237

TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE (1992) 86, 237-239

The role of shops in the treatment coast of Kenya

and prevention

of childhood

malaria

on the

R. W. S~OW~~~,N. Peshu’, D. ForsteG, H. Mwenesi2 and K. Marsh1r2 1 Ke nya Medical Research Institute, P.O. Box 230, Kilifi, Kenya; 2Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DlJ, UK Abstract

A community survey of 388 mothers in a rural and peri-urban population surrounding a district hospital on the coast of Kenya revealed that the preferred choice of treatment for childhood febrile illnesses was with proprietary drugs bought over the counter at shops and kiosks (72% of interviews). 67% of the mothers who reported using shops claimed they would buy chloroquine-based drugs. Preventative measuressuch as mosquito nets were uncommon (6.2%), but the use of commercial pyrethrum mosquito coils was reported more frequently (46.4%). Separateinvestigations of treatment given to 394 children before presentation at hospital with severe and mild malaria was consistent with the reports in the community of high usage of shopbought anti-malarials and anti-pyretics. The involvement of the private sector in peripheral health care delivery for malaria is discussed. Introduction

Chemotherapv of febrile illnesses is still the mainstay of malaria co&o1 in much of Africa (ANONYMOUS, 19831.The focus for deliverv of anti-malarials has been throigh the regional and disirict hospital, health centre and primary health care infrastructure. A major constraint upon the reduction of malaria mortality has been accessibilitv to treatment centres UEFFREY, 1984). It has been estimated that only 20% of‘“Africa’s iural population have easy access to medical facilities (MACCORMACK, 1984): It is perhaps for this reason that, in countries such as Central African ReDublic. Zaire and Congo, the use of anti-malarials purchased lrom street venaois and traders in the presumptive home treatment of malaria is between 27% and 69% (BREMAN & CAMPBELL, 1988). Other possible reasonsfor the high utilization of shops could include lack of health awareness, overcrowded facilities, long waiting times and unnecessary referrals (HASSOUNA, 1983). The commercial sector may have an important role in the treatment of malaria at the peripheral level and yet shop-bought anti-malarials have received surprisingly little attention from either researchers or health planners. This paper describes the sources used by Kenyan mothers in the prevention and treatment of malaria in an areaof stable, high endemicity. Materials and Methods Study population

Kilifi District Hospital is situated on the Kenyan coast north of Mombasa. Approximately 50% of all paediatric hospital admissions come from an area40 km north and 30 km west of the hospital. Within this area there are 2 government dispensaries, an estimated 6 private clinics and over 500 licensed shops selling a variety of household goods and a limited range of pharmaceuticals. The areacomprises a peri-urban, administrative town encompassing the hospital (estimated population 9500) and widely separated, rural homesteadsalong the coast and inland to- an altitude of 250 m (estimated population 55 5001.The Giriama (a aroun of the Miiikendal are the largest’ ethnic group ‘in-the- area. Most of the rural population are farmers of maize for home consumption and coconuts and cashew nuts for cash crops. Those-who live close to the sea both farm and fish. The town dwellers constitute a variety of ‘white collar’ workers and traders. Sample recruitment

The study was carried out as part of a larger case-control study on the risk factors associatedwith the development of severe, life-threatening malaria which will be described elsewhere. This paper describesthe treatmentAddress for correspondence: 230, Kilifi, Kenya.

Dr Bob Snow, KEMRI,

P.O. Box

seeking behaviour of 2 groups of mothers. First, mothers of ‘well’ children recruited in the community (group A) co describe the general population’s malaria treatment and prevention practices. Second, a group of mothers of children with clinically defined malaria to describe prior treatments for these illnesses by a hospital-using population (groups B and C). Full details of the recruitment procedures for the casecontrol study will be presented elsewhere but, in brief, patients admitted to the paediatric ward at Kilifi District Hospital with a primary diagnosis of malaria were eligible for recruitment into the case-control study if they had one of the criteria shown in Table 1 (group B). Table 1. Definition Hospital, Kenya

