title: Perceptions and utilization of the anti-malarials artemether-lumefantrine and dihydroartemisinin-piperaquine in young children in the Chikhwawa District of Malawi: a mixed methods study.
abstract: BACKGROUND
  Adherence to anti-malarial dosing schedules is essential to ensure effective treatment. Measuring adherence is challenging due to recall issues and the participants' awareness of the desired behaviour influencing their actions or responses. This study used qualitative methods, which allow for rapport building, to explore issues around anti-malarial utilization in young children, and used the results to guide the development of a context specific questionnaire on perceptions and adherence to artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DHA-PPQ).
  
  
  METHODS
  Qualitative data collection included 12 focus group discussions which explored community perceptions of anti-malarials and experiences of administering medications to children. Critical incidence interviews were conducted with 22 caregivers to explore experiences of administering the dispersible or original formulation of AL to young children during recent febrile episodes. A structured questionnaire was used to gather data on experience of recent treatment and adherence to anti-malarials during follow-up visits with 218 caregivers whose child was recently treated with either dispersible AL or DHA-PPQ.
  
  
  CONCLUSIONS
  Caregivers experience great difficulty in administering medication to children. While the sweet taste of dispersible AL may have reduced conflict between the child and caregiver, sub-optimal dosing due to medication loss remained a problem and overall adherence was greater among those receiving DHA-PPQ, which requires fewer doses. Some caregivers were found to deliberately alter the dosing schedule according to whether they perceived the medication to be too weak or strong. They also developed theories for poor treatment outcomes, such as attributing this to lack of compatibility between the medication and the child. Health education messages should be strengthened to ensure a combination of clear pictorial and verbal instructions are used during dispensing, and consequences of under and over-dosing are explained alongside appropriate responses to possible adverse events. Further optimizing of anti-malarial adherence among children requires the development of anti-malarials with pharmacological properties that allow user-friendly administration and simplified dosing schedules.
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, Blantyre, Malawi. victoria@theglobalhealthnetwork.org.|Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK. victoria@theglobalhealthnetwork.org.
authors.forename: Victoria L
authors.initials: VL
authors.lastname: Ewing
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, Blantyre, Malawi. anja.terlouw@lstmed.ac.uk.|Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK. anja.terlouw@lstmed.ac.uk.
authors.forename: Dianne J
authors.initials: DJ
authors.lastname: Terlouw
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, Blantyre, Malawi. kapindaandrew@gmail.com.
authors.forename: Andrew
authors.initials: A
authors.lastname: Kapinda
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK. Cheryl.Pace@lstmed.ac.uk.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Pace
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK. esther.richards@lstmed.ac.uk.
authors.forename: Esther
authors.initials: E
authors.lastname: Richards
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK. R.J.Tolhurst@lstmed.ac.uk.
authors.forename: Rachel
authors.initials: R
authors.lastname: Tolhurst
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK. dlalloo@lstmed.ac.uk.
authors.forename: David G
authors.initials: DG
authors.lastname: Lalloo
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000627:therapeutic use*; D002675:Child, Preschool; D004338:Drug Combinations; D004363:Drug Utilization; D004983:Ethanolamines / Q000627:therapeutic use*; D005260:Female; D005449:Fluorenes / Q000627:therapeutic use*; D006801:Humans; D007223:Infant; D008288:Malaria / Q000188:drug therapy*; D008295:Malawi; D008297:Male; D055118:Medication Adherence; D011804:Quinolines / Q000627:therapeutic use*; D011795:Surveys and Questionnaires; D010879:Piperazines
chemical_list: D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes; D011804:Quinolines; C039060:artenimol; C034759:piperaquine; D010879:Piperazines