Management of febrile children under five years in hospitals and health centres of rural Ghana

After several decades of presumptive treatment of febrile children for malaria in moderate to high transmission areas, a new global policy was introduced in 2010 for the parasitological diagnosis of malaria [1]. The confirmation of diagnosis of malaria must be implemented within the broader diagnosis and treatment of febrile illness as part of the Integrated Management of Childhood Illness (IMCI) [2‐4]. The IMCI diagnostic algorithm provides a step-by-step approach to the clinical assessment of a febrile child based on danger signs, symptoms and clinical examinations. The IMCI clinical assessment algorithm has however been poorly implemented in many countries [5‐7].

Once a febrile child has been diagnosed, they must be given appropriate treatment for the condition diagnosed and the carer should be given clear instructions on administration of the treatment. Currently the treatment for malaria defined by the national guidelines in sub-Saharan Africa is an artemisinin combination therapy (ACT). All commonly used artemisinin-based combinations, including artesunate-amodiaquine (ASAQ) and artemether lumefantrine (AL), even where the first dose of the treatment is given under observation within the health facility, require further doses to be taken at home. Effective treatment therefore requires that the carer understands, remembers and adheres to instructions on how the treatment should be administered to the child.

Whilst the increased access to rapid diagnostic tests (RDTs) has improved the diagnosis of malaria, the differential diagnoses of other childhood febrile illnesses have not advanced. These depend on robust assessment and interpretation of clinical symptoms and signs and therefore rely on the skills of the clinician. However the clinical assessment of febrile children is often incomplete [8]. This lack of reliable differential diagnoses of febrile illnesses has prompted the concern that the use of RDTs for malaria, whilst decreasing the over-administration of anti-malarials, would result in increased use of antibiotics in children found to be negative for malaria parasites [9]. This has been shown to be the case in several study settings [10‐14].

In this study, the case management of febrile children in hospitals and health centres was compared using a health system’s effectiveness algorithm. This system’s effectiveness analysis measures the cumulative effectiveness of all processes and the effectiveness of individual processes in the delivery of case management of febrile children. Adherence and the predictors of adherence to treatment guidelines where children are presumptively and parasitologically diagnosed for malaria are compared. This study was undertaken pre-roll out of the new policy on parasitological diagnosis of malaria and therefore provides a baseline against which future studies on diagnosis and treatment behaviours may be assessed. However, without an assured supply of RDTs, these findings may also be applicable to the programmatic context for long or short periods of time until product supply management chains and sustained funding can be strengthened.

In this study, the treatment of febrile children with anti-malarials and antibiotics was described based upon clinical and parasitological diagnosis comparing with and contrasting those attending hospitals from those attending health centres.

The study had several limitations. Whilst majority of the data was taken from structured exit interviews with carers of febrile children, some of the data including that of presenting symptoms and examinations conducted were based on structured observations. It is possible that both health workers and carers of children may have changed their behaviours because they were being observed. Such Hawthorne effects are well documented [17, 18]. It was assumed that the behaviours observed here were ‘best behaviours’ of both the health workers and the carers. As the cumulative system’s effectiveness was rather low in the hospitals and health centres, any positive change in behaviour due to Hawthorne effect was assumed to be minimal. The enrolment of children and their carers was based upon the number of observations and interviews that can be conducted per day by the available number of field workers and the selection of children were not random. The time of attendance was not, however, a significant predictor in univariate analyses of receiving an ACT, an antibiotic or of the carer knowing how to administer antibiotics and therefore did not impact on the study findings. A stock-take of ACT and antibiotics was not conducted on the day of the survey in each health facility and this may have impacted on the study findings [19]. However, all hospitals and health facilities had ASAQ or AL in stock on the day of the health facility audit and these audits were undertaken immediately prior to the collection of observation and exit interview data. The cadre of health worker conducting both history and vital signs and doing consultation was recorded; however the individual health worker was not. This was a limitation to the inclusion of further health worker characteristics other than cadre, which was a predictor of all three outcomes.

Although having a positive malaria test was associated with receiving an ACT, one-third of children parasite positive in hospitals were not given an ACT and two-thirds of these children with confirmed malaria who were not given an ACT were given amodiaquine monotherapy. One possibility for this practice may be the relative ease of administering a suspension to children as compared to a tablet. Often, even in studies, artesunate-amodiaquine tablets are crushed in sugared syrup to ease administration to children [20] and in the programmatic setting this would require the availability of such a syrup. More than 10% of children given an ACT in health centres were also given quinine and in hospitals this proportion was approaching 20%. Further studies particularly qualitative studies are needed to explain and understand this practice of giving amodiaquine monotherapy in this setting and of giving quinine alongside ACT.

A rationale for the introduction of malaria test-based management of febrile children is that this will reduce over treatment with ACT. In this study setting based on the use of microscopy, this was found to be true. It is also the case that a greater proportion of those found to be positive for malaria parasites were given an ACT than those who were found to be negative. However, there is still considerable effort needed to convince clinicians to adhere to recommendations for negative test results. These behaviours, however, were in response to parasitological testing with microscopy rather than RDTs and children with a negative RDT have been shown to be more likely to be prescribed an anti-malarial treatment than children with a negative microscopy for malaria in some settings [21].

