Transcript Poster presentation

Title: Constructing the Meaning of
Malaria Illness and Its TreatmentSeeking Behaviour in Children under
the Age of Five Years among the
Winamwanga of Nakonde District,
Northern Province of Zambia
Institution (s): Mwengu Social and Health Research Center,
Ndola, Zambia and Applied Research in Child Health, LusakaZambia
Author (s): Tuba M, Kaona FAD, Mac'wangi M
Supported by: Applied Research in Child Health (ARCH)
Project, At HIID, Harvard University, through a grant from
International Network for Rational Use of Drugs (INRUD), USA.
BACKGROUND
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The degree to which health education influences recognition,
treatment seeking behaviour, dispensing practices, as well as
antimalarial drug use,-were not well understood in Zambia.
The study was conducted in Nakonde District, Northern Province of
Zambia in 2000.
Objective: To investigate how households identified and treated
malaria in children five years and below.
Nakonde is in the hyper endemic Malaria Province where
plasmodium falciparum is predominant.
Population is about 153,548.
Mostly peasant farmers.
MATERIALS
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Design: A sub-sample of caretakers from those who had taken their underfive children suffering from fever to a health facility was drawn. Key
informant interviews were conducted with local leadership, indigenous
healers, drug vendors, male heads of households; Traditional Birth
Attendants were conducted at household level. Those who participated in
the in-depth interviews were 15 years old and above.
Setting: Community based survey.
Study Population: A total of 35 in-depth interviews consisting of 13
caretakers whose children presented with fever at the health facility. Others
included 5 indigenous healers, 5 health care providers, 5 headmen, 2 TBA's
and 5 male heads of households.
Outcome Measures: Definition and identification of malaria; treatment
procedures at household, community and health facility levels; and types of
antimalarials used for treatment.
RESULTS
Causes of Malaria
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Finding out what the community believed caused malaria was important. Informants were asked to give what they
thought were causes of malaria.
Social environment
A male caretaker aged 26 years old said;
There are many reasons why people develop malaria Faith (referring to spirit). Eating some type of relish, bad
water and many others.
Natural environment
Further statements concerning causes of malaria were sought. A 32-year-old female caretaker reported thus:
Malaria? Yes, some people believe that it is by drinking bad water, exposure to wind, getting soaked in cold water
and sleeping at the funeral.
Spiritual environment
Further in-depth interviews revealed that evil spirits or witchcraft might cause persistent fever. One 52 year old
indigenous healers said:
These are evil spirits and bad people what can we say mama? [referring to the anthropologist who was a lady]
Supporting the causation given by the healer, a 56 years old opinion leader reported:
…you see in these villages, we people look at each other differently, if you have many children, your friends are
not happy, suddenly the child has high fever. I mean a child like this one [pointing at a boy of about 3 years old]…
Causes of malaria were multi-faceted, which included witchcraft, getting soaked in cold water, exposure to wind,
sleeping at the funeral, eating some type of relish, bad water and spirits.
TYPES OF FEVER AND THEIR
TREATMENT
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Natural fever
It was important to establish whether caretakers of children five years old and below could
identify fever as a key symptom to possible malaria episode in children under the age of
five years. One male informant aged 38, who was a head of household warned against
fever in children:
a child, I mean your own child, he is having fever the one all children sometimes have.
(ordinary fever). According to these findings, management of fevers by most of informants
was done at household level. An episode of fever was a natural and acceptable thing,
since it was believed to come from God. Causes of ordinary fever were believed to be
beyond the carers’ control. It was said every child has fever, giving episodes a natural tag
free from stigma. In implication, fever was believed to be unpreventable.
Treatment of Natural fever
The first thing caretakers did when they identified fever in children was an important action
to establish. A 32-year-old married mother of a 3-year-old child was asked, she reported
thus; You know, when a child is hot, you pick the leaves and bath her.
One head of household aged 48 years old reported; I mean, your own child, he is having
fever, the one all children sometimes have, this normal fever, when you steam, then it goes
away.
Reports from many informants were in support of this action.
TYPES OF FEVER AND THEIR
TREATMENT CONT.
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Small malaria
Prolonged fever forced carers to move perceptions to another level, where fever begun to be associated with
malaria. Causes of small malaria comprised eating some type of relish, bad water, drinking bad water, exposure to
wind, getting soaked in cold water and sleeping at the funeral.
Another informant who was an opinion leader reported;
Malaria comes in many forms. There is that one impep [referring to simple malaria], were the body ukulungula
[gets very hot] it changes. This time it gets cold. Sometimes the head ukuluma [have headache], the joints
pain, the whole body starts to pain. The next time it gets cold uzakazaka [you shiver].
In-depth interviews have revealed that in rural Zambia, a combination of signs and symptoms was key to
constructing malaria in the under five children.
Treating small malaria
It was common for most informants to mention involvement of drug vendors and other respectable elders living in
the village, as the third and forth lines of treatment for prolonged fever (see chart 1). During in-depth interviews,
one married anti-malarial drug vendor aged 28 years said;
Yes, there are herbs we use to treat impepo. Some of these herbs I know them as Chesa [indigenous herb], but I
cannot identify them. There are elders in the village who know it.
In addition, drug vendors were mentioned as sources of treatment at levels 3 and 4. A mother of a three year old
under five children said;
For children, because they are very young, you take a chloroquine tablet, and break it in four, you give quarter,
four times a day, for one day. By the time you give the second quarter, the child is playing.
When fever moved from being natural to small malaria, treatment was mainly outside the home. Treatment
sources included consultation with the family members, respectable community elders and drug vendors.
