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Community response to artemisinin-based combination therapy for childhood malaria: a case study from… Kamat, Vinay R; Nyato, Daniel J Feb 26, 2010

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RESEARCH Open AccessCommunity response to artemisinin-basedcombination therapy for childhood malaria:a case study from Dar es Salaam, TanzaniaVinay R Kamat1*, Daniel J Nyato2AbstractBackground: New malaria treatment guidelines in Tanzania have led to the large-scale deployment of artemether-lumefantrine (Coartem®), popularly known as ALu or dawa mseto. Very little is known about how people in malariaendemic areas interpret policy makers’ decision to replace existing anti-malarials, such as sulphadoxine-pyrimethamine (SP) with “new” treatment regimens, such as ALu or other formulations of ACT. This study wasconducted to examine community level understandings and interpretations of ALu’s efficacy and side-effects. Thepaper specifically examines the perceived efficacy of ALu as articulated by the mothers of young childrendiagnosed with malaria and prescribed ALu.Methods: Participant observation, six focus group discussions in two large villages, followed by interviews with arandom sample of 110 mothers of children less than five years of age, who were diagnosed with malaria andprescribed ALu. Additionally, observations were conducted in two village dispensaries involving interactionsbetween mothers/caretakers and health care providers.Results: While more than two-thirds of the mothers had an overall negative disposition toward SP, 97.5% of themspoke favourably about ALu, emphasizing it’s ability to help their children to rapidly recover from malaria, withoutundesirable side-effects. 62.5% of the mothers reported that they were spending less money dealing with malariathan previously when their child was treated with SP. 88% of the mothers had waited for 48 hours or more afterthe onset of fever before taking their child to the dispensary. Mothers’ knowledge and reporting of ALu’s dosagewas, in many cases, inconsistent with the recommended dosage schedule for children.Conclusion: Deployment of ALu has significantly changed community level perceptions of anti-malarial treatment.However, mothers continue to delay seeking care before accessing ALu, limiting the impact of highly subsidizedrollout of the drug. Implementation of ACT-based treatment guidelines must be complemented with educationalcampaigns to insure that mothers seek prompt help for their children within 24 hours of the onset of fever.Improved communication between health care providers and mothers of sick children can facilitate betteradherence to ALu’s recommended dosage. Community level interpretations of anti-malarials are multifaceted;integrating knowledge of local beliefs and practices surrounding consumption of anti-malarials into programmaticgoals can help to significantly improve malaria control interventions.* Correspondence: kamatvin@interchange.ubc.ca1Department of Anthropology, University of British Columbia, Vancouver,CanadaKamat and Nyato Malaria Journal 2010, 9:61http://www.malariajournal.com/content/9/1/61© 2010 Kamat and Nyato; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.BackgroundIn December 2006, Tanzania implemented new malariatreatment guidelines requiring the large scale deploy-ment of Coartem® (Novartis), a fixed-dose artemether/lumefantrine-based combination therapy (ACT) popu-larly known as ALu or dawa mseto in public healthfacilities, to treat uncomplicated malaria [1]. These newguidelines were implemented five years after the govern-ment decided to replace chloroquine (CQ) with sulpha-doxine-pyrimethamine (SP) as the first-line treatmentfor uncomplicated malaria. Studies detailing how peoplein malaria endemic areas interpret policy makers’ deci-sions to replace existing anti-malarials, such as SP, with“new” treatments, such as ALu or another artemisinin-based combination therapy (ACT), are lacking. Examin-ing how adults and children use a newly introduceddrug can inform the design of interventions aimed atimproving drug use and therapeutic outcomes in com-munity settings [2-4].Documenting community level understandings andinterpretations of ALu’s efficacy and side effects isimportant for several reasons. First, the deployment ofACT on a large scale marks a major shift in global dis-courses on malaria control, mainly because ACT is avery expensive therapy that is unsustainable in poorcountries like Tanzania without substantial donor fund-ing [5,6]. Second, ACT is often described as “the keyweapon” in the fight against malarial parasites becausethere are few affordable alternatives to ACT [7,8]. Third,researchers fear that malaria parasites could developresistance to component drugs in ACT, due to the inap-propriate use of artemisinin monotherapies [9,10].Finally, medical anthropologists in particular have con-sistently pointed out that the perceived efficacy of adrug is embedded in culturally specific expectations.Thus, the perceived efficacy