SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
March, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Millions of people contract malaria each year. The WHO currently promotes artemisinin-based combination therapy for treating uncomplicated malaria, but this may be more difficult for patients to correctly adhere to than other treatments.
Packaging a course of treatment in units of a single dose may be a more effective way of ensuring that patients take the correct dosage, and thus of increasing treatment success. In this approach, drugs to be taken together are packaged adjacent to each other, sometimes with colours or other markers to show that the drugs should be taken together.
Key messages
No studies measured treatment failure on or by day 28 after initiation of treatment, which was the primary outcome in this review.
The use of blister packs compared to paper envelopes for antimalarial drugs may improve adherence to treatment and may slightly improve clinical outcomes. No studies reported adverse events.
The use of sectioned polythene bags compared with bottled syrup may improve adherence to treatment in children under 5 years who have malaria, but may increase vomiting. It is uncertain whether there is a difference in clinical outcomes.
The use of sectioned polythene bags compared to paper envelopes for antimalarial drugs probably improves adherence to treatment and may slightly improve clinical outcomes in children over 7 years and adults with malaria. Their use may lead to little if any difference in adverse events.
It is uncertain whether the use of sectioned compared to unsectioned polythene bags leads to a difference in adherence, clinical outcomes, or adverse events.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Millions of people contract malaria each year, mainly in areas such as sub-Saharan Africa, South-East Asia and South America.
The WHO currently promotes artemisinin-based combination therapy. Unless the drugs are coformulated, people are often required to follow a regimen that includes more than one antimalarial drug at a time. Such regimens may be more difficult to follow correctly than single therapies. If treatment responses relate to the dose and schedule of a therapy, non-adherence may reduce treatment benefits.
Packaging a course of treatment in units of a single dose may help to ensure that the correct dosage is taken and thus to increase the success of treatment.
The packaging systems adopted by different countries and pharmaceutical companies vary widely. Some types of packaging, such as the the WHO-recommended blister packaging for artemisinin-based regimens, require certain levels and types of technology. Variations are also found in the products developed within this packaging type.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
This review found five studies conducted in low- and middle-income countries that evaluated and compared the use of labelled and boxed blister packs and simple, labelled and sectioned polythene bags, with the use of paper envelopes, bottled syrup or unsectioned bags. All studies measured adherence and some measure of the impacts of treatment. No studies measured treatment failure as defined in the review. Only two studies reported adverse events.
1) The use of blister-packed tablets and capsules compared with the provision of tablets and capsules in paper envelopes to improve adherence and patient outcomes in uncomplicated malaria
Two studies in adolescents and adults evaluated the use of boxed blister packs that had the drug name on the blister pack and inside the box. These packs were used for a 3-day course of the drug chloroquine and an 8-day course of primaquine, taken each day together from individual blister units.
The use of blister packs compared to paper envelopes for antimalarial drugs may improve adherence to treatment and may slightly improve clinical outcomes. The certainty of this evidence is low.
No studies measured treatment failure or reported adverse events.
2) The provision of tablets in sectioned polythene bags compared with the provision of drugs in bottled syrup form to improve adherence and patient outcomes in uncomplicated malaria
One study in children aged 0 to 5 years, evaluated the use of hermetically sealed, sectioned polythene bags containing daily doses of chloroquine tablets (labelled ‘1’, ‘2’, or ‘3’ to indicate the day of dosage) and compared this with the provision of the same drug in bottled syrup form.
The use of sectioned polythene bags compared to bottled syrup may improve adherence to treatment in malaria, but may increase vomiting. The certainty of this evidence is low.
Treatment failure was not measured and it is uncertain whether there is a difference in clinical outcomes. The certainty of this evidence is very low.
3) The provision of tablets in sectioned polythene bags compared with the provision of the tablets in paper envelopes to improve adherence and patient outcomes in uncomplicated malaria
One study of adults and children (7+ years) compared the use of hermetically sealed, sectioned polythene bags containing daily doses of chloroquine tablets (labelled ‘1’, ‘2’ or ‘3’ to indicate the day of dosage), with the same dosage provided in paper envelopes.
The use of sectioned polythene bags compared to paper envelopes for antimalarial drugs probably improves adherence to treatment. The certainty of this evidence is moderate.
The use of sectioned polythene bags may slightly improve clinical outcomes and may lead to little if any difference in adverse events. The certainty of this evidence is low.
Treatment failure was not measured.
4) The provision of tablets in sectioned polythene bags compared with the use of unsectioned polythene bags to improve adherence and patient outcomes in uncomplicated malaria
One study in adults evaluated a 3-day regimen of drugs administered in sealed, clear and sectioned polythene bags stapled to a card base with the daily dosage of tablets in each colour-coded section, and the name of the drugs and instructions written below each section.
It is uncertain whether the use of sectioned polythene bags compared with the use of unsectioned bags increases adherence or improves clinical outcomes. The certainty of this evidence is very low.
No studies reported treatment failure or adverse events.
Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2008 (2): CD000011
Horne R, Weinman J, Barber N, et al. Concordance, adherence and compliance in medicine taking: a scoping exercise. London: NCCSDO; 2005.
Gabriel Rada, Unit for Health Policy and Systems Research, Faculty of Medicine, Pontificia Universidad Católica de Chile.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Lois Orton, Paul Garner, Simon Goudie, and Hanna Bergman.
Orton LC, Barnish G. Unit-dose packaged drugs for treating malaria. Cochrane Database Syst Rev 2005; (2):CD004614
Rada G. What are the effects of using drugs packaged in unit doses to treat malaria? A SUPPORT Summary of a systematic review. March 2017. www.supportsummaries.org
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, malaria, unit-dose packaging, medication adherence, medication compliance, medication non-compliance, medication non-adherence, patient compliance, treatment refusal
