IMPACT OF AN INTERVENTION PROGRAM FOR THE TREATMENT OF MALARIA IN CHILDREN IN PAPUA NEW GUINEA SUNDERLAND VB JOSHUA IB

1
IMPACT OF AN INTERVENTION PROGRAM FOR THE
TREATMENT OF MALARIA IN CHILDREN IN PAPUA NEW
GUINEASUNDERLAND VB JOSHUA IB PASSMORE
PRSchool of Pharmacy, Curtin University of
TechnologyKent Street, Bentley, Western
Australia 6102 Currently, Discipline of
Pharmacy, University of Papua New Guinea,Port
Moresby, Papua New Guinea
Abstract This study evaluated the impact of
patient carer directed drug information on the
understanding and treatment outcomes in
uncomplicated malaria in children. A pre-post
intervention study was carried out at an urban
health clinic using an intervention of written
and verbal reinforcement of directions and
information about treatments, drug
administration, compliance and understanding of
the treatment with respect to the control
group. Patient carer understanding of basic
medication administration dosage and frequency
was unchanged (Pgt0.05) however significant
improvements were evident in patient carer
understanding of medications (Plt0.05),
understanding of storage of medicines (Plt0.001),
reading labels and instructions (Plt0.001),
remembering to give medicines (Plt0.001) and
correct administration timing (Plt0.001). The
reported improvement in treatment cure rate
(health outcome) increased from 57.9 to 92.3
(P0.007). Other than understanding of
administration all other parameters showed marked
improvements as a result of the intervention
including self-reported patient outcomes.
Background and Setting Malaria is still
significant today with in excess of 2 million
deaths reported annually, and most are children
(1). Few studies have been reported for malaria
with an aim to improve patient compliance and
understanding of their medications. One study in
China initially with inferior quality medications
showed that lack of understanding of
administration instructions was improved by
blister packaging and provision of written
instructions (2). A study from Cambodia found
that public education of patients by posters and
videos was effective if patients visited health
practitioners rather than drug vendors (3). A
recently reported study found additional
labelling and verbal instruction of carers
significantly improved compliance with
chloroquine in uncomplicated malaria in
children(4). In other disease states patient
education has been shown to result in significant
and long lasting improvements in Type 1 diabetes
(5).

• Study Aims
• The aims of this study were
• Evaluate the impact of an intervention program on
  patient carers on the understanding of
  antimalarial drugs in children for uncomplicated
  malaria.
• Evaluate the level of rational use for
  uncomplicated malaria in children.

• Methods
• The trial was a pre-post intervention protocol
  with a control group (Control). The intervention
  arm (Clinic) was at an urban clinic in the
  National Capital District of PNG serving
  approximately 20,000 people. The control clinic
  was similar in size and services provided but
  located about 15km distant serving a different
  population. Inclusion criteria children 0-10
  years diagnosed with uncomplicated malaria and
  prescribed the standard treatment protocol.
  Consent was required from carers. Exclusions
  were children in the post-intervention phase who
  participated in the pre-intervention phase.
• In the pre-intervention current and previously
  prescribed drugs, doses and frequencies
  prescribed were recorded. Patients were asked to
  complete a standardised questionnaire on past and
  present medications and issues related to
  compliance (6). Patients were requested to
  return to the clinic after 7 days and report to
  the researcher if the child had recovered or not.
• In the post-intervention phase the following were
  introduced
• A dispensing label providing directions for use
  and the importance of completing the course
• The carer was verbally counselled on the
  directions and importance of completing the
  treatment
• The same questionnaire was administered.
• Carers were advised to return to the clinic after
  7 days and report if the child was well or not.
  The pre-intervention stage was maintained for the
  whole period of the study at the control clinic.
• Differences in pre-post elements of the study
  periods were evaluated using Chi-squared,
  Kruskal-Wallis, Fishers Exact or Students - t
  tests as appropriate.
• Diagnosis and treatment was from national
  standard treatment guidelines which require any
  child with fever to be treated for malaria. The
  first line treatment was amodiaquine with
  chloroquine or Fansidar(7).

