UMEÅ INTERNATIONAL SCHOOL OF PUBLIC HEALTH

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1 UMEÅ INTERNATIONAL SCHOOL OF PUBLIC HEALTH Late health seeking behaviour among caretakers of under-five children with malaria at Muhimbili National Hospital, Dar-es- Saalam, Tanzania: A study protocol Pastory Sekule MASTER THESIS IN PUBLIC HEALTH, 20 POINTS 2007 Epidemiology and Public Health Sciences Department of Public Health and Clinical Medicine Umeå University

2 DEDICATION This thesis is dedicated to my daughter Leticia-precious Ngikulu who tolerate my absence due to this master s programme while she was just five months of age Asante sana mama. 2

3 CONTENTS CONTENT PAGE ABSTRACT 5 ACKNOWLEDGEMENT 6 ABBREVIATIONS 7 PREFACE 8 1. INTRODUCTION Basic concepts Global burden of malaria Global management of malaria Global malaria prevention and control 10 2 LITERATURE REVIEW Methods of literature search Results of literature search Cultural-context and treatment seeking Community perception and treatment seeking Knowledge, attitude and practices Distance to the health institution and treatment seeking Conclusion 15 3 BACKGROUND Tanzania country profile Malaria situation in Tanzania Management of malaria and health care delivery in Tanzania Justification of the study 22 4 AIMS 24 5 SUBJECT AND METHODS Study area Study design 25 3

4 5.3 Study population Qualitative study (I) Study period Sampling method Measure instrument Data collection procedure Data analysis Qualitative study trustworthiness Quantitative study (II) Study period Study participants Measure instrument Data collection procedure Main outcome measure Data analysis Quantitative study validity Dissemination of study results Study protocol strength and limitation Strengths Limitations Ethical consideration Time plan Budget 35 6 REFERENCES 36 7 APPENDIX Qualitative interview guide themes Summary of qualitative study 40 4

5 ABSTRACT Malaria remains a disease of public health importance in Sub-Saharan Africa region which contribute about 90% of the global total malaria episodes. About 10% of total disease burden in this region is due to malaria which is a frequent cause of death in children below five years of age, roughly 3000 children per day. Tanzania is among the malaria endemic countries in this region with 90% of its total population at risk. About 30% of national disease burden is due to malaria which is a leading cause of health institutions attendance in all ages. Estimated to cause 100, ,000 deaths annually among 16 million cases of which about 70% of deaths occur in under-five children. Therefore is a major cause of socio-economic problem in Tanzania through prevention, treatment and death costs. Also reduced work-force productivity and school absenteeism. Aims of the thesis are to review literature on the factors contributing to late health seeking behaviour among caretakers of under-five children with malaria in different parts of the world and to develop a study protocol to determine contributing factors and prevalence of late health seeking behaviour among caretakers at Muhimbili National Hospital (MNH), a Tanzania s tertiary referral hospital located in Dar-es-Saalam city. Triangulation of both qualitative and quantitative methodologies will be used during the study. Qualitative study will start aiming at gaining deep, enriched and elaborative understanding of contributing factors using a standardized interview guide with open ended questions. Followed by quantitative study using a structured questionnaire to estimate the prevalence of late health seeking behaviour among caretakers. All caretakers available at MNH during the study period and six clinical officers of the three convenient located peripheral health institutions in Dar-es-Saalam are expected to be enrolled in the study which will be conducted from July 2008 to July The study is expected to come out with results which will assist in identifying contributing factors and extent of the problem in both referral hospitals and urban setting in Tanzania. Such that relevant interventions could be implemented in improving cure rate and thus reducing morbidity and mortality due to malaria in children below five years of age. 5

6 ACKNOWLEDGEMENT First, I would like to express my greatest gratitude to Almighty God whose blessing enabled me to finish this master s programme and for guiding me through out my life. Special appreciation to my parents Judge & Mrs Sekule for their love, guidance, encouragement and sponsoring my studies at Umeå university. Thank you so much. Sincerely gratitude to my supervisor Lennarth Nyström (Associate Professor, Department of Public Health and Clinical Medicine, Umeå University) who devoted his time tirelessly for guidance, advice, support and going through draft so as to make this thesis to be of good quality and standard. Thank you so much. Special thanks are given to the teaching and supporting staffs of the Department of Public Health and Clinical Medicine for their support and make my stay in Umeå to go smoothly, enjoyable and rememberable. I am greatly indebted to my sisters Caroline, Kashindye, Pamella, Janeth, and Clara; my young brothers Christopher and Aloyce as well my cousins Alfred and Theodory for their encouragement, moral and material support during my studies. I really appreciate your concern. Lastly, I would like to convey my everlasting love and appreciation to my wife Agnes and daughter Leticia-precious for their love, encouragement, patience and tolerate loneliness created by my absence during my studies in Umeå. I love you so much. 6

