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Treatment of Childhood Fevers and Other Illnesses in Three Rural Nigerian Communities by L. A. Salako,a W. R. Brieger,b B. M. Afolabi,a R. E. Umeh,c P. U. Agomo,a S. Asa,d A. K. Adeneyea B. O. Nwankwo,a and C. O. Akinladeb aNigerian Institute of Medical Research and Training, Yaba, Lagos, Nigeria bAfrican Regional Health Education Centre, College of Medicine, University of Ibadan, Ibadan, Nigeria cDepartment of Ophthalmology, College of Medicine, University of Nigeria, Enugu, Nigeria dDepartment of Demography and Social Statistics, Obnafemi Awolowo University, Osun State, Nigeria

Summary The seeking of healthcare for childhood illnesses was studied in three rural Nigerian communities of approximately 10 000 population each. The aim was to provide a baseline understanding of illness behaviour on which to build a programme for the promotion of prepackaged chloroquine and cotrimoxazole for early and appropriate treatment of childhood fevers at the community level. A total of 3117 parents of children who had been ill during the 2 weeks prior to interview responded to questions about the nature of the illness and the actions taken. Local illness terms were elicited, and the most prevalent recent illness and the actions taken. Local illness terms were elicited, and the most prevalent recent illnesses were ‘hot body’ (43.9 per cent), malaria, known as iba (17.7 per cent), and cough (7.4 per cent). The most common form of first-line treatment was drugs from a patent medicine vendor or drug hawker (49.6 per cent). Only 3.6 per cent did nothing. Most who sought care (77.5 per cent) were satisfied with their first line of action, and did not seek further treatment. The average cost of an illness episode was less than US$2.00 with a median of US$1.00. Specifically, chloroquine tablets cost an average of US 29¢ per course. Analysis found a configuration of signs and symptoms associated with chloroquine use, to include perception of the child having malaria, high temperature and loss of appetite. The configuration positively associated with antibiotic use consisted of cough and difficult breathing. The ability of the child’s care-givers, both parental and professional, to make these distinctions in medication use will provide the foundation for health education in the promotion of appropriate early treatment of childhood fevers in the three study sites. Introduction Early and appropriate treatment of childhood illness is by definition an illness behaviour, which consists of those actions people take when they feel unwell in order to determine the nature of their sickness and to seek help.1 Several factors are involved including illness recognition, awareness of sources of help, medication knowledges (types and dosages) and skills in administering the medication in the correct dosages. Early treatment depends upon prompt recognition of symptoms and signs of malaria in the household, i.e., mainly by women. Early treatment also requires that appropriate

Acknowledgements This project was funded by a grant from the UNDP/World Bank/WHO Special Programme of Research and Training in Tropical Diseases (TDR). Correspondence: W. R. Brieger, African Regional Health Education Centre, College of Medicine, University of Ibadan, Ibadan, Nigeria.

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health services and medication are accessible and used.2 Several studies have shown that illness recognition determines treatment responses. For example, in the rural Ibarapa Central Local Government Area (LGA) of Oyo State, Nigeria, people view malaria and febrile convulsions as completely separate conditions with the former caused by heat and sun and the latter caused by cold. Malaria is perceived as a less serious condition, while convulsions prompt an immediate treatment response, often using dangerous herbal concoctions.3 Not only do people in Ibarapa dissociate malaria and convulsions, they also perceive different types of malaria itself, including ‘cold’, ‘yellow’, and ‘ordinary’ varieties.4 In the Nsukka area of eastern Nigeria people describe ‘ordinary’, ‘coloured’, ‘wet’, ‘dry’, and ‘shaking’ malaria.5 In a recent study in Kenya, it was found that public facilities are preferred at the first source of care for acute malaria. However, if the malaria became ‘persistent’, other forms of treatment, especially private clinics and medicinal plants, seem to have been preferred.6 Without an understanding Vol. 47

