Treatment Seeking Practices for Malaria: A Household Case of Uasin Gishu County, Kenya
European Scientific Journal April 2018 edition Vol.14
Treatment Seeking Practices for Malaria: A Household Case of Uasin Gishu County, Kenya
Kerich J. Caroline 0
0 Moi University, School of Public Health Kemei K. William, Cherop K. Cleophas, Jomo Kenyatta University of Agriculture and Technology
Introduction: Malaria is among the leading cause of morbidity and mortality in Kenya. Malaria treatment seeking practices in epidemic areas in Africa such as Kenya are not well studied. The study aimed at assessing the treatment seeking practices in residents of Uasin-Gishu County following Malaria infection. Methods: Study was cross sectional study design. Stratified random sampling was used to identify 341 study participants. Principal component analysis was applied to compute the wealth index and the chisquare tests of association were carried out to determine factors associated with choice of treatment. Multivariate logistic regression determined predictors of treatment seeking practices. P<0.05 significance level was used during the study. Results: Fever was reported in 62.8% of all households; 94% sought treatment for the fever. Commonly assessed facility was government health facility (63%), chemists (15%), private clinics (12%) and traditional healers (2%). Educated persons' were 8.7 fold more likely to seek care from a private hospital. Employed and business owners were 4.1 fold more likely to purchase medicines from chemists. There were significant negative associations between wealth index and education level and seeking care in a government health facility. Respondents in the middle and fourth quintile with tertiary education level rarely sought care from a government health facility respectively. Conclusion: Treatment practices among households were: through government health institutions, private/clinics and chemists. Wealth index, age category of household heads, education level and occupation influenced treatment seeking practice. Reccomendation: There is need for the government for the government to strength community-based interventions and health facilities.
Malaria; world health organization; fever
Malaria remains an important cause of death, especially in sub-Saharan
Africa. Self-medication with anti-malarial drugs is commonly practiced which
raises issues to policy-makers. The toll of human suffering and death, malaria
saps the work force and drains the economy
(Das et al., 2013)
malaria affects people of all age groups, under five years and pregnant women
living in malaria prone areas are most vulnerable(Rowe et al., 2013).
The distribution of malaria is mainly in the tropical areas and in
resource poor countries especially in Africa
(Karyana et al., 2016; Nabyonga
Orem, Mugisha, Okui, Musango, & Kirigia, 2013)
. World malaria report of
2011, indicates that 216 Million malaria cases and close to 655 000 deaths
were reported in 2010. Globally Malaria mortalities have dropped by more
than 25% since 2000 and by 33% in WHO regions in Africa. In Africa, every
minute a child dies of malaria and this accounts for 22% of childhood
Currently in Kenya, malaria accounts for up to 30 % of all day care
attendance and 19% per cent are in-patients (Programme, 2016). The huge
burden of disease poses a big challenge as well as a strain on already
overburdened and under equiped health systems across SSA(World malaria
report 2017, 2017).
Intensifying use of long-lasting insecticide nets (LLINs), combination
therapies (ACTs) and indoor residual spraying (IRS) provides the best
opportunity to control and, in some countries, malaria elimination is achieved
(World malaria report 2017, 2017). To speed up the progress in control of
malaria, the 2005 World Health Assembly devised the Roll Back Malaria
(RBM) targets defined in four key interventions; insecticide-treated nets
(ITNs) for those people at risk, appropriate anti-malarial drugs for probable
and confirmed cases, IRS in cases of households at risk, and intermittent
preventive treatment in pregnancy (in high-transmission areas) (World
malaria report 2017, 2017).
Achieving and maintaining malaria control is key to meeting the
Millennium Development Goals (MDGs), One of which relates to malaria,
AIDS and other infectious and chronic diseases. Other goals specifically are
those related to child and maternal health will be difficult to reach in endemic
countries without substantially reducing the malaria burden.
In the recent years there have been changes of national malaria drug
policies in most countries in malaria risk areas in Africa, mostly from
Chloroquine to Sulfadoxine-pyrimethamine and now to ACTs. Malaria
parasites, in particular Plasmodium falciparum, developed resistance to these
earlier anti-malarial drugs necessitating the changes. Currently, WHO
recommends ACTs as the first-line drugs for treatment of malaria (World
malaria report 2017, 2017). Current debates focus on feasibility goals such as
eradication of malaria. Though such an (long-term) agenda is welcome, there
is need to ensure prompt access to effective malaria treatment to the children
less than five years, the most vulnerable, in SSA if the mortality reduction
goals set by RBM partners and/or the United Nations (UN) MDGs are to be
Malaria still remains a major health problem in Kenya and accounts
for an estimated 18% of outpatient consultations and 10% of hospital
admissions based on data from The routine health information system(USAID,
2016). Malaria transmission and infection risk in Kenya is determined largely
by altitude, rainfall patterns, and temperature. Therefore, malaria prevalence
varies considerably by season and across geographic regions(Sumba, Wong,
Kanzaria, Johnson, & John, 2008; USAID, 2016).
