“I thought it was only ordinary fever!” cultural knowledge and the micropolitics of therapy seeking for childhood febrile illness in Tanzania

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Abstract

Economic considerations are often cited as important determinants of health-seeking behavior. This paper describes a situation in peri-urban Tanzania where user fees do not constitute the primary reason why mothers delay seeking prompt treatment at a public health facility for their young, febrile children. Mothers commonly believe that they are dealing with an ordinary fever and not malaria or any other serious illness complicated by fever. Hence, they engage in extended home-based treatment. Drawing upon an ethnographic study, this paper illustrates how cultural knowledge about disease symptomatology, cultural meanings associated with febrile illness, gender relations, and patterns of communication between health care providers and mothers significantly influence outcomes for childhood febrile illnesses. It is argued that an overemphasis on the correlation between user fees and treatment delays with regard to childhood illnesses tends to divert attention from other significant cultural factors and existing structural constraints that influence the dynamics of health care seeking and health outcomes. At a time when calls to implement artemisinine-based combination therapy as one of the front-line strategies in Tanzania are increasingly frequent, there is a need to pay closer attention to the contextual factors and socio-cultural dynamics that influence patterns of treatment-seeking for childhood malaria.

Introduction

Even a few hours of delay in seeking appropriate medical treatment for childhood Plasmodium falciparum malaria can result in severe complications, if not death (cf. Baume, Helitzer, & Kachur, 2000; Maitland & Marsh, 2004; Makemba et al., 1996; Mwenesi, Harpman, & Snow, 1995; Winch et al., 1996). As a result, the World Health Organization has reemphasized the importance of early diagnosis and effective biomedical treatment as one of the key factors in preventing high levels of malaria-related deaths in Sub-Saharan Africa (WHO, 2005). Those involved in the planning and implementation of malaria control programs in East Africa and elsewhere continue to ask, why do some mothers and caretakers delay in seeking help, while others take their sick children to a biomedical health facility promptly—often within 24 h after the onset of fever? (Amin, Marsh, Noor, Ochola, & Snow, 2003). These questions are being raised with an added sense of urgency along with calls to replace inefficacious, monotherapy antimalarials with artemisinine-based combination therapy (ACT) (cf. Bloland, Ettling, & Meek, 2000; D’Alessandro, Talisuna, & Boelaert, 2005; Kachur et al., 2004; Nosten & Brasseur, 2002).

Economic considerations are often cited as important determinants of health care decision making in poor communities (cf. Mathews & Hill, 1990; Oths, 1994; Weller, Ruebush, & Klein, 1997; Young, 1981).1 Within poor communities, the anticipated high cost of treatment is often perceived as the cause for treatment delays. In the Tanzanian context, some scholars have argued that user fees introduced as part of cost recovery programs deter—if not prevent—the local indigent populations from attending government health facilities (Tibandebage & Mackintosh, 2005). Indeed, several scholars have argued that user fees have led to increasing levels of morbidity and mortality, especially among women and young children in Africa (cf. Lugalla, 1995; Turshen, 1999). Therefore, on the grounds of health inequities, there are calls to discontinue the practice of charging patients user fees as this practice tends to hurt patients who are at greatest risk for disabling and fatal illnesses (cf. Creese, 1997; Gilson, 1997; Russell & Gilson, 1997).

This paper examines the complexities surrounding the process of treatment-seeking for acute febrile illness among children under the age of five in a peri-urban village in Dar es Salaam, Tanzania. This paper draws on data from a larger ethnographic study of the impact of health sector privatization on health care seeking in post-socialist Tanzania (Kamat, 2004). By drawing upon ethnographic examples, excerpts from illness narratives, case materials and quantitative data, I make a case for addressing issues that go beyond the user fees debate, and provide a more textured understanding of why some mothers and caretakers delay in seeking early diagnosis and treatment at government health facilities for their young, febrile children. I discuss the data under specific themes: (a) local cultural models of fever and treatment delays; (b) strategic symptom reporting by mothers; (c) lay cost reckoning and treatment delays; and (d) misdiagnosis and subsequent treatment delays. I also present two case studies to draw attention to the difficulties that mothers face in their search for therapy for their young, febrile children. Through these case studies I seek to highlight how health-care-seeking surrounding childhood febrile illnesses is often mediated by a multiplicity of factors—cultural meanings, perceived severity and past experience, structural disadvantages affecting women's access to societal resources, contingent circumstances, and, above all, the patterns of communication between patients/caretakers and health care providers in government health facilities.

