Transcript of "Perceptions of malaria and treatment-seeking in Tanzania"
Perceptions of malaria andtreatment-seeking inTanzania Matthew Rollosson, RN, BSN, CNRN TRMD 782 18 April 2008
Qualitative studies• Surveys of household/individuals • Traditional healers Hausmann Muela, 2002 Hausmann Muela 2002 Minja, 2001 Gessler, 1995 Ringsted, 2006 Makundi, 2006 Tarimo, 1998 Warsame, 2007• Mothers/caregivers • Health workers accompanying <5 year olds at Comoro, 2003 health care facilities Warsame, 2007 Nsimba, 2002 Tarimo, 2000 • Verbal autopsy: families/mothers Warsame, 2007 of children that died de Savigney, 2004• Group meetings: mothers, village Makemba, 1996 members Comoro, 2003 Oberländer, 2000 Warsame, 2007 Winch, 1996
Tanzania• Population: 34.5 million• 16 million cases of malaria reported each year• 100,000 to 125,000 death due to malaria/year• 70,000 to 80,000 deaths of children under 5 years of age Makundi, 2006• Entire population of Tanzania is at risk for malaria de Savigney, 2004
Access to health care• 90% of Tanzanian live within 1 hour of government health facilities• Treatment of children under 5 years of age and pregnant women is free of charge at government health facilities• Non-governmental health facilities• Antipyretics, antimalarials also available at private pharmacies, shops, kiosks de Savigney, 2004
Access to health care• Informants frequently complained about difficulty arranging transportation to health facilities• Government facilities frequently lacked supplies Warsame, 2007• Traditional healers usually the most convenient health care providers in rural areas
Health care providers• 1 : 33,000 medical doctors/population Makundi, 2006• 1 : 7,431 health care facilities/population• 1 : 1,122 nurses/population MOH, 1999• 1 : 350 traditional healers/population Makundi, 2006
Health education• A frequently mentioned health education campaign is Mbu ni Afya (Man is Health) • a series of radio broadcasts with accompanying study guides and group meetings in the 1970s• Tanzanians also receive health education from researchers working in their districts• Health care providers Hausmann Muela, 2002; Minja, 2001
Health education• Some of the informants in these studies named Plasmodium as the malaria parasite transmitted by the bite of the female Anopheles mosquito• Means of preventing malaria transmission are frequently mingled with other health messages from the Mbu ni Afya campaign • keeping the area around houses clean • drinking/contact with dirty water Gessler, 1995; Hausmann Muela, 2002; Oberländer, 2000
Mosquitoes• Malaria believed to be caused by mosquitoes • risk of malaria believed to be proportional to size of mosquito population Comoro, 2003; Hausmann Muela, 2002; Minja, 2001; Winch, 1996• Unsure how mosquitoes acquire malaria parasites • mosquitoes drink dirty water • possibly Mtu ni Afya message mingled with malaria message Hausmann Muela, 2002
Mosquitoes• Others doubt link between mosquitoes and malaria • difficult to understand why every mosquito bite does not result in malaria • malaria perceived to be a mild or ‘normal’ illness • mosquitoes seen as a nuisance, but not a health threat Gessler, 1995; Minja, 2001• Link between mosquitoes and severe malaria questioned • “Everyone would be dead” Minja, 2001
Knowledge of malaria• Recognition of malaria symptoms usually occurs in the home• Mothers’ familiarity with and recognition of signs and symptoms of mild malaria is well documented in these studies and studies conducted in other sub-Saharan African countries• Mothers’ perception of malaria symptoms correlates well with biomedical definition of mild malaria
Homa• Fever• Not specific to malaria• Symptom of malaria most frequently mentioned by mothers and caregivers• Homa often used interchangeably with ‘malaria’• Often treated at home with antipyretics and/or antimalarials bought over-the-counter • paracetamol, aspirin, chloroquine • malaria perceived to be mild illness, easily treated • under-dosing of chloroquine common de Savigney, 2004; Hausmann Muela, 2002; Tarimo, 1998, 2000; Winch, 1996
