Managing malaria in under-fives : Prompt access, adherence to treatment and referral in rural Tanzania

摘要

Background: Nearly a million people die of malaria each year, the majority are children in ruralAfrican settings. These deaths could be reduced if children had prompt access to artemisinin-basedcombination therapy (ACTs), demonstrated adherence to treatment and to referral advice for severemalaria. However, health systems are weak to deliver the interventions. Although many Africancountries, including Tanzania, changed malaria treatment policy to ACTs in the last decade, fewchildren reportedly get prompt access to ACTs.Main aim: To determine factors influencing prompt access to effective antimalarials; adherence totreatment schedules and to referral advice among children under five, in rural settings.Methods: Community-based studies were conducted in rural villages in Kilosa (I,II) and Mtwararural (II,IV) districts, in Tanzania. Study I and II were prospective designed while study III and IVwere nested in a community-based rectal-artesunate deployment intervention study. In study I, atotal of 1,235 children from 12 randomly selected villages were followed up for six months.Caretakers of children reported to have fever were interviewed at home about the type and sourceof treatment using a questionnaire. In study II, all children (3918) in five selected villages werefollowed-up for 12 months, to determine adherence to treatment when they had malaria, diagnosedusing Rapid Diagnostic Test (RDT) and treated with artemether-lumefantrine (ALu). In study III,587 children who received pre-referral rectal artesunate during the deployment study were tracedhome and caretakers interviewed on a number of factors likely to influence adherence to referraladvice, using a questionnaire. Study IV was qualitative, 12 focus group discussions wereconducted in three purposively selected villages to explore reasons for non-adherence to referraladvice.Results: Only one-third (37.6%) of febrile children had prompt access to ALu, the recommendedACTs in Tanzania, mainland (I). Lack of prompt access was mostly (>80 percent) attributed toreceiving non-recommended drugs. Less than half of the febrile children were taken to governmentfacilities, where they were 17-times more likely to have prompt access compared to those whowent elsewhere. Less than 10% (41/607) of febrile children had access to ALu (I) from faith-basedorganisation facilities and accredited drug dispensing outlets, despite having subsidized ALu.Reported adherence to treatment schedules was high (>80 percent) and non-adherence wasattributed mainly to untimely dosing, rather than taking a fewer number of doses (II). While socialeconomic status influenced prompt access to ALu and adherence to treatment, basic education didnot (I, II). Caretakers of children with altered consciousness and convulsion were almost 4-timesmore likely to adhere to referral advice than those whose children had less severe symptoms (III).They seemed to weigh child condition against obstacles to accessing care at health facilities, if thecondition was less severe prior to or improved after rectal artesunate dose, caretakers were likely tobe deterred from adhering to referral advice (IV). Detailed understanding of provider’s advice waslikely to lead to adherence to the treatment schedule (II) and to referral advice (III, IV).Conclusion: This thesis has shown that once a child had access to ALu, caretakers were likely toadhere to treatment schedule; and to referral advice, if child had severe symptoms or not improvedafter pre-referral treatment. More efforts should therefore be directed towards increasing access toALu by strengthening the public health sector to reach rural remote areas. A wide coverage in prompt access to ALu will also reduce the need for the rectal artesunate strategy