Strengthening Referral Linkages for Malaria in Nigeria.

Author(s) Chinazo Ujuju1, Ernest Nwokolo2, Jennifer Anyanti3, Chinwoke Isiguzo 4, Onoriode Ezire 5, Ifeanyi Udoye6, Wellington Oyibo7
Affiliation(s) Research and Evaluation Division, Society for Family Health, Abuja, Nigeria, Global Fund Malaria project, Society for Family Health, Abuja, Nigeria, Technical Services, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, College of Medicine , University of Lagos, Lagos, Nigeria, 8
Country - ies of focus Nigeria
Relevant to the conference tracks Education and Research
Summary Lack of referral linkage from PPMVs to health facility may have contributed to increased mortality due to the home management of malaria illnesses. This study showed that of the 461 clients who were tested for malaria at PPMV outlet, 88 tested positive while 365 who tested negative were referred to a nearby health facility for further diagnosis and treatment. Only 18 referral cards were retrieved from health facilities. There is a need to integrate PPMVs into the national referral system to ensure appropriate treatment for severe malaria, other febrile infections and reduce morbidity and mortality due to home management of illnesses.
Background In Nigeria malaria remains a major cause of morbidity and mortality among children under 5 years of age. Most of the early treatments of fever and malaria occur through self medication with anti malarial bought over the counter from drug vendors. The Nigerian health system provides for three tiers of health care: primary, secondary and tertiary. The primary health centers should be the point of first contact for patients from where they are referred to other levels of health care. This is far from reality as Private Patent Medicine Vendors (PPMVs) found across Nigeria are the first point of call for malaria treatment. Global malaria initiatives highlight the potential role of PPMVs in improving access to early effective malaria treatment. Parasitological diagnosis before administration of anti-malarial treatment has recently been recommended by WHO for everyone presenting with symptoms compatible with malaria at all level of the health system.
Objectives In Nigeria, more than half of household members sought treatment for fever at PPMV shops. Anecdotal evidence suggests that PPMVs do not refer clients to the health facility. There is a need to explore whether PPMVs would actually refer clients who accessed the malaria rapid diagnostic test (RDT) from their outlet to a health facility. This study was conducted to determine whether PPMVs referred clients who visited their outlet for malaria diagnosis to a health facility.
Methodology A cross-sectional pilot study to explore RDT feasibility and use was conducted in six states (Adamawa, Cross River, Enugu, Lagos, Kaduna and F.C.T) of Nigeria, each representing a geo-political zone of the country. About 20 registered PPMVs were selected from each of the selected states. Multi-stage purposive sampling was used to select the state and the PPMVs that participated in the study. These outlets were grouped into clusters of 6 per state. Two days of curriculum based training was conducted for the selected PPMVs. Nurses and laboratory personnel were recruited to monitor the PPMVs as they conducted the malaria RDT. The RDT test was conducted for clients aged 18 years and above after obtaining informed consent to participate in the study. Clients who tested negative were referred to a higher health facility identified within the cluster for further diagnosis and treatment, while those who tested positive for malaria were offered a full course of medicine according to Nigerian malaria treatment guidelines. During the study, referral was tracked in two states; Kaduna and Lagos state. Ethical clearance was obtained from the National Health Research and Ethics Committee prior to commencing the study. Data generated from the study was entered and verified using data management software, CSPro 2.6. The data was subsequently imported into SPSS (version 18) for statistical analysis. Descriptive statistics were used and data for the two states where referrals were tracked were analysed for this paper. Socio economic status of the respondents was calculated based on reported household’s ownership of consumer goods, dwelling characteristics, source of drinking water and sanitation facilities. To construct the index, each asset was assigned a weight (factor score) generated through principal component analysis, which was divided into quintiles from one (lowest) to five (highest).
Results 461 clients who visited PPMV outlet in Kaduna and Lagos received malaria RDT as confirmatory diagnosis of their illness. The proportion of males in the population was slightly higher (58%) than the proportion of females (42%). More than half (69%) of the respondents were married. There was variation in the educational attainment of respondents who participated in the survey. While about 48% had attained a secondary level of education, about one in four (23%) of the respondents had attained a higher level of education. A higher proportion of respondents were aged between 25-34 years (36%) and ranked as average socio economic status (26%). The reported symptoms experienced by most of the respondents can be associated with malaria illness. These symptoms include fever (55%), headache (77%), joint pains (54%), tiredness (39%), bitter taste (27%) and poor appetite (25%). About 88 clients tested positive for malaria while 365 who tested negative were referred to a nearby health facility for further diagnosis and treatment. A few visited the health facility for further diagnosis and treatment and 18 referral cards were retrieved from the health facilities.
Conclusion There is a need to integrate PPMVs into the national referral system and strengthening referral of client from drug store outlets to a higher quality of care. There is a need to implement malaria RDT among PPMVs and ensure that this group of health workers is trained and their activities monitored effectively to ensure proper management of malaria illness at the community level. It would also provide avenue for PPMVs to refer febrile clients who tested negative to malaria RDT to a health facility for further diagnosis and treatment. It would reduce the possibility of parasitic resistance as a result of repeated home treatment of unconfirmed malaria cases. Hence, this would increase clinical effectiveness of recommended drug regimen, Artemisinin-based Combination Therapies (ACTs). It would strengthen the referral linkages for treatment of severe malaria, treatment for other febrile infections and ultimately reduce the morbidity and mortality due to home management of illnesses.

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