Homa• homa ya malaria: term frequently used by health care workers• homa ya mbu: fever due to mosquitoes• homa kali: severe fever• malaria ya kawaida: normal malaria• malaria kali: severe malaria (consistent with biomedical definition of mild malaria) Makundi, 2006; Winch, 1996
Homa• “Homa is the mother of all illnesses”• Viewed as a disease in itself that can progress to other illnesses Hausmann Muela, 2002; Winch, 1996 • mother takes child to a health facility for fever • is told by health care worker child has malaria • fever believed to cause malaria Minja, 2001
malaria ya tumbo• Malaria of the stomach• Vomiting/GI disturbance 2nd most frequently mentioned symptom of malaria Tarimo 1998, 2000• Malaria parasites believed to move to stomach Gessler, 1995; Hausmann Muela, 2002• Vomiting seen as sign of improvement• Associated with witchcraft • vomiting poison from witch • cleansing the body Hausmann Muela, 2002
Witchcraft• “Witches like to ‘play’ with malaria” • create “fake malaria” • people will be mislead into seeking treatment at hospital • witches can interfere with normal malaria by ‘hiding’ the parasites, making them invisible in the blood, undetectable at the hospital Hausmann Muela, 2002• Belief system • “Why does this happen to me and not somebody else?” • “Who sent the illness?” Gessler, 1995
Treatment-seeking for uncomplicatedmalaria• Mothers have high index of suspicion for uncomplicated malaria in children Tarimo, 2000• Uncomplicated malaria not seen as a serious problem by some Hausmann Muela, 2002; Tarimo, 1998, 2000; Winch, 1996• Others consider malaria a ‘hospital disease,’ illness that can only be treated with western medicine Hausmann Muela, 2002; Oberländer, 2000
Treatment-seeking for uncomplicatedmalaria• Western medicine considered to be superior to traditional medicine in treating uncomplicated malaria • infallible• Malaria considered a foreign disease • “[Malaria, tetanus, malnutrition, TB] are not our diseases, these are your diseases!” • “Malaria is something ‘they’ know about, ‘people of your sort’” • “white man’s medicine” Hausmann Muela, 2002; Oberländer, 2000; Winch, 1996
Signs of severe malaria recognized bymothers• Mothers accompanying children less than 5 years of age to health facility • prostration/lethargy/inactivity: 46% • coldness/shivering, sweating: 15% • convulsions: 5.8% • belief that persistent high fever leads to convulsion/worsening of child’s condition: 81.3% • significantly associated with mother’s age >30 and primary school education or above Tarimo, 2000
Signs of severe malaria recognized bymothers• Mothers accompanying children less than 5 years of age to health facility • 38% of mothers reporting their child as having had severe malaria were knowledgeable of symptoms of severe malaria • WHO clinical definition of severe malaria: fever and convulsions or prostration • significantly associated with mothers’ level of education Tarimo, 1998
Upungufu wa damuLack of blood• Anemia most frequent complication of malaria• Considered a separate illness, not related to malaria• Mothers’ recognition of pallor does not lead to action unless accompanied by other symptoms• Breastfeeding failure, prostration/lethargy, ‘soft body’/weakness recognized as danger signs and are predictive of moderate to severe anemia• Mothers able to identify danger signs early and took action within 24 hours Ringsted, 2006; Warsame, 2007• Traditional healers assess anemia by pinching patient’s palm Gessler, 1995
Severe malaria• Manifestations of severe malaria are not associated with malaria• Believed to have supernatural causes • shetani: evil spirits • angered ancestral spirits • witchcraft• Malaria (natural cause) and illnesses with supernatural causes are mutually exclusive• Must be treated by traditional healer• Western medicine believed to be fatal if used to treat severe malaria Comoro, 2003; Gessler, 1995; Hausmann Muela, 2002; Makundi, 2006; Warsame, 2007; Winch, 1996
Degedege• Convulsions in a child• Not specific to cerebral malaria • febrile seizures • meningitis• Sudden onset frightening• Believed to be caused by • bird (dege) flying over the house at night • large moth called degedege • ibilisi: spirit that assumes the form of a bird • shetani Hausmann Muela, 2002; Makemba, 1996; Makundi, 2006; Warsame, 2007; Winch, 1996
