ABSTRACT

This PhD dissertation is based on a health unit-based study that investigated treatment seeking patterns and practices for children with severe malaria in Busia district in eastern Uganda. The principal respondents were 210 consenting caretakers of children seeking treatment at the district referral unit and diagnosed with severe malaria between October 2001 and March 2002. An ecological perspective was adopted, emphasising the interplay between intrapersonal, interpersonal and community (including service delivery and policy) factors in treatment seeking. Caretakers' own accounts of the development of symptoms and the efforts to get treatment illustrate the interaction of symptom recognition, mobilisation of assistance, medication and the problems of using the government health facilities.

The study showed that 82% of the children were given pharmaceutical medicines in the home before being taken to the health unit. Of these, 55% were given pharmaceutical medication within 24 hours of onset of illness. One in four (26%) children was first given antimalarials. One in five (19%) was given antimalarials within 24 hours of onset of illness. The crucial issue for the children in this study was that caretakers needed to recognise when the illness was severe, requiring treatment at the health unit. Convulsions and difficulties in breathing were perceived as danger signals, but only half the children who convulsed were taken to the health unit on the same day. The ready availability of drugs from private sources facilitated continuation of home treatment for too long in some cases.

Only 17% of the caretakers contacted the health unit as a first option. Unavailability of drugs and inadequacies at health units are some of the reasons why patients contacted them late. The district referral unit did not have enough quinine, intravenous fluids and giving sets, nor could it provide blood transfusions. This inhibited its ability to treat severe malaria. There was referral from a higher level of service (health Centre level IV) to a lower level of service (health Centre level III) especially for blood transfusion. The conclusion is that ensuring effective service delivery at public health units is as important as illness identification and home medication by the caretaker in improving treatment seeking for severe malaria.