All four species of human Plasmodium: Plasmodium falciparum,
Plasmodium malariae, Plasmodium ovale and Plasmodium vivax occur in
Kenya. P. falciparum causes the most severe form of the malaria and accounts
for 98 % of all malaria cases. In Kenya vectors known to be spreading malaria
are; An. gambiae complex (An. gambiaess, An. arabiensis, An. merus) and An.
funestus. The malaria vector distribution in the country is not uniform due to
variation in climatic factors, particularly temperature and rainfall
Orem et al., 2013; USAID, 2016; World Health Organization, 2015)
Prompt and appropriate malaria treatment response is essential for
effective malaria management and reduces severe morbidity and mortality. An
understanding of treatment -seeking practices enables communities and the
formal system of health care to design interventions that cater to a specific
population. A concern of current malaria control programmes is the
significance of delayed treatment in morbidity, mortality and transmission of
malaria. If people could recognize early symptoms of Malaria and take
appropriate actions like seeking treatment, mortality is reduced.
Treatment seeking practices from previous studies shows that people
with malaria-like symptoms are more likely to resort self-medication at as they
wait for a time during which they monitor their progress
(Naing et al., 2017;
Romay-Barja et al., 2016)
. This allows them to minimize expenditure incurred
as a result of the sickness. The decisions to seek treatment from either visiting
a private health care practitioner, a government health centre or going to a
hospital are made when the situation gets serious. Know-how, duration of
sickness, the anticipated cost of medication, and a patient's judgment of the
seriousness of sickness determines their choice of type of treatment
(Uzochukwu & Onwujekwe, 2004)
Statement of the problem
Despite the resulting high case fatality rates, malaria treatment seeking
patterns in Malaria prone areas of Africa and especially Kenya are not well
studied. Studies that have examined malaria treatment seeking practices in
Kenya reveal that determinants such as symptom severity, literacy level and
proximity to medical facility affects the likelihood of seeking medication
(Sumba et al., 2008). It has been forwarded that fever is likely to prompt
suspecting people to seek treatment in health services, self-medication
through pharmacies and drug sellers is the most common response when
people experience symptoms that could be malaria
(Ayieko, Akumu, Griffiths,
& English, 2009; Deressa, 2007; Sumba et al., 2008)
Rapid screening of malaria and adequate diagnosis are essential for
preventing complications and most deaths. But even in areas served well with
good to health care services; it’s common for patients to present late to the
health facility or fail to attend. In a study done in Nandi, Kenya, results
documented that although health care facilities provide primary care for
malaria, ordinary shops are still frequent alternative source of care. Individuals
with signs consistent with malaria are not often given anti-malarial drugs at
these shops, resulting to lower recovery rates (Sumba et al., 2008). It is in this
light that this study aimed to bring out an understanding of treatment-seeking
practices at the household level among residents in this highland region. The
evidence will inform public health policies and systems in designing
appropriate interventions that cater to specific populations with the overall aim
of reducing the burden of malaria in the general population.
Materials and methods
Study area and population
The study was carried out Uasin Gishu County in western Kenya. This
is a highland-2073 Altitude malaria epidemic area with 24 % Prevalence. The
study area has a total population of 25 082 individuals according as per Kenya
National Census Survey 2010. Subsistence and dairy farming are the main
economic activities of the area. The study area is well served with several
Health centres, private hospitals and a National referral Hospital situated in its
Headquarters. The government facility offers free malaria screening and
treatment services. Study population composed of selected household in the
region with the target being household heads (male or female) above 18 years.
The study adopted a cross-sectional study design to determine
treatment seeking practices post malaria episode. Study was conducted
between the month on September and October following a short rainy season.
341 study participants were selected through stratified sampling then
proportionately divided into two strata’s to meet the target population and
finally specific household were selected through simple random sampling.
An interviewer-administered questionnaire was used to gather
socio-demographic and fever episodes among others factors. Completed
questionnaires were checked for completeness, coded, entered into Microsoft
Access then exported SPSS v.22.1 for further management and analysis.
