Background
Febrile illnesses like malaria and pneumonia are major contributors to the high child mortality rates in sub-Saharan Africa [
1]. Various countries committed themselves to reduce child mortality rates by two thirds by 2015 [
2]. The distribution of anti-malarials and antibiotics at community level by community medicine distributors (CMDs) [
3,
4] is one of the interventions recommended to reduce mortality from febrile illnesses. This strategy has been shown to reduce morbidity in Burkina Faso [
5] under five mortality due to malaria in Ethiopia [
6] and mortality due to pneumonia in Nepal [
7]. A meta-analysis of community case management of pneumonia in India, Pakistan, Bangladesh, Philippines and Tanzania showed a mortality reduction of 27% [
8,
9]. The momentum of introducing community case management of pneumonia is high in Africa [
10] and national programmes for community health workers are being planned in Ethiopia, India, Kenya, Uganda and South Africa [
11].
However, drugs distributed by CMDs have been perceived by some caretakers as weak [
12] or ineffective [
13]. Community management of febrile illnesses has used pre-packed drugs [
14], but some women in western Uganda did not like pre-packed drugs [
15]. New drugs are to be distributed, which are different from the previous ones. Caretakers trusted in the efficacy of chloroquine as an anti-malarial due to its bitter taste [
16]. Artemether/lumefantrine (AL), the new first-line treatment of malaria is not bitter. Cotrimoxazole is the first-line of treatment for pneumonia in Uganda, but a high in vitro resistance has been reported [
17]. Amoxicillin is the second drug of choice. Studies differ on caretaker use of antibiotics with some showing high utilization [
18] and others showing that antibiotics are not cited in the treatment for fever [
19]. Much of the community management of pneumonia has been in Asia and few studies have taken place in sub-Saharan Africa. Even in the presence of CMDs, some caretakers prefer to go to drug shops and private clinics [
12]. Utilization of CMDs was noted to be low where the community distribution of anti-malarials was done in Democratic Republic of Congo [
20], The Gambia [
21], Uganda [
14] and Kenya [
22].
If the community distribution of anti-malarials and antibiotics is to have an impact on child mortality, it needs to be used by a big proportion of the febrile children. The strategy needs to offer drugs that are seen by caretakers as efficacious. The CMDs need to be seen as providers that would manage malaria and pneumonia. The aim of the study was to explore caretakers' use of drugs, perceptions of drug efficacy and preferred providers and make suggestions for the distribution of anti-malarials and antibiotics at community level.
Results
There were four key findings of the study: (1) Quite often respondents were not up-to-date with the newly recommended drugs as some of them said they were still using chloroquine and/or SP for fever. They also tended to mix anti-malarials and antibiotics as belonging to one category. Drugs used for fever that were commonly mentioned included analgesics, anti-malarials, antibiotics, anticonvulsants, steroids and traditional medicines. (2) Caretakers gave divergent views about efficacy of different drug combinations, packaged drugs and significance of side effects. (3) Both private and public health providers were used for treating febrile illness, each in specific circumstances. (4) The ideal provider was that who had diagnostic capability, was nearby, available all the time and provided a constant supply of a variety of drugs.
Caretakers' use of drugs
Drugs used by caretakers to treat febrile children included analgesics, such as Panadol®, diclofenac® and ibuprofen; anti-malarials, such as chloroquine, Fansidar®, quinine and Coartem®. Other drugs included diazepam, dexamethasone and traditional herbs like "lubirizi"(Vernonia amygdalina) and "akabombo akaganda" (Cyphostemma adenocaule). Chloroquine and Panadol® were the commonest drugs cited for treating fever. For treating cough, the majority mentioned septrin (cotrimoxazole). Other drugs included chloramphenicol syrup, ampicillin syrup, PPF (procaine penicillin) and herbs, like aloevera (Aloe vera chinensis) and lemon leaves. Majority of the participants indicated that they would give a sick child drugs they would either already have at home or getting them from a drug shop. Care from health facilities would be sought when the child would not improve. Traditional medicine for treating fever was known by the caretakers themselves and they did not need to get it from a traditional healer.
