Improving access to health care for malaria in Africa: a review of literature on what attracts patients

The Malaria Burden: A South African Perspective

Malaria is a deadly disease caused by protozoan pathogens of the Plasmodium parasite. Transmission to humans occurs through the bite of an infected female Anopheles mosquito. According to the World Health Organization (WHO), an estimated 247 million cases of malaria were recorded worldwide in 2021, with approximately 619 000 malaria deaths. The initial signs of malaria can be mild and challenging to diagnose due to the signs and symptoms being similar to those of other illnesses. The malaria burden remains largely concentrated in the WHO sub-Saharan African region and has been recognised as a significant contributor to morbidity and mortality. This review aims to contribute to the existing knowledge on malaria in South Africa, a region within sub-Saharan Africa, focusing on the epidemiology and life cycle of the malaria parasite as well as diagnostic approaches for detecting malaria. In addition, nonpharmacological and pharmacological interventions for treating and preventing malaria infections will also be discussed herein. While there has been a significant reduction in the global burden of this disease, malaria remains a public health issue in South Africa. As such, the implementation of effective preventative measures and strategies, early diagnosis, and appropriate treatment regimens are crucial to reducing the malaria burden in South Africa.

Request for Antimalarial Medicines and Their Dispensing Without a Prescription in Community Pharmacies in Rwanda

Purpose

This study aimed to explore the request and dispensing of antimalarial medicines without a prescription in community pharmacies in Rwanda, as well as factors associated.

Methods

We employed an embedded mixed-methods design that involved a convenience sample of 235 licensed community pharmacists between February and April 2022. To simultaneously collect qualitative and quantitative data, we used a self-administered questionnaire containing a combination of close and open-ended questions. Bivariate and multivariate regression analyses were performed to examine the relationship between dispensing antimalarial medicines without a prescription and the selected independent variables. Statistical significance was set at p<0.05, and a 95% confidence interval was applied. The factors influencing the dispensing of antimalarial medicines without a prescription were analyzed using thematic content analysis as a qualitative analysis approach.

Results

Most respondents (88.5%) were asked to dispense antimalarial medicines by clients without a prescription. More than half of them (54%) agreed, but 34.5% refused; instead, they referred clients to malaria diagnostic testing facilities. Those who had rapid diagnostic tests for malaria in stock (OR=2.08, 95% CI:1.1-3.94), and thought that antimalarials were over-the-counter medicines (OR=7.03, 95% CI:2.01-24.5) were more likely to dispense antimalarial medicines without prescriptions. The primary reasons reported by community pharmacists for dispensing antimalarial medicines without prescriptions included their prior knowledge of malaria diagnosis, client pressure, and fear of losing clients. However, non-adherence to negative results obtained from formal health facilities and long queues at these institutions have also been cited as additional factors driving clients to seek antimalarial medicines without prescriptions.

Conclusion

Dispensing antimalarial medicines without prescriptions is a common practice in community pharmacies in Rwanda. The main factors contributing to this practice include lack of awareness regarding the classification of antimalarials as prescription medicines, the availability of malaria diagnostic tests, client pressure, and fear of losing clients.

Private sector antimalarial sales a decade after “test and treat”: A cross-sectional study of drug shop clients in rural Uganda

Background

The World Health Organization has promoted “test and treat” guidelines for malaria since 2010, recommending all suspected malaria cases be confirmed with a parasitological test, typically a rapid diagnostic test (RDT), prior to treatment with antimalarial medications. However, many fevers at private drug shops in Uganda continue to be treated presumptively as malaria without diagnostic testing.

Methods

The purpose of this study was to document private sector malaria case management in rural Uganda through a cross-sectional survey of drug shop clients in Bugoye sub-county. Drug shop vendors (n = 46) recorded information about sales interactions with clients reporting fever or requesting antimalarials and collected capillary blood samples from clients who purchased medications without an RDT. We estimated the proportion of clients who purchased an RDT, adhered to the RDT result, and received antimalarials without having laboratory-confirmed malaria.

Results

Most drug shops were unlicensed (96%) and sold RDTs (98%). Of 934 clients with suspected malaria who visited study drug shops during the data collection period, only 25% bought an RDT. Since some clients reported previous RDTs from the public sector, 40% of clients were aware of their malaria status at the drug shop. Among those with negative tests, 36% still purchased antimalarials. Sixty-five percent of clients who purchased an antimalarial without an RDT subsequently tested negative.