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of such local perceptions and treatment preferences, health education to improve malaria illness and treatment behaviours may fall on deaf ears. The importance of early and appropriate home management in rural areas with poor access to health facilities was demonstrated in Kenya by Schellenberg, et al.7 Using admission rates of children with severe malaria to a health facility as an indicator of access, their study found that those living more than 25 km from the hospital had admission rates that were about one-fifth of those for children living within 5 km of the hospital. Those living more than 2.5 km from the nearest road had admission rates that were about half of those for children living within 0.5 km of a road. After studying 719 children with severe malaria in Burkina Faso, Sanou, et al.8 concluded that early therapeutic management of febrile attacks with chloroquine would reduce the incidence of severe and complicated malaria. These studies point to the need for timely and appropriate home-treatment of malaria. In fact, self-care efforts are the norm. Julvez reported that in Niamey, Niger Republic, street vending of chloroquine products is common.9 While few people were found who buy and administer the correct dosages, Julvez concluded that self-treatment was still valuable in protecting against severe attacks of malaria. The present study is based on three rural communities in Nigeria where early and appropriate treatment of febrile child illness is being promoted through the use of prepackaged chloroquine and cotrimoxazole tablets in doses for children between the ages of 6 months and 6 years. A baseline survey of illness experiences and treatment practices was conducted to learn about illness behaviour and to identify factors that may influence choice of treatment. This information is being used to design health education to promote the use of the prepackaged medicines. Methods The survey was designed to elicit illness experiences of children aged 6–72 months during a 2-week period prior to interview, and the actions of their care-givers to resolve those illnesses. Approximately 20 survey instruments were pretested in villages near each of the three rural study villages/towns: Idere in Ibarapa LGA of Oyo State, Ukehe in Igbo Etiti LGA of Enugu State, and Mbaugwu in Isuikwato LGA of Abia State. After adjustments were made the instruments were administered by trained interviewers who had previous experience in community health research. A standard coding guide was constructed to ensure comparability of results among the three sites. Idere is located in southwestern Nigeria, and is inhabited primarily by the Yoruba people. Both Ukehe and Mbaugwu are in the eastern part of the Journal of Tropical Pediatrics

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country, and are populated primarily by the Igbo ethnic group. Access to orthodox healthcare is minimal in these communities. While each community has a LGA health facility, staffed primarily by Community Health Extension Workers, these suffer from what is known as the ‘out-of-stock syndrome’, in which supplies of essential drugs are quite variable. The communities are quite dispersed, so that distance to the orthodox facilities may be as far as 20 km. There are private clinics in both Ukehe and Mbaugwu, but the nearest to Idere is 7 km. Between four and eight patent medicine vendors (PMVs) are established in each community, and unlike the LGA health facilities, are open in the evening. Indigenous healers are common, but are patronised primarily when an illness is either persistent or unusual in its presentation. Most therefore, practise healing as an adjunct to a major income-earning occupation, such as farming or crafts. Self-care using both orthodox medicine and local herbal home remedies is the norm in these communities.10 Some sections of each community also have trained village health workers (VHWs) who were selected by their co-villagers as part of primary healthcare and/or Bamako Initiative programmes. Each community was chosen on the basis that the population comprised approximately 10 000 people. It was estimated that in each community one would expect approximately 1500 children between the ages of 6 and 72 months. Every household was visited during a 3-week period and all parents of children in the target age group who had an illness episode in the preceding 2 weeks were interviewed. It was expected that this would produce a minimum study group of 750 children per site. Representatives of the three interview teams assembled at the Idere site for data entry and cleaning. Analysis employed EPI INFO software version 6.04a. A limitation of this type of survey research in the community was the inability to make a definitive diagnosis of the children’s illnesses based on the parents’ report of symptoms and local illness categorizations. Results Demographic characteristics A total of 3117 interviews were conducted. As noted, the goal was approximately 700 childhood illness episodes per site. All sites surpassed this goal with 774 in Idere (24.8 per cent of total), 1095 in Mbaugwu (35.1 per cent) and 1248 in Ukehe (40.0 per cent). The majority of respondents (68.7 per cent) were the mothers of the sick child. Other respondents included the child’s father (20.5 per cent), grandmother (5.6 per cent), or another relative (5.2 per cent). Most respondents (74.6 per cent) had some education, ranging as follows: some primary (14.3 231