Whilst a greater proportion of malaria parasite-negative than malaria parasite-positive children were given an antibiotic, a smaller proportion of those tested compared to those not tested were administered an antibiotic and therefore overall the use of testing could be said to have reduced the administration of antibiotics in this study. This is, however, within the context of only a small proportion of children being tested and the situation may differ with increases in the proportion of children tested as the proportion of negative tests compared to those not tested increases.

There were few overlaps in predictors of children receiving an ACT or antibiotic and the carers knowing the correct dose schedule of the ACT received in hospitals and health centres. Characteristics of the child and the carer were infrequently predictors of the three outcomes of interest in this study. There were three exceptions to these amongst those attending a hospital which were: 1) that children of 12 months and above were more likely to be given an ACT; 2) children whose carer spoke one of the three local dialects were more likely to be given an ACT; and, 3) the carers of children 23 to 23 months were more likely to know how to give the ACT correctly. It is likely that the diversity of attendees and their ethnic backgrounds is greater at the district hospital than at the health centres, which would go some way to explaining why speaking a local dialect is not a predictor of a child receiving an ACT in a health centre. It does not however explain why in a hospital, a child should be more likely to receive an ACT if the carer speaks the local dialect, except perhaps if the health workers were worried about communicating how the drug should be used. Data to enable analysis by socio-economic indicators was not collected in this study and therefore are not able to determine whether this predictor is confounded by socio-economic status.

Children attending health centres were more likely to receive an antibiotic if they had national health insurance and the carers of children with health insurance were less likely to know how to correctly administer ACT. The proportion of children with health insurance in this study population was very high (89%) overall and was higher for hospitals than health centres, 96 versus 82%. Further studies are needed to understand the influence of the increasing uptake of national health insurance on the prescribing and possible over-administration of antibiotics. It is possible that carers whose children are administered both ACT and antibiotics are less able to remember how to take ACT due to confusion between the two drugs.

The cadre of health worker conducting the consultation was a common predictor of the outcomes of interest in this study; as doctors in this setting are less likely to over-prescribe both ACT and antibiotics than are lower level cadres of health workers but less likely to ensure the understanding of the carer on how to administer the ACT.

Treatment-seeking factors were more influential in the management of febrile children in hospitals than in health centres particularly in terms of previous treatment seeking for the current febrile episode. Children were less likely to be given an ACT if it was more than seven days since their fever began and if they had already been given medicines at another health facility, but more likely to be given an ACT if they had previously taken a medicine from an LCS. This suggests a perception of hospital prescribers that children were likely to have already been given an ACT if they had previously attended another health facility but not if they had got medicine from and LCS.

As assessed using the health system’s effectiveness approach, the most ineffective process in administering an ACT in this study was that of ensuring that the carer of the child knew how to administer the ACT correctly. This approach provides a quantitative comparison of the proportion of children for whom each defined process in delivering effective case management is achieved. The findings were not disaggregated by categories of diagnosis in this system’s analysis where the focus was on the overall picture. Subsequent disaggregation of the findings by diagnosis showed that the aggregated data masked some issues in treatment with amodiaquine and dispensing of both ACT and quinine for a single febrile episode. These two analytical approaches were used effectively to 1) determine the overall quantitative process problems and then, 2) to illuminate more deeply upon treatment based upon diagnosis.

The efficacy of the ACT depends upon adherence to its correct administration and this in turns depends upon the carer’s knowledge of the correct administration. Adherence can be improved by interventions focussing on provider knowledge and behaviour [22]. However, more research using qualitative methodologies is required in this study setting to understand the barriers to carers’ knowledge and how these can be mitigated within the hospital and health centre settings.

Less than 15% of children were tested for malaria parasites in the five district hospitals included in the study, the rest were clinically diagnosed. The behaviour and process changes required for hospitals and their staff to provide a parasitological test to all febrile children is quite different to that in health centres in which microscopy has not been available in the past. In hospitals, health workers make decisions on the need for a malaria test, generally by microscopy. A guideline of all febrile patients to be tested for malaria would require that they changed this practice. This policy is likely to be less effectively implemented by higher level cadres such as doctors who have been more highly trained in using their clinical judgement based upon signs and symptoms. In a study in Western Kenya, the proportion of patients given a diagnostic test post introduction of the new parasitological diagnosis guidelines did not increase, but the majority of these tests were by RDT rather than microscopy [23]. More studies are needed on the programmatic implementation of the new parasitological diagnosis of malaria guidelines in hospitals to understand 1) whether all patients are given a parasitological test; 2) the impact of having a parasitological test on overall quality of care; and, 3) the cost and time (for health staff and patients) implications given the generally high patient loads in district hospitals.

Interventions are needed to improve case management of febrile children in hospitals and health centres. Non-adherence to malaria microscopy negative results is a problem in both hospitals and health centres with microscopy and prescribing anti-malarial monotherapy for parasite-positive children is not uncommon in hospitals. A high proportion of carers of children did not know how to administer ACT correctly, and this problem is more acute in hospitals than health centres. This suggests that education on drug administration that carers receive in the health facilities is inadequate for its purpose. Predictors of being given an ACT, given an antibiotic and of the carer knowing how to administer the ACT are different in hospitals and health centres and therefore different interventions are need to improve case management of febrile children at these two levels of the health system. Studies to direct appropriate and effective interventions in hospitals are particularly needed.