Ewing Victoria L, Tolhurst Rachel, Kapinda Andrew, Richards Esther, Terlouw Dianne J, Lalloo David G
Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital College of Medicine, P.O. Box 30096, Blantyre, 3, Malawi.
Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK.
Malar J. 2016 Oct 24;15(1):521. doi: 10.1186/s12936-016-1559-0.
This study used qualitative methods to investigate the relationship between geographic access and gendered intra-household hierarchies and how these influence treatment-seeking decision-making for childhood fever within the Chikwawa district of Malawi. Previous cross-sectional survey findings in the district indicated that distance from facility and associated costs are important determinants of health facility attendance in the district. This paper uses qualitative data to add depth of understanding to these findings by exploring the relationship between distance from services, anticipated costs and cultural norms of intra-household decision-making, and to identify potential intervention opportunities to reduce challenges experienced by those in remote locations. Qualitative data collection included 12 focus group discussions and 22 critical incident interviews conducted in the local language, with primary caregivers of children who had recently experienced a febrile episode.
Low geographic accessibility to facilities inhibited care-seeking, sometimes by extending the 'assessment period' for a child's illness episode, and led to delays in seeking formal treatment, particularly when the illness occurred at night. Although carers attempted to avoid incurring costs, cash was often needed for transport and food. Whilst in all communities fathers were normatively responsible for treatment costs, mothers generally had greater access to and control over resources and autonomy in decision-making in the matrilineal and matrilocal communities in the central part of the district, which were also closer to formal facilities.
This study illustrates the complex interplay between geographic access and gender dynamics in shaping decisions on whether and when formal treatment is sought for febrile children in Chikwawa District. Geographic marginality and cultural norms intersect in remote areas both to increase the logistical and anticipated financial barriers to utilising services and to reduce caretakers' autonomy to act quickly once they recognize the need for formal care. Health education campaigns should be based within communities, engaging all involved in treatment-seeking decision-making, including men and grandmothers, and should aim to promote the ability of junior women to influence the treatment-seeking process. Both mothers' financial autonomy and fathers financial contributions are important to enable timely access to effective healthcare for children with malaria.
本研究采用定性方法，调查了马拉维奇夸瓦区地理可及性与家庭内部性别等级制度之间的关系，以及这些因素如何影响儿童发热时的就医决策。此前该地区的横断面调查结果表明，与医疗机构的距离和相关费用是该地区居民前往医疗机构就诊的重要决定因素。本文利用定性数据，通过探究与服务机构的距离、预期费用和家庭内部决策文化规范之间的关系，加深对这些调查结果的理解，并确定潜在的干预机会，以减少偏远地区居民面临的挑战。定性数据收集包括以当地语言进行的12次焦点小组讨论和22次关键事件访谈，访谈对象是近期孩子有发热症状的主要照顾者。
医疗机构的地理可及性低阻碍了人们寻求治疗，有时会延长对儿童疾病发作的“评估期”，并导致寻求正规治疗的延迟，尤其是在夜间发病时。尽管照顾者试图避免产生费用，但交通和食物通常需要现金。虽然在所有社区，父亲在规范上负责治疗费用，但在该地区中部实行母系制和从妻居的社区，母亲通常更容易获得和控制资源，在决策中也更具自主权，这些社区离正规医疗机构也更近。
本研究表明，在奇夸瓦区，地理可及性和性别动态在决定是否以及何时为发热儿童寻求正规治疗方面存在复杂的相互作用。地理边缘性和文化规范在偏远地区相互交织，既增加了利用服务的后勤和预期经济障碍，又减少了照顾者一旦认识到需要正规护理时迅速采取行动的自主权。健康教育活动应在社区内开展，让所有参与就医决策的人参与进来，包括男性和祖母，并应旨在提高年轻女性影响就医过程的能力。母亲的经济自主权和父亲的经济贡献对于确保患疟疾儿童能够及时获得有效的医疗保健都很重要。
