Elsevier

The Lancet

Volume 356, Issue 9229, 12 August 2000, Pages 550-555
The Lancet

Articles
Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial

https://doi.org/10.1016/S0140-6736(00)02580-0Get rights and content

Summary

Background

No satisfactory strategy for reducing high child mortality from malaria has yet been established in tropical Africa. We compared the effect on under-5 mortality of teaching mothers to promptly provide antimalarials to their sick children at home, with the present community health worker approach.

Methods

Of 37 tabias (cluster of villages) in two districts with hyperendemic to holoendemic malaria, tabias reported to have the highest malaria morbidity were selected. A census was done which included a maternity history to determine under-5 mortality. Tabias (population 70 506) were paired according to under-5 mortality rates. One tabia from each pair was allocated by random number to an intervention group and the other was allocated to the control group. In the intervention tabias, mother coordinators were trained to teach other local mothers to recognise symptoms of malaria in their children and to promptly give chloroquine. In both intervention and control tabias, all births and deaths of under-5s were recorded monthly.

Findings

From January to December 1997, 190 of 6383 (29·8 per 1000) children under-5 died in the intervention tabias compared with 366 of 7294 (50·2 per 1000) in the control tabias. Under-5 mortality was reduced by 40% in the intervention localities (95% Cl from 29·2–50·6; paired t test, p<0·003). For every third child who died, a structured verbal autopsy was undertaken to ascribe cause of mortality as consistent with malaria or possible malaria, or not consistent with malaria. Of the 190 verbal autopsies, 13 (19%) of 70 in the intervention tabias were consistent with possible malaria compared with 68 (57%) of 120 in the control tabias.

Interpretation

A major reduction in under-5 mortality can be achieved in holoendemic malaria areas through training local mother coordinators to teach mothers to give under-5 children antimalarial drugs.

Introduction

Falciparum malaria is a major cause of mortality in children less than 5 years of age in Africa. No satisfactory strategy for reducing the high child mortality has yet been established for most of tropical Africa. Although several studies have shown that insecticide-treated bednets can reduce parasitaemia,1, 2 clinical attacks,3 and mortality,4, 5 they have limited widespread use. There is as yet no vaccine.6

Treatment with antimalarial drugs has been the most widely used approach in efforts to reduce the effect of malaria in Africa.7, 8 However, treatment provided through health centres and health posts has been of little help in reducing infant and deaths in young children because severe falciparum malaria in these children strikes so rapidly that mothers are not able to obtain treatment in time.9, 10, 11

Because of Ethiopia's varied geography and ecology, transmission of malaria is highly variable—ranging from holoendemic in low-lying tropical-valley areas mainly in the south, to hypoendemic and mesoendemic transmission in the central and northern highland plateaux. Tigray, too, is characterised by great variability in altitude, ranging from more than 2400 m in the high plateau areas to less than 1200 m in the low-lying rifts and valleys that crisscross the plateau.12

Civil war raged in Tigray from 1974 until 1991 when the combined Tigrayan and Eritrean forces finally overthrew the Mengistu regime and peace was restored to the area. During the civil war the only health services available in the Tigray area were community-based primary health care initiated by the Tigray Peoples Liberation Front (TPLF).12, 13, 14 This programme was strengthened after the end of the civil war, becoming a community-based malaria control programme with volunteers mainly recruited from among former TPLF community health workers (CHW)12 who received a 7 day malaria training course.

Being based on local community involvement, this programme was generally well accepted. However, limitations that were related to the sparse numbers of CHWs, who were generally located only in main villages and were virtually all men, became evident over time. An assessment of the programme in 1994–95 found that the main users were older children and adults and that very few of the young and most vulnerable children were actually being seen or treated for malaria. After careful review and extensive discussions with community leaders and local women, a completely new approach was designed to overcome these limitations and meet the needs of the under-served rural women and their families. The new approach was based on the selection and training of mother coordinators to teach all mothers to recognise possible malaria and give chloroquine to their young children. To assess its effectiveness, we decided to do a randomised trial of this new approach. The objective of the trial was to determine the effect on under-5 mortality of teaching mothers to promptly provide antimalarials to their sick children at home compared with the present CHW facility-based approach.

Section snippets

Study population

The study was done in the Alamata and Raya Azebo districts of the Tigray region in northerm Ethiopia (figure 1) in 1996–98. Most of Tigray is high plateau, and has little if any malaria transmission. However, in these two districts in the southern part of Tigray much of the population lives in lower-lying land at 1000–1250 m in which there is seasonal hyperendemic malaria. The rainfall in 1997, the year the intervention was in place, was unusual because it was untimely and irregular, with rain

Results

The registered population of the 24 tabias was 70 506, with 14 001 children less than 5 years of age (figure 2).

Table 2 gives the under-5 mortality rates per 1000 under-5s by tabia and lists them by tabia pair group, one of which had been randomised to the intervention group and the other to the control group. The overall under-5 mortality in the intervention tabias was 29·8 per 1000 child-years compared with 50·2 per 1000 in the control tabias; a 40·6% reduction in the under-5 mortality rate.

Discussion

The much lower under-5 mortality in the intervention group shows that although malaria is a major killer in this population mothers can ably take care of their sick children when taught and supplied with appropriate guidance and drugs for home medication. The approach taken in this study was based on quality design principles.19 After analysis of the then current TCBMCP and extensive discussions with mothers and community leaders in 1996, it was agreed that the TCBMCP would train mother

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