ABSTRACT

Background: Malaria is still a major cause of death and severe illness among children in many parts of tropical Africa with one child dying every two minutes from this preventable and curable disease. Community case management of malaria through Community Health Workers is a promising strategy to improve the access of populations to prompt and effective management of uncomplicated cases. However, several studies have shown the low availability of Community Health Workers at the crucial time when HCGs need them for the care of their children. This study generally sought to assess the impact of an alternative strategy in the Home-based Management of Malaria among under-five children by home caregivers in Santchou and Penka-Michel Health Districts.

Methods: This study was a sequential exploratory mixed-methods design that involved both qualitative and quantitative approaches. For the qualitative methods; chart review, focus group discussions, in-depth interviews, and observations of home caregivers and Community Health Workers on the field-work were conducted. Quantitative methods involved a cross-sectional study and a randomized control trial which was registered at the Pan-African Clinical Trials Registry and WHO Trails Registry. A cluster sampling design followed by a systematic random sampling technique was used to select participants for the cross-sectional study. Judgmental and purposeful sampling was used to select the participants for focus group discussions and in-depth interviews. In the randomized control trial, a parallel-group design using a 1:1 allocation concealment ratio was used to distribute the participants into the two groups. Ethical approval was obtained from the Institutional Review Board of the Faculty of Health Sciences of the University of Buea.

Results: A total of 32,976 consultation files of under-five children were reviewed in the 36 health facilities visited. Height FGDs were conducted among home caregivers and 15 in-depth interviews among Community Health Workers. The number of detected malaria cases increased significantly from 2733 (33.7%) before Community Directed Intervention (CDI) to 5202 (38.4%) after CDI in the Penka Michel Health District. During the eight months of the intervention, ​the proportion of all malaria follow-up indicators (mean proportion of suspected malaria cases in under-five children, of children tested, of children testing positive for malaria, of children treated for malaria, and of those referred) were significantly higher in the intervention group compared to the control group. The Knowledge, Attitudes and Practices scores of home caregivers increased significantly respectively (7.44 versus 6.94; Mean diff= 0.50, p=0.001); (6.69 versus 6.29; Mean diff= 0.40, p=0.011); (6.20 versus 5.93; Mean diff= 0.30, p=0.024) from baseline to post-intervention in the intervention group but not in the control group.

Conclusion: HPTM intervention greatly improved early detection, treatment, and referral of childhood malaria cases and this could help to resolve the challenges of severe malaria and limit the death of under-five children due to malaria. HPTM intervention improved home caregivers’ perception of childhood malaria.

Keywords: Home-based Management of Malaria, under-five children, RCT, HPTM, Home caregivers, Cameroon.

CHAPTER ONE

INTRODUCTION

1.1 Background

Malaria is one of the leading causes of childhood morbidity and mortality in Africa [1]. Each year, 0.7 to 2.7 million people die of malaria of whom more than 75% are African children [2, 3, 4]. The World Malaria Report 2017 sadly notes that “malaria control is on a worrying trajectory; progress seems to stop” [5]. This stagnation reported by the World Health Organization (WHO) has not changed, because the 2018 global report reveals 219 million cases of malaria in 2017, an additional 3.5 million cases of malaria compared to the previous year. In 2017, 435,000 deaths were reported from malaria in the world with most of the cases reported in Africa, the majority being under-five children with one child dying every two minutes from this preventable and curable disease [6]. Under-five children are the most vulnerable group affected by malaria.

In 2017, they accounted for 61% of all malaria deaths worldwide [6].  In the same year, like the 10 African countries most affected, Cameroon recorded an increase of  131,000 additional cases of malaria compared to the previous year [6]. This report also reveals insufficient levels of access and use of tools and interventions for an effective fight against malaria. WHO believes that to truly overcome malaria, we need a global approach that includes vector control measures, early diagnosis and treatment, especially at the community level [7]. In Africa, more than 70% of episodes of malaria in rural areas and more than 50% in urban areas are self-treated, and formal health care is sought only upon failure of initial treatment [8]. The cornerstone of the WHO malaria control strategy is a prompt and effective treatment for all episodes of malaria [9].

