (P < 0.0005) as over half of the respondents (76% of men, 53% of women) (P < 0.0005) did not use the manual or had difficulty in understanding it.
• An important barrier to correct treatment with chloroquine was the difficulty in understanding the tabular format for its doses given in the manual, worsened by poor knowledge of drug sellers.
• Matched pair analyses revealed poor agreement to seek help from the formal sector by only 38% of couples.
• Though women believed training was confined to them, 96% of men thought that they should also attend. Low attendance rates of women at the training (45%) and distribution of manuals to households with low literacy rates did. not allow villagers to improve their knowledge.
• Although the manual was perceived as useful by 96% of men and 78% of women (P < 0.0005), it was used by only 24% of men and 47% of women (P < 0.0005). Non-use of the manual was higher for men in fishing non-remote villages and for women who worked all year round. Households with literate males and previous experience of malaria had lower chances of men using the manual, while the presence of representatives at the self-care training, higher levels of schooling and good literacy skills favoured women's use of the manual.
• Residing in fanning villages (remote and non-remote) and working all seasons significantly contributed to women's preference for face to face discussion and health talks and journal/posters/pamphlets over the self-care manual.
Tackling gender issues alone cannot solve the problem of poor knowledge and practices. Targeting men for training and health education, sustaining functional literacy, creating opportunities for household income generation, improving access to sources other than the self-care manual, modifying the manual into a more readable format, training drug sellers, strengthening collaboration between authorities, health workers, education sector and local Maternal and Child Welfare Associations could improve self-care and accessibility to diagnostic and curative services.