Conclusions

Despite national guidelines, drug shop clients who purchase antimalarials from drug shops in Bugoye are often not tested to confirm a malaria diagnosis prior to treatment. Most clients treated presumptively with antimalarials did not have malaria. Interventions are needed to improve malaria case management and rational drug use in the private sector.

Effectiveness of antimalarial interventions in Nigeria: Evidence from facility-level longitudinal data

OBJECTIVE

To evaluate the effectiveness of a program of antimalarial interventions implemented in 2010-2013 in Niger State, Nigeria.

DATA SOURCES

Utilization reports from 99 intervention and 51 non-intervention health facilities from the Niger State Malaria Elimination Program, supplemented by data on facility-level characteristics from the Niger State Primary Health Care Development Agency and Local Government Malaria Control units.

STUDY DESIGN

Estimated with mixed-effects negative binomial modeling, a difference-in-differences method was used to quantify the impact of the program on the number of febrile illness cases and confirmed malaria cases. Potential confounding factors, non-stationarity, seasonality, and autocorrelation were explicitly accounted for.

DATA EXTRACTION METHODS

Data were retrieved from hard copies of utilization reports and manually inputted to create a panel of 5550 facility-month observations.

PRINCIPAL FINDINGS

The program was implemented in two phases. The first phase (August 2010-June 2012) involved the provision of free artemisinin-based combination therapies, long-lasting insecticidal nets, and intermittent preventive treatments. In the second phase (July 2012-March 2013), the program introduced an additional intervention: free parasite-based rapid diagnostic tests. Compared to the pre-intervention period, the average number of monthly febrile illness and malaria cases increased by 20.876 (P < 0.01) and 22.835 (P < 0.01) in the first phase, and by 19.007 (P < 0.05) and 19.681 (P < 0.05) in the second phase, respectively. The results are consistent across different evaluation methods.

CONCLUSIONS

This study suggests that user-fee removal leads to increased utilization of antimalarial services. It motivates future studies to cautiously select their investigative methods.

Factors contributing to low uptake and renewal of health insurance: a qualitative study in Ghana

Background

The effort to expand access to healthcare and reduce health inequalities in many low income countries have meant that many have adopted different levels of social health protection mechanisms. Ghana introduced a National Health Insurance Scheme (NHIS) in 2005 with the aim of removing previous barriers created by the user fees financing system. Although the NHIS has made health accessible to some category of people, the majority of Ghanaians (60 %) are not enroled on the scheme. Earlier studies have looked at various factors that account for this low uptake. However, we recognise that this qualitative study will nuance the depth of these barriers to enrolment.

Methods

Minimally structured, qualitative interviews were conducted with key stakeholders at the district, regional and national levels. Focus group discussions were also undertaken at the community level. Using an inductive and content analytic approach, the transcripts were analyzed to identify and define categories that explain low uptake of health insurance.

Results

The results are presented under two broad themes: sociocultural and systemic factors. Sociocultural factors identified were 1) vulnerability within certain groups such as the aged and the disabled groups which impeded access to the NHIS 2) cultural and religious norms which discouraged enrolment into the scheme. System-wide factors were 1) inadequate distribution of social infrastructure such as healthcare facilities, 2) weak administrative processes within the NHIS, and 3) poor quality of care.

Conclusions

Mapping the interplay of these dynamic relations between the NHIS, its clients and service providers, the study identifies critical factors at the policy-making level, service provider level, and client level (reflective in household and community level institutional arrangements) that affect enrolment in the scheme. Our findings inform a number of potential reforms in the area of distribution of health resources and cost containment to expand coverage, increase choices and meeting the needs of the end user.

Impact of introducing subsidized combination treatment with artemether-lumefantrine on sales of anti-malarial monotherapies: a survey of private sector pharmacies in Huambo, Angola

BACKGROUND

Artemisinin-based combination therapies (ACTs) against malaria are subsidized in many African countries, but the impact of subsidy programs in reducing the sales of concomitantly available antimalarial monotherapies is poorly defined.

METHODS

Data from The MENTOR initiative, that introduced subsidized artemether-lumefantrine (sAL) in the private sector of Huambo province, Angola, were used. The main response variable was represented by sales of sAL and of monotherapies, measured as number of treatment courses. Sales in private pharmacies of sAL and four antimalarial monotherapies between 2009 and 2013 were organized in four time-periods, and analyzed using generalized linear models for repeated measures. A secondary analysis evaluated changes in relative market share.

