title: Management of febrile children under five years in hospitals and health centres of rural Ghana.
abstract: BACKGROUND
  The case management of febrile children in hospitals' and health centres' pre-roll out of the new WHO policy on parasitological diagnosis was assessed. The delivery of artemisinin combination therapy (ACT) at these two levels of the health system was compared.
  
  
  METHODS
  Structured observations and exit interviews of 1,222 febrile children attending five hospitals and 861 attending ten health centres were conducted in six districts of the Brong Ahafo Region of Ghana. Effectiveness of delivery of case management of malaria was assessed. Proportions of children receiving ACT, anti-malarial monotherapy and antibiotics were described. Predictors of: a febrile child being given an ACT, a febrile child being given an antibiotic and of carers knowing how to correctly administer the ACT were assessed using logistic regression models stratified by hospitals and health centres.
  
  
  RESULTS
  The system's effectiveness of delivering an ACT to febrile children diagnosed with malaria (parasitologically or clinically) was 31.4 and 42.4% in hospitals and health centres, respectively. The most ineffective process was that of ensuring that carers knew how to correctly administer the ACT. Overall 278 children who were not given an ACT were treated with anti-malarial monotherapy other than quinine. The majority of these children, 232/278 were given amodiaquine, 139 of these were children attending hospitals and 93 attending health centres. The cadre of health staff conducting consultation was a common predictor of the outcomes of interest. Presenting symptoms and examinations conducted were predictive of being given an ACT in hospitals and antibiotic in hospitals and health centres but not of being given an ACT in health centres. Treatment-seeking factors were predictive of being given an ACT if it was more than seven days since the fever began and an antibiotic in hospitals but not in health centres.
  
  
  CONCLUSIONS
  Interventions to improve adherence to negative parasitological tests are needed, together with guidance on dispensing of antibiotics, but improving the education of carers on how to administer ACT will lead to the greatest immediate increase in the effectiveness of case management. Guidance is needed on implementation of the new test-based treatment for malaria policy in health facilities.
authors.affiliation: Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK. jayne.webster@lshtm.ac.uk.
authors.forename: Jayne
authors.initials: J
authors.lastname: Webster
authors.forename: Frank
authors.initials: F
authors.lastname: Baiden
authors.forename: Justina
authors.initials: J
authors.lastname: Bawah
authors.forename: Jane
authors.initials: J
authors.lastname: Bruce
authors.forename: Mathilda
authors.initials: M
authors.lastname: Tivura
authors.forename: Rupert
authors.initials: R
authors.lastname: Delmini
authors.forename: Seeba
authors.initials: S
authors.lastname: Amenga-Etego
authors.forename: Daniel
authors.initials: D
authors.lastname: Chandramohan
authors.forename: Seth
authors.initials: S
authors.lastname: Owusu-Agyei
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D000962:Antimalarials / Q000008:administration & dosage / Q000627:therapeutic use; D037621:Artemisinins / Q000008:administration & dosage / Q000627:therapeutic use; D017028:Caregivers; D002662:Child Health Services; D002675:Child, Preschool; D003153:Community Health Services; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care; D019468:Disease Management; D004359:Drug Therapy, Combination; D004363:Drug Utilization; D005260:Female; D005334:Fever / Q000188:drug therapy* / Q000453:epidemiology; D005869:Ghana / Q000453:epidemiology; D057220:Health Literacy; D006780:Hospitals, Rural; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D019458:Insurance Coverage; D008288:Malaria / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D008297:Male; D008485:Medical Audit; D012424:Rural Population; D012494:Sampling Studies; D012959:Socioeconomic Factors
chemical_list: D000900:Anti-Bacterial Agents; D000962:Antimalarials; D037621:Artemisinins; C031327:artemisinin