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“Waiting for chloroquine”: A community understanding of changes in 1 st -line treatment for uncomplicated malaria, and the need for effective policy communication. Vincent Okungu. Background.

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“Waiting for chloroquine”: A community understanding of changes in 1st-line treatment for uncomplicated malaria, and the need for effective policy communication

Vincent Okungu

  • 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

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
  • 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.
  • 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)
  • Analysis: thematic analysis, iteration

How treatment policy change from SP to AL was communicated to the study community:

Print & electronic media



From through To

what did the policy communication approach achieve in the study 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]

awareness and knowledge about changes in treatment policy
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)


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

3. Knowledge and perceptions about AL, other drugs

  • Extremely limited knowledge of AL as the recommended 1st-line drug (6 people in total)
  • 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

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)

explaining lack of awareness knowledge and perceptions about changes in treatment policy
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

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)

channels for policy communication preferred by the community
Channels for policy communication preferred by the community:

From through To

Interpersonal communication

[Public health officers, local authority, teachers, (radio)]




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)


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 across- fast acting and easy to use- sometimes we wonder why the replacement occurred too soon.”


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)

  • 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

Swedish International Development Agency (SIDA)

  • HEPNet
  • Study participants
  • Prof. Lucy Gilson
  • Health Economics Unit, University of Cape Town
  • KEMRI-Wellcome Trust Research Programme