RESULTS

We analyzed data from 34 pharmacies at four time points, taken from a larger survey that involved 165 pharmacies between June 2009 and March 2013. The sAL, following its introduction, became the dominant antimalarial treatment in the private sector, usually exceeding the total sales of all antimalarial monotherapies combined (1480/2800 total treatment courses, 52.8% of all sales in March 2013). Sales of monotherapies decreased significantly, but did not stop, representing 36.7% (1028/2800) of sales at the end of the survey.

CONCLUSIONS

Subsidized ACTs can attain rapidly a high relative market share. Their introduction reduced, but did not eliminate the demand for less effective monotherapies, that might favor parasite resistance.

Towards subsidized malaria rapid diagnostic tests. Lessons learned from programmes to subsidise artemisinin-based combination therapies in the private sector: a review

The idea of a private sector subsidy programme of artemisinin-based combination therapies (ACTs) was first proposed in 2004. Since then, several countries around the world have hosted pilot projects or programmes on subsidized ACTs and/or the Affordable Medicines Facility-malaria programme (AMFm). Overall the private sector subsidy programmes of ACTs have been effective in increasing availability of ACTs in the private sector and driving down average prices but struggled to crowd out antimalarial monotherapies. The results obtained from this ambitious strategy should inform policy makers in the designing of future interventions aimed to control malaria morbidity and mortality. Among the interventions recently proposed, a subsidy of rapid diagnostic tests (RDTs) in the private sector has been recommended by governments and international donors to cope with over-treatment with ACTs and to delay the emergence of resistance to artemisinin. In order to improve the cost-effectiveness of co-paid RDTs, we should build on the lessons we learned from almost 10 years of private sector subsidy programmes of ACTs in malaria-endemic countries.

Prompt access to effective malaria treatment among children under five in sub-Saharan Africa: a multi-country analysis of national household survey data

Background

Scaling up diagnostic testing and treatment is a key strategy to reduce the burden of malaria. Delays in accessing treatment can have fatal consequences; however, few studies have systematically assessed these delays among children under five years of age in malaria-endemic countries of sub-Saharan Africa. This study identifies predictors of prompt treatment with first-line artemisinin combination therapy (ACT) and describes profiles of children who received this recommended treatment.

Methods

This study uses data from the most recent Demographic and Health Survey, Malaria Indicator Survey, or Anaemia and Parasite Prevalence Survey conducted in 13 countries. A Chi square automatic interaction detector (CHAID) model was used to identify factors associated with prompt and effective treatment among children under five years of age.

Results

The percentage of children with fever who received any anti-malarial treatment varies from 3.6 % (95 % CI 2.8–4.4 %) in Ethiopia to 64.5 % (95 % CI 62.7–66.2 %) in Uganda. Among those who received prompt treatment with any anti-malarial medicine, the percentage who received ACT ranged from 32.2 % (95 % CI 26.1–38.4 %) in Zambia to nearly 100 % in Tanzania mainland and Zanzibar. The CHAID analysis revealed that country of residence is the best predictor of prompt and effective treatment (p < 0.001). Depending on the country, the second best predictor was maternal education (p = 0.004), place of residence (p = 0.008), or household wealth index (p < 0.001).

Conclusions

This study reveals that country of residence, maternal education, place of residence, and socio-economic status are key predictors of prompt access to malaria treatment. Achieving universal coverage and the elimination agenda will require effective monitoring to detect disparities early and sustained investments in routine data collection and policy formulation.

Disease mapping for informing targeted health interventions: childhood pneumonia in Bohol, Philippines

BACKGROUND

Acute lower respiratory tract infections (ALRI) are the leading cause of childhood mortality worldwide. Currently, most developing countries assign resources at a district level, and yet District Medical Officers have few tools for directing targeted interventions to high mortality or morbidity areas. Mapping of ALRI at the local level can guide more efficient allocation of resources, coordination of efforts and targeted interventions, which are particularly relevant for health management in resource-scarce settings.

METHODS

An efficacy study of 11-valent pneumococcal vaccine was conducted in six municipalities in the Bohol Province of central Philippines from July 2000 to December 2004. Geocoded under-five pneumonia cases (using WHO classifications) were mapped to create spatial patterns of pneumonia at the local health unit (barangay) level.

