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International Quarterly of
CO~ N
HE H
EDUCATIO
A Joumet of Policy and Applied Research
Editor: GEORGE P. CERN!\ D/-I,
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Volume 22, Number 1\ - 2003-2004
Enhancing Treatrncr-r ':0'11 ;,lj;l" "r'
i-s the Home Management of Childhood Malaria:
The Use of a Parricipatory Approach
in Ensuring Intervention Appropriateness
. A . .1.1'a, Caleb A. Adegbcnro F 0. Dare,
J. D. Atleniyi, U S. Osowole, and U Oladepo
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UNIVERSITY OF IBADAN LIBRARY
240 / ASA ET AL.
some of the best ways of achieving intervention effectiveness. II a is« iT\Tak.j
that treatments with tablets predispose to higher compliance rates than syrups.
Public participation in the diagnosis of management problems and proffering
of interventions bas shi fled the role of researchers from interventionists to
a supportive role of these populations. This strategy can save cost and ensure
the permanence of interventions beyond the lifespan of the research.
INTRODUCTION
Malaria remains one of the most serious public health problems in numerous
countries of the world, especially in developing countries. Malaria serves as one
of the main etiological factors responsible for more than half of the children
in developing countries who suffer from anemia as well us <l major cause (,,-.
childhood deaths. In Sub-Saharan Africa, an increase in hospital admission as
well as the use of traditional health services are a result of the significant burden
exerted by malaria on health facilities [1].
Mothers are particularly the first in the home to recognize fever in chi ldre:
as well as seek pathways for first treatment [2]. More women are supporting the
use of modern medical treatment in preference to traditional methods [3]. The
different pathways identified in the treatment-seeking behavior of mothers and
other caregivers include patent medicine sellers, modern health Iacili ties, as well
as traditional or herbal homes. The use of modern drugs for malaria treatment
is, however, very high [4]; traditional drugs are used either as a first line drug or
resorted to as alternatives when modern drugs fail to cure the disease.
The strategy for reduction of malaria morbidity and mortality has shifted Croll'
malaria eradication to malaria control [5). One of the major strategies is prompt
access to effective anti-malarial treatment. The promptness has to do with having
treatment available and as near the home as possible [6). Effective and better
,Ht·.,.· .•.·c••,.'" .'<:~', "·i ••: ....:.. . '",'1 V'~."· . ",'" ,;
~::. '\compliance~-i;esultlrfrom home visits as well as follow-up of sick children b)
community-based volunteers. A post-intervention study in Nigeria reveals an
increase in the proportion of children who received correct dosage (from 14.3%
to 26.7%) [6]. Haynes et aI., in their critical review of interventions to improve
compliance with prescribed medications, revealed that .compliance with short-
term treatments (less than two weeks) can be improvedby clear instructions. The
instructions consist of parenteral dosage forms, special reminder pill containers
and calendars, and simplified drug regimens [7].
The introduction of a health education package aimed at teaching women bow
to perceive and treat episodes of malaria was put in place in a rural area of
The Gambia. The study revealed that after a period of health education, 67.9%
of the study women dispensed complete courses of chloroquine as instructed.
Chloroquine consumption was on the increaseas a result of weekly rnorlidity
surveillance tbat was put in place. Mothers interviewed on a weekly basis dis-
pensed more chloroquine than mothers interviewed less frequently [8, 9]. Kidane
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UNIVERS TY OF IBADAN LIBRARY
CHILDHOOD MALARIA TREATMENT COMPLIANCE / 241
and Morrow, i-i their study of teaching mothers to provide horne treatment of
malaria in Tigray, Ethiopia, conclud~dthaJ .a.major reductio!!. in under-five
mortality could be 'achieved through tnlining¥of mothers by trainedloca I mother
coordinators on how to give under-five children anti-malarial drugs (10). Theil
findings showed that under-five mortality was reduced by 40% in the intervention
localities [1 OJ.
Experiences and findings from these studies have suggested various ways r i].
overcoming the problem, including the use of prepackaged drugs, health cduca-
tion, frequent home visits and training on case management, clear instructions and
reminder slips on containers, and simplified drug regimen for mothers. These
experiences alsr emphasized that treatment of malaria requires taking the correct
dose at the appropriate time and for the entire length of the duration.