Some of the drugs considered weak were used as first aid and more powerful ones as last resort. Drugs perceived to be weak included chloroquine, Fansidar®, Panadol®, diclofenac and septrin. However, there were some of the respondents who perceived these drugs to be efficacious and were using them to treat children. According to the majority of the caretakers, even weak drugs had an important role to play.
For me what I know is that there is no treatment, which does not work because it only depends on the severity of the fever. (FGD women)
Quinine was considered powerful and often used as last resort.
For us we know that we first begin with a weak drug and advance to powerful drugs as the sickness worsens. Quinine is given last when the other drugs have failed. (FGD Men)
This was in agreement with opinions of providers on caretakers:
Parents consider chloroquine a weak drug but they also think that if the child has slight malaria, chloroquine can be adequate and can help the person to get cured. (KI former CMD)
Use of drugs was also influenced by how much money one could spend and presence of the drug on the market.
Capsules are very expensive so I rather settle for the tablets like septrin because one capsule costs 100/= and for 100/= you get 8 septrin tablets." (FGD women)
Sometimes money is also a determinant. The child can be four months and you advise the caretaker to use quinine syrup but the caretaker will tell you that she has very little money so you give them chloroquine tablets. (KI Drug shop attendant)
Most caretakers say septrin is weak yet we have it on open market.... we have to buy septrin tablets and give them to the patients because they are on open market. (KI clinic attendant)
Caretakers' perception of drug efficacy
Views on drug efficacy were diverse and there were often disagreements on which drug is efficacious when combined with others, what side effects show about drug efficacy, packaging, what prompt recovery shows about the drug taken and efficacy of using a drug for some time. Taste and cost as indicators of efficacy were discussed though without much disagreement.
The majority of the participants argued that drugs are effective when given in combinations. They maintained that there are some drugs which cannot work unless they are combined with others. Some participants thought Panadol® was best because it is given with other drugs, like Fansidar®. Some other participants perceived a drug like Panadol®, which is usually added onto other drugs, as weak.
There were many considerations that made people conclude that a drug was efficacious. Such considerations included side effects, packaging, the drug source, how quickly the body responded to the drug. There was no consensus on the implications of a drug having side effects. For some, it was a sign of a drug being strong.
For me, the drug that cures very well is quinine. Even when you take quinine you can feel it. It is very strong because you even feel pain in the ears after taking it. (FGD Men)
Sometimes if they give a drug to a child and he/she weakens then they say the drug is strong. (KI drug shop attendant)
While others argued that when a drug has no side effects, it is a sign that the drug is efficacious and appropriate for the disease in question.
Once the drug is given to the child and does not involve any complications like convulsions, vomiting or shivering, then I know that the drug is recommended for malaria and I know that that drug works. (FGD Men)
There were also diverse views on packaging with some saying that pre-packaged drugs were the ones which were efficacious.
Those drugs that are not in the blister pack are the ones that are most likely to be duplicated. Me I prefer the ones in the blister seal. (FGD Men)
However, there were others who on the contrary argued that since the government health facilities usually had the tablets that are not packed; those in blister packs were fake.
I think that the drugs in the blister seal are not as original as the other common ones (loose ones) because even government has the loose ones which they keep in the tins, so I think that the ones in the tins are the original ones and those in blister packs are fake.(FGD men).
Drugs that had immediate effect on the condition of the child were considered by some of the respondents as efficacious. Other participants argued to the contrary and said that no drug cures immediately.
There is no medicine that cures immediately, they all work gradually because diseases come quickly but go slowly. (FGD women)
There were disagreements as to what happens when a person has used a drug for some time. Some held the view that when a person uses a drug for some time, the drug would no longer cure that particular person.
On my side, quinine works well on my child but these days when I use it, the fever resumes after some time. ... May be the child's body has gotten used to quinine and the child's body is not responding hence quinine cannot treat the fever any more. (FGD women)
Experience with the use of some of the drugs influenced the way people perceived the drugs.. It was common for people to refer to the drugs they use often as being less efficacious. Other participants had dissenting views suggesting that people are cured by certain drugs which they have gotten used to.
Some people use chloroquine injections but they fail to get cured from the fever because they are used to another type of treatment. For instance I may use chloroquine injections and I do not get cured and yet when I use fansidar tablets, I get cured. (FGD women)
A summary of divergences in perceptions of drug efficacy is shown in Table
1.
