Irene Akua Agyepong, Patricia Anafi, Margaret Gyapong

1. 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

2. 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 andConclusions: 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 Abstract

3. 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

4. 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

5. 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

6. Study Setting • Prampram – a rural fishing community of the Ga Adangme of Southern Ghana • Population about 6,000 • Medical Setting • Health center • Private clinic • Licensed drug shops • Traditional healers • Traditional drug sellers • Spiritual healers

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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