7 ABBREVIATIONS Abbreviation AIDS ALu AMR CDC DDT DFID G8 GDP GNP HIV IPT IRS ITN MCH MMR MNH MOHSW IVM NMCP PI RBM SDS SP SPSS TB TDHS WHO In plain text Acquired Immuno Deficiency Syndrome Artemether-Lumefantrine Africa Malaria Report Centre for Disease Control and Prevention Dichloro Diphenyl Trichloro-ethane Department for International Development (United Kingdom) Group of Eight Highly Industrialized Countries in the World Gross Domestic Product Gross National Product Human Immunodeficiency Virus Intermittent Preventive Treatment Indoor Residual Spraying Insecticides Treated Net Maternal and Child Health Maternal Mortality Rate Muhimbili National Hospital Ministry of Health and Social welfare Integrated Vector Management National Malaria Control Programme Principal Investigator Roll Back Malaria Swiss Agency for Development and Cooperation Sulphadoxine Pyrimethamine Statistical Package for the Social Sciences Tuberculosis Tanzania Demographic and Health Survey World Health Organisation 7

8 PREFACE I am general practitioner from Tanzania, one of the malaria endemic country in Sub-Saharan Africa in which this disease is a major cause of socio-economic problem with about 90% of the population at risk. During my daily clinical practice I have experienced a number of events concern the behaviour of caretakers of under-five children with malaria to seek appropriate treatment at health institutions late since the onset of child illness. Most of them mentioned cultural beliefs, lack of knowledge, poverty, gender inequity and inaccessible reliable health institutions as reasons for their delay. Malaria is a leading cause of morbidity and mortality in Tanzania especially among under-five children who might have been cured if prompt diagnosis and effective treatment was sought early. Thus in this thesis I have tried to highlight basic concept concerning malaria and the situation of this disease in Tanzania and globally. Identify some factors which seem to cause late health seeking behaviour among caretakers in the literature review and develop a study protocol for determining contributing factors and prevalence of late health seeking behaviour of under-five children with malaria at Muhimbili National Hospital, Dar-es-Saalam. 8

9 1. INTRODUCTION For far too long, malaria has been a forgotten epidemic. It s a disgrace that the world has allowed malaria death to double in the last 20 years, when so much more could be done to stop the disease. Millions of children have died from malaria because they were not protected by an insecticide treated nets or did not receive effective treatment. If we expand malaria control programs and invest what s needed in research and development, we can stop this tragedy (Gates, 2005) 1.1 Malaria basic concept Malaria is a disease which resulted from invasion of the human erythrocytes with one of the four species of Protozoan parasite of the genus Plasmodium namely falciparum, vivax, ovale and malariae. Plasmodium falciparum causes the most fatal type of malaria termed as malignant tertian malaria which actually contributes to the majority of mortality from this group of disease. Malaria is usually acquired following a bite by previously infected female Anopheles mosquitoes while taking its blood meal. Inside the human host the plasmodium parasite subjected to series of changes as a part of its complex life cycle which eventually allow it to invade the immune system of the host, infect the liver and red blood cells. Finally develop into a form that is able to infect uninfected mosquito when bites an infected person. Inside the mosquito, the parasite matures into asexual form which is capable of infect a human being when the infected mosquito takes her next blood meal, or more days later (RBM, 2001). Other mode of transmission is through transfusion with malaria infected blood as well as congenitally acquired. Malaria symptoms normally appear 9-14 days after infectious mosquito bite especially for the case of Plasmodium falciparum infection. Patients usually present with fever, chills, shivering, profuse sweating, headache, vomiting, joints ache and flu like symptoms. Children may present with quite variable and difficult to recognize symptoms as compared to adult patients which may include loss of appetite, vomiting everything, extreme body weakness, restlessness, cough, diarrhoea, palmar pallor and convulsion (MOHSW, 2006). The infection can progress rapidly to become life threatening unless early diagnosis and effective treatment is done. 1.2 Global burden of malaria Globally malaria is a disease of public health importance. Annually there are million 9

10 illness episodes which resulted into million deaths, particularly in poor people societies in Africa, Asia and Latin America (Bruce-Chwatt, 1993) of which more than 90% occur in African children (WHO, 1996). Sub-Saharan Africa alone contributes approximately 90% of the globally total malaria episodes. More than 10% of total disease burden in this region is due to malaria (Basch, 1999) million illness episodes occur annually which resulted into million deaths, majority in under-five children (WHO, 1996; 1997). Malaria contributes 25-40% and 20-50% of all out patient visits and admissions in health institutions in endemic countries of this region, whereby it is estimated to be responsible for at least 20% of all under-five children deaths (AMR, 2003). Thus malaria together with HIV/AIDS and tuberculosis (TB), are the major public health challenges which undermining development of the poorest countries in the world. 1.3 Global management of malaria World Health Organisation (WHO) together with Roll Back Malaria initiative (RBM, 2001) recommend prompt and accurate diagnosis of malaria together with early treatment with safe and effective anti malarial drugs within 24 hours of onset of symptoms. With the aim of minimising progression to severe disease due to treatment delay which is usually associated with a high mortality in non immune patients especially under-five children in endemic areas. Emphasize is on ensuring the management is appropriate with the respective national diagnostic, treatment and referral policy (WHO, 2004b). 1.4 Global malaria prevention and control Intermittent preventive treatment (IPT) has been recommended by WHO to be used by pregnant women living in areas with moderate or high transmission of malarial parasite to reduce the risk of maternal anaemia, stillbirth, spontaneous abortion, low birth weight and neonatal death. At least two preventive doses of sulphadoxine pyrimethamine (SP) should be given during their routine antenatal clinic visits, an intervention that has been found to be safe, inexpensive and effective. It has been integrated into the malaria control programmes in a number of endemic countries (WHO, 2004b; RBM, 2001). Vector control remains the most effective measure to prevent malaria transmission and hence morbidity and mortality reduction. WHO recommend a systematic approach based on evidence and knowledge of the local situation namely integrated vector management (IVM). It emphasizes a decision making process for the vector control based on taking into account 10

