Research Article: Understanding the context of delays in seeking appropriate care for children with symptoms of severe malaria in Uganda

Date Published: June 5, 2019

Publisher: Public Library of Science

Author(s): Arthur Mpimbaza, Susan Nayiga, Grace Ndeezi, Philip J. Rosenthal, Charles Karamagi, Anne Katahoire, Julie Gutman.


A large proportion of children with uncomplicated malaria receive appropriate treatment late, contributing to progression of illness to severe disease. We explored contexts of caregiver delays in seeking appropriate care for children with severe malaria.

This qualitative study was conducted at the Children’s Ward of Jinja Hospital, where children with severe malaria were hospitalized. A total of 22in-depth interviews were conducted with caregivers of children hospitalized with severe malaria. Issues explored were formulated based on the Partners for Applied Social Sciences (PASS) model, focusing on facilitators and barriersto caregivers’promptseeking and accessing ofappropriate care. The data were coded deductively using ATLAS.ti (version 7.5). Codes were then grouped into families based on emerging themes.

Caregivers’ rating of initial symptoms as mild illness lead to delays in response. Use of home initiated interventions with presumably ineffective herbs or medicines was common, leading to further delay. When care was sought outside the home, drug shops were preferred over public health facilities for reasons of convenience. Drug shops often provided sub-optimal care, and thus contributed to delays in access to appropriate care. Public facilities were often a last resort when illness was perceived to be progressing to severe disease. Further delays occurred at health facilities due to inadequate referral systems.

Communities living in endemic areas need to be sensitized about the significance of fever, even if mild, as an indicator of malaria. Additionally, amidst ongoing efforts at bringing antimalarial treatment services closer to communities, the value of drug shops as providers ofrationalantimalarialtreatment needs to be reviewed.

Partial Text

For African children with uncomplicated malaria, the World Health Organization (WHO) recommends prompt treatment with artemisinin-based combination therapies (ACTs) within 24 hours of illness onset as a key strategy for preventing progression to severe malaria [1]. Unlike in the past, when ACTs were scarce and expensive [2], efforts by governments, international organizations, and partner institutions have resulted in increased availability of high quality and affordable ACTs in both the private and public health sectors [3]. This achievement has likely contributed greatly to reductions in malaria morbidity and mortality in Africa [4, 5]. However, despite increases in ACT coverage rates, the proportion of eligible children receiving ACTs within 24 hours of illness onset remains low [6], partly explaining why hundreds of thousands of children continue to die of malaria each year [7].

We studied contexts that contributed to delays in appropriate care for children who eventually developed severe malaria. Consistent with previous reports[20], mild fevers led to delays in response. Caregivers responded to what they perceived as mild illness with ineffective home interventions. When care was sought outside the home, drug shops were preferred over public facilities, but because the care was often sub-optimal, there was delay in accessing appropriate treatment.




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