Participants sought different treatments from a range of public and private health workers. Distance to a facility and availability of qualified staff and medicines were important factors influencing choice of provider.

‘Okay, the hospital I go to is the government hospital. Either in my Local Government or State government i.e. government hospital or the clinic in my local government area ‘(P1, Enugu, FGD, Adult Men)

Many visited patent medicine dealers (from 14 FGDs), health centres (from 13 FGDs) and private hospitals/clinics (from 11 FGDs) respectively to seek treatment for malaria.

‘The place nearer to us where we receive treatment is the health centre’ (P8, Udi, Adult Women)

‘Me, usually..... Like last month I had malaria, there was no doctor so I went to a private clinic’ (P2, Udi, Adult Men)

Some participants also visited traditional healers (2 FGDs) and pharmacies (2 FGDs) to seek malaria treatment. For these patients, seeking care was often a process of 'trial and error'; if conventional medicines were judged not to have worked, then herbal remedies were sought.

Just as some the others have said, I use herbs. There is a herbal doctor in our place called “Oyi- umuaka. I go there for herbal treatment after orthodox drugs fail. He demonstrated with his hands and pointing to different places....... thanks’ [P9, Udi, Adult Men].

‘I go to pharmacy, buy Amalar and use it for treatment’ [P1, Enugu Adult Men]. 'I treat my own by going to a chemist, any drug they give me I take it; because I don't know about drugs. If I don't get better after drinking it, I go back to the chemist again, where they will ask me how the first drug they gave me reacted, I tell them, then they look for another type and give it to me. That's how I do my own because I cannot take Igbo traditional herbal medicine' [P4, Udi, Adult women].

The majority of FGD participants identified fever and loss of appetite as the major symptoms of malaria in a child. Illustrative quotes from some of the FGD participants are given below.

‘Once my child starts running fever and is always crying, then I know certainly is malaria that is disturbing him.’ [Baby shouts] (P8 FGD, Enugu, Primary Caregivers)

‘How I know is that my child will start having loss of appetite, and also gets weak always, I will now know it’s malaria, because I know the symptoms of malaria’.(P4, FGD Enugu, Primary Caregivers);

Other caregivers (4 FGDs) stated that headaches and weakness of body were key signs of malaria as illustrated below.

‘They will have headache as in baby will have headache ‘(P1, FGD, Primary Caregivers).

‘My child has malaria at times it makes the baby weak; sometimes it makes the baby not to feed/eat well… (P4, FGD, Udi, Primary Caregivers)

Contrary to the malaria treatment guidelines that recommend testing before treatment, most workers freely indicated that in their present practice, they diagnose malaria based on symptoms alone using a combination of the patient’s description of their symptoms and their own observations.

‘Based on our standing orders we are basing on signs and symptoms, if somebody presents with febrile conditions, headache, dizziness then we suspect malaria… Then you administer malaria drug to the person…’ (IDI, Enugu Health centre, Nurse,)

‘What I learnt or trained for is much, malaria can come inform of fever, can make the person emaciate, sometimes if the colour of the person’s eyes and urine will change, when the patient explains these, you know it’s malaria’ (IDI, Udi, Drug Retailer).

‘Is it by physical observation ‘… if somebody just comes in and says I have weakness, headache, fever and all those symptoms of malaria, then you do not have any choice than to give the person malaria drug' (IDI, Enugu Pharmacy).

' Because even if I did not conduct any test maybe because of the signs and symptoms I have seen on the patients and I want to administer anti malaria treatment on the patient I will still use the same type of anti malaria … know that malaria has different stages since there is type 1, type 2 and type 3 it is when you test it, when the person has gone through test you now know whether it is in the second stage or first stage to know the drug to administer to get rid of that malaria because if the person does not undergo test example if we have laboratory here it would be very necessary to know the stage but since we do not have I treat according to symptoms and signs that we see' (IDI, Enugu, Health Centre, Nurse).

Community members identified a range of press and print media including radio, television adverts and posters as key sources of information on malaria prevention and treatment as shown in the quotes below.

‘I see posters and TV. In the Adverts, one man came and was advising people to keep their environment clean and tell the children to close windows and doors in the evenings. He said shutting the windows/door stops mosquitoes coming in’ (P8. Udi FGD Adult women].

' According to adverts on the television and radio, they will always advise that after taking a drug for two to three days, if symptoms continue, consult a doctor. So I wait and see the effect of the drugs I take for three to four days, if it heals me then I know that it is working, but if it doesn’t, I will consult a doctor’ [P7 Udi FGD Adult men].

Focus group participants also relied on other community members, most commonly friends, neighbors and family, for information on malaria treatment irrespective of whether it was known to be effective or not.