DESiGN OF INTERVENTION APPROPRIATENESS
THROUGH PARTICIPATORY APPROACH
In this study, baseline findings revealed that the factors are not "what" to
do, as previous studies suggest, but "why" the factors and "how" to tackle them.
Mothers and caregivers believe that the administration of malaria drugs should
be terminated as soon as they perceive that the child is (clinically) well. Clinical
wellness was based on the disappearance of fever or high body temperature. This
has had an adverse effect on the cure rates for malaria reported by mothers after
treating their children with chloroquine and.le~ding to.the belief that the drugs
aI r)e;.~n-. ol'r'effectiv•e. ~ :'.... ~.•..:·:-:~~O~I..!:.~.~ -. '''':, ".'_.I<(' -"~':..:. •..••.••.~...;..t.f•~•~. ·;",.".... . •.~. .
...~
,T, '.' ~ . ,,:-- . "'...•. ,.:~. c.· •
Also, it was found• that there was no age-specific dosage for the treatment of
malaria. Various sizes' of spoons were used (such as 5 ml spoon for syrup
measurement) and the number of tablets given to a child was sometimes wha: a b'.
parent could afford to buy. As a result, children were under-dosed. Additionally,
the findings showed that a majority of the mothers and caregivers obtained their
drugs from sources outside the health facilities, especially patent medicine sellers,
where the quality L f drugs in terms of composition and shelf life was doubtful.
Based on these findings, the intervention program was therefore jointly
designed by resea.:chers in participatory relationship with the health workers,
patent medicine sellers, and mothers. The intervention was done at two levels.
The first level wrs fO ensure that correct quantity and quality (drugs whose
shelf life had not ex.y'ired) of anti-malaria (chloroquine) tablets and syrups was
dispensed to careg.vers by health workers and patent medicine sellers. In the
process of participatory discussions and to solve the problem of quantity, the
patent medicine sellers in their own contributions suggested the use of prescription
charts that will show the age specific dosage of chloroquine tablets and syrup.
The chart would shew the number of tablets as well as the number of5 ml spoons
of syrup and the time regimen that will correspond. to the age of the 'child.'
However, the recognition of the 5 ml spoon by drug sellers and mothers still posed
: . .' .
,o y'.
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UNIVERSITY OF IBADAN LIBRARY
242 I ASAETAL. .' ,', . ',' " ,,~,
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a problem. After a long deliberation on a solution, the patent medicine sellers '''~.c_
suggested that a plastic 5 ml spoon can be produced en-mass and distributed in "-
, large quantities to all the members through the platform of their association. Eachmember would display the age-specific prescription chart in the shop and it
would be the basis for selling chloroquine to mothers of children diagnosed as .
having malaria. Additionally, the sellers would undertake to give the 5 ml plastic
spoon to every mother who has purchased chloroquine syrup. The executive
members of the Association would ensure strict compliance. As to' the quality
of the drugs, the patent medicine sellers association made and enforced a regu-
lation that no member should stock or sell expired drugs to any customer.
Mothers on their own were trained to be self-confident and assertive in asking
for evidence that a drug had not expired before purchasing it from the drug store
or health facility.
The second level consists of a program of educating mothers and caregivers
about the importance of completing treatment regimens. It was visually demon-
strated to the mothers, with the aid of microscopic electronic projection, that the
cause of malaria is a living parasite which must be totally killed with a sufficient
quantity of drugs. If tile parasite was half-killed with insufficient .drugs and
it survived, the drug may' no longer be effective in killing subsequent parasites
produced 'by those that 'sutvived:!Th~refore;;it;is' important .that the:..quantity of
age-specific drug dispensed by the health workers or the patent medicine sellers
be completely taken. ,The mothers were shown samples of blood taken from
children who were not apparently sick but contain malaria parasites to convince
that the disappearance of fever symptoms did not necessarily imply that the child
was fully cured of the disease.
"
METHODOLOGY
Two Local Government Areas (LOA), namely Kajola and Iseyin, were used as
the study areas. Kajolahad a total population, of 168,260 in 1991 with a projected
population of231,504 in the year 2002. Iseyin LOA had a population of 170,936
in 1991 with a projected population of235,186 in the year 2002. The two areas are
indigenous Yoruba tribe with farming as their major occupation. Kajola is a rural
LGA contiguous to Iseyin, a semi-urban local government area.
