Child malaria treatment decisions by mothers of children less than five years of age attending an outpatient clinic in south-west Nigeria: an application of the PEN-3 cultural model

<p>Abstract</p> <p>Background</p> <p>Using the PEN-3 cultural model, this study sought to understand mothers treatment decisions about their child febrile illness by examining positive health beliefs and practices held by mothers, examine existential (unique) practices that are indigenous to mothers and have no harmful health consequences, and explore negative beliefs and practices that limit recommended responses to febrile illness in children.</p> <p>Methods</p> <p>This qualitative study was conducted in the paediatric section of an outpatient clinic in south-west Nigeria. A total of 123 mothers with children less than five years of age with febrile illness diagnosed as malaria by physicians were individually interviewed on their treatment-seeking practices prior to visiting the clinic and their reasons for attendance at the clinic.</p> <p>Results</p> <p>For some mothers interviewed, effective treatment from the clinic for their child's febrile illness, coupled with physician's approach with malaria diagnosis and treatment practices was important in generating positive maternal treatment-seeking responses to child febrile illness. In addition, beliefs related to a child teething highlighted existential decisions with treatment-seeking for child febrile illness in this setting. Finally, the belief that febrile illness is not all that severe despite noticeable signs and symptoms was a concerning negative perception shared by some mothers in this study.</p> <p>Conclusion</p> <p>The findings highlight the need to consider not only the responses that may serve as barriers to effective treatment, but also an acknowledgment of the positive and existential responses that are equally critical in influencing mothers' management of malaria in their children.</p

Two treatments, one disease: childhood malaria management in Tanga, Tanzania

<p>Abstract</p> <p>Background</p> <p>In the Tanga District of coastal Tanzania, malaria is one of the primary causes of mortality for children under the age of five. While some children are treated with malaria medications in biomedical facilities, as the World Health Organization recommends, others receive home-care or treatment from traditional healers. Recognition of malaria is difficult because symptoms can range from fever with uncomplicated malaria to convulsions with severe malaria. This study explores why caregivers in the Tanga District of Tanzania pursue particular courses of action to deal with malaria in their children.</p> <p>Methods</p> <p>Qualitative data were collected through interviews with three samples: female caregivers of children under five (N = 61), medical practitioners (N = 28), and traditional healers (N = 18) in urban, peri-urban, and rural areas. The female caregiver sample is intentionally stratified to reflect the greater population of the Tanga District in level of education, marital status, gender of household head, religion, and tribal group affiliation. Qualitative data were counted, coded and analysed using NVivo7 software.</p> <p>Results</p> <p>Results indicate that a variety of factors influence treatment choice, including socio-cultural beliefs about malaria symptoms, associations with spiritual affliction requiring traditional healing, knowledge of malaria, and fear of certain anti-malaria treatment procedures. Most notably, some caregivers identified convulsions as a spiritual condition, unrelated to malaria. While nearly all caregivers reported attending biomedical facilities to treat children with fever (N = 60/61), many caregivers stated that convulsions are best treated by traditional healers (N = 26/61). Qualitative interviews with medical practitioners and traditional healers confirmed this belief.</p> <p>Conclusion</p> <p>Results offer insight into current trends in malaria management and have implications in healthcare policy, educational campaigns, and the importance of integrating traditional and biomedical approaches.</p

Barriers to the effective treatment and prevention of malaria in Africa: A systematic review of qualitative studies

<p>Abstract</p> <p>Background</p> <p>In Africa, an estimated 300-500 million cases of malaria occur each year resulting in approximately 1 million deaths. More than 90% of these are in children under 5 years of age. To identify commonly held beliefs about malaria that might present barriers to its successful treatment and prevention, we conducted a systematic review of qualitative studies examining beliefs and practices concerning malaria in sub-Saharan African countries.</p> <p>Methods</p> <p>We searched Medline and Scopus (1966-2009) and identified 39 studies that employed qualitative methods (focus groups and interviews) to examine the knowledge, attitudes, and practices of people living in African countries where malaria is endemic. Data were extracted relating to study characteristics, and themes pertaining to barriers to malaria treatment and prevention.</p> <p>Results</p> <p>The majority of studies were conducted in rural areas, and focused mostly or entirely on children. Major barriers to prevention reported included a lack of understanding of the cause and transmission of malaria (29/39), the belief that malaria cannot be prevented (7/39), and the use of ineffective prevention measures (12/39). Thirty-seven of 39 articles identified barriers to malaria treatment, including concerns about the safety and efficacy of conventional medicines (15/39), logistical obstacles, and reliance on traditional remedies. Specific barriers to the treatment of childhood malaria identified included the belief that a child with convulsions could die if given an injection or taken to hospital (10/39).</p> <p>Conclusion</p> <p>These findings suggest that large-scale malaria prevention and treatment programs must account for the social and cultural contexts in which they are deployed. Further quantitative research should be undertaken to more precisely measure the impact of the themes uncovered by this exploratory analysis.</p

