Bangem, Tombel, Nguti, Limbe, Muyuka and Kumba), which are subdivided into 61 health areas. The total area of. SW1 is approximately 14 300 km2, and the ...
Tropical Medicine and International Health
doi:10.1111/j.1365-3156.2012.03007.x
volume 00 no 00
Characteristics of persons who complied with and failed to comply with annual ivermectin treatment William R. Brieger1, Joseph C. Okeibunor2, Adenike O. Abiose3, Richard Ndyomugyenyi4, Samuel Wanji5, Elizabeth Elhassan6 and Uche V. Amazigo7 1 2 3 4 5 6 7
Department of International Health, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA Department of Sociology ⁄ Anthropology, University of Nigeria, Nsukka, Nigeria Sightcare International, Ibadan, Oyo State, Nigeria National Onchocerciasis Control Programme, Kampala, Uganda Research Foundation in Tropical Diseases and Environment, Buea, Cameroon Sight Savers International, Kaduna, Nigeria African Programme for Onchocerciasis Control, Ouagadougou, Bukina Faso
Abstract
objective To assess individual compliance with annual ivermectin treatment in onchocerciasisendemic villages. methods Multi-site study in eight APOC-sponsored projects in Cameroon, Nigeria and Uganda to identify the socio-demographic correlates of compliance with ivermectin treatment. A structured questionnaire was administered on 2305 persons aged 10 years and above. Two categories of respondents were purposively selected to obtain both high and low compliers: people who took ivermectin 6–8 times and 0–2 times previously. Simple descriptive statistics were employed in characterizing the respondents into high and low compliers, while some socio-demographic and key perceptual factors were employed in regression models constructed to explain levels of compliance among the respondents. results Some demographic and perceptual factors associated with compliance were identified. Compliance was more common among men (54.4%) (P < 0.001). Adults (54.6%) had greater rates of high compliance (P < 0.001. The mean age of high compliers (41.5 years) was significantly older (35.8 years) (t = 8.46, P < 0.001). Perception of onchocerciasis and effectiveness of ivermectin influenced compliance. 81.4% of respondents saw benefits in annual ivermectin treatment, high compliance among those who saw benefits was 59.3% compared to 13.3% of those who did not (P < 0.001). conclusion Efforts to increase compliance with ivermectin treatment should focus on providing health education to youth and women. Health education should also highlight the benefits of taking ivermectin. keywords compliance, ivermectin, mass treatment, onchocerciasis
Introduction The community-directed treatment with ivermectin (CDTI) programme of the African Programme for Onchocerciasis Controls (APOC) was established in 1995 (Amazigo & Boatin 2006) with the goal of maintaining a minimum of 65% annual population coverage in endemic communities over a minimum of 15 years for effective control of onchocerciasis (Plaisier et al. 1997; Borsboom et al. 2003; Tielsch & Beeche 2004). CDTI has been established in over 95 000 communities where more than 98 million ivermectin tablets are distributed annually to treat 33 million people (Amazigo et al. 2007).
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Community-directed treatment with ivermectin is a process in which the community itself has responsibility for organization and execution of treatment of its members (Remme 1997; Brieger et al. 2002). CDTI entails the empowerment of communities to decide on dates of distribution, mode of distribution (e.g. house-to-house, central place) and the persons who will guide distribution, the Community-Directed Distributors (CDDs). Other community responsibilities include conducting a census, collecting drug supplies, mobilization during the distribution, and recording and reporting coverage. There may be one or more CDDs per community and playing a major role in conducting these activities (APOC 2007). 1
Tropical Medicine and International Health
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W. R. Brieger et al. Who complies with annual ivermectin treatment?