There were two studies: a based-line community survey on home treatment and
management practices' of mothers and caregivers covering the two lqcal govern-
ment areas, and a second which was a post-evaluation study of compliance of the
treatment regimen by a sample of mothers and caregivers from the study area.
The criteria for participation in the first survey\vas:thiltthe'mothers/caregivers
. should have children (under five) who had at least one episode ofma'laria within
?"'tWo'weeks preceding'thedate of survey. Thelespondents·for'the baseline survey'_, .
were 1009 mothers ~hd' caregivers selected from a representative .sample .ot·"
households using a multistage cluster sampling technique. Later, a subset of lSG
UNIVERSITY OF IBADAN LIBRARY
·.",'. ,.,
CHILDHOOD MALARIA TREATMENT COMPLIANCE I 243
representative sample of mothers and caregivers were randomly selected fur
the second compliance study. For the second study on compliance, they must be
mothers and caregivers who had perceived that their children were currently
having clinical symptoms of malaria. Structured questionnaires were designed
and used as instruments for the collection of data in the two studies, but the
compliance study included an observation check-list.
FINDINGS
Base-Line Community Survey I
1
Preferred Formulation of Anti-Malaria Drugs
The community-based survey on preferred formulation of anti-malaria drugs
showed little difference in preferences for syrup (43.2%) and tablets (47.7%) and I
j:1 ,'. ",'.: x . n; ':.':!J./',: '<i' •..,.i.J,:yf'oi-: .)'10..:'-'",," "A~""·"';;'''''.''''.'"~''''''<'''''':;'~ ;..• ', •.. '. , " . .that' 6.8% preferred ··injections (Table' 1P'Wt'the' ~training of tra inersmeeti ng.
injections were discouraged because of the lack of persons with expertise and .;!
shortage or facilities and equipments in the rural areas which are potential causes ,
of complications.
Perceived Effectiveness of Last Treatment
with Chloroquine ;)rug ,
; .
A greater proportion of the respondents showed that treatment with modern :~
drugs was very effective (98.0%) (see Table 2). This is further confirmed JI1
;~
the fact that 99.5'~o of the respondents revealed their intention to use the same ~1
treatment as the ~ast one used. This finding supported the popularity of modem
drug treatment. ft
~~.'
,:-.~,
Table 1. Distribution of Respondents
by Preferred Formulation of
Anti-Malaria Drugs . :.-~
...
Baseline survey I",.
Formulation (N = 1009)
I. ·1 ~.:""-
Syrup 436 (43.2%)
I·
Tablet 481(47.7%)
Injection 69 (6.8%)
Capsule 4 (0.4%)
No response 19 (1.9%)
--'
UNIVERSI Y OF IBADAN LIBRARY
244 I ASA ET AL.
When to Stop Anti-Maiaria Drug Administration ."
for a Sick Child
T~~econ~'m\1nity sur'~:~y re~ealed that m-o~etha~half of the respondents (50.·\%)
f would stop Ill<' administration of anti-mal.,.,;",. ,l.",,,s \\,'. "11 t1'" drur . are ·-'nisho'd.
Thus, the baseline study justified tl«, :;~-:..
on chloroquine treatment compliance in the target area (Table 3).
Compliance Study
The 186 respondents with children currently having c inical symptoms or
malaria areas were given age-specific doses of chloroquine and paracetamol by
health workers and members of the patent medicine sellers association who had
attended a training of trainers meeting conducted by the research team and were
also educated on the need to complete the treatment regimen as well as the timing
of the adminisi rat ion of the drugs. Table 4 presents the distribution of respondents
by the existence of perceived malaria symptoms. Table 4 shows that at least 87.6%
of the respondents reported the absence of the different symptoms of malaria
Table 2. Distribution of Respondents
by Perceived Drugs Effectiveness
Baseline survey
':.:"::~Effe~~tvEmess (N,:" 1000)
:.~;"'.