Frequency tables were generated for categorical variables while
mean/median was generated for continuous variables (after normality tests).
Bivariate analysis was done using chi-square test for associations between the
dependent variables (treatment seeking practices for malaria) and the
independent variables (Socio- demographic characteristics, economic factors,
and health facility related factors). Multivariate analysis by logistic regression
was done to test the strength of associations between the dependent and the
independent variables and the resulting odds ratios was used to interpret the
associations. Statistical significance was considered when p value was less
The wealth index was constructed based on household’s data
ownership of domestic goods; residential characteristics; water source;
sanitary facilities; and other characteristics that relate to a household’s
socioeconomic status as is done by demographic and health surveys. To
construct the index, each of these assets were assigned a factor score generated
from principal component analysis (PCA), standardization of the resulting
asset scores was done in relation to a standard normal distribution, having zero
and one as mean and standard deviation respectively. A score for each asset
was assigned to each household, and then the scores were cumulated for each
household. Ranking was done according as per score of the resided household.
The sample was then divided into wealth indices from one to five lowest to
the highest respectively. Single asset index was developed based on the data
from the overall sample. The outcome of interest was measured as choice of
treatment for malaria a categorical variable, which was the main dependent
variable. Independent variables such as, marital status, occupation age,
education level, and wealth index were measured and later tested if they
influenced dependent variable.
Institutional Research Ethics Committee (IREC) of the Moi University
and Moi Teaching and Referral Hospital gave approval for the study before
commencement. Further Permission was sought from Ministry of Public
Health and Sanitation and Ministry of Medical services authorities in the study
area as well as the area chiefs. The respondents’ consent was sought and they
were assured of privacy and confidentiality and further that the information
would not be used in any way against them.
A total of 341 questionnaires were administered with 100% response.
Socio-demographic variables were measured including occupation, marital
status, age, education level, occupation and religion of the respondents. 72%
of the respondents were female. Mean age (SD) of the respondents was 32.7
(11.46) ranging between 18 and 80 years. Majority of respondents were
between the age group of 20-29 years, 164 (48.1%), while those above the age
of 50 were the least, 36 (9.9%).
Two hundred and sixty four (77.4%) were married and 77 (22.6%)
were single or formally married. In regard to education level, 207 (60.7%) of
the respondents had achieved at least a primary education, 104 (30.5%) had
secondary education, while 30 (8.8%) had a higher education. Majority of the
respondents were protestant Christians, 202 (59.2%).
According to the study findings, wealth was evenly distributed with
about 20.4% of the total population falling in the lowest wealth line.
Using fever as a proxy to malaria respondents were asked if anyone in
the household had fever two months preceding the survey. 62.8 %(n=214)
reported episodes of fever with the two months preceding the survey and
94 %(n=201) sought treatment. Seeking professional medical care through the
government health facility was the mostly preferred (63%), Chemists (15%),
private clinics (12%), retail shops (8%) and traditional healers (2%) and finally
community health workers (1%).
On Treatment Seeking Attitudes and Perceptions of Seriousness of
Fever; over 90% of respondents believe that anti-malarial drugs can cure fever
of which 73% of the respondents agreed that fever management was affordable
and available whereas 68% believe that herbal remedies should be used first
in the treatment of fever.
Continued…. Socioeconomic and socio-demographic differences in choice of healthcare
Government Private hospital (%) Chemist (%) Retail shop (%)
Persons with a higher education were 8.7 (95% CI=2.86-27.07) fold more likely to seek care from a private hospital
than persons with no & primary. Employed respondents and business owners were 4.1 (95% CI 1.57-10.86) and 3.8
(95%CI=1.52-9.91) more likely to purchase drugs from chemists while seeking care for malaria as opposed to farmers.
There were significant negative associations between wealth index and
education level and seeking care in a government health facility. Respondents
in the middle and fourth wealth index and had tertiary level of education were
47% (AOR 0.47 95% CI=0.22-0.99), 36% (AOR 0.36 95% CI= 0.16-0.77)
and 17% (AOR 0.17 95% CI=0.04-0.70) were unlikely to seek care from a
government health facility respectively. However, there was insignificant
association between occupation and seeking care in a government health
facility or private clinic, and between age and seeking care in a chemist. Sixty
three per cent of study respondents stated that lack of money hinders them
from seeking care at health facilities.