RESULTS

There were 2951 children with WHO-defined clinical pneumonia, of whom 1074 were severe or very severely ill, 278 were radiographic, and 219 were hypoxaemic. While most children with pneumonia were from urban barangays, there was a disproportionately higher distribution of severe/very severe pneumonia in rural barangays and the most severe hypoxaemic children were concentrated in the northern barangays most distant from the regional hospital.

CONCLUSIONS

Mapping of ALRI at the local administrative health level can be performed relatively simply. If these principles are applied to routinely collected IMCI classification of disease at the district level in developing countries, such efforts can form the basis for directing public health and healthcare delivery efforts in a targeted manner.

Qualitative assessment of rural health workers' management of malaria in sick children

Background

Febrile illnesses are common causes of morbidity and mortality among under-five children in sub-Saharan Africa. The recommended strategy for effective case management of uncomplicated malaria is parasitological confirmation prior to use of artemisinin-based combination therapy (ACT). There is a lack of qualitative information explaining factors, which influence malaria case management practices among health workers. This study explores the perceptions of health managers and health care providers on the case management of uncomplicated malaria among under-fives in selected primary health care (PHC) facilities of two Local Government Areas (LGAs), Katcha and Gbako, as part of baselines for capacity-building interventions planned in Niger State, Nigeria.

Methods

Interviewees included state- and LGA-level health programme managers, and frontline health workers purposively selected to cover a range of cadres involved in case management of sick children. Issues explored were history taking, diagnosis, appropriate diagnosis of malaria, prescription for malaria, referrals and adherence to referral. Data coding was carried out with Nvivo qualitative software (version 8) and content analysed.

Results

History taking was often not carried out appropriately by the health workers. Treatment of malaria was not based on parasite-based diagnosis. Most of the health workers reported that they prescribed ACTs for treating presumed uncomplicated malaria. Care givers' preferences, poor transportation systems and lack of financial resources led to poor adherence to referral advice. Absence of health workers from their duty post hindered effective service delivery. Prescription of ACTs as a first line of treatment for uncomplicated malaria without a parasite-based diagnosis was the standard case management practice.

Conclusion

Parasite-based diagnosis for malaria will invariably lead to better treatment for non-malaria fever cases among the studied age group. Continuous capacity building aimed at improving adherence to current recommendations on parasite-based diagnosis and good clinical practice would be required to support the paradigm shift to parasite-based diagnosis of malaria.

The effects of utility evaluations, biomedical knowledge and modernization on intention to exclusively use biomedical health facilities among rural households in Mozambique

In resource-limited settings, the choice between utilizing biomedical health services and/or traditional healers is critical to the success of the public health mission. In the literature, this choice has been predicted to be influenced by three major factors: knowledge about biomedical etiologies; cultural modernization; and rational choice. The current study investigated all three of these predicted determinants, applying data from a general household survey conducted in 2010 in Zambézia Province of Mozambique involving 1045 randomly sampled rural households. Overall, more respondents (N = 802) intended to continue to supplement their biomedical healthcare with traditional healer services in comparison with those intending to utilize biomedical care exclusively (N = 243). The findings strongly supported the predicted association between rational utility (measured as satisfaction with the quality of service and results from past care) with the future intention to continue to supplement or utilize biomedical care exclusively. Odds of moving away from supplementation increase by a factor of 2.5 if the respondent reported seeing their condition improve under government/private biomedical care. Odds of staying with supplementation increase by a factor 3.1 if the respondent was satisfied with traditional care and a factor of 16 if the condition had improved under traditional care. Modernization variables (education, income, religion, and Portuguese language skills) were relevant and provided a significant component of the best scientific model. Amount of biomedical knowledge was not a significant predictor of choice. There was a small effect on choice from knowing the limitations of biomedical care. The findings have implications for public healthcare promotion activities in areas where biomedical care is introduced as an alternative to traditional healing.

Are Tanzanian patients attending public facilities or private retailers more likely to adhere to artemisinin-based combination therapy?

Background

Artemisinin combination therapy (ACT) is first-line treatment for malaria in most endemic countries and is increasingly available in the private sector. Most studies on ACT adherence have been conducted in the public sector, with minimal data from private retailers.