Among malaria control interventions, prompt and effective management is a key strategy recommended by WHO [10]. Early access to effective malaria treatment is one of the main strategies for reducing the burden of malaria. This means that the treatment must be available near home within 24 hours from the onset of symptoms. More than 90% of sick children in rural areas in Senegal received their first [11] treatment at home; unfortunately, most of the time, they received inappropriate self-medication [11]. Home-based management of malaria including diagnosis by RDT and treatment based on test results is a promising strategy to improve the access of remote populations to prompt and effective management of uncomplicated malaria and to decrease mortality due to malaria [12]. To help translate the experience into practice and to develop Home-based management of malaria, a joint meeting was organized in 2002 for research and training on tropical diseases by Roll Back Malaria and United Nations Development Programme (UNDP) / World Bank / WHO Special Program [12]. It was generally agreed that it was time to intensify the HMM in endemic countries to cover the majority of their populations and that this would result in early access to good quality antimalarial drugs at appropriate doses within 24 hours from the onset of symptoms [12]. The previous report has highlighted the possibility and feasibility of improving malaria management in the household at the community levels to reduce morbidity and mortality [13].

Early treatment is essential to the outcome of the disease. A study in Burkina Faso showed that early treatment in the community halved the course of severe malaria [14]. The more the source of the appropriate treatment is close to home, the more likely it is that an appropriate treatment starts early [14]. Studies showed that HMM reduces the progression of severe malaria by more than 50% and by 40% the overall mortality of children under five [15, 14]. Mothers were thought not to be able to comply with the complicated diagnosis and the drug intake timetable required for appropriate treatment. It is now generally accepted that with appropriate training and using pre-packaged drugs, mothers can recognize malaria and administer timely and appropriate treatment [15]. In the framework of successful programs, mothers, as primary home health caregivers for their children, have been trained in the early recognition of malaria symptoms and the administration of appropriate treatment [15]. The ability of mothers to recognize malaria and administer prompt appropriate treatment resulted in a 40% reduction in overall under-five children mortality in the program area [14]. The success of the program has been attributed to the participation of mothers as the primary source of child care, and community participation. Access to treatment has been increased, compliance with recommended doses has improved, and progression from uncomplicated malaria to complicated forms of the disease has been significantly reduced [14]. Mothers could recognize the symptoms associated with uncomplicated malaria in a community in Nigeria and two ecological zones in southern Ghana; the recognition of these symptoms by mothers was very closely related to the diagnosis made by the medical assistant [16].

1.2 Statement of the problem

Poor physical access to public health facilities is a recognized impediment to the provision of early treatment of malaria in developing countries, especially in sub-Saharan Africa. To cope, communities have resorted to self-medication through the unregulated private and informal sector [17]. Thus, pharmacies, medicine shops or vendors, drug retail shops, and medicines leftovers in homes are often the first source of treatment at the onset of symptoms [11]. Many studies have shown that the majority of early treatments for childhood fever are given at home and most parents procure them medications from street vendors without formal prescription [18, 19]. These treatments are usually incorrect or suboptimal  [20, 21].

A strong healthcare delivery system would ideally be able to provide early, reliable diagnosis, appropriate, prompt, and effective treatment of malaria. However, most people at the highest risk of malaria, particularly in rural areas, live outside the easy geographical reach of health facilities, and their access to diagnosis and curative services is therefore limited [22]. The 2017 WHO Global Report on Malaria highlights the fact that access to the public health system remains very limited [5].

The majority of malaria cases are recorded in households rather than in health facilities inaccessible to the majority of malaria targets. National surveys in the WHO African region indicate that only 34% of febrile children consult a qualified health staff [5].  Surveys in Africa revealed that 80 to 90% of presumed malaria cases were treated at home  [23, 24, 25], and formal health care is sought only if initial treatment fails. WHO recommends an equity strategy aimed at improving access to essential care for children under five with the introduction of home-based management of malaria since 2001 [17]. In 2010 they recommended confirmation of diagnosis by microscopy or RDT before any treatment [26]. It ensures early recognition of and the prompt and appropriate response (treatment) to malaria illness in children under five within the home or the community [22]. Home care is a recommended strategy to improve access to timely and effective treatment.  In the case of malaria, the strategy is known as “home-based management of malaria” where malaria treatment is provided near the home by Community Health Workers (CHWs). Community management of malaria is effective in reducing malaria mortality and morbidity [14]. It could be a useful adjunct not only to reduce the progression of malaria-related mortality and morbidity but also to achieve and improve sustainable malaria control, before its elimination [27].

