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					HOME MANAGEMENT OF MALARIA
IN UNDER FIVES AND PREGNANCY
          IN UGANDA:

  A REPORT OF QUALITATIVE
         RESEARCH




                        Prepared by:

                 K2 – Research (Uganda) Ltd.

                             for

   The Delivery of Improved Services for Health
                (DISH) II Project
                          May 2002


    USAID Cooperative Agreement No. 617-A-00-00-00-0000-00
                 Prepared by:


     K2-Research (Uganda) Ltd.
  Plot 28, Kanjokya Street, Kololo - Kamwokya,
           P. O. Box 8628, Kampala.
             Tel: 531074/5, 531094
                 Fax: 531066
                    E-mail:
E-mail: k2r1@k2consult.com/k2r2@k2consult.com




                                                 1
Acknowledgements

We would like to extend our gratitude and thanks to all those who provided us with this
invaluable wealth of information that forms the basis of this document.

Special thanks go to Anne Domatob, the staff members of the Delivery of Improved
Services for Health (DISH) II Project, the Ministry of Health and World Health
Organisation (WHO) who assisted with the design and analysis of transcripts; and to the
research assistants and supervisors who collected data. Thanks also to Dr. Dan Twebase
and Anne Gamurorwa who designed and conducted this research, and to Laura Ruhl who
edited the final report.

Last but not least, special thanks go to the DISH II Project for funding this exercise that
will facilitate the designing of a communication strategy for home management of
malaria in children under five and malaria in pregnant women.
                                           Table of Contents
List of Abbreviations…………………………………………………………………….3
EXECUTIVE SUMMARY .............................................................................................. 4
1.0      INTRODUCTION                     ……………………………………………………………..7


2.0      METHODOLOGY ............................................................................................... 8

         Data Collection Methods ........................................................................................ 8
         Data Analysis .......................................................................................................... 9

3.0      MALARIA HOME MANAGEMENT IN CHILDREN UNDER FIVE
         YEARS…………………………………………………………………………..10

3.1      Malaria Recognition and Classification ............................................................ 10
         3.1.1 Terminology and Disease Classification ................................................... 10
         3.1.2 Similar Presentations Differentiated from Malaria .................................... 11
         3.1.3 Perceived Occurrence and Severity of Malaria ......................................... 11
         3.1.4 Causes of Malaria ...................................................................................... 12
         3.1.5 Danger Signs .............................................................................................. 12

3.2      Decision Making .................................................................................................. 14

3.3      TreatmentPractices...…..……………………………………………………….16
3.4      Compliance to treatment……………………………………………….………19

3.5      Health Providers Knowledge, Attitudes, Perceptions and Practices ............. 20
         Health Workers KAP………………………………………………………...…..20
         Community Drug Vendors KAP…………………………………………………20
         Traditional Herbalists KAP………………………………………………………22

3.6        Prevention ......................................................................................................... 23


4.0        MALARIA IN PREGNANT WOMEN .......................................................... 25
4.1        MALARAIA RECOGNITION AND CLASSIFICATION ........................................... 25
           4.1.1 Terminology and Disease Classification ............................................. 25



                                                                                                                                 1
           4.1.2      Recognition of Danger Signs and Severity of Malaria ..................... 26
4.2        Decision Making ............................................................................................... 28
4.3        Treatment Practices. ........................................................................................ 30
4.4        Health Workers’ Knowledge, Attitudes, and Practices ................................ 32
           Health Workers’ Knowledge, Attitude and Practices of IPT ...................... 32
           Traditional Birth Attendants Knowledge, Attitudes, and Practices………33

4.5        Prevention ......................................................................................................... 34


5.0        Sources of Information……………………………………………………….36
5.1        Available Resources…………………………………………………………..38

Annex I: Data collection Instruments ......................................................................... 39
Annex II: Research Team……………………………………………………………..77




                                                                                                                                2
                         List of Abbreviations
AIDS      Acquired Immune Deficiency Syndrome
ARI       Acute Respiratory Illnesses
CBOs      Community Based Organisations
CHW       Community Health Worker
DDHS      Director of District Health Services
DHT       District Health Team
DHV       District Health Visitor
DISH II   Delivery of Improved Services for Health II Project
DMO       District Medical Officer
FGD       Focus Group Discussion
HMIS      Health Management Information System
HSSP      Health Sector Strategic Plan
IEC       Information, Education and Communication
IMCI      Integrated Management of Childhood Illnesses
ITM       Insecticide Treated Materials
ITNs      Insecticide Treated Nets
KI        Key Informant Interview
MCU       Malaria Control Unit
MFPED     Ministry of Finance Planning and Economic Development
MHMS      Malaria Home Management Strategy
MoH       Ministry of Health
MTR       Mid-Term Review
NGO       Non Governmental Organisations
ORS       Oral Rehydration Salts
PAF       Poverty Action Fund
PDC       Parish Development Committee
PRA       Participatory Rapid Appraisal
SSS       Sugar Salt Solution
TBA       Traditional Birth Attendant
TOR       Terms of Reference
UNICEF    United Nations Children‘s Fund
USAID     United States Agency for International Development
VHW       Village Health Worker
WHO       World Health Organisation




                                                                  3
Executive Summary

In July 2001, the Uganda Ministry of Health through the United States Agency for
International Development (USAID) requested the Delivery of Improved Services for
Health II (DISH II) Project to design a communication strategy in support of the national
strategy for Home Based Management of Fever/Malaria in Children Under Five and
Pregnant Women. As a first step, the project reviewed available literature on malaria
knowledge, attitudes and practices in Uganda and designed a qualitative study to fill in
gaps. The qualitative research was conducted in 6 districts of Uganda; a total of 30 Focus
Group Discussions (FGDs) and 30 Key Informant Interviews (KIs) were carried out
during August and September 2001.

Findings –Childhood Malaria

Childhood malaria was recognised and classified in the various local languages with
terminologies that represent broad symptom complexes, and the English term ―Malaria‖
was not universally recognised. It was found that malaria fever was differentiated from
other fevers and illnesses depending on the perceived causality and observed signs and
symptoms. All respondents perceived malaria as an important health problem that often
presents itself as a mild illness that can occasionally be fatal particularly to young
children. The majority of the respondents associated malaria with mosquitoes while
some caretakers believed it to be caused by eating or drinking certain items. Although
caretakers and community drug vendors easily recognised children who were unwell, few
recognised signs of complicated or severe malaria requiring immediate medical
intervention.

Management of childhood malaria was reported to be a joint effort involving all members
of the household and the community. Mothers were reported to make the most
immediate decisions that affect the well-being of the child. While, fathers‘ decisions
were necessary and ultimate when there were financial implications. All respondents felt
that fever should first be treated with home remedies such as local herbs, tepid sponging
etc. Only after home remedies failed was care outside of the home sought. Often,
caretakers sought community drug vendors first before going to health units as a last
resort. Although home remedies are given promptly after a child falls sick, they appeared
to be relatively ineffective.

Herbalists had a limited role in the management of childhood malaria. Malaria illness
was thought to be best managed by Western drugs. Therefore, treatment is often sought
first at private vendors. Community drug vendors (CDVs) know most of the common
anti-malarials and their corresponding correct doses. However, they were often
dispensed inappropriately due to lack of client funds and clients‘ demands. CDVs knew
of Fansidar, but did not know correct dose schedules. Furthermore, they thought
Fansidar to be too strong for children presenting with mild malaria or fever. In addition,
most caretakers admitted that contrary to medical advise they discontinue drug
administration when children show signs of recovery, in cases where other siblings also
fall sick, or in other emergencies.



                                                                                        4
Health workers, both in private and government health units, know the signs and
symptoms of malaria, its transmission process, the drugs used and its importance among
other illness. Health workers in the government health units were more informed than
those in the private sector. However, health workers did not appreciate the danger signs
and symptoms for severe and complicated malaria. They also confessed that they often
do not treat malaria according to the provided guidelines because of drug stockouts and
uncooperative patients. Most frontline health workers did not have up to-date Ministry
of Health policy guidelines about treatment of childhood fever/malaria.

Child caretakers mainly receive health information from the radio and from health
workers, but health workers were reported to be the most trusted source. Although they
often hear information on the radio, they do not always retain it.

Insecticide Treated Mosquito Nets (ITNs) were not well known by caretakers but the
existence of ordinary nets was generally known. Communities reported that they were
rare and were mainly used by heads of households. Nets were not being used due to cost,
safety, availability and lack of appreciation of their importance in the control of
childhood malaria.

In conclusion, it is recommended that health messages should use local terminologies for
fever and malaria. Awareness about the danger signs of malaria should be raised among
both caretakers and health workers. Also, communication channels targeting men should
be focused on for malaria control messages. A need to start prompt and effective
treatment and the consequences of delayed treatment should be emphasized. Community
drug vendors occupy a strategic position in society; they should be targeted and also used
as a special channel of communication. Furthermore, Ministry of Health policy treatment
guidelines should be disseminated to all health workers.


Malaria in Pregnancy

As in childhood malaria, malaria in pregnancy is recognised and classified in the local
languages with terminologies that represent broad symptom complexes. Most medical
symptoms and signs are included in these classifications and definitions. Communities in
Uganda perceive mild fever (malaria) and general weakness as a normal sign of
pregnancy, but they also recognise that severe malaria can be fatal in pregnant women.
The majority of respondents associated malaria with mosquitoes both in pregnant and
non-pregnant people. However, some respondents perceived malaria to be sexually
transmitted or to be caused by the foetus in the womb. Whereas mild fever was
perceived as a normal sign of pregnancy, which would heal by itself, severe malaria was
recognised as a dangerous illness that can lead to miscarriages, premature delivery,
stillbirths or the eventual death of a baby. Furthermore, malaria in pregnancy was
believed to affect the baby more than the mother.




                                                                                        5
The majority of pregnant women seek advise from senior females, while some, especially
those who have some income, make their own decisions. Male decisions were often
ultimate and were mainly sought for financial matters. In order to preserve marital
harmony, women sought permission from their husbands or parents-in-law before
seeking care outside of the home.

Malaria in pregnancy, like in the management of childhood fever is first treated with
home remedies. When home remedies fail, women then seek care outside of the home.
Participants stated that Traditional Birth Attendants have a limited role in malaria
management and that it is best managed by western drugs.

Most respondents knew about the existence of Fansidar, however, they did not know its
dosage schedules. Fansidar was perceived to be too strong for treatment of malaria in
pregnancy. Health workers (midwives) knew the signs and symptoms of malaria, its
transmission process, the drugs used and its importance among other illnesses, but they
did not appreciate the danger signs and symptoms for severe and complicated malaria.
Health workers reported that Fansidar was too strong for pregnant women and should be
reserved for severe cases, contrary to the Ministry of Health policy guidelines. Nearly all
health workers and caretakers were unaware of Intermittent Presumptive Treatment
(IPT), and most health workers did not know the generic name (SP) of Fansidar.

Therefore, it is recommended that health messages should use local terminologies for
malaria. The misconception that fever (mild malaria) is a normal sign of pregnancy must
be addressed, and awareness about the danger signs of malaria in pregnancy should be
raised among women, men, and health workers. Furthermore, men are an important
audience for messages about malaria control in pregnancy since they influence women‘s
actions to seek health care. A need to start prompt and effective treatment of malaria and
the consequences of delayed treatment should be emphasized. Finally, the Ministry of
Health policy on IPT must be popularised and an enabling environment for its execution
provided.




                                                                                         6
1.0 INTRODUCTION
Delivery of Improved Services of Health II (DISH II) is a joint project of the Ugandan
Ministry of Health and the United States Agency for International Development
(USAID). The project is managed by the Johns Hopkins University Center for
Communication Programs (JHU/CCP), the University of North Carolina Program in
International Training and Health (INTRAH), Management Sciences for Health, and the
Johns Hopkins University Program for International Education in Reproductive Health
(JHPIEGO). DISH is a project committed to improving quality, availability, and
utilisation of reproductive, maternal, and child health services, and enhancing public
health attitudes, knowledge, and practices in Uganda. DISH began its first five-year
phase in 1994 and the second three-year phase in 1999. DISH II builds on successes
achieved during the first five years of DISH I, and operates in 12 districts: Kampala,
Mbarara, Masaka, Rakai, Ntungamo, Masindi, Luwero, Nakasongola, Sembabule, Jinja,
Kamuli, and Kasese.

In order to achieve its objectives, the DISH II Project assists the District Health Services
in:
     Training, supervision and provision of clinical services
     Health management and quality assurance
     Behaviour change communication and community activities
     Research and evaluation

The Ministry of Health through USAID requested the DISH II Project to conduct
formative research for improving understanding in the knowledge, practices, attitudes,
fears and beliefs (KAPBF) about home management of malaria in children under five and
pregnant women. The research was conducted to provide in-depth knowledge for
designing a communication strategy. The formative research had two components, a
literature review and qualitative research.

Objectives
The main objective of the study was to deepen our understanding of the gaps in
knowledge, attitudes, practices, fears and beliefs about malaria management among
children under five and pregnant women. Specifically the objectives were:
    1) To identify myths and misconceptions about management of malaria in children
       under five and in pregnant women.
    2) To identify knowledge, attitudes, practices, fears and beliefs (KAPBF) about
       home management of malaria among children under-five.
    3) To identify knowledge, attitudes, practices, fears and beliefs (KAPBF) about
       home management of malaria among pregnant women.
    4) To determine motivating and de-motivating factors in parents seeking treatment
       of malaria for children under five, and in prevention and treatment of malaria in
       pregnant women.
    5) To suggest appropriate recommendations that would assist in the designing of a
       communication strategy.


                                                                                          7
2.0 METHODOLOGY
A total of 30 Focus Group Discussions and another 30 Key Informant Interviews were
conducted in 6 districts of Uganda.

Study Area
Six different ethnic groups in Uganda were identified and a district in each group was
selected. This was done in order to improve our understanding of the KAPBFs in the
different cultural and ethnic groups of Uganda. The selected districts were:

       1)   Ntungamo
       2)   Masaka
       3)   Hoima
       4)   Lira
       5)   Kumi
       6)   Arua.

Data Collection Methods

Focus Group Discussions (FGDs)
A total of 30 FGDs were conducted in the study, 5 in each of the 6 selected districts.
Each group consisted of homogenous persons in age groups, educational background and
local language who were willing to discuss their beliefs and practices and to explain their
understanding of home management of fever and malaria. Approximately 10 to 13
individuals participated in each focus group discussion. Refer to Appendix 1 for
interview guides. The FGDs were as follows:

   a) Children Under-Five

       1) Mothers with children less than 5 years old

       2) Fathers with children less than 5 years old.

   b) Pregnant women

       1) Husbands of women who are either currently or had been pregnant in the last
          2 years.