11 utilization of available health infrastructures and resources. Integrate them with available and effective measures such as chemical, biological or environmental management measures in preventing malaria transmission. Insecticides treated nets (ITNs) have been used as both effective vector control and personal protection especially to the groups with the highest risk of malaria, young children and pregnant women. Use of ITN has been shown to reduce severe disease and all cause mortality in endemic areas by about 20% (WHO, 2004b). Various strategies have been implemented to encourage the use of ITNs, especially in pregnant women and under-five children in endemic areas. WHO, RBM initiative, donors, global fund and other public-private partnership has put a lot of efforts in mobilization of resources for ITNs use promotion as personal protection method by ensuring wide coverage of ITNs at affordable price and its re-treatment process. They have initiated a subsidies scheme on ITNs manufacturing to encourage development of local industries which manufacture ITNs so that to ensure sustainable availability (WHO, 2004b; RBM, 2001). Indoor residual spraying (IRS) remains as a valuable intervention in malarial control by reducing transmission through reducing the survival on malaria vector entering houses or resting on walls using whopes substance such as Dichloro Diphenyl Trichloro-ethane (DDT) (WHO, 1995). WHO re-introduced it in September 2006 as one of the effective vector control measure in malaria endemic areas although this method require well-trained personnel, infrastructures, adequate supplies, equipments, proper supervision and evaluation logistics for implementation. Other methods for vector control are fogging or spraying, larviciding, personnel protection through screening of houses windows and environmental approach. Environmental approach involves community participation in clearing of possible mosquito breeding sites such as ground pools, containers which contain water and grass areas. 11

12 2. LITERATURE REVIEW 2.1 Methods of literature search Pub Med, Medline, Science Direct and WHO data bases were searched using key words malaria, caretakers, under-five children, treatment seeking delay, knowledge, attitudes, practices, perceptions and beliefs focusing on various studies done in malaria endemic countries in different parts of the world. Most of the interesting literature reviews which were included were found in the Pub Med data base and Tanzania health research bulletin series. 2.2 Results of literature search The following factors found in the literature review which seem to contribute late health seeking behaviour among caretakers in different malaria endemic areas of the world; culturalcontext, community perception, knowledge, attitudes and practices and distance to the health institutions Cultural-context and treatment seeking Socio-cultural context is still playing a major role in community perception towards malaria and treatment seeking decisions in majority of community in developing countries. In a study in India it was found that socio-cultural factors were responsible for a number of human behaviour such as type of housing and sleeping habits which resulted into high malaria transmission and poor treatment seeking behaviour (Sharma et al, 2001). Cultural perception about febrile illness and its symptoms and existing gender system constraints has significant impact on health care seeking pattern and health outcome in childhood malaria. In Tanzania Kamat (2006) found that due to their cultural meaning towards malaria symptoms, mothers commonly believe that they are dealing with non serious febrile illness and hence preferring extended homebased treatment instead of going to the health institution. Also this could be due to gender inequity in Tanzania s communities whereby mother as a caretaker has to seek permission from her husband before send the child to a health institution which often results in treatment delays. Similar result was also found by Oberlander and Elverdan (2000) whereby socio-cultural perception lead to seeking different treatment options due to presence false perception on the causes of malaria in Tanzania Community perception and treatment seeking Majority of communities in malaria endemic areas have different perception on the cause, 12

