Understanding non-malaria illness in outpatients in Mozambique: An exploration of associated symptoms, diagnoses, and treatments Open Access

Biddle, Haley (Spring 2020)

Permanent URL: https://etd.library.emory.edu/concern/etds/db78td25d?locale=en


Background and Objective: A wide variety of illnesses prompt care-seeking at outpatient health care facilities in sub-Saharan Africa. While malaria remains a prominent threat in many of these countries, declines in prevalence over the past several decades, in addition to more readily available rapid diagnostic tests (RDTs) for malaria, have illuminated the substantial portion of non-malaria illness that exists in these settings. As such, there is a need to understand the presentation and case management of non-malaria illnesses in adults and children presenting at health facilities in low-resource areas. This study describes the symptom presentations, diagnoses, and treatments received by outpatients seeking care at health facilities in three provinces of Mozambique and examines associations between these variables.

Methods: A secondary analysis was performed using health facility survey data gathered in Maputo province, Zambezia, province, and Cabo Delgado provinces in Mozambique in 2018. Survey responses regarding symptoms, diagnoses, and treatments were analyzed for frequency by age group. Cross tabulations of risk ratios (RR) were conducted to determine associations between variables, and multivariate logistic regression was used to examine factors associated with antibiotic prescription.

Results: In total, 1,840 outpatients were interviewed and re-examined across 117 health facilities, including 629 children under five years of age (CU5) and 1,211 adults and children older than five. Fever was the most common symptom for both CU5 (74.6%) and older outpatients (60.4%). 53.1% of CU5 remained undiagnosed, as did 65.6% of patients five-and-over. Malaria was the most frequent diagnosis in each group, at 33.1% for CU5 and 16.1% for the older age group. The most commonly received medication was an antipyretic (52.6% of CU5, 51.5% of five-and-over). Nearly 40% of CU5 received a prescription for an antimalarial, while 21.6% of older children and adults received thisone. Antibiotic treatment was significantly more frequent among the older age group (50.3%) than in CU5 (43.7%, p<0.01). Crosstabulations showed that heart and chest symptoms (RR: 0.18), dermatologic symptoms (RR: 0.30), and ear, eye, neck and throat symptoms (RR: 0.31) were associated with a lower risk chance of malaria diagnosis. Remaining undiagnosed (RR: 2.42) or having a symptom listed as a diagnosis (RR: 1.57) increased the likelihood of receiving an antibiotic. For both febrile and non-febrile patients, antibiotic prescription was more common when patients were RDT-negative or reported not having a RDT performed. In the logistic regression, a positive RDT was the only factor significantly associated with decreased odds of receiving an antibiotic (aOR: 0.03, p<0.01). On average, patients received 1.37 unique treatment types.

Conclusion: Surveyed outpatients at health facilities in Mozambique reported a variety of symptom presentations. While fever was the most common symptom for both CU5 and patients 5-and-older, there was a wide spectrum of symptoms and these frequently differed significantly by age group. Reporting no diagnosis from a consult was common, and malaria was a frequent diagnosis when one could be reported. Most patients left their consult with a prescription for at least one medication, with antipyretics being the most widely prescribed. These results help to meet the need of understanding the presentation and case management of non-malaria illness in outpatients, and serve to enhance surveillance, improve algorithms, and guide surveys in similar settings.

Table of Contents



CHAPTER 1: Introduction  1

CHAPTER 2: Literature Review  5

     Introduction  5

      Etiology studies in sub-Saharan Africa  6

      Prescribing practices of clinicians in outpatient clinics  14

     Antibiotic-focused prescribing studies  16

     Qualitative studies  18

     Conclusion  20

CHAPTER 3: Methods and Results  21

    Materials and Methods  21

           Introduction  21

           Study population  21

           Analysis procedures: categorization  22

           Analysis procedures: statistical analysis 23

Ethical considerations  24

Methods limitations  24

    Results  25

CHAPTER 4: Discussion and public health implications  30

           Discussion  30

           Public health implications  33

           Limitations  35

           Conclusions  36


           Table 1. Symptom descriptives  37

           Table 2. Diagnosis descriptives  38

           Table 3. Treatment descriptives  39

           Table 4. Symptom-diagnosis crosstable  40

           Table 5. Diagnosis-treatment crosstable  41

           Table 6. Treatment-treatment crosstable  42

           Table 7. Treatment frequency by fever and RDT status  43

           Table 8. Treatment quantification  44

Table 9. Logistic regression results: antibiotic use  44


           Appendix 1. Original and added survey categories  45

           Appendix 2. Symptom response categorization  46

Appendix 3. Diagnosis response categorization  48

Appendix 4. Treatment response categorization  50


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