Social demographic characteristics of participants
Twenty-one focus group discussions (eight FGDs with women, seven FGDs with men and six FGDs with health workers) were done. Two in-depth interviews with the district malaria coordinator and District Health Officer as key informants were also held. A total of 197 respondents participated in this study (94 women, 57 men, 44 health workers and two KII).
Out of 94 women who participated, 6% were below 20 years of age, 92% were aged between 20 and 40 years and only two women were more than 40 years old. Most women (81%) had at least some education at primary or secondary school level and majority (88%) were involved either subsistence farming or small-scale businesses. The male participants were older with 80% aged between 20 and 40 years and 18% aged more than 40 years old. Just like the women, most men were involved either in subsistence farming or small scale business. Out of 44 health workers involved in FGDs, 13 were nurses, six were clinicians, five were medical assistants, 13 were community health workers and seven were hospital servants.
The possible sources of malaria treatment available to these communities included traditional healers, small groceries, the rural health centre, few private clinics and fellow friends with left over drugs from a previous illness.
Results are presented thematically below while Additional File 1
summarizes these findings.
Knowledge of the causes of fever and danger signs of malaria
Ability to recognize fever and associate it with malaria was very high amongst the caregivers. Fever or hot body meant that a child has malaria. However, when participants were directly asked what caused the fever in under five children, both male and female caregivers listed non-fever causes. This included poor sanitation in the home, cham'mimba which refers to uterine contraction during delivery, coldness, sleeping without a blanket, soaking in the rains, malnutrition, playing in the dust, not bathing the child, eating un-boiled food, playing in water and a result of falling down during play. Malaria, pneumonia, immunization, headache, cough, sneezing, teething, persistent crying, diarrhoea, anaemia, blisters in legs or arms, known as mwana mphepo in local language, and acute respiratory infections were also mentioned as causes of fever in children. There were strong beliefs also that mother's reproductive tract illnesses locally called mauka were responsible for fever in under-five children. Out of 15 FGDs with caregivers, 10 FGDs mentioned pathological vaginal growths such as warts and six FGDs mentioned vaginal itching, (mauka), in the mothers as being the cause of fever in under-five children.
One woman said:
"According to our traditional beliefs, fever in children under-five years old is due to various types of mother's reproductive system disorders such as vaginal itching, vaginal discharge and genital warts."
One man said:
"If a child has fever on and off, we call it 'Mauka'. The fever may disappear in the morning, then resurface in the afternoon and fever cools down at dawn."
Health care providers similarly mentioned that majority of caregivers recognize fever. It was mentioned that most women in rural areas associate fever with malaria and also link fever to mother's reproductive tract illnesses such as vaginal growths and discharge. As a result, most caregivers were of the opinion that childhood fever could only be treated if the mother's illness was appropriately treated first either by traditional healers or at the local health facility (See Table : Causes of fever mentioned by caregivers).
Causes of fever mentioned by caregivers
Majority of caregivers mentioned that apart from fever, vomiting, diarrhoea, lethargy, refusing to suck, refusing to eat, irritability, bulging fontanelle, rash, rigors, coughing, groaning and sunken eyes, were signs and symptoms they consider to diagnose that a child has malaria. Most of caregivers mentioned high fever, lethargy, refusing to eat/suck, frequent vomiting and diarrhoea as major signs of malaria. Other danger signs reported in few FGDs include bulging fontanelle, weak eyes, rigors, groaning, irritable, rash, pneumonia and mother's reproductive tract illnesses. Ignorance of danger signs of malaria was high with very few participants mentioning convulsions and anaemia as danger signs. Of all 15 FGDs with caregivers, only two had members who were able to link anaemia with malaria.
One woman said, "I go to the hospital same day of onset of fever because we fear that the child would become anemic if we don't treat him faster"
None of the FGDs, except one, linked convulsion to malaria. Convulsions and in some FGDs, anaemia, was attributed to other causes, such as epilepsy and witchcraft respectively.
One woman said, "I was just giving my child panadol because they didn't find any problem with the child at the hospital. However, things worsened when I went home as the child started convulsing and I thought it was epilepsy. We gave him herbs but did not respond favorably. Then we decided to go to the hospital, the doctor said, the child had been ill for quite some time and this was not good to bring a child for medical attention too late."
One medical assistant attested, "I have referred a child today who has been convulsing and the mother thought that it was epilepsy or witchcraft yet it was malaria".
Treatment patterns for fever
Most caregivers reported that they manage fever at home by tepid sponging; bathing the child with cold water, give water frequently, visit the herbalist to cure 'mauka', covering the child with warm clothes and giving antipyretics, such as paracetamol. The coverage with effective malaria treatment is much lower, only one FGD with the women mentioned that they give Sulphadoxine-pyrimethamine before they go to the hospital. They acknowledged that treatment for malaria with any anti-malarial drug was given after more than 48 hours, because in the first 24 hours antipyretics were given as first aid for fever and were viewed as effective treatment for fever.
One woman said, "We give our children panadol because it is what we are given when we go to the hospital with a child suffering from malaria."
