From fever to anti-malarial: the treatment-seeking process in rural Senegal

Prompt and effective case management is a key component of global strategies to reduce the burden of malaria. The Roll Back Malaria Partnership (RBM) has set the target for 2010 that "80% of malaria patients are diagnosed and treated with effective anti-malarial medicines, e.g. artemisinin-based combination therapies (ACT), within one day of the onset of illness" [1]. Available data on progress towards this goal suggest that the mean proportion of children under five years of age with a fever that were treated with an anti-malarial drug in sub-Saharan Africa between 2007 and 2008 was 32% (varying across countries from 6% to 57%); less than 15% of children were given an ACT (range: 3% to 25%) [2]. These data do not include a measure of the promptness of treatment. Therefore, considering the delays in treatment-seeking reported elsewhere [3], it is likely that the proportion of children receiving an appropriate anti-malarial drug within one day of the onset of illness will be even lower.

Alongside the shift in national treatment polices to the use of more expensive forms of ACT, the policy process has recently changed to include parasitological diagnosis rather than presumptively treating all fevers as malaria [4]. This is particularly the case in the public sector [5, 6], however increasingly discussions are also moving towards introducing use of rapid diagnostic tests (RDTs) by community health workers [7, 8]. Thus, it is important to consider diagnosis-confirmed cases of malaria, not just any febrile illness when assessing the proportion of malaria cases receiving prompt and effective treatment.

In order to understand why prompt and effective treatment of malaria (or fever) remains low it is necessary to examine the treatment pathway, comprising both treatment-seeking and the delivery process. Critical blockages in this treatment pathway may be identified by assessing the probability of a child moving from one step to the next, from getting a fever to receiving appropriate treatment [9]. Once critical blockages in the treatment pathway have been identified it may be possible to design new, or re-focus current interventions to move more rapidly towards the RBM target. If effective treatment of malaria is to be improved for children across socioeconomic groups, all sectors involved in the delivery of anti-malarials must be considered in this 'diagnostic' manner. Such an approach will enable the targeting of interventions to increase effective treatment at all sources that the caretakers of children are utilizing [10].

This paper presents the application of such a diagnostic approach to the coverage of prompt and effective treatment for febrile children in rural Senegal, assessing the critical steps at which children exit from the treatment pathway, stratified according to source of first advice or treatment.

Interviews were completed with 240 caretakers of children under five years of age with fever in the previous two weeks. As nearly a quarter of households had more than one child with a fever in the last two weeks a total of 305 febrile children were included in the survey sample. The mean number of febrile children under five years per household was 1.27 (range: 1 to 5 children). Since the majority of households with multiple febrile children under five years had two febrile children, potential clustering of treatment seeking outcomes was explored within these pairs of children. No agreement within child pairs for the outcome of receiving ACT within 48 hours was observed (correlation coefficient: 0.2344); therefore, the analysis was not adjusted for clustering at the household level. Household size varied from 3 to 39 people, with a mean of 11.0 ± 5.2. A total of 2,652 people lived in the households interviewed.

It is clear that large proportions of children exit from each step in the treatment pathway, and that a variety of interventions will be required to increase the proportion of febrile children with malaria receiving prompt and effective treatment with an ACT in the study area. Almost 40% of children with fever are not taken for any advice or treatment. This may be because the fever was only of short duration and the child quickly recovered, for example due to self-medication with drugs already in the home and/or other first aid measures such as tepid sponging. Nevertheless, the result still highlights the importance of health promotion to improve awareness of malaria symptoms and the importance of seeking prompt treatment if initial home measures such as tepid sponging do not work. The proportion of children not seeking any treatment seems high in relation to other studies [21, 22]; however it is similar to findings from Uganda [23], which also reported approximately 40% of children not seeking any care for fever. More investigation is clearly needed to understand initial treatment practices in the home, the reasons for not seeking treatment outside the home, and to follow up on health outcomes including estimation of the proportion of fevers that are self-limiting.