Strategies based on the assumption that adequate treatment, delivered at home by mothers soon after the appearance of symptoms, has shown a reduction in malaria morbidity and mortality [28]. A randomized controlled trial carried out in Ethiopia, found evidence of a reduction in child mortality after an intervention to encourage prompt and adequate home treatment of suspected malaria [15]. HMM recommended by the WHO allows a higher scaling of diagnostic tests and treatment in the community. Training and deployment of CHWs and volunteers could complement public health services widely, particularly in rural and remote areas where infrastructure is often more fragile and malaria transmission is highest. The strategic use of these staff for the prevention and care of malaria not only helps to fill the gaps in the health system but also ensures continuity of care for the most disadvantaged populations [13]. In Senegal, a pilot study on HMM conducted in 2008 demonstrated the feasibility of integrated use of RDTs and ACT in isolated villages by volunteer home health caregivers [12]. The results of this study show that HMM, including RDT and treatment based on test results, is a promising strategy to improve the access of isolated populations to the early and effective management of uncomplicated malaria and to reduce malaria mortality [12]. Strengthened to serve remote communities in areas of Senegal with the highest prevalence of malaria, home caregivers have demonstrated excellent adherence to guidelines, potentially contributing to a decrease in malaria-related deaths in the community [12].

Recently, the successful introduction of RDTs into HMM programs has been reported in several African countries [29, 30] including Cameroon. To follow up on the WHO recommendations, the Ministry of Public Health in Cameroon has undertaken enormous efforts to strengthen the health system and improve health coverage by involving the community as the main beneficiary of health care and major actor for a better chance of success [31]. Under the Global Fund facility’s new financing mechanism, Cameroon has received a grant for the following three diseases: HIV, TB, and Malaria. All three programs expressed the need for CHWs not only to increase the demand for care in the communities but also to follow patients, support treatment sites, and distribute many health inputs to communities [32]. The specific objective of the HMM component of the Integrated CDI is to test at least 80% of suspected malaria cases in the community using RDTs within 24 hours from the onset of symptoms, and properly treat 100% of confirmed uncomplicated malaria cases within 24 hours from onset of symptoms with ACTs [32].

In Cameroon, the national policy adopted the integrated CDI since 2016 [32]. To implement this integrated strategy, multitask CHWs have been trained to provide community-based care for major child killer diseases including malaria and to strengthen the promotion and prevention of the disease through educational talks and home visits [32]. The integrated CDI strategy, with funding from the Global Fund and the UNICEF Trust Fund, and technical support from UNICEF, has been implemented in 85 Health Districts in the 10 Regions of Cameroon [31]. In the context of the operationalization of the integrated CDI strategy, priority is given to regions and districts with the lowest health indicators for the three diseases, and with limited access to health facilities [31]. However, the integrated CDI strategy is implemented only in some Health Districts in Cameroon. Thus, the interventions do not have a particular action in children under five. Yet these constitute the vulnerable populations where a child continues to die from malaria in Africa every two minutes [6].

 The integrated CDI strategy has been implemented since January 2017 by three sub-recipients in 69 Health Districts and 730 health areas with 4892 community health workers. In the West Region, the strategy was implemented in five Health Districts with 223 CHWs in 55 health areas [31]. After one year, the results recorded in 2017 in the HMM component were as follows: 245,796 suspected malaria cases have undergone RDTs, 175,384 confirmed uncomplicated malaria cases antimalarial have received treatment according to the national policy in the community and 49,255 cases of severe malaria were referred and received in health facilities. These numbers exceed the ones recorded in health facilities [31]. Since the establishment of the CDI program in Cameroon, apart from a mission about the state of progress of the implementation process of the integrated CDI strategy carried out three months after the setting up of the program for knowing the reality on the ground, no evaluation study has been conducted to date [32]. The concept of a CHW extends the accessibility of health care to the majority of the population. He acts as an intermediary between the community from which he comes and the health services [33]. In the harmonized Community Directed Interventions strategy currently being implemented in Cameroon, the multitasks Community Health Worker should offer a package of services on malaria, acute respiratory infections, diarrhea, tuberculosis, HIV/AIDS, malnutrition, onchocerciasis, diseases preventable by vaccination [32].

1.3 Justification for the study

Several studies have shown the low availability of CHWs at the crucial time when HCGs need them for the care of their children [34]. Most caregivers are not very satisfied with the services of the CHWs. The factors influencing community utilization of CHWs services included: distance to CHWs, awareness of the CHWs services, trust in CHWs, and availability of services at the time of the caregivers’ visit [35]. It should be noted that distance to caregivers from the CHWs determines accessibility, availability, affordability and acceptability of services [36]; and a short distance to reach the CHWs serves this purpose efficiently.