       2) Young women 20 –25 years old, who are either currently or had been
          pregnant in the last 2 years

       3) Women older than 35 years




                                                                                         8
Table I: Table of Number of Respondents per Focus Group Discussion
                                               Participants
Category                Ntungamo Hoima Masaka Lira Kumi Arua TOTAL
Mothers of Children <      11      12        12        10   12     11 68
5 years old
Fathers of Children <      13      10         9        12   11     12 67
5 years old
Young women (20-           12      11        12        10   12     12 70
25yrs) currently or had
been pregnant in the
last 2 years.
Husbands of women          12      12        12        12   12     12 72
who are currently or
had been pregnant in
the last 2 years.
Old women >35 years        10      12        12        12   11     13 70


Key Informant Interviews (KIs)
Five Key Informant Interviews were conducted in each of the six districts. Key
Informants were persons selected from the communities considered to be frequent
participants in the home management of fever and malaria. One person from each of the
following categories was selected for an interview. Refer to Appendix 1 to view the
interview guidelines.

a) Children Under-Five
     Health Workers from the formal sector that primarily treat childhood illnesses.
     Community Drug Vendors (CDV) who work in drug stores, clinics or as shop
       keepers.
     Traditional Herbalist who are recognised and respected by the community.

b) Pregnant women
     Health Workers- Midwife or any health worker from the formal sector who
       particularly attended to pregnant women.
     Traditional Birth Attendant

Data Analysis
The researchers analysed the data after discussions and interviews. Research assistants
participating in data collection carried out data capture, and analysis was done along
major themes.

Broad categories were developed to describe the ideas and views expressed by the
participants. The ideas, opinions and attitudes that emerged were noted and related to
other objectives. Comparison and critical analysis of the ideas led to the findings and
interpretations.


                                                                                     9
3.0    MALARIA HOME MANAGEMENT IN CHILDREN LESS
       THAN FIVE YEARS

3.1 Malaria Recognition and Classification
3.1.1 Terminology and Disease Classification
Malaria in children under five was recognised and classified in the various local
languages with terms that represent broad symptom presentations and/or causalities.
Many medical signs and symptoms for malaria are included in the definition of the
terminologies and are well known by caretakers. Although, many participants
distinguished these fevers as having various causes other than malaria.

Table II: Terminologies for Malaria in Children under-five.

      District                Terminology                 Interpretation
      Masaka                  “Omusujja gwensiri”         Fever from mosquitoes (FGD,
                                                          Mothers – Masaka)
      Masaka                  “Omusujja gwakasoli”        Fever from maize. (FGD,
                                                          Mothers – Masaka)
      Kumi                    “Eimidi”                    Fever (FGD, Mothers,
                                                          Fathers –Kumi)
      Hoima                   “Omuswijja gwemibu”         Fever from mosquitoes (FGD,
                                                          Mothers- Hoima)
      Ntungamo                “Omushwija gwensri”         Fever from mosquitoes (FGD,
                                                          Fathers- Ntungamo
      Arua                    “Dri gaza”                  Fever with headache (FGD,
                                                          Mothers – Arua)
      Arua                    “Emararia”                  Fever by mosquitoes (FGD,
                                                          women – Arua)
      Lira                    “Lyeto”                     Fever (FGD, Mothers- Lira)

The English term ―Malaria‖ was not universally understood in the districts visited, but
contrary to results from the literature review, many people knew of ―Malaria‖. Many
fathers knew the English term ―Malaria‖. However, some respondents, especially
mothers, reported terms that they are told by health workers when they bring their
children to health units that sound like the English word Malaria.

               “After trying our remedies for fever and the child does not get better, we
               go to health facility to check blood and we are told that the child has
               emararia.” (FGD, Mothers of children under 5 years – Arua)


3.1.2 Similar Presentations Differentiated from Malaria
Most respondents knew that there are causes for fevers other than malaria and that
although they have similar symptoms, they are classified as other illnesses. Participants
classified these fevers according to their symptoms or perceived causality. This finding



                                                                                      10
cut across all regions and groups visited including those of health workers. For example,
many caretakers correlate ―jaundice‖ with yellow fever.

               “Rukaka (yellow fever) fever of yellowing mucus membranes, once this is
               observed the child is immediately referred to natives for further
               management.” (Heath Worker, Ntungamo)

               “Enkaka” (yellow fever), Omusujja gwomubyenda, (fever of the stomach),
               “Eyabwe” (Convulsions), “Omusujja gwomulalama” (Meningitis) (FGD,
               Mothers of children under 5 years - Masaka)

The above observation to be found among health workers is rather uncomforting, and
efforts should be made to orient health workers and caretakers to think of malaria first
when handling all forms of fever presentations.

3.1.3 Perceived Occurrence and Severity of Malaria
All respondents perceived malaria as the most common health problem among children
and also knew that it often presents as a mild illness, but can be fatal particularly in
young children. Although, many groups of respondents viewed malaria as a mild illness
that would resolve itself. Communities that have experienced epidemics such as
Ntungamo are more concerned about malaria than those that have not.

               “Sometimes malaria is serious and kills people. There are times when it
               attacks a child and she/he faints or becomes unconscious within a short
               period.” (FGD, Mothers of children under 5 years- Ntungamo)

               “…We are used to malaria and it is our most common disease. The fear is
               less, and the mother thinks the child will be able to get cured at home and
               be alright.” (FGD, Fathers of children under 5 years – Hoima)

               “These days malaria puts down people quickly, it has claimed many
               people in this area especially young children.” (KI Herbalist -Ntungamo)

3.1.4 Causes of Malaria
The majority of the caretakers associated malaria with mosquitoes. However, most of
them did not understand that the parasites transmitted through mosquito bites are
responsible for causing malaria illness. Some caretakers believed malaria is caused by
eating or drinking certain items such as eating a lot of mangoes, maize, and drinking dirty
water. Other caretakers related malaria to cold weather, playing in the rain, and from
transmission from animals to humans.

               “When a mosquito bites you and you swell which means it has infected
               you with malaria” (FGD, Mothers of children under 5 years – Arua)

               “Children like eating a lot of raw mangoes and maize which gives them
               malaria.” (FGD, Mothers of children under 5 years -Hoima)



                                                                                           11
               “Mosquitoes bite pigs and frogs in dirty water, suck their blood which
               contains malaria and give it to humans when they bite.” (FGD, Fathers
               of children under5 years- Kumi)

               “When a child suffering from malaria sleeps in the same bed with another
               who is not, then he also gets infected.” (FGD, Mothers of children under
               5 years - Masaka)

Malaria is recognised to be most rampant during the rainy and harvesting seasons.
During this period all groups agreed that there is an increase of mosquitoes.

               “It is the dirty water during the rainy seasons where mosquitoes breed,
               and it is the dirty water which mosquitoes spit in you causing malaria.”
               (FGD, Mothers of children under 5 years - Arua)

               “Malaria can also be got by using water which contains malaria germs.”
               (KI, Traditional healer – Lira)

3.1.5 Danger signs
Caretakers and community drug vendors easily recognised children who were unwell, but
danger signs, instructions for recovery, and the progression of the disease were not easily
recognised. For example, convulsions, jaundice or anaemia and splenomegaly were not
associated with malaria and were often believed to be traditional illnesses, requiring
traditional remedies.

               “Sometimes, we are told that it is the convulsing illness (Ebihungu) and
               that these are supposed to be given local medicine.” (KI, Community
               drug Vendor - Ntungamo)

               “Convulsions are caused by a lot of sunshine.” (FGD, Mothers of
               children under 5 years - Ntungamo)

Recommendations
   1) Health messages should use local terminologies for fever. However, the
      terminologies vary with the different ethnic groups. The English term ―Malaria‖
      is not universally understood nor utilised countrywide.

   2) Awareness should be raised about malaria signs and symptoms; particularly those
      that are traditionally classified as other illnesses e.g. symptoms of cerebral
      malaria. The public needs to be informed and educated about the progression of
      malaria, the signs and symptoms at different stages, how to recognise the danger
      signs of malaria, and what to do and where to go for treatment.

   3) A clear message about the danger signs of malaria should be designed so as to
      guide prompt and timely referral, targeting particularly the caretakers and the



                                                                                        12
   community drug vendors. Caretakers should be encouraged to start treatment
   early and should also be informed on home treatments with correct doses.

4) It appears communities are more worried about the mosquito-bites than malaria
   transmission. The relationship between mosquitoes and malaria should be
   emphasised, particularly introducing the concept of malaria parasites transmitted
   through mosquitoes in the messages. This will help explain the misconceptions
   associated with malaria. Use creative ways to explain the concept of a ―vector‖,
   ―parasite‖, ―poison‖, and ―malaria fever‖ using successful methods from the
   HIV/AIDS campaigns that helped to explain the HIV and AIDS relationship.




                                                                                 13
3.2 Decision Making
In the management of childhood malaria, decision-making was reported by all groups to
be a joint effort involving mothers, fathers, elderly members of the household,
neighbours and community drug vendors. However, mothers were reported to make most
of the immediate decisions that affect the well-being of children, particularly those that
affect their health. Mothers are the primary caregivers of children and are almost always
close to the child. Therefore, they are likely to be the first to notice the beginning
symptoms of illness and to decide whether to give some home treatments, to take the
child to a health facility, or to buy medicine from a vendor. They also take decisions to a
senior female or to the father of the child especially when they need money, transport, or
permission to take the child to a health facility.

Men‘s decisions were often ultimate, especially those requiring financial support. For
purposes of preserving marital harmony, women seek permission from their husbands or
parents-in-law before seeking medical care. Husband‘s support was reported to be
largely financial, usually involving transport, procurement of drugs and payment of
hospital bills.

The amount of money treatment would cost, greatly influenced caretakers‘ actions to
treat the child. Senior females‘ decisions were most respected for those illness
presentations that are perceived to be traditional illnesses or perceived to be treated best
by traditional medicine.

               “Mothers make most of the decisions concerning children‟s treatment
               because they know their health and life better than us. We are only
               consulted where money is involved.” (FGD, Fathers of children under 5
               years - Masaka)

               “Our husbands decide when we consult them but when the illness is
               serious, there is no time for consultations. The mother can rush a child to
               hospital.” (FGD, Mothers of children under 5 years- Hoima)

               “My mother-in-law advised that taking a child with “Ebihungu” to health
               units is not wise because the child will die. So we used traditional
               remedies, but it was his time and child died anyway.” (FGD, Mothers of
               children under 5 years- Ntungamo)

Recommendations
   1) Men should be targeted to raise their awareness about malaria transmission and
      prevention and also to emphasise the importance of prompt and effective
      treatment of fever. Message concepts targeting men should stress the community
      values placed on the position of a man in the household and how those values
      relate to taking action on malaria in their children. Messages such as:




                                                                                         14
         ―Responsible fathers who participate in the recognition and treatment of
         malaria in the household will….‖
         ―You will be respected in the community if you help prevent malaria in the
         community and in your children.‖
         ―The earlier you make the decision to start treating your child if he/she has
         fever, the quicker he/she will recover, and the cheaper it will be for you.‖

2) Since senior females participate in decision making, they should be taught about
   the importance of prompt and effective treatment, how to recognise the first signs
   of malaria, what home treatments to use, how to recognise the danger signs, and
   what to do about fever/malaria. Emphasis should be placed on the dangers of not
   taking the right decisions early enough in children.

3) As mothers almost always make the most immediate decisions regarding the
   child‘s health, they are an important audience for messages on how to recognise
   symptoms of malaria and the urgency that is required to treat fever in children.
   Efforts should be made to make them understand that the longer you wait to give
   a child effective treatment for fever, the more dangerous it becomes.




                                                                                   15
3.3 Treatment Practices
It was reported in all groups that caretakers and communities believed malaria could first
be treated at home. If this treatment failed, they would then seek care outside of the
home. Common home remedies include herbs, tepid sponging and the use of drug stocks
already in the home at the time of the illness such as painkillers/panadol or left over drugs
from previous illnesses. These practices are common due to the perception that malaria
is often cured with home remedies and to lack of money.

               “If you ask for money to take a sick child to a health facility, your husband
               will ask you if you have already tried herbs, and if not, he blames you for
               being wasteful.” (FGD, Mothers of children under 5 years -Masaka)

               “Mothers have too much work to do; so if malaria can be treated or
               controlled at home, then it is okay.” (FGD, Mothers of children under 5
               years Lira)

               “Home remedies are the cheapest method of treating children, and with
               the hope that they work, they are used before bothering going to the
               clinic.” (FGD, Mothers of children under 5 years - Kumi)

Caretakers stated that they start treatment early, but most of the time this treatment was
with ineffective drugs. They believed and acknowledged that although herbs can help
they are not as effective as tablets or injections.

Malaria was perceived as an illness best managed by western drugs. Herbalists had a
limited role in the treatment of malaria, compared to other illnesses considered
traditional. If home remedies or traditional medicine failed, community drug vendors
(ordinary shops, drug stores, etc) were the next choice for treatment. If illness was severe
or treatment failed at this second level, they then go to health facilities.

               “I send my first child to buy some aspirin at the shop, but if child is more
               sick I ask for chloroquine.” (FGD, Mothers of children under 5 years -
               Hoima)

               ―I always have some panadol at home and most times my children get
               cured by it. ” (FGD, Fathers of children under 5 years -Masaka)

               “Herbs do not work well like tablets.” (FGD, Mothers of children under 5
               years – Ntungamo)

               “You can not ignore your sick child, if she/he is not playing. Give the
               available remedies commonly “Mululuza” local herb commonly found in
               the nearby bush, as you observe for progress.” (FGD, Mothers of
               children under 5 years -Masaka)




                                                                                          16
              “It is better to see health workers if treatment fails.” (FGD, Mothers of
              children under 5 years- Arua)

All groups reported that community drug vendors are the preferred source for drugs
treating childhood malaria. Caretakers explained that community drug vendors were
nearby, cheap, flexible, always stocked and understanding.

