Date of Award

January 2024

Document Type


Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Becca B. Levy


Africa has the global heaviest burden of malaria. Sao Tome and Principe, a low-transmission island nation in the Gulf of Guinea with a population of about 200,000, has entered the malaria elimination phase. Despite this, the prevalence and mortality rates of malaria among the elderly in Sao Tome and Principe remain high compared to high transmission areas. This study employed a mixed-methods approach to explore the association between age and recommended malaria management strategies for adults in Sao Tome and Principe, with a focus on examining samples older than 50 years. All participants (N = 274) completed surveys, with in-depth interviews (N = 22), and focus group discussions (N = 5) assessing indigenous disease perceptions and other factors influencing the use of recommended malaria management strategies. Stratified logistic regression showed older age correlated with reduced usage. While the structural equation modeling revealed age indirectly influenced behavior via indigenous malaria beliefs, while age’s direct impact on usage was not significant, suggesting other influencing factors. Narratives and participatory observation underscore the nuanced hybridity of medical pluralism, revealing a coexistence of indigenous and biomedical approaches in malaria management among the elderly in Sao Tome and Principe. Future research should focus on understanding how cultural and social factors influence healthcare behaviors among adults, particularly the elderly population, including the use and effectiveness of traditional treatments in regions approaching malaria pre-elimination. This insight is crucial for improving community engagement, bridging gaps between biomedical and traditional practices, and promoting trust in biomedical measures among the elderly.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/07/2026