title: Malaria risk and access to prevention and treatment in the paddies of the Kilombero Valley, Tanzania.
abstract: BACKGROUND
  The Kilombero Valley is a highly malaria-endemic agricultural area in south-eastern Tanzania. Seasonal flooding of the valley is favourable to malaria transmission. During the farming season, many households move to distant field sites (shamba in Swahili) in the fertile river floodplain for the cultivation of rice. In the shamba, people live for several months in temporary shelters, far from the nearest health services. This study assessed the impact of seasonal movements to remote fields on malaria risk and treatment-seeking behaviour.
  
  
  METHODS
  A longitudinal study followed approximately 100 randomly selected farming households over six months. Every household was visited monthly and whereabouts of household members, activities in the fields, fever cases and treatment seeking for recent fever episodes were recorded.
  
  
  RESULTS
  Fever incidence rates were lower in the shamba compared to the villages and moving to the shamba did not increase the risk of having a fever episode. Children aged 1-4 years, who usually spend a considerable amount of time in the shamba with their caretakers, were more likely to have a fever than adults (odds ratio = 4.47, 95% confidence interval 2.35-8.51). Protection with mosquito nets in the fields was extremely good (98% usage) but home-stocking of antimalarials was uncommon. Despite the long distances to health services, 55.8% (37.9-72.8) of the fever episodes were treated at a health facility, while home-management was less common (37%, 17.4-50.5).
  
  
  CONCLUSIONS
  Living in the shamba does not appear to result in a higher fever-risk. Mosquito nets usage and treatment of fever in health facilities reflect awareness of malaria. Inability to obtain drugs in the fields may contribute to less irrational use of drugs but may pose an additional burden on poor farming households. A comprehensive approach is needed to improve access to treatment while at the same time assuring rational use of medicines and protecting fragile livelihoods.
authors.affiliation: Department of Public Health and Epidemiology, Swiss Tropical Institute, PO Box, CH-4002 Basel, Switzerland. manuel.hetzel@unibas.ch
authors.forename: Manuel W
authors.initials: MW
authors.lastname: Hetzel
authors.forename: Sandra
authors.initials: S
authors.lastname: Alba
authors.forename: Mariette
authors.initials: M
authors.lastname: Fankhauser
authors.forename: Iddy
authors.initials: I
authors.lastname: Mayumana
authors.forename: Christian
authors.initials: C
authors.lastname: Lengeler
authors.forename: Brigit
authors.initials: B
authors.lastname: Obrist
authors.forename: Rose
authors.initials: R
authors.lastname: Nathan
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Makemba
authors.forename: Christopher
authors.initials: C
authors.lastname: Mshana
authors.forename: Alexander
authors.initials: A
authors.lastname: Schulze
authors.forename: Hassan
authors.initials: H
authors.lastname: Mshinda
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D019353:Endemic Diseases; D005191:Family Characteristics; D005334:Fever / Q000175:diagnosis / Q000628:therapy; D006801:Humans; D007223:Infant; D008137:Longitudinal Studies; D008288:Malaria / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy*; D015999:Multivariate Analysis; D010342:Patient Acceptance of Health Care; D012307:Risk Factors; D013636:Tanzania / Q000453:epidemiology