              “You give UG Shs 1000 to get free treatment at the government
              hospital/clinic but you will end up buying drugs from drug shops anyway.
              Therefore, I should better use my money to buy drugs right away from
              shops.” (FGD, Fathers of children under 5 years - Arua)

              “Even if you find the shop closed they open for you unlike health
              facilities.” (FGD, Fathers of children under 5 years - Hoima)

              “We know the names of drugs we normally get from hospital. Instead of
              making you pay for check-up in hospital, buying the medicine is better.”
              (FGD, Mothers of children under 5 years – Masaka)

There generally is good awareness about the existence of Fansidar. Fathers questioned
had better awareness than mothers or older women. However, the dosage schedules of
Fansidar were not clear and participants did not know the name SP (Sulfadoxine
Pyramenthamine). Most focus groups of mothers had some awareness about Fansidar
though a few had never heard of it.

Fansidar was perceived to be too strong for children. They believed it should only be
used in severe cases and obtained only from qualified health workers. Participants
believed Fansidar to make patients weaker, and that to take it one must be strong enough
and be able to drink a lot of fluids.

              “We fear Fansidar because it is a terrible drug. If you are not very
              strong, it will finish you off. I heard that someone took 4 Fansidar tablets
              and collapsed thereafter. Since that time I told my family never to bring
              Fansidar to my home or even use it.” (FGD, Fathers of children under 5
              years – Lira)

              “We have seen children who take Fansidar. They become more sick,
              requiring taking them long distances to big hospitals or even sometimes
              just die.” (Mothers with children less than 5 years Arua)

Recommendations:
   1) Caretakers should be made to appreciate the need to start effective treatment
      promptly and understand the consequences of delayed treatment. The use of
      herbs needs to be discouraged in the treatment of malaria in children. Though the
      herbs may give some relief, they will not effectively treat malaria.




                                                                                       17
2) Clear and simple messages need to be developed to make caretakers aware of the
   potential dangers of mild malaria symptoms in children, especially if not promptly
   and appropriately treated.

3) Whereas the trade name Fansidar is known, the generic name SP (Sulfadoxine
   Pyrementhamine) is generally not known. Efforts should be made to promote
   generic names rather than the trade brands.

4) In line with the Ministry of Health Policy, caretakers‘ fear of Fansidar in
   treatment of malaria needs to be addressed. Satisfied users and success story
   testimonies could be utilised in the promotion campaigns.

5) Many caretakers stated that they first went to community drug vendors because
   health facilities require money. Communities should be sensitised so that they
   understand services are free at health facilities.




                                                                                  18
3.4 Compliance to treatment
When children show signs of recovery, caretakers usually do not continue giving the
prescribed drugs. Sometimes the drugs are shared with other siblings or even kept for
future use and for emergencies. Most caretakers reported not finishing the prescribed
dose because they did not appreciate the need to complete the doses after the child is
recovering. In addition, health workers do not explain the dose schedules properly.

              “If a man has 4 children, each one will get a tablet.” (FGD, Fathers of
              children under 5 years – Lira)

              “Other mothers do not give all but keep some for emergency.” (FGD,
              Mothers of children under 5 years - Arua)

              “Health workers are always in a hurry and we fear to ask them to repeat
              what they mumble.” (FGD, Mothers of children under 5 years - Hoima)

When asked to propose ways of improving compliance to proper drug administration,
respondents felt that clear explanations about the importance of completing the
prescribed dose will help improve the practice.

              “Mothers should be clearly explained to what the complete dose is and
              also told of the consequences of not taking full dose.” (FGD, Fathers of
              children under 5 years Ntungamo)

Recommendations
   1) Caretakers should be educated about the correct dosages of SP and Chloroquine
      and also about the consequences of not completing the full dose.

   2) Health workers and community drug vendors should be encouraged to give clear
      and complete instructions when dispensing malaria medicine.




                                                                                   19
3.5 Health Providers’ Knowledge, Attitudes, Perceptions and Practices
Health Workers’ Knowledge, Attitudes, Perceptions and Practices
Health workers both in private and government health units generally have good
knowledge of the signs and symptoms of childhood malaria. Those in government health
units have more knowledge of the signs and symptoms of simple and uncomplicated
malaria than those in other health units. However, health workers like caretakers do not
appreciate the danger signs and symptoms of severe and complicated malaria.

               “Some if not the majority, have a traditional belief that children suffering
               from a „Ebihungu‟ (Convulsion illness) are managed with chicken blood
               and other herbs”. (KI- Health worker, Rweikiniro Sub-dispensary –
               Ntungamo)

Health workers know very well the causes of malaria, its transmission process, and its
importance among other illnesses like pneumonia. However, illnesses like anaemia are
not commonly mentioned. Health workers know the correct anti-malarial drugs.
However, some of them had problems with correct dosage administration, especially
those of Fansidar. They also confessed that they do not practice according to what they
were taught. The reasons given for this were: stock outs and uncooperative patients.

               “We sometimes prescribe tablets but patients insist that they want
               injections, or even the drugs are not available.” (Health Worker, Arua)

               “Malaria is caused by parasites transmitted by mosquitoes.” (All Health
               worker KI in the six districts)

It was also noted that most frontline health workers both private and government did not
have up-to-date Ministry of Health policies and guidelines. They reported to have
limited training opportunities. This was especially true for those in the private sector.

               “I am here treating patients all the time, but when letters for seminars and
               important information come, it‟s only the in-charge who gets it and
               benefits with close friends only.” (Health Worker Masaka)

               “I have not had the new malaria treatment policy from the Ministry of
               Health.” (Health Worker Lira)

               Nearly all health workers interviewed felt that Fansidar was too strong for
               children and should only be reserved for severe cases like Quinine.

Community Drug Vendors’ Knowledge, Attitudes, Perceptions and Practices
The focus group discussions showed that most families first get drugs from Community
drug vendors. After interviewing the community drug vendors it was found that they are
the primary source advising caretakers on the actions and drugs to take during illness.




                                                                                         20
Although communities first go to CDVs, health workers‘ decisions on fever/malaria were
most respected.
              “I help customers on the best choice of drugs to buy after listening to the
              complaints.” (KI, Community Drug Vendor – Arua)

               “Sometimes a patient who bought drugs comes back to you either happy
               (for success) or bitter (after failure) or tells me what the situation is like
               and together we look for what to do.” (KI, Community Drug vendor -
               Lira)

Community drug vendors know most of the common anti-malarials and the correct
chloroquine dose. However, they did not commonly sell the correct chloroquine doses to
caretakers. Drugs are dispensed according to the available funds of the patient or family
not according to the correct dosage. Caretakers who have little money were reported to
take less of the effective drugs in the packages they procure. Therefore, although drug
vendors know the correct drug dosage, many of their patients leave without taking the
proper dosage.
                “I just sell to these people, what their money can buy. Even if you advise
                them they won‟t listen to you.” (KI, Community Drug Vendor Hoima)

               “Gives the caretaker what her/his money can afford but sometimes advises
               about complete dose of UG Shs 200 which include more chloroquine.”
               (KI, Community Drug vendor Kumi).

               “I give her under-dose and advise to come for the rest when she gets
               money, sometimes if credit worthy, I give credit.” (KI, Community Drug
               Vendor - Ntungamo)

Community drug vendors are key people in society and should therefore be targeted and
used as a channel for communication.

Traditional Herbalists’ Knowledge, Attitudes, Perceptions and Practices
As previously noted, most families first take their children to either traditional herbalists
or community drug vendors before going to a health facility. Even though traditional
herbalists are treating these patients for malaria, they understand the severity of malaria
and state that they take their own children to health facilities. They also understand the
importance of correct medication and often refer women to drug shops or the health
facilities.
                “I take my own children to health facilities when they get malaria.” (KI,
                Herbalist - Masaka)

               “I advise mothers that if they have failed with ordinary herbs at home,
               they should go to a drug shop or a health unit right away if illness is
               severe.” (KI Herbalist Ntungamo)




                                                                                                21
Traditional herbalists know of Fansidar, but think that it is too strong for children. Since
they are the first resort health providers, this perception of Fansidar needs to be
counteracted so that the community and traditional herbalists know that Fansidar is an
essential drug for malaria treatment of adults and children and part of the government
guidelines.
                “Children should not take Fansidar because it is too strong and will make
                them much weaker or even kill him/her if the malaria is much.” (KI
                Herbalist Ntungamo)

Recommendations
        1) Policy guidelines should be circulated to all health workers both in private
           and government health units particularly targeting front-line Health
           Workers and Community drug vendors

           2) All health workers should be equipped with skills of recognising the
              danger signs early and their appropriate management emphasised.

           3) Community drug vendors need to understand the importance of giving
              children a full dosage of malaria medication and need to promote Fansidar
              as a safe and effective malaria medication.

           4) Traditional herbalists need to be sensitised on Fansidar and its safety and
              effectiveness. They also should be encouraged to immediately refer
              children with fever to a health provider.




                                                                                          22
3.6 Prevention
There was general awareness about the existence of bed nets, although very few people
were using them. The reasons for not using the nets were cost, availability, safety and
lack of appreciation of their importance in malaria prevention. Communities considered
nets useful, however, their acquisition and use is not often a priority. Insecticide Treated
Nets (ITNs) were not well known. Among those who knew about ITNs, prolonged use
was considered unsafe

               “Most men groups reported that people were willing to buy them if prices
               are affordable at about 3000-4000 –(Ntungamo), 4000 – 6000 (Lira) and
               2000 – 3000 (Masaka) from the current price range of 7,000 to 16,000 in
               the various communities.” (FGD men all the six districts).

               “Its just the government deceiving us that people should sleep under a
               mosquito net with chemicals in it all night long.” (FGD, Fathers of
               children under 5 years Fathers- Arua).

               “We claim we do not have money to buy mosquito nets, but we have
               money to spend on beer every day.” (FGD Fathers with children under 5
               years - Kumi).

   Most respondents were of the view that priority should be given to children; however,
   often nets are used by adults. The nets are used mainly by the heads of the household
   and rarely by children in homesteads.

               “I believe that it should be children to use them but in the families that we
               know its adults who use them.” (FGD, Mothers of children under 5 years -
               Hoima)

               “Most people in our village do not have mosquito nets. For those who
               have, it‟s the adults who use them and not the children because they are
               expensive and children are careless.” (FGD, young women currently or
               had been within pregnant - Lira)

               “We heard that nets are used by adults because they are too expensive
               and children may be careless and spoil them.” (FGD Mothers of Children
               with children less than 5 years, Lira)

   There was generally good knowledge of environmental preventive actions against
   malaria; however, most actions were rarely practiced. There was a belief that malaria
   control is a government responsibility, and some believed malaria control is
   unachievable.




                                                                                         23
              “Government used to spray mosquitoes long ago, I wonder what
              happened, that‟s why we have a lot of malaria.‖ (Fathers with children
              under five, Lira)

Recommendations
   1) Benefits of insecticide treated mosquito nets should be clearly explained using
      simple messages including communal benefits.

   2) Efforts should be made to emphasise to community members that they are the
      primary players in the malaria control program and the ones who benefit
      especially in the prevention of malaria. Emphasis to be placed on the fact that
      prevention is better than treatment or loss of a child through malaria.

   3) Caretakers need reassurance that insecticide treated nets are not dangerous and are
      well worth the cost.




                                                                                      24
4.0     MALARIA IN PREGNANT WOMEN

4.1 Malaria Recognition and Classification
4.1.1 Terminology and Disease Classification
Malaria in pregnant women, as in childhood, is recognised and classified in the various
local languages with terms that represent broad symptom presentations or causality.
Most biomedically known signs and symptoms for malaria are included in the definition
of the terminologies and are well known by community members. Other common signs
and symptoms during pregnancy such as swollen feet are also classified as malaria.

Table III: Terminologies Used for Malaria in Pregnancy.

      District                 Terminology               Interpretation
      Masaka                   “Omusujja gwensiri”      Fever from mosquitoes (FGD,
                                                        Pregnant Women – Masaka)
      Masaka                   “Omusujja gwakasoli”     Fever from maize. (FGD,
                                                        Mothers & Fathers – Masaka)
      Kumi                     “Eimidi”                 Fever (FGD, Mothers,
                               “Emusuja”                Fathers –Kumi)
      Hoima                    “Ekitukumo”              Fever from mosquitoes (FGD,
                               “Omuswijja gwemibu”      Mothers- Hoima)
      Ntungamo                 “Omushwija gwensri”      Fever from mosquitoes (FGD,
                                                        Pregnant Women- Ntungamo
      Arua                     “Rua     driza    kaniku Fever with headache (FGD,
                               Dirigaza ogbeta pie rii” Pregnant Women – Arua)
      Arua                     “Emararia”               Fever by mosquitoes (FGD,
                                                        women – Arua)
      Lira                     “Lyeto”                  Fever (FGD, Mothers- Lira)

Communities know that there are other common fevers different from malaria. These are
referred to as other illnesses in pregnancy or natural diseases of pregnancy. They are
classified according to presentation or perceived causality; this finding cut across all
regions visited e.g. fever for the womb, yellow fever, etc.

Communities in Uganda perceive fever and general weakness as one of the signs and
symptoms of pregnancy. However, they also recognise that severe malaria can be fatal to
pregnant women. Communities that have experienced epidemics (Ntungamo) are more
worried about malaria especially its severity than those that have not.

                 “When a newly married women falls sick often and gets mild fever then
                 you know that she is now pregnant.” (FGD, Women above 35 years,
                 Kumi)




                                                                                     25
               “…among other signs swollen feet is also a sign of malaria in
               pregnancy.” (Young women currently or had been pregnant in the last 2
               years, Hoima)

               “Sometimes malaria is serious and kills people. There are times when it
               attacks a pregnant women and she falls very sick or dies within a short
               period.” (FGD, Husbands of women currently or had been pregnant in
               the last 2 years - Ntungamo).

The majority of the respondents associated malaria with mosquitoes, however most of
them did not understand that the parasites transmitted through mosquito bites are
responsible for causing malaria illness. There were a few who had different perceptions
such as malaria being sexually transmitted or fever being caused by the foetus. Malaria
was recognised to be most rampant during the rainy and harvesting seasons.

