Home treatment with shop-bought drugs is assumed to be the most common approach to malaria throughout sub-Saharan Africa. But research by the Danish Bilharziasis Laboratory amongst mothers shows this is not true in rural Gambia, where less than 10 % of children are treated with anti-malarials at home. Attempts to improve access to rapid treatment here should focus on government health centres, the researchers conclude.

Most young children dying from malaria do so within two to three days of getting ill. So the speed of malaria diagnosis and treatment is critical in reducing death rates. By cutting the delay before treatment, use of anti-malarials at home could save many lives. But is this approach valid in every setting?

The researchers interviewed a random sample of 917 women in 57 villages around the rural Gambian towns of Farafenni, Kaur and Soma. Only 8 % of them have had a formal school education or adult literacy training. The interviews revealed that:

• Mothers most commonly recognise fever (94 %) and vomiting (79 %) as signs that their child has malaria. Only half of them know that mosquitoes can spread malaria.
• One in three families keeps medicine at home in case of illness, but only 8 % have chloroquine. This is more common among better-educated parents, wealthier households and those further from a health facility.
• Typically the first response to malaria in a child is to try to reduce the fever at home. Steps taken at home included giving the child shop-bought paracetamol at home (60 %) or to sponge the child with tepid water (20 %). 16 % use herbal remedies.
• Prompt treatment with an anti-malarial is rare. Only 8 % of families use chloroquine at home. Home treatment is more common among better-educated parents and wealthier households. But two-thirds of the mothers reporting home-treatment with chloroquine do not know the correct dose for a child.
• It is unusual to take a child with ‘malaria’ to a local healer, but government health services are popular: 63 % visit a health centre or outreach clinic and 13 % use a village health post. But nearly a quarter of children with 'malaria' get no anti-malarial drugs at all.
• The average amount spent on drugs and transport is US$ 0.05. Families giving anti-malarials to children at home spend more than other households.

Treatment is free for children under five years at government health facilities and people usually walk to seek treatment. Active policing of the drug control and licensing policy limits the private market to urban areas. So unless a stock of anti-malarials is kept at home (which is rare), home treatment offers no cost savings over travelling to the clinic where treatment is free.

The researchers recommend taking a setting-specific approach to speed up malaria diagnosis and treatment. Policy needs to be based on knowledge of local treatment practices in both rural and urban areas. In countries with a strong private market for anti-malarials and where drugs are widely available, policy-makers should try to improve home treatment for malaria. Health education here should include men, who influence treatment decision-making and pay for drug purchases. Where use of government health services is high, they should try to find equitable ways to increase access to minimise treatment delay. Strategies include improving primary healthcare services and expanding outreach services.

Source(s):
‘Home treatment of ‘malaria’ in children in rural Gambia is uncommon’, Tropical Medicine and International Health 8 (10): 884-894, by S. Clarke, J. Rowley, C. Bøgh, G. Walraven and S. Lindsay, 2003
'Early treatment of childhood fevers with pre-packaged anti-malarials in the home reduces severe malaria morbidity in Burkina Faso', Tropical Medicine and International Health 8: 133-139, by S.K.A. Sirima et al, 2001
'Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial', The Lancet 356: 550-555, G. Kidane and R. Morrow,  2000

Funded by: Danish Bilharzia Laboratory; Danida

id21 Research Highlight: 7 January 2004

Further Information:
Siân Clarke
Gates Malaria Partnership
London School of Hygiene and Tropical Medicine
50 Bedford Square
London
WC1B 3DP
UK

Tel: +44 (0)20 7299 4642
Fax: +44 (0)20 7299 4720
Contact the contributor: sian.clarke@lshtm.ac.uk

Danish Bilharziasis Laboratory

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