Evelyn K. Ansah ¹, John O.Gyapong², Irene A. Agyepong¹, David B.Evans³

1. IMPROVING ADHERENCE TO MALARIA TREATMENT FOR CHILDREN:THE USE OF PRE-PACKAGED CHLOROQUINE TABLETS VRS. SYRUP Evelyn K. Ansah¹, John O.Gyapong², Irene A. Agyepong¹, David B.Evans³ ¹Dangme West District Health Administration /Research Centre, Ghana Health Service, P.O.Box 1, Dodowa, Ghana ²Health Research Unit, Ghana Health Service, Accra, Ghana ³Global Program on Evidence for Health Policy (GPE), World Health Organization, Geneva, Switzerland

2. ABSTRACT - IMPROVING ADHERENCE TO MALARIA TREATMENT FOR CHILDREN: THE USE OF PRE-PACKAGED CHLOROQUINE TABLETS VERSUS CHLOROQUINE SYRUP. Ansah EK1, Gyapong JO1, Agyepong IA1, Evans DB21Ghana Health Service and 2World Health Organization, Geneva, Switzerland • Problem Statement: Malaria is a major cause of morbidity and mortality among children under five in sub-Saharan Africa. Prompt diagnosis and adequate treatment of acute clinical episodes is essential in the reduction of morbidity and the prevention of complications as well as mortality. In many countries, chloroquine syrup is the mainstay of malaria treatment for children under five. In addition to syrups being more expensive than tablets, adherence to the dose prescribed at home has been observed to be a problem because mothers often use the wrong sized measuring implement or get instructions mixed up. • Objectives: To investigate the impact of the introduction of pre-packaged tablets for children 0-5years with uncomplicated malaria, on adherence to treatment, to compare the average cost of tablets with that of syrup for the same age group, and to determine the perceptions of mothers concerning the acceptability, convenience and ease of administration of pre-packaged tablets for children. • Design: Intervention Study • Setting and Population:. A total of 301 children 0-5years diagnosed with uncomplicated malaria at the only two health centers in the Cape Coast Municipality were recruited over a period of six weeks in 1998. • Intervention:. Eligible children received either pre-packaged tablets or syrup by random assignment. Mothers or principal caregivers were interviewed at home on the fourth day after attending the clinic. Outcome Measures: % adherence to treatment schedule; % administering a total dose of 25mg/kg body weight by day 3; % using 5ml measuring implement; % of care-givers who find pre-packaged tablets acceptable and the average cost of treatment with tablets as against syrups. • Results: Of 155 caregivers prescribed the pre-packaged tablets, 91% (n=141) adhered to the recommended dosage while only 42% (n=61) of 144 prescribed syrup adhered to the recommendations. Of the caregivers who received syrup, 19% (n=28) used an accurate 5ml measure (in the form of small cups or spoons). Others used measures that contained either more or less than the 5mls required to follow the recommendations. The cost of treatment with tablets was about one quarter that of syrup and 62% (n=96) of mothers receiving pre-packaged tablets showed a definite preference for the tablets. • Conclusions: The home is an important component of management of acute clinical episodes of malaria. All efforts must therefore be made to improve this very important component by making it easier for caregivers to adhere to treatment prescribed. In order to improve adherence to treatment, pre-packaged tablets for children must be considered as a viable alternative to syrups for the treatment of malaria among children 0-5 yrs. • Study Funded By: WHO/TDR

3. Introduction Background • Follow-on to initial study on adherence in the Dangme West District • Adherence to treatment schedule was found to be very poor ( Agyepong et al,2002) • Syrup mainstay of antimalarial Rx among chn <5 yrs Study Area • Cape Coast in the Central Region of Ghana • Population: 120,000 • 2 H/Centers 2 MCH Centers • Malaria is highly endemic; there is transmission all year round

4. Study Questions • Would prescribing pre-packaged tablets improve adherence to antimalarial treatment for children <5yrs? • Would tablets be acceptable to mothers as an alternative formulation for children?

5. Methods • 144 clients were randomly assigned to receive syrup, 155 to receive pre-packaged tablets at the Outpatients • Clients were visited at home on day 4 (The first day of visit to the clinic was counted as day 1) 1 2 3

6. Methods • Caregivers were interviewed to find out how medication was administered and their perceptions of the formulation received • Volume of spoons/other home implements used to administer syrup measured using a calibrated measuring syringe Definition of adherence used • Doing exactly as the provider prescribed no matter the volume and type of implement used e.g Mother gives exactly “one teaspoon” daily even if her idea of a teaspoon is a tablespoon.

7. Results • 42% of 144 clients who received syrup c/f 91% of 155 who received pre-packaged tablets adhered to Rx schedule (Syrups were/still are dispensed at the clinic without a standard measure) • 80% used spoons whilst 20% used a cup to measure the dose • Only 19.4% used an accurate 5 ml measure. 68% used measuring implements <5ml in volume whilst the rest used implements >5ml in volume

8. Results • The volume of spoons/cups used to represent 5 mls varied from 1 ml to 9 mls. • Some used teaspoons whilst others used dessertspoons and tablespoons. Apparently to most of the caregivers/mothers, “a spoon is a spoon is a spoon is a teaspoon” • 4 caregivers used two different measures to administer the CHQ syrup to the same child. They used one measure on an occasion and another at a different time or on a different day.

9. Results • Only 8.6% of caregivers had given a total dose of 25mg/kg by day 4 > 25mg/kg - 44.3% < 25mg/kg - 47.1% • Avg. cost to the caregiver when syrup was dispensed was about 4x that of tablets GHC750(US$0.36) vrs GHC168(US$0.08)

10. Results- Perceptions of Caregivers /Mothers • “Tablets are easier to administer than the syrup. I just put it in thick ‘koko’ (fermented maize porridge).” • “It is easier for me to remember how much to give. As for 1,2,3 anybody can read it” • “The tablets work faster than syrups.” • About 62% of caregivers/mothers who received pre-packaged tabs preferred it to the syrup

11. Summary • Pre-packaged tabs for chn a viable alternative for home management of malaria. • Improves adherence remarkably *Over & Under dosage ---->Toxicity or resistance • Also improves administration of the correct dose • Eliminates problem of variations in home measures and the mother’s dilemma of “HOW MUCH?’ “HOW OFTEN?” “HOW LONG?” • Reduces cost to caregiver/mother • Caregivers/ mothers are willing to use them

12. Policy/Program Implications • Policy Makers must consider using pre-packaged tabs for children. • Manufacturers must be encouraged to produce already packaged lower strength sweeter tabs for children • Where syrup MUST necessarily be dispensed, standard 5ml measures must be provided with the medication • In that case, just enough syrup with allowance for spillage must be supplied

13. Conclusion • The home is an important component in the management of acute clinical episodes of malaria. All efforts must therefore go to improve this component by making it easier for caretakers/mothers to adhere to treatment