East African Journal of Public Health East African Public Health Association ISSN: 0856-8960 Vol. 3, Num. 1, 2006, pp. 12-16

East African Journal of Public Heath, Vol. 3, No. 1, April 2006, pp. 12-16

CLIENTS’ PERCEPTIONS ON SULFADOXINE – PYRIMETHAMINE (SP) USE AS THE 1^ST LINE DRUG AND ALTERNATIVE DRUGS FOR THE TREATMENT OF UNCOMPLICATED MALARIA IN KIBAHA DISTRICT, TANZANIA

¹D.S.Tarimo and  ²W.B. Manyilizu

Correspondence to:  Tarimo, D.S, P.O.Box 65217, Muhimbili University of Health Sciences, Dar es Salaam, Tanzania.

¹Department of  Parasitology/Entomology,  ² St. Franscis Hospital, Ifakara, Morogoro

Code Number: lp06003

Abstract

Objective: To assess clients’ perceptions on Sulfadoxine / Sulfalene – Pyrimethamine (SP) use as the 1^st line drug and perceived alternative drugs for the treatment of uncomplicated malaria.
Methods: Health facilities cross-sectional survey of 365 caregivers of underfives with fever was conducted in a malaria holoendemic area. Using semi-structured questionnaires, caregivers were interviewed to explore their perceptions on efficacy & safety of SP for the management of childhood malaria and the perceived alternative drugs to SP. 
Results: Clients held the notion that childhood febrile episodes had gone down after the policy change; however, SP could fail to treat febrile episodes because of wrong diagnosis (not malaria) or ineffectiveness. There was the misconception that “SP” in the different names such as Fansidar (Sulfadoxie-Pyrimethamine) and Metakelfin (Sulfalene-Pyrimethamine) are different drugs inducing half of clients to perceive that Fansidar or Metakelfin should be used in case of “SP” failure.  Fansidar was considered to have more side effects, mainly cutaneous reactions; raising concerns as clients associated the side effects with HIV / AIDS. Adherence to SP was inconsistent, as some clients preferred Quinine.
Conclusions: The notion that “Fansidar” and “Metakelfin” are different from SP and could be used in case of “SP” failure indicates the need for using chemical rather than trade names in prescribing antimalarial drugs. The success of a new antimalarial policy requires a countrywide monitoring and reporting side effects and a mechanism for allaying fears is put in place. Continuing education to health workers and clients is necessary for consistent adherence to a new policy.

Key words: Malaria control, sulfadoxine-pyrimethamine (SP), clients’ perceptions, Tanzania

Introduction

The increasing underfives mortality in sub-Saharan Africa attributed to high resistance of Plasmodium falciparum to chloroquine (1) has prompted the Southeast African countries of Kenya, Malawi, Botswana, Zambia and South Africa to change policy from chloroquine to the fixed combination of Sulfadoxine / Sulfalene with Pyrimethamine (SP) as 1^st line treatment (2). Tanzania made a similar policy change from CQ to SP in August 2001 as the efficacy of CQ had gone down to an average of 58.0% adequate clinical responses (range: 28.0% to 72.0%) with a failure rate > 25.0% above the upper threshold for replacement (3).

Chloroquine (CQ) was in use for over four decades being the most common drug used in self-medication for malaria as it was available over the counter (4). Before policy change in Tanzania, CQ was available in different proprietary names in all retail shops as oral formulations, and was the only antimalarial stocked in the essential drugs kits distributed to rural health centres and dispensaries. SP was restricted to 2^nd levels of care, but also available in drug shops and pharmacies and was generally less known in the rural areas that might conceivably serve as a potential barrier to the acceptance of SP as the replacement of CQ. While CQ dosage is spaced over three days, SP is given as a single dose, which might make SP to be perceived as either not strong enough or too strong. This might make clients to press health workers for alternative drugs such as quinine (reserved for severe malaria), sort to non-official sources of treatment or manage more severe illnesses at home consequently delaying to get effective therapy.

SP lacks the bitter taste and the injectable formulation is not common, characteristics equated with efficacy (4,5,6). Before the policy change in Tanzania, available data showed that SP was judged by clients to be a stronger drug that should have been a 3^rd line drug, and was particularly too strong for use in children (7). Thus although SP was the 2^nd line drug and quinine (QN) 3^rd line drug, QN was commonly used as a 2^nd line drug instead of SP. The notion that SP is slow in action, conceivably due to the absence of antipyretic effects (8) is another barrier for its acceptance. The other barrier concerns the severe that commonly occur in the background of HIV/AIDS (9) raising the fear on the acceptance and wider use of SP as a 1^st line drug in areas endemic for both malaria and HIV/AIDS.