Treatment-seeking behaviour for febrile illness in an area of seasonal malaria transmission in rural Ethiopia

BACKGROUND: Very little is known about the management of malaria and treatment-seeking patterns among children and adults in areas of seasonal malaria transmission particularly in east Africa. OBJECTIVES: The aim of this study was to assess treatment-seeking behaviour for reported malaria among all age groups in an area of seasonal transmission. METHODS: A community-based cross-sectional study was carried out among 2,253 households in 12 randomly selected rural kebeles in Adami Tulu district in south-central Ethiopia, during October-November 2003, using a pre-tested interviewer-administered structured questionnaire. RESULTS: Reported malaria was 14% among 12,225 people assessed during the last 14 days. Family/self-diagnosis was most common and the main first responses included visiting village-based community health workers (CHWs) (33%), public health facility (23%) and private clinic (17%). Home treatment was the least reported first response (3%). Only 13% had sought treatment within the first 24 hours of symptom onset. Early treatment-seeking pattern was reported among those who visited CHWs and practiced home treatment, with more delays among public facility users. Treatment-seeking behaviour was similar in all age groups. CONCLUSION: A considerable proportion of visits were made to CHWs and private providers, necessitating the importance of strengthening both community-based interventions and peripheral public and private facilities. Finally, the community should be informed and educated about the importance of early diagnosis and prompt treatment with effective antimalarials

Role of traditional healers in the management of severe malaria among children below five years of age: the case of Kilosa and Handeni Districts, Tanzania

BACKGROUND: The current malaria control strategy of WHO centres on early diagnosis and prompt treatment using effective drugs. Children with severe malaria are often brought late to health facilities and traditional health practitioners are said to be the main cause of treatment delay. In the context of the Rectal Artesunate Project in Tanzania, the role of traditional healers in the management of severe malaria in children was studied. METHODOLOGY: A community cross-sectional study was conducted in Kilosa and Handeni Districts, involving four villages selected on the basis of existing statistics on the number of traditional health practitioners involved in the management of severe malaria. A total of 41 traditional health practitioners were selected using the snowballing technique, whereby in-depth interviews were used to collect information. Eight Focus Group Discussions (FGDs) involving traditional health practitioners, caregivers and community leaders were carried out in each district. RESULTS: Home management of fever involving sponging or washing with warm water at the household level, was widely practiced by caregivers. One important finding was that traditional health practitioners and mothers were not linking the local illness termed degedege, a prominent feature in severe malaria, to biomedically-defined malaria. The majority of mothers (75%) considered degedege to be caused by evil spirits. The healing process was therefore organized in stages and failure to abide to the procedure could lead to relapse of degedege, which was believed to be caused by evil spirits. Treatment seeking was, therefore, a complex process and mothers would consult traditional health practitioners and modern health care providers, back and forth. Referrals to health facilities increased during the Rectal Artesunate Project, whereby project staff facilitated the process after traditional medical care with the provision of suppositories. This finding is challenging the common view that traditional healers are an important factor of delay for malaria treatment, they actually play a pivotal role by giving "bio-medically accepted first aid" which leads to reduction in body temperature hence increasing chances of survival for the child. Increasing the collaboration between traditional healers and modern health care providers was shown to improve the management of severe malaria in the studied areas. INTERPRETATION AND CONCLUSION: Traditional health care is not necessarily a significant impediment or a delaying factor in the treatment of severe malaria. There is a need to foster training on the management of severe cases, periodically involving both traditional health practitioners and health workers to identify modalities of better collaboration

