Gaining access to prompt and appropriate malaria treatment in the Kilombero valley, Tanzania : a health social science perspective

Abstract

Malaria is a life-threatening disease causing an estimated one million death annually. Major achievements have recently been noted in Tanzania, child mortality rates are declining. If prompt and effective treatment is initiated, malaria is a curable disease; however, in many places, people still lack access to prompt and effective malaria treatment. This thesis was carried out during the first phase of the ACCESS intervention program (2004-2008) which aimed at improving access to malaria treatment in the Kilombero Valley, Tanzania. The program had three main areas of interventions: 1) in the community, 2) the drug shops and 3) the health facilities. This thesis has grown out of the monitoring and evaluation component of the ACCESS program. It specifically focuses on two monitoring and evaluation activities: 1) treatment seeking surveys which assess interventions at community level and 2) mystery shopping studies at drug shop level. The studies on treatment seeking (Chapters 4-6) investigated whether malaria treatment seeking for children with fever and convulsion has changed during the first phase of the ACCESS program. The key argument is that unprecedented achievements in the availability and affordability of effective drugs do not necessarily imply that people get the medicines they need. Access to medicines is a multifaceted phenomenon: Five dimensions of access (availability, affordability, accessibility, adequacy and acceptability) play an influential role in treatment seeking decisions. Of these dimensions, acceptability has received least attention. This study defines acceptability as the match between local and biomedical understanding and appropriate treatment seeking. Acceptability is of particular relevance if local and biomedical explanatory models of illness differ, as they did, for instance, for severe malaria with convulsions. Previous studies on explanatory models of convulsions have shown that communities may not link convulsions with malaria and prefer local treatment practices. Most of these studies have relied on what people would do in cases of illness. It is therefore impossible to assess whether and what proportion of children gain access to appropriate treatment. The studies presented here contributed to closing this knowledge gap by examining actual convulsion cases. The Explanatory Model Interview Catalogue was used to collect information on symptoms, causes and treatment seeking for fever and convulsion among children under-five years of age in four studies: i) a cross-section fever survey (2004, n= 88); ii) a longitudinal shamba fever study (2005, n=29); iii) a longitudinal degedege study (2004/06 n=135); and iv) longitudinal degedege study (2007/08 n=88). Findings indicated that the match between local and biomedical understandings of convulsions was already high in 2004/06; 68% of caregivers associated convulsion with severe malaria while 85% mentioned mosquito bites as a cause of convulsion. Significant changes were noted in the second round of interviews, specifically on i) 46% point increase among those who reported use of mosquito nets to prevent convulsions; ii) 13% point decrease among caregivers who associated convulsion with ‘evil eye and sorcery’; iii) 14% point increase in prompt use of a health facility; and iv) 16% point decrease among those who did not use a health facility. The contrast of these findings with findings from previous studies can be explained by a) differences in accuracy of data collection and b) changes in explanatory models due to long exposure to biomedical research and interventions, also through the ACCESS program. The studies on mystery shopping (Chapters 7 and 8) examined the usefulness of this methodology for assessing changes in the performance of drug sellers in community pharmacies. Indicators were developed and used to measure the quality of dispensing practices and advice before and after ADDO implementation in 2006. Results showed a 30% increase from 2006 to 2007 among clients who got correct advice and treatment based on the assessed indicators. This thesis provides the first systematic community-based study of actual treatment seeking for children with convulsions in Tanzania and to our best knowledge also in Africa. The methodology developed in this study should be refined and validated in further empirical and comparative research across regions and countries. Improving the match between local and biomedical understanding of disease is fundamental to ensuring acceptability of health care services and successful control of health problems. The thesis further showed that mystery shopping is a useful technique for assessing the impact of ADDO interventions in retail drug stores. Innovative community based participatory research approaches and more systematic mystery shopping techniques would allow for comparative community-based assessments of drug shop interventions across regions and countries.