Perceptions of malaria and

treatment-seeking in

Tanzania

Matthew Rollosson, RN, BSN, CNRN

TRMD 782

18 April 2008

Qualitative studies

• Surveys of household/individuals Hausmann Muela, 2002 Minja, 2001 Ringsted, 2006 Tarimo, 1998

• Mothers/caregivers

accompanying <5 year olds at health care facilities Nsimba, 2002 Tarimo, 2000 Warsame, 2007

• Group meetings: mothers, village

members Comoro, 2003 Oberländer, 2000 Warsame, 2007 Winch, 1996

• Traditional healers Hausmann Muela 2002 Gessler, 1995 Makundi, 2006 Warsame, 2007

• Health workers

Comoro, 2003 Warsame, 2007

• Verbal autopsy: families/mothers

of children that died de Savigney, 2004 Makemba, 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 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

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

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

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

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

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 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

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

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

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

• Herbalist-ritualist

• Ritualist-herbalist

• Spiritualist

• Some have background in Western medicine

Gessler, 1995

• Spirit mediumship

• Healers of the Book

• Pure herbalists

• Knowledgeable women Hausmann Muela, 2002

• Most are part-time healers – farm rice or cassava

• Most practitioners are herbalists

• Specialists in spirit possession

• Craftsman of the Book (Koran and other Islamic holy books)

• Traditional Birth Attendants who treat degedege as a side occupation

Makemba, 1996

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

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

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

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

• 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

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 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

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

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