and side effects of anti-malarials must be examined in specific cultural or com-munity contexts [11-13]. Although some researchershave examined community level perspectives on SPamong populations severely affected by malaria [14,15],there is very little information on the community levelperceptions of ALu after the Tanzanian governmentintroduced it on a large scale. Understanding how cul-tural perceptions influence decisions regarding the useand consumption of anti-malarials, both “old” and“new,” can provide valuable insights into how the deliv-ery of newer treatment regimens can be better managed.Determining the efficacy and side effects of anti-malarials is a complex task, both in biomedical andbehavioural terms. This is especially true when thepatients are young children who have been treated withanti-malarials, and mothers do the reporting on theirchildren’s behalf [16]. Many researchers have pointedout that there are significant discrepancies betweenreported consumption of anti-malarials, efficacy anddetectable levels of the specific anti-malarial found inblood samples [3,14]. As such, the goal of this paper isto examine the perceived efficacy of ALu as articulatedby the mothers of young children diagnosed withmalaria and prescribed ALu. Though limited in itsscope, this approach, which may be characterized as“interpretive,” is important because the success or failureof an anti-malarial treatment policy will ultimatelydepend on the perceptions and understanding about thedrug’s efficacy at the community level [13]. Given thatpeople’s prior experiences and perceptions significantlyinfluence the extent to which they “adhere” to the newACT drug regimen, community level studies of percep-tions of malaria and anti-malarials can provide usefulperspectives on how people interpret the efficacy of“new” anti-malarials in light of their experience with“old” anti-malarials. In Tanzania, for example, research-ers have documented that, while many people have anegative disposition toward SP, they are nostalgic whentalking about CQ, emphasizing that they would be verypleased if they had access to CQ because it was an inex-pensive drug, which brought immediate relief to thepatient due to its antipyretic effect [14,16].MethodsStudy area and populationThis study was conducted in the Chamazi administrativeward of Temeke District, Dar es Salaam (population: 3.5million), Tanzania’s commercial capital, which com-prises of three independently governed municipalities -Temeke, Ilala and Kinondoni. Temeke district, with apopulation of 886,529 in 2007, and an area of 656 sq.km. is the largest of the three districts that compriseDar es Salaam. Chamazi ward, which is located some 25km south of Dar es Salaam’s central business district,has two large villages – Chamazi proper (pop. 10,000)and Mbande (pop. 8,000). A number of small villagesand hamlets surround these two large villages. 85% ofthe local residents are Muslims. While the majority ofthe local residents identify themselves as Zaramo, thereare substantial numbers of people in these villages whoidentify themselves as Makonde, Matumbi, Mpogoro,Ndengereko, Ngindo, Nyamwezi, Msukuma and Myao,among others. Cash income is scarce for many of thelocal residents whose economic base is subsistence-oriented farming. The completion of the all-weatherroad in 1996, which connects the trading town of Mba-gala with Mbande village, marked the beginning of anew wave of migrants into this region, mostly fromnorth-western and south-eastern Tanzania. The roadfacilitated the rapid transportation of people and goodsKamat and Nyato Malaria Journal 2010, 9:61http://www.malariajournal.com/content/9/1/61Page 2 of 9between the villages and the city. The local health arenais pluralistic as villagers have access to municipal dis-pensaries - one of which is located in Chamazi villageand the other in Mbande village. Both dispensaries aregenerally well staffed and well stocked. Additionally, inChamazi ward, there are more than ten registered “tra-ditional healers” (waganga), two licensed private practi-tioner’s clinics, and 14 drug stores (duka la dawabaridi), which are managed by people without adequateformal training.Data collectionData were gathered during four months of fieldwork(May to August of 2007) in the Chamazi ward. Addi-tional follow-up research led by the second author wasundertaken during the months of July and August 2009.Data were gathered using a combination of participantobservation in the villages and at the health facilities,exploratory focus group discussions (FGDs) and semi-structured interviews with mothers of children belowfive years of age, who were diagnosed with malaria andtreated with ALu less than two weeks prior to the inter-view. All interviews were conducted in Kiswahili withthe help of an experienced female research assistant.The first author interacted with all the interviewees andwas present during all the interviews. The second authorconducted follow-up interviews, organized FGDs, madeobservations at the dispensaries, and translated theinterviews