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- Hildenwall, Helena, et al.
(författare)
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"I never had the money for blood testing" - caretakers' experiences of care-seeking for fatal childhood fevers in rural Uganda : a mixed methods study
- 2008
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Ingår i: BMC International Health and Human Rights. - 1472-698X. ; 8, s. 12-
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The main killer diseases of children all manifest as acute febrile illness, yet are curable with timely and adequate management. To avoid a fatal outcome, three essential steps must be completed: caretakers must recognize illness, decide to seek care and reach an appropriate source of care, and then receive appropriate treatment. In a fatal outcome some or all of these steps have failed and it remains to be elucidated to what extent these fatal outcomes are caused by local disease perceptions, inappropriate care-seeking or inadequate resources in the family or health system. This study explores caretakers' experiences of care-seeking for childhood febrile illness with fatal outcome in rural Uganda to elucidate the most influential barriers to adequate care. METHODS: A mixed methods approach using structured Verbal/Social autopsy interviews and in-depth interviews was employed with 26 caretakers living in Iganga/Mayuge Demographic Surveillance Site who had lost a child 1-59 months old due to acute febrile illness between March and June 2006. In-depth interviews were analysed using content analysis with deductive category application. RESULTS: Final categories of barriers to care were: 1) "Illness interpretation barriers" involving children who received delayed or inappropriate care due to caretakers' labelling of the illness, 2) "Barriers to seeking care" with gender roles and household financial constraints hindering adequate care and 3) "Barriers to receiving adequate treatment" revealing discontents with providers and possible deficiencies in quality of care. Resource constraints were identified as the underlying theme for adequate management, both at individual and at health system levels. CONCLUSION: The management of severely ill children in this rural setting has several shortcomings. However, the majority of children were seen by an allopathic health care provider during the final illness. Improvements of basic health care for children suffering from acute febrile illness are likely to contribute to a substantial reduction of fatal outcomes. Health care providers at all levels and private as well as public should receive training, support, equipment and supplies to enable basic health care for children suffering from common illnesses.
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| 2. |
- Hildenwall, Helena, et al.
(författare)
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Low validity of caretakers’ reports on antimalarial and antibiotic use in children with severe pneumonia at hospital in Uganda
- 2009
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Ingår i: Transactions of the Royal Society of Tropical Medicine and Hygiene. - : Elsevier. - 0035-9203 .- 1878-3503. ; 103:1, s. 95-101
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Tidskriftsartikel (refereegranskat)abstract
- Febrile children in low-income countries receive care from multiple sources, and caretakers’ ability to report drug intake is crucial for appropriate prescription of drugs when reaching health facilities. This study describes and validates caretakers’ reported use of sulfamethoxazole, chloroquine and sulfadoxine in their children. We performed a cross-sectional study in 139 children diagnosed with severe pneumonia at hospital in Kampala, Uganda. Caretakers were interviewed regarding treatments given prior to arrival at the hospital. Reported drug intake was compared to drug levels in blood sampled on filter paper, analyzed by HPLC methods. Caretakers under-reported intake of the studied drugs. Positive and negative predictive values were 67 and 64% for sulfamethoxazole, 69 and 52% for chloroquine and 85 and 62% for sulfadoxine. Many caretakers were unaware of what drug had been given to the child, and more so if treated outside the home (risk ratio 2.6, 95% CI 1.2–5.6). We conclude that caretakers’ reports of drug intake have limited validity. Health workers need to improve counseling of caretakers during drug dispensing, especially for antibiotics. The roles and names of different drugs should be emphasized during counseling, and existing information systems such as immunization cards should be considered for record-keeping of treatment given.