Methods

Parallel studies were conducted in Tanzania, in which patients obtaining artemether-lumefantrine (AL) at 40 randomly selected public health facilities and 37 accredited drug dispensing outlets (ADDOs) were visited at home and questioned about doses taken. The effect of sector on adherence, controlling for potential confounders was assessed using logistic regression with a random effect for outlet.

Results

Of 572 health facility patients and 450 ADDO patients, 74.5% (95% CI: 69.8, 78.8) and 69.8% (95% CI: 64.6, 74.5), respectively, completed treatment and 46.0% (95% CI: 40.9, 51.2) and 34.8% (95% CI: 30.1, 39.8) took each dose at the correct time (‘timely completion’). ADDO patients were wealthier, more educated, older, sought care later in the day, and were less likely to test positive for malaria than health facility patients. Controlling for patient characteristics, the adjusted odds of completed treatment and of timely completion for ADDO patients were 0.65 (95% CI: 0.43, 1.00) and 0.69 (95% CI: 0.47, 1.01) times that of health facility patients. Higher socio-economic status was associated with both adherence measures. Higher education was associated with completed treatment (adjusted OR = 1.68, 95% CI: 1.20, 2.36); obtaining AL in the evening was associated with timely completion (adjusted OR = 0.35, 95% CI: 0.19, 0.64). Factors associated with adherence in each sector were examined separately. In both sectors, recalling correct instructions was positively associated with both adherence measures. In health facility patients, but not ADDO patients, taking the first dose of AL at the outlet was associated with timely completion (adjusted OR = 2.11, 95% CI: 1.46, 3.04).

Conclusion

When controlling for patient characteristics, there was some evidence that the adjusted odds of adherence for ADDO patients was lower than that for public health facility patients. Better understanding is needed of which patient care aspects are most important for adherence, including the role of effective provision of advice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0602-x) contains supplementary material, which is available to authorized users.

Strengthening patient-centred communication in rural Ugandan health centres: A theory-driven evaluation within a cluster randomized trial

This article describes a theory-driven evaluation of one component of an intervention to improve the quality of health care at Ugandan public health centres. Patient-centred services have been advocated widely, but such approaches have received little attention in Africa. A cluster randomized trial is evaluating population-level outcomes of an intervention with multiple components, including 'patient-centred services.' A process evaluation was designed within this trial to articulate and evaluate the implementation and programme theories of the intervention. This article evaluates one hypothesized mechanism of change within the programme theory: the impact of the Patient Centred Services component on health-worker communication. The theory-driven approach extended to evaluation of the outcome measures. The study found that the proximal outcome of patient-centred communication was rated 10 percent higher (p < 0.008) by care seekers consulting with the health workers who were at the intervention health centres compared with those at control health centres. This finding will strengthen interpretation of more distal trial outcomes.

Impact of community-based interventions for the prevention and control of malaria on intervention coverage and health outcomes for the prevention and control of malaria

In this paper, we aim to evaluate the effectiveness of community-based interventions (CBIs) for the prevention and management of malaria. We conducted a systematic review and identified 42 studies for inclusion. Twenty-five of the included studies evaluated the impact of the community-based distribution of insecticide-treated nets (ITNs), indoor residual spraying (IRS), or impregnated bed sheets; 14 studies evaluated intermittent preventive therapy (IPT) delivered in community settings; two studies focused on community-based education for malaria prevention; and one study evaluated environmental management through drain cleaning.

Our analysis suggests that, overall, the community-based delivery of interventions to prevent and control malaria resulted in a significant increase in ITNs ownership (RR: 2.16, 95% CI: 1.86, 2.52) and usage (RR: 1.77, 95% CI: 1.48, 2.11). However, usage of ITNs was limited to two-thirds of the population who owned them. Community-based strategies also led to a significant decrease in parasitemia (RR: 0.56, 95% CI: 0.42, 0.74), malaria prevalence (RR: 0.46, 95% CI: 0.29, 0.73), malaria incidence (RR: 0.70, 95% CI: 0.54, 0.90), and anemia prevalence (RR: 0.79, 95% CI: 0.64, 0.97). We found a non-significant impact on splenomegaly, birth outcomes (low birth weight, prematurity, stillbirth/miscarriage), anthropometric measures (stunting, wasting, and underweight), and mortality (all-cause and malaria-specific). The subgroup analysis suggested that community-based distribution of ITNs, impregnated bed sheets and IRS, and IPT are effective strategies. Qualitative synthesis suggests that high coverage could be achieved at a lower cost with the integration of CBIs with existing antenatal care and immunization campaigns. Community-based delivery of interventions to prevent and control malaria are effective strategies to improve coverage and access and reduce malaria burden, however, efforts should also be concerted to prevent over diagnosis and drug resistance.