from Kiswahili to English.Focus group discussionsFGDs were conducted in Mbande and Chamazi with sixgroups of six to eight mothers (total 42 participants).Two field assistants who were local residents initiallyapproached mothers of young children who were diag-nosed with malaria and treated with ALu at the localmunicipal dispensary, and invited them to participate inthe FGDs. Those who were recruited at the dispensariesand were willing to participate in the FGDs were givenfurther details about the study, the venue for the FGDs,and their role in generating important information forthe study through discussions in small groups with thehelp of a moderator. Some of the key questions andtopics addressed in the focus groups were: symptomsthat prompt mothers to take their sick children to thedispensary; reasons why mothers delay seeking prompttreatment for their children when they have high fever;participants’ opinion regarding the changes they havenoticed in the quality of treatment for malaria since SPwas replaced with ALu as the first-line drug at publichealth facilities; their perceptions regarding the side-effects associated with SP and ALu; their perceptionsregarding the cost of dealing with childhood malaria;measures taken by members of the community toprotect their children from contracting malaria; whetherin their view, the malaria situation in their village hasimproved since the introduction of ALu, and whataccording to them needs to be done to minimize malar-ia’s impact on their community.Semi-structured interviewsAfter reviewing the data from the FGDs and refining thesemi-structured interview schedule, detailed interviewswere conducted with 110 mothers whose children weretreated with ALu for malaria during the past two weeks,in Mbande, Chamazi, and three adjoining villages –Wembebamia, Kiponza and Kisewe. Mothers were ran-domly selected from a list that was prepared followinginitial contacts with them at the dispensaries. Onlythose who were willing to participate in the study wereinterviewed. Mothers were interviewed regarding thechild who was under five years of age, diagnosed withmalaria and prescribed ALu at the local municipal dis-pensary less than two weeks before the interview. Twochildren in the study sample had been treated with ALufollowed by another anti-malarial, such as quinine (QN)or antibiotics.Mothers were asked to describe the symptoms thathad prompted them to take their child to the municipaldispensary; the time between the onset of symptomsand their decision to take the child to the dispensary;the advice they had received from the doctor or thenurse at the dispensary; the period they had waitedbefore concluding that their child had recovered fromhis or her illness; whether their child had experiencedany undesirable bodily side effects (madhara) afterbeing treated with ALu, and if so, to describe the sideeffects. Mothers were also asked to describe theirexperience of treating their children with ALu, and howthese compared with their experiences of SP. Finally, asa closing question, they were asked to express theirthoughts on why they believed malaria persisted in theirrespective villages.Additionally, interactions between mothers with sickchildren and the health workers at the municipal dis-pensaries, surrounding the dispensing of ALu, wereobserved, focusing mainly on the advice given by thenurse to the mothers at the dispensing counter.Data analysisAll mothers who agreed to participate in the study gavetheir oral consent for the interview. Interviews lastingabout 30 minutes were recorded on a digital audio-recorder, transcribed verbatim in Kiswahili and key pas-sages were later translated into English. Quantitativedata from the recorded interviews were entered into aspreadsheet and processed using Microsoft Excel®. Theauthors reviewed all the interview transcripts andKamat and Nyato Malaria Journal 2010, 9:61http://www.malariajournal.com/content/9/1/61Page 3 of 9extracted segments and passages that called for a closeranalysis, which were then manually encoded and ana-lysed. “Text” or qualitative data from FGDs and inter-views were first entered in MicrosoftWord® andprocessed using ATLAS.ti 6.0 for key words and quotes,and themes. Notes from the field diary were incorpo-rated into the analysis.Ethical ReviewPermission to conduct this study was given by the Tan-zania Commission for Science and Technology (COST-ECH Permit No. 2006-366-CC-2005-36). TheBehavioural Research Ethical Board, University of BritishColumbia, and the Medical Research CoordinatingCommittee of the National Malaria Research Institute,Dar es Salaam gave ethics clearance for this study. Addi-tional research and ethics clearance was obtained fromthe University of Dodoma.ResultsDemographic information on the 110 mothers inter-viewed for this study is presented in Table 1. Of thechildren whose mothers were interviewed (index child),51% were male and 49% were female. Their average agewas 38 months (range three months to 60 months).Symptom recognition, waiting period and therapy-seekingWhile early detection and access to prompt, affordableand effective treatment is regarded as the cornerstone ofa successful malaria control strategy[17], in the presentstudy, only 12% of the mothers had taken their child tothe dispensary within 24 hours after noticing that he/she had a fever. 