Table 1
Divergences in perceptions of drug efficacy
1. When using drugs in combination | A powerful drug is found in drug combinations | A weak drug is the one in drug combinations |
2. Drugs having side effects | This is a sign that a drug is efficacious | This is a sign that a drug is not efficacious |
3. Pre-packaged drugs | Are the ones which are efficacious | Are not efficacious, they are fake |
4. Drugs giving fast recovery from the illness | Shows that the drug is efficacious | There is no drug that gives quick recovery. All drugs act slowly |
5. Effect of using a drug for some time | Makes the person be cured by preferably that drug | Makes a person unable to be cured by that drug |
Most of the participants were of the opinion that having a bitter taste was a sign of a drug being efficacious for the treatment of malaria. In addition, a big section of the FGD participants held the view that expensive drugs were more efficacious than the cheap ones.
I think that all drugs that cure malaria should be bitter... this is because malaria is strong and therefore needs some mixture that is equally bitter. Me, if I tested a medicine for malaria that's not bitter, I would know that it is just a fake one and I would not accept it, I can't purchase it. (FGD Men)
For us here, if there is any medicine that's cheap, we suspect that where as it is used to treat malaria, it may not work well. We believe that certain drugs are expensive because they work. For example when you buy 10 chloroquine tablets, a dose may be only 200/= while a dose of only 3 fansidar tablets is at 1500/=. So fansidar is seen as being more powerful (FGD Men)
Preference for providers
Both private and public providers were used for managing febrile illness. However, the preferences were for providers: where there was no waiting, open all the time, which were nearby, could give treatment on credit, had drugs, and had diagnostic capability.
The majority of the participants credited drug shops for being able to give treatment promptly unlike government facilities, which do not even give special attention to very sick children.
Unlike government facilities, private clinics and drug shops care about their clients. Once you reach there, you are welcomed nicely and served immediately, but at the government health facility you can enter at 9:00 am and the doctor may or may not attend to you at 1:00 pm, so in cases where you need immediate attention you have no option but to go to the private clinic or drug shop.(FGD Men)
When you go to the main hospital you make a line even when the child is in poor condition and the child may die before being attended to. (FGD women)
Drug shops were also commended by most of the respondents for being near and being able to give services even at night unlike the government facilities that were far.
For us when get sick from malaria we get treatment through buying these drugs from the drug shops because even our government facility is very far away from here. For example a child can fall sick at night so I have to get the treatment from the drug shop other than go at night to the government facility. (FGD women)
The drug shops have a range of drugs on the shelves and can give you the quantities you want, they can mix for you the drugs according to your money, they are also near us and since we are the same customers, they can give you treatment on credit and may even bargain for a cheaper cost. (FGD Men)
When you go to Nakavule (the general hospital in the district), you need to use a motor cycle yet if you have 500/= you can go to the nearby drug shop and get drugs (KI former CMD)
However, drug shops and private clinics had drawbacks. Few of the FGD participants said that these private providers sometimes used nursing assistants without enough qualifications. The caretakers would still to go to them because of having no other choice. Drug shops did not do laboratory investigations and hence were perceived to treat the children basing on symptoms. To some participants, this was tantamount to guesswork.
I can get medicine like chloroquine from the drug shops although the nursing assistant who is there does not have enough qualifications but I have no option but to go to them. (FGD Women)
Now here we have a problem when a child is sick, the drug shop attendants just start on treatment without checking the child's blood to see what is in the blood to see the disease. When you take the child to the drug shop, they just put it on treatment. (FGD women)
Some caretakers were of the opinion that government facilities had the new and efficacious drug against malaria (Coartem®). When children needed intravenous fluids or blood, they had to be taken to the government hospital. They also had capacity to do laboratory investigations. This was also reflected in a comment from a former CMD who praised services at government facilities because there was proper diagnostic equipment;
Government facilities are good because if one falls sick they are advised to go to a health facility so that they can have a blood checkup. When my child fell sick, I was advised to take the child to the hospital for a blood test so that she can receive the appropriate treatment. (KI former CMD)
Table
2 summarizes preferred provider attributes.
