Home Management of Fever in Children in Zomba, Malawi

Abstract

Objective

To describe health-seeking behaviours of caregivers of children with fever

Design

Cross-sectional descriptive study using structured and semi-structured questions

Setting

Urban and rural areas of Zomba district, Southern Malawi

Main Outcome Measures

Caregiver knowledge, behavior and practices regarding childhood febrile illness. Results: A questionnaire was administered to 510 heads of household who had treated a child aged £12 years for fever in the previous two weeks. Children treated at home received care more rapidly than those seeking care at a health center. Overall, 37.3% of febrile children received an antimalarial for treatment. When asked what should be done for a child with fever, 74.9% of respondents recommended a form of home treatment, while 23.0% said to go to a health center. Only 28.5% of respondents knew of an effective method of preventing malaria.

Conclusion

To achieve the goal of prompt and effective care for malaria, education concerning practical methods of malaria treatment and prevention is needed, especially in areas where health care is inaccessible and unaffordable.

Introduction

Despite prevention methods and improved drug treatments, malaria continues to cause frequent illness and deaths in Malawian children. Prompt and appropriate treatment of childhood fever has been established as the key to successful case management in countries with endemic malaria, and the success of this approach lies in the behavior of the caregiver.

Due to economie, geographic, and other limitations, home medication is often the first line of treatment in childhood illness in Malawi. In urban and rural areas, groceries and shops sell basic medicines at inexpensive prices, and these drugs are often purchased for use at home. The Ministry of Health of the Government of Malawi encourages self-treatment, and advises that fevers without another identifiable cause be treated as malaria if accompanied by one of the following symptoms: headache, chills, shivering, or loss of appetite.¹ In the absence of laboratory diagnostics, the World Health Organization advises treatment for malaria to be given to all children suffering fever of unknown cause in areas of stable transmission of malaria.² When the gaps in caregiver knowledge are identified, the Ministry of Health and other organizations working in Malawi to lessen the burden of malaria will be equipped to appropriately educate caregivers about home medication.

This study is assumed to accurately represent fever treatment behavior in Malawi as a whole. Zomba District has generally similar characteristics as the whole Malawi, such as levels of education, infant mortality, and frequency of fever in children.³ The objectives of this study were to define the demographics of the study population, determine what treatments are being used for fever at home and in health care centers, describe caregiver action when confronted with childhood fever, and characterize caregiver's knowledge about malaria and its prevention.

Methods

This study was conducted in Zomba District during the rainy and late-rainy season, 2002. Information from the 1998 Malawi Population and Housing Census and maps from the Malawi National Statistics Office were used to identify areas for survey. Two urban and 15 rural clusters stratified by population density were randomly selected in enumeration areas within five of Zomba District's seven traditional authorities. In each cluster 30 households were identified and a total of 510 caregivers were surveyed. The interviewer, a translater, and a local health official questioned heads of household in a door-to-door manner.

Logistic regression was used to investigate the influence of symptoms on caregiver response. Odds ratios and confidence intervals were calculated using SPSS. A p-value of less than 0.05 was considered significant. Statistical significance was assessed using Pearsons X² test for binary and categorical data and Mann Whitney U for continuous non-parametric variables.

Results

The average age of the febrile child was 3.4 years, and the average age of the caregiver responding to the survey was 29 years. Women accounted for 96.8% of caregivers. According to caregiver report of children whose illness had concluded at the time of survey, the average duration of fever was 4.1 days. In addition to fever, 88.2% of children had one or more additional symptoms, most commonly nausea/vomiting, chills, lack of eating/fussy, and diarrhea.

Initial Responses to Fever Most caregivers (92.7%) chose to give medicine to treat childhood fever, either at home or at the health care center (Table 1).

Table 1.

