Malaria treatment practices in the transition from sulfadoxine-pyrimethamine to artemether-lumefantrine: A pilot study in Temeke municipality, Tanzania

Background: Tanzania has changed its malaria treatment policy twice; in the first change Sulfadoxine - Pyrimethamine (SP) replaced chloroquine (CQ) in August 2001. In the second change Artemether –Lumefantrine (ALu) replaced SP in January 2007. It is not known how experiences with previous policies would influence the uptake the new policy.Objective: This study assessed malaria treatment practices in the transition from SP to ALu and the implications for the uptake of the new policy.Methods: Two months prior to change from SP to ALu a survey of randomly selected households (HHs) was carried out to explore the factors influencing malaria therapy choices and formulations of antimalarial drugs preferred. Perceptions on single versus multiple doses of antimalarial drugs, awareness on dosage calculation and compliance were also explored.Results: Two thirds of the respondents held the perceptions that childhood illness corresponding to malaria would require an antimalarial drug. However, about a quarter (24.3%) held the perception that childhood convulsion is not amenable by modern medicines. Half (50.7%) held the perception that high fever causes convulsions, however only a small percentage (5.8%) linked convulsions with severe malaria. SP was the most commonly available antimalarial drug (81.8%); followed by amodiaquine (35.4%), quinine (25.5%), artemisinin monotherapies (3.2%) and chloroquine (3.2%). The larger majority (85.9%) preferred antimalarial drugs syrup for children below 12 months old; about half (52.2%) also preferred syrup for children 1 – 5 years old. More than half (57.5%) preferred antimalarial drugs as tablets for older children and adults. Less than a quarter were aware that antimalarial drugs doses are calculated based on weight and age by about a half (48.5%). About three quarters (76.5%) were aware that SP is given as a single dose. About two thirds (63.8%) preferred antimalarial drugs as a single dose; only about a third (34.5%) preferred multiple dosages.Conclusions: For uncomplicated malaria, the community would seek antimalarial drugs while traditional medicines may initially be sought for severe malaria in the form of convulsions. Experiences with and preference of single SP dose may negatively influence compliance with multiple dose ALu therapy. The absence of ALu syrup formulation may negatively influence its acceptance for young children; while the absence of injectable formulation may negatively influence its acceptance to adult patients.Key words: malaria, community, policy changes, artemisinin based combination therapy, Tanzani

'To help them is to educate them': power and pedagogy in the prevention and treatment of malaria in Tanzania.

OBJECTIVES: Acknowledging that mothers are often the primary caregivers at the household level, malaria control efforts have emphasized educating women in its early recognition. This fails to consider the context in which knowledge will be transformed into action, as women lack decision-making responsibility and financial resources. We examine the knowledge and power dynamics of provider-patient interactions and the implications for malaria treatment of educating mothers during consultations. METHODS: We conducted in-depth interviews in Tanga, Tanzania, with 79 household participants over 2 years to explore knowledge and perceptions of febrile illness, its treatment and prevention. We also interviewed 55 clinicians at government and private healthcare facilities about their patients' knowledge and treatment-seeking behaviour. We analysed our data using a grounded theory approach. RESULTS: Informants had good knowledge of malaria aetiology, symptoms and treatment. Healthcare workers reported that mothers were able to give them sufficient information about their child for accurate diagnosis. However, health staff continued to see mothers who present 'late' as uneducated, intellectually incapable and lazy. Whilst evidence shows that decisions about treatment do not rest with mothers, but with male family members, it is women who continue to be blamed and targeted by health education. CONCLUSIONS: Aggressive didactic teaching methods used by health staff may be disempowering those already equipped with knowledge, yet unable to control treatment decisions within the household. This may lead to further delays in presentation at a healthcare facility. We propose a rethinking of health education that is context-sensitive, acknowledges class and gendered power relations, and targets men as well as women