Differences in malaria care seeking and dispensing outcomes for adults and children attending drug vendors in Nasarawa, Nigeria

Use of malaria rapid diagnostic test and anti-malarial drug prescription practices among primary healthcare workers in Ebonyi state, Nigeria: An analytical cross-sectional study

BACKGROUND

The recommendation of universal diagnostic testing before malaria treatment aimed to address the problem of over-treatment with artemisinin-based combination therapy and the heightened risk of selection pressure and drug resistance and the use of malaria rapid diagnostic test (MRDT) was a key strategy, particularly among primary healthcare (PHC) workers whose access to and use of other forms of diagnostic testing were virtually absent. However, the use of MRDT can only remedy over-treatment when health workers respond appropriately to negative MRDT results by not prescribing anti-malarial drugs. This study assessed the use of MRDT and anti-malarial drug prescription practices, and the predictors, among PHC workers in Ebonyi state, Nigeria.

METHODS

We conducted an analytical cross-sectional questionnaire survey, among consenting PHC workers involved in the diagnosis and treatment of malaria, from January 15, 2020 to February 5, 2020. Data was collected via structured self-administered questionnaire and analysed using descriptive statistics and bivariate and multivariate generalized estimating equations.

RESULTS

Of the 490 participants surveyed: 81.4% usually/routinely used MRDT for malaria diagnosis and 18.6% usually used only clinical symptoms; 78.0% used MRDT for malaria diagnosis for all/most of their patients suspected of having malaria in the preceding month while 22.0% used MRDT for none/few/some; 74.9% had good anti-malarial drug prescription practice; and 68.0% reported appropriate response to negative MRDT results (never/rarely prescribed anti-malarial drugs for the patients) while 32.0% reported inappropriate response (sometimes/often/always prescribed anti-malarial drugs). The identified predictor(s): of the use of MRDT was working in health facilities supported by the United States' President's Malaria Initiative (PMI-supported health facilities); of good anti-malarial drug prescription practice were having good opinion about MRDT, having good knowledge about malaria diagnosis and MRDT, being a health attendant, working in PMI-supported health facilities, and increase in age; and of appropriate response to negative MRDT results was having good opinion about MRDT.

CONCLUSIONS

The evidence indicate the need for, and highlight factors to be considered by, further policy actions and interventions for optimal use of MRDT and anti-malarial drug prescription practices among the PHC workers in Ebonyi state, Nigeria, and similar settings.

A qualitative study on determinants of the use of malaria rapid diagnostic test and anti-malarial drug prescription practices by primary healthcare workers in Ebonyi state, Nigeria

BACKGROUND

The increased availability and use of malaria rapid diagnostic test (RDT) by primary healthcare (PHC) workers has made universal diagnostic testing before malaria treatment more feasible. However, to meaningfully resolve the problem of over-treatment with artemisinin-based combination therapy and the heightened risk of selection pressure and drug resistance, there should be appropriate response (non-prescription of anti-malarial drugs) following a negative RDT result by PHC workers. This study explored the determinants of the use of RDT and anti-malarial drug prescription practices by PHC workers in Ebonyi state, Nigeria.

METHODS

Between March 2 and 10, 2020, three focus group discussions were conducted in English with 23 purposively-selected consenting PHC workers involved in the diagnosis and treatment of malaria. Data was analysed thematically as informed by the method by Braun and Clarke.

RESULTS

The determinants of the use of RDT for malaria diagnosis were systemic (RDT availability and patient load), provider related (confidence in RDT and the desire to make correct diagnosis, PHC worker's knowledge and training, and fear to prick a patient), client related (fear of needle prick and refusal to receive RDT, and self-diagnosis of malaria, based on symptoms, and insistence on not receiving RDT), and RDT-related (the ease of conducting and interpreting RDT). The determinants of anti-malarial drug prescription practices were systemic (drug availability and cost) and drug related (effectiveness and side-effects of the drugs). The determinants of the prescription of anti-malarial drugs following negative RDT were provider related (the desire to make more money and limited confidence in RDT) and clients' demand while unnecessary co-prescription of antibiotics with anti-malarial drugs following positive RDT was determined by the desire to make more money.

CONCLUSIONS

This evidence highlights many systemic, provider, client, and RDT/drug related determinants of PHC workers' use of RDT and anti-malarial drug prescription practices that should provide tailored guidance for relevant health policy actions in Ebonyi state, Nigeria, and similar settings.