Initial response to fever

Gave medicine at home	n=234	45.9%
Health care center	227	44.5
Gave herbs	15	2.9
Sponged/bathed child	14	2.7
Nothing	10	2.0
Traditional healer	7	1.4
Other	3	0.6

Children treated at home received treatment more rapidly than those who were given treatment at a health care center (p≤0.001). In total, 37.3% of all febrile children received an antimalarial during the first caregiver action in response to fever. At health care centers, febrile children were more likely to receive the recommended treatment of an antipyretic and SP (sulfadoxine-pyrimethamine) than children medicated at home (41.9% and 16.2%, X²=55.75, p≤0.001). Seizures or loss of consciousness were observed in 10.2% of children with fever, and these children were not more likely to be taken to the health care center than other children in the study (Odds ratio [OR] 0.94, 95% confidence interval [CI]: 0.77, 1.15). The younger the febrile child, the more likely he or she was to be taken to the health center (p=0.008).

Of the 510 caregivers surveyed, 89 (17.5%) of the febrile chilren had received an antimalarial the first day fever was noticed. Aspirin was the most commonly used antipyretic at home and in health care centers (Table 2).

Table 2.

Characteristics of Home vs. Health Care

		Home care	Health care	Total*
		(n=234)	(n=227)	(n=510)
Medicines	Antimalarial (SP)	24.4% (21.4)	58.6 (47.5)	37.3 (31.0)
received-initial	Antipyretic (Aspirin)	54.5 (50.9)	66.5 (54.2)	65.3 (47.5)
treatment	SP and antipyretic	16.2	41.9	25.7
	Antimalarial and antipyretic	16.6	44.9	27.6
	Antibiotic	15.8	11.5	12.4
Days after	Same day	68.4	36.1	53.2
symptoms	Next day	23.9	47.1	35.5
noticed until	2–4 days	5.0	11.0	8.9
treatment given	5+ days	0.9	2.6	2.3

^*Includes all children, not only those treated at home or health care centers. 5.5% of respondents did not know what kind of medicine they gave/child received

Treatment at home Only 24.4% of those treated at home received an antimalarial during the first action by the caregiver. Aspirin was given to 50.9% of febrile children treated at home, and 26.5% were given aspirin only. Of the 234 respondents who gave medicine at home, 37 (15.8%) gave an antibiotic.

Of those who medicated at home, 88.5% acquired medicine at a shop, while 10.6% had saved the medicine from a previous illness. Of those who bought medicine at a grocery or shop, their average distance of travel (by foot) to acquire medicine was less than 15 minutes. Only 22.2% of people who gave medicine at home checked to see if the medicine was expired.

Treatment at health care centers Of the respondents who sought treatment at health care centers, 78.4% of caregivers were told by an employee of the formal health care system that their child was suffering from a malaria or cerebral malaria (Table 3). Of the total children diagnosed with malaria (clinically or by laboratory test, not including those diagnosed with cerebral malaria), only 48.3% were given an antipyretic and antimalarial.

Table 3.

Antimalarials received at health care centers

			Percent received antimalarial*
Results of	Positive	(n=38)	73.3%
malaria test	Negative	(n=1)	100
(n=227)	No test	(n=187)	55.6
Caregiver	Cerebral malaria	(n=10)	80.0
report of	Not told diagnosis	(n=36)	27.8
diagnosis by	Other (not malaria)	(n=13)	7.8
health care	Malaria	(n=168)	74.0
worker
(n=227)

^*5.5% of total respondents did not know what kind of medicine they gave/child received

Of the 157 children diagnosed with only malaria, 19 (12.1%) received only an antibiotic. Medical personnel did not attend to 4.4% of those who sought care because the health center was out of medicine or the caregiver was turned away due to lack of a health profile (A health profile is a card recording a child's medical history that must be purchased by the child's caregiver).

Those who chose treatment at a free, government health care center traveled (on foot) an average of 1.8 hours to receive care. Knowledge and Prevention Malaria was well known in the areas surveyed. While 15.3% of respondents believed that cold weather was the cause of malaria and 14.5% did not know the cause, the majority (67.1%) believed that mosquitoes were a cause or carriers of malaria (Table 4).

