Adherence to a six-dose regimen of artemether-lumefantrine among uncomplicated Plasmodium falciparum patients in the Tigray Region, Ethiopia

Abstract

BackgroundIn 2004, Ethiopia switched its first-line treatment of uncomplicated Plasmodium falciparum malaria from sulphadoxine-pyrimethamine to a fixed artemisinin-based combination therapy (ACT), artemether-lumefantrine (AL). Patient adherence to AL regimen is a major determining factor to achieve the desired therapeutic outcome. The aim of this study was to measure patient adherence levels to the six-dose AL regimen for the treatment of uncomplicated P. falciparum malaria and to identify its determinant factors in rural areas of the Tigray region, EthiopiaMethodsThe study was conducted under routine health service delivery at health posts level. Patients/caregivers were not informed about their home visit and were traced on the day after they finished the AL regimen. By combining the response to a structured questionnaire and the tablet count from the blister, adherence level was classified into three categories: definitely non-adherent, probably non-adherent and probably adherent. Reasons for being definitely non-adherent were also assessed. For the purpose of examine risk factors, definitely non-adherent and probably non-adherent was merged into a non-adherent group. Variables found significantly associated (p < 0.05) with the adherence level on the univariate analysis were fitted into a multivariate logistic regression model.ResultsOut of the total initially enrolled 180 patients, 86.1% completed the follow-up. Out of these, 38.7% were classified as probably adherent, 34.8% as probably non-adherent, and 26.5% were definitely non-adherent. The most common reasons that definitely non-adherents gave for not taking the full dose were "too many tablets" (37.3%) and to "felt better before finished the treatment course" (25.5%). The adherence of the patients was associated with the ownership of a radio (adjusted odd ratio, AOR: 3.8; 95% CI: 1.66-8.75), the belief that malaria can be treated traditionally (AOR: 0.09; 95% CI: 0.01-0.78) and a delay of more than one day in seeking treatment after the onset of fever (AOR: 5.39; 95% CI: 1.83-15.88).ConclusionThe very low adherence to AL found in this study raises serious concerns for the malaria control in the region. The implementation of a monitoring adherence system is essential to ensure long-term treatment efficacy.

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

“…Several important recent public sector studies, however, find adherence results close to or lower than the levels we report here [25,27,35,37,38]. It is hard to infer adherence rates among retail sector patients from these studies, however, since the types of patients, illnesses and services provided in the retail sector could differ substantially.…”

How Patients Take Malaria Treatment: A Systematic Review of the Literature on Adherence to Antimalarial Drugs

“…However, adherence to AL by “timely completion” was high in three studies (88.3%–100%) [15], [22], [33] in contrast with studies of SP + amodiaquine (37.7%) [65] and SP + artesunate (76.6%) [23]. By “verified timely completion” adherence to AL was similar in three studies (38.7%–65%) [18], [28]–[29] to adherence to other ACTs (39.4%–75%) [17], [20], [23] and higher in two other studies (90%–93%) [19], [61].…”

“…However, among studies of AL, adherence by “verified timely completion” (38.7%–65%) [18], [28]–[29] was lower compared to “timely completion” (88.3%–100%) [15], [22], [33], except in studies where the research team enrolled patients at the time the drug was obtained and likely had a more significant research presence than in other studies (90% and 93%) [19], [61]. Similarly, adherence to AL by “verified completed treatment” (64.1%–83%) [16], [24], [27], [29], [60] tended to be lower than for “completed treatment” (67%–100%) [22], [28], [36], [38], [57]–[58], with the exception of two household surveys without pill counts with adherence of 47% [41], [46].…”

Can Rapid Diagnostic Testing for Malaria Increase Adherence to Artemether–Lumefantrine?: A Randomized Controlled Trial in Uganda

“…For example, patients may not understand how to correctly take the medication, 45,56-60 they may forget to take their pills, 18,56,58,59 they may be saving some pills for a future malaria episode, 45,56 or they may stop taking the medication once they feel better. 61,62 In our study, we found no relationship between literacy or education and adherence, and we also found that 91% of patients took the first two doses of AL with the correct number of pills at approximately the correct time (data not shown). This suggests that noncomprehension of dosing may not be the major driver of nonadherence.…”