"We have become doctors for ourselves": motives for malaria self-care among adults in southeastern Tanzania

BACKGROUND

Prompt and appropriate treatment of malaria with effective medicines remains necessary if malaria control goals are to be achieved. The theoretical concepts from self-care and the health belief model were used to examine the motivations for malaria self-care among the adult population.

METHODS

A qualitative study was conducted through eight focus group discussions with adult community members to explore their general opinions, views and perceptions of malaria and of its treatments. These groups were followed by 15 in-depth interviews of participants with a recent malaria experience to allow for an in-depth exploration of their self-care practices. The analysis followed principles of grounded theory and was conducted using Nvivo 9 qualitative data management software.

RESULTS

The self-treatment of malaria at home was found to be a common practice among the study participants. The majority of the participants practiced self-medication with a painkiller as an initial response. The persistence and the worsening of the disease symptoms prompted participants to consider other self-care options. Perceptions that many malaria symptoms are suggestive of other conditions motivated participants to self-refer for malaria test. The accessibility of private laboratory facilities and drug shops motivated their use for malaria tests and for obtaining anti-malarial medicines, respectively. Self-treatment with anti-malarial monotherapy was common, motivated by their perceived effectiveness and availability. The perceived barriers to using the recommended combination treatment, artemether-lumefantrine, were related to the possible side-effects and to uncertainty about their effectiveness, and these doubts motivated some participants to consider self-medication with local herbs. Several factors were mentioned as motivating people for self-care practices. These included poor patient provider relationship, unavailability of medicine and the costs associated with accessing treatments from the health facilities.

CONCLUSIONS

Malaria self-care and self-treatment with anti-malarial monotherapy are common among adults, and are motivated by both individual characteristics and the limitations of the existing health care facilities. There is a need for public health interventions to take into account community perceptions and cultural schemas on malaria self-care practices.

Qualitative study of presumptive treatment of childhood malaria in third tier tertiary hospitals in southeast Nigeria: a focus group and in-depth study

Background

Presumptive treatment of childhood-malaria (PTCM) is common in Nigeria. Delayed laboratory result is blamed, with little attention on patients’ and providers’ roles. This study aimed to determine patient, provider and laboratory attributes that sustain PTCM in Nigeria.

Methods

Data collection was from focus-group discussions for parents/guardians, and in-depth interviews involving providers and laboratory scientists in two tertiary hospitals.

Results

All parents/guardians agreed to a malaria test. Majority accepted to come back later for full treatment, provided that some treatment was commenced. Majority affirmed that their interests are on their children’s improvement.

The providers practice presumptive treatment of childhood malaria, for the following reasons: (1) malaria is endemic and should be suspected and treated; (2) microscopy takes two days to be available and parents want immediate treatment for their children, thus delay may lead to self-medication; (3) relying on results for decision to treat creates an impression of incompetence; (4) rapid diagnostic test kits (RDTs) are not available in the consulting rooms and there is doubt about their reliability; (5) patients have already wasted time before being reviewed, so wasting more time on investigation is not advisable; (6) withhold of malaria treatment may be feasible in suspected uncomplicated malaria, but if severe, then anti-malarial treatment has to start immediately.

Interviews of laboratory scientists showed that (1) malaria microscopy test cannot be urgent; it is done in batches and takes 24 hours to be ready; (2) a request of malaria test with other investigations on the same form, contributes to the delay; (3) RDTs are unavailable in the facilities.

Conclusions

Provision of RDTs is the only feasible means to treatment of confirmed malaria at the time healthcare providers review a patient on day zero. In facilities that depend on microscopy; a common practice in resource poor countries, healthcare providers can depend on parental willingness to return later for full medication, to commence adjunctive care with antipyretics and multivitamins for uncomplicated malaria. In complicated malaria, supportive care - intravenous fluids, blood transfusion, oxygen therapy - can be commenced while awaiting the inclusion of anti-malarial drugs when the diagnosis of malaria is confirmed.

