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

"It is clear that perceptions and beliefs held by caregivers impact the way they look for treatment for their children. Health education messages need to be strengthened to ensure caregivers are aware of the importance of diagnosing the illness and treating it appropriately. Health professionals should give clear instructions, both verbally and pictorially, at the time of dispensing the medication." - Dr. Victoria Ewing

Noting that symptoms of malaria overlap with symptoms of other illnesses in the local Malawian conceptualisation as well as in the biomedical model, researchers from the ACT Consortium conducted an investigation in the Chikhwawa district to describe local classifications of childhood febrile illnesses as part of their quest to develop an overview of treatment-seeking, beginning with recognition of illness and considering utilisation of all and multiple sources of care. Barriers to effective treatment-seeking are discussed for each treatment-seeking phase. "Each step in the treatment-seeking pathway must be considered in order to establish where opportunities for successful engagement and treatment occur."

Mothers and other caregivers from this rural area in Malawi with low literacy levels and a high level of poverty, seek help depending on what they believe is causing their children's fever. Seeking treatment follows a 3-step approach: analysing symptoms and managing the illness at home, leaving the house to look for treatment, and finally assessing whether treatments work. To analyse this approach, researchers collected qualitative data between September 2010 and February 2011, conducting 12 focus group discussions (FGDs) and 22 critical incident interviews (CIIs) with primary caregivers who had reported a recent febrile episode for one of their children.

Participants described fever as "kutentha thupi" or"hot body", which could be caused by malungo, or malaria, but also other causes such as the weather, hunger, and excessive crying. The symptoms that they described for malaria overlapped with other local illnesses. Participants were aware of other illnesses that cause fever or convulsions, and named examples such as tetanus and epilepsy, while all participants interpreted "collapsing" as a sign of severe malaria. The study found that it may take up to 5 days to seek health care for an illness causing fever. When the child was unable to eat or play, these were reported as signs that a hospital visit was necessary and where "[i]t won't help to buy drugs from a shop," one participant explained. Other factors included which household members had the authority to make decisions about finding the correct treatment and the distance from health facilities. The costs and time required for different options to seek treatment were also important influences. These factors led participants to "buy time" by using paracetamol from drug shops to control the fever at home in the first instance. In phase 2, a sing'anga (traditional healer - asing'anga plural) was perceived to be the only place to receive treatment for illness caused by witchcraft, tsempho, nyankhwa, and usually mauka. Asing'anga were thought to be the only ones capable of identifying witchcraft as the cause. Despite this, most FGD participants stated that if the illness did not resolve after the assessment period, care would be sought from a formal health facility initially. Reasons for doing this rather than visiting a traditional healer included: the potential for malaria to progress rapidly, leading to death; difficulty in recognising traditional causes of illness; and the importance of biomedical diagnosis. The treatment-seeking process was not linear and caregivers described how after attending a source of care outside the home, in phase 3, they would then assess whether treatment had worked.

"The three-phased approach to treatment-seeking demonstrates the importance of considering the entire treatment-seeking pathway from initial assessment of illness severity, including attendance at non-formal sources of care and responses to non-resolving fever both by caregivers and health facility staff. Strengthening of community level care is required to improve the accessibility of services. This should be combined with focused community engagement and health promotion programmes that engage those involved in decision-making and treatment provision at each phase of the treatment-seeking process." For example, community-based health education and promotion programmes designed to engage with all those involved in treatment-seeking or provision of care within communities, including shop-keepers and traditional healers, may help to improve phase 1 decision-making. Bringing care nearer to individuals' homes by adding quality assured artemesinin combination therapy (ACTs) to the package of care delivered by community health workers (CHWs) at the community level, may improve access to appropriate treatment. Health facilities have been found to be more frequently used in the first instance in situations where it is difficult to obtain antimalarials through informal sources and where treatment from public health facilities is free, both of which are true in the Chikhwawa district of Malawi. Traditional care was reported to be used initially in some cases if the febrile illness had a perceived link to maternal reproductive illness. According to the researchers, this highlights an area requiring focused community engagement and health promotion activities. Community engagement can provide opportunities for community reflection on current practices and enable the community themselves to establish appropriate changes. Involving influential decision-makers, such as grandmothers, has been shown to positively influence treatment-seeking behaviour. The potential role of health workers in communicating accurate information about the causes of, and appropriate responses to, non-resolving fever has become more important with the increasing recognition that many childhood fevers are not due to malaria. Within the Malawian context, health workers' knowledge of these topics must first be strengthened, the researchers urge. This should include training in the causes and treatment of non-malarial febrile illnesses and the consideration of underlying chronic conditions.

The National Malaria Control Programme in Malawi is planning training of health workers in remote villages in the country on how to diagnose and treat malaria and recognise other illnesses that cause fever. Researchers from the ACT Consortium based in the Malawi-Liverpool-Wellcome Trust programme suggested that the training will help address current delays at the stage of seeking health care.

The ACT Consortium is funded through a grant from the Bill & Melinda Gates Foundation to the London School of Hygiene & Tropical Medicine.