Order of Presentation

2. IMPROVING ADHERENCE TO MALARIA TREATMENT FOR CHILDREN:THE USE OF PRE-PACKAGED CHLOROQUINE TABLETS VRS. SYRUP EVELYN K. ANSAH, IRENE A. AGYEPONG, JOHN O. GYAPONG, DAVID B. EVANS

3. Order of Presentation • Background • Study setting • Methods • Results • Key lessons learnt • Policy and Program Implications • Conclusion

4. Background • Follow-on to initial study on adherence in the Dangme West District • Adherence to Rx schedule was found to be very poor especially for chn (Agyepong et al,2002; Social Science & Medicine 2002 Dec ; 55(12): 2215-2226) • Syrup mainstay of antimalarial Rx among chn <5 yrs • Pre-packaged tablets for adults shown to improve adherence remarkably (Yeboah-Antwi et al, 2001,Quingjun et al, 1995)

5. Study Setting • Cape Coast municipality 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

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

7. Methods • 144 clients randomly assigned to receive syrup, 155 to receive pre-packaged tablets at OPD • Day 4 home visit. (The first day of visit to the clinic was counted as day 1) 1 2 3

8. 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

9. 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.

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

11. 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 tablespoon is a desertspoon is a teaspoon” • 4 caregivers used two different measures at different times or on a different days.

12. 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% • Cost to the caregiver when syrup was dispensed was about 4x that of tablets GHC750(US$0.36) vrs GHC168 (US$0.08)

13. 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

14. Key Lessons • Pre-packaged tabs for children are a viable alternative for home management of malaria. • Improves adherence remarkably & reduces over & under dosage ---->Toxicity or resistance • Also improves the administration of the correct dose

15. Key Lessons • 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

16. 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

17. Future Research Agenda • Would adherence to dosage schedule of co-packaged tablets be the same as for single drug tablets? (Current move to combination therapy for malaria) • Addition of standard measures to syrups: by how much would adherence be improved? • How do we ensure that prescribers and chemical sellers/Pharmacies do dispense adequate doses of antimalarials

18. Thank you for your attention!!!