Overtreatment of malaria in the Nigerian healthcare setting: prescription practice, rationale and consequences

Nigeria is one of the countries in the world with the highest burden of malaria, accounting for a quarter of all cases in Africa. According to the Centers for Disease Control and Prevention, microscopic examination remains the gold standard for laboratory confirmation of malaria. However, the policy and practice of presumptive treatment of malaria for all febrile illnesses has been widely advocated in sub-Saharan Africa. Presumptive management of fevers and/or other symptoms of malaria results in over-diagnosis, and consequently overtreatment. This article discusses the overtreatment of malaria as practiced in Nigeria and other African regions against standard treatment guidelines, highlights a wide range of its associated effects on patients and proffers possible solutions to curb the unethical practice of malaria overtreatment.

Knowledge of malaria control and attitudes towards community involvement among female community volunteers: effect of capacity building in a rural community, Southeast Nigeria

Introduction

community volunteers have limited skills but are an important link between the community and health facilities. We determined the effect of a capacity building intervention on knowledge of malaria control and attitudes towards community involvement among female community volunteers as part of a larger community-based intervention study on pregnant women and children under five.

Methods

we conducted a before and after intervention study (no randomization or controls) among female community volunteers in Amagu community in Abakaliki Local Government Area. The intervention consisted of training sessions on knowledge of malaria and its control. The training took the form of lectures, role plays and practical demonstrations. Supportive supervision by trained community health extension workers was also provided during their field work. We compared pre-training test and post-training test scores after six months interval and analysed the data using paired t test at 5% level of significance with EPI INFO software version 7.2.3.

Results

the mean age of the participants was 28.5(± 6.0) years. All had a minimum level of secondary education. There was significant improvement in the mean scores of their knowledge of malaria signs and symptoms (p < 0.001), preventive measures (p < 0.001) and appropriate drug treatment (p < 0.001) in the post-training test when compared with the pre-training test. The overall mean knowledge scores pre and posttest were 147.8 and 169.8 respectively (p < 0.001) out of a maximum achievable score of 195. Also there was significant improvement in the perception of the participants on community involvement in promoting referral of pregnant women with fever (p = 0.001), the use of intermittent preventive therapy with sulphadoxine-pyrimethamine (p = 0.048) and funding initiatives to sustain activities (p = 0.037).

Conclusion

capacity building of female community volunteers coupled with supportive supervision by trained community health workers improved the female community volunteers´ knowledge of malaria, its control and their perception of community involvement in control activities. It is recommended that the use of community volunteers as a low cost health resource can be explored further for incorporation into existing policies on malaria control in resource constrained environments.

Demand for malaria rapid diagnostic test, health care-seeking behaviour, and drug use among rural community members with fever or malaria-like illness in Ebonyi state, Nigeria: a cross-sectional household survey

Background

A good understanding of the demand for malaria rapid diagnostic test (MRDT), malaria health care-seeking behavior, and drug use among community members is crucial to malaria control efforts. The aim of this study was to assess the demand (use and/or request) for MRDT, health care-seeking behavior, and drug use, as well as associated factors, among rural community members (both children and adults) with fever or malaria-like illness in Ebonyi state, Nigeria.

Methods

A cross-sectional household survey was conducted between October 1st and November 7th, 2018, in 18 rural geographical clusters. Data was collected using a structured interviewer-administered questionnaire. Descriptive analysis was done using summary statistics. Associated factors (socio-demographic, knowledge and opinion level) were assessed using bivariate and multivariate binomial logistic regressions while the overall effects of these factors were assessed using the “postestimation test” command in Stata.

Results

A total of 1310 children under 5 years of age and 2329 children ages 5 years and above and adults (excluding pregnant women) (3639 overall) participated in the study. Among the 1310 children under 5 years of age: 521 (39.8%) received MRDT of which the caregivers of 82 (15.7%) requested for the MRDT; 931 (71.1%) sought care with public/private sector providers (excluding traditional practitioners/drug hawkers) the same/next day; 495 (37.8%) sought care at government primary health centres, 744 (56.8%) sought care with the patent medicine vendors (PMVs); 136 (10.4%) sought care with traditional practitioners; 1020 (77.9%) took ACTs (=88.2%, 1020/1156 of those who took anti-malarial drugs). Generally, lower values were respectively recorded among the 2329 children ages 5 years and above and adults (excluding pregnant women). The most important overarching predictor of the demand for MRDT and care-seeking behaviour was the knowledge and opinion level of respondent female heads of households about malaria and malaria diagnosis.

