Responses of caregivers to children under the age of five with fever and living where malaria is endemic.

Responses of caregivers to children under the age of five with fever and living where malaria is endemic.

 

Information Source

This Best Practice information sheet has been derived from a systematic review of research conducted by the College of Medicine, Malaria Alert Centre, Malawi and the Joanna Briggs Institute Evidence Synthesis Group: Malaria Alert Centre (2) The systematic review report is available from the Joanna Briggs Institute www.joannabriggs.edu.au

Background

The tropical parasitic disease malaria, kills more people than any other communicable diseases except AIDS and tuberculosis. (3) It constitutes a public health problem in more than 90 countries inhabited by a total of 2.4 billion people, or approximately 40% of the world's population. (4)

The WHO estimates that between 350 and 500 million clinical episodes of malaria occur each year and result in a million deaths. 5 More than 90% of malaria morbidity and mortality occurs in sub-Saharan Africa where almost all malaria related deaths occur in children under the age of five. (6)

Early diagnosis and treatment is recommended (7) and African leaders have committed to ensuring 80% of fever episodes in children are adequately treated within 24 hours of onset of symptoms by 2010. (8)

However, efforts to improve access to prompt and effective treatment requires an understanding of the social, cultural, economic and behavioural factors which can interact in complex ways and support or impede caregivers' responses to children with fever. (9)

Objectives

The purpose of this Best Practice Information Sheet is identify important social/cultural, economic and behavioural factors that can positively or negatively influence the responses of caregivers/ parents to children under the age of five with fever.

Types of Participants

Caregivers to children under the age of five with fever.

Phenomena of interest

Caregivers' responses to fever in children under the age of five.

Types of outcome measures

Types of outcome considered in the review included: early treatment seekers/late treatment seekers.

Quality of the research

All included papers were assessed by two independent researchers. Evaluation criteria included congruity between philosophical perspective and research methodology; appropriateness between methodology and research question; an agreement between methodology and data analysis; connection between research methodology and interpretation of the results; precise location of the researcher; influence of the researcher on the research stated; participants voices adequately presented and ethics.

A total of 62 articles relevant to the study were retrieved of which 22 were included. All studies bar one were conducted in Africa and approximately 4000 individuals were involved in the included studies. Of the 22 studies included, only 12 papers were purely qualitative in nature. The remainder used a combination of qualitative and quantitative methods, however only the qualitative information was analysed.

A total of 217 findings were drawn from the included studies. Levels of evidence were indicated for the findings retrieved from the original research reports and all were either credible or non-equivocal.

Findings

The first synthesised finding was that the "Majority of caregivers have reasonable knowledge of cause, symptoms and danger signs of malaria. However, various forms of treatment were practiced and had corresponding diverse health seeking behaviours." This synthesized finding was generated from the following categories:

Perceived severity of illness and duration of sickness

Caregivers' responses depended on how they classified the condition of the child, such as not serious or serious, and on onset of the illness i.e. whether it was sudden or gradual. The stage at which a particular action was taken depended also on the perception of the level of severity of the malaria. Therefore, caregivers went to a hospital for immediate treatment more often for perceived serious cases than for mild illnesses.

Perception about causes of fever illness and its interpretation

In Gabon, Pilkington et al (2004) reported that mothers provided home treatment and/ or drugs from a health facility, if the caretaker judged a child's illness was caused by "natural" fever. However, if the caregiver concluded that the fever was due to malicious intent, then Nganga (spiritual healer) was consulted first. Some caregivers believed that a strong and persistent fever was caused by the "supernatural". In the case of a supernatural fever, traditional treatment was thought to be best and would consequently be sought first.

Perceived quality of provider

Some caregivers believed that only a doctor could cure malaria and that western medicine was the optimal remedy for malaria. Some elements of perceived quality were the nature of the examination, whether the provider asked questions, touched the child, and used instruments. Also, lack of respect shown to caregivers by the general hospital staff, corruption, bribes and abuse of patients, and poor staff attitudes appeared to discourage caregivers from seeking care at a clinic.

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Availability of drugs and appropriate medication

Women who wanted to visit a health facility with a sick child would resort to self treatment if there were no drugs or the health facility did not provide appropriate medicine. In some instances caregivers felt unmotivated to visit a health facility when they realized that they were given tablets instead of the preferred injections.

Fear of injections

Concerns about giving injectable drugs to a convulsing child were raised by some caregivers. Mothers reported witnessing several incidences where a child with fever episode died after getting an injection and concluded that giving injections to a convulsing child was homicidal.

Decision making processes

Women are often the first to recognize illness in a child. However, mothers may be delayed or fail to seek appropriate treatment because ultimate decisionmaking responsibility, along with control of finances, may lie outside their influence. If mothers did not have the financial resources, they often had to receive permission and/or money from their spouse to seek care outside the home.