Table 2
Preferred provider attributes
1. Attend to clients fast | No | Yes | Some times one waits at government facilities and does not get treatment |
2. Can attend to the child any time of day or night | No | Yes | At night it is difficult to go to government facilities because they are far |
3. Are nearby | No | Yes | Sometimes the cost of transport is more than the cost of treatment |
4. Have drugs in constant supply | No | Yes | Drug shops do not have the new anti-malarials of Coartem® |
5. Can conduct investigations | Yes | No | Investigations are needed to find out why previous treatment did not work |
6. Have qualified workers | Yes | No | Drug shops have unqualified workers but there is no choice, caretakers have to use them |
7. Handle complicated illnesses | Yes | No | Without the lab, there is need for investigations and drug shops do not have that capacity |
Discussion
Drugs which caretakers consider 'weak' are still being used sometimes as a form of 'first aid' and sometimes as treatment. Caretakers' perceptions on drug efficacy are not consistent and include diverse considerations on efficacy of drugs used in combinations, significance of side effects, efficacy of pre-packed drugs and significance of prompt recovery. Caretakers' ideal providers are those who offer investigations and have a variety of drugs. Whereas government facilities are preferred for being able to conduct diagnostic investigations and handling serious illnesses, they are often short of drugs. Drug shops are the ones that can supply constantly a variety of drugs, offer treatment promptly and have convenient opening hours.
Caretakers more often use weak drugs in treating febrile children. Chloroquine and paracetamol are the commonest treatment for fever. There is much resistance to chloroquine and SP [
32]. This means that people use drugs which are less efficacious. As efficacy of a drug declines, children would not improve on drugs that they previously improved on. Drugs that were distributed by CMDs at first were chloroquine and SP [
12] but with time, their efficacy went down. This sheds more light on why drugs from CMDs were considered weak [
12‐
14]. However, caretakers still use these drugs. The Uganda Demographic and Health survey recorded a high utilization of chloroquine and SP for treating febrile children [
33]. Non-efficacious drugs could be used because they are cheap or because the efficacious ones are not in the drug shops in the rural areas [
27]. Previous studies have demonstrated that it is feasible to distribute efficacious drugs with CMDs [
34] and drug shops [
35]. Although drug shops have been associated with promptness of treatment for febrile children [
36]they are not providing the recommended drugs as per the new treatment guidelines. This continued use of non-efficacious anti-malarials brings challenges to effective treatment of malaria.
The study findings indicate that the perceptions about drugs, which are efficacious cannot be generalized. There were differences in opinion about drugs, which come in combinations, the significance of side effects, drug packaging and implications of time of symptom clearance. Most caretakers agreed that drug combinations are efficacious. This could have been a product of policy by combining chloroquine and SP or artemether and lumefantrine. There has also been occasions of poly pharmacy in drug utilization in Africa just because of the "pill for every ill" [
37,
38]. In the "pill for every ill" concept, a patient with multiple symptoms like hot body, headache, dizziness and joint pains, all of which may be symptoms of malaria, could be treated with one pill for hot body, another for headache, another for dizziness and even with another for joint pains instead of the one pill anti-malarial. Other studies have reported that CMDs were not utilized because of lack of the combination aspect-they only provided one drug [
12]. Not many studies have highlighted side effects as influencing perceptions about drug efficacy. Despite previous history of community management of fever [
14], there are still disagreements on efficacy of packaged drugs. Seeking quick recovery could partly explain the popularity of analgesics and chloroquine, which also has antipyretic properties. Based on these findings it is still difficult to point out the drugs that are perceived to be efficacious generally. It is important to note that whenever a drug works for caretakers, the drug is efficacious and there is general tendency to think that some drugs work for some children and not others [
12]. Some of these perceptions like associating efficacy with drugs that are not pre-packaged may divert caretakers from obtaining pre-packaged drugs from CMDs and need to be addressed in interventions.