Conclusions

Among the rural community members with fever or malaria-like illness in Ebonyi state, Nigeria, while majority did not receive MRDT or diagnostic testing, and sought care with the PMVs, most took anti-malaria drugs, and mostly ACTs. Interventions are needed to improve the knowledge and opinion of the female heads of households about malaria and malaria diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06865-8.

Health-seeking behavior and waste management practices among women in major urban markets in Owerri, Nigeria

Behavioral patterns on seeking health are pertinent in terms of how waste is managed. However, informal approach towards waste management has led to poor environmental attitude and pernicious health consequences for many Nigerians. Despite plethora of scientific investigation on waste management, there has been paucity of information on health-seeking behavior and waste management practices among market women, hence the need for this research. The study aimed at assessing the health-seeking behavioral pattern of women traders on waste management in major urban markets in Owerri, Nigeria by identifying the extent of their commitment to sustainable waste management practices, investigating health-seeking behaviors that influence their attitude towards waste management and measuring prevalence of waste-related diseases among them. Data collection for the study involved a cross-sectional survey of 739 women trading in three Owerri major urban markets in line with the study's aim. Results show that motivation to manage waste for disease control was effectively predicted by type of trading item (Omnibus Test: χ2 = 13.871, df = 3, p-value = 0.003); Cochran-Armitage tests of trend show that there is no statistically linear trend between the proportions of understanding the 3Rs and the rankings for methods of seeking health; understanding the 3Rs was not determined by health-seeking method as most methods were with motivation to manage waste discordant (4 out 5 health-seeking methods had negative Goodman & Kruskal's G values); PCA on the prevalence of waste-related diseases had a two-component structure which followed acute and chronic dimensions; vegetable and plastics comprised the highest waste streams with plastics being most reused waste type while government is mainly responsible for waste disposal. The study recommends a knowledge transfer approach in entrenching sustainable waste management practices.

Predictors of patients' knowledge, attitudes and practices (KAP) regarding uncomplicated malaria in the primary healthcare facilities of Plateau state, Nigeria

Purpose

This study determined factors that influenced patients' knowledge, attitudes and practices (KAP) regarding uncomplicated malaria in primary healthcare (PHC) facilities of Plateau state, Nigeria.

Design/methodology/approach

The data of 956 patients treated for uncomplicated malaria in PHC facilities of Plateau state were used for the study. Inferential statistical analyses were conducted to identify factors that influenced patients' KAP on the disease and its management.

Findings

The study revealed age (p < 0.001), level of education (p = 0.012), attitudes (p = 0.007) and practices (p < 0.001) as significant predictors of knowledge outcomes on uncomplicated malaria, while their attitudes towards the disease and its management was predicted by their gender (p = 0.011), occupation (p = 0.049), monthly income (p = 0.018), knowledge (p < 0.001) and practices (p < 0.001). Furthermore, their practices were significantly predicted by monthly incomes (p = 0.043), knowledge (p < 0.001), attitudes (p < 0.001) and number of anti-malarial and adjunct drugs administered to them (p = 0.041).

Originality/value

The study revealed a mixed influence of patients' characteristics on their KAP outcomes. This calls for appropriate intervention measures towards achieving the desired patients' therapeutic outcomes.

Social group and health care provider interventions to increase the demand for malaria rapid diagnostic test among community members in Ebonyi state, Nigeria: study protocol for a cluster randomized controlled trial

BACKGROUND

The World Health Organization recommended (in 2010) universal testing for suspected malaria, due to some fundamental changes in malaria trends such as the declining incidence of malaria in high-burden countries, the emergence of parasite resistance to anti-malarial drugs especially artemisinin-based combination therapies (ACTs) and the increased availability of diagnostic testing such as the malaria rapid diagnostic test (MRDT). The Nigerian government has long adopted this recommendation and with the support of foreign partners has scaled up the availability of MRDT. However, the malaria/MRDT rate in the communities is still far short of the recommendation. This study aims to evaluate the effectiveness of social group and social group/provider interventions in increasing the demand (use and/or request) for MRDT among community members with fever or malaria-like illness in Ebonyi state, Nigeria.