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per cent), complete primary (32.8 per cent), some secondary (12.0 per cent), complete secondary (10.7 per cent), and post-secondary (4.8 per cent). In keeping with the geographical distribution of the sites, 23.5 per cent of respondents were Yoruba and 74.8 per cent were Igbo. In hamlets surrounding Idere, 44 (1.4 per cent) Fulani were interviewed, and six from other ethnic groups (0.2 per cent) rounded out the survey. The large majority of respondents (82.1 per cent) were Christians, 12.5 per cent were Moslems, 5.2 per cent were adherents of indigenous religions, and 0.2 per cent belonged to other religions or did not state a religious preference. Children who had a recent illness episode ranged in age from 6 to 72 months in line with the study target group. The average age was 38.2 months and the median age was 37. Just over half of the children (51 per cent) were male. Over one-quarter (27.4 per cent) were the first born of their mothers. These children had an average of 0.4 younger and 0.9 older siblings. The average number of children for the mother or care-giver being interviewed was 2.3 with a median of 2.

accounted for 17.7 per cent of reported illnesses in Idere, compared to 37.0 per cent in Mbaugwu and 27.6 per cent in Ukehe. The other commonly reported illnesses were cough (12.4 per cent), diarrhoea (4.1 per cent), convulsion (3.5 per cent), stomach ache/upset (3.3 per cent), measles (3.2 per cent), catarrh (3.0 per cent), skin rashes (2.7 per cent), chickenpox (2.6 per cent), teething problems (2.2. per cent), headache (1.9 per cent), and vomitting (1.0 per cent). Illnesses that were mentioned by less than 1 per cent of respondents included lack of blood, dysentery/constipation, boils, ear infections, cold, worms, pneumonia, and various skin problems. Respondents were asked to describe the illness experience. Note was made of those signs and symptoms that were of relevance to the prompt treatment of childhood febrile illness that may involve malaria or pneumonia. Figure 1 shows those mentioned both spontaneously and as a result of probing. High temperature was mentioned by 83.5 per cent spontaneously and by 3.8 per cent after probing. Cough received the second highest spontaneous mention (22.3 per cent), while 14.7 per cent mentioned cough after probing. Catarrh was mentioned spontaneously by 17.6 per cent, and by 19.0 per cent after probing. Rapid breathing was mentioned by only 4.4 per cent spontaneously, but 10.7 per cent, or more than double, conceded to rapid breathing after probing.

Illness experiences In reporting the recent illness, care-givers mentioned up to three terms that described their child’s illness. ‘Iba’ was a common term used for malaria in all three sites. In Mbaugwu the term ‘oyi’ was also used. A total of 886 (28.4 per cent) of the children were reported to have suffered from iba/oyi in the previous 2 weeks among the multiple illnesses that they had experienced. The 13 most common illnesses are listed in Table 1. Reported local illnesses called ‘hot body’ were the most common (40.5 per cent), followed by iba/oyi. There were site differences. Iba

Treatment seeking Most (96.5 per cent) of the care-givers said that something had been done about the child’s illness. Those 111 who had not done anything gave the following reasons: no time yet/child just became sick (27.9 per cent), problem not so serious (36.9 per

TABLE 1 Common illness complaints among children in study areas Illnesses

Study site Idere (%)

Hot body Iba/malaria Cough Diarrhoea Convulsion Stomach ache Measles Catarrh Rashes Chicken pox Teething Headache Vomiting

340 137 57 30 17 24 36 7 31 81 65 5 7

Number

774

232

(43.9) (17.7) (7.4) (3.9) (2.2) (3.1) (4.7) (0.9) (4.0) (10.5) (8.4) (0.6) (0.9)