Consultation with elders marked the beginning of use of oral indigenous medicines, while consultation with drug
vendors’ marked initiation into use of biomedical anti-malarial drugs that mainly constituted chloroquine. At this
point it was common for most carers to combine the two therapies.
TYPES OF FEVER AND THEIR
TREATMENT CONT.
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Big malaria
It was common for many informants to classify malaria as big, when the child did not respond to treatment
administered either during natural fever or small malaria. Prolonged fever changed definition of malaria, shifting its
cause to the supernatural world, which symptoms were persistent fever, vomiting, diarrhea, convulsions and
hallucination, speaking to oneself, use of strange language, fitting and shivering. It was common for most
informants to provide both simple and complicated malaria. A 54-year-old key informant who was indigenous
healer said:
Severe malaria…[says it in English], we call it inzekema. A lot of times we don’t know what causes cerebral
malaria (says it in English). We only know that this stage, it is cerebral malaria. and that it is the spirit that has
caused that, when one starts hallucinating, this is when they start saying… they have seen that when it is not
there.
Emphasising on key symptoms that were suggestive of big malaria, a 36-year-old head of household said;
But you see by the afternoon, he changes, And then you see him start seeing things ordinary eyes cannot see
people are difficult. he begins to speak to himself a language you cannot understand, he has high fever, vomits
and sometimes fits, then you know this is malaria and it is big malaria. (big malaria)
Treating big malaria
Once the cause of malaria was defined within the spiritual world, treatment regimes automatically changed, which
is consistent with Ghana findings. Primary treatment focused on the spirit, hence, neglecting the biological
therapy. This was the major conflict that was established between policy makers and community. Stressing on
the change in constructing malaria, one 72-year-old indigenous healer clearly reported;
If the temperature does not go down, that is when we use mbozyo [indigenous herb]. It means somebody is
playing with your spirits, you give them mbozyo, so that the bad spirits do not haunt the patient.(big malaria)
When identifying fevers in children under five years old, three types were found namely: natural fever, small
malaria and big malaria. One 58-year-old informant who was the head of household strongly stressed on use of
indigenous healers and said;
How do you even ask? we live almost 20km from the health center. With this work, can you manage getting to the
clinic? No, no father. It is not easy, even if we go there, the doctors [referring to clinical officers and nurses] can
they give you even one grain of chloroquine? So, we go to ba singa’nga for help, which is what they mainly know.
Use of health facility
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A 43-year-old Traditional Birth Attendant stressing on
further action after consultation from healer failed to yield
positive results reported;
When my child has fever, which is not stopping, I take
him to the hospital, then they can say whether it is
malaria or not, sometimes when you feel cold it may not
be malaria.
Many informants reported contemplating reporting
persistent fever to the “hospital” at this stage, so that the
child could be examined and investigated further. It is
important to note that at this stage six to seven days
could have elapsed since fever was first identified.
Lessons learned
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The important issue raised by this study is that social
environments, natural and spiritual environments
determined construction of meaning of malaria,
diagnosis and treatment in rural Zambia.
Close collaboration with indigenous healers may improve
prompt and early use of specialized health care.
Carers in rural Zambia used combined therapy to treat
severe malaria in under fives
This paper revealed significant conflicts regarding
causes of malaria and treatment recourse between
policy makers and the rural community.
Immediate Term implications for
implementing policies and programmes
to improve use of medicines
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Findings from this in-depth study have reaffirmed that the first five actions taken by
most carers in rural Zambia comprised
home management.
Long Term implications for implementing
policies and programmes to improve use
of medicines
Rapid assessment surveys should
precede implementation of any
intervention,
 Promote community based interventions
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Studies resulting from this work
Training indigenous healers in early
identification of severe malaria and
promote appropriate treatment of malaria
 Promote prompt referral practices among
healers
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Acknowledgement
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Applied Research in Child Health (ARCH) project – Harvard: USA,
for their financial and technical support rendered.
Tropical Diseases Research Center under which institution the study
was conducted
MIM conference organisers held between 17th and 22nd November
2002, in Arusha – Tanzania. Their sponsorship to enable us attend
this valuable conference was a source of encouragement and
motivation to writing this paper.
Her Royal Highness Chiefteness Waitwika of the Winamwanga
people, who mobilized and encouraged communities through her
headmen and village secretaries to support this important study.
Nakonde district residents together with the District Health
Management Board for their patience and endurance during the life
of this study.
Figure 1: Health Seeking Behaviour Patterns of Carers
for Children Five Years Old in Rural Zambia When
Treating Fever
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Action 1:
Caretaker
Sponge bath
HOME MANAGMENT
Action 2:
Caretaker
Steaming
HOME MANAGEMENT
Action 3:
Consult family,
Administer
Drug vendors Anti-malaria drug
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HOME MANAGEMENT
Cont. Health Seeking Behaviour Patterns of Carers for
Children Five Years Old in Rural Zambia When Treating
Fever
Action 4:
Consult family,
other elders
Indigenous herbs
used
HOME MANAGEMENT
Action 5:
Consult
Indigenous healer
Use indigenous
Herbs
HOME MANAGEMENT
Action 6:
Consult
Specialised
Health care
Health
Facility
HEALTH FACILITY
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CONSTRUCTING MALARIA IN
CHILDREN UNDER FIVE YEARS
Inzekema
Highfever,
vomiting,
hallucinating, fitting,
loss of appetite
shivering, diarrhoea
convulsions
Impepo
Fever,
coldness,
body
hotness, severe
headache , flu, body
weakness
Ordinary fever
Fever alone