In this study, a common belief was that people may get used to a drug, which means that the drug cannot be used to cure them next time. Conversely, other participants argued that only drugs that the body has gotten used to can cure the illness. This could be a community way of explaining drug failure, stemming from the common caretaker use of drugs with reduced efficacy in treating malaria. There has been an increase in malaria parasite resistance to chloroquine and SP [
39,
40]. The first-line treatment for malaria has been changed to AL. Different scenarios could explain this drug failure. It is possible that caretakers use drugs like chloroquine and SP that have reduced efficacy because they are still on the open market. It is also possible that the caretakers give a wrong medicine like an anti-malarial drug to a child with pneumonia and say that the drug is less efficacious [
19]. The
emic concepts – cultural constructs of efficacy – often differ from the
etic explanations – concepts with scientific explanation [
41]. While biomedical efficacy would be tagged to clearance of malarial parasites in blood, caretakers would be satisfied with lowering of body temperature or as indicated by some, presence of side effects like noise in the ears after taking quinine. Another possibility could be that the caretakers have not yet adopted the new first line drug for malaria treatment. Communities have been shown to be slow to take on new policies as demonstrated in Tanzania [
42]. It becomes more problematic when the drug shops where the caretakers seek treatment first do not have first line treatment for malaria [
27]. Drug shops provide drugs in respect for consumer preferences and the client's ability to pay for the drugs. They often do not consider the symptoms but rather what the person requests. Because people do not have a clear understanding of the right drugs for fever, they often ask for wrong drugs and sometimes take under dose, which they can afford. Efficacious drugs remain outside the reach of the majority when drugs are difficult to obtain from outside the government health facilities [
43].
Community interventions could build on the preference of caretakers for drug shops because the latter offered a constant supply of drugs, treated clients promptly, gave treatment on credit, and were nearby. This has influenced caretakers to choose them for care [
44,
45]. Some of the challenges levelled against the home based management of fevers have been frequent stock outs of drugs at the CMDs [
46]. Frequent stock outs will drive caretakers to drug shops who don't stock the first-line anti-malarials (artemether/lumefantrine) [
27].
Caretakers prefer government facilities when children have more serious symptoms because the government facilities are able to conduct laboratory investigations. When caretakers take children for treatment outside the home, they want to know the cause of the illness that is not responding to treatment. The acceptance of CMDs could potentially increase if they were equipped with diagnostic tests such as rapid diagnostic tests (RDTs) for malaria. RDTs have been promoted in situations where there are no laboratories for microscopy [
47] and are being used to identify cases of malaria at community level so as not to give artemether/lumefantrine, an expensive anti-malarial, to any child with fever [
48]. Drug shops have been shown to offer poor quality [
25,
49]. However, febrile children would benefit if multifaceted interventions including training, supervision, and regulation were extended to drug shops and private clinics [
50].
Methodological considerations
Using different methods and respondents, and having researchers from different backgrounds from social science, medicine and the basic sciences was aimed at getting an objective perspective of the data. The study was faced with the challenge of the limitations of the qualitative methods, which do not give the magnitude across the different categories of the respondents. However triangulation of information across caretakers and health providers, across mothers and fathers, using both FGDs and KIIs, was very useful in checking consistency and contradictions both across and within groups [
51,
52]. The use of purposively selected participants makes the research findings not generalizable to the general population. Another limitation is that the study reports the caretakers'
stated use of drugs rather than
actual practices. However, separating women from men in the FGDs and asking questions focussed on common health care-seeking practices could have promoted free expression of the participants and also reduced answers given to please the researcher. Further studies will be needed to address the impact of these caretakers' perceptions on the actual care that the febrile children receive.
Conclusion and recommendations
Caretakers sometimes use what they perceive as 'weak' drugs as 'first aid' and if the child does not get well, go for more powerful drugs. This aggravates the problem of drug resistance and misuse. There are divergent views among caretakers on what factors imply that a drug is efficacious. Some perceptions may divert caretakers from using pre-packaged drugs from CMDs. As caretakers would prefer to get the drugs from providers that have diagnostic ability, attend to clients fast, and are available all the time, nearby, trained and have a constant supply of efficacious drugs, there is great potential for community distribution of anti-malarials and antibiotics to meet community expectations if CMDs live up to these standards. To increase the success of the home management of fever strategy, there is need to develop strategies for constant drug supply, to sensitize caretakers on which drugs are currently efficacious, and to avail subsidized efficacious drugs also in the private sector.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
ER, XN, GP, GT, SP and KK took part in designing the study, in tools development, in data analysis and in manuscript writing. ER, XN and KK did field work. All authors approved the final manuscript.