Factors affecting adherence to chloroquine prophylaxis for malaria among children with sickle cell anaemia in Mulago hospital

Abstract

INTRODUCTION: Sickle cell anemia (SCA) is one of the most common inherited hemoglobinopathies in the tropics. Children with sickle cell anemia are at increased risk of morbidity and mortality from malaria, and are therefore put on malarial prophylaxis for life. WHO and the Cochrane review recommend the use of prophylaxis in the prevention of malaria attacks in SCA, and this has been found to significantly reduce the morbidity from malaria in sickle cell anaemia. Weekly chloroquine is currently recommended for use as malarial prophylaxis in the mulago sickle cell clinic. It is known that medication non- adherence in the treatment of chronic diseases. Compromises the effectiveness of therapy. There is limited published data regarding adherence to chloroquine chemoprophylaxis in children with sickle cell anaemia. OBJECTVES: To determine the levels of adherence to chloroquine prophylaxis and factors affecting adherence to chloroquine prophylaxis for malaria among children with SCA attending the Mulago Sickle cell clinic (MSCC). STUDY DESIGN: A Cross-sectional study was used to collect both quantitative and qualitative data using a questionnaire and focus group discussions guide respectively. METHODS: A total of 200 children with SCA aged between 1 to 12 years on chloroquine prophylaxis attending the MSCC were enrolled after obtaining informed conscent, and all these were assessed for adherence by self-report. Atotal of 173 children of these had their plasma analyzed for chloroquine drug levels. Adherence was defined as taking 100% of the chloroquine doses over a 4 week period. This was assessed using a self-report, and validated using drug levels. Child, caregiver, drug and health unit factors affecting adherence to chloroquine prophylaxis were assessed using structured questionnaire and focus group discussions. RESULTS: 200 children were assessed for adherence to chloroquine prophylaxis using self-report, and this was found to be 34%. Factors that enhanced adherence to chloroquine prophylaxis were a caregiver who had a set day for giving chloroquine (OR 3.7, P=0.004) and a well counselled caregiver (OR 2.9, p=0.04). Those associated with non-adherence were children being more sick as a consequence of not taking chloroquine prophylaxis (OR 0.2, P=0.004), well child (OR 0.2, P=0.011) as well as having no drugs (OR 0.2, P=0.005). Factors independently associated with not taking chloroquine were use of analgesics (OR 0.34, P=0.033), a child who was away from home (OR 0.2, P=0.069), a child who was well (or 0.3, p=0.012), and side effect of pruritis (OR 0.3, P=0.017). Forgetfulness, unavailability of chloroquine and fear of side effects were the reasons given in the focus group discussions for poor adherence.

CONCLUSIONS: The level of adherence to prophylactic chloroquine in the Mulago Sickle cell clinic was low (34%). Only half of the 34% who said they were adherent had adequate drug levels. Child and caregiver factors were significant determinants of adherence. RECOMMENDATIONS: Counseling of caregivers and children should be priotized to improve adherence to chloroquine prophylaxis.