METHODS

A three-arm, parallel, stratified cluster randomized design will be used to evaluate the effect of two interventions compared to control: control involves the usual practice of provision of MRDT services by public primary healthcare providers and patent medicine vendors; social group intervention involves the sensitization/education of social groups about MRDT; social group/provider intervention involves social group treatment plus the training of healthcare providers in health communication about MRDT with clients. The primary outcome is the proportion of children under 5 years of age with fever/malaria-like illness, in the 2 weeks preceding a household survey, who received MRDT. The co-primary outcome is the proportion of children ages 5 years and above and adults (excluding pregnant women) with fever/malaria-like illness, in the 2 weeks preceding a household survey, who received MRDT. The primary outcome will be assessed through household surveys at baseline and at the end of the study.

DISCUSSION

The pragmatic and behavioural nature of the interventions delivered to groups of individuals and the need to minimize contamination informed the use of a cluster-randomized design in this study in investigating whether the social group and social group/provider interventions will increase the demand for MRDT among community members. "Pragmatic" means the interventions would occur in natural settings or real- life situations.

TRIAL REGISTRATION

ISRCTN, ISRCTN14046444 . Registered on 14 August 2018.

Demand-related factors influencing caregivers' awareness of malaria tests and health workers' testing practices, in Makarfi, Nigeria

Background

Despite the World Health Organization’s recommendation of malaria test-treat strategy, which is the treatment of parasitological confirmed malaria cases with anti-malarials, presumptive diagnosis of malaria remains fairly common in Nigeria. The reasons for this have not been established in Makarfi, Nigeria, despite the high burden of malaria in the area. A study was conducted among caregivers of febrile children less than 5 years presenting for treatment to understand their awareness of malaria diagnostic testing and being offered testing by clinicians, the determinants of these outcomes, and caregivers’ perspectives of health workers’ testing practices.

Methods

Using mixed-methods, data was combined from sub-analysis of cross-sectional survey data (n = 295) and focus group discussions (n = 4) with caregivers conducted in Makarfi General Hospital (Kaduna State, Nigeria) and surrounding communities in 2011. Bivariate and multivariate analysis of the quantitative survey data was conducted to examine associations of caregivers’ sociodemographic characteristics with testing awareness and having ever been offered testing. Transcripts from focus group discussions (FGD) were analysed for emerging themes related to caregivers’ perspectives on malaria testing.

Results

Among surveyed caregivers who were predominantly female (81.7%), not formally educated (72.5%), and were housewives (68.8%); only 5.3% were aware of any diagnostic testing for malaria, and only 4.3% had ever been offered a malaria test by a health worker. Having at least a primary level education (adjusted odds ratio [aOR] 20.3, 95% CI 4.5–92.1) and living within 5 km of the hospital (aOR 4.3, 95% CI 1.5–12.5) were determinants of awareness of malaria testing. Also, these were determinants of previously having been offered a test (aOR 9.9, 95% CI 2.1–48.7; and aOR 4.0, 95% CI 1.1–14.7). FGD showed many caregivers believed that malaria testing was for severe illness only, and that proximity to a health facility and cost of treatment influenced the seeking and receiving of care.

Conclusions

Uptake of malaria testing prior to treatment can be improved by increasing its awareness and addressing misunderstandings among caregivers, promoting testing practices among health workers, and availing caregivers living farther from health centres alternative opportunities for community case management of febrile illnesses.

Targeted community based interventions improved malaria management competencies in rural Ghana

Background

Malaria is one of the most challenging public health concerns in the developing world. To address its impact in endemic regions, several interventions are implemented by stakeholders. The Affordable Medicine Facility-malaria (AMFm) is an example of such interventions. Its activities include communication interventions to enhance the knowledge of caregivers of children under five years, licensed chemical sellers (LCS) and prescribers on malaria management with artemisinin-based combination therapy (ACT). This study was conducted to evaluate the effectiveness of the AMFm activities on malaria among targeted groups in two rural communities in Ghana.

Methods

A communication intervention study was conducted in the Asante-Akim North and South Districts of Ghana. Repeated cross-sectional pre and post surveys were deployed. Relevant malaria messages were designed and used to develop the information, education and communication (IEC) tools for the intervention. With the aid of posters and flipcharts developed by our study, community health workers (CHWs), prescribers, and licenced chemical sellers provided proper counselling to clients on malaria management. Trained CHWs and community based volunteers educated caregivers of children under five years on malaria management at their homes and at public gatherings such as churches, mosques, schools. Chi-square tests and logistic regression were run to determine associations and control for demographic differences respectively.