13 symptoms and treatment of the disease which quite often has impact on the treatment seeking pattern and health outcome especially in under-five children. Some communities in Kenya believe malaria has a number of causes such as mosquitoes, wild vegetables, water and milk (Munguti, 1998). Similar situation was found in a study done in Uganda whereby Omusujja (malaria) was thought to be caused by food, drinks, environmental conditions and mosquitoes. People preferred to use local herbs as first choice followed by hospital care if herbs fail (Kengeya-Kayondo et al, 1994). Majority of caretakers in Kibaha district, Tanzania did not perceive convulsion as a symptom of severe malaria which probably affect treatment seeking pattern and hence health outcome (Tarimo et al, 2000). It was further found that although majority of the mothers (93%) seek care at modern health institutions once their children had malaria. They did not perceive febrile convulsion as a symptom of severe malaria and half of them gave traditional drugs for children with convulsions rather than send them to the health institution. They believe that, giving injection to a child with convulsion worsen the condition. This concur with a study done early in the same area which came out with similar results, whereby fever and vomiting were mentioned by caretakers as symptoms of severe malaria by 93% and 52% respectively as compared to convulsions,16% (Tarimo et al, 1998). Due to this perception, traditional healer has a role to play in the health outcome of children with severe malaria and caretakers treatment seeking pattern rely much on their perception. Hence they have an impact on people s choice of health care provider which is common when an illness is associated with witchcraft beliefs. Most of the caretakers reports to the formal health institutions when the condition has worsened. In Nigeria, despite of knowing symptoms and signs of malaria, traditional healer believe local herbs are more effective in treating severe malaria than modern drugs resulting in delaying of getting appropriate treatment. Majority have misconception that convulsion is inherited from parents (Okeke et al, 2006). Misconception that severe malaria in childhood is not associated with malaria was also found in Tanzania (Gessler, 1995). Recently a cross-sectional study in Kilosa and Handeni districts, Tanzania found that traditional treatment practice is not a delaying factor in management of severe malaria. Although both traditional healers and majority of the mothers (75%) perceived convulsions (dege dege) to be caused by evil spirits which resulted in ambivalence of where to seek 13

14 treatment. However traditional healer play a significant role in facilitating referral of those children to the health institutions after giving them first aid using modern anti pyretics which help to reduce fever and hence prevent worsen of the illness (Makundi et al, 2006). This concur with the findings from (de Savigny et al, 2004) study also in Tanzania which showed that traditional care is no longer a significant delaying factor in the management of childhood severe malaria as a majority of the caretakers were preferring modern care. Hence collaboration with traditional hearers on management of childhood severe malaria could reduce morbidity and mortality in endemic areas Knowledge, attitudes and practices Level of education of the caretakers is important on determination of the knowledge concerning cause, symptoms, treatment and prevention of malaria in children. Hence automatically has an impact on the treatment seeking pattern and health outcome of the child. In India it was found that poor knowledge on malaria transmission and prevention affect the treatment seeking behaviour in those communities (Singh et al, 2003). Poor knowledge also sometimes causes caretakers to be even unaware of both the vulnerability of children to malaria disease and how to practice appropriate homebased treatment which they prefer as compared to seeking treatment at the nearest health institution (Oguonu et al, 2005). Similarly in Sudan it was found that a majority of the mothers recognize malaria but they delay in seeking treatment at the health institutions because majority of them prefer to practice homebased treatment. If there is no response they select on whether to go the modern health care or to traditional healers, depending on availability of the nearest health institution, user fee, service satisfaction and beliefs (Malik et al, 2006). Slutsker et al (1994) in Malawi found that, high level of education in majority of caretakers in endemic areas is associated with moderate or high socio-economic status which influences treatment seeking behaviour and hence better health outcome. Children with caretakers from the households whose head has secondary education and moderate or high socio-economic status were more likely to attend clinic once they had malaria regardless the severity of the disease and age of the child. This was different to those from household with head who had no education or with low socio-economic status. Similar findings were found in Uganda and Tanzania which showed that high level of education of the caretakers is associated with better malaria related knowledge, attitudes and practices. Which eventually influences early 14

15 treatment and hence reduction of morbidity and mortality due to malaria (Njama et al, 2003; Tarimo et al, 1998) Distance to the health institution and treatment seeking Distance to a reliable health institution has been observed as a constraining factor in obtaining early and appropriate treatment especially in under-five children with malaria in majority of communities living in malaria endemic areas. Due to long distance to the reliable health institution services and transport costs, many residents in Sub-Saharan Africa receive initial treatment of febrile illness at home. Depending on using local herbs or modern drugs bought without prescription in local shops despite of lacking adequate knowledge on how to use them. In Sudan (Malik et al, 2006) found that availability and accessibility of the health institutions was a determinant factors in the choice of treatment among caretakers of underfive children. Caretakers have a number of options ranging from homebased treatment practice or local herbs use to treatment at health institutions. Exposure of caretakers to a number of options was obviously ending up with late health seeking. Similar results was found also in Ngorongoro district, Tanzania, where burden of seeking treatment was great, due to the fact that majority of the people (60%) had to travel for more than 4 kilometres through areas with wild animals to get medical attention (Mboera et al, 2005). Due to this long distance, unaffordable transport costs and low socio-economic status, majority preferring homebased treatment practice using drugs bought from retail market outlets. However others are consulting traditional healers which delay effective treatment. Poverty and inaccessible health institutions were also found to be barriers to access modern health institutions in Korogwe district, Tanzania (Mubyazi, 2005). Hence long distance to the reliable health institution, homebased treatment practice and poverty plays a significant role in treatment seeking delays in majority of communities in malaria endemic areas. 2.3 Conclusion From the literature review, it can be concluded that the factors contributing to the late health seeking behaviour among caretakers in various malaria endemic areas in the world are more or less the same, for instance socio-cultural beliefs and perceptions, lack of knowledge, attitudes, practices such as extended homebased treatment preferences, poverty, gender inequity and inaccessible health institutions. Most of the community in endemic areas they have beliefs and perception that convulsion is not caused by severe malaria but is caused by evil spirit or witchcrafts which significantly 15