               “During the rainy seasons, most pregnant women get sick.” (Traditional
               Birth attendant, Masaka)

                “Malaria can also be got by using water which contains malaria germs.”
               (KI, Traditional Birth attendant – Lira)

               “We all agree that mosquitoes cause fever in all people including
               pregnant women.” (FGD, Young women currently or had been pregnant
               within 2 years - Hoima)

               “If a man suffering from malaria plays sex with a non-infected woman she
               can get malaria even the unborn child gets it through the infected
               mother.” (FGD Men with wives currently or had been pregnant within 2
               yeas - Arua)

               “The baby causes heat in the womb making the mother get malaria called
               “omussujja gwoluto” (fever of the womb).” (FGD, young women
               currently or had been pregnant within 2 years - Masaka)

4.1.2 Recognition of danger signs and severity of malaria
Mild fever (malaria) in pregnancy was believed to be a normal sign of pregnancy, which
would heal by itself. Therefore, there is no urgency of treatment of fever as they see the
symptoms. However, severe malaria was recognised as a dangerous illness, which can
easily lead to miscarriages, premature delivery, stillbirths, and eventual death of a baby.
Symptoms of severe malaria identified by communities included fatigue, weakness,
yellowish eyes, chills, anaemia, and vomiting. Participants felt that fever was normal
during pregnancy, but if it continues, becomes very high, or is combined with the
previous symptoms the pregnant woman should then be treated for malaria. Malaria
fever was perceived particularly by elderly women to harm the fetus/baby more than the
mother.




                                                                                        26
Pregnant women were recognised to be more prone to malaria compared to other adults,
and communities generally knew that pregnant women were affected by malaria more
than other adult females.

             “Malaria these days is very strong it can cause miscarriages, premature
             births, prolonged labour, or even weakens the baby and may sometimes
             harm the mother also.” (FGD, Women 35 years and above -Ntungamo).

             “Malaria may cause delivery of a lame child and the skin peels off.”
             (FGD, Women 35 years and above -Kumi)

             “Since I am pregnant and my blood is not enough, unlike women who are
             not pregnant, I am more susceptible to malaria. Pregnant women suffer
             from malaria more than other women because they have weak blood.”
             (FGD, young women currently or had been within pregnant - Kumi)

Recommendations

 1) Health messages should use local terminologies for fever/malaria and should
    emphasise the seriousness of fever in pregnancy.

 2) Awareness should be raised about malaria signs and symptoms particularly its
    potential danger in pregnancy as to guide prompt and timely action and referral
    where necessary.

 3) It appears communities do not understand how malaria is transmitted. The
    relationship between mosquitoes and malaria should be emphasised particularly
    introducing the concept of malaria parasites transmitted through mosquito bites.
    This will help clear misconceptions associated with malaria transmission. Efforts
    should be made to use creative ways to explain the concept of a ―vector‖,
    ―parasite‖, ―poison‖, and ―malaria fever‖ the disease which results using the
    successes from the HIV/AIDS campaigns that helped to explain the HIV and AIDS
    relationship.

 4) The misconception that ―fever‖ (malaria) is one of the pregnancy signs and
    symptoms must be addressed and awareness that all fevers during pregnancy are
    signs of malaria and require immediate attention.




                                                                                  27
4.2 Decision Making
 The majority of pregnant women seek advise from senior females while some make their
own decisions. Most of the financially independent women make their own decisions.
Senior females‘ decisions were most respected for illness presentations that are perceived
as traditional illnesses and for their advise on herbs. Health workers‘ decisions on
malaria management were also very respected.

Men‘s‘ decisions were often ultimate, especially those requiring financial support.
Women sought permission from their husbands or parents-in-law before seeking medical
care, especially if it were sought from outside the home. Husband‘s support and
decisions were reported to be largely financial involving transport, procurement of drugs
and payment of hospital bills. Young pregnant women were reported to often first
consult their husbands for advice when they get malaria except in emergencies when
there may be no time.

               “I make my decisions since I am aware of my health.” (FGD, Young
               women currently or had been pregnant within 2 years –Hoima)

               “The pregnant woman decides and consults an elder nearby depending on
               how she feels, if not very sick may use local medicines or wait to seek
               permission from the husband to seek western remedies.‖ (FGD, Young
               women currently or had been pregnant within 2 years –Masaka)

               “When the condition of the sick person is not good the husbands, and
               maybe the neighbours can make the decision to treat at home or
               elsewhere” (FGD, Young women currently or had been pregnant within 2
               years –Kumi)

               “Our wives decide when we consult them but when the illness is serious,
               there is no time for consultations. She may take action and report to us
               later.‖ (FGD, Husbands of women currently or had been pregnant within
               2 years –Ntungamo)

               “I usually tell everything to my husband since he is the one who looks
               after me. I also ask him when I am sick.” (FGD, Young women currently
               or had been pregnant within 2 years –Hoima)

               ―Health workers‟ decisions on the treatment options are best because they
               know better.” (FGD, Husbands of women currently or had been pregnant
               within 2 years –Arua)




                                                                                       28
Recommendations

  1) Men should be targeted and their awareness about malaria transmission and
     prevention raised. Emphasis should be placed on the importance of prompt and
     effective treatment of fever during pregnancy. Benefits for the men could
     include:
         a. You are caring for your unborn baby. If the mother is treated early and
             effectively, your child will have a better chance of being born healthy.
         b. By learning about malaria and taking the right decisions, you will be
             showing that you are a responsible or caring man.
         c. As head of the household, it is your duty to prevent malaria in your family.

  2) Senior females should be taught about the importance of prompt and effective
     treatment of fever during pregnancy. They need to know how to recognise the
     first signs of malaria, how to recognise the danger signs, and what to do about it.
     Emphasis should be placed on the dangers of not making the right decisions early
     enough.

  3) Pregnant women also need to be encouraged to inform their husbands and senior
     females when they have fever and to get treatment early enough.




                                                                                     29
4.3 Treatment Practices
As in home management of childhood fever, communities believed fever during
pregnancy could first be treated at home. Its only when the home remedies fail that they
seek care outside the home. Home remedies included use of herbs, tepid sponging, and
use of drug stocks in the home. Most avoided going to a health facility because they
believed that home remedies usually cured fever and because they lacked money.

Community drug vendors (ordinary shops, drug stores, etc) were reported to be the next
choice of resort. If illness was severe or treatment fails at this second level, they then go
to health facilities. Pregnant women often start treatment early, but most of the time not
with effective drugs. They believed and acknowledged that although herbs can help, they
are not as effective as tablets or injections from health facilities. Malaria is perceived as
an illness best managed by Western drugs.

               “My mother in-law advised that if you take a herb called “Mumbwa”, the
               fever would go, so it is not necessary go to health units all the time since
               its costly, unless the illness is serious.” (FGD, Young women currently or
               had been pregnant within 2 years – Masaka)

               ―We village people usually buy 2 chloroquine and aspirins if your wife is
               unwell, but she is expected to use some local medicines first. These are
               usually available locally and are obtained by and given by her female
               friends.” (FGD, husbands of women currently or had been pregnant
               within 2 years –Ntungamo)

               ―I always have some medicines (tablets) at home, when ever I fall sick I
               use them.” (FGD, Young women currently or had been pregnant within 2
               years –Masaka)

               “Herbs give you only some relief before you get money, they do not work
               well like tablets.” (FGD, Young women currently or had been pregnant
               within 2 years –Kumi, Masaka and Ntungamo).

There was good awareness about the existence of Fansidar, but the term ―SP‖ was
virtually unknown. Also, Fansidar`s dosage schedules were not clear. Fansidar was
perceived to be too strong for pregnant mothers, and communities believed that it should
only be used in severe cases and obtained from qualified health workers. Those who had
taken Fansidar in the past stated that it was very successful in treating malaria.

               “Pregnant women should not take Fansidar because it is bitter and, it is
               believed that pregnant women are not supposed to take anything bitter.”
               (FGD, husbands of women currently or had been pregnant within 2 years
               - Ntungamo)

               “My wife has been using Fansidar and has experienced tremendous
               improvement in her health and no longer falls sick at the same rate as


                                                                                          30
            before.” (FGD, husbands of women currently or had been pregnant
            within 2 years - Hoima)

Recommendations:

  1) Pregnant women and other decision makers including the husbands and senior
     females should be targeted for an awareness campaign so that they appreciate the
     need for pregnant women to start effective treatment promptly after developing
     fever and that they know the consequences of delayed treatment. Effective
     treatment should be explained and ineffective treatment discouraged.

  2) Community‘s awareness about the potential dangers of fever during pregnancy
     especially if not promptly and appropriately treated should be emphasised with
     clear and simple messages.

  3) Fears of Fansidar must be countered. Perhaps testimonies from women who have
     used Fansidar without problems could help.




                                                                                  31
4.4 Health Workers’ Knowledge. Attitudes, Perceptions and Practices
Health workers (Midwives) in health units appreciated the prevalence of malaria in
pregnancy but did not appreciate its seriousness. They knew very well the signs and
symptoms of malaria in pregnancy. However, health workers like pregnant women did
not appreciate the danger of fever in pregnancy. This was a widely held view in most
districts visited.

Health workers know very well the causes of malaria, its transmission process, and its
importance in the community. However, other pregnancy complications were considered
to be a greater health risk than malaria in pregnancy.

Health workers knew correctly the anti-malarial drugs. However, some of them had
problems with correct dosage administration, especially for Fansidar. They also
confessed that they do not practice according to what they were taught because of stock
outs and inadequate time for patients. Most health workers first treat pregnant women
with Chloroquine and will then use Fansidar if the first treatment fails.

              “All pregnant women get fever in the early pregnancy. It is nothing to
              worry about, they get better as the pregnancy progresses.” (KI- Health
              worker Midwife- Arua, Masaka, Hoima)

              “…Although most pregnant women suffer from malaria, obstetric
              emergencies are more severe and life threatening.” (KI- Health worker
              [Midwife], Kumi)

              “…These days we see very many pregnant women in the antenatal clinics.
              There is hardly time for adequate counselling and drugs are now a
              problem with the abolition of cost sharing.” (Health Worker, Lira)

 Health Workers’ Knowledge. Attitudes, Perceptions and Practices of IPT
Nearly all health workers interviewed felt that Fansidar was too strong for pregnant
women and should only be reserved for severe cases. Like quinine, it was believed to
make women weak and to even cause abortions. Many health workers interviewed did
not know the generic names of Fansidar.

              “I have always known that Fansidar causes abortions and is reserved for
              only severe cases.. (KI, Health Worker Lira)

              “When we give Fansidar to pregnant women, they get many side effects.”
              KI, Health Worker, Masaka)

Only one out of six midwives had heard about IPT, and the rest had not. When explained
what IPT was and its purpose, most felt drugs would not be available, and the majority
also felt that it was a waste of medicine. It was very clear that IPT policy was not well
known, most health workers did not know how to administer it, and they were not in
favour of the idea.


                                                                                       32
Furthermore, none of the health workers had knowledge of using Fansidar as the first line
anti-malarial, and most had limited opportunities for accessing the Ministry of Health
Policies and guidelines.

              “…The unit now has drug stock problems, I think we can not waste our
              strong drugs for prevention on well clients.” (KI, Health Worker, Kumi)

              “We used to get free drugs during the epidemics. If the District gives us
              drugs and directions we shall do as told until the drugs are finished and
              we ask for more.” (KI Health worker, Ntungamo)

              “I have seen a circular letter from MoH stating that women should be
              given Fansidar to prevent the unborn baby from getting malaria. That
              Fansidar should be given when the pregnancy is 4 months (1st dose) and
              when it reaches 7 months, then dose is repeated. But we have not began
              doing so.” (KI, Health worker, Arua).

Traditional Birth Attendants’ Knowledge. Attitudes, Perceptions and Practices
Traditional Birth Attendants admitted that they play a limited role in the management of
malaria in pregnancy, unless the woman is in labour. Although they state that they do not
treat pregnant women for malaria but refer them instead, most women first go to TBAs
before going to a health facility. Many TBAs stated that they felt Fansdar to be too
strong for pregnant women and that they preferred to tell a woman to use local herbs.

              “…Unless in labour pains, I advise my client to go to hospital or use local
              herbs if illness is not serious. Most women in this area know the local
              herbs.” (Traditional Birth Attendant Kumi).

              “……no, I advise them to go to hospitals or drug shops right way.”
              (Traditional Birth Attendant Lira, Ntungamo)

              “On the 14th October 2001, a pregnant woman took Fansidar tablets and
              the child died in the womb.” (KI, Traditional Birth Attendant, Ntungamo)

Recommendations
1) IPT policy guidelines should be circulated to all health workers both in private and
   government units.
2) Current policy guidelines for management of malaria in pregnancy should also be
   circulated. As some health workers do not believe malaria should be treated with
   Fansidar, it will be important to emphasise the rationale for IPT and for the use of
   Fansidar in treatment.
3) Health workers need to be educated about the safety of Fansidar.
4) Traditional Birth Attendants need to be sensitised to refer pregnant women with fever
   immediately and to refer pregnant women to a health facility for IPT.




                                                                                      33
4.5      Prevention
Everyone in the discussions knew of mosquito nets, but few people in the communities
use the nets in their homes. They explained that nets are expensive and not often
available at the shops near to them. Furthermore, some doubted their safety, and many
did not appreciate the importance of malaria prevention and of protection from
mosquitoes. Most communities considered nets useful, however, their acquisition and
use is not a priority in households. Although communities were aware of mosquito nets,
Insecticide Treated Nets (ITNs) were not well known. Among those who know about
ITNs, participants explained them to be unsafe over a long period of time. After
discussing ITNs, respondents stated that priority should be given to pregnant women and
children, but said that nets are often used by their husbands or the head of the household.

                “If we could pool money together or if we could buy mosquito nets for all
                families one after another…” (FGD, young women currently or had been
                within pregnant –Ntungamo)

                “I believe that it should be pregnant women to use them, unfortunately in
                the families that I know its heads of households who use them.” (KI,
                Traditional Birth Attendant -Hoima)

Communities knew of certain environmental preventive actions that can be used against
malaria, but most actions were rarely practiced because participants thought that nothing
could be done to prevent mosquitoes. Generally, participants felt that mosquito bites are
unavoidable because mosquitoes are so abundant in their communities. Those who did
feel mosquitoes could be controlled felt that it is a government responsibility.

                “The government is the one to help us deal with the mosquitoes as they
                used to do in the past, but don‟t ask us about that! We don‟t even have
                water” (FGD Men with wives currently or had been pregnant within 2
                yeas -Kumi)

                “Eh‟ how can you stop mosquitoes which are everywhere, shall we cut all
                our banana plantations?‖ (FGD husbands of women currently or had
                been pregnant within 2 yeas - Ntungamo)

      No community members knew of Intermittent Presumptive Treatment (IPT), and all
      efforts to explain IPT were met with surprise and resistance from the community
      members. Some participants thought that IPT was a waste of medicine and thought
      women should just be treated if they have malaria. Health workers do not discuss
      malaria with pregnant women during routine antenatal visits unless asked or the
      woman is suffering from it.