35% of the mothers had waited for twodays (48 hours); 34% had waited for three days (72hours) and the remaining 19% had waited between fourand six days (92+ hours) before taking their child to thedispensary. While the majority (81%) of the mothershad treated their child’s fever with a store-bought anti-pyretic such as Panadol® (paracetamol) a small number(2.5%) had used Panadol® in combination with SP.Another 2.5% had given their child SP albeit to no avail.14% of the mothers had not given their child any medi-cation before taking him/her to the dispensary.Nearly 90% of the mothers mentioned high fever orpersistent fever as the most important symptom influen-cing their decision to take their child to the dispensary.They denoted key symptoms by using terms and phrasessuch as homa kali (high fever) or mwili ulichemka (thebody temperature was very high), (22.5%), homahaishuki (the fever wouldn’t come down), (34%), homailikuwa inatisha (the fever was frightening) (6%), haliiliharibika zaidi (the condition worsened) (20%), hali yamtoto haikuboreka (the child’s condition did notimprove), (7.5%), and alichoka na kutapika (he/she wasexhausted and vomited) (2.5%). The remaining 7.5% hadtaken their child to the dispensary “without thinking toomuch about it,” mainly to get the doctor’s advice. Thus,the key symptom prompting mothers to consider takingtheir sick child to the dispensary is high fever that doesnot subside following treatment with an antipyretic.However, observational data gathered at the two munici-pal dispensaries revealed that in addition to persistenthigh fever, mothers also mentioned alitapika (vomiting),aliharisha (diarrhoea) and ananyongea (bodily weak-ness) as other symptoms that had prompted them totake their sick child to the dispensary.Treatment recall and perceived efficacyWhile 80% of the mothers reported that their child wasprescribed ALu along with an antipyretic, often recognizedas Panadol® or Panadol syrup (Panadol ya maji), 15% ofthem reported that their child was prescribed only ALu.Table 1 Background information on mothers interviewedfor the study (n = 110)Residence n %Chamazi Kwamkongo 30 27.27Kiponza 13 11.83Kisewe 29 26.36Mbande Kijiji 31 28.18Wembebamia 07 6.36Age17-21 15 13.6322-26 38 34.5427-31 26 23.6332-36 10 9.1040-50 21 19.10EducationNil 16 14.55Primary school years 1-6 18 16.36Primary school year 7 70 63.64Primary school year 8 2 1.81Secondary school Form 2 4 3.64Marital StatusMarried 57 51.82Unmarried 34 30.91Widow 2 1.81Divorced 17 15.46ReligionMuslim 91 82.73Christian 19 17.27Number of Children1 36 32.732 32 29.093 20 18.184 14 12.735-7 8 7.27Kamat and Nyato Malaria Journal 2010, 9:61http://www.malariajournal.com/content/9/1/61Page 4 of 9The remaining 5% of the mothers said that their child wasprescribed ALu along with Panadol® and either a coughsyrup or a packet of oral rehydration solution (ORS). Sig-nificantly, 92.5% of the mothers had taken their child tothe dispensary only once. The remaining 7.5% of themothers had gone to the dispensary at least twice becausetheir child’s condition had not improved even after com-pleting the dosage. Four children in the study sample hadreceived further treatment at the district hospital, and twoothers were taken to the Muhimbili National Hospital(MNH) located 30 km away.Focusing on perceptions of ALu’s curative efficacy,mothers were asked whether they believed ALu was aneffective drug in the treatment of malaria. Responses tothe above question, coded retrospectively as positive ornegative revealed that 97.5% of the mothers had anoverall positive disposition toward ALu. They confi-dently stated dawa inafaa, amepona kabisa, anaendeleavizuri tu (the drug is effective, the child has completelyrecovered, and is doing well) (55%); anaendelea vizuri,anacheza na anachangamka vizuri (the child is doingfine, and is very active) (42.5%) to indicate that theirchild had completely recovered following treatment withALu. Two mothers were uncertain if their child hadcompletely recovered. Significantly, the data in Table 2reveal that although all the index children in the studywere prescribed ALu at the local dispensary, in manycases mothers’ knowledge and reporting of the dosageschedule was inconsistent with the recommendeddosage for their children.Perceived efficacy and side effects of ALu comparedwith SP94% of the mothers reported that they had not noticedany madhara or “undesirable” side effect in their childwho was most recently treated with ALu. They emphati-cally stated that they had not seen any side effects andthe drug had helped the child to recover completely.The remaining five mothers mentioned various sideeffects including the worsening of the child’s fever. Bycontrast, when asked to compare their experiences withSP, a majority