Transcript Poster presentation

UNDERSTANDING FACTORS
THAT IMPROVE ADHERENCE
TO ANTI-MALARIAL THERAPY
AS AN ESSENTIAL STEP IN
DEVELOPING INTERVENTIONS
TO IMPROVE ADHERENCE
Irene Akua Agyepong, Patricia Anafi,
Margaret Gyapong
Dangme West District Health
Administration and Research Center
Ghana Health Service
Abstract
Title: UNDERSTANDING FACTORS THAT IMPROVE ADHERENCE TO ANTI-MALARIAL THERAPY AS AN
ESSENTIAL STEP IN DEVELOPING INTERVENTIONS TO IMPROVE ADHERENCE
Authors and Affiliation: Irene Akua Agyepong, Patricia Anafi, Margaret Gyapong. Dangme West District Health
Administration and Research Center, Ghana Health Service
Problem Statement: Adherence to prescribed antimalarials is important to clear infection and reduce the chances of
complicated malaria, and also to slow down the rate of development of drug resistance. As part of the analysis of data from a
quasi-experimental study to improve adherence to chloroquine, an attempt was made to develop a predictive model of factors
influencing adherence(1). Data were available on key suspected factors, namely the number of drugs per prescription, the
form of the drug (tablets or syrup), information provision in the dispensary and the labeling of the drugs. However the best
predictive model correctly predicted only 70% of the observations with a sensitivity of 51% and a specificity of 81% .It had a
positive predictive value of 62% and a negative predictive value of 73%. It was a far from perfect predictive model. It was
clear that there is a need to better explore and qualitatively understand factors in the study setting that predict adherence.
Objectives: To explore at the community and household level the factors that affect client adherence to antimalarial and
other drug therapy as part of the process of designing appropriate interventions to improve adherence.
Design: A purely exploratory study with the study team living in a rural community for a couple of weeks and using
qualitative methods such as observation, FGD, in-depth interviews and case studies.
Setting and Study Population: The primary study setting was Prampram, a rural town of the Ga-Adangme people of
Southern Ghana with a population of about 6,000.
Results and Conclusions: What the earlier study may not have been able to measure adequately in trying to develop a
predictive model of factors affecting adherence is the quality of communication. Preliminary data suggests that the current
levels of information provision and labeling of drugs by prescribers and dispensers is not enough to improve adherence. The
clarity as well as the quality and interactiveness of client-prescriber and client-dispenser communication and a more detailed
explanation of biomedical paradigms in providing counseling on prescribed treatment may be needed to improve adherence.
(1) Agyepong I.A., Ansah E., Gyapong M., Adjei S., Barnish G., Evans D. (2002) Strategies to improve adherence to
recommended chloroquine treatment regeimes: a quasi-experiment in the context of integrated primary health care delivery in
Ghana. Social Science and Medicine 55 (2002) 2215 – 2226
Introduction /Background
• A study in the Dangme West district in 1996/1997
measured different variables suspected to improve
adherence and also assessed the effect of an
intervention to improve prescriber /dispenser and
client communication and labeling of drugs on
adherence
• Variables assessed and found to be important
included using regression included:
– The form of the drug (tablets or syrup)
– The number of drugs on the prescription
– Communication – labeling of the drug, information
provision on dose, duration, side effects, opportunity to
ask questions
Introduction /Background
• Data gave a lot of information but there were still
unanswered questions e.g.
– The best predictive model was far from perfect,
correctly predicting only 70% of observations with a
sensitivity of 51%, a specificity of 81%, +ve predictive
value of 62% and –ve predictive value of 73%
– Number of drugs prescribed was a predictor of
adherence, but the direction was unexpected –
adherence increased as the number of drugs increased
• The clearest observation was that adherence was
very closely related to the form of the drug and
much better for tablets than syrup
Objectives/Study Questions
• To explore and better understand at the
community, household and individual level
concepts of medicines and how they work
and the factors that affect adherence to
antimalarial and other medicines as part of
the process of designing appropriate
interventions to improve adherence
Study Setting
• Prampram – a rural fishing
community of the Ga
Adangme of Southern Ghana
• Population about 6,000
• Medical Setting
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Health center
Private clinic
Licensed drug shops
Traditional healers
Traditional drug sellers
Spiritual healers
Methods
• Qualitative and exploratory study
• Apart from day visits, study team
lived in the community for a week
• Data was collected using:
• Observation
– General observation of community life
and practice especially as it relates to
biomedical and traditional medicine use
– Observation of prescribing and dispensing
at drug outlets (health center, private
clinic, drug shops, traditional drug seller,
traditional healer)
– Home follow up of clients to see what
they had done /were doing with their
medicines and why
Methods
• Data was collected using (continued)
– Individual in-depth interviews with
• Clients followed up from the clinic to see what they did with
their medicines and why
• Traditional healers
• Traditional drug sellers
• Health center, private clinic and drug shop staff
• Community leaders
– Informal conversations and interactions
– Focus group discussions
• Mothers and grandmothers of small children, fathers and
grandfathers, adult male, adult female, health center staff
Results
• A pluralistic medical setting
• People move freely between the
different medical systems in a trial
and error process
• They use whatever concepts they are
familiar with to interpret and use
traditional and biomedicines
• People are more familiar with
traditional medical concepts relating
to medicines than they are with
biomedical ones
• Both biomedical and traditional
herbal medicines are widely and
freely used in the community
Results
• Home management is done with herbal remedies
passed on down the family and from neighbor to
neighbor as well as with biomedical drugs
• External packaging is important to people in
ascribing quality to biomedicines
• Combining several medicines is an accepted
traditional medical practice that has been
translated into the use of biomedicines
• The ability of a medicine on initial trial to produce
a rapid cure without complications is important
• An effective medicine can get blacklisted if used
inappropriately (e.g. adherence incomplete) and a
rapid cure without complications is not achieved
Results
• Traditional medicince sellers and healers tend to
carefully counsel their clients, explain things to
them and if necessary follow them up home
• Biomedicine sellers and healers seem to give less
priority to and spend less time on communication,
and biomedicines are prescribed and dispensed
much less interactively
• Biomedicines and traditional medicines are seen
by community members as working in similar
ways to cleanse the blood or stomach of illness or
dirt and bring it out in the urine stools and sweat
Results
• People tend to stop taking biomedicines when they
start feeling better, often not completing the full
treatment for several reasons including a lack of
awareness that biomedicines may need to be taken
even after you feel better to uproot the illness
• Perhaps related to this is a perception in the
community that biomedicines work fast but the
illness sometimes tends to recur
• On the other hand, traditional medicines are seen
to work slowly and may have to be taken over an
extended period. However, they completely
uproot the illness and it does not recur
Implications /Conclusions
• The quality of communication between prescriber,
dispenser and client is an essential factor in
adherence and not simple to quantify
• Quality in communication involves listening to
and understanding the client as well as getting the
client to listen to you and understand you
• Prescribers and dispensers of biomedical drugs
need to put more effort into communication with
clients such as simple explanations of biomedical
concepts of drug use and why adherence matters
• The effort to visit the client at home for follow up
can be worthwhile