Mbaugwu (%) 159 405 181 67 75 48 38 59 38 0 0 46 7 1095

(14.5) (37.0) (16.5) (6.1) (6.8) (4.4) (3.5) (5.4) (3.5) (0.0) (0.0) (4.2) (0.6)

Total (%) Ukehe (%) 765 344 150 32 17 30 26 29 15 0 4 9 18

(61.3) (27.6) (12.0) (2.6) (1.4) (2.4) (2.1) (2.3) (1.2) (0.0) (0.3) (0.7) (1.4)

1248


1264 886 388 129 109 102 100 95 84 81 69 60 32

(40.5) (28.4) (12.4) (4.1) (3.4) (3.3) (3.2) (3.0) (2.7) (2.6) (2.2) (1.9) (1.0)

3117

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FIG. 1. Reported signs and symptoms accompanying childhood illnesses. cent), child’s father not around to approve action (8.1 per cent), no money (10.8 per cent), we do not use medicines (4.5 per cent), and child got better (2.7 per cent). Eight gave no reason. Most of the 3006 who got help for their child appeared satisfied with the results of the first action taken for the child as only 4.2 per cent said that the child’s condition remained the same after the first action and 0.8 per cent said the child’s condition worsened. Even so, 22.5 per cent undertook a second action, but only 1.7 per cent took a third action. Table 2 summarizes the various actions taken by the care-givers. Seeking medicine from a chemist or PMV was the most frequent form of first-line and second-line care. Other common forms of first-line care included private clinic, government clinic, herbs prepared at home, and orthodox drugs found at home. Few sought help from drugs from hawkers, used other

, Probed;

, spontaneous.

non-pharmaceutical items (e.g. oral rehydration therapy, tepid sponging, and use of Robb, a balm), VHWs, indigenous healers, and faith healers. Clinics, either government or private, were a popular form of second-line and third-line care. Figure 2 shows that seeking a second line of care varied by source of first-line care. Relatively few people who used a PMV/drug hawker, government clinic/government-trained VHW, or private clinic sought a second source of care. In contrast, approximately half of those who used drugs found at home and who used herbs or indigenous healers sought a second line of care. Table 3 traces the second line of treatment compared to first choice. The most popular source of second-line care for those who started with herbs but later sought additional help was the PMV/hawker. Among those who used drugs found at home and later tried a second line of treatment, most went to either a government or a private

TABLE 2 Treatment choices for recent illness episodes Treatment choices

First choice Number (%)

Home herbs Home drugs (orthodox) Chemist/PMV Hawker Government clinic Private clinic Volunteer village health worker Indigenous healer Faith healer Othera

317 239 1391 99 340 419 62 30 28 81

Number

3006

aOther

(10.6) (7.9) (46.3) (3.3) (11.3) (13.9) (2.0) (1.0) (0.9) (2.7)

Second choice Number (%) 46 13 199 38 139 167 34 24 8 7 675

(6.8) (1.9) (29.5) (5.6) (20.6) (24.7) (5.0) (3.6) (1.2) (1.0)

Third choice Number (%) 7 1 9 0 11 15 2 4 0 1

(13.7) (2.0) (17.6) (0) (23.5) (29.4) (3.9) (7.8) (0) (2.0)

51

= non-pharmaceutical actions including oral rehydration, tepid sponging, balm.


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FIG. 2. First source of care and whether sought second source. , Sought second source; * Other = faith healer, neighbour etc.

clinic. Those who were not satisfied with the chemist as their first line of care went primarily to a private clinic. The PMV was the most popular choice for the parents who started out at a government clinic but continued their search for treatment.

, first source only.

