Case management practices for children under-five with severe malaria : facilitators and barriers to appropriate care at Kayunga Hospital

Abstract

Background: Severe malaria is a medical emergency that requires prompt diagnosis and treatment to prevent long-term disability or death. In 2020, over 90% of the severe malaria cases in sub-Saharan Africa and 77% of deaths due malaria worldwide occurred in children under-five. Children who develop severe malaria rapidly deteriorate and die or are left with disabilities like neurocognitive impairment. Suboptimal case management practices that are not in accordance with National Treatment Guidelines is one of the reasons for the high mortality due to severe malaria in children under-five years of age. Objective: To evaluate the case management practices for children under five years with severe malaria, describe the facilitators and barriers to appropriate care at Kayunga District Hospital, Uganda. Methods: This was a mixed methods study with retrospective review of hospital records for 377 children under five years of age with severe malaria who were admitted at Kayunga District Hospital from January to December 2020. Quantitative data was abstracted into abstraction forms and qualitative data was collected through twelve key informant interviews with health workers. Categorical variables were summarized into frequencies and percentages, continuous variables as means/ medians and their measures of dispersion. Qualitative data was analyzed using the content thematic approach. Results: The median age of the children was 24 months, Interquartile range (IQR 17, 36) months with majority being aged between 12 to 24 months. More than half of the children were males at 58% (218/377). The proportion of children under five years of age with severe malaria who were diagnosed in accordance with the national treatment guidelines was 67.1% (253/377) and those who received appropriate specific treatment was 47.7% (180/377). Overall, 34% (128/377) of the children were appropriately managed for severe malaria. The facilitators to appropriate management of under-fives with severe malaria were availability of: microscopes, malaria rapid diagnostic test kits (mRDT) and parenteral anti-malarial drugs. Others facilitators included: support supervision by the District Health Team (DHT), team work among health workers and parental co-operation. Barriers to appropriate management of severe malaria included: lack of equipment to aid diagnosis of complications of malaria disease, stock out of oral anti-malarial drugs and medical supplies for supportive treatment of severe malaria, lack of job aides, inadequate human resource and health workers’ lack of interest to attend trainings on malaria management. Conclusions: The case management practices for children under five years with severe malaria at the hospital were sub-optimal. Two-thirds of the children were correctly diagnosed with severe malaria and appropriate specific treatment was received by one in two of them. The overall level of appropriate case management was low at 34%, being practiced for one in three patients. Recommendations: There is need for the hospital administration and pediatrician to continue prioritizing the pediatrics while distributing drugs and medical supplies, carry out support supervision within the hospital and organize Continuing Medical Education (CMEs) session at the hospital. Attendance of CMEs and trainings should be mandatory for all health workers by making it a key element in staff appraisal.