of the mothers recalled a range of unde-sirable madhara they believed were caused by SP suchas inachokesha, mtoto ana legea sana (causes extremeexhaustion, the child become very weak), homahaishuki, haipungui, iko pale pale wiki nzima (the feverdoes not go away for a week), inaleta vipele mdomoni,mapele mwilini (it results in mouth ulcers and rasheson the body), kuwashwa washwa (there’s itching all overthe body) and anakuwa na marengerenge (he/she devel-opes impetigo), mtoto hatulii (the child becomes rest-less). A 40-year-old mother of three children explained:My son became very weak after he was treated withSP. I thought to myself “Have we treated the illnessor have we worsened it?!” It took about two weeks forhim to return to his normal self. But last week whenhe had malaria, he was treated with ALu; he wokeup in the morning and started playing as usual andhis condition returned to normal.Perceptions of ALu’s efficacy were closely tied to theperceived cost of dealing with a child’s malaria episode.More than 90% of the mothers emphatically stated thatALu was far superior to SP because of its long-lastingeffect, and also because the process of treatment-seekingwas less expensive. A 27-year-old mother of a three-yearold child contextualized her experience with ALu andSP as follows:It’s a lot better now because ALu really helps. Earlieryou had to pay to get SP, which in any case did nothelp; the fever wouldn’t go away so you had to takeyour child to the dispensary three or four times. Bythen you’ll have exhausted all your money. But nowit’s different; the medicine is good. At the dispensarythey also do a blood test. If your child is treated withALu, he’ll get better right away. The medicine oftoday is genuine (dawa za uhakika). If you use itonce, you get better right away, so there’s no need togo to the dispensary again and again.Perceptions of the drug’s efficacy were also reflected instatements about the expenses incurred in the treatmentof childhood malaria. 62.5% of the mothers reportedspending less money treating malaria than when SP wasthe first-line drug. Owing to the fact that ALu was pre-scribed to them free of cost at the local dispensary andtreatment seeking did not involve multiple trips to theTable 2 Mothers’ recall of ALu’s dosage (n = 110)Dosage recall n %Twice a day for three days, six tablets in total 63 57.30Three times a day for three days 11 10.00Two times a day for five days 4 3.64Two times a day for six days 3 2.72Three times a day for six days 4 3.64Two times a day for seven days 3 2.72One tablet for seven days 5 4.55Half a tablet, three times a day for seven days 3 2.72Half a tablet, twice a day for seven days 2 1.81Half a tablet, twice a day for two days 1 .90Quarter tablet, three times a day for three days 2 1.81One table a day for five days 2 1.81Forgot the dose, cannot recall 7 6.36Note: For children in the 4 months to 5 years age group, weighing between 5and 14 kilos, the standard recommended dose of artemether-lumefantrine isone tablet, twice a day after a gap of 8 hours, for three days in total(Guidelines for the treatment of malaria, WHO 2006).Kamat and Nyato Malaria Journal 2010, 9:61http://www.malariajournal.com/content/9/1/61Page 5 of 9health facilities, they could “afford” to deal with a malariaepisode. However, 30% said that dealing with malaria hadbecome more expensive than before, although many ofthem added that while SP was a relatively inexpensivedrug, they could not trust it because it took a lot longerfor the drug to work and they had to make multiple tripsto health facilities. The remaining 7.5% of the motherssaid that they did not find any significant difference in theexpenses incurred during the SP era and now.Advice95% of the mothers had received at least some advicefrom the dispensary staff along with a prescription forALu. 77.5% reported that they were told to continuegiving Panadol® to their child and to return to the dis-pensary if the fever did not go away after three days.Another 17.5% were specifically told to keep their houseand surroundings clean by clearing the grass, and to usean ITN to minimize mosquito bites. The remaining 5%of the mothers stated that they had not received anyadvice from the dispensary staff. Observational datarevealed that the dispensary staff, usually one of thenurses, spent an average of two minutes advising themothers on how to use ALu and reminding them thatthey need to give their child plenty of water to drinkduring the treatment period.Perceptions of malaria’s persistenceWhile all mothers who participated in the FGDs and nearly90% of those who were interviewed said that they weresatisfied with ALu’s efficacy, they frequently exclaimedmalaria iko nyingi! meaning that there was still a lot ofmalaria in their respective villages. Elaborating on theirresponse, more than 75% of the mothers attributed thepersistence of malaria in their respective villages to povertyand poor environmental conditions (mazingira machafu).A 40-year-old mother of four children explained:We are poor so we don’t have enough