A successful policy change requires an understanding of the perceptions of individuals, families and communities regarding the drug to replace a previously commonly known drug such as CQ. The socio-cultural and psychological risks perceived in adoption of SP as the replacement of CQ must be taken into consideration (10) in particular focusing on the potential barriers to its acceptance for the wider use as a 1^st line drug. This study aimed to generate, from a client perspective, information on the perceived efficacy and safety of SP as the 1^st line drug in comparison to CQ and therefore adherence to the new policy; and the perceived alternative drugs to SP. The study addressed the following questions: Are clients aware of the change of malaria treatment policy? Given the new policy, what are the current practices regarding management of childhood fevers at home and health facilities? What are the clients’ perceptions regarding the previous policy for chloroquine versus the new policy for SP in the management of uncomplicated malaria? What are the available alternative treatment options for malaria? What are the perceived alternative treatment options to chloroquine and SP? This information will highlight on the actual and potential barriers to the implementation of a new policy and should be addressed in the awareness and sensitization campaigns (11).

Methodology

Study area

The study was carried out in the holoendemic Kibaha district, coastal Tanzania, where febrile illnesses represent the commonest childhood health problem (12). The integrated management of childhood illnesses (IMCI) strategy is actively being implemented in the region through training of health workers on the guidelines for the management of the common childhood febrile illnesses. This is accompanied with the provision of information, education and communication to families and communities to improve their practices regarding early case management of childhood illnesses, appropriate care seeking and compliance with treatment. Malaria transmission is perennial but with peak transmission during or soon after rains i.e March to July, and October to December. The district has one public hospital, two public health centres and 18 public & 12 private dispensaries

Study population and sample size

A health facilities based survey was carried out on parents / guardians accompanying underfives to the respective health facilities on account of fever (hot body). The sample size was estimated for a cross sectional survey: assuming 61.2% of parents / guardians would have given an antimalarial drug to children aged £ 5 years during febrile episodes (12), with a standard normal deviate (Z) of 1.96 and degree of accuracy 0.05 a minimum sample of 365 clients was obtained. We studied 375 clients randomly sampled by taking every third consenting client from four 1^st level health facilities selected for convenience.

Clients’ interviews

At the respective health facilities, consecutive parents / guardians were interviewed using semi-structured questionnaires administered by a nurse or clinical officer. For each client, information was obtained on the socio-demographic profile and the presenting complaints for the child. To get an impression on the magnitude of childhood fevers, respondents were asked to mention the frequency of fever episodes in the preceding three months and the treatment given. To validate this information, clients were asked to mention the antimalarial drugs they knew spontaneously and by probing. Then they were asked to mention the formulation of antimalarial drugs they prefer most for children.

To assess perceptions on efficacy and safety of SP for the treatment of childhood malaria, clients were asked to mention spontaneously and by probing what they thought would be the reasons for not getting better when children with fever were treated with antimalarial drugs mentioned. To validate this information, respondents were further asked as to whether they thought specifically SP could fail or has ever failed to treat fever (homa) in children, and if so to mention the alternative drugs they would prefer to use or have used in such cases. This was supplemented with in-depth interviews of randomly selected clients so as to get more insight to general perceptions and knowledge on the efficacy and safety of SP for the treatment of childhood malaria.

The questionnaire included the key questions: Which medicines do you normally give to a child with fever? When you give a child medicine for fever how do you assess whether the child is getting better or not? If in your opinion the child is not getting better, what do you think might be the reasons? Are you aware that CQ has been replaced with SP as the 1^st line drug? With reference to SP, do children with fever always get better when given SP? What are your opinions regarding the effectiveness of SP in comparison to CQ? Has it ever happened that your child had fever and was given SP but did not get better? In your opinion, if this child with fever takes SP and does not get better, which other medicines would you prefer to use?Which formulation of SP do you normally prefer to give a child with fever? 

To assess the frequency of SP side effects clients were asked as to whether they have had any problems after SP use or heard persons who got problems after SP use and the type of problems experienced?  The questions were translated into Swahili and back to English with the assistance of a Sociologist and pre-tested in the study population.    

Ethical considerations

The Muhimbili University College of Health Sciences (MUCHS) ethical committee cleared the study; permission to carry out the study was sought from the district local authority. The purpose of the study was clearly explained and informed verbal consent obtained from the interviewees.

Data Analysis

On each day, the data were cleaned and validated so as to ensure consistency. At the end of the fieldwork, the open-ended questions were coded and the data were entered into the SPSS version 10.1 statistical package. Explorative analysis was carried out to assess clients’ awareness and perceptions on SP use as the 1^st line drug. Proportions and associations were assessed by the Chi-squared test provided in the EPI table calculator. Signifi9cance was set at the 0.05 level.