                                                                                        34
            “That is a wastage of drugs. How can you give strong drugs to treat a
            normal person” (FGD, young women currently or had been within
            pregnant –Hoima)

            “Discussion about malaria rarely comes up during antenatal visits unless
            one has fever, or a health worker is asked.” (FGD, young women
            currently or had been within pregnant - Kumi)

Recommendations

  1) Benefits of insecticide treated mosquito nets should be clearly explained using
     simple messages including communal benefits.

  2) Messages should be designed to increase the self-efficacy of men and women
     towards malaria control. Emphasis should be placed on what couples can do to
     protect pregnant women and their babies from mosquito bites and from malaria.

  3) Men and women need to understand the rationale for IPT and made aware that
     malaria in pregnancy can be prevented.




                                                                                 35
5.0 Sources of Information
Communities receive information about malaria from multiple sources, especially from
health workers and the radio. Other sources include neighbours, lower local council
officials, community based groups, and organisations, although health workers and radio
are the most trusted. Although the radio is one of the common sources of information,
caretakers do not easily retain the information conveyed. Therefore, messages need
reinforcement by other channels of communication.

              “What health workers say is right because they went to school to learn
              about health so they know better.” (FGD, Mothers of children under 5
              years –Masaka)

              “Radios disseminate a lot but sometimes we forget what we hear on
              radio.” (FGD, Young women currently or had been pregnant within 2
              years –Hoima).

              “We listen to the radio when we are resting, men have more time to listen
              and they come and tell us. We must work and then there is no time.”
              (FGD, husbands of women currently or had been pregnant within 2 years
              –Lira).

 Recommendations
1) A multimedia behaviour change communication campaign needs to be launched to
   inform and motivate the communities to practice better prevention and treatment for
   malaria in children and in pregnant women. As radio is a powerful and trusted source
   of information, it can be used as a lead channel of communication using radio
   programmes and radio spots, with other channels supporting it e.g. print,
   interpersonal, drama, song and dance. This should give messages about the following
   topics:
           a) Malaria prevention including use of insecticide treated bed nets and IPT.
           b) Recognition of the first signs of malaria in children and what to do for
              home treatment.
           c) Danger signs of malaria in children and what action to take.
           d) Danger signs of complicated malaria in pregnant women and what action
              to take.
           d) The danger of untreated or incomplete treatment of malaria in children and
              in pregnant women.
           e) The dangers of waiting too long to take a child or pregnant woman for
              effective treatment of fever.
           f) The safety of SP (Fansidar) during pregnancy.
           g) The need for immediate treatment of fever during pregnancy and in
              children with malaria medicine.




                                                                                     36
2) Efforts should be made to support health workers to give clear and correct
   information to caretakers of children, to pregnant women, and to husbands of
   pregnant women.

3) Health workers need counselling support materials and some leaflets for the
   caretakers, pregnant women and their spouses to take home as reminders and to help
   in discussions with other members of the household. Health workers should be
   updated in the new treatment regimes, new policies, IPT guidelines and the danger
   signs of malaria. This should make the health worker more knowledgeable and
   therefore more confident in counselling and treating malaria in children and in
   pregnant women.

4) Health workers should be supported to do outreach activities and to attend public
   gatherings like LC meetings, churches, and women‘s meetings and should lead
   discussions on malaria in children and in pregnant women in order to better inform
   communities about malaria.

5) Health workers and caretakers alike need to be convinced that SP (Fansidar) is safe
   for treatment of children and pregnant women, and the rationale for its use.




                                                                                         37
5.1 Available Resources
Communities have structures that can be utilised to propagate messages for malaria in
childhood and in pregnancy. The preferred structures of communities are community
leadership structures, community organisations for credit schemes and social support
groups and churches. Respondents seemed willing to take action and stated different
community plans that could be used for reducing mosquito numbers and malaria
frequency in their area.

              Messages could be sent through religious gatherings. People believe in
              them. ‖ (Mothers with children under 5 years, Hoima)

              “We can sell nets though LCs and small business people, instead of us
              walking long distances to big towns.” (Mothers wit Children Under Five
              Kumi)

              “We can organise ourselves in groups and clear where mosquitoes
              breed.” (Fathers of children under 5 years Ntungamo)

   Recommendations
   Communities have immense potential and resources to propagate messages for
   malaria, especially the groups that are self-mobilising.

       1) The leadership structures in Uganda are also a good opportunity to organise
          community actions. The Local Councils make good entry points as there is a
          Secretary for Children Affairs, Women Affairs, and the Environment. These
          need to be sensitised and monitored in order that they have correct knowledge
          about malaria.

       2) Religious or faith-based organisations are also another powerful structure that
          can advocate for malaria programmes.

       3) Other groups that need correct information about malaria control include:
          women‘s groups, credit groups, and ―Batuka‖ or ―burial societies‖.




                                                                                      38
Annex I:      Data Collection Instruments
Malaria in Children Under Five
FGD for Fathers of Children Under-Five Years

FGD for Mothers of Children Under-Five

KI of Traditional Healers

KI of Facility-Based Health Workers

KI of Drug Vendors/Shop Owners at Community Level


Malaria in Pregnant Women
FGD of Older Women, 35 Years and above

FGD of Pregnant Women, 20-25 Years Old

FGD of Men with Wives who are Currently Pregnant or have been Pregnant in the last 2
years

KI of Facility-Based Health Workers

KI of Traditional Birth Attendants




                                                                                   39
                           FOCUS GROUP DISCUSSION GUIDE

                         Home Treatment of Malaria in Under Fives

                              Fathers of Children Under-Five Years

The moderator should make the effort to interact with the participants briefly outside of
the discussion room before the focus group discussion takes place.

I.         INTRODUCTION

           Good morning/afternoon and thank you all for coming. My name is _______ and
           this is my colleague _____. We are working with a Research Firm, ------- We are
           conducting several meetings with people like you to find out how you feel about
           several health issues. We will be talking to groups of men and women. Your
           opinions are very important, and they will help us improve the kind of services
           that are provided. Please tell us your feelings and ideas about the topics that come
           up in today's talk.

           There are no right or wrong answers, and you do not have to agree with what
           someone else says. Everyone's contribution is valuable. We want this to be a
           group discussion; so don't wait for me to call on you. Just speak up. Speak up
           one at a time so we all can hear.

           Your answers will remain confidential and anonymous. Your answers will help
           us plan programs for your area.

           So that we do not lose any important information, we would like to tape-record
           the discussion. Is that all right with everyone? You may listen to the discussion
           at the end if you wish.

                  Note to the moderator: Moderators should pay attention to the mood of
                  the group, and ask questions about respondents' personal opinions and
                  practices as much as possible with phrases like "How about you?"


     II.      ICE-BREAKER EXERCISE

              Conduct round-table introductions. Request each participant to take a few
              minutes to talk with the person on his left. He should find out all they can
              about that person--where he lives, how he spends his time in the village and
              what his interests are. Give participants 2 or 3 minutes to talk with their
              neighbours. Then ask each participant to introduce his neighbour to the
              group




                                                                                            40
   III. WARM-UP

            Make small talk, such as:

         How do you find life here these days?

         Pick up on what they talk about and expand into section IV

   IV.      FOCUSSED DISCUSSION

        Symptom recognition and Seriousness


   1. What are the three most common health problems among children in this
      community? List them in order of importance.

   2. Is malaria a serious health problem among children in this community? (If not
      already mentioned in #1)

   3. What are the common signs and symptoms of malaria in children?

   4. What other fevers do you know of in this community? What are the
      causes of these fevers?

   5. Among those mentioned, which are most dangerous fevers in this community?
      (Probe: To children under five?)

   6. We have learned that when a child gets malaria, mothers give herbs, sponging
      with cold water or give a panadol and only buy Chloroquine/Fansidar or take the
      child to a health facility as a last resort. Why do you think this is happening?

   7. How do you define successful or unsuccessful treatment? (Probe: What are the
      warning signs that tells the mothers to switch to another treatment? How do you
      interpret success or failure)?

Causality

   8. In your view, how does a mosquito cause (malaria?)? (Please use name given)
      (Probe: When a mosquito bites, what happens?)
      What is the relationship between (malaria) and mosquito bites?

   9. When is (malaria) most rampant in this area? (Probe: what is the relationship
      between malaria, mosquitoes and seasons of the year, especially the rainy season
      or the harvest season? maize and mangoes




                                                                                   41
Decision Making

   10. How are decisions made, whether to treat at home or elsewhere? Who influences
       mothers to seek effective treatment for malaria (Chloroquine Fansidar) for their
       sick children?

   11. What are some of the signs that indicate to the family that a child needs attention
       of a health worker? (Probe for perceived danger signs, severity)

   12. What makes mothers rush their sick child to a health facility for some conditions
       (e.g. snake bite) and not malaria? (If response is ―Snake bite kills‖ then ask ―What
       about malaria?‖


Treatment Practices

   13. What is the best treatment today, for malaria in children? (Probe:
                   i. Have you heard about chloroquine- Fansidar combination?
                  ii. What are the barriers to effective treatment of malaria in
                      children?

   14. We have learned that some mothers fear drugs like Fansidar? (.Probe:
                   i. What have you heard? What have you experienced?
                  ii. How can we convince those mothers that it is an effective
                      treatment for malaria?
                iii. Who is a credible person to convince them?
                 iv. How can we convince mothers to obtain and these drugs before
                      any other type of treatment for malaria in children?

Compliance to Treatment

   15. Do mothers always give all drugs as prescribed by the health worker or drug
       vendor to their sick children? (Probe: Always, sometimes, never) Why or why
       not?)

   16. How can we convince mothers to complete the prescribed treatment of malaria for
       their sick children?


Sources of Treatment

   17. Why do you think that some families prefer ordinary shops /drug stores to health
       facilities for obtaining effective anti-malarials?

Sources of Information




                                                                                        42
   18. What are the sources of information about malaria for people in the community?
       (Probe: on prevention, on treatment)
       Which sources of information do they trust most (Probe and rank – most to least
       trusted)

Preventive Measures

   19. What can be done to prevent malaria? (Probe: do you do it? Why/Why not?)
       What can be done to prevent mosquito bite? (Probe: Do you do it? Why/Why
       not?)

   20. Have you heard that children should sleep under a mosquito net? Who told you?

      Do you know of any family in this community that uses them? What have they
      said about them?

      Do you think that they are useful? Would you be willing to pay for them?)

   21. How can a community make it easy for families to buy mosquito nets?

Confirmation of Terminology and Illness Concepts

   22. What should we call malaria in this community? How should we describe the
      relationship between mosquitoes and malaria? How can you help others to know
      this information?)

   23. What resources do you have in this community that will enable you to effectively
       manage malaria? (If the following structures are not mentioned, Probe if they are
       available and if they can be used: local councils, Bataka Groups, Revolving
       Funds for prevention of Malaria, Religious organisations, CBO‟s)


WRAP-UP
              Wrap up the discussion:

   This has been a very interesting discussion....

              End by saying:

   Is there anything else you'd like to mention to me or to the group?

              Ask more than one respondent in different ways. Then be sure to correct
              any blatant, dangerous misconceptions and ask the group if they have any
              questions about the facts.



                                                                                     43
                       FOCUS GROUP DISCUSSION GUIDE

                    Home Treatment of Malaria in Under Five
                             Mothers of Children Under-Five

The moderator should make the effort to interact with the participants briefly outside of
the discussion room before the focus group discussion takes place.

INTRODUCTION

       Good morning/afternoon, and thank you all for coming. My name is _______ and
       this is my colleague _____. We are working with a Research Firm, ------- We are
       conducting several meetings with people like you to find out how you feel about
       several health issues. We will be talking to groups of men and women. Your
       opinions are very important, and they will help us improve the kind of services
       that are provided. Please tell us your feelings and ideas about the topics that come
       up in today's talk.

       There are no right or wrong answers, and you do not have to agree with what
       someone else says. Everyone's contribution is valuable. We want this to be a
       group discussion; so don't wait for me to call on you. Just speak up. Speak up
       one at a time so we all can hear.

       Your answers will remain confidential and anonymous. Your answers will help
       us plan programs for your area.

       So that we do not lose any important information, we would like to tape-record
       the discussion. Is that all right with everyone? You may listen to the discussion
       at the end if you wish.

              Note to the moderator: Moderators should pay attention to the mood of
              the group, and ask questions about respondents' personal opinions and
              practices as much as possible with phrases like "How about you?"


ICE-BREAKER EXERCISE

              Conduct round-table introductions. Request each participant to take a
              few minutes to talk with the person on her left. She should find out all they
              can about that person--where she lives, how she spends her time in the
              village and what her interests are. Give participants 2 or 3 minutes to talk
              with their neighbours. Then ask each participant to introduce her
              neighbour to the group




                                                                                        44
WARM-UP

           Make small talk, such as:

How do you find life here these days?

Pick up on what they talk about and expand into section IV

FOCUSSED DISCUSSION

   Symptom recognition and Seriousness


1) What are the three most common health problems among children in this
   community? List them in order of importance.

2) Is malaria a serious health problem among children in this community? (If not
   already mentioned in #1)

3) What are the common signs and symptoms of malaria in children?

4) What other fevers do you know of in this community? What are the
   causes of these fevers?

5) Among those mentioned, which are most dangerous fevers in this community?
(Probe: To children under five?)

6) We have learned that when a child gets malaria, mothers give herbs, sponging
with cold water or give a panadol and only buy Chloroquine/Fansidar or take the
child to a health facility as a last resort. Why do you think this is happening?

7) How do you define successful or unsuccessful treatment? (Probe: What are the
warning signs that tells the mothers to switch to another treatment? How do you
interpret success or failure)?

   Causality

8) In your view, how does a mosquito cause (malaria?)? (Please use name given)
(Probe: When a mosquito bites, what happens?)
    What is the relationship between (malaria) and mosquito bites?

9) When is (malaria) most rampant in this area? (Probe: what is the relationship
between malaria, mosquitoes and seasons of the year, especially the rainy season or
the harvest season? maize and mangoes




                                                                                45
   Decision Making

10) How are decisions made, whether to treat at home or elsewhere? Who influences
mothers to seek effective treatment for malaria (Chloroquine Fansidar) for their sick
children?