Degedege• Some mothers reluctant to say ‘degedege’ • ugonjwa wa kitoto ‘childhood illness’ used euphemistically Comoro, 2003; Winch, 1996• Giving a child with degedege an injection believed to be fatal • shock caused by needle penetration will cause a sudden rise in the child’s temperature • puncture allows spirits to remove all of the child’s blood • will cause convulsions Makemba, 1996; Oberländer, 2000; Tarimo, 2000
Verbal autopsiesBagamoyo District, Coastal Region• Traditional care had been used at some point during illness in 38% of child deaths• 62% of children with degedege had received treatment from traditional healer• 3 to 7 days for traditional healer to treat degedege Makemba, 1996• Switching between traditional and biomedical care common de Savigney, 2004• Belief that degedege must be cured by traditional healer before biomedical care can be used to treat residual illness de Savigney, 2004; Hausmann Muela, 2002; Oberländer, 2000
Verbal autopsiesRufiji District, Coastal Region• Of deaths attributed to malaria: • without convulsions: 88.4% sought modern treatment first, 99.4% by second choice (0.9% switched from modern care to traditional care) • with convulsions: 90% sought modern care first, 29.6% switched to traditional care as 2nd choice • children with convulsions are more likely to be taken to traditional healer first • switching between biomedical and traditional care more likely with children with convulsions de Savigney, 2004
Verbal autopsiesRufiji District, Coastal Region• 21.3% of deaths attributed to malaria did not receive modern care (11.9% no care)• Traditional care may have delayed biomedical care in 9.4% of deaths attributed to malaria• Modern care more popular than previous reports suggest de Savigney, 2004
Severe malaria• Some mothers, including some who live in urban areas, who relate degedege to malaria said they would take child to traditional healer Comoro, 2003• Comoro, et al. (2003) in Kibaha District and Winch, et al. (1996) in Bagamoyo District found that people who had migrated to those areas from other parts of the country were less likely to use traditional healers that indigenous people • viewed as progress, bettering their lives • more likely to send children to government schools, own bed nets, grow new crops
Traditional healers• Herbalist • Most are part-time healers• Herbalist-ritualist – farm rice or cassava • Most practitioners are• Ritualist-herbalist herbalists• Spiritualist • Specialists in spirit• Some have background in possession Western medicine • Craftsman of the Book Gessler, 1995 (Koran and other Islamic• Spirit mediumship holy books)• Healers of the Book • Traditional Birth Attendants• Pure herbalists who treat degedege as a• Knowledgeable women side occupation Hausmann Muela, 2002 Makemba, 1996
Reasons for seeking care from atraditional healer• High empirical efficacy • initial treatment of degedege is cooling the child by sponging or spraying with cool water • febrile seizures more common than cerebral malaria • fever resolution that would have occurred spontaneously• Low empirical efficacy of hospital treatment • delays in getting child to health facility and severity of disease associated with poor outcome Makemba, 1996• Diallo, et al. (2006) in Mali found no statistically significant difference in outcome between traditional and biomedical treatment of both uncomplicated and severe malaria
Reasons for seeking care from atraditional healer• Close proximity Warsame, 2007• Part of African culture • closely linked to belief system Gessler, 1995• Respected members of the community Makemba, 1996• Holistic approach to illness • considered in social context • concerns whole family, community • physical, mental, and spiritual state Gessler, 1995
Five step healing process for child withsevere malaria• Reception • mother warmly welcomed into compound • culturally appropriate greeting• Reduce the child’s temperature • bathing with ground herbs • sponging with warm water• Diagnosis • divination • mother may need to be treated first to remove evil spirits• Treatment • local herbs • to be given over 3 to 5 days• Prevention • ritual Makundi, 2006
