title: Seasonal and geographic differences in treatment-seeking and household cost of febrile illness among children in Malawi.
abstract: BACKGROUND
  Households in malaria endemic countries experience considerable costs in accessing formal health facilities because of childhood malaria. The Ministry of Health in Malawi has defined certain villages as hard-to-reach on the basis of either their distance from health facilities or inaccessibility. Some of these villages have been assigned a community health worker, responsible for referring febrile children to a health facility. Health facility utilization and household costs of attending a health facility were compared between individuals living near the district hospital and those in hard-to-reach villages.
  
  
  METHODS
  Two cross-sectional household surveys were conducted in the Chikhwawa district of Malawi; one during each of the wet and dry seasons. Half the participating villages were located near the hospital, the others were in areas defined as hard-to-reach. Data were collected on attendance to formal health facilities and economic costs incurred due to recent childhood febrile illness.
  
  
  RESULTS
  Those living in hard-to-reach villages were less likely to attend a formal health facility compared to those living near the hospital (Dry season: OR 0.35, 95%CI0.18-0.67; Wet season: OR 0.46, 95%CI0.27-0.80). Analyses including community health workers (CHW) as a source of formal health-care decreased the strength of this relationship, and suggested that consulting a CHW may reduce attendance at health facilities, even if indicated. Although those in hard-to-reach villages were still less likely to attend in both the dry (OR 0.53, 95%CI 0.25-1.11) and wet (OR 0.60, 95%CI 0.37-0.98) seasons. Household costs for those who attended a health facility were greater for those in HTR villages (Dry: USD5.24; Wet: USD5.60) than for those living near the district hospital (Dry: USD3.45; Wet: USD4.46).
  
  
  CONCLUSIONS
  Those living in hard-to-reach areas were less likely to attend a health facility for a childhood febrile event and experienced greater associated household costs. Consulting CHWs was infrequent, but appeared to reduce attendance at a health facility, even when indicated. Health service planners must consider geographic and financial barriers to accessing public health facilities in designing appropriate interventions.
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. vewing@liv.ac.uk
authors.forename: Victoria L
authors.initials: VL
authors.lastname: Ewing
authors.forename: David G
authors.initials: DG
authors.lastname: Lalloo
authors.forename: Kamija S
authors.initials: KS
authors.lastname: Phiri
authors.forename: Arantxa
authors.initials: A
authors.lastname: Roca-Feltrer
authors.forename: Lindsay J
authors.initials: LJ
authors.lastname: Mangham
authors.forename: Miguel A
authors.initials: MA
authors.lastname: SanJoaquin
mesh_terms: D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005191:Family Characteristics; D005260:Female; D005335:Fever of Unknown Origin / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics; D005843:Geography; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008295:Malawi; D008297:Male; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D012621:Seasons