title: Treatment actions and treatment failure: case studies in the response to severe childhood febrile illness in Mali.
abstract: BACKGROUND
  Appropriate home management of illness is vital to efforts to control malaria. The strategy of home management relies on caregivers to recognize malaria symptoms, assess severity and promptly seek appropriate care at a health facility if necessary. This paper examines the management of severe febrile illness (presumed malaria) among children under the age of five in rural Koulikoro Region, Mali.
  
  
  METHODS
  This research examines in-depth case studies of twenty-five households in which a child recently experienced a severe febrile illness, as well as key informant interviews and focus group discussions with community members. These techniques were used to explore the sequence of treatment steps taken during a severe illness episode and the context in which decisions were made pertaining to pursing treatments and sources of care, while incorporating the perspective and input of the mother as well as the larger household.
  
  
  RESULTS
  Eighty-one participants were recruited in 25 households meeting inclusion criteria. Children's illness episodes involved multiple treatment steps, with an average of 4.4 treatment steps per episode (range: 2-10). For 76% of children, treatment began in the home, but 80% were treated outside the home as a second recourse. Most families used both traditional and modern treatments, administered either inside the home by family members, or by traditional or modern healers. Participants' stated preference was for modern care, despite high rates of reported treatment failure (52%, n=12), however, traditional treatments were also often deemed appropriate and effective. The most commonly cited barrier to seeking care at health facilities was cost, especially during the rainy season. Financial constraints often led families to use traditional treatments.
  
  
  CONCLUSIONS
  Households have few options available to them in moments of overlapping health and economic crises. Public health research and policy should focus on the reducing barriers that inhibit poor households from promptly seeking appropriate health care. Enhancing the quality of care provided at community health facilities and supporting mechanisms by which treatment failures are quickly identified and addressed can contribute to reducing subsequent treatment delays and avoid inappropriate recourse to traditional treatments.
authors.affiliation: Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Amy A
authors.initials: AA
authors.lastname: Ellis
authors.forename: Sidy
authors.initials: S
authors.lastname: Traore
authors.forename: Seydou
authors.initials: S
authors.lastname: Doumbia
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Dalglish
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Winch
mesh_terms: D000328:Adult; D000368:Aged; D002675:Child, Preschool; D005191:Family Characteristics; D005260:Female; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D008288:Malaria / Q000628:therapy*; D008297:Male; D008302:Mali; D008519:Medicine, Traditional / Q000706:statistics & numerical data; D008875:Middle Aged; D009035:Mothers / Q000523:psychology*; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D036301:Qualitative Research; D012424:Rural Population; D017211:Treatment Failure; D055815:Young Adult