16 affect their decision of where to seek treatment. As a result majority of them go to traditional healers. Gender inequity also affect early treatment seeking in most of the community whereby mothers cannot make their own decision, they have to seek permission first from their husband before sending children to hospital which result in unnecessary delays. Level of education of the caretakers is important on determining their knowledge, attitude and practices towards childhood malaria and thus health outcome of the child. High level of education among caretakers is associated with better knowledge, attitudes and practices regarding malaria and they seek treatment early which reduces morbidity and mortality. Caretakers with poor knowledge preferring extended homebased treatment instead of going to the nearest health institutions as they thought they are not dealing with serious febrile illness. Long distance to the reliable health institutions has been observed as a constraining factor in obtaining early and appropriate treatment in majority of communities living in malaria endemic areas. Most of them they are unable to meet transport costs due to their low socioeconomic status and hence practicing homebased treatment with unprescribed drugs bought from drug sales shops with unqualified sellers or consulting the nearest traditional healers. Finally, perhaps it is a time now to emphasize the improvement of living condition of peoples in endemic areas which should go simultaneously with poverty reduction, women empowerment, level of education and health institutions coverage improvement. Also emphasize collaboration with traditional healers on management of childhood severe malaria which could reduce morbidity and mortality significantly in endemic areas. Traditional healers could facilitate referral of those children to the modern health institutions after giving them first aid using modern antipyretics to reduce fever and hence prevent worsen of illness. Malaria control programmes in endemic areas should try to collaborate with traditional healer by giving them training on how to provide first aid to children with malaria simultaneously facilitate their referral to modern health institutions. This is crucial as it seems to be a window of opportunity for decreasing effective treatment delays. 16

17 3. BACKGROUND 3.1 Tanzania country profile Tanzania is located in East-Africa between longitude 29 o and 41 o east, latitude 1 o and 12 o south and is the biggest among East African countries (i.e. Kenya, Uganda and Tanzania).It has a population of over 39 million people and population growth rate of 2.9% per year. The union is formed by two sovereign states namely Tanganyika and Zanzibar in April Figure 1. Tanzania Map 17

18 Politically, Tanzania is the most stable country in East Africa and Great lakes region, with the history of passing three peaceful multiparty elections since re-introduction of multi party democracy 15 years ago with the 4 th phase government current in power. Tanzania has a mixed economy in which agriculture sector plays a key role as the largest contributor to the gross domestic product (GDP) as it contribute about 50% of national income. Other sectors are trade, financial and business services, industrial, tourism and rapidly growing mining sector. GDP has increased up to 6.8% in 2005 due to government initiatives to achieve sustainable economic growth and reduction of nationwide poverty. Tanzania was one of the highly indebted poor countries but its debt to the multilateral creditors, World Bank and International Monetary Fund, was cancelled during the G8 summit in 2005 so that to direct its resources to the poverty alleviation strategies and improving social services budget allocation. Currently the 4 th phase government is aiming at promotion of good governance, promoting private sector, human capital development. Through expansion of both local and foreign investments so as to achieve poverty alleviation and improving standard of living of people in Tanzania. 18

19 Table 1. Basic demographic data of Tanzania Area 945,000 km 2 Population 38,277,506 Population density 39/km 2 Population growth rate 2.9%/year Urbanized population 23% GDP per capita 251 US$ GNP per capita 246 US$ Poverty ~50% is living below poverty line Literacy rate Men = 80%, women = 67% Total fertility rate Life expectancy at birth Infant mortality rate Under-five mortality rate MMR 5.7 children/woman 51 years 68 deaths/1000 live birth 112 deaths/1000 live births 578 deaths/100,000 live births Total health expenditure (% of GDP) 4.3 Total health expenditure per capita (US$) 12 Source: national web site ( & (TDHS, 2005) 19