"Even if the test result is negative, they should be able to tell us what is wrong with us": a qualitative study of patient expectations of rapid diagnostic tests for malaria

Background

The debate on rapid diagnostic tests (RDTs) for malaria has begun to shift from whether RDTs should be used, to how and under what circumstances their use can be optimized. This has increased the need for a better understanding of the complexities surrounding the role of RDTs in appropriate treatment of fever. Studies have focused on clinician practices, but few have sought to understand patient perspectives, beyond notions of acceptability.

Methods

This qualitative study aimed to explore patient and caregiver perceptions and experiences of RDTs following a trial to assess the introduction of the tests into routine clinical care at four health facilities in one district in Ghana. Six focus group discussions and one in-depth interview were carried out with those who had received an RDT with a negative test result.

Results

Patients had high expectations of RDTs. They welcomed the tests as aiding clinical diagnoses and as tools that could communicate their problem better than they could, verbally. However, respondents also believed the tests could identify any cause of illness, beyond malaria. Experiences of patients suggested that RDTs were adopted into an existing system where patients are both physically and intellectually removed from diagnostic processes and where clinicians retain authority that supersedes tests and their results. In this situation, patients did not feel able to articulate a demand for test-driven diagnosis.

Conclusions

Improvements in communication between the health worker and patient, particularly to explain the capabilities of the test and management of RDT negative cases, may both manage patient expectations and promote patient demand for test-driven diagnoses.

Aspirations for quality health care in Uganda: How do we get there?

BACKGROUND

Despite significant investments and reforms, health care remains poor for many in Africa. To design an intervention to improve access and quality of health care at health facilities in eastern Uganda, we aimed to understand local priorities for qualities in health care, and factors that enable or prevent these qualities from being enacted.

METHODS

In 2009 to 2010, we carried out 69 in-depth interviews and 6 focus group discussions with 65 health workers at 17 health facilities, and 10 focus group discussions with 113 community members in Tororo District, Uganda.

RESULTS

Health-care workers and seekers valued technical, interpersonal and resource qualities in their aspirations for health care. However, such qualities were frequently not enacted, and our analysis suggests that meeting aspirations required social and financial resources to negotiate various power structures.

CONCLUSIONS

We argue that achieving aspirations for qualities valued in health care will require a genuine reorientation of focus by health workers and their managers toward patients, through renewed respect and support for these providers as professionals.

"Souls of the ancestor that knock us out" and other tales. A qualitative study to identify demand-side factors influencing malaria case management in Cambodia

Background

Appropriate case management of suspected malaria in Cambodia is critical given anti-malarial drug resistance in the region. Improving diagnosis and the use of recommended malarial treatments is a challenge in Cambodia where self-treatment and usage of drug cocktails is widespread, a notable difference from malaria treatment seeking in other countries. This qualitative study adds to the limited evidence base on Cambodian practices, aiming to understand the demand-side factors influencing treatment-seeking behaviour, including the types of home treatments, perceptions of cocktail medicines and reasons for diagnostic testing. The findings may help guide intervention design.

Methods

The study used in-depth interviews (IDIs) (N = 16) and focus group discussions (FGDs) (N = 12) with Cambodian adults from malaria-endemic areas who had experienced malaria fever in the previous two weeks. Data were analysed using NVivo software.

Results

Findings suggest that Cambodians initially treat suspected malaria at home with home remedies and traditional medicines. When seeking treatment outside the home, respondents frequently reported receiving a cocktail of medicines from trusted providers. Cocktails are perceived as less expensive and more effective than full-course, pre-packaged medicines. Barriers to diagnostic testing include a belief in the ability to self-diagnose based on symptoms, cost and reliance on providers to recommend a test. Factors that facilitate testing include recommendation by trusted providers and a belief that anti-malarial treatment for illnesses other than malaria can be harmful.

Conclusions

Treatment-seeking behaviour for malaria in Cambodia is complex, driven by cultural norms, practicalities and episode-related factors. Effective malaria treatment programmes will benefit from interventions and communication materials that leverage these demand-side factors, promoting prompt visits to facilities for suspected malaria and challenging patients’ misconceptions about the effectiveness of cocktails. Given the importance of the patient-provider interaction and the pivotal role that providers play in ensuring the delivery of appropriate malaria care, future research and interventions should also focus on the supply side factors influencing provider behaviour.