Academic journal article Bulletin of the World Health Organization

Clinical Management of Children with Fever: A Cross-Sectional Study of Quality of Care in Rural Zambia/Prise En Charge Clinique Des Enfants Fievreux: Une Etude Transversale De la Qualite Des Soins Dans Des Zones Rurales De Zambie/Gestion Clinica De Ninos Con Fiebre: Un Estudio Transversal De la Atencion En Ka Zambia Rural

Academic journal article Bulletin of the World Health Organization

Clinical Management of Children with Fever: A Cross-Sectional Study of Quality of Care in Rural Zambia/Prise En Charge Clinique Des Enfants Fievreux: Une Etude Transversale De la Qualite Des Soins Dans Des Zones Rurales De Zambie/Gestion Clinica De Ninos Con Fiebre: Un Estudio Transversal De la Atencion En Ka Zambia Rural

Article excerpt

Introduction

In Africa, historically, fever in children younger than 5 years has been considered to be due to malaria and has been treated immediately with antimalarial drugs without laboratory confirmation to avoid treatment delays. (1) The recent reduction in malaria-related morbidity and mortality (2) has prompted a change in clinical management of children presenting with fever. (3-5) In 2010, the World Health Organization (WHO) updated its guidelines from presumptive antimalarial treatment of children with fever to recommend diagnostic testing for malaria, by either microscopy or malaria rapid diagnostic test, to ensure rational use of antimalarials. (6)

Reflecting global trends, Zambia has recently made progress in reducing its malaria-associated disease burden by about 7% annually from 2000 to 2010, (7,8) resulting in over 50% reduction in malaria deaths. (9)

Health-care services in Zambia are delivered through a five-level hospital system, which includes three tertiary hospitals, 21 provincial or general hospitals and 85 district hospitals, employing specialist staff. These hospitals receive referrals from urban and rural health centres and community-based health posts at the lowest levels of the health-care system throughout the country. Health care in Zambia faces chronic challenges with human resources and inadequate supplies of drugs, equipment and medical supplies. Starting in 1996, the Zambian Ministry of Health adopted an integrated management of childhood illness (IMCI) approach to managing the causes of childhood febrile illness, including malaria, viral or bacterial infections. (10) The health ministry has made several adaptations to the generic IMCI guidelines issued by WHO and the United Nations Children's Fund (UNICEF), to include guidelines for human immunodeficiency virus (HIV), diarrhoea management, use of malaria rapid diagnostic test for classifying fever and newborn care. In the country, the principles of the IMCI guidelines are incorporated into pre-service curricula and training programmes and the approach is implemented in all districts. However, less than 10% of the districts have the minimum level of 80% health workers trained in IMCI as required by the ministry of health. (11) As a result, health workers in Zambia face the challenge of managing febrile illness when malaria test results are negative. (12)

With this study, we aimed to evaluate current practices and standards of care for childhood febrile illness at different levels of the health-care system, in Southern Province, Zambia.

Methods

Study site

In 2013, Southern Province had an estimated population of about 1.6 million. (13) It is one of 10 provinces in Zambia and is divided into 13 districts. (13) Malaria transmission in the province ranges from hypoendemic (less than 10% of children aged 2-9 years are parasitemic) to holoendemic (more than 75% of children aged 2-9 years are parasitemic). In recent years, Southern Province has been the focus of intensive malaria control activities using reactive case detection (14) and mass malaria test and treat strategies, with the aim of creating malaria-free areas within the province. (15) In 2012, in Southern Province, 44% of children younger than 5 years slept under a treated bednet and 22% of all households reported indoor residual spraying in the previous 12 months. (16)

Study design

We conducted two types of cross-sectional surveys; one for facilities and one for health workers. Fundamental aspects of the survey design and execution were described previously. (17) The facility survey was used to record level of staffing, health services provided by the facility, availability and adequacy of medical equipment, availability of basic drugs and supplies and availability of treatment charts and guidelines. We also reviewed outpatient, inpatient and laboratory or malaria rapid diagnostic test registers to document the number of children consulted at the facility, proportions with febrile illness and proportions of confirmed cases of malaria who presented with a febrile illness in the last month. …

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