20 3.2 Malaria situation in Tanzania Tanzania is the third in Sub-Saharan Africa, after Nigeria and the Democratic Republic of Congo for having serious malaria problem (de Savigny et al, 2004). The epidemiological pattern in Tanzania is heterogeneous as it varies from intense perennial to highly seasonal low transmission for a relatively short time and sometimes epidemics in formally known to be free malaria areas (Mboera & Kitua, 2001). Eighty percent of the country is highly endemic with 90% of the total population at a risk especially the most vulnerable groups under-five children and pregnant women. It is the leading cause of both in-patient and out-patient health care in all ages, whereby for the case of under-five children it contributes 38% of outpatient attendance and 43% of their admission respectively (Kitua, 2003). It is estimated that 100, ,000 deaths occurs annually due to malaria among 16 million cases of which 70,000-80,000 deaths occurs in under-five children. Being responsible for 30% of national disease burden, malaria is therefore a major cause of socio-economic problem through prevention, treatment and death costs as well as reduced workforce productivity and school absenteeism. 3.3 Management of malaria and health care delivery in Tanzania The national malaria control programme in Tanzania (NMCP) is responsible in preparing national guidelines for diagnosis and treatment of malaria. Aiming at achieving safe, effective, affordable and accessible malaria case management in the country with rational drug use to minimise the development of drug resistance. NMCP is also responsible for coordinating preventive strategies country wide so that to reduce morbidity and mortality as well as socioeconomic losses caused by malaria. Management of malaria involve both symptoms and clinical signs based approach as a means of diagnosis and treatment in Tanzania. Categorised into four categories starting from category 1 as the lowest level up to category 4 as the highest level with sufficient clinical expertise (Table 2). 20

21 Table 2. Health care delivery in Tanzania Category Health care delivery 1 Composed of home, village/ community primary health care post, pharmacy and drug stores whereby service is being provided by parents/ guardians, community health workers and dispensing staff of drug stores. 2 Include dispensaries which are being served by clinical officers or their assistants, trained nurses/ public health nurses and MCH aides, pharmaceutical assistants and medical attendants. 3 Include health centres whereby services are being offered by assistants medical officers, clinical officers or their assitants,public health, midwife nurses and medical attendants, laboratory technicians/ assistants and pharmaceutical technicians/ assistants 4 This consist of district, regional/municipal and referral hospitals whereby services are being offered by specialists, medical officers,assitants medical officers, clinical officers, public health and nursing officers, midwives nurses, laboratory technicians/ assitants,pharmacists or pharmaceutical technicians and medical attendants. Source: MOHSW, 2006 The categories mentioned above should not be looked at as a rigid sequence of referral procedures. Instead a well trained health worker is supposed to be able to recognise the severity of malaria and refer the patients directly to the most appropriate category of care consistent with that condition for specialized management. Tanzania has just introduced Artemisinin based Combination Therapy drug. Artemether- Lumefantrine (ALu) as a first line drug for treating uncomplicated malaria instead of SP, after the parasite developed resistance against SP. Quinine is second line and treatment for severe malaria as well for treating children below 5 kilograms and pregnant women in the first trimester. For the case of malaria control and prevention, IPT using SP is also given to pregnant women in their routine antenatal visits according to WHO recommendation. The first dose is given between weeks of gestational age and the second one should be given at weeks. 21

22 Insecticide treated mosquito s nets use among pregnant women and under-five children living in endemic areas have shown remarkable benefit in reducing malaria exposure, transmission and its associated risks. It has been shown to reduce all cause mortality by about 20% and also child mortality by as much as 40% (WHO, 2004a). Since Tanzania adopted a new policy for treated nets, various strategies were implemented in scaling up the coverage country wide through increase in production and sustainable market. Promotion and distribution measures were also emphasize through introduction of discount voucher system in purchasing treated nets for under-fives and pregnant women. These strategies achieve to reduce out pocket costs from more than 3.00 US$ to as little as 0.25 US$. National insecticide treated nets programme was established simultaneously with public-private partnership initiatives. Partners such as global fund, Swiss agency for development and cooperation (SDS), United Kingdom department of international development (DFID), US president s malaria initiative were involved. Together with non-governmental and faith-based organizations to facilitate achievement of these goals (REAPING, 2003). Today more than 20% of households have access to treated nets country wide (CDC, 2005) and almost 50% of all households own at least one mosquito net (TDHS, 2005). For the case of other vector control methods, Tanzania mostly utilizes the environment management through emphasizing community participation in clearing of possible mosquitoes breeding sites. Ground pools, water in artificial containers, septic tanks coverage and grass areas are cleared from the family level up to the entire community. Malaria control programme is about to start using Indoor residual spraying (IRS) national wide, after getting guideline from the ministry of health. IRS was previously used occasionally in refugees camps in northern-western Tanzania as a means of epidemic prevention and control. 3.4 Justification of the study Malaria is a major public health concern in Tanzania especially among pregnant women and under-five children. It is a leading cause of morbidity and mortality in both outpatient attendance and admissions (Kitua, 2003). Malaria poses a high burden in societal and economic terms ranging from prevention, treatment and death costs to low productivity at work places and school absenteeism. Late health seeking behaviour among under-five children caretakers which is inconsistent with Abuja target (REAPING, 2003) is still a problem in majority of communities in Tanzania 22

23 which resulted in high morbidity and mortality. However, no study has been done to address the magnitude and determinants of late health seeking behaviour among caretakers in a tertiary referral hospital as Muhimbili National Hospital (MNH) and larger city like Dar-es- Saalam. As the country is facing socio-economic burden due to this disease, results of this study could help to devise measures to decrease delays during treatment seeking process. Hence decreasing morbidity and mortality due to malaria in under-five children according to national Malaria Medium Term Strategic Plan (MOHSW, 2003). 23

