Health seeking for malaria before and after the implementation of a community-based health worker strategy: Implications for providing timely and appropriate treatment of malaria? Obinna Onwujekwe, Nkem Dike, Benjamin Uzochukwu, Elvis Shu and Paul Okonkwo Gates Malaria Partnership LSHTM and College of Medicine, University of Nigeria, Enugu

Problem statement Malaria is the number one public health problem in Nigeria Limited access to good-quality health providers especially in rural areas People with malaria indulge in health-seeking behavior that might lead to wrong diagnosis and inappropriate consumption of drugs. Most mothers treat malaria at home, usually with inappropriate and inadequate doses of drugs & some stop medication as soon as fever subsides (Okonkwo et al, 2001). African Heads of State meeting in Abuja adopted effective treatment of malaria nearer the home as one of the strategies for malaria control in Africa (WHO, 2000). Home treatment is the current global focus for provision of near and appropriate treatment of malaria No evidence that home treatment is the best or the most preferred strategy by consumers for the timely treatment of malaria

Conceptual framework and Aim There could be better strategies than home treatment for providing timely and appropriate treatment of malaria Community-based health workers (CBHW) strategy could be effectively used to bring treatment of malaria closer to the homes The CBHW would be better able than householders to diagnose and treat malaria and refer the patients when treatment fails and for complicated malaria Implementation research to determine the processes and outcomes of a CBHW system for improving the timely treatment of malaria is needed The information is needed for improved timely treatment for malaria nearer the homes and reduced delay before seeking formal care Aim: Investigate whether the CBHW strategy could be used to improve the provision of near and appropriate treatment of malaria

Operational definitions Home treatment: Malaria treatment undertaken by householders without recourse to diagnosis and/or treatment by trained health personnel. Home management: All actions taken in the home to manage a malaria case with or without recourse to diagnosis and/or treatment by trained health personnel. Community-based health worker: A residence of a community (could be an indigene or non- indigence), who is trained and provides treatment for malaria to his/her community members. Community-based treatment: Treatment that is provided within a malaria sufferer’s community

Study design: –A prospective study was undertaken in four rural Nigerian villages with all year high malaria transmission rate. The study was conducted in five phases which were: –(1) the first survey that was used to collect baseline data in the four villages –(2) the participatory design of the intervention in the two intervention villages (Adu and Ahani) –(3) the implementation, supervision and monitoring of the intervention in the two intervention villages –(4) a second survey to evaluate the intervention at the end of the third phase –(5) the handing over of the project to the community

Results Before implementation of CBHW Self-diagnosis was the most common diagnostic method in the 4 villages Patent medicine dealers (chemists) were the most common source of treatment Minor use of home treatment and CBHW Ready drug availability, good quality services and closeness were major determinants of care seeking CBHW were mostly preferred for provision of near and appropriate treatment of malaria After implementation of CBHW Marked decline in use of home treatment and increased use of CBHW in intervention villages Shift of some patients from chemists to CBHW in intervention villages CBHW still mostly preferred in intervention villages

Table 1: Expressed preference for the provision of near and appropriate treatment before the implementation of CBHW Adu(N=299) n (%) Ahani(N=298) Amaetiti(N=300) Enugu-akwu(N=300) Home treatment 47 (15.7) 21 (7.0) 81 (27.3) 53 (17.7) CBHW 205 (68.6) 110 (36.9) 127 (42.3) 156 (52.0) Education to mothers 10 (3.3) 25 (8.4) 19 (6.3) 10 (3.3) PHC centres 12 (4.0) 60 (20.1) 48 (16.0) 34 (11.3) Train shopkeepers and PMD 2 (1.7) 21 (7.7) 1 (0.7) 0 (0) Others (eg hospitals) 23 (7.7) 59 (19.8) 23 (7.7) 65 (21.7)

Table 2: Expressed preferences for different providers for timely and appropriate treatment of malaria after implementation of the CBHW strategy Adu(N=150) n (%) Ahani(N=148) Amaetiti(N=149) Enugu-akwu(N=149) Home treatment 4 (2.7) 13 (8.8) 15 (10.1) 5 (3.4) CBHW 100 (66.7) 109 (73.6) 44 (29.5) 77 (51.7) Education to mothers 8 (5.3) 1 (0.7) 11 (7.4) 20 (13.7) Treat in PHC centres 23 (15.3) 18 (12.2) 37 (24.8) 28 (18.8) Train shopkeepers and PMD 1 (0.7) 7 (4.7) 32 (21.5) 6 (4.0)

Table 3: Places where treatment was first sought before implementation of CBHW system RespondentsAdu(N=139)Ahani(N=88)Amaetiti(N=89)Enugu-akwu(N=104) Home treat. 12 (8.6%) 8 (9.1%) 10 (11.2%) 2 (1.9%) Private clinic 2 (1.4) 13 (14.8) 16 (18.0) 9 (8.7) PMD 68 (48.9) 28 (31.8) 30 (33.7) 40 (38.5) CBHW 2 (1.4) 13 (14.8) 18 (20.2) 21 (20.2) Hospital 12 (8.6) 13 (14.8) 5 (5.6) 12 (11.5) Children(N=104)(N=36)(N=38)(N=53) Home treat. 4 (3.9) 3 (8.3) 8 (21.1) 1 (1.9) Private clinic 11 (10.6) 4 (11.1) 4 (10.5) 2 (3.8) PMD 72 (69.2) 13 (36.1) 17 (44.7) 17 (50.9) CBHW 3 (2.9) 10 (27.8) 8 (21.1) 15 (28.3) Hospital 10 (1.9) 3 (8.3) 2 (5.3) 6 (11.3)

Table 4: Places where treatment was first sought after implementation of CBHW system RespondentsAduN=33AhaniN=38AmaetitiN=53 Enuguakwu N=44 Home treat. 0 (0%) 2 (3.8%) 4 (9.1) Clinic 6 (18.2) 15 (39.5) 9 (17.0) 3 (6.8) PMD 8 (24.2) 8 (21.1) 33 (62.3) 23 (52.3) CBHW 14 (42.4) 8 (21.1) 1 (1.9) 0 (0) Hospital 3 (9.1) 4 (10.5) 3 (5.7) 5 (11.4) ChildrenN=47N=26N=24N=25 Home treat. 3 (6.4) 3 (11.5) 0 (0) 2 (8.0) Clinic 2 (4.3) 8 (30.8) 4 (16.7) 1 (4.0) PMD 18 (38.3) 3 (11.5) 15 (62.5) 14 (56.0) CBHW 12 (25.5) 6 (23.1) 1 (1.9) 0 (0) Hospital 8 (17.0) 1 (3.8) 0 (0) 1 (4.0)

CONCLUSION Villagers backed up their preferences by actually paying for care from the community-based health workers. People will not use home treatment and patent medicine dealers if there are better treatment options are readily available Community based workers were most likely to improve rational use of drugs when compared with most providers found in the villages Improvement in methods of diagnosis (?rapid) and treatment of malaria through an enhanced PHC system could be the best strategy to improve appropriate and timely treatment of malaria Increased number and improved quality of trained malaria treatment providers == Improve the healthcare system

AREAS FOR FUTURE RESEARCH Implementation research to determine the effectiveness of scaling-up the use of CBHW strategy to improve the treatment of malaria in rural areas. Cost-effectiveness analysis, acceptability and sustainability comparison of CBHW with other means of treating malaria nearer the homes, such as home treatment in different settings Develop how the CBHW strategy could become part of the PHC system for its sustainability and enhanced status Funding agency: International Development Research Centre (IDRC), Canada