Impact of home-based management on malaria outcome in under-fives presenting in a tertiary health institution in Nigeria

Abstract

BackgroundHome-based management of malaria involves prompt delivery of effective malaria treatment at the community by untrained caregiver. The aim of this study was to document home-based treatment of suspected malaria by non-medical caregivers and to identify its health impact on malaria outcome (severe malaria prevalence, parasite load and mortality) in children (6–59 months).MethodsA descriptive cross-sectional study carried out from June 2012–July 2013. Data was obtained by researcher-administered questionnaire and malaria was confirmed in each child by microscopy. Analysis was by Statistical Package for Scientific Solutions version 16.ResultsOf the 290 caregivers (31.2 ± 6.1 years)/child (21.3 ± 14.4 months) pairs recruited, 222 (76.6%) caregivers managed malaria at home before presenting their children to hospital. Majority (99.0%) practiced inappropriate home-based malaria treatment. While only 35 (15.8%) caregivers used the recommended artemisinin-based combination therapy, most others used paracetamol either solely or in combination with anti-malarial monotherapy [153 (69.0%)]. There was no significant difference in mean [±] parasites count (2055.71 ± 1655.06/µL) of children who received home-based treatment and those who did not (2405.27 ± 1905.77/µL) (t = 1.02, p = 0.31). Prevalence of severe malaria in this study was 111 (38.3%), which was statistically significantly higher in children who received home-based malaria treatment [90.0%] (χ2 = 18.4, OR 4.2, p = 0.00). The mortality rate was 62 per 1000 and all the children that died received home-based treatment (p < 0.001). While low socio-economic class was the significant predictor of prevalence of severe malaria (β = 0.90, OR 2.5, p = 0.00), late presentation significantly predicted mortality (β = 1.87, OR 6.5, p = 0.02).ConclusionsThe expected benefits of home-based management of malaria in under-fives were undermined by inappropriate treatment practices by the caregivers leading to high incidence of severe malaria and mortality.

Effect of health seeking behaviour of caregivers on severe malaria outcome in under-fives seen in a tertiary health institution in Nigeria

“…[14][15][16] Due to this, the choice for alternative care outside health facilities is high among the lower social class hence the high patronage of the PMVs as the first line healthcare provider as observed in this study. 8,13 The fact that level of education was not significantly associated with HSB suggests that economic power could be a major factor in the decision to visit PMVs as the first health care provider than to go to the health centres/ hospitals which in most cases cost more.…”

“…8,13 Although the close-to-client phenomenon of the PMVs could be a major factor warranting the first point of visit during illnesses at the community level; however, some poor practices of these PMVs contribute significantly to poor disease outcome. [8][9][10][11][12]13 Figure 1 Symptoms of severe malaria as volunteered by the caregivers There were multiple responses and features at presentation* Figure 2 Features of severe malaria identified by the physician There were multiple responses and features at presentation* For example, studies have shown that the prescription pattern of antimalarial drugs, especially for paediatric age groups by the PMVs is poor and most times inaccurate. 24 Etiaba et al 12 recently documented that the first line visit of most caregivers to the PMVs contributed significantly to wrong diagnosis, inability to detect malaria co-morbidities, worsening of malaria morbidities; and perhaps increased mortality.…”

“…[4][5][6][7] Recent hospital-based study in Benin City Nigeria showed that the prevalence rate of severe malaria is 38.3% with a mortality rate of 60 per 1000. 8 In Nigeria, the National Malaria Elimination Program (NMEP) has instituted some strategic plans to educate caregivers through a compre-hensive malaria control programme from the Federal to the communities at the Local Government level. 10 These programmes included long-lasting insecticide-treated nets (LLIN) campaign, training and re-training of healthcare providers on case management of malaria, and step-down Advocacy Communication and Social Mobilization (ACSM) strategy for malaria control at the community level.…”

“…[3][4][5] Some studies in Nigeria and other malaria endemic regions have shown that majority of households initially visit the patent medicine vendors (PMVs) and other sources for treatment (including neighbours) for simple acute malaria, before finally attending a health facility for proper management. 8,[11][12][13] This finding could be attributed to the close-to-client operation of the PMVs (being available virtually in every community and their operation is as close as possible to the homes of patients/ caregivers). Severe malaria, on the other hand, is a medical emergency and requires prompt evaluation and treatment in a well-organised health facility.…”

“…In under-fives, a delay in accessing treatment for malaria beyond 48 hours from the onset of symptoms usually progresses to severe morbidity and increases fatality. 8 To reduce the malaria burden, the World Health Organization (WHO) recommends home treatment of uncomplicated malaria with the recommended antimalarial drugs within 24 hours of the onset of symptoms or seeking for prompt treatment in a health facility within 24 hours of onset severe malaria symptoms. 1,2 The management of severe malaria remains challenging in most malaria endemic regions.…”