Caregivers’ Treatment-Seeking Behaviors for Malaria in Children Five and Under: A Field Study in Uganda’s Butaleja District

Background: Reducing malaria mortality is a global priority. Uganda has focused its national strategic plan to have by 2010: 85% of children under five receive first-line antimalarials within 24 hours of fever onset and following diagnostic confirmation. In 2004, artemisinin-combination therapies (ACTs) were adopted as first-line treatment for uncomplicated malaria in children older than 4-months. Method: A three-study series investigated caregivers’ malaria related treatment-seeking behaviors for young children to inform future public health initiatives in Uganda’s Butaleja District: a literature review, a household survey, and a multiple case study. In this document, these appear as three manuscripts in Chapters 2-4. Results: While drug delivery improvements have increased ACT usage, these studies concur that initiatives still failed to meet the 2010 national target. Only 21% of children received blood tests, 31.6% received no antimalarials, 31.6% received “appropriate” (only first-line) antimalarials, and 36.8% received subordinate antimalarials. Among subordinates, 5.8% of children were mis-prescribed ACTs and 22.4% received ACTs and subordinate antimalarials. Home management was an important initial treatment source since visits to public facilities were commonly associated with hardships. Caregivers’ knowledge and preference about antimalarials varied with prior experiences and beliefs. The survey evaluated 160 behavioral questions in determining four independent predictors of likelihood that a child would receive an “appropriate” antimalarial: obtaining antimalarials from regulated outlets (OR=14.99); keeping ACT in the home for future use (OR=6.36); reporting they would select ACT given the choice (OR=2.31); and child’s age older than 4 months (OR=5.67). The study further employed the Health Belief Model to identify 10 scales of “Assets” and “Challenges” to guide more precise insights into caregivers’ behaviors. Four “Asset” scales predicted significantly whether a child received an “appropriate” antimalarial: Precursors to Receiving an Appropriate Antimalarial (R2=21%); Episode Management (R2=39%); Caregiver Knowledge (R2=6%); and Professional Assistance with Critical Decision (R2=9%). Similarly, two “Challenge” scales were significant predictors: Lack of Assistance with Critical Decision (R2=9%), and Problems Obtaining a Best Antimalarial (R2=4%).Conclusions: To conform practice to policy, this research sequence highlighted the importance of engaging the full spectrum of stakeholders in public health initiatives to manage malaria, including licensed and unlicensed providers, caregivers and family members.