Class presentation, 2008

1. Perceptions of malaria and
treatment-seeking in
Tanzania
Matthew Rollosson, RN, BSN, CNRN
TRMD 782
18 April 2008

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Treatment-seeking for uncomplicated
malaria
• 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

18. Treatment-seeking for uncomplicated
malaria
• 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

19. Signs of severe malaria recognized by
mothers
• 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

20. Signs of severe malaria recognized by
mothers
• 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

21. Upungufu wa damu
Lack 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

22. 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

23. 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

24. 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

25. Verbal autopsies
Bagamoyo 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

26. Verbal autopsies
Rufiji 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

27. Verbal autopsies
Rufiji 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

28. 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

29. 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

30. Reasons for seeking care from a
traditional 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

31. Reasons for seeking care from a
traditional 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

32. Five step healing process for child with
severe 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

33. 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

34. 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

35. 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

36. Proposed solutions
• Improve malaria case-management at primary
health facilities
• adequately trained staff
• clinical skills
• consultation time
• supervision
• essential drugs
• diagnostic equipment
• microscopy
• rapid diagnostic tests
Nsimba, 2002

37. 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

38. 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

39. 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 can't 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

40. 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

41. 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

42. 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

43. 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.

44. 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.

45. 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.

46. 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
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