Encounter with traditional healer• Takes a history• Examines patient • body temperature • inspects skin and eyes• Talks to family• May send patient to hospital for lab tests Gessler, 1995• Healer takes time to explain disease and treatment Makemba, 1996
Primary health facilities• Long waits in line• Unfamiliar environment• No opportunity to express concerns• Medication given without explanation of cause of illness• Brief encounters with doctor/clinic staff Gessler, 1995• Unofficial expenses (bribes) Oberländer, 2000
Primary health facilities• Nsimba, et al. (2002) observed health care workers at 10 primary health facilities in Kibaha District • average consultation time 3.8 minutes • 75% < 5 minutes, none more than 10 minutes • physical exam performed on 39% of children • for the purpose of this study, merely touching the child was considered an examination • 71% of children treated presumptively for malaria • 38% of those found to have parasitemia • quality of consultation found to be worse in rural areas
Proposed solutions• Tarimo, et al. (1998, 2000) found knowledge of signs of severe malaria significantly associated with mothers’ level of education • improve literacy rates among women
Health messages• Social marketing • messages promoted together with product• ITN marketed under the name Zuia Mbu (prevent mosquitoes)• Marketing messages include • malaria is transmitted by mosquitoes that bite at night • good sleep without worries • malaria causes degedege, bandama, and homa kali Minja, 2001
Collaboration with traditional healers• Makundi et al. (2006) found that 85% of traditional healers had referred malaria cases to health centers• "I abide to the guide from my ancestral spirits who direct the kind of medication to use. Therefore, I cant use conventional drugs "dawa ya vidonge" because my spirits will ask me where I got them from!"• Some traditional healers use biomedical drugs • paracetamol • aspirin
Collaboration with traditional healers• Gessler et al. (1995) spoke to two traditional healers who had started using chloroquine and stopped using traditional medicine to treat malaria• Reasons for combining chloroquine with traditional medicines included • no adverse interactions • speeds up recovery • additional effects • unwilling to interrupt Western treatment
Collaboration with traditional healers• Gessler et al. (1995) found many traditional healers, especially younger healers, expressed interest in: • health training courses • collaboration with western facilities • reciprocal referrals • combining traditional and western medicine • acquiring new approaches in diagnosis and managing health problems • attending training sessions about primary health care issue
Conclusion• Beliefs about malaria, its causes, and treatment are evolving• Tanzanians incorporate health messages and knowledge in culturally meaningful ways• Greater understanding of concepts of illness outside of the Western model can improve the quality and effectiveness of public health interventions
References• Comoro, C., Nsimba, S. E. D., Warsame, M., Tomson, G. (2003). Local understanding, perceptions and reported practices of mothers/guardians and health workers on childhood malaria in a Tanzanian district – implications for malaria control. Acta Tropica, 87(3), 305-313.• de Savigney, D., Mayombana, C., Mwangeni, E., Masanja, H., Minhaj, A., Mkilindi, Y., et al. (2004). Care-seeking patterns for fatal malaria in Tanzania. Malaria Journal, 3(27), doi:10.1186/1475-2875-3-27.• Diallo, D., Graz, B., Falquet, J., Traoré, A. K., Giani, S., Mounkoro, P. P., et al. (2006). Malaria treatment in remote areas of Mali: use of modern and traditional medicines, patient outcome. Transactions of the Royal Society of Tropical Medicine and Hygiene, 100(6), 515-520.• Gessler, M. C., Msuya, D. E., Nkunya, M. H. H., Mwasumbi, L. B., Schär, A., Heinrich, M., et al. (1995). Traditional healers in Tanzania: the treatment of malaria with plant remedies. Journal of Ethnopharmacology, 48(3), 131-144.• Gessler, M. C., Msuya, D. E., Nkunya, M. H. H., Mwasumbi, L. B., Schär, A., Heinrich, M., et al. (1995). Traditional healers in Tanzania: sociocultural profile and three short portraits. Journal of Ethnopharmacology, 48(3), 145-160.