Table 4.

Knowledge and prevention of malaria by education level

		Level of education
	None	1–4	5–8	More	Total
		(n=128)	years	years	than 9	(n=510)
			(n=139)	(n=203)	years
					(n=40)
Prevention
	Knew of effective method	13.3%	23.7	35	50	28.5
	Used effective method	10	19.4	30	50	23.7
	Named nets as prevention	13.3	20.1	33	50	25.7
	method
Used nets at home	6.3	12.9	21.2	40	16.7
Knowledge
	Believes mosquitoes cause	53.1	61.2	75.4	90	67.1
	malaria
	Believes cold weather causes	21.3	21.6	8.8	10	15.3
	malaria
Did not know cause of	20.3	16.5	11.8	2.5	14.5
malaria

Mothers who knew that seizures or loss of consciousness could be caused by malaria or high fever numbered 51.6%. Most respondents (82.0%) stated that they learned the most about malaria from their local health care center or community health care worker, while 16.3% responded that they had never learned about malaria.

Only 28.5% of respondents knew of an effective method to prevent malaria, such as bed nets (25.7%), covering up with clothing at night (2.0%), and repellant or sprays (0. 8%). Good household hygiëne was the most common method used for preventing malaria (50.3%). Slashing grass around households, keeping children warm, and feeding children clean food and water were common practices used to prevent malaria at home. Bed nets were used in the homes of 16.7% of the caregivers surveyed.

Practices of Home Medication When asked what a mother should do if a child has fever, most mothers (74.9%) feit that some form of home care was most appropriate (Table 5).

Table 5.

Home medication practices

What should a parent do if	Sponge/bathe child	49.3%
his/her child has a fever?*	Give medicine	30.6
	Go to the health care center	23.0
	Give herbs/trad healer	3.7
	Keep child warm	1.2
Do you have medicine to treat malaria
in your home for future use?	No	90.6
	Yes	9.4

^*More than one answer allowed

When asked what a parent should do if a child has seizures or loss of consciousness, 54.5% replied that they should go to the health care center.

The most common reason for not seeking care at a health care center was that the caregiver wanted to treat children at home (30.9%) or stated that health center care was too expensive (29.0%). Of those who chose not to give medicine upon noticing fever, many were deterred by the cost of accessing health care (25.0%) or a closed health center (19.4%). Of those who did nothing in response to a child's fever, the most common reason for lack of action was that any action was too expensive.

Discussion

Caregiver behavior: determining where and when to seek care The limited amount of money a caregiver can spend is a determinant of both home and health center care; some respondents who went to the health care center stated that they did so because they did not have enough money to buy medicine, while some who bought medicine said they did so because they did not have enough money to go to the health care center. Lack of incentive, health center reputation, and inconvenience also influence caregivers' decisions. As one respondent commented,

“I didn't think of going to the hospital. My friends discouraged mefrom going to the hospital because you will only get aspirin there and they are scarce of medicine…Sometimes laziness is a reason I don't go to the health care center.”

The symptoms that caregivers believe are severe often determine their actions. In this study, seizures or loss of consciousness did not prompt caregivers to seek formal health care for their children any more often than less severe symptoms. Similarly, many caregivers believe that a particular symptom, measure of severity, or the length of illness indicate a need for formal health care.

“I give herbs and if there is no improvement after three days I go to the health center. Or, it is too long ifthe baby still refuses food after two days, so I go to the health center.”

Caregivers who did not have health profiles for children were deterred from seeking care. Health profiles are important for recording a child's medical history; however, lacking a health profile should not result in the denial of care as it does in some areas of Zomba district. Ministry of Health policy states that children should be treated regardless of whether the patiënt provides a health profile.

Drug choice Although most caregivers believe that Western medicine is effective for treating fever, most have little education concerning medicines. Most caregivers believe that giving any kind of pill or injection will treat an illness. Therefore, most people surveyed did not differentiate between kinds or amounts of medicine, and were unaware of whether they were treating symptoms (as in Panadol for a fever) or the disease itself (as in SP for malaria). As exemplified by one caregiver,

“I gave aspirin to my child because aspirin is medicine.”

