Exploring malaria case mangement of underfive children at households and public primary health care facilities in Kibaha district, Tanzania

Abstract: Background: Chloroquine (CQ) was the first line drug for treating malaria in Tanzania until 2001 when it was replaced with sulfadoxine/pyrimethamine (SP). The first four studies (I -IV) were conducted before the policy change, and the last one (V) after. Aim: To explore different aspects of malaria case management of underfives in households and at primary health care facilities in the Kibaha district. Materials and methods: Four cross-sectional studies (I, II, IV & V) were carried out 1997-2002. Household surveys were conducted before (II) and after (V) the policy shift. Study I used 16 Focus Group Discussions (FGDs), 10 with mothers/guardians of underfives visiting health facilities and 6 with health workers. In study 11, interviews using questionnaires were done with heads of households and mothers/guardians of underfives in 1000 households. Antimalarial drug inventory at 59 drug stores was recorded. Study III in a laboratory experiment, assessed the quality and bioavailability of a sugarcoated CQ and an ordinary CQ brand in 20 healthy adult volunteers using high performance liquid chromatography (HPLC). Study IV was a survey at all 10 public health facilities in the Kibaha district. Mothers/guardians (n=652) with underfives seeking care were interviewed. Capillary blood samples from the children were analysed for CQ using HPLC. The performance of care providers was assessed through observations and the examination of treatment books. In study V, within a year after the policy shift, interviews using questionnaires were done with heads of households and mothers/guardians in 729 households. Capillary blood samples from 336 children were analysed for CQ and SP using HPLC. Twelve FGDs were carried out with mothers/guardians of underfives (4), fathers (4) and health workers (4). Results: Mothers/guardians in most FGDs (1) believed that convulsions (degedege) were caused by "evil spirits" and should be treated by traditional methods such as urinating on the sick child or fuming with elephant dung smoke. Grandmothers and traditional healers were stated first contact for care. CQ was stocked in one third of the households and drug stores were stated main source of antimalarials (11). No significant difference was found in the pharmacokinetic parameters between the two selected CQ formulations (III). In the facility survey (IV), mothers/guardians reported providing home treatment for their children with antipyretics (57%) and/or CQ (22%). Average consultation time was 3.8 minutes and 61% were not physically examined. Whereas 71 % were diagnosed with malaria, only 38% had detectable malaria parasites. Ninety seven percent of all the children had detectable CQ blood levels prior to the consultation. The post policy shift household survey (V) revealed a high awareness of SP being the first line drug, but low stocking of antimalarials (10%). The majority of mothers/guardians (76%) stated seeking care in public facilities and obtaining SP. SP and CQ drug levels from underfives reported to seek care within 4 weeks were 32% and 6% respectively. Few mothers/guardians of underfives knew the correct paediatric dose regimen of SP. Negative perceptions of SP were common and especially mothers/guardians and fathers expressed fear of adverse reactions stating mass media as key informants. Conclusion: Major changes in drug stocking, self-treatment and care seeking were noted in household surveys conducted before and after the policy shift. Both households and facilities need to be included in multi-faceted interventions for improved malaria care. Both perceptions about degedege and where SP should be made available are critical issues.