Adherence to 14-day radical cure for Plasmodium vivax malaria in Papua, Indonesia: A mixed-methods study

Annisa Rahmalia, Jeanne Rini Poespoprodjo, Chandra U.R. Landuwulang, Maya Ronse, Enny Kenangalem, Faustina H. Burdam, Kamala Thriemer, Angela Devine, Ric N. Price, Koen Peeters Grietens, Benedikt Ley, Charlotte Gryseels

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BACKGROUND: Reducing the risk of recurrent Plasmodium vivax malaria is critical for malaria control and elimination. Primaquine (PQ) is the only widely available drug against P. vivax dormant liver stages, but is recommended as a 14-day regimen, which can undermine adherence to a complete course of treatment. METHODS: This is a mixed-methods study to assess socio-cultural factors influencing adherence to a 14-day PQ regimen in a 3-arm, treatment effectiveness trial in Papua, Indonesia. The qualitative strand, consisting of interviews and participant observation was triangulated with a quantitative strand in which trial participants were surveyed using a questionnaire. RESULTS: Trial participants differentiated between two types of malaria: tersiana and tropika, equivalent to P. vivax and Plasmodium falciparum infection, respectively. The perceived severity of both types was similar with 44.0% (267/607) perceiving tersiana vs. 45.1% (274/607) perceiving tropika as more severe. There was no perceived differentiation whether malaria episodes were due to a new infection or relapse; and 71.3% (433/607) acknowledged the possibility of recurrence. Participants were familiar with malaria symptoms and delaying health facility visit by 1-2 days was perceived to increase the likelihood of a positive test. Prior to health facility visits, symptoms were treated with leftover drugs kept at home (40.4%; 245/607) or bought over the counter (17.0%; 103/607). Malaria was considered to be cured with 'blue drugs' (referring to dihydroartemisinin-piperaquine). Conversely, 'brown drugs,' referring to PQ, were not considered malaria medication and instead were perceived as supplements. Adherence to malaria treatment was 71.2% (131/184), in the supervised arm, 56.9% (91/160) in the unsupervised arm and 62.4% (164/263) in the control arm; p = 0.019. Adherence was 47.5% (47/99) among highland Papuans, 51.7% (76/147) among lowland Papuans, and 72.9% (263/361) among non-Papuans; p < 0.001. CONCLUSION: Adherence to malaria treatment was a socio-culturally embedded process during which patients (re-)evaluated the characteristics of the medicines in relation to the course of the illness, their past experiences with illness, and the perceived benefits of the treatment. Structural barriers that hinder the process of patient adherence are crucial to consider in the development and rollout of effective malaria treatment policies.

Original languageEnglish
Article number162
Pages (from-to)1-16
Number of pages16
JournalMalaria Journal
Issue number1
Publication statusPublished - Dec 2023

Bibliographical note

Funding Information:
We thank all the patients, health staff, and the study team who took part in this study. We thank Mark T. Westra and Satya Nugraha ( , Amsterdam, The Netherlands) for the technical support in survey data management, and Niamh Meagher (Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, VIC, Australia) for providing the trial data. We are grateful for Pak Reynold Rizal Ubra (District Health Office, Papua, Indonesia) and Prof Yati Soenarto (Universitas Gadjah Mada, Yogyakarta, Indonesia) for their continuing support to our works in Timika, Indonesia.

Funding Information:
The trial that this study was embedded in was funded by the Gates Foundation (INV-007122) and the Department of Foreign Affairs of the Australian Government (72904). RNP is a Wellcome Trust Senior Fellow in Clinical Science (200909), and KT is a CSL Centenary Fellow. The trial was supported by the Australian Centre for Research Excellence on Malaria Elimination (ACREME), funded by the NHMRC of Australia 91134989. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Publisher Copyright:
© 2023, The Author(s).


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