The cheapest and most widely available drug, aspirin, lowers fever but does not eradicate malaria parasites from the body, and can cause a rare but serious disease called Reye's syndrome when given to children.⁴

Knowledge and prevention In many areas there are persisting beliefs that activities such as eliminating standing water, good household hygiëne, and slashing grass around the household prevents malaria. Respondents stated that they received this information from malaria education programs at health centers, given by health center employees and health surveillance assistants (HSAs). Although these practices are important for other public health reasons, they do not prevent malaria. Few caregivers are aware of specific practices that prevent malaria.

Bed nets are not widely known as a method of preventing malaria. Insecticide treated mosquito nets, insect sprays, and coils require frequent spending; in most areas of rural Malawi it is unlikely that malaria prevention is a financial priority, particularly during malaria season, which often occurs during periods of drought and famine. In order for malaria prevention measures to reach poverty-affected populations, affordable means of prevention must be available.

Improving home medication in Malawi Presently, many cases of childhood fever are treated inappropriately whether the caregiver seeks care at a health care center or treats a child at home. Giving medicine at home is more convenient for some, while for others it is the only realistic option for adequate or timely care. By educating the community and caregivers about appropriate home-medication, the rapid and effective treatment of fever will reduce childhood illness and death due to malaria.

A large portion of the caregiving population utilizes under five clinics at health care centers, and education of caregivers regarding home medication through existing channels is possible. Information regarding the following subjects needs to be clarified and disseminated to caregivers throughout Malawi: 1) Knowledge regarding recommended treatments for fever, consistent with Ministry of Health advising, 2) Signs and symptoms of severe or complicated illnesses that require formal medical care, and 3) Appropriate use of basic drugs such as aspirin, Panadol and other antipyretics, antibiotics, ORS, SP, etc.

Health employees need updated information and resources in the form of information sessions at their regular meetings, and if possible, a manual for reference purposes. This group should review under five clinic education points listed above for caregivers and methods of effective malaria prevention.⁵ Improved communication between the Ministry of Health, District Health Offices, and HSAs is required to ensure that programs carried out are'consistent with national policies. Additional methods of information dissemination such as public announcements and community activities would also improve knowledge about home medication, and could be undertaken by the Ministry of Health or health NGO's.

These data show that the same numbers of people are seeking medicine at shops and health centers; therefore to neglect the education of shopkeepers is to ignore half of the source of drugs used to treat fever. Shopkeepers and grocery workers selling medicine in communities should be trained in the same manner as community health workers or HSAs. The Ministry of Health does not currently possess the financial resources to undertake these trainings; however, donor organizations or NGO's active in malaria prevention and treatment could collaborate with the government to conduct this program. In Zomba District, a brief but very successful training of a small amount of rural shopkeepers was conducted in the past.⁶ Shopkeepers in other countries of endemic malaria in sub-Saharan Africa have been successfully trained and have reduced morbidity and mortality of malaria by advising customers appropriately.⁷

In the absence of resources to formally train shopkeepers, the formal invitation of shopkeepers to join health committees or decision-making bodies at the village level will encourage new cooperation between communities and shopkeepers. The sharing of infomiation from HSA to grocery worker (information about drugs, their uses, and symptoms that require formal health care) and from grocery worker to HSA (trends in home medication and usual practices) could lead to improved home medication as well as increased communication between the government health system and the public. This partnership should be initiated by local HSA's or village leadership, and encouraged by the Ministry of Health and District Health Offices.

Thorough and repeated training of caregivers, shopkeepers and government health employees will result in a decreased caseload of already overburdened health care centers and improved treatment of malaria in Malawi.

Note: The term ‘health care center’ is used to describe any formal health care facility such as health post, under five clinic, hospital, etc.