Academic journal article Bulletin of the World Health Organization

The Effect of Drug Packaging on Patients' Compliance with Treatment for Plasmodium Vivax Malaria in China

Academic journal article Bulletin of the World Health Organization

The Effect of Drug Packaging on Patients' Compliance with Treatment for Plasmodium Vivax Malaria in China

Article excerpt


Hunan Province in south-central China comprises 14 prefectures and 125 counties with a population of 64 million. Since the start of the malaria control programme in this province in the 1950s, there have been three Plasmodium vivax malaria outbreaks with annual incidences of 1560 per 100 000 in 1955, 1690 per 100 000 in 1962, and 1323 per 100 000 in 1971. Despite a comprehensive malaria control programme, the incidence since 1986 has risen and, for counties in the south and south-west of the province, is five times higher than the provincial average.

Chloroquine and primaquine are produced in China for the treatment of P. vivax malaria, and are generally dispensed by health workers from 1000-tablet bottles or tins. The current treatment regimen for adults is 4 chloroquine tablets (each containing 0.25 mg chloroquine phosphate) on day 1, 3 tablets on days 2 and 3, and 3 tablets of 13.2 mg primaquine daily from day 1 to 8. The curative dosage of each drug is dispensed by a health worker or pharmacist from the container in a paper envelope or small paper bag, and given to the patient without any identification of the drugs or written directions on their use. The doctor's or health worker's oral instructions to the patient on the number of tablets to be taken and for how many days are brief and do not include any advice or health education. Treatment is often incomplete due to its discontinuation once the symptoms have disappeared, or to disintegration or loss of the tablets. Sometimes patients take an excessive dose so as not to risk loss of the drug, and can experience unpleasant side-effects.

Over 20 years ago, compliance was assured by delivering drugs on a daily basis to patients with direct observation of therapy. While clearly effective, this was unsustainable owing to the need for large numbers of health workers. To improve compliance and use of antimalarial drugs, a pilot intervention study was undertaken to determine the effects of new packaging of drugs and written instructions on compliance.

The specific objectives of the study were as follows:

-- To compare the compliance of patients in completing a full course of antimalarial treatment; a control group received medication in paper envelopes and a second group were given the improved packaging with simple, written instructions on their use.

-- To determine the possible reasons for noncompliance in both groups and whether they were related to the type of packaging and instructions on use.

-- To evaluate the impact of the new packaging and of providing simple, written instructions with the medication.

-- To determine the difference between reported compliance (Phase-I study, based on only patients' reports) and true compliance (Phase-II study, including use of a pharmacological marker inserted with each antimalarial tablet).

Materials and methods

Blister packs. The tablets of chloroquine and primaquine for the study were provided in two packs, one for chloroquine (with daily doses separated for three consecutive days) and the second for primaquine (with daily doses of 3 tablets for a total of 8 days). The number 8, according to Chinese beliefs, brings good luck and it was considered that a course of primaquine over 8 days would enhance compliance more than one for 14 days. Detailed oral instructions were given to the patients on the correct dosage and the need to complete the treatment.

The new blister pack was hermetically sealed, separately for each day's supply of tablets, with the name of the drug on the back of the pack. The blister packs were inserted into boxes, with the drug name on the front and dosage directions and precautions on the back; clear instructions were given on a leaflet inside the box. Each pack measured 8 x 5.5 cm and contained 10 tablets of chloroquine for use over 3 days, or 24 tablets of primaquine for 8 days.

Study sites. …

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