Factors associated with delayed access of care among children under five with malaria and their outcomes at a regional referral hospital in Eastern Uganda

Technical Summary: Factors Associated with Delayed Access of Care Among Children Under Five with Malaria and Their Outcomes at a Regional Referral Hospital in Eastern Uganda

Problem Statement
Uganda bears the highest burden of malaria cases in East and Southern Africa, accounting for 3% of deaths in 2020. Malaria in children under five is particularly critical, as the condition can progress to severe malaria within 24 hours of symptom onset. Despite existing interventions to prevent transmission, delays in diagnosis and treatment remain a primary driver of mortality and adverse outcomes. While various factors such as traditional beliefs, healthcare system structure, and socioeconomic status have been linked to care-seeking delays in other contexts, there was a lack of published data specifically addressing the causes and outcomes of these delays at the Mbale Regional Referral Hospital (MRRH) in Eastern Uganda. This study aimed to fill that gap by exploring the factors associated with delayed access to care and the subsequent clinical outcomes for children under five.

Methodology
The study employed a cross-sectional design conducted at MRRH, a public facility serving a population of nearly 4.5 million across multiple districts in Eastern Uganda.

• Population: The target population consisted of parents or caretakers of children under five admitted with malaria.
• Sampling: A consecutive sampling technique was used to recruit 216 participants who met the inclusion criteria (consenting parents/caretakers of children under five with malaria). Exclusion criteria included mentally incapacitated, critically ill, deaf, or mute caretakers.
• Data Collection: Quantitative data were gathered using researcher-administered questionnaires via Google Forms on mobile devices and laptops. Interviews were conducted in the acute and pediatric wards, lasting approximately 20 minutes. To ensure accuracy, self-reported data were verified against patient medical records. Two nurses fluent in local languages (Lugisu, Ateso, and Lugwere) assisted with translation.
• Variables:
  • Independent Variables: Socio-demographics (age, sex, education, occupation, marital status), decision-making factors, transport logistics (distance, cost, mode), and facility-level factors (waiting time, drug availability, health worker attitude).
  • Dependent Variable: Delay in access of care, defined as taking more than 24 hours to seek professional medical care after symptom onset. Outcomes included progression to severe malaria, prolonged hospital stay (>5 days), and recovery.
• Analysis: Data were analyzed using STATA version 15. Bivariate regression identified associations between independent variables and delay. Significant factors (p < 0.05) were included in multivariable logistic regression using a backward elimination method to control for confounders.

Key Results

• Prevalence of Delay: Among the 216 children admitted, 59.26% received care from a health facility more than 24 hours after symptom onset. The average time to seek care was 1 day and 6 hours.
• Predictors of Delay: Multivariate analysis identified two significant predictors of delayed care:
  1. Caregiver Education: Caregivers with tertiary education were significantly more likely to delay seeking care compared to those with no formal education (Adjusted Odds Ratio [AOR] = 7.1; p = 0.02).
  2. Initial Management: Caregivers who implemented measures other than administering medication or herbs (e.g., monitoring the child, waiting for resources) before visiting a health center were more likely to delay (AOR = 4.1; p = 0.00).
• Care-Seeking Behaviors:
  • 61.57% of caretakers initially gave medication (often from drug shops or leftover stocks) before seeking professional care.
  • 69.44% of children were referred from peripheral facilities to MRRH, while 30.56% were self-referred.
  • Common reasons for delay included the belief that the child would improve (43.52%) and lack of funds (24.54%).
• Clinical Outcomes:
  • 92.59% of children had progressed to severe malaria by the time of contact at the hospital.
  • 87.04% were responding to treatment/recovering, while 17.13% experienced prolonged hospital stays.
  • Association with Outcomes: Contrary to expectations, the study found no statistically significant association between the timing of care access (delayed vs. non-delayed) and specific outcomes such as progression to severe malaria, prolonged hospital stay, or recovery. The authors attribute this to the multifactorial nature of delay and individual variations in disease progression.

Significance and Claims
The paper claims that despite numerous national interventions to curb malaria, delayed access to care remains a significant contributor to adverse effects among children under five in the study region. The findings highlight a counter-intuitive trend where higher education levels (tertiary) were associated with greater delays, potentially due to work commitments or different risk perceptions, challenging the assumption that education always correlates with prompt health-seeking behavior.

The study concludes that health education regarding the impact of delayed access to care must be intensified at all levels of the healthcare system. It emphasizes that since health-seeking for children under five is entirely dependent on parents and caretakers, interventions must target caregiver decision-making processes, specifically addressing the tendency to wait for improvement or rely on self-medication before seeking professional help.

Limitations
The authors acknowledge that the sample was biased toward the most ill children (admitted cases), which may limit the generalizability of findings to the broader community. Additionally, the cross-sectional design precludes causal inferences, and the single-site nature of the study (MRRH) limits the extrapolation of results to all caretakers in the region.