Abstract:
Background: Adherence to anti-malarial medication is highly variable but frequently
suboptimal. Numerous interventions with a variety of methodological approaches have
been implemented to address the problem. A recently conducted, randomized, controlled
trial in western Kenya evaluated the effects of short message service (SMS) reminders on
paediatric adherence to artemether-lumefantrine (AL) and found over 97% adherence
rates in both intervention and control arms. The current study was undertaken to explore
participants' experiences in the trial and identify the factors contributing to the high
adherence rates.
Methods: In July 2016, 5 months after the trial completion, focus group discussions
(FGDs) were undertaken with caregivers of children who had been treated in the
intervention (n = 2) or control (n = 2) arms and who, post-trial, had received malaria
treatment from the same facilities. The FGDs explored similarities and differences in
perceptions and experiences of the care they received during and after the trial.
Results: Intervention-arm participants reported that SMS messages were effective dosing
reminders. Participants from both arms reported that trial instructions to keep empty AL
packs for verification during a home visit by a health worker affected their dosing and
adherence practices. Differences between trial and post-trial treatment experiences
included: administration of the first AL dose by health workers with demonstration of
dispersible tablets dilution; advice on what to do if a child vomited; clear instructions on
timing of dosing with efforts made to ensure understanding; and, information that dose
completion was necessary with explanation provided. Participants reported that after the
trial AL was not available at facilities, constraining their ability to adhere to
recommended malaria treatment. They emphasized receiving respectful and personal
treatment from trial health workers contributing to perceptions of high quality care and
enhanced readiness to adhere to dosing instructions.
Conclusions: This study highlights the complex range of factors that influence AL
adherence. The results suggest that in addition to standardized definitions and
measurement of adherence, and the influence of enrolment procedures, AL adherence
trials need to take account of how intervention impact can be influenced by differences in
the quality of care received under trial and routine conditions.