Very effective 980 (98.0%)
Partially effective 20 (2.0%)
Effective
Not effective o (0.0%)
Table 3. Distribution of Respondents by
When to Stop Administration of
Anti-Malaria Drugs
Baseline survey
When to stop I (N::: 1009)
When a child is well 524 (51.9%)
When the drug is finished 509 (50.4%)
When high body
temperature subsides 4~~ (44.5%)
'i..':"~."
UNIVERSITY OF IBADAN LIBRARY
CHILDHOOD MALARIA TREATMENT COMPLIANCE I 245
Table 4. Distribution of Respondents by Perceived Symptoms of
Malaria in Their Sick Children
Symptoms No. Yes No response Total
.f
. t Cold .. 4,~~«2.2'1'0) 181 (97.3%) 1 (0.5%) 186
Fever 11 (5.9%) 174 (99.5%) 1 (0.5%) 186
"<~'~!~1i{>r . :'::'"i; I;~"s: '~,.~;~&~H.~e: ada-che >1+ihxf."~;"k~3~j:(1~6%);':ifH!.'182.\(9.7..8Wo)[";"",,s;,",.1,(0.5%;),J.; ... ,~.,186 .-j ~ ,.". •..• •••• ," ,.".~ ,.,- "'c' J :,:~,;>:,~~·~•..•.·•t.;,·'S'\.,·!.,:,,;,?fh'~\~'<,. s ;t.,.-",~;;:~:,:".'~~¢I.++.~.'t";~,.l'~~•...;.:..:',t
l '
! ,, Weakness 11 (5.9%) 174 (93.5%) 1 (0.5%) 186
Cough 22 (11.8%) 163 (87.6%) 1 (0.5%) 186
Diarrhea 4 (2.2%) 181 (97.3%) 1 (0.5%) 186
Rashes 16 (8.6%) 169 (90.9%) 1 (0.5%) 186
Loss of Appetite 8 (4.8%) 177 (95.2%) 1 (0.5%) 186
Vomiting 6 (3.2%) 179 (96.2%) 1 (0.5%) 186 I
Restlessness 2 (1.1 %) 183 (98.4%) 1 (0.5%) 186
Breathlessness 1 (0.5%) 184 (98.9%) 1 (0.5%) 186
Yellow eyes 4 (2.2%) 181 (97.3%) 1 (0.5%) 186 ,
Convulsion 2 (1.1%) 183 (98.4%) 1 (0.5%) 186
Table 5 shows reported treatment outcome of treatment with correct age-
specific doses of chloroquine. More than half (55.4%) of the respondents reported
d the post-treatment status of the child as being "very well," while less than half
T (43.5%) repo~ted the"'present' heaifh"';it1itUsf'as"well." Two of..!th(;!\r,e.sPQndents,\,~.,;
however, reported the present health status of the child as not being different. .
; '''' :6n~ihe><d~~iri1fuitHaidy~fol1owiti!f'ftne~last;~day, of-treatment.sthe ,eseax:ch:~_i.t
team checked on the mothers' level of compliance with treatment regimen. An
indirect w(~yof confirming compliance with treatment regimen was put in place.
Respondents were asked for the amount of leftover drugs that they had on them
after the third day of administration. During the single day visit, 155 of the
186 respondents used tablets while three used syrups. Tablcs6 and 7 show the
distribution of the amount of left over drugs after Day 3 (Table 6 for tablets and
Table 7 for syrups). The results show that 146 (94.2%) of mothers and caregivers
completed the full dose of prescribed chloroquine tablets while 48.4% completed
the syrup doses. i
DISCUSSION
Enhancement of Home Management of Childhood Malaria can be achieved
through the use of a participatory approach in ensuring intervention appro-
priateness .. Having treatment available as near the home as possible as well as
UNIVERSITY OF IBADAN LIBRARY
'~.~.
246 / ASA ET AL.
