title: Factors influencing choice of care-seeking for acute fever comparing private chemical shops with health centres and hospitals in Ghana: a study using case-control methodology.
abstract: Several public health interventions to improve management of patients with fever are largely focused on the public sector yet a high proportion of patients seek care outside the formal healthcare sector. Few studies have provided information on the determinants of utilization of the private sector as against formal public sector. Understanding the differences between those who attend public and private health institutions, and their pathway to care, has significant practical implications. The chemical shop is an important source of care for acute fever in Ghana.
  
  
  
  Case-control methodology was used to identify factors associated with seeking care for fever in the Dangme West District, Ghana. People presenting to health centres, or hospital outpatients, with a history or current fever were compared to counterparts from the same community with fever visiting a chemical shop.
  
  
  
  Of 600 patients, 150 each, were recruited from the district hospital and two health centres, respectively, and 300 controls from 51 chemical shops. Overall, 103 (17.2 %) patients tested slide positive for malaria. Specifically, 13.7 % (41/300) of chemical shop patients, 30.7 % (46/150) health centre and 10.7 % (16/150) hospital patients were slide positive. While it was the first option for care for 92.7 % (278/300) chemical shop patients, 42.7 % (64/150) of health centre patients first sought care from a chemical shop. More health centre patients (61.3 %; 92/150) presented with fever after more than 3 days than chemical shop patients (27.7 %; 83/300) [AOR = 0.19; p < 0.001 CI 0.11-0.30]. Although the hospital was the first option for 83.3 % (125/150) of hospital patients, most (63.3 %; 95/150) patients arrived there over 3 days after their symptoms begun. Proximity was significantly associated with utilization of each source of care. Education, but not other socioeconomic or demographic factors were significantly associated with chemical shop use.
  
  
  
  The private drug retail sector is the first option for the majority of patients, including poorer patients, with fever in this setting. Most patients with fever arrive at chemical shops with less delay and fewer signs of severity than at public health facilities. Improving chemical shop skills is a good opportunity to diagnose, treat or refer people with fever early.
authors.affiliation: Research and Development Division, Ghana Health Service, P.O. Box MB-190, Accra, Ghana. Ansahekdr@yahoo.co.uk.
authors.forename: Evelyn K
authors.identifier: 0000-0003-0401-8606
authors.initials: EK
authors.lastname: Ansah
authors.affiliation: Research and Development Division, Ghana Health Service, P.O. Box MB-190, Accra, Ghana.
authors.forename: Margaret
authors.initials: M
authors.lastname: Gyapong
authors.affiliation: Research and Development Division, Ghana Health Service, P.O. Box MB-190, Accra, Ghana.
authors.forename: Solomon
authors.initials: S
authors.lastname: Narh-Bana
authors.affiliation: National Malaria Control Programme, Ghana Health Service, Accra, Ghana.
authors.forename: Constance
authors.initials: C
authors.lastname: Bart-Plange
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Christopher J M
authors.initials: CJ
authors.lastname: Whitty
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D003151:Community Health Centers / Q000706:statistics & numerical data*; D005260:Female; D005334:Fever / Q000175:diagnosis* / Q000188:drug therapy*; D005869:Ghana; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D010594:Pharmacies; D011247:Pregnancy; D017149:Private Sector / Q000706:statistics & numerical data*; D017150:Public Sector / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: ACT; Chemical shop; Diagnosis; Drug retail shop; Fever; Health centre; Hospital; Malaria; Targeting