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| 3. |
- Hildenwall, Helena
(författare)
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Managing children with pneumonia symptoms in malaria endemic Uganda
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Pneumonia is one of the leading killers of children under five years of age. In sub-Saharan Africa, symptoms of pneumonia often overlap with those of malaria. While many countries have made public commitments to improve malaria management, similar efforts for pneumonia are lacking. The overlap of symptoms between pneumonia and malaria, in combination with more efforts for appropriate malaria management, raises worries that pneumonia cases are being mismanaged. More information is needed on how caretakers and health workers respond to children with pneumonia symptoms. Main objective: To explore caretakers and health care providers understanding and response to children with symptoms of pneumonia in order to identify issues that need to be addressed for improved management of children with acute febrile illness. Methods: A triangulation of a qualitative community study with mothers, traditional healers and health workers (I), two hospital based studies with structured interviews with caretakers of children with symptoms or diagnosis of severe pneumonia (II, IV) and a mixed qualitative-quantitative community study with verbal and social autopsies with caretakers of children deceased in acute febrile illness (III) was done. To compare stated drug use with blood drug concentrations, blood samples were collected on filter papers (IV). Qualitative interviews were analyzed using content analysis (I, III). Blood drug concentrations of sulfamethoxazole, chloroquine and sulfadoxine were analyzed using high performance liquid chromatography methods (IV). Results: Many terminologies were used to refer to symptoms of pneumonia (I). Mothers tended to interpret any febrile condition as malaria and stated differing preferred care-seeking actions for difficult/rapid breathing in their children (I). Severe pneumonia developed two days after first recognition of difficult/rapid breathing (II). Half of the children diagnosed with severe pneumonia had seen another health care provider prior to arrival at a hospital (II). Barriers to adequate management of a child with fatal acute febrile illness (III) included: Illness interpretation barriers - when care was delayed or inappropriate due to caretakers interpretation of illness; Barriers to seeking care involving gender roles and household financial constraints; and Barriers to receiving adequate treatment revealing caretakers discontents with providers and possible deficiencies in quality of care. Positive and negative predictive values for caretakers reports of drug intake for the child s acute illness were 67% and 64% for sulfamethoxazole, 69% and 52% for chloroquine and 85% and 62% for sulfadoxine, respectively (IV). Many caretakers could not name the drug given to the child, and more so if treated in a health facility than in the home (RR 2.6 (1.2-5.6)) (IV). Discussion: There is a need to find ways to encourage caretakers to seek immediate and appropriate care after recognition of key pneumonia symptoms. Ideally, adequate antibiotic treatment should be provided close to where people live and one option is to allow community health workers to diagnose and treat pneumonia in addition to malaria. Quality of care must be improved in the whole health care chain, public as well as private. Health care providers need to be aware of key pneumonia symptoms, appropriate biomedical treatment for these symptoms, and the common co-existence of pneumonia and malaria symptoms.
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| 4. |
- Holloway, Bronwen, 1982-
(författare)
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Acute febrile illness, antibiotic use, and the role of diagnostics to target treatment in India
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aim: This thesis examined the causes of acute febrile illness (AFI), the current use of antibiotics and diagnostics, and evaluated the diagnostic accuracy of C-Reactive Protein (CRP) to differentiate bacterial from non-bacterial causes of AFI in children and adult outpatients at R.D. Gardi Medical College hospital, in Ujjain, India. Methods: A prospective cross-sectional study of children and adult outpatients with fever ≥37.5°C, or history of fever in the past 48 hours, and no signs of severe illness. Patient history, physical examination, culture, rapid diagnostic tests, and follow-up after one week was performed for all patients. Whole blood and urine were collected from all patients, and symptom based nasopharyngeal throat swabs, stool, and skin/ear/joint/aspirate specimens. Fever was classified as bacterial or non-bacterial based on microbiology and laboratory results together with an expert panel review. Data on antibiotic use before, during, and after enrolment was described by Anatomical Therapeutic Chemical classification and AWaRe categories. Serum CRP levels were measured and the performance characteristics for CRP to differentiate between bacterial and non-bacterial AFI were calculated. The area under the receiver operating curve (AUC), sensitivity, specificity, positive and negative predictive values, and likelihood ratios were estimated using 10, 20, 40, 60 and 80 mg/L thresholds. A rapid ethnographic qualitative study on the utilization of diagnostics was conducted using unstructured observations, structured observations and 43 semi-structured interviews. Interview data were analyzed using inductive thematic analysis. Results: Of 1000 outpatients, 24.4% were categorized as bacterial; 71.8% non-bacterial; and 3.8% an undetermined cause of fever. Throughout the course of AFI, 41.0% of patients received one or more antibiotics. The leading contributors to total antibiotic volume were macrolides. ‘Watch’ antibiotics accounted for 72.3%, 52.7%, and 32.6% of encounters before, during and after the outpatient visit. The overall median CRP was low but higher in the group classified as bacterial compared to non-bacterial (3.6 mg/L vs. 2.7 mg/L, p<0.0001, respectively). The AUC was low at 0.60 (95% CI 0.56 - 0.65). Caregivers trusted and understood the importance of diagnostics, but their acceptance wavered depending on the severity of illness and preference to treat their child directly with medicines. Caregivers struggled to get tests done and return for follow-up due to costs, delays in testing, further complicated by travel time, distance and competing priorities. Conclusion: This thesis highlights the challenges in determining the cause of AFI. Over,under, and inappropriate use of antibiotics throughout the course of AFI are of major concern.The organization of diagnostic services, together with direct and indirect costs, hinder caregiversfrom utilizing diagnostics. CRP is too weak as a single indicator of bacterial infection to safelysupport physicians in making treatment decisions for febrile outpatients in India.
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| 5. |
- Holloway, Bronwen, et al.
