Understanding Interpretations of and Responses to Childhood Fever in the Chikhwawa District of Malawi

Abstract

BackgroundUniversal access to, and community uptake of malaria prevention and treatment strategies are critical to achieving current targets for malaria reduction. Each step in the treatment-seeking pathway must be considered in order to establish where opportunities for successful engagement and treatment occur. We describe local classifications of childhood febrile illnesses, present an overview of treatment-seeking, beginning with recognition of illness, and suggest how interventions could be used to target the barriers experienced.MethodsQualitative data were collected between September 2010 and February 2011. A total of 12 Focus Group Discussions and 22 Critical Incident Interviews were conducted with primary caregivers who had reported a recent febrile episode for one of their children.Findings and ConclusionThe phrase ‘kutentha thupi’, or ‘hot body’ was used to describe fever, the most frequently mentioned causes of which were malungo (translated as ‘malaria’), mauka, nyankhwa and (m)tsempho. Differentiating the cause was challenging because these illnesses were described as having many similar non-specific symptoms, despite considerable differences in the perceived mechanisms of illness. Malungo was widely understood to be caused by mosquitoes. Commonly described symptoms included: fever, weakness, vomiting, diarrhoea and coughing. These symptoms matched well with the biomedical definition of malaria, although they also overlapped with symptoms of other illnesses in both the biomedical model and local illness classifications. In addition, malungo was used interchangeably to describe malaria and fever in general. Caregivers engaged in a three-phased approach to treatment seeking. Phase 1—Assessment; Phase 2—Seeking care outside the home; Phase 3—Evaluation of treatment response. Within this paper, the three-phased approach is explored to identify potential interventions to target barriers to appropriate treatment. Community engagement and health promotion, the provision of antimalarials at community level and better training health workers in the causes and treatment of non-malarial febrile illnesses may improve access to appropriate treatment and outcomes.

Increasing understanding of the relationship between geographic access and gendered decision-making power for treatment-seeking for febrile children in the Chikwawa district of Malawi

“…Participants differentiated between “ordinary fever”, and that requiring malaria treatment, using a ‘wait and see’ approach which usually took between 2 and 5 days (A detailed analysis of this approach and perceptions of severity has been published elsewhere [13]). Participants explained that formal health facilities were the most appropriate source of care for fever assessed as requiring malaria treatment.…”

“…Qualitative analysis adds depth and complexity to these findings. In addition to recognizing the need for seeking formal care outside the home which have been discussed in a another previous paper [13], participants’ accounts of decision-making considerations and processes highlight the interaction of distance to facilities and the anticipated costs related to this, with access to resources to meet costs and decision-making autonomy.…”

“…Qualitative methods were therefore used to add depth of understanding to the previous quantitative findings. Earlier qualitative work in the district examined how decision-making on whether and when to seek care outside the home in this setting is guided by interpretation of illness causation and severity [13]. This paper presents qualitative findings that explore how gender and generational dynamics in the decision-making process interact with geographic access to services and anticipated costs to further add to the complexity of the treatment-seeking decision-making process and delays in seeking care.…”

Principles, practices and knowledge of clinicians when assessing febrile children: a qualitative study in Kenya

“…Outside of the neonatal period, common febrile illnesses including malaria, diarrhoea, and pneumonia are still the leading causes of mortality in Kenyan children [ 9 ]. Prior qualitative studies of both clinicians and caregivers in various communities in African countries have indicated that resource availability, need for additional training in differentiating non-malarial viral and bacterial illnesses, and lack of understanding within the community of when to seek care play a role in effective diagnosis and treatment [ 10 – 13 ]. In one prior study, health workers in Zanzibar identified a need for improved point-of-care testing for diseases other than malaria.…”

Challenges of malaria diagnosis in clinical settings and disease surveillance under reduced malaria burden in Tanzania

“…Traditionally, patients have equated fever (hot body) to malarial illness [60]; thus when laboratory findings show no malaria, clients get disappointed and may opt to consult another laboratory, because quite often the reason for demanding a laboratory test for malaria is to get the assurance that the fever is due to malaria and thus a justification to take an antimalarial drug. Most community members in malaria endemic countries, including Tanzania lack the correct knowledge about the causes of febrile illnesses and most have the notion that fever and malaria are synonymous and quite often used interchangeably [30,54]; therefore even at a time that malaria has remarkably declined, malaria is still perceived to be a much more common cause of fever [12,13,61,62]. Due to lack of knowledge, most clients expect a positive malaria test and when given negative results, sometimes they may not accept them and would put pressure on the prescriber to consider a diagnosis of malaria [63], and if the prescriber do not concur they may resort to self-medication with antimalarial drugs [64,65].…”