A total of 6257 different types of medications were reported. Products containing paracetamol topped the list (28.3 per cent), followed by vitamins and tonics (20.6 per cent), and chloroquine (16.9 per cent). Antibiotics accounted for 9.8 per cent of total drugs, while 14.1 per cent did not know the name of the drug. The remaining medications included other anti-malarials, products containing aspirin, antihistamines and non-project related drugs (e.g. medicines for skin and eye problems). As with treatment choices generally, the majority of medications (54.2 per cent) were obtained from chemists and drug shops. The most common of the 296 drugs kept at home was paracetamol (48.6 per cent). Paracetamol comprised 37.3 per cent of 158 drugs obtained from VHWs, 31.7 per cent of 3389 drugs bought from chemists, 24.9 per cent of 158 from hawkers, 21.1 per

Medication usage Respondents who used orthodox medications were asked to list those drugs that they had used (Fig. 3). Concerning anti-malarials, 33.1 per cent said they had used chloroquine, and 2.4 per cent used other anti-malarials (e.g. Fansidar). Cotrimoxazole (Septrin) was used by 6.2 per cent. Ampicillin and other antibiotics were used by 11.2 per cent. Paracetamol was the most commonly used antipyretic (52.2 per cent), and 4.8 per cent used products containing aspirin. Antihistamines were used by 5.4 per cent, and vitamins and tonics by 30.4 per cent.

TABLE 3 Most popular second sources of care compared with first choice Second source of carea

First source of care Home herbs, herbalist (%)

Herbs, herbalist Drugs at home PMV, hawker Government clinic, VHW Private clinic

6 4 104 46 18

Total

178

a

234

(3.4) (2.2) (58.4) (25.8) (10.1)

Drug at home (%)

PMV, hawker (%)

6 0 22 55 43

37 3 14 44 91

128

(4.7) (0) (17.2) (43.0) (33.6)

(19.2) (1.6) (7.3) (22.8) (47.2)

193

Government clinic, VHW (%) 13 0 50 7 8

(16.0) (0) (61.7) (8.6) (9.9)

81

Private clinic (%) 8 0 10 10 2

(25.0) (0) (31.3) (31.3) (6.3)

32

Most common sources of care only, faith healer and others not included, so not total 100%.


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FIG. 3. Antibiotic ( ), anti-malarial (), and

cent of 963 from private clinics, and 18.4 per cent of 1130 from government clinics (2 = 167.74, d.f. = 5, p < 0.0001). Chloroquine accounted for a greater proportion of medications obtained from drug hawkers (22.4 per cent) and VHWs (24.7 per cent) than from home stocks (14.9 per cent), chemists (16.6 per cent), government clinics (16.3 per cent) and private clinics (16.4 per cent) (2 = 15.434, d.f. = 5, p < 0.009). On the other hand, most of the chloroquine (53.0 per cent), either in tablet or syrup form, was obtained from chemists and drug shops. Antibiotics comprised a smaller proportion of medications obtained from government clinics (5.7 per cent) and hawkers (6.2 per cent) than from private clinics (8.3 per cent), home stocks (8.4 per cent), VHWs (8.9 per cent) or chemists (12. 1 per cent) (2 = 49.955, d.f. = 5, p < 0.0001). As with other medications, the chemist/drug shop was the source of the majority (65.4 per cent) of this type of drug.

, antipyretic drugs used.

Another distinction among the types of medication sources was observed in the proportion of respondents who did not know the name of a drug they received. Overall, the names of 14.1 per cent of the 6257 drugs were not known. This ranged from a low of 0.3 per cent for the drugs kept at home to 28.8 per cent and 24.4 per cent of the drugs obtained from government and private clinics, respectively. For the remaining sources, the average proportion of unknown medications was 8.2 per cent. A total of 2677 respondents recalled the total cost of treating their sick child. This ranged from zero to = N6000, with a mean of = N199.76 and a median of = N100.00. At the time of the study, 90 Naira = US$1. Concerning individual medicines of relevance to the project, the average price for tablets was always cheaper than that for syrups, as seen in Table 4. Overall, most parents spent less than US$2.00 to treat their sick child.

