Home based care

Home or community-based programs for treating malaria prevent 42% of child deaths and result in prompt treatment being 8 times more likely.

 

Photo Credits: Unknown (L),

  

Why is home or community-based care important in malaria treatment?

Some of the barriers of effective treatment for malaria in many countries are the distance to health services and the cost of transportation. The cost of the artemsinin-based combination therapy itself is also a barrier but subsidized and reduced costs of treatment are not enough to improve access if people can get to the treatment. Home or community-based care is a strategy to address this barrier.

Home-based management of malaria is treatment of fever in children at or near their home (by mothers, health workers, drug sellers) with prepackaged antimalarial medicines with or without a malaria diagnosis.

Does home or community based care work?

  • Home or community-based care increases the number of people who receive prompt treatment with an antimalarial (within 24 hours) when suffering fever. One study found that they reduced mortality.
  • Home or community-based programs for treating malaria prevent 42% of child deaths and result in prompt treatment being 8 times more likely.

Equity: does it work in the disadvantaged?

  • The greatest burden of malaria is among the disadvantaged. Improving time to treatment for malaria by providing treatment in the home or community and addressing barriers related to travel to health centres will improve malaria-related health outcomes for the disadvantaged. 

Intervention Delivery

  • The included interventions involved training of mothers or basic level health workers. 8 of the 10 studies treated malaria without a confirmed diagnosis while 2 studies trained community health workers (CHW) to use rapid diagnostic tests. The WHO now recommends confirmation of malaria before treatment to avoid overuse of antimalarials and rule out other causes of fever.
  • Most of the interventions provided the antimalarial treatment for free or at a reduced cost.
  • All studies included an educational component through community awareness, social marketing, or training of mothers and CHWs.
  • Follow up ranged from 5 to 24 months.

Population and Setting

  • The review utilized 10 studies conducted in low and middle income countries in Africa, including Burkina Faso, Democratic Republic of the Congo, Ethiopia, Kenya, Tanzania, Uganda, and Zambia.

Summary of Findings [SOF] Tables: Home- or community-based programs for treating malaria

Patient or population: children with fever or malaria symptoms
Settings: Malaria endemic areas
Intervention: home- or community-based
Comparison: standard care

 Outcomes

 

Anticipated absolute effects per year

Relative Effect

(95% CI)

No of Participants

(studies)

Quality of the evidence

(GRADE)

 

 

Risk without home or community program (Control)

Risk difference with home or community programs (95% CI)

 

 

 

All-cause mortality

 

50 per 1000

21 fewer per 1000 (from 11 to 28  fewer)

OR 0.58 (0.49-69)

13677 (1)

Moderate2,3

Prompt treatment with an effective antimalarial

 

100 per 1000

369 more per 1000 (from 0 to 900 more)

OR 8.11 (6.40-10.27)

3099 (2)

Moderate1

Adverse Events: None reported

1. Downgraded by 1 for indirectness: all included studies treated children with clinical diagnosis of malaria without parasitological confirmation which is no longer recommended by the WHO and may lead to undertreatment of other illness which may need alternative treatments.
2. No serious risk of bias: although the baseline characteristics of the intervention and control areas were not well described, deaths were well balanced at baseline.
3. Downgraded by 1 for indirectness: The study was conducted in a setting where community-based interventions such as this had been in operation for 20 years, and so the findings may not be easily generalized to other settings.


 

Summary of Findings [SOF] Tables: Home- or community-based programs using RDT diagnosis versus the same programs using clinical diagnosis

Patient or population: children with fever or malaria symptoms
Settings: Malaria endemic areas
Intervention: home- or community-based using RDT diagnosis
Comparison: home- or community-based programs using clinical diagnosis

Outcomes

 

Anticipated absolute effects per year

Relative Effect

(95% CI)

No of Participants

(studies)

Quality of the evidence

(GRADE)

 

 

Clinical diagnosis (Control)

RDT diagnosis(95% CI)

 

 

 

Treatment with an anti-malarial

980 per 1000

598 fewer per 1000 (from 157 to 804 fewer)

0.39 (0.18-0.84)

5977 (2)

Moderate1

All cause mortality

1 per 1000

1 more per 1000 (from 1 fewer to 10 more)

3.51 (0.68-18.22)

6055 (2)

Low2,3

Hospitalizations

7 per 1000

5 fewer per 1000 (from 7 fewer to 4 more)

0.25 (0.04-1.50)

3125 (1)

Low2,3

Adverse Events: None reported

1. Downgraded by 1 for serious indirectness: the introduction of RDTs was only tested in 2 settings. Compliance with the RDT protocol was high under trial conditions. Further effectiveness studies may be necessary to have full confidence in this result.
2. Downgraded by 1 for serious indirectness: the intro duction of RDTs was only tested in 2 settings. It appeared safe under trial conditions without an increase in mortality or hospitalizations. Further effectiveness studies may be necessary to have full confidence in this.
3. Downgraded by 1 for serious imprecision: these 2 studies were not powered to look for effects on mortality or hospitalization.

 

Relevance of the review for disadvantaged communities

Findings

Interpretation

Equity - Which of the PROGRESS groups examined

All included studies were conducted in low and middle income countries in Africa.

Home and community-based programs for treating malaria are effective for preventing child deaths and promoting prompt malaria treatment among disadvantaged populations.

7 of the 10 studies targeted children younger than 6 years and the other 3 studies included children of all ages.

The results of this study are applicable to both children and adults. The review does not report on differences associated with any other PROGRESS groups.

Equity Applicability

All included studies were conducted in Africa in both urban and rural locations.

The results are likely applicable to other malaria-endemic regions in Africa.

Cost-equity

Home or community-based programs for treating malaria which provide antimalarials for free or at a reduced cost improve access to prompt treatment.

Policymakers implementing a home or community-based malaria treatment program should consider whether providing subsidized antimalarials is feasible. This will ensure that people with malaria receive prompt treatment and promote cost-equity since barriers to treatment are removed for the most disadvantaged groups of the population.

Comments on this summary? Please contact Jennifer Petkovic