While reports of coverage are encouraging (APOC 2004; Amazigo et al. 2007), coverage rates in a community may not give the full picture of programme success because there may be individuals or groups who systematically do not comply over the years and thus provide a continued focus for transmission. Compliance, also known as adherence, is defined as ‘the extent to which a patient acts in accordance with the prescribed interval and dose of and dosing regime (IPSOR Medication Compliance and Persistence Special Interest Group 2006). Compliance with annual ivermectin treatment, therefore, has become a major challenge for APOC as it enters its second decade of implementation on the ground. To date, very few localized published reports of CDTI have actually determined the extent to which individual community residents comply with ivermectin treatment consistently each year and their reasons for doing so or not. This may be due in part to the fact that in the early years of the programme not enough annual distributions had accumulated to provide a meaningful measure of compliance. Now that the original 25 projects, which started in 1997–1998, have been operating for almost a decade; annual compliance studies become possible. Such studies also become extremely desirable because researchers are now pushing back the timeframe for controlling onchocerciasis through annual ivermectin dosing from 15 to 25 or more years (Winnen et al. 2002). APOC has a mandate to establish within a period of 12 to 15 years, effective and sustainable, CDTI throughout the endemic areas within the geographical scope of the programme (APOC 2006) and thus requires a clear understanding of the long-term compliance process to guide countries toward sustainability. Considering that ivermectin treatment will be needed for many years into the future, the Technical Consultative Committee of APOC requested a study to learn what factors might be associated with compliance over time so that appropriate education and intervention could be designed to help sustain annual treatment (APOC 2005). High levels of compliance are even more important now than at the time the study was conducted because of the shift in the objectives of APOC from ‘controlling onchocerciasis as a public health problem’ to ‘interrupting transmission where feasible’. Some studies have identified factors that encourage or discourage taking ivermectin during a given distribution such as age, gender and ethnicity (Brieger et al. 2002; Maduka et al. 2004; Semiyaga et al. 2005; Lakwo & Gasarasi 2006). Social support and drug perceptions are other factors that have influenced coverage, and hence may impact on compliance (Nuwaha et al. 2005). Akogun et al. (2000) discuss the importance of perceived benefits of ivermectin treatment, 2
which could be another motivating factor in annual compliance. These factors may or may not explain longterm compliance. APOC therefore wants a scientific basis to frame health education and communication that will promote the sustainability of CDTI. Compliance studies on other medical conditions have shown that adhering to a medical regimen may be influenced by the characteristics of the patient ⁄ client and provider as well as the nature of the regimen and may guide thinking about compliance with ivermectin treatment. Patient factors often include ethnic origin (Yuan et al. 2006). Educational level has a positive association with compliance (Iliyasu et al. 2005). This study presents results of a multi-site study of compliance with ivermectin treatment in three APOCassisted countries with CDTI programmes. The main aim was to identify the factors associated with levels of compliance among villagers with varying socio-demographic and perceptual characteristics. The conclusion of the study would help in designing programmes to ensure compliance to ivermectin treatment. Results are expected to contribute to developing a simple and efficient protocol for determining compliance rate at regular intervals, which could be used by the National Onchocerciasis Taskforces for periodic monitoring of compliance to treatment with ivermectin in their respective project areas.
Methods Study design The study was designed to allow an assessment of compliance to and perceived benefits of annual ivermectin treatment and the feasibility of assessing long-term compliance. The cross-sectional approach was adopted in collecting qualitative data from seven study sites in three countries that scaled through the feasibility study conducted in 2005. The study took place in Cameroon, Nigeria and Uganda. These are the countries with CDTI projects that have been implementing CDTI since at least 1998 and where the feasibility study demonstrated adequate records at all levels. The levels in CDTI implementation are the Project (Provincial ⁄ State), District ⁄ Local Government Areas, Frontline and Community. Records of CDTI implementation are kept at each level and the records include, among others, the number of people treated each year as well as the number of distributions. These project areas include Cameroon (SW1 CDTI project), Nigeria (Kaduna, Imo, Taraba and Cross River States CDTI projects) and Uganda (Phase 1 and 2) CDTI projects.
ª 2012 Blackwell Publishing Ltd
Tropical Medicine and International Health
volume 00 no 00
W. R. Brieger et al. Who complies with annual ivermectin treatment?
Cameroon study site The South West 1 (SW1) Project covers part of the southwest province of Cameroon and includes three administrative divisions (Fako, Kupe and Manengouba, Meme). SW1 is divided into eight health districts (Buea, Tiko, Bangem, Tombel, Nguti, Limbe, Muyuka and Kumba), which are subdivided into 61 health areas. The total area of SW1 is approximately 14 300 km2, and the population is estimated to 710 050 people living in 465 communities. The vegetation here is predominantly the equatorial rain forest. Beside this main type of vegetation, there is mangrove vegetation on the coast (Atlantic Ocean). The altitude ranges from 0 m on the coast to 2200 m in Buea town (headquarter of the province), with a multitude of small hills. Mount Cameroon, the highest peak in West Africa with 4100 m of altitude, stands in Buea town. The SW1 has a very rich network of drainage systems most of which flow from high altitudes and are interrupted by numerous cascades, rapids and waterfalls constituting suitable breeding site for the simulium vector. The climate is tropical. The rainy season lasts from mid-March to midOctober with its peak around July and August. Farming is the main activity of population year-round. The rich volcanic soil encourages the cultivation of various food crops. Distinct ethno-linguistic groups live in SW1. These include the Bakweries, Bafaws, Bakossis, Orokos and Balongs. The communities in the SW1 are generally permanent settlers. The official language of communication is English. Nigeria study sites With a population of more than 140 million in 36 States and a Federal Capital Territory (FCT), Nigeria has a total of 27 CDTI projects in 32 States, including the FCT, located in four health zones, namely north–west, north– east, south–west and south–east. These health zones serve as operational zones for APOC CDTI implementation in the country. The health zones are culturally distinct with varying health-seeking behaviour. Ten of the CDTI projects, with a population of