TABLE 4 Anti-malarial, antibiotic and antipyretic drugs and their costs Drug

Form

Number who remember cost

Mean cost in Nairaa

Median cost

Standard deviation

Chloroquine

Tablet Syrup Tablet Syrup Tablet Syrup Tablet Syrup Tablet Syrup

297 229 39 15 45 81 92 99 746 332

29.21 80.64 64.64 280.33 16.53 90.68 28.23 107.57 35.41 78.20

15.00 50.00 50.00 200.00 10.00 70.00 15.00 90.00 10.00 50.00

53.71 205.05 91.01 243.02 12.71 71.95 56.57 64.62 100.92 200.44

Other anti-malarial Cotrimoxazole Other antibiotic Paracetamol

a

Note: = N90.00 ≈ US$1.00 at time of survey.


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The two major drugs of concern in the project were anti-malarials and antibiotics. Therefore analysis was undertaken to identify factors associated with the use of each type of drug. Dummy variables were created for the purpose of regression. Taking or not taking an anti-malarial (or antibiotic) was coded 1 or 0. The presence or absence of the major signs and symptoms (e.g. high temperature, cough) were similarly coded 1 or 0. The respondent’s own defining of the child’s illness as malaria (iba, oyi) was coded as 1 and its absence as 0. Two other dummy variables were care source (orthodox trained provider at private or public clinic or VHW = 1, other forms = 0) and ethnic group (Yoruba = 1, others = 0). The analysis presented in Table 5 identified seven factors associated with using chloroquine or another anti-malarial drug. The configuration of signs and symptoms that were positively associated with chloroquine use were: (1) designating the child’s condition as being iba; (2) having high temperature; (3) loss of appetite. There was a definite negative association with the signs and symptoms of difficult breathing and convulsions. Yoruba parents and persons who sought care from orthodox trained providers were also more likely to have used chloroquine. Table 6 shows that the two signs and symptoms most commonly associated with antibiotic use were difficult breathing and cough. Four conditions precluded the likelihood of antibiotic use including high temperature, loss of appetite, convulsions and designation of the condition as iba. Again, the Yoruba ethnic group appeared more likely to use antibiotics, although less strongly than in the case of

chloroquine. Child age had a negative relationship with antibiotic use. Discussion There appear to be few inhibitions to seeking care for children, as only 3.6 per cent of parents had not sought care for the illness at the time of the survey. In most cases of non-treatment, the illness was too recent for the parent to decide on a course of action. Since the survey did not determine a diagnosis for each child, it is not possible to determine if the reported parental actions were appropriate, but the propensity for parents to respond to childhood illness is positive and can be built upon during health education activities that promote early and appropriate treatment of childhood febrile illnesses. It was not possible to determine whether the decision to use a particular medication was solely that of the care-giver or a provider. National malaria policy does promote presumptive treatment of fever with anti-malarial drugs,11 and therefore, one might assume that those children presenting at a government health facility with fever would have been given chloroquine by the attending health worker. The findings do suggest that parents are less involved in medication decisions and that communication with providers is poorer when they attend government and private clinics, as evidenced by the fact that the names of one-quarter of the drugs provided from these sources were not known. Therefore, the importance of provider–patient communication should form part of the training for such health workers.

TABLE 5 Factors associated with use of chloroquine or other anti-malarial during a recent childhood illness Variable

Mean

B coefficient

Had Iba High temperature Loss of appetite Difficult breathing convulsion Seek trained providers Yoruba Y-intercept

0.284 0.892 0.576 0.151 0.064 0.369 0.236

0.143 0.141 0.123 –0.118 –0.068 0.072 0.278 0.040

0.107 0.089 0.091 –0.162 –0.133 0.039 0.241

0.178 0.193 0.155 –0.074 –0.004 0.105 0.316

d.f.