Table 5. Reported Treatment Outcome of
Recent Childhood Fever After Treatment
with Chloroquine
j Present health status Frequency Percentage
Very well 103 55.4
Well 81 43.5
Still the same 2 1.1
Total 186 100.0
:"" .~ ,: r Table 6:,Distril;lution of Left Over Drugs (Tablets)
'\;( ,After DaY'3"" / '<:/ OJ' ,
No tablets remaining 146 94.2%
1 tablet remaining 1 0.6%
2 tablets remaining 4 2.5%
6 tablets remaining 1 0.6%
No response 3 1.9% --
Total 155 100%
Table 7. Distribution of Left Over Drugs (Syrups)
After Day 3
Left over syrups No. of respondents Percent
I
15 48.4% I'I
.';.1, I
I•••• '! ~ •
2 6.5%
6 19.3%
2 6.5%
Total 31 100%
"
UNIVERSITY OF IBADAN LIBRARY
CHILDHOOD MALARIA TREATMENT COMPLIANCE I 247
having prompt access to affordable and appropriate treatment within 24 hours or I
the onset of syr rptoms (TDRnews No. 67) may not be enough as an intervention
strategy to reduce the burden of malaria. To ensure high compliance rates by
mothers and other caregivers to treatment regimen in terms of taking correct
dosages when cue and completing the required number of doses. the root causes 0 r
non-compliance that are peculiar to different target populations must first be
identified.
It is revealed from this study that tailoring educational intervention to the
special needs of tl.e various groups and involving them in the design of inter-
ventions are sene of the best ways of achieving intervention effectiveness.
Treatment with .al.lets predisposes to higher compliance rates than syrups. :rhe.
participation of groups in ·the'diagnosis'of'mati~gerrientprbblems and proffering Y"
of interventions has shifted the role of researchers from interventionists to a
supportive role of these populations. This strategy can save cost and ensure the
permanence of interventions beyond the life-span of the research-a problem
fac d in the sustuinability of research initiatives.
REFERENCES
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M. Tanner, X. Bosch-Capblanch, and P. L. Alonso, Cost-Effectiveness of Non-
Supplementation and Malaria Chemoprophylaxis in the Prevention of Anaemia
and Malaria among Tanzanian Infants, Bulletin of the World l Iealtn Organization.
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2. 1\. B. Diallo, 0. B. De Serres, C. Lapointe, and P. Views, Home Care of Malaria-
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Guinea, Bullet ..vof the World Health Organization. 79:, pp. 28-32, 2001.
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chez lesfemmes.des campements de pecheurs dans la zone de selingue au Mali, lnstitut
National de Recherche en Sante Publique, Bamako, Mali, 1992.
4. G. B. Fosu, Access to Health Care in Urban Areas of Developing Societies, Journal
of Health and Social Behaviour. 30:4, pp; 33Q~341, .1989... > " "0 ,.<.' .: ·''.;.-!It',
5. L. G. Bruce-Cr.awatt}Les"sons' l:earnid"fro'rit Appii"'e'a'Field Research Activili~s of
A frica during the Malaria Eradication Era, Bulletin WHO. 62:Suppl, pp. 19-29, 1984.
6. TDRllews. Scaling Up Home Management of Malaria, p. 67,2002.
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Improve Compliance with Prescribed Medications, Patient Education and Counseling,
10. pp. 155-166, i987.
8. A. Menon, D. J00f, K. M. Rowan, and B. M. Greenwood, Maternal I\dlllinistr~tion of .-
Chloroquine: AI':'Unexplored Aspect of Malaria Control, Journal of Tropical Medicine
and Hygiene. 9 l., pp. 49-54, 1988.
9. P. Wilairatana, :,.'Y..rudsood, W. Chokejindachai, V. Bussaratid, U, Silachamroon,
P. Viriyarejakul, C Hendriksen, M. W. Scheiwe, and S. Looareesuwan, A Critical
Trial of Combi;),at~oll of Artesunatc and Mefloquine in the Treatment of Acute
UNIVERSITY OF IBADAN LIBRARY
248 I ASA ET AL.
Uncomplicated Falciparurn Malaria: A Short and Practical Regimen. Southeast Asian
Journal of Tropical ;Aedicil/e and Public Health, 29:4, pp. 696-701, 1<)?5.
10. G. Kidane and R. n. Morrow, Teaching Mothers to Provide Home Treatment of
I Malaria in Tigray, <jlhiopia: A Randomized Trial, Lancet, 356:9229, pp. 550-555,
2000.
Direct reprint requests to:
Prof. Sola Asa
Dept. of Demography and Social Statistics
Faculty of Social Sciences
Obafemi Awolowo University
lIe-Ife, Nigeria
e-rnail: solaasa2000@yahoo.com
. ,
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