BMC Public Health 2009, 9:259 http://www.biomedcentral.com/1471-2458/9/259 thing or sought treatment (n = 601), excluding 5.5% of those who did not take any action. An additional visit in Table 5 indicates that recovery was not successful in the previous visit. Among patients who made the first visit to various sources of antimalarial treatment, about 77% (463 of 601) reported recovery from the illness. About 23% (n = 138) of those who visited the first source of anti- malarial treatment made a subsequent visit to the second source of treatment, of whom 12% again resorted to the third choice of treatment. The detail of the patterns of resort for treatment seeking for malaria in the study women is presented in Figure 1. The patterns highlighted in this study indicate that multiple visits were more com- mon among those women who made the first visit to CHWs. Most of the women participants in all FGDs and in-depth interviews indicated similar patterns of treatment seeking behaviour for malaria. CHWs, public facilities and private clinics were identified as the main sources of treatment for malaria. In all FGDs, the inefficiencies of public health facilities mainly due to long waiting time, overcrowding, health workers misconduct and drug prescription without being examined in the laboratory were the main deter- rents reported. However, private care providers were per- ceived to be rendering better quality particularly due to the availability of drugs and injections, but incriminated for expensive services. On the other hand, proximity to the village, free antimalarial treatment and good interper- sonal relationship and communication with CHWs made their services to be more utilized by patients with per- ceived malaria. Discussion The study women have an understanding of malaria aeti- ology, symptoms, severity, treatment and preventive methods, as observed in other study areas [17,19,26,38,39]. The local term busaa is shared by all members of the community and considered to be a com- mon and widespread health problem affecting both chil- dren and adults, particularly during the peak transmission season from September to December, a time that overlaps with the major harvest in the area. Although the malaria situation in the area is seasonal, about 60% of the respondents perceived the role of mosquito bite in malaria transmission, showing similarity with the find- ings from intense transmission areas in SSA [17,26,39]. Although mosquitoes were recognized to be the main agents in the transmission of malaria in this study, mis- perceptions such as eating eshet, sleeping together with a malaria patient, hunger and exposure to unhygienic sur- roundings were widely perceived as a cause of malaria. These misconceptions were also common in those respondents who recognized the role of mosquito in the chain of malaria transmission. In Ghana, it has been reported that malaria is presumed to be caused as a result of excessive heat and eating oily or starchy food [17,19,38]. In Uganda, malaria is believed to be caused by poor diet and exposure to bad environmental conditions [26]. In Guatemala, malaria is thought to be caused by exposure to cold or wet conditions, weakness or poor gen- eral health, poor eating habits and problems related to hygiene [39]. A study from coastal Kenya also found that most mothers did not know the association between mos- quitoes and malaria [40]. People's perceptions and under- standings about the perceived cause and transmission of malaria have strong implications on the preventive meas- ures such as the current scale-up ITNs implementation [17,19]. The majority of the study participants recognized two or more symptoms of malaria. This is of obvious importance in a home-based management of malaria among children under the age of five years. The high level of knowledge pertaining to severe malaria was striking. However, there is definitely a need for further exploration of mother's views about causes and health seeking behavior for man- aging convulsions in children due to malaria. Many stud- ies have identified a strong belief that convulsions are due to supernatural causes and best treated by traditional medicine [22,29,40,41]. Table 5: Women's pattern of visits to sources of antimalarial treatment, Adami Tulu District, Ethiopia, 2003 First visit, n (%) Second visit, n (%) Third visit, n (%) Source of treatment CHWsa Public health facility Private clinic Drug shop/vendor Traditional medicine Other sort a Community Health Worker. 242 (40.3) 225 (37.4) 87 (14.5) 39 (6.5) 5 (0.8) 3 (0.5) 601 (100) 10 (7.2) 81 (58.7) 36 (26.1) 11 (8.0) 0 (0.0) 0 (0.0) 138 (100) 0 (0.0) 8 (50.0) 6 (37.5) 2 (12.5) 0 (0.0) 0 (0.0) 16 (100) Page 8 of 12 (page number not for citation purposes)