of severe malaria at Kilii

District

Child admitted to the paediatric ward by clinical auxiliaries The child should have malaria as a orimarv diagnosis for admission and demonstrate one-or m&e gf the following conditions (i) Unrousable coma (ii) Anaemia with haemoglobin ~5.1 g/d1 (iii) Two or more generalized convulsions in the preceeding 24 h (iv) Parasitaemia 320% (v) Unable to sit unaided or take oral medication (vi) Death with confirmed diagnosis of malaria Age-matched controls were then selected from out-patients at Kilifi Hospital presenting within the next 14 d with a primary diagnosis of malaria (excluding the criteria shown in Table 1) and who had parasitaemia 2 10 000 per ~1(group C). The homes of both the severecaseand the mild out-patient case were then visited and agematched contr& were recruited from the communityat least 100 m from the index case’s home (erouu Al. All subjects were recruited only after inform;4 coiseni had been obtained fray the parents or normal guardian. Maternal interviews

Mothers of casesand controls were interviewed at the time of recruitment of their children by field staff fluent in the local languages, using a standardized interview protocol. Preceded responseswere recorded on the nature and source of treatments given to the child for the present illness; the utilization of local repellents, mosquito coils and canned aerosol insecticides in the room where the child slept; and the use of mosquito nets. Mothers were then asked an open-ended auestion without any additional prompts: “What do you do if your child has fever?” The answerswere coded separately into 15 types of response. Mothers were then asked to list the

238 drugs they would usually buy at a shop to treat fevers in their children. No prompts were given for this question.

Table 4. The numbers of mothers using different treatment practices for malaria episodes before recruitment at Kilifi District Hospital, Kenya

Results Between 1 May 1989 and 28 February 1991, 388 children were recruited as age-matchedcommunity controls for severeand mild casesof malaria. Reported treatment seeking behaviour for fevers and use of anti-mosquito measures by the community

The frequencies of responses by mothers of control children recruited in the community to the question ‘what do vou do when vour child has fever?’ are shown in Table 2. 272 (72.3Oi) of the respondents mentioned Table 2. Reported practice in the treatment of childhood fevers by 376 mothers in a community on the coast of Kenya

Practice Visit a health facility only Shop-bought drugs only Shop-bought drugs followed by visit to a health facility Tepid sponging followed by shop-bought drugs Tepid sponging and use of shop-bought drugs followed by visit to a health facility Tepid sponging followed by visit to a health facility Tepid sponging- only Use of traditional medicine followed by shop-bought drugs Pray for the child and give shop-bought drugs Visit traditional healer then go to hospital

Number

(%)

93 163

(24.7) (43.4)

88 12

(23.4) (3.2)

7

(1.9)

5 5

(1.3) (1.3)

1 1 1

(0.3) (0.3) (0.3) “In 12 interviews (3%) no responsewas recorded as the mother was either absent or unwilling to answer.

the use of shops for self-treatment of fevers. The most common treatment-seeking behaviour was the use of shops alone. The most frequently reported types of drug purchased were anti-pyretics (97.0% of mothers) and anti-malarials (69.4% of mothers). Table 3 indicates the Table 3. Reported use of anti-mosquito measures by mothers in a community on the coast of Kenya Type of measure Pyrethrum coils Aerosol insecticide Mosquito nets Local repellents Baobab fruits Mvumbani leaves (Ocium canum) Mkilifi leaves (Azadirachta indica) Coconut remains

Number (%) 180 (46.4) zzx i::;; 7; (32.2) 9

Source of treatment

Number (%) Mild Severe out-patient in-patient malaria malaria (n=186) (n=208)

Shop only Government health facilitv onlv Private health facility o&y . Traditional healer only Home remedies Shop and health facility Traditional healer and shop Other combinations including shops Other combinations excluding shops No treatment sought

130 (69.9) 13 17.0) 2 (i,ij 0 3 (1.6) 6 (3.2) 2 (1.1) 3 (1.6) 1 (0.5) 26 (14.0)

a4 (40.4) 43 (20.7) 5 ‘(2.4j 2 (1.0) 5 (2.4) 22 (10.6) 9 (4.3) 7 (3.4) 11 (5.3 20 (9.6)

“22 severe casesof malaria were not matched within 14 days to mild, out-patient cases of malaria.

