Access to health care for febrile children in Uganda : symptom recognition, care seeking practices and provider choice

Background: Febrile illnesses including malaria and pneumonia are leading causes of death among children under five in Uganda. The survival of a sick child depends on access to prompt and appropriate care. Despite government efforts to increase health care access by offering free services at government facilities, the majority of the sick children receive care after 24 hours, often with less efficacious drugs. One of the strategies suggested for increasing access is the distribution of antimalarials and antibiotics at community level. However, determinants on access to health care for febrile children are not sufficiently understood.

Main aim: The aim of this study was to assess the factors associated with access to treatment for febrile children under five in order to inform the implementation of child survival interventions at community level.

Methods: Four studies were conducted in the Iganga Mayuge Demographic Surveillance Site in eastern Uganda (I IV). Study I used key informant interviews (KIIs) with eight health workers and eight traditional healers and five focus group discussions (FGDs) with mothers of children under five. Study II was a cross sectional survey of 9,176 children under five. Study III was a survey of a random sample of 1078 households with children under five. Study IV used four FGDs with fathers and mothers of children under five and eight KIIs with health workers in government and Non-Governmental Organization facilities, community medicine distributors (CMDs), and attendants in drug shops and private clinics. Content analysis was used for qualitative data. Quantitative data was analysed at univariate, bivariate and multivariate levels to determine the independent predictors of delayed care or choice of provider.

Results: There is general lack of knowledge on antibiotics as first treatment for fever with pneumonia symptoms (I) and use of less efficacious drugs for malaria acquired from the open market (IV). Caretakers prefer health care providers with a variety of drugs and able to do diagnostic investigations (IV). Two thirds of the caretakers consult the private sector and 27% of them among other things because they can get treatment on credit (III).There are diverse perceptions on drug efficacy among caretakers (IV). Being of low socio-economic status (OR 1.45; 95% CI 1.06 1.97) and presenting with pallor (OR 1.58; 95% CI 1.10 2.25) are associated with delay in care seeking >24 hours after onset. Children seeking care outside the home <24 hours had fast breathing (OR 0.75; 95% CI 0.60 0.87), had had tepid sponging (OR 0.43; 95% CI 0.27 0.68), had provider proximity (OR 0.72; 95% CI 0.60 0.87) and went to drug shops (OR 0.70; 95% CI 0.59 0.84) or CMDs (OR 0.33; 95% CI 0.15 0.74) (II). Caretakers more likely went to government facilities when children had vomiting (OR 2.07; 95% CI 1.10 3.89), or when expecting qualified (OR 10.32; 95% CI 5.84 18.26) or experienced workers (OR 1.93; 95% CI 1.07 3.48). Caretakers went to private providers when seeking treatment as first aid (OR 0.20; 95% CI 0.08 0.52) (III).

Discussion: Caretakers should be sensitized on recognition of symptoms for pneumonia, prompt care seeking and use of efficacious drugs. CMDs should be able to do some diagnostic investigations and have constant drug supply. Using drug shops and private clinics in community interventions could complement government efforts to deliver timely treatment.

List of scientific papers

I. Hildenwall H, Rutebemberwa E, Nsabagasani X, Pariyo G, Tomson G, Peterson S (2007). "Local illness concepts--implications for management of childhood pneumonia in eastern Uganda." Acta Trop 101(3): 217-24. Epub 2007 Feb 15
https://pubmed.ncbi.nlm.nih.gov/17374351

II. Rutebemberwa E, Kallander K, Tomson G, Peterson S, Pariyo G (2009). "Determinants of delay in care-seeking for febrile children in eastern Uganda." Trop Med Int Health 14(4): 472-9. Epub 2009 Feb 14
https://pubmed.ncbi.nlm.nih.gov/19222823

III. Rutebemberwa E, Pariyo G, Peterson S, Tomson G, Kallander K (2009). "Utilization of public or private health care providers by febrile children after user fee removal in Uganda." Malar J 8: 45
https://pubmed.ncbi.nlm.nih.gov/19284673

IV. Rutebemberwa E, Nsabagasani X, Pariyo G, Tomson G, Peterson S, Kallander K (2009). "Use of drugs, perceived drug efficacy and preferred providers for febrile children: implications for home management of fever strategies." (Submitted)