More than half of study participants reported evidence of fever. This
concurred with a study findings in Kipsamoite, Nandi where 53% of adults
reported having experienced fever six months prior to the survey(Sumba et al.,
2008) and of which 94% of them sought at least one form of care, similar to a
study findings in Nigeria (Seck et al., 2017).
Studies have demonstrated that response to malaria is dependent on
accessibility to a health facility, severity of the disease, expected quality of
care, cultural and traditional beliefs, and knowledge of the symptoms
(Karyana et al., 2016; Nabyonga Orem et al., 2013)
. Also found that malaria
treatment usually starts at home and referrals if home treatment is not
(Deressa, 2007; Ladner, Davis, Audureau, & Saba, 2017)
, which in
turn results to delayed in treatment from a proper care provider. Significant
delays before seeking care for fever was well documented in this study where
an average of 5 days could elapse before any form of care was sought. This
delay was much higher compared to a study done in Nigeria (4 days). A study
in Ethiopia found that, only 13% of respondents sought treatment within 24
hours of onset of symptoms
which is the best time for
management of fever.
This study revealed that several choices made by households in
seeking care for treatment after experiencing fever. The most preferred choice
for treatment of fever was a government health facility where 63% of
respondents sought care. Therefore confirming that seeking care at
government owned facilities is the most preferred by most people in the region
as it concurs with a study findings in Nandi with 66 %(Sumba et al., 2008) but
differed from the situation in malaria endemic regions(Win et al., 2017), where
drugs from local shops constituted the most popular first response to
(Das et al., 2013)
Significant variation exists in levels of socio-economic and
sociodemographic factors. The study revealed that households from the lowest
wealth index were likely to use a government health facility more than those
from higher wealth index (p=0.05). This is contrary to findings from a study
done in Nigeria where a larger population did not use health centers where
user fees were lower, no fees was charged for consultation(Uzochukwu &
Onwujekwe, 2004). Respondents with higher education were most likely to
visit private hospitals than respondents from other education levels. It is
possible that these individuals have good jobs as they are well educated and
can thus afford private hospitals. Statistically significant association existed
between occupation and seeking care from chemists. Previous study findings
have demonstrated that many drugs vendors at such outlets have no formal
trainings as pharmacists or medics hence resulting to wrong dispensation,
incorrect drugs or inappropriate courses based on a person’s ability to pay. On
contrary, life-threatening health problems such as malaria may be mistreated,
and regretfully unregulated and over use of such antibiotics may lead to drug
resistance. Upon missing to failing to attend to health care when ill they miss
not only proper diagnosis but also miss out on important treatments that may
only be offered at such health facilities, such as co-artem (Artemether–
lumefantrine combination therapy) for malaria.
Of those who sought treatment from the informal sector (retail shops),
majority were from the lower wealth index. This may be because health
facilities are more scattered in rural areas which hinders access to all. Care
seeking from traditional herbalists in this area occurred, although only 2%
admitted to such. There was likelihood of under-reporting of the use of
traditional herbs in this study, as the respondents may shy revealing such
information to this health seeking oriented study.
The study findings concluded that the main treatment-seeking
practices was mainly by visiting professional medical care, such as
government health institutions and private hospitals. Further it was agreed and
believed that anti-malarial drugs could treat fever promptly. Education level
and wealth index level too determined the type of health facility attended by
people with fever.
Public health programmes to combat malaria should incorporate
traditional healers, retail shop owners and pharmacy staffs play a big role in
treating malaria within this community.
There is need to emphasize on improving early and prompt diagnosis
and treatment with effective anti-malarial drugs in order to curb morbidities
and mortalities associated with this disease. People should be mobilized on the
importance of early diagnosis with effective anti-malarial drugs within 24
hours of symptom onset.
Further research should be conducted to understand reasons why
people prefer a particular choice for treatment of fever in order to inform
public health policy planning.
9. Programme, N. M. C. (2016). Malaria Indicator Survey 2015. Ministry
of Health Kenya, 2.
10. Romay-Barja, M., Cano, J., Ncogo, P., Nseng, G., Santana-Morales,
M. A., Valladares, B., … Benito, A. (2016). Determinants of delay in
malaria care-seeking behaviour for children 15 years and under in Bata
district, Equatorial Guinea. Malaria Journal, 15(1), 1–8.