Perhaps the starkest finding from this process analysis of the treatment pathway was that over 70% of febrile children taken to any provider did not receive an anti-malarial. Given the national policy for confirmed diagnosis in formal public health facilities, it is not unexpected that a lower proportion of febrile children received an anti-malarial when taken to a public health facility rather than a community delivery point. However, assuming that 47% of fevers are malaria (78% febrile children receive an RDT and of these 60% are positive), one would expect 47% of febrile children to receive an ACT in the public sector whilst our findings show that only 26.7% of those promptly seeking treatment in the public sector received any anti-malarial and 15.0% an ACT. The proportion of those promptly seeking treatment for a febrile child at any provider and not being given an appropriate anti-malarial (i.e. AS-AQ) is 84.6%. The not uncommon occurrence of children being given anti-malarials other than ACT (including chloroquine) in the public sector is an indication that improvements are still necessary. The results of the present study support those of the 2008 Senegal Malaria Indicator Survey, which found that only 2.2% of children in the Tambacounda region with fever in the previous two weeks received an ACT on the same or next day [24].

Effective treatment of malaria does not stop at prescription of an ACT to patients with a confirmed diagnosis; the caretaker of the child also needs to access the prescribed medication and fully adhere to the complete treatment regimen making sure that the child takes the correct dose and for the correct number of days. In addition to including an indication of promptness of treatment-seeking (within 48 hours of the child first showing signs of fever), these elements make up the full RBM indicator of prompt and effective treatment of malaria [1]. In this study, only 1.3% of children with fever received an ACT within 48 hours of presenting with fever, which was reportedly taken at the correct dose and for the correct duration.

The exiting of children from steps in the treatment pathway seen in this study is very similar to findings from Uganda; Nsungwa-Sabiiti et al found that in a population of 260 children with fever, 87% received any treatment, 44% within 24 hours, 26% with an appropriate anti-malarial and only 7% at correct dose and duration [25]. This emphasizes the need to target both users and providers if improvements in the prompt and effective treatment of malaria in children are to be achieved. Qualitative work is now needed to understand the reasons for the observed losses at each step in the treatment pathway in order to design appropriate interventions.

Studies investigating how the use of RDTs in routine health services influence clinical decisions have shown mixed results. For example, research in Tanzania and Burkina Faso found that many health providers continue to prescribe anti-malarials to patients with a negative RDT result [26, 27], whereas this practice was much less frequent in studies in Kenya and Zanzibar [28, 29]. Modelling of the impact of RDT-confirmed diagnosis did not incorporate interpretation of the result into the treatment received by the febrile child, meaning that some of those given an anti-malarial may have been negative and some of those not given an anti-malarial may have been positive which would have influenced the proportion of febrile children being appropriately treated. RDTs are likely to be less cost effective if the results are not used properly, particularly in areas with falling malaria transmission such as Senegal [12] and where treatment is with more expensive ACTs [30, 31]. A key intervention in addition to increasing the use of RDTs in the public sector is, therefore, to encourage appropriate treatment of positive results with an anti-malarial (more importantly, an ACT) and negative results with a suitable alternative treatment, for example an antibiotic or antipyretic.

Interestingly, the proportion of febrile children taken to a health centre that were given an antibiotic supports that differential diagnosis based on a confirmed RDT may have been appropriately implemented since almost 40% of children received an antibiotic (approximately the proportion that would have been expected to receive a negative RDT). Overall, 1.6% of children received both an anti-malarial and an antibiotic. However, at the health post level only 15% of febrile children received an antibiotic. It is possible that the prescription of ACT was low in the public sector due to problems with stock-outs, known to have adverse effects on appropriate treatment of malaria in other countries after changing their national malaria drug policy [32]. Alternatively, it may have been because of health worker reluctance to prescribe AS-AQ due to perceived or observed side effects of amodiaquine which have previously been found in Senegal [33]. Household surveys are currently the standard method used to assess the RBM malaria treatment indicator; however, to truly understand the provider-side factors such as stock and quality of care that influence the ultimate treatment received and adhered to by children with malaria, it is necessary to also conduct concurrent health facility and health worker surveys.