nets for every-one in the house. When our relatives come to visit us,we’ll say, Ah! Alright, let the guests sleep there underthe net, and I’ll sleep on this side with my childrenwithout a net. Naturally the mosquitoes bite us andwe get malaria. What can we do? We are poor.There are many large families in this village whohave only one net, and many people sleep in placeswhere there are no nets at all.Mothers gave multiple responses to describe theirefforts to minimize the impact of malaria on their lives –use of ITNs to prevent mosquito bites (76.5%) and cover-ing the bed with an ITN early during the evening; keep-ing surroundings clean (76%) and making sure thatchildren wear a sweater in the evenings before going tobed to prevent mosquitoes from biting them (27.5%)DiscussionThe Tanzanian government’s decision to deploy ALu asthe first-line anti-malarial on a large scale, mainlythrough public health facilities, is laudable from a publichealth point of view. This decision, however, also invitesmore attention to how communities that are affected bymalaria interpret the efficacy and side effects of newerand older anti-malarials. Monitoring how the introduc-tion of new anti-malarials affects people’s treatmentexpectations, the cultural meanings they attribute to oldand new drugs, their reckoning of the cost factor intheir search for therapy, and their responses to uncer-tainty in the context of poverty is critical for the suc-cessful deployment of new anti-malarial regimens.The data from this study suggest that even thoughmothers are aware that they have access to a highlyeffective anti-malarial free of cost, the majority (88%) ofthem do not rush their child to a health facility for diag-nosis and treatment within 24 hours of the onset offever. Instead, they first treat their febrile child with astore-bought antipyretic to see if the fever subsides.They continuously monitor and evaluate their child’sfever for up to three days, and in some cases for up tosix days, before deciding to take him/her to a healthfacility. The data also suggest that self-treatment of feb-rile children with a store-bought anti-malarial in theDar es Salaam region is uncommon. This observation isconsistent with findings of recent studies in the Tanza-nian context, which have reported that unlike duringthe chloroquine era when self-medication was the norm,there is a noticeable reluctance among the people ofTanzania to use a store-bought anti-malarial to treatchildhood malaria as a first resort [14,18-20].The data also suggest that mothers who participatedin FGDs and those who were interviewed for this studywere satisfied with ALu’s therapeutic efficacy as well aswhat it costs them to access the drug; they were equallypleased with the fact that the personnel at the local dis-pensary perform a blood test (vipimo) on their childrento confirm that they have malaria before prescribingALu. While this often leads to longer waiting periods,not one mother in the study complained about theextended waiting periods at the dispensary. Thus,improved perception of ALu is related to improved per-ception of the quality of care exemplified by blood testsfor malaria. These data are striking when compared tomothers’ responses regarding sick children to a similarquestion pertaining to treatment with SP in a previousstudy in the same research setting [16]. In the previousstudy, 32% of the mothers were not satisfied with thetreatment that their child had received at the first placeKamat and Nyato Malaria Journal 2010, 9:61http://www.malariajournal.com/content/9/1/61Page 6 of 9of medical consultation and nearly 50% of the mothersattributed their child’s recovery from the illness to amedicine/treatment other than SP given at the localmunicipal dispensary.For the majority of the mothers interviewed for thisstudy, the blood test marks a significant departure fromthe SP era when children were routinely/clinically diag-nosed with malaria and presumptively prescribed SP,even as the majority of the mothers deemed it a uselessand/or a dangerous drug. In addition to efficacy, costentered the evaluation of anti-malarials. During the SPera, dealing with childhood malaria was usually anexpensive undertaking. In the previous study up to 59%of the mothers had consulted more than one healthfacility in search of an alternative therapy for their sickchild. In the process they had incurred additionalexpenses and lost precious time [16]. The financial bur-den increased exponentially from CQ to SP for mothersof febrile children, especially those who lacked a strongsupport network to help them out during a health crisis.Faced with repeated treatment failure, mothers soughttreatment from multiple sources, incurring additionalcosts and other burdens. By contrast, the introductionof ALu has significantly changed the situation, as mostof the mothers who participated in this study believedthat they were spending significantly less money ondealing with a malaria episode than before. Althoughmothers identified ALu as cost-effective, as noted ear-lier, the