Results
The main findings of the study were (1) communities had not received sufficient information to enable them to understand the rationale of home based management of fever (2) the community's high appreciation of HOMAPAK as the most accessible, free and prompt treatment of hot body which has reduced the prevalence of severe malaria among under fives (3) the perception of HOMAPAK as a "light drug" of lower quality which can not treat severe malaria and not matching with some children's blood (4) the concern of focusing on one disease instead of an integrated approach for managing multiple conditions (5) the lack of community ownership and facilitation of DDs as critical barriers to the sustainability of the programme with motivated DDs.
In terms of preparation, a national communication strategy [
17] was developed but never fully implemented. As per the HBMF implementation guideline [
4], community mobilization and sensitization was supposed to complement the activities to select and train DDs.
The DDs were given job-aids to explain to mothers how to administer the drugs and when to go for referral. In practice only caregivers visiting the DDs received information through face-to-face counselling. Similarly, the leaflets with drug information enclosed in the HOMAPAK boxes were only accessed by those who had already brought the children to a DD for treatment. In addition a few posters were displayed mainly in the clinics, and village sensitization meetings were only held at the beginning during selection of the DDs.
Respondents reported that HBM made a substantial contribution to the management of malaria in the community. Overall, caretakers in FGDs and KIs concurred that provision of HOMAPAKs by DDs makes the drug easily accessible, hence reducing treatment delays and risks of development of severe malaria with convulsions.
"It [HOMAPAK] has helped in reducing ekikangararo (convulsions). In the past, children would die a lot but now the rate has reduced. We honor HOMAPAK" (FGD, old mothers).
Most caretakers during FGDs confidently argued that HOMAPAK is effective if administered in time:
"In fact in this village we have mothers who do not like taking their children early enough for treatmentthey even blame other mothers who attend quickly to child's illness. It is always out of negligence and carelessness. And for your information it is such people who will preach that HOMAPAK does not work well on children" (FGD, old mothers).
However, a few caretakers in FGDs remarked that HOMAPAKs are not effective, especially when the malaria is severe.
"HOMAPAKs can only be good when the child is not very sick. You need strong drugs if malaria is high" (FGD, old mothers).
Both DDs and health workers agreed that some people in the community perceived HOMAPAK as a weak drug and only useful for non severe malaria. Some of the caretakers who perceive HOMAPAK as weak drug may avoid going to the drug distributor when their children have fever.
"You know people in our community think that drugs provided in the community are very weak. They refer to them as 'omubatsi owahesi' meaning 'drugs of lower quality'. They believe that the drugs provided in the clinics and drug shops are better" (a DD).
Health workers and DDs also confirmed that community members sometimes bypassed the DDs and sought treatment directly from health facilities or drug shops where they perceived the drugs to be 'stronger'. This was also confirmed by the drug sellers who reported that the introduction of HOMAPAKs had not affected their sales and many people still prefer drugs from their shops:
"For me I have not seen how it has affected my business. People still come to me because I have all the drugs they need like panadol, aspirin and some antibiotics. There are some people who come after failing with HOMAPAK and I give them quinine. People prefer my drugs because I have sugar coated chloroquine which most people prefer to the bitter one" (a drug seller).
In addition, DDs and caretakers reported that there were some children whose fever does not respond to HOMAPAK treatment, which has led to mistrust of the drug. While health workers were aware of the problem with drug resistance, caretakers on the other hand attributed this to the mismatch between the child's blood and HOMAPAK.
"The resistance to HOMAPAK nowadays is a common problem. When there is no effect for those who have used the drug, they lose confidence and spread the rumours to others" (a health worker).
"We did not go for HOMAPAK again because we suspected that the blood of the child does not work with HOMAPAK or there was another complication or probably the drug was not effective" (a caretaker in clinic).
The community members were not satisfied with the fact that HBM only brings one type of treatment and demanded more drugs for the management of other childhood illnesses.