In addition to the existing use of RDTs in public health facilities, they are also presently being rolled out for use in the diagnosis and treatment of malaria at the community level in Senegal. Community health workers (ASCs) will be supplied with RDTs and trained in their use. Use of RDTs by community volunteers has been shown to be feasible in other settings [7, 8]; however, concerns with appropriate use of the tests and correct interpretation of results mean that close monitoring of the new system will be important. Similarly, the inclusion of a confirmed malaria diagnosis as a specific step in the treatment pathway, regardless of source of treatment, will be important in assessing effective treatment of febrile children in the intervention area in future surveys.

Another interesting, if not surprising, finding of this study is that there is minimal activity in the retail sector in relation to ACT; although 8.5% of febrile children were taken to a retail outlet, only 3.8% of these received an ACT.

The predictors for a child with fever seeking treatment vary depending on the type of provider that they are initially taken to. For example, access to the public sector increases with higher socioeconomic status. However, socioeconomic status is not a predictor of accessing community-based delivery points. This supports data from other studies that suggest providing ACT through community-based systems such as health huts may be an appropriate way to increase equity of access to effective malaria treatment [34]. However, there is still debate as to whether community health workers are able to increase socioeconomic equity in the coverage of interventions as effectively as they improve geographic equity, especially as some level of payment is usually involved [35, 36]. Finding that carers of febrile children were seeking treatment from the community sector in areas with non-functional health huts may have been due to a small number of health huts being rehabilitated and receiving their ACT supplies whilst the survey was underway, or to people travelling large distances to access functioning health huts.

The sample size is a limitation of this survey, resulting in wide 95% confidence intervals. This is due to the decreasing numbers of children progressing to each step of the treatment pathway, particularly when they are stratified by provider and categorized determinant. Future studies wishing to assess the different steps in the treatment pathway, particularly when including stratification by type of provider, should allow a sufficiently large sample size to account for the decreasing numbers of children remaining in the evaluable sample as the pathway progresses.

It is important to note that there may be some inaccuracies in the names and types of drugs that the caretakers reported giving to their children [37], particularly due to problems with recall of an event that occurred up to two weeks ago. Although we tried to limit this source of bias by providing the interviewers with a photo board for anti-malarials available in the region, non anti-malarials were not included. It is difficult to predict however, whether this would mean anti-malarials or non anti-malarials would have a greater chance of being reported by caretakers.

Despite the sample size and other limitations, it is clear that large proportions of children exit from each step in the treatment pathway, and that intervention is required at multiple steps to increase the proportion of febrile children with malaria receiving prompt and effective treatment in the study area.

Progress towards achieving the RBM goal of 80% of malaria patients being diagnosed and treated with effective anti-malarial medicines (ACT) within one day of the onset of illness is slow. In order to understand the reasons for this and to generate improvements, it is necessary to identify the steps within the treatment pathway where the greatest proportion of children exit from the process of receiving effective treatment. This will enable the identification of the steps where interventions can or should be targeted to achieve the greatest impact. Limited impact will be achieved if interventions only target one step in the pathway. In the Tambacounda region of Senegal, the most important targets for interventions are increasing initial care seeking for fever, improving uptake of RDTs at the public and community levels and correctly treating parasite positive patients with an ACT. There is also a need for complementary qualitative work to investigate in more detail why these processes are not occurring effectively so that the most appropriate interventions can be designed. It is important that this diagnosis of the treatment pathway is further broken down by provider type since the public, community-based and retail sectors behave differently but are all important if the RBM targets for prompt and effective treatment of malaria are to be achieved.