Results

A total of 375 parents/guardians were interviewed, 92.3% being mothers. The median age was 27 years (range: 15 – 55 years). About two-thirds (65.1%) of clients had primary level of education (standard I – VII), 22.9% had no formal education and 12.0% had secondary (form I – IV) education or higher school education. Majority (84.0%) of the clients was aware of the change of malaria treatment policy from CQ to SP; and about three quarters (73.7%) were knowledgeable that drug ineffectiveness (resistance) was the main reason for policy change.

The age group and level of education were not associated with awareness of the new malaria treatment policy. Generally clients perceived that the incidence of fever episodes has gone down after the policy change.

Fever (hot body) alone was the commonest symptom of childhood illnesses that contributed 63.7% followed by a combination of fever with respiratory symptoms (cough and difficult in breathing) that contributed 15.5% (Table 1). Majority of the clients (85.1%) would normally give antipyretic drugs (paracetamol/acetylsalicylic acid) as home treatment when they had a child suspected to have malarial fever before further action; only a very small percentage (1.1%) of the clients would give SP with or without paracetamol as the initial home treatment before the next decision. Less than a half of the clients (44.6%) would go to health facility immediately after home treatment, while 54.5 % would wait and see the progress of the illness before they take next action; only a very small percentage (0.9%) would go to a traditional healer after home treatment. Level of education was not associated with the next action taken after home treatment (p-value >0.05)

Table 1: Distribution  of common presentation of childhood illnesses (N = 375).

The commonest antimalarial drug received at health facilities was SP that was received by 64.3% of clients, 13.6% quinine; while only 9.6% and 0.8% of the clients received amodiaquine and chloroquine respectively (Table 2). More than half of the clients (61.5%) prefer SP as the antimalarial drug of choice; while 19.1% prefer quinine, 3.2% prefer amodiaquine, 1.9% chloroquine (Table 3).  More than three quarters (84.4%) of SP users were satisfied with fever response to SP in that temperature goes down, the child becomes active with increased food and fluids intake; only a small percentage (7.9%) was not satisfied. 

Table 2: Antimalarial drugs prescribed and received at health facility (N = 375).

Table 3: Antimalarial drug commonly preferred by clients (N = 252).

More than a quarter (32.8%) of the clients held the perception that the lack of response of malarial fever to antimalarial drug was attributed to drug ineffectiveness (resistance); while 37.6% were either not sure or didn’t know the cause and 25.6% thought the prescribed antimalarial drug was not proper for the diagnosis meaning probably the illness might not be malaria or might be another illness in addition to malaria (Table 4). The most preferred SP formulations were tablets (33.9%) and syrups (30.1%) (Table 5). About half of the clients [61/135 (54.5 %)] preferred SP syrup because it is to administer; while [28/135 (25.0%)] thought the syrup acts faster and is more effective

Table 4: Clients’ perceived reasons of lack of response to antimalarial drugs (N = 375)

Table 5: SP formulations preferred by clients  (N = 375).

Only a small percentage (14.9%) of the clients was aware that SP, Fansidar and Metakelfin are similar drugs with different proprietary names. Majority of the clients (85.1%) held the notion that SP, Fansidar and Metakelfin are different drugs that have different efficacy and rate of side effects. This corroborated with the findings from in-depth interviews that showed that clients use SP in the different proprietary names as different drugs, thus one client stated, “I used Fansidar first, I did not get better until I used SP”. Thus clients perceived Fansidar as having the highest rate of side effects (64.0%), followed by Metakelfin (20.4%) and SP (15.6%). The commonly reported side effects due to SP were: severe headaches (46.7%), severe vomiting (26.7%) and skin-mucous membranes reactions (20.0%).

More than half of the clients (65.3%) held the perception that SP gives a good response, only a small percentage (11.5%) perceived that SP gives no good response; about a quarter (23.2%) were undecided. This corroborated with the findings from in-depth interviews, which showed a similar picture as some respondents stated that “not always when one takes SP will get better” and that “SP will subsequently fail to treat malaria just as CQ failed”. One respondent remarked that “SP has a doubtful response; is not fully effective and normally response is very slow hence it takes long to get better, sometimes you don’t get better at all.” Paradoxically about half of the clients (48.6%) held the perception that “Fansidar” or “Metakelfin” should be the alternative treatment option to SP failure while about a quarter (30.3%) held the perception that quinine should be the alternative option to SP failure (Table 6).

Table 6: Perceived alternative treatment options to SP failure (N = 346)

Discussion

This study investigated clients’ awareness on the new malaria treatment policy, perceptions & practices regarding malaria treatment in children two years after the policy change from CQ to SP. Majority of the clients (84.0%) were aware of the new policy indicating that public health education about the policy change had been very well received. Despite the public outcry that SP was not the appropriate replacement for CQ, it is generally perceived that the incidence of fever episodes has gone down after the introduction of SP as the 1^st line drug; and there was the conviction that the response of childhood malaria treatment with SP was good.