district hospital, maintained that they would use proprietary drugs bought from local shops and kiosks in the treatment of febrile illnesses in their children. 68% of thesemothers said they would buy Malariaquine@, a proprietary form of chloroquine. Although single treatment of fevers at home with shop-bought drugs was the most common practice, government facilities were also widely used but commonly associated with prior shop attendance. Overall use of mosquito nets was low (6.2%), but the use of pyrethrum-based mosquito coils in the rooms where the children slept was high (46.4%). These coils were purchased from the same commercial outlets that sell anti-malarials and anti-pyretics, which thus act as a source of both prevention and cure. Children with well-documented episodes of clinical malaria had in 67% of casespreviously been treated by their mothers with proprietary drugs -at home (54% df them with Malariaauine@J This was clearlv a self-selected population of metiers who, by defidition, used hospitals and health centres, but it nevertheless confirmed the high reported use of the commercial sector for anti-malarials. Interestingly, the reported use of traditional medicines and healers varied with different clinical presentations of malaria disease. Although we suspect that the true utilization of this form of-medicine was under-reDorted bv mothers in this studv. 15 of the 134 (11.2%) children &ho presented with a l&tory of generalized convulsions had consulted a traditional healer compared to 3 of the 74 (4.1%) who did not report generalized convulsions (x2=3.07, v= 1, P=O.O8). The common local belief is that fits are spiritual in origin and not amenable to modern western medicine (OLENJA, 1988).

ii

use of personal protection measuresagainst nuisance insectsin the rooms slept in by the 388 community-control children. Treatment-seeking behaviours recorded in children detected as either having severe or mild malaria at a district hospital

Table 4 shows the treatment-seeking behaviours undertaken for both the severeand mild illness episodes. The use of shops by the mothers of these sick children reflects a Dattern similar to that shown in Table 2, of reported practices in the community from which they came. Discussion There is no specific vernacular word for malaria used by this population; the term homa is synonymous with fever and is the nearest term to the syndrome of uncomplicated malaria. 72% of mothers from the communities surrounding 3 government health facilities, including a

The averagetravelling time for a mother outside Kilifi town is one hour by foot and public transport, costing on average 17 Kenyan shillings (US$ 0.6) per visit to a clinic. In addition, mothers typically have to face long queues at clinics before seeing a medical auxiliary who will usually give presumptive treatment for febrile episodes with chloroquine, an anti-pyre& and maybe an antibiotic. Although the service is free, the common prescriptions can also be purchased over-the-counter at shops which are closer to home. Retailers sell Malariaquine@ at approximately O-75 Kenyan shillings (US$ 0.03) per 250 mg tablet (up to 3 tablets, depending upon the child’s age, would be required for the recommended treatment of malaria in children under 5 years old). Compared to the 3 government health facilities, there are over 500 licensed shops or kiosks distributed around the study area. More importantly, a mother can send another member of the household to purchase the drugs at a shop whilst she cares for the sick child, her other siblings and domestic duties at home. The mothers’ time and inconvenience is a non-monetary cost which may be under-estimated when considering health centre attend-

ante. The issues of preference and costs are currently being explored in more detail in the population described in this paper. Although there is only a limited literature covering the use of over-the-counter anti-malarials, a similar situation appears to exist in several other African countries (BREMAN & CAMPBELL. 1988). In western Kenva. over 30% of respondents said that’they would treat ‘malaria with shop-bought drugs at home (ONGOREet al., 1989). MWABU (1986) observed patients’ treatment-seeking behaviours during a rural health survey in eastern Kenya. The greatest use immediately after any illness began was outside the ‘free’ government services, with 58.8% reported to have sought treatment from the commercial sector. A similar situation orevails in Toeo. where 79% of villagers with accessto functioning dspensaries still preferred to treat ‘malaria’ with aspirin, chloroquine and caffeine-based drugs purchased from the market (BA, 1988). The actual patterns of proprietary anti-malarial drug use have received little attention, but doses of chloroquine given at home are often reported to be inadequate. This may be particularly relevant considering the alarming spread of chloroquine resistance in Africa (BREMAN & CAMPBELL,1988). Furthermore, new more effective anti-malarials are gradually being introduced into areas where there are high levels of chloroquine resistance, such as the Kenyan coast (BRANDLING-BENNETTet al., 1988). Several mothers in this study had purchased Fansidar@over-the-counter. This is an important secondline treatment for chloroquine-resistant malaria and uncontrolled distribution could quickly compromise its useful life expectancy. Although there are possible disadvantagesin the use of commercial retailers in the treatment of malaria, it must be accepted that this constitutes part of the natural history of fever treatment in many communities. It appears that planners of chemotherapy strategies for malaria through primary health care h&e often-ignored the private sector (WHO, 1983). However. in manv Darts of Africa shops‘provide the ‘most readily accessiblesource of anti-malarials for the majority of the population. Attempts should be made to integrate them into existing peripheral health care systems and improve the services they can offer. In addition, public health education is likely to be necessaryto improve the consumers’ awareness of appropriate doses of anti-malarials. Where the commercial provision of prevention and cure is well accepted by the population it could form an appropriate means of providing community-based malaria control. Attempting to manipulate the commercial sector as part of an organized control programme would raise many