11) What are some of the signs that indicate to the family that a child needs attention
of a health worker? (Probe for perceived danger signs, severity)

12) What makes mothers rush their sick child to a health facility for some conditions
(e.g. snake bite) and not malaria? (If response is ―Snake bite kills‖ then ask ―What
about malaria?‖

   Treatment Practices

13) What is the best treatment today, for malaria in children? (Probe:
              i. Have you heard about chloroquine- Fansidar combination?
             ii. What are the barriers to effective treatment of malaria in
                 children?

14) We have learned that some mothers fear drugs like Fansidar? (.Probe:
            iii. What have you heard? What have you experienced?
             iv. How can we convince those mothers that it is an effective
                 treatment for malaria?
              v. Who is a credible person to convince them?
             vi. How can we convince mothers to obtain and these drugs before
                 any other type of treatment for malaria in children?

   Compliance to Treatment

15) Do mothers always give all drugs as prescribed by the health worker or drug
vendor to their sick children? (Probe: Always, sometimes, never) Why or why not?)

16) How can we convince mothers to complete the prescribed treatment of malaria
for their sick children?

   Sources of Treatment

17) Why do you think that some families prefer ordinary shops /drug stores to health
facilities for obtaining effective anti-malarials?

   Sources of Information

18) What are the sources of information about malaria for people in this community?
(Probe: on prevention, on treatment)



                                                                                    46
    Which sources of information do they trust most (Probe and rank – most to least
    trusted)

   Preventive Measures

19) What can be done to prevent malaria? (Probe: Do you do it? Why/Why not?)
What can be done to prevent mosquito bite? (Probe: Do you do it? Why/Why not?)

20) Have you heard that children should sleep under a mosquito net? Who told you?

    Do you know of any family in this community that uses them? What have they
    said about them?

    Do you think that they are useful? Would you be willing to pay for them?)

21) How can a community make it easy for families to buy mosquito nets?

   Confirmation of Terminology and Illness Concepts

22) What should we call malaria in this community? How should we describe the
relationship between mosquitoes and malaria? How can you help others to know this
information?)

23) What resources do you have in this community that will enable you to effectively
manage malaria? (If the following structures are not mentioned, Probe if they are
available and if they can be used: local councils, Bataka Groups, Revolving Funds
for prevention of Malaria, Religious organisations, CBO‟s)


WRAP-UP

           Wrap up the discussion:

This has been a very interesting discussion....

           End by saying:

Is there anything else you would like to mention to me or to the group?

           Ask more than one respondent in different ways. Then be sure to correct
           any blatant, dangerous misconceptions and ask the group if they have any
           questions about the facts.




                                                                                 47
                       MALARIA IN Children Under Five

                KEY INFORMANT INTERVIEW GUIDE 3

           To be conducted among Traditional Healers

The purpose of the interview is to elicit a comprehensive story from each interviewee
about their knowledge and attitudes and practices with regard to Malaria in children
under five years of age. As much as possible, let the interviewee talk. Only interject
occasionally to be sure that the topic areas in the question guide are covered.

                                 I.     INTRODUCTION

Good morning/afternoon, and thank you for coming. My name is
______________ I am working with a Research Firm to improve delivery
of services in this community. I am conducting several meetings with
people like you to find out how you feel about certain health issues.
Your opinions are very important, and they will help us improve the kind
of service we provide.

Your answers will remain confidential and anonymous. Your answers
will help us plan programs for your area. Therefore, please be as
detailed as possible. We have plenty of time.

So that we do not lose any important information, I would like to tape-
record the discussion. Is this all right with you? You may listen to the
discussion at the end if you wish.

                                 II. WARM-UP

Ask the respondent his/her name, occupation, how long he/she has lived there and
things she/he likes to do, etc. SHARE SOMETHING PERSONAL ABOUT
YOURSELF TOO.




                                                                                    48
                                   III. INTERVIEW

     I am going to ask a few questions about some health problems in this community.

    Symptom recognition and Seriousness
1. What are the three most common health problems among children in this
   community? List them in order of importance.

2. Is malaria a serious health problem among children in this community? (If not
   already mentioned in #1)

3. What are the common signs and symptoms of malaria in children?

4. What other fevers do you know of in this community? What are the
   causes of these fevers?

5. Among those mentioned, which are the most dangerous fevers in this
   community? (Probe: To children under five?)

6. How do you define successful or unsuccessful treatment? (Probe: What are
   the warning signs that tell the mother to use another type of treatment? How
   do you interpret success or failure)?

    Causality

7. In your view, how does a mosquito cause malaria? (Please use name given
   and Probe: When a mosquito bites, what happens?)

8.   When is (malaria) most rampant in this area?
    Probe: what is the relationship between:
    Malaria and mosquitoes
    Malaria, mosquitoes and the rainy season?
    Malaria, mosquitoes, the rainy season, the harvest season - maize and
     mangoes?)

9. In your view, what do people of this area think is the cause of malaria?


    Decision Making

10. How are decisions made, whether to treat at home or elsewhere? Who influences
    mothers to seek effective treatment for malaria (Chloroquine & Fansidar) for their
    sick children? Are you sometimes consulted?




                                                                                         49
11. What makes mothers rush their sick child to a health facility for some
    conditions (e.g. snake bite) and not malaria? (If response is “Snake bite kills,”
    then ask, “What about malaria?”)

   Treatment Practices

12. If a child is brought to you and you suspect the child is suffering from malaria, what
    do you do? (Probe for advice given, medication, referral)

13. What is the best treatment today, for malaria in children? (Probe:
 Have you heard about chloroquine- Fansidar combination?
 What are the barriers to effective treatment of malaria in children?

14. We have learned that some mothers fear drugs like Fansidar? (.Probe:
 What have you heard? What have you experienced?
 How can we convince those mothers that it is an effective treatment for malaria?
 Who is a credible person to convince them?
 How can we convince mothers to obtain and use these drugs before any other type of
    treatment for malaria in children?

   Compliance to Treatment

15. Do mothers always give all drugs as prescribed by the health worker or drug vendor
    to their sick children? (Probe: Always, sometimes, never) Why or why not?)

16. How can we convince mothers to complete the prescribed treatment for malaria for
    their sick children?

   Sources of Information

17. What are the sources of information about malaria to people in the community?
   (Probe: on prevention, on treatment, etc.)?

18. Which of these sources of information do they trust most? (Probe and rank – most to
   least trusted)

19. What resources do you have in this community that will enable you to effectively
   manage malaria? (If the following structures are not mentioned, Probe if they are
   available and if they can be used: local councils, Bataka Groups, Revolving Funds
   for prevention of Malaria, Religious organisations, CBO‟s)

       Preventive Measures




                                                                                         50
20. What are the sources of information about malaria to people in the community.

    Have you heard that children should sleep under a mosquito net? Who told you?

    Do you know of any family in this community that uses them? What have they
    said about them?

    Do you think that they are useful? Would you be willing to pay for them?)


21. How can a community make it easy for families to buy mosquito nets?

   Confirmation of Terminology and Illness Concepts

22. What local name should we call malaria in this community? How should we
describe the relationship between mosquitoes and malaria? How can you help others
to know this information?)


                                 IV.    WRAP-UP

Wrap up the discussion: "This has been a very interesting discussion"

Clarify unclear points made by the interviewee by stating: ―You said….. Did I
understand you correctly?"

Be sure to correct any incorrect information that the interviewee may have told you
during the interview.

                                 V.     CLOSURE

Thank the interviewee




                                                                                      51
                       MALARIA IN Children Under Five

                   KEY INFORMANT INTERVIEW GUIDE 4

           To be conducted among Facility-Based Health Workers

The purpose of the interview is to elicit a comprehensive story from each interviewee
about their knowledge and attitudes and practices concerning Malaria in pregnant
women. As much as possible, let the interviewee talk. Only interject occasionally to
be sure that the topic areas in the question guide are covered.

I. INTRODUCTION

Good morning/afternoon, and thank you for coming. My name is ______________ I
am working with a Research Firm to improve delivery of services in this community.
I am conducting several meetings with people like you to find out how you feel about
certain health issues. Your opinions are very important, and they will help us improve
the kind of service we provide.

Your answers will remain confidential and anonymous. Your answers will help us
plan programs for your area. Therefore, please be as detailed as possible. We have
plenty of time.

So that we do not lose any important information, I would like to tape-record the
discussion. Is this all right with you? You may listen to the discussion at the end if
you wish.

II. WARM-UP

Ask the respondent his/her name, occupation, how long he/she has lived there and
things she/he likes to do, etc.   SHARE SOMETHING PERSONAL ABOUT
YOURSELF TOO.

III. INTERVIEW

   Symptom Recognition and Seriousness

I am going to ask a few questions about some health problems in this community.

1. What are the 3 most common health problems among children under five years
   old in this community? (List them in order of importance).

2. Is malaria a serious or common health problem among children under five years
   old in this community? (If not already mentioned in #1)

3. What other fevers do you know of in this community? What are the
   causes of these fevers?


                                                                                   52
4. Among those mentioned, which are the most dangerous? (Probe: To children
   under five, to pregnant women?)

5. What is the fever that is recognized as malaria in this community? (Probe: In
   children under five. In pregnant mothers? What do people in this area call this
   type of fever? (local name)

6. We have learned that when a child gets malaria, mothers give herbs, sponge with
   cold water or give a panadol and only buy Chloroquine/Fansidar or take the child
   to a health facility as a last resort. In you opinion, why do you think this is
   happening?

7. What makes mothers rush their sick child to a health facility for some conditions
   (e.g. snake bite) and not malaria? (If response is ―Snake bite kills‖ then ask ―What
   about malaria?‖

   Causality

8. When is malaria most rampant in this area?
   Probe: what is the relationship between
      a. Malaria and mosquitoes
      b. Malaria, mosquitoes and the rainy season?
      c. Malaria, mosquitoes, the rainy season and the harvest season (maize and
          mangoes)?

9. In your view, what do people of this area believe is the cause of malaria?

   Sources of Information and community Resources

10. What are the sources of information about malaria to people in the community?
   (Probe: on prevention, on treatment, etc.)?

11. Which sources of information do they trust most? (Probe and rank – most to least
    trusted)

12. What resources do you have in this community that will enable you to effectively
    manage malaria? (If the following structures are not mentioned, Probe, if they are
    available and if they can be used: local councils, Bataka Groups, Revolving
    Funds for prevention of Malaria, Religious organizations, CBO‟s).

   Treatment Practices

           Now, I am going to ask a few questions about how malaria is treated in
           this community you are serving.




                                                                                    53
    13. What type of things do people in this community use or do to treat malaria in
        children under five years old? Of these, which are the most effective? Which of
        these are negative, which are positive?

    14. How do you define successful or unsuccessful treatment? (Probe: How do you
        decide that this treatment is not working to be able to switch to another line of
        treatment? How do you interpret success or failure of treatment?)

    15. What types of drugs do you prescribe for children under five suffering from
        malaria? What dose do you prescribe?

       Prevention

    16. What can people in this community do to prevent malaria (Probe: Do they do it?
        Why/Why not?) what can people in this community do to prevent mosquito bites
        (Probe : Do they do it? Why/Why not?)

   Anti Malarial Drug Policy.

    17. Have you heard of the IPT guidelines from the Ministry of Health?

    18. Have you heard of a Malaria Drug Policy for treating children? What have you
        heard?

    19. How can the Ministry help you to implement the guidelines?

    20. What do you health workers believe about the effectiveness of the recommended
        and alternative drugs mentioned in the policy guidelines?


       Confirmation of Terminology and Illness Concepts

    21. What local name should we call malaria in this community?

IV. WRAP-UP

    Wrap up the discussion: "This has been a very interesting discussion"

    Clarify unclear points made by the interviewee by stating: ―You said….. Did I
    understand you correctly?"

    Be sure to correct any incorrect information that the respondent may have told you
    during the interview.

V. CLOSURE
Thank the interviewee


                                                                                      54
                          MALARIA IN Children Under Five

                   KEY INFORMANT INTERVIEW GUIDE 5

              To be conducted among Drug Vendors/Shop Owners at Community Level


   The purpose of the interview is to elicit a comprehensive story from each interviewee
   about their knowledge and attitudes and practices with regard to Malaria in children
   under five years of age. As much as possible, let the interviewee talk. Only interject
   occasionally to be sure that the topic areas in the question guide are covered.

                                      I. INTRODUCTION

   Good morning/afternoon, and thank you for coming. My name is
   ___________ I am working with a Research Firm to improve delivery of
   services in this community. I am conducting several meetings with
   people like you to find out how you feel about certain health issues.
   Your opinions are very important, and they will help us improve the kind
   of service we provide.

   Your answers will remain confidential and anonymous. Your answers
   will help us plan programs for your area. Therefore, please be as
   detailed as possible. We have plenty of time.

   So that we do not lose any important information, I would like to tape-
   record the discussion. Is this all right with you? You may listen to the
   discussion at the end if you wish.

                                    II. WARM-UP

   Ask the respondent his/her name, occupation, how long he/she has lived there and
   things she/he likes to do, etc. SHARE SOMETHING PERSONAL ABOUT
   YOURSELF TOO.

                                  III. INTERVIEW

      Symptom Recognition and Seriousness

   I am going to ask a few questions about some health problems in this community.

1. What are the 3 most common health problems among children under five
   years old in this community? (List them in order of importance).

2. Is malaria a serious or common health problem among children under five
   years old in this community? (If not already mentioned in #1)


                                                                                       55
3. What other fevers do you know of in this community? What are the
   causes of these fevers?

4. Among those mentioned, which are most dangerous? (Probe: To children
   under five)

5. What is the fever that is recognised as malaria in this community? (Probe: In
   children under five. What do people in this area call this type of fever? (local
   name)

6. We have learned that when a child gets malaria, mothers give herbs,
   sponging with cold water or give a panadol and only buy
   Chloroquine/Fansidar or take the child to a health facility as a last resort. Why
   do you think this is happening?

7. What makes mothers rush their sick child to a health facility for some
   conditions (e.g. snake bite) and not malaria? (If response is “Snake bite kills”
   then ask “What about malaria?”)

   Causality

8. When is (malaria) most rampant in this area? Probe:
    what is the relationship between, Malaria and mosquitoes
    Malaria, mosquitoes and the rainy season?
    Malaria, mosquitoes, the rainy season and the harvest season (maize
      and mangoes)?

