This study determined the factors influencing patients’ adherence to malaria ACT treatment. Final analysis on adherence in this study was measured by tablet counting and patient recall, particularly with dosing and timing. Patients’ adherence to ACT treatment was just above average at 69.7%. The current study’s finding is consistent with a Kenyan study seeking services from public health facilities [42]. However, it contradicts those reporting ACT low adherence below 50% [18, 20, 22, 34] and those reporting high adherence above 80% [17, 19, 21, 33]. The variations in the current study finding versus other studies might be due to varied methodologies employed per study [33, 34]. In addition, the previous studies were conducted during the era of chloroquine and primaquine as drugs in the management of malaria. We further take note of the fact that in the Ugandan study in which an integrated approach was used, the high adherence to ACT could have been masked by the effect of poly-pharmacy [17]. Additional findings in the current study shows that the contribution of drug stock out and failure for patients to buy drugs was linked to the adherence to ACT. The current study also demonstrated age to be statistically associated with patients’ adherence to ACT. In addition, adherence was further shown to be higher among the youngest age which was consistent with a Ghanian study [27]. However, the current findings contradict the findings in previous studies [16, 18–20]. These differences in the current versus previous studies could be due to extra care parents/ caregivers give when attending to the young patients in the current study population, which then enhances adherence levels in this category. However, the adults themselves are always trapped with other engagements and forgetfulness without anyone reminding them, thus leading to low adherences. The study also revealed that household head had a statistical association with patients’ adherence to ACT., and those with a household head were 2.817 times more likely to adhere to ACT prescriptions than those without a household head. This finding shows the role of figure-head in a family in an African setting when it comes to accessing, utilization, and decision making in regards to healthcare services. The study revealed that relationship to household head, gender, marital status, and household size were not statistically associated with patients’ adherence to ACT. We hypothesized that these factors were not associated with adherence to ACT since there is no discrimination among family members based on above constructs in traditional African settings and every member of the family is treated with due respect especially when it comes to health-seeking behaviour to malaria. Thus, the figurehead ensures the health of the family members at all times.
There was also a significant association of patients’ employment status with ACT adherence, with those employed formally 1.402 times more likely to adhere than those not employed at all. This is in line with studies which have shown that families spend a lot in accessing healthcare services [43, 44]. Therefore, only those who are engaged in some income generating activity can have access to money to spend on their healthcare, more so, in times of scarcity of drugs at these public facilities. Other observation was that patients’ preference of ACT to other antimalarials had a statistical significance with adherence. This contradicts a Kenyan study that showed a statistical association between patient’s dislike of ACT and adherence [14]. The behaviour could be attributed to the perceived knowledge about the efficacy of the drug. The study also revealed that source of health information, education level, monthly income, household means of transport to health facility, perceived preference of drug formulation, and nature of family house were not statistically associated with patients’ adherence to ACT. The current study finding contradicts other studies which found a statistical association between education and patient adherence to ACT [14, 30, 45]. Moreover, an Ethiopian study had shown earlier that illiteracy is a major hindering factor of patient adherence to ACT [29]. It is believed that proper education empowers and enables one to make informed decisions and discern between what is wrong and right about one’s health. Therefore, there is need to study the value of a tailored community education on malaria and use of ACT to provide evidence on what really works. The current study findings are consistent with another Ugandan study by Niringiye and Douglason showing no association between income and patients’ adherence to ACT [46]. This could be due to poor health-seeking and utilization behaviours of the society. However, further studies are needed to explore this trend.
There was also significant association of giving a patient/ caregiver instruction on how to take the medication with adherence. This is in line with a study that showed that giving clear instructions to patients and caregivers on how to correctly take the medicines is key in their adherence to treatment [37]. More so, Kalyango and others noted that failure to understand instructions results in non-adherence [17]. Clear instructions can improve knowledge and demystify several factors and improve adherence to medication. The more the patient has correct information about the treatment, the better the adherence to the guidelines provided hence adherence to treatment.
We also observed a significant relation between being satisfied with getting ACT at facility and adherence, and those who got ACT at facilities were 3.063 times more likely to adhere to ACT prescriptions than those who didn’t get. It has been noted that public health facilities experience stock-outs of ACT and diagnostic services for malaria [47], and ACTs are costly at private market [48], hence those who get it for free are always satisfied with the service and hence can improve their adherence to treatment. In addition, there was a significant association between patients who had history of saving ACT medicines and adherence, and those who had history of saving ACT were 4.088 times more likely to adhere to ACT prescriptions. This could be explained by the frequent stock-out of ACTs [47] and heightened demand [24, 25] at the public facilities and thus it is expected that patients would prefer to save for future use and feeling better before dosage completion. It’s further hypothesized that community members tend to seek services and forge sickness to obtain drugs at public facilities with hope of using them during times of scarcity. However, this was beyond the scope of this study and needs to be explored more.