CHWs have difficulty undertaking home visits and consider they have work overload. In the literature, the definition of a CHW states that they should work part-time enabling them therefore to subsist by performing agriculture or other work and possibly by receiving a subsidy from either the local community or the national health services [37]. There are varied experiences concerning the conditions in the employment of CHWs. In several programmes they are employed voluntarily [38, 39]. Studies have shown that home caregivers (HCGs) continued to seek care elsewhere despite the presence of CHWs in the implementation of the CDI. A survey in Uganda indicated that only 27.3% of HCGs sought care from CHWs for childhood malaria in the CDI implementation [35]. A study showed that CHWs are rarely used in Burkina-Faso to treat malaria in children [40]. Treatment coverage by CHWs was considerably less than that reported by previous trials and pilot projects [40]. Issues of implementation fidelity, a lack of adaptation to the local context and problems of acceptability/feasibility may undermine the effectiveness of community management of malaria cases, highlighting the necessity of evaluating public health interventions under real-world conditions of implementation. There are also problems in the CHWs selection process that does not always respect the different steps that are intended to be participatory and inclusive [41]. The community should, after notification of the selection criteria and the profile of CHWs, choose the person accepted by the populations and meeting the different criteria [41]. Community factors such as community participation, membership, and support for CHW programs are more difficult to control by program administrators, these factors are the most critical to the success of the programs [42, 43].

In addition, CHWs also face difficulties related to their work. These difficulties are most often inadequate logistics, lack of financial motivations, the high workload of CHWs, and difficulties of referring patients. It was observed that when CHWs do not have adequate supplies, trust in the program will be eroded and result in a lack of patronage by the caregivers, who go where there are available supplies such as traditional healers and street vendors [44]. Several reports of HMM supervision activities in the West Region of Cameroon mention problems such as the non-availability of CHWs, their resignation, the overloading of polyvalent CHWs’ tasks, their demotivation, the poor road conditions which slow down CHWs’ work in the implementation of schedules, causing great difficulties to CHWs who also start losing confidence in their communities [45].

Finally, while community-based malaria management is thought to reduce the monetary and geographical barriers that prevent individuals from seeking treatment, few studies have implemented other strategies that can address the problems of non-availability and lack of trust in CHWs that community-based malaria management poses. Innovative interventions are needed at all levels, particularly concerning prompt and effective malaria management cases, a key strategy recommended by WHO [46]. We believe that placing malaria kits in households and training users will not only make treatment more accessible but also improve the prompt management of malaria in children at the onset of symptoms.

1.4 Research questions 

1. What is the impact of the home-based management of malaria on morbidity and mortality in under-five children in Penka-Michel and Santchou Health Districts during the period of July 2014 to June 2019?
2. What is the process for implementing the home-based management of malaria in Fombap and Baneghang Health Areas?
3. What is the level of caregiver’s perception of the home-based management of childhood malaria in Baneghang and Fombap Health Areas?
4. What is the impact of Home-based Prevention and Treatment of Malaria (HPTM) in under-five children by home caregivers on key malaria follow-up indicators and home caregivers’ perception in Baneghang and Fombap Health Areas?

1.5 Research hypotheses

1. Home-based management of malaria has a positive impact on malaria morbidity and mortality in under-five children in Penka-Michel and Santchou Health Districts during the period of July 2014 to June 2019.
2. The process of implementing the home-based management of malaria in Fombap and Baneghang Health Areas is inadequate.
3. The activities of the home-based management of malaria influence the perception of home caregivers about prevention, diagnosis and treatment in Fombap and Baneghang Health Areas.
4. The impact of Home-based Prevention and Treatment of Malaria (HPTM) in children under five by home caregivers on key malaria follow-up indicators and home caregivers’ perceptions could be better than the home-based management of malaria by Community Health Workers.

1.6 Research objectives        

1.6.1 General objective

To assess the impact of alternative strategy in the home-based management of malaria among under-five children in Penka-Michel and Santchou Health Districts of the West Region of Cameroon.

1.6.2 Specific objectives

1. To determine the impact of the home-based management of malaria on morbidity and mortality in under-five children in Penka-Michel and Santchou Health Districts.
2. To determine the process of implementation of the home-based management of malaria in Fombap and Baneghang Health Areas.
3. To evaluate the level of caregiver’s perception on the home-based management of childhood malaria in Baneghang and Fombap Health Areas.
4. To assess the impact of Home-based Prevention and Treatment of Malaria (HPTM) by home caregivers on key malaria follow-up indicators and home caregivers’ perception in Baneghang and Fombap Health Areas.