Sum of squares

Mean square

F-statistic

7 3109 3117

93.510 613.507 707.017

13.358 0.197

67.70

Source

Regression Residuals Total

236

95% confidence interval –––––––––––––––––––––––––– Lower Upper

Standard error

Partial F-test

0.018 0.026 0.016 0.022 0.033 0.017 0.019

62.388 28.719 55.667 27.676 4.313 18.866 210.853


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TABLE 6 Factors associated with use of antibiotics during a recent childhood illness Variable

Difficulty breathing Cough High temperature Loss of appetite Convulsion Had Iba Yoruba Child’s age Y-intercept

Mean

B coefficient

0.150 0.369 0.893 0.576 0.064 0.283 0.235 38.197

0.070 0.125 –0.072 –0.059 –0.076 –0.041 0.038 –0.001 0.253

0.034 0.098 –0.133 –0.083 –0.127 –0.069 0.008 –0.0018

0.107 0.152 –0.031 –0.033 –0.024 –0.012 0.068 –0.0006

d.f.

Sum of squares

Mean square

F-statistic

8 3101 3109

26.767 386.029 412.797

3.346 0.124

26.88

Source

Regression Residuals Total

95% confidence interval –––––––––––––––––––––––––– Lower Upper

With PMVs, the decision-making process is often one of negotiation. Customers most frequently come requesting a particular medication and then bargain over the quantity and price they can afford.12 At present PMVs are the most popular source of care. While VHWs exist in all three sites, their use to date is minimal. Government clinics are rarely the first choice of care. These have implications for both selection and training of persons who will distribute the new medications. VHWs and LGA health staff may be more easily recruited for training programmes, but reliance on them alone will mean that the drugs and health education about prompt and appropriate treatment may be inaccessible to many parents unless PMVs are trained. Training should address the fact that PMVs are the major source of antibiotics in the community, but by law they should not dispense these drugs except on prescription. The relatively minimal use of indigenous healers and home herbal remedies is in keeping with experiences of the researchers in the study areas. This may also correspond with the fact that very few respondents are adherents of indigenous religions. Parents in these communities believe that herbal medicines are quite strong, and in contrast, that small children are weak. This perspective produces a bias toward giving children western medicines, which are seen as less harsh than indigenous ones. Also, people resort to an indigenous healer primarily when a condition persists longer or when it presents in a more serious or unusual form than expected. Parents’ response to malaria is a case in point. The illness, iba, is viewed as a minor problem, often receiving minimal attention, but once febrile convulsions ensue, local remedies, Journal of Tropical Pediatrics

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Standard error

0.018 0.014 0.021 0.013 0.026 0.014 0.015 0.0003

Partial F-test

14.722 83.981 11.833 20.253 8.369 7.9755 6.147 14.110

some containing dangerous components, such as cow’s urine, are sought.3 It is encouraging that when respondents perceive that the child has malaria (iba) and high temperature, chloroquine is more likely to be given, either directly by their own choice of medicine at a shop, or indirectly by their choice of visiting a government health facility where presumptive treatment with chloroquine for suspected malaria and fevers is the norm. Health education activities should build on this positive link. The greater use of chloroquine by Yoruba parents implies that greater promotional efforts will be needed with other groups. Likewise, it was encouraging that a link is recognized between antibiotics and both difficult breathing and cough. The negative association with child’s age may reflect a greater perceived seriousness of illness in younger children. Generally the use of antibiotics is relatively limited, and care should be taken not to promote indiscriminate use of these drugs. A disturbing point is the fact that nearly 5 per cent used aspirin and aspirin products for small children, and this issue will be emphasized in health education activities. Overall, it appears that a positive foundation for appropriate self-care for febrile illnesses exists in the study communities and will be used as a basis for health education. Proper training and supervision of PMVs and VHWs will form an integral part of this effort. References 1. Kasl SV, Cobb S. Health behavior, illness behavior, and sick role behavior. Arch Environ Hlth 1966; 12: 246–66, 531–41.

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Vol. 47

August 2001