"I would not suggest to change it but it [HOMAPAK] should be accompanied with another pack containing cough tablets, painkillers and those of flu" (FGD, young mothers).
DDs also confirmed that caretakers expected them to have a variety of drugs to treat other childhood diseases in addition to malaria. In addition, both caretakers and DDs expressed the need for antimalarial drugs for the adults because if not treated, their malaria was believed to spill over to the children.
"HOMAPAKs are unpopular because they do not provide them for the old people. Only children are given the drugs and yet sometimes the fever attacks the whole family at once. Instead of going to the DDs, they will go to the drug shops where they will get drugs for everyone" (a DD).
Both caretakers and DDs were concerned that HOMAPAK was not being provided with Oral Rehydration Salt (ORS) which, according to them, is essential for the management of most of childhood illnesses. DDs acknowledged the fact that caretakers had extensive knowledge about ORS and considered it to be important also for fever management. Reasons mentioned included that it restores water in the body, gives the child strength, adds blood, reduces the body temperature, stops the diarrhea, and supports the other drugs the child is taking. They further argued that ORS would be especially necessary in combination with HOMAPAK which is perceived to dehydrate children.
"I use ORS for rehydration purposes. Also we want ORS because Fansidar requires a lot of fluids. Also if the child is too weak, he/she needs ORS and drinks. So we need ORS to be part of the HOMAPAK. That is why mothers prefer going to Kagando [Hospital] because in Kagando, they are given ORS especially to a child who is vomiting and has diarrhea" (FGD, old mothers).
"If the DDs were given ORS they would be more respected in the community" (KI, community Leader).
Lack of facilitation of DDs was raised by different respondents. Respondents maintained that DDs lacked tools to make their work easier and both DDs and caretakers agreed that diagnostic equipment would improve diagnosis and hence attract more caretakers of febrile children. Equipment such as thermometers and microscopes were cited as critical.
"We need thermometers to check the level of temperature. During the training we were told that we should always establish the temperature and when we find that it is too high we refer the children to the health facility" (a DD).
Apart from diagnostic equipment, DDs said they needed facilitation with lighting to enable them identify the colored packs at night, gumboots to guard against snake bites when visiting homes, soap to wash hands before handling medicines and containers to keep medicine safely. The concern about lack of DD facilitation was frequently raised also by mothers.
"What happens is when you call him [DD] he comes and checks your child and after another parent may call him in another place. So if it is at night, these people [DDs] suffer in the darkness and you know our place is hilly so they need lamps and paraffin" (FGD, old mothers).
Moreover, DDs and caretakers were concerned about the lack of remuneration and recognition by local government authorities for the work performed. According to the DDs' coordinator, the work load at the health centers hampers health staff from interacting with and supervising the DDs in the community. This problem was also confirmed during informal discussions with DDs and community leaders who mentioned the lack of payment and supervision as a great barrier to motivation.
"What makes somebody happy is the stomach. Although the DDs may not be complaining directly, lack of allowances is demotivating them. They will do their work at their own pace. They cannot leave their gardens to attend the ailing children" (Community Leader).
Authors' contributions
1. XN conceived the study, participated in the planning and implementation of the study, analyzed the data, drafted and finally revised the manuscript
2. JNS conceived the study, participated in the planning and implementation of the study, analyzed the data, commented on the draft manuscript and participated in the revision of the manuscript
3. KK conceived the study, participated in the planning and implementation of the study, analyzed the data, commented on the draft manuscript and participated in the revision of the manuscript
4. SP conceived the study, participated in the planning of the study, analyzed the data, commented on the draft manuscript and participated in the revision of the manuscript
5. GP conceived the study, participated in the planning of the study, analyzed the data, commented on the draft manuscript and participated in the revision of the manuscript
6. GT conceived the study, participated in the planning of the study, analyzed the data, commented on the draft manuscript and participated in the revision of the manuscript
All authors read and approved the final manuscript.