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Open Access Research

Febrile illness management in children under five years of age: a qualitative pilot study on primary health care workers’ practices in Zanzibar

Kimberly Baltzell1*, Kristina Elfving23, Deler Shakely24, Abdullah S Ali5, Mwinyi Msellem5, Shilpa Gulati6 and Andreas Mårtensson27

Author Affiliations

1 Departments of Family Health Care Nursing & Global Health Science, University of California San Francisco, San Francisco, CA, USA

2 Malaria Research, Department of Medicine Solna, Retzius väg 10, Karolinska Institutet, Stockholm, 171 77, Sweden

3 Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden

4 Kungälvs Hospital, Department of Medicine, Kungälv, Sweden

5 Zanzibar Malaria Control Programme, Ministry of Health, Mkwerekwe Street, Zanzibar

6 University of Michigan School of Medicine, Ann Arbor, MI, USA

7 Division of Global Health (IHCAR), Department of Public Health Sciences, Nobels väg 9, Karolinska Institutet, Stockholm, 171 77, Sweden

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Malaria Journal 2013, 12:37  doi:10.1186/1475-2875-12-37

Published: 28 January 2013

Abstract

Background

In Zanzibar, malaria prevalence dropped substantially in the last decade and presently most febrile patients seen in primary health care facilities (PHCF) test negative for malaria. The availability of rapid diagnostic tests (RDTs) allows rural health workers to reliably rule out malaria in fever patients. However, additional diagnostic tools to identify alternative fever causes are scarce, often leaving RDT-negative patients without a clear diagnosis and management plan. This pilot study aimed to explore health workers’ practices with febrile children and identify factors influencing their diagnostic and management decisions in non-malarial fever patients.

Methods

Semi-structured key informant interviews were conducted with 12 health workers in six PHCFs in North A district, Zanzibar, April to June 2011. Interviews were coded using Atlas.ti to identify emerging themes that play a role in the diagnosis and management of febrile children.

Results

The following themes were identified: 1) health workers use caregivers’ history of illness and RDT results for initial diagnostic and management decisions, but suggest caregivers need more education to prevent late presentation and poor health outcomes; 2) there is uncertainty regarding viral versus bacterial illness and health workers feel additional point-of-care diagnostic tests would help with differential diagnoses; 3) stock-outs of medications and limited caregivers’ resources are barriers to delivering good care; 4) training, short courses and participation in research as well as; 5) weather also influences diagnostic decision-making.

Conclusions

This pilot study found that health workers in Zanzibar use caregiver history of fever and results of malaria RDTs to guide management of febrile children. However, since most febrile children test negative for malaria, health workers believe additional training and point-of-care tests would improve their ability to diagnose and manage non-malarial fevers. Educating caregivers on signs and symptoms of febrile illness, as well as the introduction of additional tests to differentiate between viral and bacterial illness, would be important steps to get children to PHCFs earlier and decrease unnecessary antibiotic prescribing without compromising patient safety. More research is needed to expand an understanding of what would improve fever management in other resource-limited settings with decreasing malaria.

Keywords:
Malaria elimination; Diagnostic decision-making; Non-malarial fevers