' It was from my neighbour who used a particular drug in time past so when my children took ill, she gave me the pack of the drug she used to treat her children and asked me to go and buy. So that was how I know artesunate' [P1 Enugu FGD primary care giver].

' How I recognized or know the artesunate is from my husband when he was sick, he went to lab test and he was given artesunate, so he drank it and he was okay. So now, when my Children is sick, I also give it to them'. [P1 Enugu FGD primary care giver].

‘… my friend recommended artesunate to me but the doctor prescribed Alaxin for me in the hospital … after my house help did a lab test and it was malaria, the doctor wrote Alaxin and other drugs, plus Halfan too and she finished drinking them, she quickly recovered because it was good on her. That’s how I know. So if malaria comes now and maybe I can’t go to hospital, I just go and get Alaxin or artesunate but since it is not the doctor that is giving it to me directly, I add blood tonic and paracetamol to give to my child. That’s how I learnt my own' [P2. Enugu. FGD primary care giver].

Health workers typically sought information on how to treat malaria from their colleagues as shown in the quotes below.

‘Moreover I have some medical doctor friends who I liaise with even when I have complicated issues I do phone them. Somebody like a certain doctor here, I do call him and he will direct me on how I will handle some complicated cases’ (IDI, Udi drug Retailer)

‘Ok of course yes some of the doctors that do treat, I use to observe the way that they treat (IDI, Enugu Health Centre Nurse)

Health workers also relied on professional materials including the Nigerian standard treatment guidelines and publications from medical journals and books to help them diagnose and treat malaria patients.

‘….Ok, from, like West African Post Graduate College of Pharmacy, we are talking about malaria, treatment procedures and all the rest of them, they even reference standard treatment Guideline. (IDI, Enugu Pharmacy)

Health workers, especially pharmacists and PMDs, were open to information delivered through the media especially where it was produced by international organizations such as the World Health Organization.

‘TV advert by WHO that people should go for ACT. Both combine to make one think of giving more of ACT and give less of the old’ (IDI, Enugu pharmacy)

Health workers acknowledged training workshops organized by a range of groups such as the Ministry of Health and the Nigerian Agency for Food and Drug Administration and Control (NAFDAC) as another important source of up to date information on malaria treatment and diagnosis. It was also noted that in practice they did not always follow that training especially where less effective older antimalarials were more affordable for poorer patients.

‘…….Yes it changed it because actually, we only relied on other malaria drugs like Amalar and Chloroquine but after the knowledge acquired from the training, we now accept this combination therapy as the best treatment of malaria’(IDI, Enugu Centre Nurse).

‘The training was more of acquainting us with the way malaria is common in this part of West Africa. So we were told that some of the drugs that most people are not responding to in terms of when they now have malaria… some of the drugs like this Chloroquine are fading out of fashion so the new drugs that are to be administered with dosages and the durations. And those things to look for before you now begin to suspect malaria on your patients. I also learnt through those workshops that we should not neglect malaria that it might lead to somebody’s death something like that so we have to make sure that we tackle it as quickly as possible so that it doesn’t get to that acute stage’ (IDI, Enugu Health Centre Nurse).

‘They taught us how to use the rapid malaria test, like the one I attended last year, they encouraged us to tell people to use this ACT that it is better and more powerful than other drugs because it is a combination' (IDI, Enugu Health Centre Nurse).

‘The workshop/training was ok because they emphasized mainly on the fact that the plasmodium parasite has become resistant to a lot of antimalaria and they emphasized the fact that combination products are better. Then they regarded the old ones as long acting and the new ones like Arthemeter and ehhh others as short acting and more effective but malaria parasite is getting resistant so combination works better. That is why emmm we want to give Coartem or any other combination of ACT instead of the old ones but if one does not have money to buy all these, the person does not have option than to buy the old one' (IDI, Enugu Pharmacy).

Finally, health workers were confident that their personal experience and ‘on the job’ training provided them with much of the information necessary to effectively treat and diagnose their patients. Similarly, community members commonly felt that due to the high frequency of malaria episodes experienced, they too had considerable knowledge of the disease and could recognize symptoms.

‘Nothing it’s just that when a patient enters here and complain on malaria from my experience I will know how to treat the sickness’ (IDI, Enugu Drug Retailer)

‘Well another thing that influences my practice is this because the bible says in an adage says that “experience is the best teacher” And as a health worker in the village, I confront many problems so from the additional experience I acquire from those complicated cases I handle, it helps in advancing my knowledge' (IDI, Udi, Drug Retailer).

' Before, I used to be very sick, always having malaria and the drugs I take from the chemist were not working so my friend..eemm. told me about Amalar, so I bought Amalar and recovered. Since then whenever I have malaria, I always buy Amalar’ [P5 FGD, Udi Adult women].

