Do patients adhere to over-the-counter artemisinin combination therapy for malaria? evidence from an intervention study in Uganda

Abstract

BackgroundIncreasing affordability of artemisinin combination therapy (ACT) in the African retail sector could be critical to expanding access to effective malaria treatment, but must be balanced by efforts to protect the efficacy of these drugs. Previous research estimates ACT adherence rates among public sector patients, but adherence among retail sector purchasers could differ substantially. This study aimed to estimate adherence rates to subsidized, over-the-counter ACT in rural Uganda.MethodsAn intervention study was conducted with four licensed drug shops in Eastern Uganda in December 2009. Artemether-lumefantrine (AL) was made available for sale at a 95% subsidy over-the counter. Customers completed a brief survey at the time of purchase and then were randomly assigned to one of three study arms: no follow-up, follow-up after two days or follow-up after three days. Surveyors recorded the number of pills remaining through blister pack observation or through self-report if the pack was unavailable. The purpose of the three-day follow-up arm was to capture non-adherence in the sense of an incomplete treatment course ("under-dosing"). The purpose of the two-day follow-up arm was to capture whether participants completed the full course too soon ("over-dosing").ResultsOf the 106 patients in the two-day follow-up sample, 14 (13.2%) had finished the entire treatment course by the second day. Of the 152 patients in the three-day follow-up sample, 49 (32.2%) were definitely non-adherent, three (2%) were probably non-adherent and 100 (65.8%) were probably adherent. Among the 52 who were non-adherent, 31 (59.6%) had more than a full day of treatment remaining.ConclusionsOverall, adherence to subsidized ACT purchased over-the-counter was found to be moderate. Further, a non-trivial fraction of those who complete treatment are taking the full course too quickly. Strategies to increase adherence in the retail sector are needed in the context of increasing availability and affordability of ACT in this sector.

Socioeconomic Determinants of Antimalarial Drug Use Behaviours: A Systematic Review

“…Adherence and education P= 0.024 with 22% more adherence in participants with secondary education [21] Caretaker's educational level and reported adherence showed no statistically significance (p=0.354) [27] [18-21,2 P=0.005 with participants with ≤ 7ys of formal education more likely to adhere [18] Participants educational level was not associated with reasons for nonadherence (p=0.825) [24] P<0.01; OR 0.074; 95% CI 0.017-0.322. higher education level was associated with ACT adherence [20] There was no statistically significant association between the educational level of patients or caregivers and probably adherence (p=1.00) [29] Uptake of IPTp-SP increased with education, from as low as 38.9% among those who had no education to as high as 52.3% among those with secondary and higher education.Women with secondary and higher education were almost twice as likely as those who had never been to school for formal education to receive complete IPTp-SP doses (RRR=1.93, 95% CI 1.04 -3.56). (P <0.001) [26] No association between educational level and adherence/non-adherence [19] The adjusted odds of completed treatment for those who has finished primary school was 1.68 times that of patients who has not (95% CI: 1.20, 2.36; P=0.003) [28] No significant for mothers' attainment of tertiary (or higher) education and the use of ACTs (OR 0.905, CI0.195-4.198; P=0.898) [25] There was a statistically significant association between fathers' attainment of tertiary (higher education) and use of ACTs, when compared to fathers who had not attained this level of education (OR 0.054, CI 0.006-0.510; P=0.011) [25] Adherence and income P=0.003; OR 0.340; 95% CI, 0.167-0.694. higher income level (Ksh >9000 (i.e., >GBP 66 monthly) was associated with ACT adherence [20] [14,20,2 7,31] P=0.034 with participants of higher income salary showing correct dosage of drugs [31] Initiation of home treatment was higher in the poorer households.…”

“…At the end of the assessment and appraisal exercise, seventeen (17) studies [14][15][16][17][18][19][20][21][23][24][25][26][27][28][29][30][31] that were of good quality based on the PCAqs assessment were included in this systematic review.…”

“…Nevertheless, the contributions of socioeconomic factors to antimalarial drug use behaviours have only been sparsely reported in studies; with most of the studies not primarily designed to identify or assess the association of these variables [15,17,19,21,[23][24][25]. In addition there is no existing systematic review of studies on the socioeconomic determinants of antimalarial drug use.…”

“…In addition, other socioeconomic factors like educational level, the type of settlement and ability to read have been reported to be associated with adherence to the treatment dose and regimen [17][18][19][20][21]. It is also important to mention that low socioeconomic status (SES) is a common feature in the Thai-Cambodia area which has been serving as the major hub of development and subsequent spread of resistance to most antimalarial drugs [22].…”

Health – Seeking Behaviour of Rural Dwellers for the Treatment of Presumptive Malaria in North-Western Nigeria

“…Moreover, the drug vendors know little or nothing about the correct dosage of the drugs. It is therefore not surprising that a signifi cant proportion of patients do not complete the entire treatment course when drugs are purchased over-the-counter in rural communities (Cohen et al 2012). This poses another threat to effective malaria treatment.…”