Factors associated with non-adherence to Artemisinin-based combination therapy (ACT) to malaria in a rural population from holoendemic region of western Kenya

Abstract

BackgroundOver the years, reports implicate improper anti-malarial use as a major contributor of morbidity and mortality amongst millions of residents in malaria endemic areas, Kenya included. However, there are limited reports on improper use of Artemisinin-based Combination Therapy (ACT) which is a first-line drug in the treatment of malaria in Kenya. Knowing this is important for ensured sustainable cure rates and also protection against the emergence of resistant malarial parasites. We therefore investigated ACT adherence level, factors associated with non-adherence and accessibility in households (n = 297) in rural location of Southeast Alego location in Siaya County in western Kenya.MethodsACT Adherence level was assessed with reference to the duration of treatment and number of tablets taken. Using systematic random sampling technique, a questionnaire was administered to a particular household member who had the most recent malaria episode (<2 weeks) and used ACT for cure. Parents/caretakers provided information for children aged <13 years. Key Informant Interviews (KIIs) were also conducted with healthcare providers and private dispensing chemist operators.ResultsAdherence to ACT prescription remained low at 42.1% and 57.9% among individuals above 13 and less than 13 years, respectively. Stratification by demographic and socio-economic characteristics in relation to ACT adherence revealed that age (P = 0.011), education level (P < 0.01), ability to read (P < 0.01) and household (HH) monthly income (P = 0.002) significantly affected the level of ACT adherence. Consistently, logistic regression model demonstrated that low age (OR, 0.571, 95% CI, 0.360-0.905; P = 0.017), higher education level (OR, 0.074; 95% CI 0.017-0.322; P < 0.01), ability to read (OR, 0.285, 95% CI, 0.167-0.486; P < 0.01) and higher income (Ksh. > 9000; OR, 0.340; 95% CI, 0.167-0.694; P = 0.003) were associated with ACT adherence. In addition, about 52.9% of the respondents reported that ACT was not always available at the source and that drug availability (P = 0.020) and distance to drug source (P < 0.01) significantly affected accessibility.ConclusionsThis study demonstrates that more than half of those who get ACT prescription do not take recommended dose and that accessibility is of concern. The findings of this study suggest a potential need to improve accessibility and also initiate programmatic interventions to encourage patient-centred care.

Socioeconomic Determinants of Antimalarial Drug Use Behaviours: A Systematic Review

“…4500-9000 (48.5%) took the correct dosage of drugs as opposed to individuals with below KShs 4500 and above KShs 9000 [31] Caretakers from the third SES quintile were most likely to adhere to treatment compared to the first quintile [27] Adherence and ability to read P<0.01 OR 0.285; 95% CI 0.167-0.486. Ability to read was associated with ACT adherence [20] [ 20,21] However, ability to read was statistically significant to number of antimalarial tablets left (p=0.049) [21] Adherence in urban and rural 96% of rural dwellers would not administer appropriate dosages [17] 65% of urbanites would use incomplete dose. Only 35% would administer correctly [17] [ 16,17,2 7] The consumption of ACTS was more in the urban areas for both adults (P value=0.001) and children (P value=0.005) [16].…”

“…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.…”

“…(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. 25% of the poorest will use home treatment first as against 14% in wealthiest SE category [14] In addition, household monthly income significantly influenced dosage of the drugs used (P=0.034) primarily due to the fact that higher proportions of respondents with an income salary of KShs.…”

“…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.…”

“…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].…”