• Table 3 Patient/Carer Understanding of
• Use of the Medicine

Drug Uses count Subgroups Subgroups Subgroups Subgroups Total P-value
Drug Uses count Con-pre Con-post Clin-pre Clin-post Total P-value
Amodiaquine 100mg tablet Incorrect 10 (45.5) 25 (39.7) 25 (29.1) 22 (26.8) 82 (32.4) 0.184
Amodiaquine 100mg tablet Correct 12 (54.5) 38 (60.3) 61 (70.9) 60 (73.2) 171 (67.6) 0.184
Chloroquine 150mg tablet Incorrect 2 (28.6) 2 (100.0) 4 (30.8) 0.098
Chloroquine 150mg tablet Correct 1 (100.0) 3 (100.0) 5 (71.4) 9 (69.2) 0.098
Quinine 300 mg tablet Incorrect 1 (100.0) 1 (50.0) 0.157
Quinine 300 mg tablet Correct 1 (100.0) 1 (50.0) 0.157
Results and Discussion The demographic data
(Table 1) show that the mean age for each of the
groups was approximately 2 years. There were no
significant differences in any of the population
characteristics. Table 1. Patient demographics at
the clinic pre-post and control pre-post groups
Subgroups Subgroups Subgroups Subgroups Total
Con-pre Con-post Clin-pre Clin-post
Sample Size N 25 (8.3) 75 (24.8) 103 (34.0) 100 (33.0) 303 (100.0)
Age (years) Mean 1.90 1.99 2.78 2.32 2.36
SD 2.14 1.93 2.60 1.98 2.23
P-value1 0.079
Weight (kg) Mean 10.04 10.16 11.87 11.01 11.01
SD 3.97 3.60 5.51 5.25 4.92
P-value1 0.094
Gender Male 15 (60.0) 35 (46.7) 59 (57.3) 51 (51.0) 160 (52.8)
Female 10 (40.0) 40 (53.3) 44 (42.7) 49 (49.0) 143 (47.2)
P-value2 0.455
(b) Dosage of the Medicine
Drug Dose count Subgroups Subgroups Subgroups Subgroups Total P-value
Drug Dose count Con-pre Con-post Clin-pre Clin-post Total P-value
Amodiaquine 100mg tablet Incorrect 4 (18.2) 14 (22.2) 25 (29.1) 30 (36.6) 73 (28.9) 0.175
Amodiaquine 100mg tablet Correct 18 (81.8) 49 (77.8) 61 (70.9) 52 (63.4) 180 (71.1) 0.175
Chloroquine 150mg tablet Incorrect 2 (28.6) 1 (50.0) 3 (23.1) 0.545
Chloroquine 150mg tablet Correct 1 (100.0) 3 (100.0) 5 (71.4) 1 (50.0) 10 (76.9) 0.545
Quinine 300 mg tablet Incorrect 1 (100.0) 1 (100.0) 2 (100.0)
Quinine 300 mg tablet Correct
In contrast to the specific directions recall
patient carers in the intervention (clinic) group
showed much improved understanding about the
storage and usage of their medicines as shown in
Table 4 Table 4 Patient Carers responses to
aspects of knowledge about medicines
Group Activity Sub-group N Mean rank P-value
Control groups Store the medicines Con-pre 25 47.40 0.014
Control groups Store the medicines Con-post 75 51.50
Control groups Read label / understand instructions Con-pre 25 56.36 0.153
Control groups Read label / understand instructions Con-post 75 48.55
Control groups Remember to give the medicines Con-pre 25 51.00 0.884
Control groups Remember to give the medicines Con-post 75 50.33
Control groups To give the medicines on time Con-pre 25 49.78 0.836
Control groups To give the medicines on time Con-post 75 50.74
Clinic groups Store the medicines Clin-pre 102 77.48 0.000
Clinic groups Store the medicines Clin-post 100 126.00
Clinic groups Read label/understand instructions Clin-pre 102 69.64 0.000
Clinic groups Read label/understand instructions Clin-post 100 134.00
Clinic groups Remember to give the medicines Clin-pre 102 60.37 0.000
Clinic groups Remember to give the medicines Clin-post 100 143.45
Clinic groups To give the medicines on time Clin-pre 102 60.37 0.000
Clinic groups To give the medicines on time Clin-post 100 143.45
P-value1 from oneway-anova Test P-value2 from
Pearson Chi-Square Test
(c) Frequency of Dosage
Drug Frequency count Subgroups Subgroups Subgroups Subgroups Total P-value
Drug Frequency count Con-pre Con-post Clin-pre Clin-post Total P-value
Amodiaquine 100mg tablet Incorrect 4 (18.2) 15 (23.8) 24 (27.9) 24 (29.3) 67 (26.5) 0.699
Amodiaquine 100mg tablet Correct 18 (81.8) 48 (76.2) 62 (72.1) 58 (70.7) 186 (73.5) 0.699
Chloroquine 150mg tablet Incorrect 2 (28.6) 2 (100.0) 4 (30.8) 0.098
Chloroquine 150mg tablet Correct 1 (100.0) 3 (100.0) 5 (71.4) 9 (69.2) 0.098
Quinine 300 mg tablet Incorrect 1 (100.0) 1 (100.0) 2 (100.0)
Quinine 300 mg tablet Correct
The appropriate drug prescribing (Table 2)
according to the PNG guidelines for malaria (7)
showed no change in either setting over the
course of the study. No intervention occurred in
relation to prescribing. Table 2 Levels of
appropriate prescribing in accordance with the
PNG prescribing guidelines
Count Subgroup Subgroup Total
Count Clin-pre Clin-post
Not appropriate 36 (36.0) 27 (27.8) 63 (32.0)
All aspects appropriate 64 (64.0) 70 (72.2) 134 (68.0)
P-value 0.141
Subgroup Subgroup Total
Con-pre Con-post
14 (58.3) 37 (52.1) 51 (53.7)
10 (41.7) 34 (47.9) 33 (46.3)
0.387
P-value from Fishers Exact Test The not
appropriate category usually occurred from
prescribing additional drugs such as primaquine