Results

There was significantly high exposure to malaria/ACT interventions in the intervention district than in the comparison district (OR = 16.02; 95% CI = 7.88–32.55) and same for malaria/ACT-related knowledge (OR = 3.63; 95% CI = 2.52–5.23). The participants in the intervention district were also more knowledgeable about correct administration of dispersible drug for children <5 years than their counterparts in the unexposed district.

Conclusion

Our data show that targeted interventions improve malaria based competences in rural community settings. The availability of subsidized ACTs and the intensity of the communication campaigns contributed to the AMFm-related awareness, improved knowledge on malaria/ACTs and management practices.

Evaluating the Treatment Costs for Uncomplicated Malaria at a Public Healthcare Facility in Nigeria and the Implications

BACKGROUND

Accurate information on the facility costs of treatment is essential to enhance decision making and funding for malaria control.

OBJECTIVE

The objective of this study was to estimate the costs of providing treatment for uncomplicated malaria through a public health facility in Nigeria.

METHODS

Hospital costs were estimated from a provider perspective, applying a standard costing procedure. Capital and recurrent expenditures were estimated using an ingredient approach combined with step-down methodology. Costs attributable to malaria treatment were calculated based on the proportion of malaria cases to total outpatient visits. The costs were calculated in local currency [Naira (N)] and converted to US dollars at the 2013 exchange rate.

RESULTS

Total annual costs of N28.723 million (US$182,953.65) were spent by the facility on the treatment of uncomplicated malaria, at a rate of US$31.49 per case, representing approximately 25% of the hospital's total expenditure in the study year. Personnel accounted for over 82.5% of total expenditure, followed by antimalarial medicines at 6.6%. More than 45% of outpatients visits were for uncomplicated malaria. Changes in personnel costs, drug prices and malaria prevalence significantly impacted on the study results, indicating the need for improved efficiency in the use of hospital resources.

CONCLUSION

Malaria treatment currently consumes a considerable amount of resources in the facility, driven mainly by personnel cost and a high proportion of malaria cases. There is scope for enhanced efficiency to prevent waste and reduce costs to the provider and ultimately the consumer.

Evaluation of SMS reminder messages for altering treatment adherence and health seeking perceptions among malaria care-seekers in Nigeria

In Nigeria, access to malaria diagnostics may be expanded if drug retailers were allowed to administer malaria rapid diagnostic tests (RDTs). A 2012 pilot intervention showed that short message service (SMS) reminder messages could boost treatment adherence to RDT results by 10–14% points. This study aimed to replicate the SMS intervention in a different population, and additionally test the effect of an expanded message about anticipated RDT access policy change on customers’ acceptability for drug retailers’ administration of RDTs. One day after being tested with an RDT, participants who purchased malaria treatment from drug shops were randomized to receive (1) a basic SMS reminder repeating the RDT result and appropriate treatment actions, (2) an expanded SMS reminder additionally saying that the ‘government might allow pharmacists/chemists to do RDTs’ or (3) no SMS reminders (i.e. control). Using regression analysis, we estimate intent-to-treat (ITT) and treatment effects on the treated for 686 study participants. Results corroborate previous findings that a basic SMS reminder increased treatment adherence [odds ratio (OR) = 1.53, 95% CI 0.96–2.44] and decreased use of unnecessary anti-malarials for RDT-negative adults [OR = 0.63, 95% CI 0.39–1.00]. The expanded SMS also increased adherence for adults [OR = 1.42, 95% CI 0.97–2.07], but the effects for sick children differed—the basic SMS did not have any measurable impact on treatment adherence [OR = 0.87, 95% CI 0.24–3.09] or use of unnecessary anti-malarials [OR = 1.27, 95% CI 0.32–1.93], and the expanded SMS actually led to poorer treatment adherence [OR = 0.26, 95% CI 0.10–0.66] and increased use of unnecessary anti-malarials [OR = 4.67, 95% CI 1.76–12.43]. Further, the targeted but neutral message in the expanded SMS lowered acceptance for drug retailers' administration of RDTs [OR = 0.55, 95% CI 0.10–2.93], counter to what we hypothesized. Future SMS interventions should show consistent positive results across populations and be attuned to message length and content before initiating a larger messaging campaign.

The role of drug vendors in improving basic health-care services in Nigeria

OBJECTIVE

To characterize patent and proprietary medicine vendors and shops in Nigeria and to assess their ability to help improve access to high-quality, primary health-care services.