1 Announcement

difficult issuesbut is worthy of serious consideration. Acknowledgements

This investigation received financial support from the UNDR’World Bank/WHO Special Programme for Research and Training in Tropical Diseases. The work would not have been possible without the special efforts of the field staff: Grace Bomu, Rodgers Chishenga, Elizabeth Bomu Msanzu, and Edna Ngumbao. We also thank the unit’s clinical staff and Joanna Armstrong of the Tropical Health Epidemiology Unit, London School of Hygiene and Tropical Medicine. Drs Bob Snow and Kevin Marsh are Wellcome Senior Research Fellows in Biomedical and Clinical Sciences respectively. This paper is published with the permission of the Director of the Kenya Medical ResearchInstitute. References

Anonymous (1983). Malaria control and primary health care. Lancet, i, 963-964.

Ba, 0. (1988). Depenses annuelles pour la samefamiliale et volume de la morbidite darts les villages d’Af?ique de POuest. 1. En republique Togolaise. Geneva: World Health Organization, mi-

meographed document no. TEC/OCP/EPII88/1. Brandling-Bennett, A. D., 0100, A. J., Watkins, W. M., Boriga, D. A., Kariuki, D. M. & Collins, W. E. (1988). Chloroquine treatment of falciparum malaria in an area of Kenya of intermediate chloroquine resistance. Transactions of the Royal Society of Tropical Medicine and Hygiene, 82,833-837. Breman, J. G. & Campbell, C. C. (1988). Combating severe malaria in African children. Bulletin of the World Health Organization, 66,61 I-620. Hassouna, W. A. (1983). Reaching the people: a three country study of health systems. World Health Forum, 4? 57-62. Jeffrey, G. M. (1984). The role of chemotherapy m malaria control through primary health care: constraints and future prospects. Bulletin of the World Health Organization, 62, supplement, 49-53. MacCormack, C. I’. (1984). Human ecology and behaviour in malaria control in tropical Africa. Bulletin of the World Health Organization, 62, supplement, 81-87. Mwabu, G. M. (1986). Health care decisions at the household level: results from a rural health survey in Kenya. Social Science andMedicine, 22,315-317.

Olenja, J. (1988). Health care delivery. In: Kilif District Sociocultural Profile. Nairobi: Ministry of Economic Planning and National Development, Republic of Kenya, pp. 96-98. Ongore, D., Kamunvi, F., Knight, R. & Minawa, A. (1989). A study of knowledge, attitudes and practices (KAP) of a rural community on malaria and the mosquito vector. East African MedicalJournal,

66,79-90.

WHO (1983). Primary health care and malaria in Africa. Report on a workshop held in Arusha, Tanzania, April 1983. Geneva: World Health Organization, mimeographed document no. MAPISHSI83.1. Received 2 August 1991; revised 5 December 1991; accepted for publication 5 December 1991

1 XIIIth

International Congress for Tropical Medicine and Malaria ‘Appropriate Technology for Better Health’ 29 November4 December 1992 Pattaya, Thailand

Last date for registration at reduced rate: 30 June 1992 (late registrations can be accepted on arrival). Further information can be obtained from Professor Thanongsak Bunnag, Congress Secretariat Office, the XIIIth International Congress for Tropical Medicine and Malaria, c/o Faculty of Tropical Medicine, Mahidol University, 42016 Rajvithi Road, Bangkok 10400, Thailand.

The role of shops in the treatment and prevention of childhood malaria on the coast of Kenya.

A community survey of 388 mothers in a rural and peri-urban population surrounding a district hospital on the coast of Kenya revealed that the preferr...
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