majority of them had delayed in bringing theirsick children to a health facility because they thoughtthey were dealing with an ordinary fever (homa yakawaida) or teething fever (mtoto anaota meno). Mostof the mothers had decided to “wait and see” (unasubiriukimtazamia) if the fever would go away followingtreatment with a store-bought antipyretic. These obser-vations are significant in the context of recent discus-sions and debates surrounding the accuracy of malariadiagnosis, misdiagnosis, over-diagnosis, and the questionwhether to treat all fever cases presumptively with ananti-malarial or to rely on laboratory-confirmed diagno-sis and treatment [21,22]. On the one hand, it may beargued that mothers who resort to a store-bought anti-pyretic and engage in a “wait and see” approach beforedeciding whether to rush the child to the dispensary ornot, may in fact be minimizing the chances of theirchild being wrongly diagnosed and unnecessarily pre-scribed an anti-malarial. On the other hand, it may beargued that the ease with which mothers are able toobtain ALu, a highly effective anti-malarial at the dis-pensary, free of cost, may in fact be a key deterrent intheir decision to rush their febrile child to the dispen-sary within 24 hours of the onset of fever. Experiencedmothers in Dar es Salaam know fully well that if theirchild’s condition were to worsen, they would mostcertainly get ALu at the dispensary that would enabletheir child to recover rapidly.While plans are being implemented to provide thepublic with better access to ACT, there is an urgentneed to implement socio-cultural and behavioural inter-ventions that would persuade mothers to bring theirsick children to a health facility for diagnosis and treat-ment within 24 hours of the onset of symptoms, andnot wait for three or more days to see if the fever wouldsubside with an antipyretic. This would minimize child-hood mortality resulting from other severe febrile ill-nesses, such as pneumonia or meningitis, which cannotbe easily managed at home [23]. Concurrently, thesebehavioural interventions will have to be accompaniedby “technical” interventions to ensure more accuratediagnosis and appropriate treatment of febrile children.Further, health care providers need to be better trainedto communicate more effectively with mothers whosechildren have been diagnosed with malaria. Many stu-dies have reported that health care providers, especiallyin public health facilities in Tanzania, do not communi-cate well with their patients, as they frequently fail toinform them of the nature of the illness and details ofthe prescription [24,25].This is especially true in situations where, due toshortage of drugs, health care providers may give Coar-tem® blister package meant for adults to mothers, ask-ing them to break up the tablets into two or four parts,and give them to their febrile children. In the presentcase, the discrepancy between the recommended dosageand schedule for ALu and the mothers’ reporting of thedosage and schedule they adhered to (see Table 2), maybe due to a combination of poor adherence, reportingproblems, problems in recall, and insufficient communi-cation between the health staff at the dispensary and themothers. However, it is important to address the issueof discrepancy between recommended dosage and sche-dule and the patient’s adherence to the correct drugregimen because partially effective treatment may resultin recrudescence of the infection, and in the long run,contribute to the development of anti-malarial drugresistance [3,26,27].This study has some limitations that should be consid-ered. First, the study was conducted in a region andamong a population that is relatively well served by thehealth care system, and where people have access toACT. Caution must be exercised in extrapolating thefindings of the study to other regions of Tanzania wherethere are remarkable differences in population config-urations, health infrastructure, and people’s access toACT. Second, the sample size is relatively small to makemajor statistical inferences. Third, a bulk of the dataanalysed for this study is derived from narrative inter-views with mothers. It was beyond the scope of theKamat and Nyato Malaria Journal 2010, 9:61http://www.malariajournal.com/content/9/1/61Page 7 of 9study to verify their reports about the drug’s efficacythrough other measures, including ascertaining druglevels in blood samples. The findings of this study are,therefore, context-based and limited in their generaliz-ability. However, the findings of this study provide valu-able insights into how community level interpretationsof newly introduced anti-malarials can inform furtherresearch and policy decisions aimed at improving thecoverage and delivery of ACT among economically vul-nerable populations.ConclusionThe deployment of ALu in public health facilities fortreatment of uncomplicated malaria has significantlyaltered people’s perceptions of anti-malarial treatment.In the present study, the majority of the mothers notonly regarded ALu as an effective