9. In your view, what do people of this area think is the cause of malaria?

10. Sources of Information and Community Resources

11. What are the sources of information about malaria to people in this
    community?(Probe: on prevention, on treatment)

12. Which sources of information do they trust most (Probe and rank – most to
    least important)?

13. What resources do you have in this community that will enable you to
    effectively manage malaria? (If the following structures are not mentioned,
    Probe if they are available and if they can be used: local councils, Bataka
    Groups, Revolving Funds for prevention of Malaria, Religious organisations,
    CBO’s)

       Treatment Practices




                                                                                  56
              Now, I am going to ask a few questions about how malaria is treated in
              this community you are serving.

14. What type of things do people in this community use or do to treat malaria in
    children under five years old? Of these, which are most effective? Which
    ones are negative? Which ones are positive?

15. How do you define successful or unsuccessful treatment? (Probe: How do
    you decide that this treatment is not working to be able to switch to another
    type? How do you interpret success or failure of treatment?

16. What types of drugs do you prescribe for children under five suffering from
    malaria?

17. If a mother comes to you to buy medicine for malaria, which you know, is
    under-dose, what do you do?

      Anti Malarial Drug Policy.

18. Have you heard of IPT (Intermittent Presumptive Treatment ) guidelines from
    the Ministry of Health?

19. Have you heard of a Malaria Drug Policy guidelines for treating malaria in
    children? What have you heard? (if response is “no” go to # 21)

20. How can the Ministry help you to implement the guidelines?

21. What do you as drug vendors/ shop owners believe about the effectiveness of
    the recommended and alternative drugs mentioned in the policy?

      Confirmation of Terminology and Illness Concepts

22. What local name should we call malaria in this community? How should we
   describe the relationship between mosquitoes and malaria? How can you
   help others to know this information?

                                IV. WRAP-UP
   Wrap up the discussion: "This has been a very interesting discussion"

   Clarify unclear points made by the interviewee by stating: ―You said….. Did I
   understand you correctly?"

   Be sure to correct any incorrect information that the interviewee may have told you
   during the interview.
                                      V. CLOSURE
   Thank the interviewee


                                                                                         57
                       FOCUS GROUP DISCUSSION GUIDE

                               Malaria in Pregnancy
                          Older Women, 35 Years and above

The moderator should make the effort to interact with the participants briefly outside of
the discussion room before the focus group discussion takes place.

I. INTRODUCTION

Good morning/afternoon and thank you all for coming. My name is _______ and this is
my colleague _____. We are working with a Research Firm, ------- We are conducting
several meetings with people like you to find out how you feel about several health
issues. We will be talking to groups of men and women. Your opinions are very
important, and they will help us improve the kind of services that are provided. Please
tell us your feelings and ideas about the topics that come up in today's talk.

There are no right or wrong answers, and you do not have to agree with what someone
else says. Everyone's contribution is valuable. We want this to be a group discussion; so
don't wait for me to call on you. Just speak up. Speak up one at a time so we all can
hear.

Your answers will remain confidential and anonymous. Your answers will help us plan
programs for your area.

So that we do not lose any important information, we would like to tape-record the
discussion. Is that all right with everyone? You may listen to the discussion at the end if
you wish.

Note to the moderator: Moderators should pay attention to the mood of the group, and
ask questions about respondents' personal opinions and practices as much as possible
with phrases like "How about you?".


II. ICE-BREAKER EXERCISE

Conduct round-table introductions. Request each participant to take a few minutes to talk
with the person on her left. She should find out all they can about that person--where she
lives, how he spends her time in the village and what her interests are. Give participants
2 or 3 minutes to talk with their neighbours. Then ask each participant to introduce her
neighbour to the group.




                                                                                        58
III. WARM-UP

Make small talk, such as:

How do you find life here these days?

Pick up on what they talk about and expand into section IV

IV. FOCUSSED DISCUSSION

       Symptom Recognition and Seriousness


1. What are the 3 most common health problems among pregnant women in this
   community? (List them in order of importance).

2. Is malaria a serious or common health problem among pregnant women in this
   community? (If not already mentioned in #1)

3. What are the symptoms of malaria?

4. What other fevers do you know of in this community? What are the
   causes of these fevers?

5. Among those mentioned, which are most dangerous fevers in this community?
   (Probe: To children under five, to pregnant women?)

6. What is the fever that is recognized as malaria in this community? (Probe: In children
   under five. In pregnant mothers? What local name(s) should we call this type of
   fever?)

7. Do you think that malaria (use name mentioned) can kill a pregnant woman?

   Causality

8. In your view, how does a mosquito cause (malaria?)? (Please use name given)
   (Probe: When a mosquito bites, what happens?)


9. When is (malaria) most rampant in this area?
   Probe: what is the relationship between:
    Malaria and mosquitoes
    Malaria, mosquitoes and the rainy season?
    Malaria, mosquitoes, the rainy season and the harvest season (maize and
      mangoes)?




                                                                                      59
10. What causes malaria in pregnant women? Is the cause different from that of a woman
    who is not pregnant? Why?

11. What danger does malaria have on pregnant women? (Probe: On the woman, unborn
    baby? On their lives?)

   Treatment Practices

12. What type of things do people use or do to treat malaria in pregnant women? Of
    these, which are most effective?

13. How do you define successful or unsuccessful treatment? (Probe: How do you
    decide that this treatment is not working to be able to switch to another type? How do
    you interpret success or failure of treatment?

14. How are decisions made, whether to treat at home or elsewhere? Who makes them?
    Who else is involved in the discussion?

15. What are some of the signs that indicate to the family that a pregnant woman
    suffering from malaria needs attention of a health worker? (Probe for perceived
    danger signs. Probe for severity)

   Sources of Information and advice about Malaria

16. What are the sources of information for people about malaria in this community?
    (Probe: on prevention, on treatment.)?

17. Which of these sources of information do they trust most (Probe and rank for most to
    least trusted)

18. Who do pregnant women seek advice from first, when they feel signs of discomfort?
    Of malaria? (Probe and rank - First, second, third – husband, senior female member,
    someone at the community level, someone at the health facility, drug vendor?)

19. What role do husbands play in deciding what to do if their pregnant wives get
    malaria?

20. Does a pregnant woman get special treatment for malaria even if she is not sick?

   Preventive Measures

21. What can be done to prevent malaria? (Probe: do you do it? Why/Why not?)
    What can be done to prevent mosquito bites? (Do you do it? Why/Why not?




                                                                                       60
22. Have you heard that pregnant women should be given malaria treatment even if they
    are not sick? (If ‗yes‘, Probe: why and how should it be given? Who told you about
    it?)

23. Do you know of any family in this community that uses mosquito nets? Who uses
    them in the family? Why do you think that person(s) is (are) using them?

24. Who needs to use them most? Why? (Probe: are they useful? Will you be willing to
    pay for them)?

   Confirmation of Terminology and Illness Concepts

25. What should we call malaria in this community? How should we describe the
   relationship between mosquitoes and malaria? How can you help others to know this
   information?)

26. What resources do you have in this community that will enable you to effectively
    manage malaria? (If the following structures are not mentioned, Probe if they are
    available and if they can be used: local councils, Bataka Groups, Revolving Funds
    for prevention of Malaria, Religious organisations, CBO‟s)

V. WRAP-UP

Wrap up the discussion:

This has been a very interesting discussion....

End by saying:

Is there anything else you'd like to mention to me or to the group?
Ask more than one respondent in different ways. Then be sure to correct any blatant,
dangerous misconceptions and ask the group if they have any questions about the facts.




                                                                                   61
                       FOCUS GROUP DISCUSSION GUIDE

                               Malaria in Pregnancy
                          Pregnant Women, 20-25 Years Old

The moderator should make the effort to interact with the participants briefly outside of
the discussion room before the focus group discussion takes place.

I. INTRODUCTION

Good morning / afternoon, and thank you all for coming. My name is _______ and this
is my colleague _____. We are working with a Research Firm, ------- We are conducting
several meetings with people like you to find out how you feel about several health
issues. We will be talking to groups of men and women. Your opinions are very
important, and they will help us improve the kind of services that are provided. Please
tell us your feelings and ideas about the topics that come up in today's talk.

There are no right or wrong answers, and you do not have to agree with what someone
else says. Everyone's contribution is valuable. We want this to be a group discussion; so
don't wait for me to call on you. Just speak up. Speak up one at a time so we all can
hear.

Your answers will remain confidential and anonymous. Your answers will help us plan
programs for your area.

So that we do not lose any important information, we would like to tape-record the
discussion. Is that all right with everyone? You may listen to the discussion at the end if
you wish.

Note to the moderator: Moderators should pay attention to the mood of the group, and
ask questions about respondents' personal opinions and practices as much as possible
with phrases like "How about you?".


II. ICE-BREAKER EXERCISE

Conduct round-table introductions. Request each participant to take a few minutes to talk
with the person on her left. She should find out all they can about that person—where
she lives, how she spends his time in the village and what her interests are. Give
participants 2 or 3 minutes to talk with their neighbours. Then ask each participant to
introduce her neighbour to the group




                                                                                        62
III. WARM-UP

Make small talk, such as:

How do you find life here these days?

Pick up on what they talk about and expand into section IV

IV. FOCUSSED DISCUSSION

      Symptom Recognition and Seriousness


   1. What are the 3 most common health problems among pregnant women in this
      community? (List them in order of importance).

   2. Is malaria a serious or common health problem among pregnant women in this
      community? (If not already mentioned in #1)

   3. What are the symptoms of malaria?

   4. What other fevers do you know of in this community? What are the
      causes of these fevers?

   5. Among those mentioned, which are most dangerous fevers in this community?
      (Probe: To children under five, to pregnant women?)

   6. What is the fever that is recognized as malaria in this community? (Probe: In
      children under five. In pregnant mothers? What local name(s) should we call this
      type of fever?)

       Do you think that malaria (use name mentioned) can kill a pregnant woman?

   7. What makes mothers rush their sick child to a health facility for some conditions
      (e.g. snake bite) and not malaria? (If response is ―Snake bite kills‖ then ask ―What
      about malaria?‖)

      Causality

   8. In your view, how does a mosquito cause malaria? (Please use name given and,
      Probe: When a mosquito bites, what happens?)


   9. When is (malaria) most rampant in this area? (Probe: what is the relationship
      between malaria, mosquitoes and seasons of the year, especially the rainy season
      or the harvest season? maize and mangoes



                                                                                       63
10. What causes malaria in pregnant women? Is the cause different from that of a
    woman who is not pregnant? Why?

11. What danger does malaria have on pregnant women? (Probe: On the woman,
    unborn baby? On their lives?)

   Treatment Practices

12. What type of things do people use or do to treat malaria in pregnant women? Of
    these, which are most effective?

13. How do you define successful or unsuccessful treatment? (Probe: How do you
    decide that this treatment is not working to be able to switch to another type?
    How do you interpret success or failure of treatment?

14. How are decisions made, whether to treat at home or elsewhere? Who makes
    them? Who else is involved in the discussion?

15. What are some of the signs that indicate to the family that a pregnant woman
    suffering from malaria needs the attention of a health worker? (Probe for
    perceived danger signs. Probe for severity)

16. Are any of you currently attending and receiving care at an ante-natal clinic?
            If yes, ask, ―Did the service provider discuss malaria with any of you
               during any of your visits?‖
            If no, ask, ―Why not?‖
            Then ask everyone, ―Has any of you received/taken medicine for
               malaria during this pregnancy? If ‗yes‘, what did you take? Why did
               you take it? If ‗no‘, why not?

   Sources of Information and source of advice about Malaria

17. What are the sources of information about malaria for people in this community?
    (Probe: on prevention, on treatment.)?

18. Which of these sources of information do they trust most (Probe and rank for
    most to least trusted)

19. Who do pregnant women seek advice from first, when they feel signs of
    discomfort? Of malaria? (Probe and rank - First, second, third – husband, senior
    female member, someone at the community level, someone at the health facility,
    drug vendor?)

20. What role do husbands play in deciding what to do if their pregnant wives get
    malaria?


                                                                                 64
   21. Does a pregnant woman get special treatment for malaria even if she is not sick?

      Preventive Measures

   22. What can be done to prevent malaria? (Probe: Do you do it? Why/Why not?)
       What can be done to prevent mosquito bites? Do you do it? Why/Why not?)

   23. Have you heard that pregnant women should be given malaria treatment even if
       they are not sick? (If yes, Probe: why and how should it be given? Who told you
       about it?)

   24. Do you know of any family in this community that uses mosquito nets? Who
       uses them in the family? Why do you think that person(s) is (are) using them?

       Who needs to use them most? Why? (Probe: are they useful? Will you be willing
       to pay for them)?

      Confirmation of Terminology and Illness Concepts

   25. What should we call malaria in this community? How should we describe the
      relationship between mosquitoes and malaria? How can you help others to know
      this information?)

   26. What resources do you have in this community that will enable you to effectively
       manage malaria? (If the following structures are not mentioned, Probe if they are
       available and if they can be used: local councils, Bataka Groups, Revolving
       Funds for prevention of Malaria, Religious organisations, CBO‟s)


V. WRAP-UP

Wrap up the discussion:

This has been a very interesting discussion....

End by saying:

Is there anything else you'd like to mention to me or to the group?
Ask more than one respondent in different ways. Then be sure to correct any blatant,
dangerous misconceptions and ask the group if they have any questions about the facts.




                                                                                      65
                     FOCUS GROUP DISCUSSION GUIDE

                              Malaria in Pregnancy

 Men with Wives who are Currently Pregnant or have been Pregnant in the
                             last 2 years

The moderator should make the effort to interact with the participants briefly
outside of the discussion room before the focus group discussion takes place.


I. INTRODUCTION

Good morning/afternoon, and thank you all for coming. My name is
_______ and this is my colleague _____. We are working with a Research
Firm, ------- We are conducting several meetings with people like you to find
out how you feel about several health issues. We will be talking to groups
of men and women. Your opinions are very important, and they will help us
improve the kind of services that are provided. Please tell us your feelings
and ideas about the topics that come up in today's talk.

There are no right or wrong answers, and you do not have to agree with
what someone else says. Everyone's contribution is valuable. We want
this to be a group discussion; so don't wait for me to call on you. Just
speak up. Speak up one at a time so we all can hear.

Your answers will remain confidential and anonymous. Your answers will
help us plan programs for your area.

So that we do not lose any important information, we would like to tape-
record the discussion. Is that all right with everyone? You may listen to
the discussion at the end if you wish.

Note to the moderator: Moderators should pay attention to the mood of the
group, and ask questions about respondents' personal opinions and practices as
much as possible with phrases like "How about you?".