Deployment of ACT antimalarials for treatment of malaria: challenges and opportunities

Following a long period when the effectiveness of existing mono-therapies for antimalarials was steadily declining with no clear alternative, most malaria-endemic countries in Africa and Asia have adopted artemisinin combination therapy (ACT) as antimalarial drug policy. Several ACT drugs exist and others are in the pipeline. If properly targeted, they have the potential to reduce mortality from malaria substantially. The major challenge now is to get the drugs to the right people. Current evidence suggests that most of those who need the drugs do not get them. Simultaneously, a high proportion of those who are given antimalarials do not in fact have malaria. Financial and other barriers mean that, in many settings, the majority of those with malaria, particularly the poorest, do not access formal healthcare, so the provision of free antimalarials via this route has only limited impact. The higher cost of ACT creates a market for fake drugs. Addressing these problems is now a priority. This review outlines current evidence, possible solutions and research priorities

Reviewing the literature on access to prompt and effective malaria treatment in Kenya: implications for meeting the Abuja targets

<p>Abstract</p> <p>Background</p> <p>Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment.</p> <p>In Kenya, the Division of Malaria Control is committed to ensuring that 80 percent of childhood fevers are treated with effective anti-malarial medicines within 24 hours of fever onset, but this target is largely unmet. This review aimed to document evidence on access to effective malaria treatment in Kenya, identify factors that influence access, and make recommendations on how to improve prompt access to effective malaria treatment. Since treatment-seeking patterns for malaria are similar in many settings in sub-Saharan Africa, the findings presented in this review have important lessons for other malaria endemic countries.</p> <p>Methods</p> <p>Internet searches were conducted in PUBMED (MEDLINE) and HINARI databases using specific search terms and strategies. Grey literature was obtained by soliciting reports from individual researchers working in the treatment-seeking field, from websites of major organizations involved in malaria control and from international reports.</p> <p>Results</p> <p>The review indicated that malaria treatment-seeking occurs mostly in the informal sector; that most fevers are treated, but treatment is often ineffective. Irrational drug use was identified as a problem in most studies, but determinants of this behaviour were not documented. Availability of non-recommended medicines over-the-counter and the presence of substandard anti-malarials in the market are well documented. Demand side determinants of access include perception of illness causes, severity and timing of treatment, perceptions of treatment efficacy, simplicity of regimens and ability to pay. Supply side determinants include distance to health facilities, availability of medicines, prescribing and dispensing practices and quality of medicines. Policy level factors are around the complexity and unclear messages regarding drug policy changes.</p> <p>Conclusion</p> <p>Kenya, like many other African countries, is still far from achieving the Abuja targets. The government, with support from donors, should invest adequately in mechanisms that promote access to effective treatment. Such approaches should focus on factors influencing multiple dimensions of access and will require the cooperation of all stakeholders working in malaria control.</p

Management of uncomplicated malaria in febrile under five-year-old children by community health workers in Madagascar: reliability of malaria rapid diagnostic tests

<p>Abstract</p> <p>Background</p> <p>Early diagnosis, as well as prompt and effective treatment of uncomplicated malaria, are essential components of the anti-malaria strategy in Madagascar to prevent severe malaria, reduce mortality and limit malaria transmission. The purpose of this study was to assess the performance of the malaria rapid diagnostic tests (RDTs) used by community health workers (CHWs) by comparing RDT results with two reference methods (microscopy and Polymerase Chain Reaction, PCR).</p> <p>Methods</p> <p>Eight CHWs in two districts, each with a different level of endemic malaria transmission, were trained to use RDTs in the management of febrile children under five years of age. RDTs were performed by CHWs in all febrile children who consulted for fever. In parallel, retrospective parasitological diagnoses were made by microscopy and PCR. The results of these different diagnostic methods were analysed to evaluate the diagnostic performance of the RDTs administered by the CHWs. The stability of the RDTs stored by CHWs was also evaluated.</p> <p>Results</p> <p>Among 190 febrile children with suspected malaria who visited CHWs between February 2009 and February 2010, 89.5% were found to be positive for malaria parasites by PCR, 51.6% were positive by microscopy and 55.8% were positive by RDT. The performance accuracy of the RDTs used by CHWs in terms of sensitivity, specificity, positive and negative predictive values was greater than 85%. Concordance between microscopy and RDT, estimated by the Kappa value was 0.83 (95% CI: 0.75-0.91). RDTs stored by CHWs for 24 months were capable of detecting <it>Plasmodium falciparum </it>in blood at a level of 200 parasites/μl.</p> <p>Conclusion</p> <p>Introduction of easy-to-use diagnostic tools, such as RDTs, at the community level appears to be an effective strategy for improving febrile patient management and for reducing excessive use of anti-malarial drugs.</p

