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Access to Appropriate Malaria Treatment Among Children in the Chikhwawa District of Malawi

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Access to Appropriate Malaria Treatment Among Children in the Chikhwawa District of Malawi Access to appropriate malaria treatment among children in the Chikhwawa district of Malawi Thesis submitted in accordance with the requirements of the University of Liverpool for the degree of Doctor of Philosophy by Victoria Louise Ewing June 2012 1 Abstract Access to appropriate antimalarial treatment is essential to reduce the impact of malaria - a major cause of morbidity and mortality in Malawi. This study responds to recent calls to improve access to malaria treatment, by providing insight into existing barriers and making suggestions for improvement. It is among a limited number of studies which explore multiple dimensions of access. A mixed-methods approach was taken to investigate the influence of a number of factors on access to appropriate treatment among children in the Chikhwawa district of Malawi. Two cross-sectional household surveys enabled quantification of differences in health facility attendance between two study areas, which differed in terms of distance from health facility and ethnic and cultural backgrounds. Mean costs associated with childhood fever were calculated and compared between study areas. Qualitative methodologies provided insight into caregivers’ behaviour during treatment- seeking and after receiving antimalarials. The study found that individuals engaged in a three-phased approach to treatment-seeking. During Phase 1 caregivers assessed the illness in order to establish the need for care and appropriate action. Phase 2 involved seeking care outside of the home, in most cases from a health facility. However a number of barriers to health facility attendance were identified, including: geographic location, direct and opportunity costs; women's lack of decision-making and financial autonomy; and perceptions of available care. Health facility attendance did not guarantee appropriate treatment. Adverse events, such as vomiting; lack of understanding of the correct dosing schedule; and challenges associated with administering antimalarials to children impacted on adherence. Treatment failure led to Phase 3, which frequently involved returning to the health facility. However, repeated treatment failure, fear of receiving repeated antimalarial treatment, and advice from health facility staff led caregivers to seek alternative sources of care, such as traditional healers. This thesis provides a valuable addition to our knowledge of multiple dimensions of access to appropriate malaria treatment. Caregivers experience a number of barriers during treatment- seeking and utilisation of antimalarials, and equity of access remains a challenge. The issues raised within this thesis are specific and targetable, and the findings indicate the considerable potential impact of strengthening the existing community-based treatment and referral system, community- based health education, and diagnosis and treatment at health facility level. 2 Declaration I declare that this thesis has been composed by me and that it presents work which I undertook under the guidance of my supervisors David Lalloo and Miguel Sanqoaquin. Additional support came from the following individuals: Lindsay Mangham provided guidance during the design and implementation of the economic aspects of the study Rachel Tolhurst provided guidance during the design and implementation of the qualitative research Esther Richards provided comments throughout drafting of the thesis Mavuto Mukaka provided advice on the statistical analysis The contributions of other individuals, such as my research assistant Andrew Kapinda are clearly stated within the text. A limited analysis of the first round of the household survey (dry season) data was submitted in part fulfilment of an MSc in Public Health in Developing Countries at the London School of Hygiene and Tropical Medicine. 3 Acknowledgements This thesis would not have been possible without the input of a number of people, both in the UK and Malawi. Firstly I am grateful to my supervisors, David Lalloo and Miguel SanJoaquin: David, for his breadth of knowledge and experience and making sure that I submitted before the arrival of baby Ewing; Miguel for his dedicated support and pastoral care. I would also like to thank Lindsay Mangham and Rachel Tolhurst, for contributing their expertise to the design and implementation of the study. Thanks also to Esther Richards, for her encouragement and helpful responses to my queries throughout the writing up process. I owe a huge debt to Anja Terlouw for going beyond the call of duty to provide logistical support, assisting with funding applications and always making the time. The study was financially supported by the ACT Consortium, which is funded through a grant from the Bill & Melinda Gates Foundation to the London School of Hygiene and Tropical Medicine. I would also like to thank the Ministry of Health in Chikhwawa and the various village head persons who gave permission for the study to take place. The study would not have been possible without the generous contributions of the study participants, who gave their time and shared their experiences. I’m grateful to all those living in Mbame, who graciously accepted us into their community, and especially Esnat, for always being ready with a plate of nsima! I am immensely thankful to all of the MLW staff who contributed to the project, especially the members of the ACTia team: Arantxa Roca-Feltrer – the maps of the ACTia field-site are hers, Paul Chipeta, James Chirambo, Emma Nyirenda, Clara Tembo, Kondwani Mzembe, Fletcher Nangupeta, Andrew Naunje, Frank Mbalume, Friday Nantonwe, Sara Magombo, Maria Milinyu, Isaac Kamvazakazi, Austin Kadulo and Flaless Mhango who was a loved member of the team and is sadly no longer with us. There are many others who contributed to the work: Andrew Kapinda, my research assistant who worked diligently to keep the work on track and made many useful contributions. Simon Simbi, who demonstrated abundant patience and perseverance during two years of Chichewa lessons; I am thankful for the many hours he spent explaining Malawian beliefs and customs, answering my endless questions and translating my data. A big thank you goes to Catherine Amasi for transcribing the sound files and the other members of the transcription and translation team, who conducted the quality assurance. 4 There are many friends who helped me make it through. Hannah – thanks for your friendship over the years; Rory and Charlotte, for teaching me so much; Eugene, Annie, Tandu, and all the PhDers who brightened the dull moments, especially Mavuto for the early morning chats and faithfully answering my statistics questions. Finally I would like to thank my parents for their unending support: Mum, for leaping into action when I gave her two months notice that I was getting married and moving to Malawi(!); Dad, for his wisdom, and always being on the end of the phone; and of course my brothers and sisters. I’m thankful to my in-laws for their hospitality and support. Finally my husband and rock of support, Simon, for countless hours of computer programming, generally being an IT whizz, not letting me give up, and for making so many huge sacrifices to ensure that I completed this thesis. 5 TABLE OF CONTENTS GLOSSARY OF ABBREVIATIONS, TERMS AND DEFINITIONS .......................................................... 10 CHAPTER 1 INTRODUCTION ................................................................................................... 14 1.1 INTRODUCTION .................................................................................................................................... 14 1.2 BACKGROUND TO THE RESEARCH .............................................................................................................. 14 1.3 WHAT IS ACCESS?................................................................................................................................. 15 1.4 JUSTIFICATION FOR THE STUDY ................................................................................................................. 17 1.5 AIMS AND OBJECTIVES OF THE THESIS ........................................................................................................ 18 1.6 METHODOLOGICAL APPROACH ................................................................................................................ 18 1.7 ORGANISATION OF THE THESIS ................................................................................................................. 18 CHAPTER 2 LITERATURE REVIEW ............................................................................................ 21 2.1 INTRODUCTION .................................................................................................................................... 21 2.2 BACKGROUND TO MALAWI ..................................................................................................................... 22 2.2.1 Malaria in Malawi ....................................................................................................................... 22 2.2.2 Malawi Health system structure .................................................................................................. 23 2.2.3 Brief political and economic background of Malawi ..................................................................... 24 2.3 TREATMENT-SEEKING BEHAVIOUR FOR ‘MALARIA’ ........................................................................................ 27 2.3.1 Perceptions of malaria................................................................................................................
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