II. ICE-BREAKER EXERCISE

Conduct round-table introductions. Request each participant to take a few
minutes to talk with the person on his left. He should find out all they can about
that person--where he lives, how he spends his time in the village and what his
interests are. Give participants 2 or 3 minutes to talk with their neighbours. Then
ask each participant to introduce his neighbour to the group.




                                                                                66
III. WARM-UP

Make small talk, such as:

How do you find life here these days?

Pick up on what they talk about and expand into section IV

IV. FOCUSSED DISCUSSION

      Symptom Recognition and Seriousness

   1. What are the 3 most common health problems among pregnant women in
   this community? (List them in order of importance).

   2. Is malaria a serious or common health problem among pregnant women in
   this community? (If not already mentioned in #1)

   3. What are the symptoms of malaria?

   4. What other fevers do you know of in this community? What are the
      causes of these fevers?

   5. Among those mentioned, which are most dangerous fevers in this
   community? (Probe: To children under five, to pregnant women?)

   6. What is the fever that is recognised as malaria in this community? (Probe:
   In children under five. In pregnant mothers? What local name(s) should we
   call this type of fever?)

       Do you think that malaria (use name mentioned) can kill a pregnant
       woman?

      Causality

   7. In your view, how does a mosquito cause malaria? (Please use name
   given and Probe: When a mosquito bites, what happens?)

       What is the relationship between (malaria) and mosquito bites?

   8. When is (malaria) most rampant in this area? (Probe: what is the
   relationship between malaria, mosquitoes and seasons of the year, especially
   the rainy season or the harvest season? maize and mangoes



                                                                              67
9. When is (malaria) most rampant in this area?
   Probe: what is the relationship between
      d. Malaria and mosquitoes
      e. Malaria, mosquitoes and the rainy season?
      f. Malaria, mosquitoes, the rainy season and the harvest season
         (maize and mangoes)?


10. What causes malaria in pregnant women? Is the cause different from that
of a woman who is not pregnant? Why?

11 What danger does malaria have on pregnant women? (Probe: On the
woman, unborn baby? On their lives?)


   Treatment Practices

12. What type of things do people use or do to treat malaria in pregnant
women? Of these, which are most effective?

13. How do you define successful or unsuccessful treatment? (Probe: How
do you decide that this treatment is not working to be able to switch to
another type? How do you interpret success or failure of treatment?

14. How are decisions made, whether to treat at home or elsewhere? Who
makes them? Who else is involved in the discussion?

15. What are some of the signs that indicate to the family that a pregnant
woman suffering from malaria needs attention of a health worker? (Probe for
perceived danger signs. Probe for severity)


   Sources of Information and source of advice about Malaria

16. What are the sources of information about malaria for people in this
community? (Probe: on prevention, on treatment.)?

17. Which of these sources of information do they trust most (Probe and rank
for most to least trusted)

18. Who do pregnant women seek advice from first, when they feel signs of
discomfort? Of malaria? (Probe and rank - First, second, third – husband,
senior female member, someone at the community level, someone at the
health facility, drug vendor?)




                                                                           68
   19. What role do husbands play in deciding what to do if their pregnant wives
   get malaria?

   20. Does a pregnant woman get special treatment for malaria even if she is
   not sick?

      Preventive Measures

   21. What can be done to prevent malaria? (Probe: Do you do it? Why/Why
   not?) What can de done to prevent mosquito bite? (Probe: Do you do it?
   Why/Why not?)

   22. Have you heard that pregnant women should be given malaria treatment
   even if they are not sick? (If yes, Probe: why and how should it be given?
   Who told you about it?)

   23. Do you know of any family in this community that uses mosquito nets?
   Who uses them in the family? Why do you think that person(s) is (are) using
   them?

       Who needs to use them most? Why? (Probe: are they useful? Will you be
       willing to pay for them)?

      Confirmation of Terminology and Illness Concepts

   24. What should we call malaria in this community? How should we describe
   the relationship between mosquitoes and malaria? How can you help others
   to know this information?)

   25 What resources do you have in this community that will enable you to
   effectively manage malaria? (If the following structures are not mentioned,
   Probe if they are available and if they can be used: local councils, Bataka
   Groups, Revolving Funds for Prevention of Malaria, Religious organisations,
   CBO’s)

V. WRAP-UP

Wrap up the discussion:
This has been a very interesting discussion....
End by saying:

Is there anything else you'd like to mention to me or to the group?
Ask more than one respondent in different ways. Then be sure to correct any
blatant, dangerous misconceptions and ask the group if they have any questions
about the facts.




                                                                                69
                           MALARIA IN PREGNANCY

                   KEY INFORMANT INTERVIEW GUIDE 1

           To be conducted among Facility-Based Health Workers

The purpose of the interview is to elicit a comprehensive story from each interviewee
about their knowledge and attitudes towards new treatment practices recommended
for treatment of Malaria in pregnant women. As much as possible, let the interviewee
talk. Only interject occasionally to be sure that the topic areas in the question guide
are covered.

I. INTRODUCTION
Good morning/afternoon and thank you for coming. My name is _____________. I
am working with a Research Firm to improve delivery of services in this community.
I am conducting several meetings with people like you to find out how you feel about
certain health issues. Your opinions are very important, and they will help us improve
the kind of service we provide.

Your answers will remain confidential and anonymous. Your answers will help us
plan programs for your area. Therefore, please be as detailed as possible. We have
plenty of time.

So that we do not lose any important information, I would like to tape-record the
discussion. Is this all right with you? You may listen to the discussion at the end if
you wish.

II. WARM-UP

Ask the respondent his/her name, occupation, how long he/she has lived there and
things she/he likes to do, etc.   SHARE SOMETHING PERSONAL ABOUT
YOURSELF TOO.

III. INTERVIEW

   Symptom Recognition and Seriousness

I am going to ask a few questions about some health problems in this community.

1. What are the 3 most common health problems among pregnant women in this
   community? (List them in order of importance).

2. Is malaria a serious or common health problem among pregnant women in this
   community? (If not already mentioned in #1)
3. What other fevers do you know of in this community? What are the
   causes of these fevers?



                                                                                    70
    4. Among those mentioned, which are the most dangerous? (Probe: To pregnant
       women?)

    5. What is the fever that is recognized as malaria in this community? (Probe: In
       children under five. In pregnant mothers? What do people in this area call this
       type of fever? (local name)

   Causality

    6. When is malaria most rampant in this area? (Probe: what is the relationship
       between:
     Malaria and mosquitoes?
     Malaria, mosquitoes and the rainy season?
     Malaria, mosquitoes, the rainy season, the harvest season (maize and mangoes)?

    7. In your view, what do people of this area think is the cause of malaria?

   Sources of Information and Community Resources

    8. What are the sources of information about malaria to people in the community?
       (Probe: on prevention, on treatment, etc.)?

    9. Which sources of information do they trust most (Probe and rank – most to least
       important)

    10. What resources does this community have that can enable them to effectively
        prevent and treat malaria? (If the following structures are not mentioned, Probe if
        they are available and if they can be used: local councils, Bataka Groups,
        Revolving Funds for Prevention of Malaria, Religious organisations, CBO‟s)

   Treatment Practices and Intermittent Presumptive Treatment for Malaria

    11. Now, I am going to ask a few questions about how malaria is treated in this
        community you are serving.

    12. What type of things do people in this community use or do to treat malaria in
        pregnant women? Of these, which are most effective? Which of these are
        negative and which are positive?

    13. How do you define successful or unsuccessful treatment? (Probe: How do you
        decide that this treatment is not working to be able to switch to another line of
        treatment? How do you interpret success or failure of treatment?

    14. What types of drugs do you prescribe for pregnant women suffering from
        malaria? What doses do you prescribe?




                                                                                        71
      15. Have you heard of IPT? If yes, what drug is used? (If not mentioned in # 13)

      16. Why should Intermittent Presumptive Treatment be administered?
      17. When should Intermittent Presumptive Treatment be administered?
      18. Do you prescribe Intermittent Presumptive Treatment to pregnant women?

     Preventive Measures

      19. What can people in this community do to prevent malaria? (Probe: Do they do it?
          Why/Why not?) What can people in this community do to prevent mosquito bite
          (Probe: Do they do it? Why/Why not?)

     Policies (Dissemination): Anti Malarial Drug Policy.

      20. Have you heard of IPT guidelines from the Ministry of Health?

      21. Have you heard of the Malaria Drug Policy for children? In Pregnant women?

      22. How can the Ministry help you to implement the guidelines?

      23. What do you health workers believe about the effectiveness of the recommended
          and alternative drugs mentioned in the policy?

     Confirmation of Terminology and Illness Concepts

      24. What local name should we call malaria in this community?

IV.      WRAP-UP

         Wrap up the discussion: "This has been a very interesting discussion"

         Clarify unclear points made by the interviewee by stating: ―You said….. Did I
         understand you correctly?"

         Be sure to correct any incorrect information that the interviewee may have told
         you during the interview.

V.       CLOSURE
         Thank the interviewee




                                                                                         72
                           MALARIA IN PREGNANCY

                KEY INFORMANT INTERVIEW GUIDE 2

           To be conducted among Traditional Birth Attendants (TBA‟s)


The purpose of the interview is to elicit a comprehensive story from each interviewee
about their knowledge and attitudes and new treatment recommended for Malaria in
pregnant women. As much as possible, let the interviewee talk. Only interject
occasionally to be sure that the topic areas in the question guide are covered.

                                II.     INTRODUCTION

Good morning/afternoon, and thank you for coming. My name is
______________ I am working with a Research Firm to improve delivery
of services in this community. I am conducting several meetings with
people like you to find out how you feel about certain health issues.
Your opinions are very important, and they will help us improve the kind
of service we provide.

Your answers will remain confidential and anonymous. Your answers
will help us plan programs for your area. Therefore, please be as
detailed as possible. We have plenty of time.

So that we do not lose any important information, I would like to tape-
record the discussion. Is this all right with you? You may listen to the
discussion at the end if you wish.

                                 II. WARM-UP

Ask the respondent his/her name, occupation, how long he/she has lived there and
things she/he likes to do, etc. SHARE SOMETHING PERSONAL ABOUT
YOURSELF TOO.

                               III. INTERVIEW

Symptom Recognition and Seriousness

I am going to ask a few questions about some health problems in this community.

1. What are the 3 most common health problems among pregnant women in
this community? (List them in order of importance).

2. Is malaria a serious or common health problem among pregnant women in
   this community? (If not already mentioned in #1)


                                                                                   73
3. What are the symptoms of malaria?

4. What other fevers do you know of in this community? What are the
   causes of these fevers?

5. Among those mentioned, which are most dangerous? (Probe: to pregnant
   women?)

6. What is the fever that is recognised as malaria in this community? (Probe:
   In pregnant mothers? What local name(s) should we call this type of
   fever?)

   Causality

7. In your view, how does a mosquito cause malaria? (Please use name
   given, and Probe: When a mosquito bites, what happens?)
   What is the relationship between (malaria) and mosquito bites?

8. When is (malaria) most rampant in this area?
   Probe: what is the relationship between
      g. Malaria and mosquitoes
      h. Malaria, mosquitoes and the rainy season?
      i. Malaria, mosquitoes, the rainy season and the harvest season
         (maize and mangoes)?

9. What causes malaria in pregnant women? Is the cause different from that
   of a woman who is not pregnant? Why?

10. What danger does malaria have on pregnant women? (Probe: On the
   woman, unborn baby? On their lives?)


   Treatment Practices
          Now, I am going to ask a few questions about how malaria is
          treated in this community you are serving.

11. What type of things do people use or do to treat malaria in pregnant
    women? Of these, which are the most effective?

12. Do women come to you for help/advice if they are pregnant and suffering
    from malaria? If a pregnant woman comes to you and you suspect that it
    may be malaria, what do you do? (probe for advice given, medication and
    referral)
13. How do you define successful or unsuccessful treatment? (Probe: How
    would you decide that this treatment is not working to be able to advise


                                                                           74
    the woman to switch to another treatment? How do you interpret success
    or failure of treatment?


   Decision Making

14. In this community, how are decisions made, whether to treat at home or
    elsewhere? Who makes them? Who else is involved in the discussion?
    Are you sometimes consulted?

15. What are some of the signs that indicate to the family that a pregnant
    woman suffering from malaria needs attention of a health worker? (Probe
    for perceived danger signs. Probe for severity)


   Sources of Information and Resources

2. What are the sources of information about malaria to people in the
   community? (Probe: on prevention, on treatment, etc.)?

16. Which of these sources of information do they trust most (Probe and rank
    – most to least trusted)

17. What resources do you have in this community that will enable you to
   effectively manage malaria? (If the following structures are not mentioned,
   Probe if they are available and if they can be used: local councils, Bataka
   Groups, Revolving Funds for prevention of Malaria, Religious
   organisations, CBO’s)


   Preventive Measures

18. What can people in this community do to prevent malaria? (Probe: Do
    they do it? Why/Why not?) What can people in this community do to
    prevent mosquito bite (Probe: Do they do it? Why/Why not?)


19. Do you know of any family in this community that uses mosquito nets?
    Who uses them in the family? Why do you think that person(s) is (are)
    using them?

20. Who needs to use them most? Why? (Probe: are they useful? Do you
    think members of this community can pay for them?)




                                                                             75
21. Have you heard that pregnant women should be given malaria treatment
    even if they are not sick? (If yes, Probe: why? In which months of
    pregnancy and how many times? Who told you about it?)


   Confirmation of Terminology and Illness Concepts

22. What local name should we call malaria in this community?
   How should we describe the relationship between mosquitoes and
   malaria? How can you help others to know this information?


                              V.     WRAP-UP

Wrap up the discussion: "This has been a very interesting discussion"

Clarify any unclear points made by the interviewee by stating: “You said…..
Did I understand you correctly?"

Be sure to correct any incorrect information that the interviewee may have
told you during the interview.

                              VI.    CLOSURE

Thank the interviewee




                                                                              76
Annex II:      Research Team


Principal Investigator (Public Health Specialist)   Dr. Dan Twebaze
External Investigator (Communication Specialist)    Anne Domatob
Co-Investigator        (Communication Specialist)   Anne Gamurorwa
Co-Investigator        (Field Team Manager)         William Nyombi

Interviewers

Atugonza Monik
Agaba Joseph
Margaret Kyohairwe
Babbu Richard
Balikudembe David
Nanyonga Margaret
Okillan Henry
Kyozira Alex
Akello Jackie
Proscovia Mungasa
Naome Namakula




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