The malaria treatment policy emphasizes on the need for mothers and caregivers to recognize the symptoms of malaria while at home so that treatment can be started early enough to prevent the progression of otherwise mild illness to severe illness (11). In this study, fever alone or in combination with other symptoms was mentioned at a frequency of (88.5%) as the most important symptom of malaria. This indicates that mothers / caregivers are aware of the commonest symptoms of childhood malaria with the potential to properly manage childhood fevers. Thus majority (85.1%) of the mothers / caregivers would give appropriate home remedy as soon as they recognize a child is febrile, and would subsequently take the appropriate action as previously shown (12). However, only a minority of clients would give SP at home as it is not available over the counter. For effective home based management of childhood fevers, any 1^st line antimalarial drug must be available at home so that it can be given as soon as the child is febrile (11).

At health facilities, SP was readily available; and more than half (64.3%) of the clients received SP in accordance to the national policy. However, since some prescribers prefer quinine (7), a 13.6% of the clients received quinine indicating some inconsistencies in adherence to the new policy hence the need for continuing education to health workers to enforce adherence to national policies. From the clients perspective, SP seemed to be still effective as more than three quarters of the clients were satisfied with SP treatment outcome in terms of fever going down, the child becoming active with increased food and fluid intake; parameters equated with efficacy (12).

Generally clients were aware that lack of response to antimalarial treatment including SP could be attributed to drug resistance or incorrect diagnosis as previously shown (7). This has important implications for malaria control and the strategy for the integrated management of childhood illness (IMCI) in holoendemic areas as the syndromic overlap of malaria with other childhood illnesses requires the administration of an antimalarial drug for any febrile illness. Available data show that close to 50.0% of febrile children have no malaria (4) implying that when given an antimalarial drug they will not improve and this might make clients loose trust to malaria control services. When CQ was in use, there was the advantage that it has properties of lowering fever and pain due to its antipyretic and anti-inflammatory properties that are lacking in SP (8). Thus patients with self-limiting viral syndromes which present with fever alone or in combination with respiratory & gastrointestinal symptoms (as shown in this study) would get symptomatic relief with CQ but not with SP clearly making SP less preferable.      

The study shows that there is the general misconception that SP in the different proprietary names such as SP per se, Fansidar and Metakelfin are different drugs with different efficacy and rates of side effects. Clearly this has negative implications for the successes of the new policy as all the prescription are labeled “SP” but in the market you also find Fansidar & Metakelfin. This might make clients to demand for other drugs such as quinine, which should normally be reserved for severe malaria.

There is the potential for clients to use SP in different proprietary names twice a week because of slow response to treatment as stated by one client, “I used Fansidar first, I did not get better until I used SP in the same week”. This misconception is further escalated as close to half (48.6%) of the clients held the perception that the alternative treatment option to SP failure is Fansidar or Metakelfin.  Public health education was therefore essential so as to reverse the misconception on the proprietary names.

Generally clients were aware of the potential mild cutaneous and severe muco cutaneous reactions that are due to the sulfonamide content (Sulfadoxine or Sulfalene) of SP (13). Though rare, the severe muco-cutaneous reaction (Stevens Johnson syndrome) is life-threatening especiallyin the background of HIV/AIDS (9); and this raises concerns on the acceptance and wider use of SP as a 1^st line drug in areas endemic for malaria & HIV/AIDS.It is therefore important for health workers to elicit any history of drug reactions before prescribing SP in view of the public outcry regarding skin reaction (Stevens Johnson syndrome) due to SP. However, severe skin reactions due to SP use are more commonly associated with prophylactic than therapeutic use, the risk being 40 times higher in prophylactic than single therapeutic doses (14). Although the risk of severe cutaneous reaction is low in developing countries (11), widespread self-medication with SP in the long run may conceivably mimic prophylactic use thus leading to an increased risk to severe cutaneous reactions.  Although headaches featured as an important side effect of SP, this is most probably due to the lack of antipyretic & anti-inflammatory properties in SP that makes malaria symptoms including headache to persist (13,15).

Conclusions and recommendations

The notion that “Fansidar” and “Metakelfin” are different from SP and could be used in case of “SP” failure indicates the need for using chemical rather than trade names in prescribing antimalarial drugs. The success of a new antimalarial policy requires a countrywide monitoring and reporting side effects and a mechanism for allaying fears is put in place. Continuing education to health workers and clients is necessary for consistent adherence to a new policy.

Acknowledgements

This work recieved financial support from the Ministry of Health, Tanzania in colaboration with the World Bank. Thanks are due to the care givers attending to the respective health facilities in Kibaha for their time and cooperation in this work. We thank the regional and district authorities in Coast Region and Kibaha respectively for giving us the permission to carry out this work. Special thanks go the staff of the health facilities in Kibaha for facilitating this work.

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