The study also revealed a statistical association between patients who shared ACT medicines and adherence, and those who shared were 2.134 times more likely to adhere. As revealed in this study, those who shared medicine did so due to excessive cost of the drug and could share with a sick family member. Though the current study shows its power to increase their adherence to ACT prescription, it could easily downplay and expose them to suboptimal doses with its consequences [11, 12]. Further, the behaviour of using drugs without prior testing during this era of test and treat [39] is very dangerous and counterproductive to government efforts of fighting this old enemy. The study further showed that religion, satisfaction with waiting time to get services, taking herbal medicines together with ACT, taking first dose of ACT at facility under observation of qualified professional, patient being seen by qualified personnel, use of ACT package as a visual aid for instructions, patient knowledge of right dosage, history of fever and type of malaria diagnostic technique did not have a statistical association with patients’ adherence to ACT prescriptions. As in a study by Afaya and others [22, 49], Christians dominated the study and healthcare workers should operate in harmony with clients and relatives in decision making by seeking their opinions and beliefs to avoid conflict with their underlying religious ethos. Unlike in a Kenyan study [14], waiting time did not contribute significantly to patient adherence. The difference could be in the time measurements employed and the use of RDTs which are more rapid and fast [50] in the current study. Also on the use of herbal or co-current taking of herbal medicine, the current study did not establish a similar trend as in Yakasai and others study [37] where patients preferred to use of herbals due to high costs involved in disease management at health facilities. This could be due to some ongoing health education talks and sensitization in this community. Knowledge of right dosage of ACT was not associated with patients’ adherence in the current study, contrary to previous studies [14, 30, 45, 51]. This could be due to differences in the study areas and designs employed. The current study revealed that the vast knowledge of benefits arising out of good adherence to treatment does not really result in improved adherence to ACT prescriptions. Therefore, knowledge alone is not enough to improve one’s adherence. Other factors like availability of drugs (Tables 3 and 4) play a role in influencing patients’ adherence to ACT prescriptions. The use of ACT package as a visual aid for instructions was just average despite its power to enhance one’s adherence through boost of memory. Similar findings were posited in another Ugandan study [35], however, a Malawian study showed statistical association [32]. This could have affected the adherence of patients in this study. It has also been revealed [35], just like in in the current study that history of fever and quick recovery from symptoms results in non-adherence of patients. Taking of first dose at facilities was very low and not statistically associated with patients’ adherence unlike in a Malawian study [32]. This is majorly attributed to lack of safe drinking water supplies at facilities/ dispensing points. Further, there is no strict law requiring malaria directly observed treatment. Further still, the study revealed that patients are more concerned with receiving a service in-terms of consultation, diagnosis and drug(s) and not knowing which healthcare worker offered it. This is compounded by many public health workers wearing uniforms without proper identification, for example name and cadre.
Non-adherence to ACT in this study has been attributed to several factors such as lack of money to buy medicines, delay in buying the medicines in line with previous studies [13, 14], feeling better and stopping to take medicine [15, 16], forgetfulness, vomiting of drugs, [17]. Patients’ visiting public facilities expect to find all medicines at all times and failure to get them results in delays in making decisions to buy and sometimes fail to buy as they expect them for free and sometimes lack money. Therefore, MoH should avail sufficient medicines including antimalarials to all public facilities. Other factors were saving for future use, loss of drugs, sharing of drugs, unpleasant smell of drugs, taking of herbs instead of ACT, all of which are modifiable by tailored education. During the study time, some facilities were experiencing ACT stock-out. As National warehouse was preparing to deliver, the community remained generally poor, and ACT is expensive on the open market. Further, the current study shows that non-adherence is a recipe for poor disease prognosis and development of severe disease, lack of complete cure, death, disease recurrence, drug resistance and more disease spread as has been noted in other studies [12, 52]. To avert the current situation and to reap the full benefits of proper adherence, patients’ education on proper usage of ACT in-terms of dosage and timing, its health benefits and related adverse events should aggressively be conducted by professionals as previously noted [53], and we believe that this would improve their overall adherence to prescription and health.
Limitations
The study was conducted only in public health facilities, which then limits generalizability to only public facilities. Secondly, it was conducted in one district with high malaria transmission, which in essence might not apply in other districts with less malaria transmissions. Finally, HC IIs were not studied due to lack of laboratories. This limits generalization at all levels of healthcare system continuum.