Abstract

Background
Malaria remains a global health issue with the burden unevenly distributed to the disadvantage of the developing countries of the world. Nigeria, a middle-income country in sub-Saharan Africa, is one of the countries with high malaria burden in the world. As a socioeconomic issue, the high level of poverty in Nigeria is an important factor that reinforces the persistent malaria burden in the population. Poverty contributes to the malaria burden as it can affect integral aspects of malaria control like treatment seeking behaviours, access to preventive measures and treatment. Presently, there have been renewed efforts in the global malaria control resulting in reductions in the global malaria burden over the last decade. However, the development of resistance to artemisinin-based combination therapies threatens the sustainability of the present success in malaria control. The mechanism behind the development and spread of antimalarial drug resistance is a complex one with multiple factors in play. Nevertheless, antimalarial drug use behaviours remain critical drivers of drug resistance as they can affect some of the other factors. This study adopted a social epidemiological stance in exploring existing antimalarial drug use behaviours that have the potential to drive drug resistance development and spread. The study went further to investigate the role of socioeconomic factors in the adoption of the identified behaviours when treating malaria.
Methods
An exploratory mixed methods research design was adopted in this study. This design involved an initial systematic review of the literature to create a holistic picture of what is known about the issue under study. The systematic review informed the design of a qualitative study involving the use of interviews to explore the existing antimalarial drug use practices in the Nigerian population; and the different socioeconomic factors influencing the behaviours. The qualitative interviews informed the design of a measurement instrument and hypotheses that were tested in a survey with larger number of participants from Nigeria
Findings
The important malaria treatment seeking and drug use behaviours identified in this study were the practice of mixing drug for malaria treatment, presumptive treatment of malaria, sharing of malaria treatment course, and saving antimalarial drugs for future use. When symptoms are experienced, socio-economic factors, like the educational level, type of settlement, and
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household income level, tend to determine the treatment behaviours and therefore inform and determine the experience of malaria illness. There were statistically significant relationships between socioeconomic measures and drug use behaviours like the use of mixed drugs, stopping treatment to save drugs, sharing of antimalarial drugs, adherence to recommended dose and time of administration, presumptive treatment and use of recommended drugs for malaria treatment. These behaviours differ regarding the specific socioeconomic measures that are significantly associated with them.
Discussion
Physical and social environments can place constraints on an individual’s choices as well as that of a population. As shown in this study, education, income level and type of settlement, as structural factors, affect the decision on how to seek malaria treatment, what antimalarial drug to get, and how to use antimalarial drugs. Practices like mixing, stopping treatment to save drugs, and sharing of antimalarial drugs with others have the potential to encourage the development and spread of antimalarial drug resistance by exposing the parasite to sub-therapeutic doses of antimalarial drugs. Also, mixing of drugs paves the way for the sale of fake as well as expired antimalarial drugs thereby affecting malaria morbidity and illness experience.
Conclusions and Recommendations
In malaria campaigns, there is need to broaden the scope of antimalarial drug resistance control strategies to include strategies targeted at improving the socioeconomic status of people in malaria endemic areas. The informal health facilities were significantly associated with most of the reported resistance-promoting drug use behaviours like mixing; as such efforts to improve the way antimalarial drugs are used should target these facilities. Population-wide improvements in income level, educational level, environmental and structural conditions of the rural areas in malaria endemic settings like Nigeria, will encourage behavioural changes on how antimalarial drugs are used.