Institution (s): Mwengu Social and Health Research Center, Ndola, Zambia and Applied Research in Child Health, Lusaka-Z

1. Title: Constructing the Meaning of Malaria Illness and Its Treatment-Seeking 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, Lusaka-Zambia 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.

2. BACKGROUND • 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.

3. MATERIALS • Design: A sub-sample of caretakers from those who had taken their under-five 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.

4. RESULTSCauses of Malaria • 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.

5. TYPES OF FEVER AND THEIR TREATMENT • 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.

6. TYPES OF FEVER AND THEIR TREATMENT CONT. • 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.

7. TYPES OF FEVER AND THEIR TREATMENT CONT. • 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.

8. Use of health facility • 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.

9. Lessons learned • 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.

10. Immediate Term implications for implementing policies and programmes to improve use of medicines • Findings from this in-depth study have re-affirmed that the first five actions taken by most carers in rural Zambia comprised home management.

11. 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

12. 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

13. Acknowledgement • 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.

14. Figure 1: Health Seeking Behaviour Patterns of Carers for Children Five Years Old in Rural Zambia When Treating Fever • Action 1: Caretaker Sponge bath HOME MANAGMENT • Action 2: Caretaker Steaming HOME MANAGEMENT • Action 3: Consult family, Administer HOME MANAGEMENT Drug vendors Anti-malaria drug

15. Cont. Health Seeking Behaviour Patterns of Carers for Children Five Years Old in Rural Zambia When Treating Fever Action 4: Consult family, Indigenous herbs HOME MANAGEMENT other elders used • Action 5: Consult Use indigenous HOME MANAGEMENT • Indigenous healer Herbs • Action 6: Consult Health HEALTH FACILITY Specialised Facility • Health care

16. 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