anti-malarial, theyalso found that it significantly reduced their expenditureon dealing with a malarial episode because it did notrequire them to go through multiple treatment stages aswas common during the SP era. However, the majorityof the mothers delayed before accessing ALu, limitingthe impact of the subsidized roll out of these drugs onhealth outcomes. Current efforts to make highly subsi-dized ACT more readily available through private retailpharmacies may result in patients being promptlytreated with a highly effective anti-malarial. However,this complex intervention may also result in people’soverdependence on the commercial sector for treatmentof childhood fevers, and lead to additional financial bur-den on poor households [25,28]. Further, the resultshighlight the importance of educational campaigns torefine prompt treatment-seeking messages targeted atfamilies by taking into account community beliefs andpractices. It is important to continuously monitor peo-ple’s discourse on treatment decisions, alternativecourses of possible action, and to document how theyinterpret the efficacy and side effects of anti-malarialsthat are deployed as first-line drugs, and their treatmentexpectations and perceptions of medicine compatibility.At a time when approaches to dealing with malaria arebecoming increasingly treatment-oriented, community-based behavioural research can remind us that theefficacy of anti-malarials is multifaceted. It is one thingto demonstrate the in vivo clinical or pharmacologicalefficacy of various anti-malarials in controlled environ-ments, and quite another to ensure the effectiveness ofthe drugs in “real-life” situations [29]. In other words,anti-malarials, which reveal excellent efficacy under con-trolled clinical trial conditions, may not demonstrateequally excellent “effectiveness” when they are deployedwidely under real-life conditions [3]. Successful deliveryof effective malaria treatment requires that health plan-ners do not downplay the broader socio-cultural,economic, technical, and political environments inwhich treatment regimens are implemented [30]. Thus,a lot more is at stake in malaria control than the rollingout of highly subsidized, highly efficacious ACT. Inte-grating knowledge of local beliefs and practices sur-rounding consumption of anti-malarials intoprogrammatic goals can be immensely valuable inimproving the rigor and effectiveness of malaria controlinterventions [31].AcknowledgementsResearch on which this paper is based was generously supported by theSocial Sciences and Humanities Research Council, Canada (File # 410-2006-2371). Permission to conduct research in Tanzania was made possible by theTanzania Commission for Science and Technology (COSTECH - Permit No:2006-366-CC-2005-36). The project was given ethics clearance by theBehavioral Research Ethical Board, University of British Columbia, the Directorof Research and Publications, University of Dodoma (UDOM/DPR/SSRC/02),and the Medical Research Coordinating Committee of the National MalariaResearch Institute (NMRIHQ/R.8a/Vol.IX/467), Dar es Salaam. The authors areimmensely grateful to Mariam Mohamed, Shakila Omari and Robert Kihamafor their wholehearted support during fieldwork. We would also like toacknowledge the detailed, constructive comments given by Clare Chandler,Rene Gerrets, Rachel Houmphan, and the journal’s anonymous reviewers onearlier drafts of this paper. However, we alone take full responsibility for theinformation and interpretation presented here.Author details1Department of Anthropology, University of British Columbia, Vancouver,Canada. 2Department of Political Science and Sociology, University ofDodoma, Dodoma, Tanzania.Authors’ contributionsDJN supervised data collection, translated the interviews, contributed to dataanalysis and write-up of the manuscript. VRK conceived of the study,participated in its design and coordination, carried out fieldwork, anddrafted the manuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 13 November 2009 Accepted: 26 February 2010Published: 26 February 2010References1. Tanzania Ministry of Health and Social Welfare (TMHSW): National Guidelinesfor Malaria Diagnosis and Treatment 2006 Dar es Salaam: Government ofTanzania.2. 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Durrheim DN, Williams HA: Assuring effective malaria treatment in Africa:drug efficacy is necessary but not sufficient. J Epidemiol CommunityHealth 2005, 59:178-179.31. Krause G, Sauerborne R: Comprehensive community effectiveness ofhealth care. A study of malaria treatment in children and adults in ruralBurkina Faso. Ann Trop Paed 2000, 20:273-282.doi:10.1186/1475-2875-9-61Cite this article as: Kamat and Nyato: Community response toartemisinin-based combination therapy for childhood malaria: a casestudy from Dar es Salaam, Tanzania. Malaria Journal 2010 9:61.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitKamat and Nyato Malaria Journal 2010, 9:61http://www.malariajournal.com/content/9/1/61Page 9 of 9

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