According to health workers, when mothers were asked for drugs they administered to children before seeking treatment at a health facility, majority of the mothers mentioned antipyretics and antibacterial treatment. Anti-malarial treatment, such as Sulphadoxine-pyrimethamine was only given when the child's symptoms did not improve following the use of antipyretics and anti-bacterials.
A clinician at Neno rural hospital said, "Women say, we gave him/her panadol thinking that it cures malaria."
For those who believed that fever was caused by the mothers' illness, traditional healers were their first source of treatment for fever:
One man said: "If a child has fever on and off we call it mauka (vaginal growths) and the best remedy is having those warts removed by the traditional healer and the fever in the child will disappear 3 to 5 days after removing the mauka".
Health care providers confirmed that caregivers' belief in traditional healers was one of the reasons distracting attention from prompt effective treatment of malaria as reported by one clinician:
"So many times, I see fresh tattoos on children's bodies as I examine them which confirm a visit to a traditional healer."
Poor access to anti malarial drugs at the community level
In all the FGDs, lack of access to anti-malarial drugs was mentioned as one of the problems that prevented caregivers from giving the needed drugs promptly. Financial constraints to buy anti-malarial drugs, inadequate knowledge on the correct dosage, and fear of giving expired drugs from shops and distance to health facilities were some of the main reasons given for failing to provide an effective anti-malarial treatment within the home.
One woman said, "It is a long distance to the health facility, so we give panadol purchased from the shops first and wait for the child to improve. We go to the hospital when there is no improvement. There are no anti-malarial drugs in the community except for left over drugs given from the hospital sometimes from a previous episode".
Perceived severity of fever
Caregivers had their own way of categorizing fever into mild and severe. In general, children with fever who are able to play were classified as having mild fever whereas febrile children who could not play were considered as having severe fever. Most caregivers did not appreciate the potential harm of mild fever, hence the delay in starting appropriate treatment. This was corroborated by health workers who believed that caregivers only sought effective treatment when life-threatening symptoms and signs were noticed. Health workers from all facilities said that 30% of under- five children only sought treatment from public health facilities when severe signs such anemia, convulsions, respiratory distress and cerebral malaria had developed.
One clinician said, "Most women say that their child has been ill since dzana (three days ago) and they come to the hospital with bad cases like complications of anaemia and you know that it is not dzana but sometime back".
This is evidenced from FGDs with women when they were asked time they take to treat children from onset of fever. Majority of the women admitted that treatment was only sought from health facilities more than 48 hours after symptoms developed or only when symptoms were considered severe.
One caregiver said, "It depends on severity of fever, if it is not severe, we stay. When we have given the child painkillers and the fever goes down within 2 to 3 days, we don't go to the hospital and we conclude that it was not malaria, but attribute this to something else like food poisoning".
Health facility characteristics as barriers to prompt treatment of fever
Health facilities promote long queues due to the design of the system which mixes adults, youths with under five children and due to the fact that there is no specific clinician for under five children. The facilities close at 12 o'clock, for a lunch break, leaving behind a number of children unattended. Further, the facilities are closed during weekends and sometimes the medical assistant is not around.
"I visited the hospital very early and when I saw the clinician coming, I thought he wanted to open the hospital, only to be told that go and buy drugs in the shop, am going to Mwanza boma."
Health workers and caregivers also mentioned other facility-based factors such as shortage of drugs and lack of diagnostic capacity as reasons for not seeking care promptly.
One woman said, "We get demotivated after walking to the health center, waiting for treatment and only to be told that drugs are out of stock".
Some caregivers complained of mistreatment by health workers as reasons for not seeking care at health facilities. They reported that there is no triage at the hospital a result some children die while on the queue and due to long queues clinicians make hasty examinations, missing out some relevant information for appropriate treatment.
Another woman said, "They question, 'where were you in the morning?' Yet we don't plan that a child falls sick in the afternoon, and are shouted at badly"
During health worker FGDs, health workers acknowledged that there is usually a shortage of staff, which negatively affects their attitude towards care seekers.
One clinician said, "Just imagine, we sometimes see over 120 patients a day and we get tired and we may speak badly in the process."
Lack of women empowerment in decision making
The majority of women caregivers felt that they were not empowered to make decisions affecting positive health-seeking behaviour independent of their husbands or other family members. Health workers and caregivers highlighted that the absence of family heads or other key decision makers from households often contributed to delays in seeking care.
Most women reported that their health-seeking behaviour is very poor because men usually don't respond when a child has fever; they respond only when a child's condition worsens.
One woman said, "Men are not moved with fever but when they see the child is very sick, breathless and your facial expressions have changed, that's when they panic and take a step to seek medical attention."
Men in FGDs reported that they are always busy and have no time to attend to a sick child and women fail to decide to seek medical attention.
One man said, "When the women say the child has fever, we tell them to buy panadol for the child. Thereafter, we go on to attend to other activities; we get to see the child later".
A medical assistant said, "One woman came with a very sick child and when asked about the delay she said that she was waiting for approval from her uncle who was in Mozambique by then."