Transcript Vincent Okungu Waiting for chloroquine

“Waiting for chloroquine”: A community
understanding of changes in 1st-line treatment
for uncomplicated malaria, and the need for
effective policy communication
Vincent Okungu
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Background
 Although malaria remains a serious public health
problem, there is evidence of decline; some SSA
countries report 50% decline
 Control measures partly involve changing 1st-line
treatment policy for uncomplicated malaria whenever
there is drug resistance
 Introducing new drugs into the health system is
complex and sensitive
 Requires effective communication to minimize
resistance and improve uptake
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
 Kenya rolled out artemether-lumefantrine (AL) in
2006 to replace sulfadoxine-pyrethamine (SP)
 Uptake was still very low in 2009; reasons not
exhaustively explored
 Unclear whether the public is usually adequately
prepared for the changes in drugs; its
understanding of the purpose for the changes;
 Unclear the extent to which communication about
the change of drugs influences public perceptions,
expectations and use of recommended drugs
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Objectives
 To contribute to malaria control efforts by
analyzing gaps in policy communication at the
community level and making suggestions for future
strategies in policy communication.
 To explore community awareness and understanding of
changes in 1st-line treatment for uncomplicated malaria
in Kenya;
 To critically analyze the role of policy communication in
the uptake of newly introduced 1st-line drugs
 To propose alternative means to improve future policy
communication strategies.
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Methods
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Qualitative cross-sectional study
Setting: remote district at the Kenyan coast
Sampling: purposive
Data collection methods

FGDs (n=14)
In-depth interviews (n=29)
Patient narratives (n=8)

Informal conversational interviews (n=11)
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 Analysis: thematic analysis, iteration
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Findings
How treatment policy change from SP to AL was
communicated to the study community:
From
Government
through
Print & electronic media
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
To
Community
What did the policy communication approach
achieve in the study community?
 Knowledge and awareness of changes in 1st-line
treatment policy for uncomplicated malaria
 Perceptions about why 1st-line drugs change
 Knowledge and perceptions about AL
[Implications for uptake and universal access to malaria
drugs]
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
1. Awareness and knowledge about changes in
treatment policy
 General lack of accurate knowledge about the changes
in the 1st-line treatment policy:
“We don’t know that drugs have changed, only that there are seasons
for each malaria drug. It is now the season for malara-tab [AQ] and
the other one... [AL]. We are waiting for CQ season, then we will have
no problems treating malaria…” (Male, FGD)
“I have no information about any changes in malaria drugs, but if
there are indeed changes, then the new drugs have not yet reached
this village.” (Female patient, 24)
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
2. Perceptions about why 1st-line drugs change
 For commercial purposes (all study participants
including most health workers)
“We keep asking why AL and not any other ACT? This
question has not been answered and sometimes we
believe that the change was motivated by non-health
reasons... may be someone just wanted to make
money.” (District health worker)
 Govt is experimenting with different types of drugs
 Intends to find a more effective drug
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
3. Knowledge and perceptions about AL, other drugs

Extremely limited knowledge of AL as the recommended
1st-line drug (6 people in total)
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AL is harmful:
“Recently, I asked my wife why she was given fewer drugs
than those given to everyone who goes to the dispensary. She
responded that the other drug [AL] cannot be given to
pregnant women. This confirms that the new drug is harmful.”
(Male, FGD).

Too strong for ‘weak’ malaria: implications for recovery
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
 AL is not a good drug: weak, too many tablets
“We heard that malaria drugs currently available are not
good. We hoped for a new and better drug, but the new
drug has 24 tablets instead of just a few. Why are the
tablets so many if it is a good drug?”
 Use of AL leaves no room for diversity
“…one type of drug cannot treat people suffering from
different types of malaria. I suggest that each type of
malaria should have its own drug….” (Male, 39- FGD)
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Explaining lack of awareness, knowledge and
perceptions about changes in treatment policy
 Choice of communication channels
 Conflicting messages from the media and informal
drug sellers
 Lack of dialogue between providers and patients
 Health worker perceptions and practice
 Community treatment behaviors
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
1. Choice of communication channels to pass
messages about change to AL
 Print and electronic media were not the
preferred sources of health information
 Inaccessible: illiteracy, lack of radios among
primary caretakers
“...all we see are graphics and pictures, which we
often take for decorations in the dispensary.”
(Female, 33)
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Channels for policy communication preferred by the
community:
From
Government
through
Interpersonal
communication
[Public health officers,
local authority,
teachers, (radio)]
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
To
Community
2. Confusion created by competing media messages
and private drug sellers:
“There is a lot of information coming through radios and
posters regarding different types of malaria drugs, but with
no one to differentiate for the ordinary people and show
them that AL is the best and recommended drug, they get
confused by the adverts....” (Health worker).
“…the dispensary gave my wife what it said were the latest
malaria drugs, but the shopkeeper also had the latest
drugs different from the dispensary’s… this is confusing.”
(Male 27, FGD)
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
3. Lack of dialogue between health workers and
patients over AL
“I wanted to know why I was given [malaria] drugs different
from the ones I have known all along but the nurse asked
me whether I came to be treated or to know what drugs I
would take….”
4. Perception among some health workers that SP is
still effective
“SP is one of the best malaria drugs I have ever come acrossfast acting and easy to use- sometimes we wonder why the
replacement occurred too soon.”
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
5. Reluctance to change to less familiar drugs
“…I prefer the older drugs... I do not like the new one
because of many tablets and the fact that patients
who use it never recover. I think there should be a
warning on the [AL] package that it may not cure
malaria the same way it is done to warn smokers
against cigarette consumption.” (Female, 46- ID)
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Conclusion
 The limited knowledge about AL and the negative
perceptions created among community members by
change of 1st-line treatment policy:
 Are a barrier to universal access to malaria drugs
(acceptability), proper use and uptake of AL
 Negate malaria control efforts
 Future policy communication needs sustained public
education using culturally sensitive channels
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Acknowledgements
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Swedish International Development Agency (SIDA)
HEPNet
Study participants
Prof. Lucy Gilson
Health Economics Unit, University of Cape Town
KEMRI-Wellcome Trust Research Programme
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011