title: Understanding caretakers' dilemma in deciding whether or not to adhere with referral advice after pre-referral treatment with rectal artesunate.
abstract: BACKGROUND
  Malaria kills. A single rectal dose of artesunate before referral can reduce mortality and prevent permanent disability. However, the success of this intervention depends on caretakers' adherence to referral advice for follow-up care. This paper explores the dilemma facing caretakers when they are in the process of deciding whether or not to transit their child to a health facility after pre-referral treatment with rectal artesunate.
  
  
  METHODS
  Four focus group discussions were held in each of three purposively selected villages in Mtwara rural district of Tanzania. Data were analysed manually using latent qualitative content analysis.
  
  
  RESULTS
  The theme "Caretakers dilemma in deciding whether or not to adhere with referral advice after pre-referral treatment with rectal artesunate" depicts the challenge they face. Caretakers' understanding of the rationale for going to hospital after treatment--when and why they should adhere--influenced adherence. Caretakers, whose children did not improve, usually adhered to referral advice. If a child had noticeably improved with pre-referral treatment however, caretakers weighed whether they should proceed to the facility, balancing the child's improved condition against other competing priorities, difficulties in reaching the health facilities, and the perceived quality of care at the health facility. Some misinterpretation were found regarding the urgency and rationale for adherence among some caretakers of children who improved which were attributed to be possibly due to their prior understanding.
  
  
  CONCLUSIONS
  Some caretakers did not adhere when their children improved and some who adhered did so without understanding why they should proceed to the facility. Successful implementation of the rectal artesunate strategy depends upon effective communication regarding referral to clinic.
authors.affiliation: Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. dsimba@muhas.ac.tz
authors.forename: Daudi O
authors.initials: DO
authors.lastname: Simba
authors.forename: Deodatus C
authors.initials: DC
authors.lastname: Kakoko
authors.forename: Marian
authors.initials: M
authors.lastname: Warsame
authors.forename: Zul
authors.initials: Z
authors.lastname: Premji
authors.forename: Melba F
authors.initials: MF
authors.lastname: Gomes
authors.forename: Goran
authors.initials: G
authors.lastname: Tomson
authors.forename: Eva
authors.initials: E
authors.lastname: Johansson
mesh_terms: D000285:Administration, Rectal; D000328:Adult; D000368:Aged; D000962:Antimalarials / Q000008:administration & dosage*; D037621:Artemisinins / Q000008:administration & dosage*; D000077332:Artesunate; D017028:Caregivers / Q000523:psychology*; D003376:Counseling; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D016778:Malaria, Falciparum / Q000175:diagnosis / Q000188:drug therapy* / Q000469:parasitology; D055118:Medication Adherence; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D010963:Plasmodium falciparum / Q000302:isolation & purification; D012017:Referral and Consultation; D012720:Severity of Illness Index; D013636:Tanzania; D055815:Young Adult
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D000077332:Artesunate
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