Care-seeking patterns for fatal malaria in Tanzania

Abstract

Background: Once malaria occurs, deaths can be prevented by prompt treatment with relatively affordable and efficacious drugs. Yet this goal is elusive in Africa. The paradox of a continuing but easily preventable cause of high mortality raises important questions for policy makers concerning care-seeking and access to health systems. Although patterns of care-seeking during uncomplicated malaria episodes are well known, studies in cases of fatal malaria are rare. Care-seeking behaviours may differ between these groups.

Methods: This study documents care-seeking events in 320 children less than five years of age with fatal malaria seen between 1999 and 2001 during over 240,000 person-years of follow-up in a stable perennial malaria transmission setting in southern Tanzania. Accounts of care-seeking recorded in verbal autopsy histories were analysed to determine providers attended and the sequence of choices made as the patients' condition deteriorated.

Results: As first resort to care, 78.7% of malaria-attributable deaths used modern biomedical care in the form of antimalarial pharmaceuticals from shops or government or non-governmental heath facilities, 9.4% used initial traditional care at home or from traditional practitioners and 11.9% sought no care of any kind. There were no differences in patterns of choice by sex of the child, sex of the head of the household, socioeconomic status of the household or presence or absence of convulsions. In malaria deaths of all ages who sought care more than once, modern care was included in the first or second resort to care in 90.0% and 99.4% with and without convulsions respectively.

Conclusions: In this study of fatal malaria in southern Tanzania, biomedical care is the preferred choice of an overwhelming majority of suspected malaria cases, even those complicated by convulsions. Traditional care is no longer a significant delaying factor. To reduce mortality further will require greater emphasis on recognizing danger signs at home, prompter care-seeking, improved quality of care at health facilities and better adherence to treatment.

Figure 1

Risk of malaria transmission. Length of malaria transmission season in Tanzania based on the MARA climate model. (Source, Ministry of Health TEHIP and MARA-Tanzania).

Figure 2

Initial care-seeking patterns. Care of first resort sought during the final illness by 320 fatal "malaria" cases in children less than five years of age in the Rufiji DSS sentinel area, 1999–2001.

Figure 3

Frequency of care-seeking events. Distribution of frequency of care-seeking events at differing categories of provider among those who sought care during the final illness in fatal episodes of malaria in 320 children under five years of age with (dark shading) and without convulsions (light shading).

Figure 4

Loyalty to first provider. Comparison of loyalty to first provider of modern or traditional care during the final illness in fatal cases (all ages) that saw two or more providers.