METHODS

In 2013 and 2014, a census of patent and proprietary medicine shops in 16 states of Nigeria was carried out to determine: (i) the size and coverage of the sector; (ii) the basic characteristics of shops and their staff; and (iii) the range of products stocked for priority health services, particularly for malaria, diarrhoea and family planning. The influence of the medical training of people in charge of the shops on the health-care products stocked and registration with official bodies was assessed by regression analysis.

FINDINGS

The number of shops per 100,000 population was higher in southern than in northern states, but the average percentage of people in charge with medical training across local government areas was higher in northern states: 52.6% versus 29.7% in southern states. Shops headed by a person with medical training were significantly more likely to stock artemisinin-based combination therapy, oral rehydration salts, zinc, injectable contraceptives and intrauterine contraceptive devices. However, these shops were less likely to be registered with the National Association of Patent and Proprietary Medicine Dealers and more likely to be registered with the regulatory body, the Pharmacist Council of Nigeria.

CONCLUSION

Many patent and proprietary medicine vendors in Nigeria were medically trained. With additional training and oversight, they could help improve access to basic health-care services. Specifically, vendors with medical training could participate in task-shifting interventions.

A qualitative study on health workers' and community members' perceived sources, role of information and communication on malaria treatment, prevention and control in southeast Nigeria

Background

It has been widely acknowledged that well-planned and executed communication programmes can contribute to achieving malaria prevention and treatment goals. This however requires a good understanding of current sources and roles of information used by both health workers and communities. The study aimed at determining health workers’ and community members’ sources, value and use of information on malaria prevention and treatment in Nigeria.

Methods

Qualitative data was collected from six selected communities (three urban and three rural) in Enugu state, southeast Nigeria. A total of 18 Focus Group Discussions (FGDs) with 179 community members and 26 in-depth interviews (IDIs) with health workers in public and private health facilities were used to collect data on where people receive treatment for malaria and access information on malaria. The FGDS and IDIs also provided data on the values, uses and effects of information and communication on malaria treatment seeking and provision of services.

Results

The findings revealed that the major sources of information on malaria for health workers and community members were advertisements in the mass media, workshops and seminars organized by donor agencies, facility supervision, posters, other health workers, television and radio adverts. Community involvement in the design and delivery of information on malaria control was seen as a strong strategy for improving both consumer and provider knowledge. Information from the different sources catalyzed appropriate provision and consumption of malaria treatment amongst health workers and community members.

Conclusion

Health workers and consumers receive information on malaria prevention and treatment from multiple sources of communication and information, which they find useful. Harnessing these information sources to encourage consistent and accurate messages around malaria prevention and treatment is a necessary first step in the design and implementation of malaria communication and behaviour change interventions and ultimately for the sustained control of malaria.

Care-seeking at patent and proprietary medicine vendors in Nigeria

Background

To achieve health development goals, policymakers are increasingly focused on improving primary care in low- and middle-income countries, and private sector drug retailers offer one channel through which basic services may be delivered. In Nigeria, patent and proprietary medicine vendors (PPMVs) serve as a main source of medications, but little is known about their clientele or how care is sought at PPMVs for common illnesses. We explore differences in care-seeking at PPMV shops based on the most commonly reported symptoms.

Methods

In Kogi and Kwara states, Nigeria, 250 PPMV shop workers and 2,359 customers purchasing drugs were surveyed, and each worker-customer interaction was observed. Multivariate regression analysis was used to assess the association of commonly reported symptoms with care-seeking behavior prior to attending the shop and while interacting with the provider at the shop.

Results

Most customers sought care for headache (30.5 %), fever (22.9 %), cough/cold (18.1 %), or diarrhea (8.4 %). Customers with fever were more likely to report being diagnosed by a formally trained person, to have discussed the illness with and be examined by the shop worker, and have more difficulty paying. In contrast, customers with headache symptoms were less likely to experience these outcomes and spent less money purchasing drugs. Those reporting cough or cold symptoms were less likely to have been diagnosed by a formally trained person, waited longer before visiting the PPMV shop, and were more likely to discuss the illness with the shop worker, but were less likely to be examined or to recommend the purchased drug themselves. If a sick child was brought to the shop, a discussion of the illness and an exam were more likely and more money was spent on drugs.

Conclusions

Because care-seeking behaviors vary by symptoms and the sick person’s age, PPMVs should be trained to treat common illnesses for which customers are unlikely to seek a formal medical consultation. Interventions aimed at improving primary care need to target the places where most people access care, and equip PPMV workers with knowledge and tools to provide basic services.