Management and Follow-up Practices of Children with Unclassified Fever in Rural Ethiopia: Experiences of Health Extension Workers and Caregivers

Abstract

Different health-care management guidelines by the World Health Organization exist to help health workers in resource-limited settings treat patients. However, for children with unclassified fever and no danger signs, management guidelines are less clear and follow-up recommendations differ. Both a "universal follow-up" for all children, irrespective of health status, and a "conditional follow-up" only for children whose fever persists are recommended in different guidelines. It is unclear how feasible and acceptable these two different follow-up guidelines are among community health workers and caregivers of the sick child. This qualitative study was conducted in Ethiopia and was nested within a cluster-randomized controlled trial (cRCT). It aimed to determine health extension workers' (HEWs') and caregivers' experiences of the management of febrile children and their perceptions of universal versus conditional follow-up recommendations. Seventeen HEWs and 20 caregivers were interviewed. The interviews revealed that HEWs' understanding of how to handle an unclassified fever diagnosis increased with the implementation of the cRCT in both study arms (universal versus conditional follow-up). This enabled HEWs to withhold medicines from children with this condition and avoid referral to health centers. Both follow-up recommendations had perceived advantages, while the universal follow-up provided an opportunity to see the child's health progress, the conditional follow-up advice allowed saving time and costs. The findings suggest that improved awareness of the unclassified fever condition can make HEWs feel more comfortable in managing these febrile children themselves and omitting unnecessary medication. Future community-level management guidelines should provide clearer instructions on managing fever where no malaria, pneumonia, diarrhea, or danger signs are present.

‘I also take part in caring for the sick child’: a qualitative study on fathers’ roles and responsibilities in seeking care for children in Southwest Ethiopia

“…The design and results of this trial are published elsewhere, as is the qualitative evaluation of HEW's and caregivers' perception of the recommendations. [25][26][27] For this study, 24 semistructured interviews were conducted with fathers who had at least one child aged 2-59 months presenting to the HEW with fever. Half of the interviews (n=12) were conducted in Halaba woreda, 8 in Boloso Sore and 4 in Damot Gale.…”

Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in Ethiopia: A cluster-randomised non-inferiority trial

“…Recent studies show that mRDT-negative patients with cough or difficult breathing complaints in Malawi had 16.8 times higher odds of antibiotic overtreatment than mRDT-positive patients [ 41 ]; in Burkina Faso and Uganda both community and health facility workers prescribed antimalarials to mRDT-negative patients if no other fever cause was identified, often due to parental pressure [ 41 , 42 ]. However, when clear case management instructions were provided, as in this study, and non-malaria fever was introduced as a diagnostic term, HEWs felt empowered to withhold medicines, while simultaneously reassuring caregivers that their child was cared for [ 22 ]. This finding is supported by the low number of children in our study who were taken to another provider and provided with secondary treatment after being enrolled by the HEW.…”

“…There are typically 2 HEWs assigned to a health post in a sub-district with a population of 3,000–5,000; they are supported by the Health Development Army, female volunteers who enhance community engagement and encourage use of maternal and newborn health services [ 21 ]. While IMNCI recommends conditional follow-up, HEWs and their supervisors report a range of other practices for children with unclassified fever, including universal follow-up advice, immediate referral to health centres, and treatment with antimalarial tablets [ 22 ].…”

Quality of care provided to sick children in health facilities in Ethiopia: a systematic review

“…The reviewed studies suggested solutions pertinent to the barriers discussed above. Various health systems strengthening, and quality improvement interventions, have been recommended by many studies, ranging from enhanced demand creation to realizing a reliable and consumer-centered service delivery (20,33,36,39,40,42,45,49,54,59,61,64).…”

“…Maintaining a consistent supply of essential drugs, supplies and equipment (49,60), and ensuring a functional referral system (39) were among the speci c solutions suggested to realize quality service delivery to improving health outcomes. Some studies (20,36,40,42) also emphasized the critical role of building the capacity of the health workforce through training, supervision, and availing clinical guidelines and protocols. For instance, iCCM-trained workers provided good quality care (36), and the training of providers also resulted in higher client satisfaction (20).…”