‘Like the sickness we suffer from since we were born, we got to know there is malaria, typhoid, when we go to hospital. We also got to know that malaria causes fever, cold, weakness of the body’ (P9. Udi FGD Adult women).

Community members rely on information obtained from a variety of sources including television, radio and newspaper adverts on malaria, as well as malaria posters in hospitals and health centers to understand how malaria should be properly diagnosed and appropriate medicines used for treatment. Information from friends, family, neighbors and other community members was important in guiding decision making around preferred medicines for malaria treatment. Examples of the responses obtained from some FGD participants are provided below.

' ………….I was using Chloroquine but it used to itch me but because I did not know which other drug to substitute it with I continued using it, but when I learnt about Amalar from an advert, I took Amalar (SP) but it did not heal me completely, before I saw Artesunate (monotherapy) advert on television which I then took and it healed me completely’ (P9. Enugu FGD Adult women).

‘I see posters and TV. In the Adverts, one man came and was advising people to keep their environment clean and tell the children to close windows and doors in the evenings. He said shutting the windows/door stops mosquitoes coming in’ (P8. Udi FGD Adult women].

‘Like the sickness we suffer from since we were born, we got to know there is malaria, typhoid, when we go to hospital. We also got to know that malaria causes fever, cold, weakness of the body’ (P9. Udi FGD Adult women).

Health workers acknowledged participation in training workshops was of particular importance in understanding the changing landscape of malaria resistance, how to use RDTs for malaria and for understanding the new drug combinations for treating uncomplicated malaria and the complex dosage regimes that accompany these medicines.

‘…….Yes it changed it because actually, we only relied on other malaria drugs like Amalar and Chloroquine but after the knowledge acquired from the training, we now accept this combination therapy as the best treatment of malaria’(IDI, Enugu Centre Nurse).

‘The training was more of acquainting us with the way malaria is common in this part of West Africa. So we were told that some of the drugs that most people are not responding to in terms of when they now have malaria… some of the drugs like this Chloroquine are fading out of fashion so the new drugs that are to be administered with dosages and the durations. And those things to look for before you now begin to suspect malaria on your patients. I also learnt through those workshops that we should not neglect malaria that it might lead to somebody’s death something like that so we have to make sure that we tackle it as quickly as possible so that it doesn’t get to that acute stage’ (IDI, Enugu Health Centre Nurse).

‘They taught us how to use the rapid malaria test, like the one I attended last year, they encouraged us to tell people to use this ACT that it is better and more powerful than other drugs because it is a combination ‘(IDI, Enugu Health Centre Nurse).

Across the 18 FGDs held for community members, participants suggested the use of various channels for communicating information about malaria prevention and treatment to members of the public. A number of routine channels for communication were identified including the dissemination of written information through health centres and hospitals as well as adverts and messages through the media, especially radio, television, newspaper and magazines. Other suggestions included holding public meetings in villages, market places, and schools. Church announcements were also flagged as an alternative avenue for communicating messages about appropriate malaria treatment and prevention. It was emphasized that a multi-pronged approach was required since one source may not meet the needs of all members of the community especially those those from different geographic areas or from different socio-economic groups.

‘The way to circulate information is to print it on paper and give to churches because it is churches that people use this day. Then, you people will come to churches and talk to the congregation’ (Demonstrates using his hand and legs)' [P2. Udi FGD Adult men].

‘The best is the radio because not everybody will get up to go and watch TV in somebody’s house. So a lot of people have radio than TV. Like myself I will not go to somebody’s house to watch TV advertisement on health while radio is in my house. Radio is better’ [P2. Enugu FGD Adult women].

Furthermore, approximately half of the health workers interviewed emphasized the importance of communicating through existing channels such as government training programmes, support visits to the health workers and through health workers' unions. Other complementary means of communication included the use of radio jingles, through TV adverts, advert by drug manufacturers, using handbills, posters and bill boards.

‘The way I prefer is for you to call us, because if say it is on radio, some may not have time to listen to the radio. In the morning the person takes his bath and leaves the house and goes to the shop and stays. So the best way is for you to call us and tell everybody to come with a biro and you teach us do it this way and that way, just doing it face to face, for me I like it best’ (IDI, Udi Drug Retailer).

I feel that it is through training’ (IDI, Udi Drug Retailer).

‘Em, I think this system or technique you now use will be very helpful to us Nigerians generally, now like today I know you have my phone number, and here (touching the information sheet given to him) I know you have your phone numbers here and I believe that this is an easy form of communication and if we ourselves are able to liaise with people like you, it will help in enhancing our profession and work and it will improve our understanding about the business’(IDI, Udi, Drug Retailer) .