24 4. AIMS The aim is to review the literature on factors contributing to the late health seeking behaviour among caretakers of under-five children with malaria and to develop a study protocol to estimate the prevalence of late health seeking behaviour among caretakers of under-five children with malaria at MNH, Dar-as-Salaam and to determine its contributing factors. Caretakers sought treatment for the first time at any health institution within 24 hours since the onset of childhood illness will be considered to be early/ appropriate and those sought treatment after more than 24 hours elapsed will be considered to be late caretakers. 24

25 5. SUBJECT AND METHODS 5.1 Study area The study will be conducted in the department of Peadiatric and Child Health at MNH, Daras-Salaam. A tertiary referral and teaching hospital in Tanzania, with 1000 beds and providing services to about 1000 out-patients daily. The paediatric department is responsible for providing care to children below twelve years of age. 90% of about children attended per day are under-five children and half of them have malaria (Kitua, 2003). The department is chosen because it receives referred children who need further management from peripheral health institutions especially those located in Dar-es-Salaam, such as dispensaries, health centres and three municipal hospitals. There are also a few self-referral patients seeking treatment directly at the hospital. Dar-es-Saalam is the fastest growing city in Tanzania with about 3.5 million inhabitants. Characterized by hot and humid tropical climate with two rainy seasons occurring between October-December and February-May months. Malaria transmission occurs throughout the year, however intense transmission usually occurs during the rainy seasons. After arriving at MNH, the ill child get first aid treatment to stabilize his/her condition at the casualty unit of the paediatric department. Blood slide for malaria parasite investigation is routinely done at this unit before transferring them to wards for further management. Underfive children diagnosed with malaria require at least 24 hours close observation at MNH because of their unpredictable condition changes and investigation requirements, regardless the time period which has elapsed before their caretakers seek treatment. Principal investigator and his assistant they will work closely with casualty medical officers in identifying and obtaining study participants at the casualty unit. 5.2 Study design This study will combine qualitative and quantitative research methodologies with the aim of integrating complementary strength of both methods so as to access enriched, elaborative understanding of the phenomenon of interest. In this context late health seeking behaviour and contributing factors among caretakers with children with malaria at MNH (Morgan, 1998). 25

26 5.3 Study population The study population constitute of all caretakers of under-five children with malaria available at MNH during the study period. Because of the prevailing gender-relationship in African cultural-context, majority of caretakers who are expected to be found in hospital are women. Also convenient selected six clinical/medical officers, two from each of the three convenient located peripheral health institutions namely dispensary, health centre and a municipal hospital in Dar-es-Saalam, will be interviewed to explore their experience of caretakers with under-five children with malaria who seek treatment late. 5.4 Qualitative study (I) A qualitative study is an inquiry process of understanding based on distinct methodological of traditions of inquiry that explore a social or human problem (Creswell, 1998). This qualitative study will consist of in-depth interviews of the caretakers in the first part and of the clinical/medical officers in the second part Study period The qualitative study will be carried out during October- December rainy season Sampling method Approximately 20 caretakers will be selected purposively, half of them will be those who had sought treatment early and half of them had sought treatment late. The total number of caretakers who are going to be involved in qualitative interviews will depend with attainment of saturation point. Purposive samples are thus considered theoretically representative of their source population, by trying to represent their range of variation, so that information obtained from them is credible and generalisable. Also the sampling is supposed to be adaptive to what is being learned in the research process, guided by a desire to select cases differ in certain characteristics of interest who could contributing to the working hypothesis and eventually illustrate the range of variation within the study area (Dahlgren et al, 2004). 26

27 5.4.3 Measure instrument Qualitative interviews will be conducted using a standardized interview guide with short and clear open ended questions so as to capture subject reality. The guide will be made up by themes identified from literature review as potential determinants of treatment seeking behaviour among caretakers such as cultural beliefs/ perceptions, level of education and gender-relationship in decision making process concern treatment seeking. Also socioeconomic status of the caretakers households and distance to the nearest health institutions. The guide will be tested in a pilot study and modifications will be incorporated into the final interview guide. To check whether themes are understandable with the presence of expected good response and if any necessary modification is needed due to new ideas which were not anticipated during study planning (Kelly et al, 2003). The guide will be translated to swahili and then back to english version for the final study. Tape recorder will be used also after seeking permission from informants to ensure accurate recording of all responses from them and investigators will be trained how to tape recording interviews accurately Data collection procedure The qualitative interviews of caretakers agreed to participate will be carried out in a private room located within paediatric wards complex by a PI and one assistant. One interview session per day will be conducted so that insight gained from each interview after preliminary analysis could be used in the next session. Interview guide themes will be explored in order to gain deeper understanding of factors contributing to the late health seeking behaviour and caretakers will be interviewed until saturation point is attained. Qualitative interviews of clinical/medical officers will be carried out in their health institutions. Apart from potential determinants of treatment seeking behaviour themes, exploration will also be done on their experience of attending caretakers who seek treatment late at their institutions. Guidelines concerning child referral criteria, how urgent the process is being done and if there is any unnecessary delays will be explored too. This is important to establish as a majority of patients referred to MNH come from the peripheral health institutions. 27

