Access to and provider knowledge and practices on artemisinin-based combination therapy and quinine in drug outlets and their use in households in malaria endemic areas of western Kenya

Abstract

Artemisinin-based Combination Therapy (ACT) was adopted as the most effective treatment option against malaria in Kenya. Artemether-Lumefantrine (AL) is the first-line ACT drug for treatment of uncomplicated malaria, while quinine is preferred for complicated and severe malaria. Information on access and knowledge and practices of providers prior to or during implementation of ACT and quinine is scanty. Moreover, the evaluation of how these factors influence the use of these drugs in households is rare. The results could be used as a guideline to step-up the activities to enhance malaria treatment and as a key bench-mark to evaluate the success of the implementation of the malaria treatment policy in Kenya and further evaluate the role of policy implementation in malaria burden in the study region. The study adopted World Health Organization (WHO) and Health Action International (HAl) standardized methodologies to evaluate access and provider knowledge and practices and use of these drugs. A cross-sectional survey using three-stage sampling was conducted in two Plasmodium falciparum endemic regions. Based on WHO and HAl methodologies, two main health facilities were selected. This was followed by additional selected of five district hospitals under each main facility and eight other facilities (health centres and dispensaries) under each district hospitals to give a total of 96 outlets (including 4% non-response). A matching number of private outlets were randomly selected. In addition, all (66) not-forprofit outlets and additional 30 public facilities within the study area were sampled to get the required sample size of 288. For every outlet targeted, one household was surveyed to give a total of 288 households. Results revealed that most private outlets, 27 (40.5%) did not stock the first-line anti-malarial. Quinine was the most available in private 45 (68.8%). AL was 1.88 times more expensive in private outlets relative to the government recommended price. Private sector had 50 (52.1%) who failed to state the correct anti-malarial for complicated and severe malaria. Only 15 (15.6%) of providers in private outlets had been trained on the use of ACT for malaria treatment. Those trained were 2-3 times more likely to provide the correct treatment regimen for uncomplicated (OR, 2.01; CI, 1.66-3.83; P=0.039) and severe malaria in children (OR, 2.66; CI; 1.88-5.44; P<O.OOOI) and in adults (OR, 2.01; CI, 1.88- 4.25 P=0.002). Those who had gone through in-service training among the private providers were almost 4 times unlikely to sell partial packs of ACT (OR, 3.79; CI, 2.77-11.2; P<O.OOOl), were 3 times likely to request for written prescription (OR, 3.00; CI, 2.45-10.4; P=O.OOl) Anti-malarial price (OR, 2.88; CI, 1.99-4.31; P<O.OOOl), affordability (OR, 3.01; CI, 2.45-5.01; P=0.005) and knowledge of dosing regimen (OR, 2.67; CI, 2.02-4.33; P<O.OOOl), sale of partial packs (OR, 2.78; CI, 2.22-4.45; P<O.OOOI) and advice given by providers (OR, 1.24; CI, 1.10-2.67; P=0.004) were several folds likely to influence antimalaria use in households. There is low accessibility to policy recommended anti-malarials (ACTs and quinine) in outlets. The government should ensure continuous availability of recommended drugs to the consumers in right package sizes, and at affordable prices in all outlet types and train stakeholders on new policies. It is essential to educate the consumers on the need to adhere to the correct treatment regimen and ensure that changes in treatment guidelines are accompanied by subsequent implementation activities involving all health sector players