The world health report

Chapter 3

Perceptions of health risks in developing countries

Risks to health, as an area for further study, have only recently begun to receive attention in developing countries. The need to view such risks in their local context is obvious when analysing perceptions of risk in these countries, especially when risk factors are considered alongside life-threatening diseases such as tuberculosis, malaria and HIV/AIDS. There are also other daily threats, such as poverty, food insecurity and lack of income. In addition, families may face many other important "external" risks, such as political instability, violence, natural disasters and wars. Thus every day there is a whole array of risks that have to be considered by individuals and families.

Models of individual risk perception and behaviour were, however, mainly developed in industrialized countries where people have considerably higher personal autonomy and freedom to act, better access to health information, and more scope for making choices for better health. These models may be less appropriate in low and middle income countries, where illnesses and deaths are closely associated with poverty and infectious and communicable diseases (35). In industrialized countries, studies of HIV/AIDS and, to a lesser extent, noncommunicable diseases such as cancer (5)and coronary heart disease(33) have been carried out using the perspectives of applied medical anthropology and sociology (36). However, in developing countries where communicable diseases still cause a high proportion of the avoidable mortality, these disciplines have most frequently been coopted to help evaluate the effectiveness of disease control programmes. Perceptions of disease, use of health services and reasons for non-compliance are some areas often studied (37).

For communicable diseases, it is important to differentiate perceptions of the risk of a disease from those concerned with the risk of acquiring the infection, particularly as not all infections, such as sexually transmitted infections and tuberculosis, will develop into symptomatic disease. Interrupting transmission of infections, for example through the use of measles vaccine or bednets in malaria control, is the main way in which control programmes reduce risk. In such situations, risks are often determined from the point of view of whether an effective response exists in practice. Thus effectiveness evaluation is based on such indicators as early recognition of signs for severe illness (for example, acute respiratory infections), symptoms requiring self-referral for treatment (for example, leprosy and schistosomiasis), or use of impregnated bednets to prevent malaria transmission. Much of this anthropological research for effectiveness evaluation has been supported by multilateral agencies and bilateral donors, including WHO and UNAIDS.

Because of the effects of the demographic and epidemiological transitions, many middle and low income developing country populations face existing risks from communicable diseases, as well as rapid increases in risks to health from many risk factors and noncommunicable diseases. Although avoidance of risks of infection, often perceived as risk of disease, are implicit in most biomedical and public health models of disease control in developing countries, more research from the anthropological point of view is clearly needed to place these risks in perspective among a whole array of other risks to life. Given competing risks, it cannot be assumed that if people are better informed on their exposures to risk factors they will necessarily act to change their health behaviours.