The second synthesised finding was that "A combination of factors interacts in complex ways to influence positively and negatively caregiver's responses to fever episodes in children." This synthesised finding was supported by (5) categories as described and illustrated below:

Limited access to health services

Lack of health facilities, private dispensaries, drug shops or pharmacies situated within villages and lack of shops stocking and selling antimalarials all limited access to prompt treatment of fever in children and promoted use of anti-pyretic/ analgesics only, obliged caregivers to resort to a traditional healer for help or self medicate using herbs.

Economic barriers

The economic barrier of seeking care was frequently raised to explain the reasons for self treatment and delays in accessing biomedical treatment. Such barriers were cost for treatment, doctor's fee, user charges or health facility fees and/or cost of travel to the health centre. Caregivers also worried about the expected cost of antimalarials from shops and drug vendors when none were available from the hospital.

Distance to health facilities

Another element that caused delays in accessing treatment for fever was distance. When hospitals were available many people complained that they were too far from their communities, for example 14-31 Kilometres. Sometimes parents would seek advice from other community members to avoid paying the cost of travelling.

Transport to health facilities

The absence of and/or inaccessibility of roads during the rainy season, general poor road conditions year round, lack of any type of transport and infrequent public transport services discouraged the use of local health facilities and contributed to people preferring self treatment of an illness.

Night time

Another significant barrier of caregiver's delivering a sick child to a health clinic was fear of darkness. Fear of wild animals and unspecified dangers after sunset" were limiting factor to seeking prompt care until the next morning. If facilities were within reach, they would rush to the facility in the night. Otherwise caregivers would wait till day break while neighbors provided support in terms of drugs, advice and reassurance during night time hours.

The synthesised findings were used to generate a summary of the care givers' responses and health seeking behaviours (Figure 1).

Conclusion

In areas where malaria is endemic, most cases of fevers are managed outside the formal health sector either in the homes or community. Caregivers, (generally parents, most often the mothers) are pivotal and play a critical role in provision of medical care for children with fevers.

Responses of caregivers to fever in children under the age of five years are multiple but can broadly be categorised into two groups depending on the how soon after fever onset caregivers seek treatment for their children: early treatment seekers and late treatment seekers. Within each group, the specific actions taken by caregivers are variable and dynamic and commonly do not lead to the child with fever illness getting prompt and effective antimalarial treatment. Numerous social, cultural and economic factors interact in complex ways and influence caregivers' responses to children with fever.

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Acknowledgments

This Best Practice information sheet was developed by the Joanna Briggs Institute.

References

(1.) The Joanna Briggs Institute. Systematic reviews the review process, Levels of evidence. Accessed on-line 2009 http://www.joannabriggs.edu.au/pubs/approach.php#B

(2.) Chinkhumba, J. & Chibwana A, Responses of caregivers to children under the age of five with fever and living in areas where malaria is endemic: a systematic review of qualitative studies. Joanna Briggs Institute Library of Systematic Reviews, 2010; 8 (13): 520-588.

(3.) http://www.who.int/vaccine_research/diseases/soa_parasitic/en/index4.html

(4.) WHO Fact sheet No. 94 Revised October 1998, World Health Organisation, Geneva

(5.) World Health Organisation's World Malaria Report 2005

(6.) http://www.theglobal fund.org/en/files/about/replenishment/disease_report_malaria_en.pdf

(7.) Okenu, DMN. Malaria and Infectious Diseases in Africa 10:4-13, 1999

(8.) WHO/RBM In: Global strategic plan 2005-2015. World Health Organisation/Roll Back Malaria Partnerships; 2005.

(9.) Hetzel MW, Iteba N, Makemba, A, Mshanea C et al. Malaria J. 2007: 6;83.

(10.) Pearson A, Wiechula R, Court A, Lockwood C. The JBI model of evidence-based healthcare. Int J of Evid Based Healthc 2005; 3(8):207-215.

Recommendations

* Social and cultural factors that impact on health seeking behaviour vary from country to country and, within a country, from region to region depending culture. (Grade B)

* There is a need therefore to design context specific behaviour change communication messages that incorporate prevailing local terminologies and address important cultural and social issues that negatively influence health seeking behaviour. (Grade A)

* There is also need for multi sectoral approaches to addressing the multiple barriers that limit access to prompt and effective fever treatment in children. (Grade A)

* Finally there is need for paradigm shift and cultivation of new effective partnership with other care providers such as traditional healers, vendors and shop keepers within the context promoting access to early and effective antimalarial treatment for children. (Grade A)

Grades of Recommendation

These Grades of Recommendation have been based on the JBI-developed 2006 Grades of Effectiveness (1)

Grade A Strong support that merits application

Grade B Moderate support that warrants consideration of application

Grade C Not supported