(författare)
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Antibiotic use before, during and after seeking care for acute febrile illness at a hospital outpatient department : a cross-sectional study from rural India
- 2022
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Ingår i: Antibiotics. - : MDPI AG. - 2079-6382. ; 11:5
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Tidskriftsartikel (refereegranskat)abstract
- Antibiotic resistance is a naturally occurring phenomenon, but the misuse and overuse of antibiotics is accelerating the process. This study aimed to quantify and compare antibiotic use before, during, and after seeking outpatient care for acute febrile illness in Ujjain, India. Data were collected through interviews with patients/patient attendants. The prevalence and choice of antibiotics is described by the WHO AWaRe categories and Anatomical Therapeutic Chemical classes, comparing between age groups. Units of measurement include courses, encounters, and Defined Daily Doses (DDDs). The antibiotic prescription during the outpatient visit was also described in relation to the patients’ presumptive diagnosis. Of 1000 included patients, 31.1% (n = 311) received one antibiotic course, 8.1% (n = 81) two, 1.3% (n = 13) three, 0.4% (n = 4) four, 0.1% (n = 1) five, and the remaining 59.0% (n = 590) received no antibiotics. The leading contributors to the total antibiotic volume in the DDDs were macrolides (30.3%), combinations of penicillins, including β-lactamase inhibitors (18.8%), tetracyclines (14.8%), fluoroquinolones (14.6%), and third-generation cephalosporins (13.7%). ‘Watch’ antibiotics accounted for 72.3%, 52.7%, and 64.0% of encounters before, during, and after the outpatient visit, respectively. Acute viral illness accounted for almost half of the total DDDs at the outpatient visit (642.1/1425.3, 45.1%), for which the macrolide antibiotic azithromycin was the most frequently prescribed antibiotic (261.3/642.1, 40.7%).
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| 7. |
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| 8. |
- Johansson, Emily White, 1976-, et al.
(författare)
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Effect of diagnostic testing on medicines used by febrile children less than five years in 12 malaria-endemic African countries: a mixed-methods study.
- 2015
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Ingår i: Malaria journal. - : Springer Science and Business Media LLC. - 1475-2875. ; 14
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Tidskriftsartikel (refereegranskat)abstract
- In 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age.
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| 9. |
- Johansson, Emily White, 1976-, et al.
(författare)
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"It could be viral, but you don't know. You have not diagnosed it" : Health worker challenges in managing non-malaria pediatric fevers in the low transmission area of Mbarara District, Uganda
- 2016
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Ingår i: Malaria Journal. - : Springer Science and Business Media LLC. - 1475-2875. ; 15
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Tidskriftsartikel (refereegranskat)abstract
- Background: In 2012, Uganda initiated nationwide deployment of malaria rapid diagnostic tests (RDT) as recommended by national guidelines. Yet growing concerns about RDT non-compliance in various settings have spurred calls to deploy RDT as part of enhanced support packages. An understanding of how health workers currently manage non-malaria fevers, particularly for children, and challenges faced in this work should also inform efforts. Methods: A qualitative study was conducted in the low transmission area of Mbarara District (Uganda). In-depth interviews with 20 health workers at lower level clinics focused on RDT perceptions, strategies to differentiate non-malaria pediatric fevers, influences on clinical decisions, desires for additional diagnostics, and any challenges in this work. Seven focus group discussions were conducted with caregivers of children less than five years in facility catchment areas to elucidate their RDT perceptions, understandings of non-malaria pediatric fevers and treatment preferences. Data were extracted into meaning units to inform codes and themes in order to describe response patterns using a content analysis approach. Findings: Differential diagnosis strategies included studying fever patterns, taking histories, assessing symptoms and analyzing other factors such as child’s age or home environment. If no alternative cause was found, malaria treatment was reportedly often prescribed despite a negative result. Other reasons for malaria over-treatment stemmed from RDT perceptions, system constraints and provider-client interactions. RDT perceptions included mistrust driven largely by expectations of false negative results due to low parasite/antigen loads, previous anti-malarial treatment or test detection of only one species. System constraints included poor referral systems, working alone without opportunity to confer on difficult cases, and lacking skills and/or tools for differential diagnosis. Provider-client interactions included reported caregiver RDT mistrust, demand for certain drugs, and desire to know the ‘exact’ disease cause if not malaria. Many health workers expressed uncertainty about how to manage non-malaria pediatric fevers, feared doing wrong and patient death, worried caregivers would lose trust, or felt unsatisfied without a clear diagnosis. Conclusions: Enhanced support is needed to improve RDT adoption at lower level clinics that focuses on empowering providers to successfully manage non-severe non-malaria pediatric fevers without referral. This includes building trust in negative results, reinforcing integrated care initiatives (e.g. Integrated Management of Childhood Illness) and fostering communities of practice according to the Diffusion of Innovation model.
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