Factors influencing implementation of the Ministry of Health-led private medicine retailer programmes on malaria in Kenya

<p>Abstract</p> <p>Background</p> <p>Kenya has experienced a number of retail sector initiatives aimed at improving access to antimalarial medicines. This study explored stakeholders' perceptions of the role of private medicine retailers (PMRs), the value and feasibility of programme goals, perceived programme impact, factors influencing implementation and recommendations in three districts of Kenya.</p> <p>Methods</p> <p>This study was part of a larger evaluation of PMR programmes, including quantitative and qualitative components. The qualitative research was conducted to assess implementation processes and actors' experiences in the programmes, through focus group discussions with trained PMRs and mothers of children under five years, and in-depth interviews with programme managers, trainers and co-trainers.</p> <p>Results</p> <p>PMRs were perceived to provide rapid cheap treatment for non-serious conditions and used as a deliberate and continuously evaluated choice between different treatment sources. All stakeholders supported programme goals and most PMRs described increased customer satisfaction, more rational purchasing of medicine stock and increased medicine sales after participation. Factors undermining programme implementation included a lack of MoH resources to train and monitor large numbers of PMRs, the relative instability of outlets, medicines stocked and retail personnel, the large number of proprietary brands and financial challenges to retailers in stocking antimalarial medicines, and their customers in buying them. Unambiguous national support and a broad range of strategies are important to strengthen the feasibility of change in OTC antimalarial use.</p> <p>Conclusions</p> <p>Understanding the context and implementation processes of PMR programmes and the perspectives of key actors are critical to identifying measures to support their effective implementation. Financial barriers underlie many described challenges, with important implications for policies on subsidies in this sector. In spite of barriers to implementation, increased exposure to programme activities promoted trust and improved relationships between PMRs and their clients and trainers, strengthening feasibility of such interventions. Public information can strengthen PMR training programmes by engaging local communities and may facilitate performance monitoring of PMRs by their clients.</p

Recognition, Perceptions and Treatment Practices for Severe Malaria in Rural Tanzania: Implications for Accessing Rectal Artesunate as a Pre-Referral

OBJECTIVES: Preparatory to a community trial investigating how best to deliver rectal artesunate as pre-referral treatment for severe malaria; local understanding, perceptions of signs/symptoms of severe malaria and treatment-seeking patterns for and barriers to seeking biomedical treatment were investigated. METHODOLOGY/PRINCIPAL FINDINGS: 19 key informant interviews, 12 in-depth interviews and 14 focus group discussions targeting care-givers, opinion leaders, and formal and informal health care providers were conducted. Monthly fever episodes and danger signs or symptoms associated with severe malaria among under-fives were recorded. Respondents recognized convulsions, altered consciousness and coma, and were aware of their risks if not treated. But, these symptoms were perceived to be caused by supernatural forces, and traditional healers were identified as primary care providers. With some delay, mothers eventually visited a health facility when convulsions were part of the illness, despite pressures against this. Although vomiting and failure to eat/suck/drink were associated with malaria, they were not considered as indicators of danger signs unless combined with another more severe symptom. Study communities were familiar with rectal application of medicines. CONCLUSIONS/SIGNIFICANCE: Communities' recognition and awareness of major symptoms of severe malaria could encourage action, but perceptions of their causes and poor discrimination of other danger signs – vomiting and failure to feed – might impede early treatment. An effective health education targeting parents/guardians, decision-makers/advisors, and formal and informal care providers might be a prerequisite for successful introduction of rectal artemisinins as an emergency treatment. Role of traditional healers in delivering such medication to the community should be explored