28 5.4.5 Data analysis Analysis will be carried out simultaneously with data collection so that saturation could be identified in proper way. Analysis will focus on interpreting the caretakers experience thematically whereby the tape recorded interview data will be transcribed to verbatism (written text) and analyzed qualitatively through an interpretative inductive approach, using grounded theory involving reflexive process moving back and forth between data on a sentence-by-sentence basis. Memoing in relation to each sentence will be done followed by an attempt to establish patterns and links between emerging themes by trying to abstract, conceptualize and develop categories and core categories from transcribed data. Then these categories will be linked into new concepts, hypothesis, models and theories which give out the themes of what is happening in the transcribed data. Finally, the meeting between these discovered themes and existing theories/ themes concerning treatment seeking behaviour will be made. Gender-relationship perspective has emerged as one of the important themes for the case of african cultural-context, by having an influence on other themes in the interview guide. Women (mothers) are responsible for daily caring of the children from feeding issues, general cleanliness and other caring activities such as when to send them to health institutions once they are sick. However, men (fathers) are controller of the household resources and responsible for making decision in all household related matters for example treatment seeking issues without assistance from their wives, which often resulted into unnecessary avoidable delays. Thus exploration of this theme is important also in understanding contribution of other themes in the late health seeking behaviour Qualitative study trustworthiness Trust worthiness of the qualitative study will be considered with respect to the following criteria; credibility, transferability, dependability and confirmability. Credibility; To achieve credibility, the researcher will use a triangulation of cross sectional and in-depth interview methods for exploring the same topic. Spending a lengthy period with participants during interviews and send results/interpretations back to them for clarification and confirmation. Transferability; Will be achieved through purposively sampling selection to ensure each 28

29 subject selected contribute to the theory that is being generated. This will ensure knowledge gained from that theory fit all scenarios identified in a larger population. Also a thick description of the research context will be done so that choice could be made about transferring generated knowledge to other context. Dependability; Will be achieved by keeping records concerning methodological decision and different types of personal notes/memos used during the study as important tools for future decision audit. Confirmability; Will be achieved by ensuring that study conclusion is grounded in the data. 5.5 Quantitative study (I1) The quantitative study will be a cross-sectional survey based on a structured questionnaire, which is easier to conduct and cost effective as compared to other quantitative study designs. Magnitude in terms of prevalence will be estimated, which will be helpful in planning and implementation of a relevant intervention against late health seeking behaviour and hence reduce morbidity and mortality in under-five children Study period The quantitative study data collection and preliminary analysis will be done simultaneously for about three months during February-May rainy season. However there will be also additional two months after data collection for final analysis. February-May rainy season, is a period of the year with intense malaria transmission among underfive children because of an increase in mosquitoes breeding sites due to heavy rain fall. Late health seeking behaviour is often experienced among caretakers during this period of the year because majority of them are busy engaged themselves in various socio-economic activities such as agricultural activities which often results in treatment seeking delay once their children are sick Study participants All caretakers with under-five children with malaria available at MNH during the quantitative study period will be invited to participate. 29

30 5.5.3 Measure instrument A structured questionnaire will be developed for the quantitative study consisting of both open and close ended questions (Harge & Cahill, 1998). The first draft of the questionnaire will include socio-demographic characteristics and the time which elapsed before the caretakers seek treatment for the first time at nearest health institution since the onset of child illness. The questionnaire will explore caretakers level of knowledge towards malaria symptoms, transmission and prevention, treatment option the caretaker use after the onset of illness. Also will explore on socio-economic status of the caretaker, decision making process concern treatment seeking in the caretaker s household, current condition of the child at the hospital and distance caretaker lives from the nearest health institution. Findings from preceding qualitative study concerning late health seeking behaviour will be incorporated too into the questionnaire. The questionnaire will be tested in a pilot study and any modification will be incorporated into the final questionnaire. The pilot study is important to know whether respondents understand the questions and to get highlights of other potential problems such as poor response rate (Kelly et al, 2003) Data collection procedure The PI will be responsible for the data collection process with assistance from one investigator with medical background for example a nurse or a medical officer who will be involved on daily basis administering and collection of all filled questionnaires after data collection activities. An investigator will be trained and supervised during administering questionnaire to avoid errors in the data that can be introduced by an incompetent investigator. Structured questionnaires will be filled personally by an investigator during data collection to ensure accuracy and completeness. All data collection activities will be carried out in a private room located within paediatric wards complex daily except weekends during the study period Main outcome measure Main health outcome measure will be prevalence of late health seeking behaviour among caretakers which will be defined by number of caretakers who had sought treatment for the first time at the nearest health institution in more than 24 hours since the onset of childhood illness per total number of caretakers who will be present during the study period at MNH. 30