and antibiotics which were not according to the
guidelines. It is evident that carers had a
reasonable understanding of their medicines.
(Table 3) Approximately 70 understood the dosing
schedules for antimalarial medication. It is
evident the intervention provided no improvement
in patients ability to describe their
understanding of these requirements.
(d) Duration of Treatment
Drug Days count Subgroups Subgroups Subgroups Subgroups Total P-value
Drug Days count Con-pre Con-post Clin-pre Clin-post Total P-value
Amodiaquine 100mg tablet Incorrect 4 (18.2) 13 (20.6) 24 (27.9) 24 (29.3) 65 (25.7) 0.519
Amodiaquine 100mg tablet Correct 18 (81.8) 50 (79.4) 62 (72.1) 58 (70.7) 188 (74.3)
Chloroquine 150mg tablet Incorrect 2 (28.6) 2 (100.0) 4 (30.8) 0.098
Chloroquine 150mg tablet Correct 1 (100.0) 3 (100.0) 5 (71.4) 9 (69.2) 0.098
Quinine 300 mg tablet Incorrect 1 (100.0) 1 (100.0) 2 (100.0)
Quinine 300 mg tablet Correct
P-Value from Kruskal-Wallis Test
It is evident from the above data that the
education elements of the intervention were
valued when compared with the control group
Follow-up data for patients carers returning
after 7 days to provide information on the
treatment outcome is provided in Table 5. Table
5 Follow up data comparing control pre-post and
clinic pre-post
Discussion The populations enrolled into this
study were homogeneous. This study has shown
that a simple intervention of providing detailed
information on a label regarding exact dosage,
storage and use of medicines together with verbal
reinforcement provided no improvement in patient
reported understanding the basics of medicine
dosage administration. Correct response levels
in all cases were approximately 70 in all pre
and post categories. This may indicate a ceiling
effect or other barriers (e.g. literacy) limiting
improvement of this finding. Additional
underlying information would need to be collected
to provide an understanding of the basis of this
lack of improvement. In both control and clinic
groups the pre-intervention group had a history
of greater numbers of previous prescribed
medications from earlier consultations than the
post intervention period for both groups. This
would indicate both post groups would be less
experienced in medication based upon previous
prescribing. The intervention had a marked
improved influence on patients knowledge relevant
to compliance such as the understanding of
instructions, remembering to give the medications
and giving the medications on time. Overall the
intervention seems to have had a significant
improvement on reported cure rates and therefore
patient outcomes which is a significant community
benefit.
Activity Count Subgroup Subgroup Total P-value
Activity Count Con-pre Con-post
Are they cured No 3 (27.3) 9 (31.0) 12 (30.0) 0.570
Are they cured Yes 8 (72.7) 20 (69.0) 28 (70.0)
Clin-pre Clin-post
Are they cured No 16 (42.1) 3 (7.7) 19 (24.7) 0.000
Are they cured Yes 22 (57.9) 36 (92.3) 58 (75.3)

• References
• www.emro.who.int/ accessed 5th March 2004
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  A, Shires S, Navaratnam V, The effect of drug
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  1) 21-27.
• Denis MB. Improving compliance with quinine
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  Evaluation of health education interventions in
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  Organisation 1998 79 (suppl 1) 43-49.
• Okonkwo PO, Akpala Co, Okafor HU, Mbah AU, Nwaiwo
  O. Compliance to correct dose of chloroquine in
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P-value from Fishers Exact Test
As expected the response rate was not high
(approximately 40) as it required the patient
carer to report back. There does seem to be
sufficient evidence in the clinic-post
(post-intervention) group to indicate the overall
simple intervention had a significant effect on
the numbers cured.
Conclusions and Recommendations This study has
demonstrated that a targetted intervention has
shown significant improvements in aspects of
patients understanding of medicines in relation
to compliance. It has demonstrated no impact on
the understanding of the basic issues of medicine
administration. A significant improvement
occurred in patient outcomes. The study found
that less than 75 of patients received treatment
in accordance with the guidelines. Improved
packaging and labelling of medications and
procedures to be followed when a dose was vomited
should be incorporated into routine patient carer
information. The provision of liquid medications
rather than the crushing of tablets should be
trialled in children who have difficulties with
medication administration.