11. Rowe, A. K., Rowe, S. Y., Snow, R. W., Korenromp, E. L.,
Schellenberg, A., Stein, C., … Bryce, J. (2013). Europe PMC Funders
Group The burden of malaria mortality among African children in the
year 2000, 35(3), 691–704. https://doi.org/10.1093/ije/dyl027.The
12. Seck, M. C., Thwing, J., Fall, F. B., Gomis, J. F., Deme, A., Ndiaye, Y.
D., … Ndiaye, D. (2017). Malaria prevalence, prevention and
treatment seeking practices among nomadic pastoralists in northern
Senegal. Malaria Journal, 16(1), 1–11.
13. Sumba, P. O., Wong, S. L., Kanzaria, H. K., Johnson, K. A., & John,
C. C. (2008). Malaria treatment-seeking behaviour and recovery from
malaria in a highland area of Kenya. Malaria Journal, 7, 1–8.
14. USAID. (2016). President ’s malaria initiative 2016, 1–45. Retrieved
15. Uzochukwu, B. S. C., & Onwujekwe, O. E. (2004). Socio-economic
differences and health seeking behaviour for the diagnosis and
treatment of malaria: A case study of four local government areas
operating the Bamako initiative programme in south-east Nigeria.
International Journal for Equity in Health, 3, 1–10.
16. Win, A. Y. N., Maung, T. M., Wai, K. T., Oo, T., Thi, A., Tipmontree,
R., … Kaewkungwal, J. (2017). Understanding malaria
treatmentseeking preferences within the public sector amongst mobile/migrant
workers in a malaria elimination scenario: A mixed-methods study.
Malaria Journal, 16(1), 1–13.
17. World Health Organization. (2015). Treatment of Severe Malaria.
Guidelines For The Treatment of Malaria, 71–88.
18. World malaria report 2017. (2017).
1. Ayieko , P. , Akumu , A. O. , Griffiths , U. K. , & English , M. ( 2009 ). The economic burden of inpatient paediatric care in Kenya: Household and provider costs for treatment of pneumonia, malaria and meningitis . Cost Effectiveness and Resource Allocation , 7 , 1 - 13 . https://doi.org/10.1186/ 1478 -7547-7-3
2. Das , A. , Gupta , R. Das , Friedman , J. , Pradhan , M. M. , Mohapatra , C. C. , & Sandhibigraha , D. ( 2013 ). Community perceptions on malaria and care-seeking practices in endemic Indian settings: Policy implications for the malaria control programme . Malaria Journal , 12 ( 1 ). https://doi.org/10.1186/ 1475 -2875-12-39
3. Deressa , W. ( 2007 ). Treatment-seeking behaviour for febrile illness in an area of seasonal malaria transmission in rural Ethiopia . Malaria Journal , 6 , 1 - 7 . https://doi.org/10.1186/ 1475 -2875-6-49
4. Kanté , A. M. , Nathan , R. , Helleringer , S. , Sigilbert , M. , Levira , F. , Masanja , H., … Phillips , J. F. ( 2014 ). The contribution of reduction in malaria as a cause of rapid decline of under-five mortality: Evidence from the Rufiji Health and Demographic Surveillance System (HDSS) in rural Tanzania . Malaria Journal , 13 ( 1 ). https://doi.org/10.1186/ 1475 -2875-13-180
5. Karyana , M. , Devine , A. , Kenangalem , E. , Burdarm , L. , Poespoprodjo , J. R. , Vemuri , R. , … Yeung , S. ( 2016 ). Treatment-seeking behaviour and associated costs for malaria in Papua, Indonesia . Malaria Journal , 15 ( 1 ), 1 - 12 . https://doi.org/10.1186/s12936-016-1588-8
6. Ladner , J. , Davis , B. , Audureau , E. , & Saba , J. ( 2017 ). Treatmentseeking patterns for malaria in pharmacies in five sub-Saharan African countries . Malaria Journal , 16 ( 1 ), 1 - 13 . https://doi.org/10.1186/s12936-017-1997-3
7. Nabyonga Orem , J. , Mugisha , F. , Okui , A. P. , Musango , L. , & Kirigia , J. M. ( 2013 ). Health care seeking patterns and determinants of out-ofpocket expenditure for Malaria for the children under-five in Uganda . Malaria Journal , 12 ( 1 ), 1 - 11 . https://doi.org/10.1186/ 1475 -2875-12- 175
8. Naing , P. A. , Maung , T. M. , Tripathy , J. P. , Oo , T. , Wai , K. T. , & Thi , A. ( 2017 ). Awareness of malaria and treatment-seeking behaviour among persons with acute undifferentiated fever in the endemic regions of Myanmar . Tropical Medicine and Health , 45 ( 1 ), 1 - 10 . https://doi.org/10.1186/s41182-017-0070-9