References• Gessler, M. C., Msuya, D. E., Nkunya, M. H. H., Schär, A., Heinrich, M., Tanner, M. (1995). Traditional healers in Tanzania: the perception of malaria and its causes. Journal of Ethnopharmacology, 48(3), 119-130.• Hausmann Muela, S., Muela Ribera, J., Mushi, A. K., Tanner, M. (2002). Medical syncretism with reference to malaria in a Tanzanian community. Social Science & Medicine, 55(3), 403-413.• Makemba, A. M., Winch, P. J., Makame, V. M., Hehl, G. L., Premji, Z., Minjas, J. N., et al. (1996). Treatment practices for degedege, a locally recognized febrile illness, and implications for strategies to decrease mortality from severe malaria in Bagamoyo District, Tanzania. Tropical Medicine and International Health, 1(3), 305-313.• Makundi, E. A., Malebo, H. M., Mhame, P., Kitua, A. Y., Warsame, M. (2006). Role of traditional healers in the management of severe malaria among children below five years of age: the case of Kilosa and Handeni Districts in Tanzania. Malaria Journal, 5(58), doi:10.1186/1475-2875-5-58.• Ministry of Health, Tanzania. (1999). Basic health indicators. Retrieved April 4, 2008 from http://www.moh.go.tz/Health%20Indicators.php.
References• Minja, H., Schellenberg, J. A., Mukasa, O., Nathan, R., Abdulla, S., Mponda, H., et al. (2001). Introducing insecticide-treated nets in the Kilombero Valley, Tanzania: the relevance of local knowledge and practice for an Information, Education and Communication (IEC) campaign. Tropical Medicine and International Health, 6(8), 614-623.• Nsimba, S. E. D., Massele, A. Y., Eriksen, J., Gustafsson, L. L., Tomson, G., Warsame, M. (2002). Case management of malaria in under-fives at primary health care facilities in a Tanzanian district. Tropical Medicine and International Health, 7(3), 201-209.• Oberländer, L., Elverdan, B. (2000). Malaria in the United Republic of Tanzania: cultural consideration and health-seeking behavior. Bulletin of the World Health Organization, 78(11), 1352-1357..• Ringsted, F. M., Bygbjerg, I. C., Samuelsen, H. (2006). Early home-based recognition of anaemia via general danger signs, in young children, in malaria endemic community in north-east Tanzania. Malaria Journal, 5(111), doi:10.1186/1475-2875-5-111.
References• Tarimo, D. S., Lwihula, G. K., Minjas, J. N., Bygbjerg, I. C. (2000). Mothers’ perceptions and knowledge on childhood malaria in the holoendemic Kibaha district, Tanzania: implications for malaria control and the IMCI strategy. Tropical Medicine and International Health, 5(3), 179-184.• Tarimo, D. S., Urassa, D. P., Msamanga, G. I. (1998). Caretakers’ perceptions of clinical manifestations of childhood malaria in holo-endemic rural communities in Tanzania. East African Medical Journal, 5(3), 93-96.• Warsame, M., Kimbute, O., Machinda, Z., Ruddy, P., Melkisedick, M., Peto, T., et al. (2007). Recognition, perceptions and treatment for severe malaria in rural Tanzania: implications for accessing rectal artesunate as a pre-referral. PLoS ONE, 2(1), e149. doi:10.1371/journal.pone.0000149.• Winch, P. J., Makemba, A. M., Kamazia, S. R., Lurie, M., Lwihula, G. K., Premji, Z., et al. (1996). Local terminology for febrile illnesses in Bagamoyo District, Tanzania and its impact on the design of a community-based malaria control programme. Social Science & Medicine, 42(7), 1057-1067.
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