RESUMEN
BACKGROUND: The evidence on determinants of individuals' choices for anti-malarial drug treatments is scarce. This study sought to measure the strength of preference for adult antimalarial drug treatment attributes of heads of urban, rural and peri-urban households in a resource-limited malaria-endemic area of sub-Saharan Africa. METHODS: Discrete choice experiments were conducted with 508 heads of household interviewed face-to-face for a household population survey of health-seeking behavior in Zomba District, Malawi. The interviews were held in Chichewa and the choice experiment questions were presented with cartoon aids. The anti-malarial drug attributes included in the stated preference experiment were: speed of fever resolution, side effects (pruritus) risk, protection (duration of prophylactic effect), price, duration of treatment course and recommendation by a health professional. Sixteen treatment profiles from a fractional factorial design by orthogonal array were paired into choice scenarios, and scenarios were randomly assigned to participants so that each participant was presented with a series of eight pairwise choice scenarios. Respondents had the option to state indifference between the two profiles or decline to choose. Data were analysed in a mixed logit model, with normally distributed coefficients for all six attributes. RESULTS: The sex ratio was balanced in urban areas, whereas 63% of participants in rural areas were male. The proportion of individuals with no education was considerably higher in the rural group (25%) than in the urban (5%) and peri-urban (6%) groups. All attributes investigated had the expected influence, and traded-off in most respondents' choices. There were heterogeneous effects of price, pruritus risk, treatment recommendation by a professional, and duration of prophylaxis across respondents, only partly explained by their differences in education, household per capita expenditure, sex and age. Individuals' demand elasticity (simulated median, inter-quartile range) was highest (most responsive) to speed of symptom resolution (0.88, 0.80-0.89) and pruritus risk (0.25, 0.08-0.62). CONCLUSIONS: Most adult antimalarial users are willing to use treatments without recommendation from health professional, and may be influenced by price. Future studies should investigate the magnitude of differences in price and treatment attribute sensitivity between adult anti-malarial drug users in rural, peri-urban and urban areas in order to determine optimal price subsidies.
Asunto(s)
Antimaláricos/uso terapéutico , Enfermedades Endémicas , Malaria/tratamiento farmacológico , Prioridad del Paciente , Adulto , Antimaláricos/efectos adversos , Antimaláricos/economía , Países en Desarrollo , Femenino , Grupos Focales , Encuestas Epidemiológicas , Humanos , Malaria/epidemiología , Malaui , Masculino , Modelos Teóricos , Motivación , Aceptación de la Atención de Salud , Honorarios por Prescripción de Medicamentos , Prurito/inducido químicamente , Población Rural , Muestreo , Población Suburbana , Encuestas y Cuestionarios , Factores de Tiempo , Población UrbanaRESUMEN
Informal sources of care may lead to ineffective use of antimalarial drugs. A survey conducted in Malawi estimated the frequency of use of informal and formal services, medications, and household costs. A total of 508 household interviews were conducted. Treatment with an antimalarial was reported in 24% of young children accessing the informal sector and in 91% accessing formal services. Informal care was associated with shorter travel and waiting times, a lower proportion of carers or feverish adults missing work or studies and losing earnings, and a lower proportion of older children missing studies or work. Total out of pocket costs of fever episodes constitutes between 9% and 14% in young children and 18% in adults of their total available resources. Patients may perceive informal services to be associated with opportunity cost advantages; however, these may be associated with health risks of inadequate prescribing, particularly in young children.