title: Increasing understanding of the relationship between geographic access and gendered decision-making power for treatment-seeking for febrile children in the Chikwawa district of Malawi.
abstract: 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.
authors: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital College of Medicine, P.O. Box 30096, Blantyre, 3, Malawi. ewingvl@googlemail.com.|Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK. ewingvl@googlemail.com.
authors: Victoria L
authors: 0000-0001-5381-7864
authors: VL
authors: Ewing
authors: Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK.
authors: Rachel
authors: R
authors: Tolhurst
authors: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital College of Medicine, P.O. Box 30096, Blantyre, 3, Malawi.
authors: Andrew
authors: A
authors: Kapinda
authors: Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK.
authors: Esther
authors: E
authors: Richards
authors: 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.
authors: Dianne J
authors: DJ
authors: Terlouw
authors: Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK.
authors: David G
authors: DG
authors: Lalloo
mesh_terms: D000293:Adolescent; D002675:Child, Preschool; D005191:Family Characteristics; D005260:Female; D005335:Fever of Unknown Origin / Q000175:diagnosis* / Q000628:therapy*; D005843:Geography; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007407:Interviews as Topic; D008295:Malawi; D008297:Male; D010342:Patient Acceptance of Health Care; D012737:Sex Factors; D055815:Young Adult
keywords: Gender; Intra-household decision-making; Malaria; Malawi; Treatment-seeking