Section snippets

Research setting

I carried out fieldwork between May 2000 and September 2001 in a village I will call Mdafu. Mdafu has a population of about 5500 people and is located on the periphery of Temeke District, Dar es Salaam. The village does not have electricity and has only recently benefited from a safe drinking water project. Ninety-five percent of the local residents are Muslim, and 40% of these residents identify themselves as Zaramo—the original inhabitants of Dar es Salaam. The economic base for the majority

Methods

Data for the larger ethnographic study were gathered using a combination of methods: participant observation, key informant interviewing, oral life history, illness narrative interviews, a household census and a household socioeconomic survey (n=116). This paper, however, draws primarily on (a) participant observation data gathered at the local municipal dispensary, which included engagement in informal conversations with more than 150 mothers/caretakers and the documentation of many

Study participants’ socio-demographic background

The basic socio-demographic characteristics of the 45 mothers and background information on the patients are presented in Table 1, Table 2. Of the mothers who were interviewed for the study, 93% were familiar with the practice of bringing a sick child to the dispensary for treatment. In other words, they were familiar with the routine of medical consultation, and the expectations and everyday practices of the dispensary staff. Mothers commonly expressed their familiarity with the dispensary by

Cultural models of fever and treatment delays

The majority of the 45 mothers had delayed in bringing their children to the dispensary by at least 48 h after the onset of fever (see Fig. 1). Eighteen percent of the mothers had waited for nearly a week before deciding to bring their feverish child to the dispensary. In response to questions about delays in treatment seeking, two-thirds of the mothers spontaneously replied: “I thought it was only ordinary fever!” Many mothers were surprised when they found out what they thought as ordinary

Strategic symptom reporting

Interactions between the dispensary staff and the patients/mothers were routine, predictable and uneventful. Occasionally, the scene at the dispensary became a bit unsettled, when, for example, a nurse advised one of the mothers to begin sponging her feverish child so as to lower the child's body temperature. Typically, the mother followed suit, sat on the floor, and started sponging her child with a wet cloth. In nearly all the cases, sponging had a positive effect by lowering a feverish

Narrative accounts of care seeking

As will be illustrated through the following case studies, while the identity of the illness had remained the same, the perceptions of the severity of the symptoms had changed. In other cases, the identity of the illness was revised (e.g., homa ya kawaida to homa ya kali) following the failure of a previous treatment, a form of “diagnosis by treatment.” Illness identities were subject to constant revision and reinterpretation with the presentation of a new diagnosis, including the recognition

Lay cost reckoning and treatment delays

For the majority of the 45 mothers, the anticipated cost of treatment was not the dissuading factor in their decision to seek treatment for their sick child at the dispensary. Even in the context of poverty, 78% of the 45 mothers said that they were willing to pay the nominal Tsh. 100 charged at the dispensary, provided that they received satisfactory treatment for their sick children. This is not to discount the fact that in Mdafu I interacted with scores of people who were in desperate need

Misdiagnosis and treatment delays

As noted earlier, this research was conducted at a time when the clinical efficacy of chloroquine in Tanzania was under question (Premji, Makwaya, & Minjas, 1999). However, in Mdafu, the perceived efficacy of chloroquine among mothers for the treatment of their febrile children was notably high. Nearly two-thirds of the mothers mentioned that the chloroquine given at the dispensary for malaria was effective. This could be due to the fact that chloroquine has both antipyretic and antiparasitic

Discussion

Proponents of “free market medicine” have argued that charging user fees in public health facilities has an efficiency-enhancing effect because it rationalizes attendance, discourages frivolous consultations, and forces patients to use the referral system for specialized care. However, critics have pointed out that the privatization of health care, characterized most evidently by user fees, has a devastating effect on the health of the poor, and the sick, especially women and young children

Conclusion

This paper has argued that economic considerations do not constitute the primary reason why mothers in peri-urban Tanzania delay seeking prompt treatment at a government health facility for their young, febrile children. Mothers commonly believe that they are dealing with an ordinary fever and not malaria or any other serious illness complicated by fever. Hence they extend their “wait and watch” period. Poor communication patterns between health care providers and mothers regarding the symptoms

Acknowledgements

Research on which this paper is based was generously supported by the National Science Foundation Doctoral Dissertation Research Improvement Program (Grant no. BCS-9904347), the Wenner Gren Foundation for Anthropological Research (Grant no. 6645:2000), Fund for Internationalization, Dissertation Research Award (May 1999), and the Institute of African Studies, Emory University. I gratefully acknowledge their generous support. Permission to carry out this research in Tanzania was made possible by

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