Mobile Phone Short Message Service to Improve Malaria Pharmacoadherence in Zambia

Zambia, located in the heart of sub-Saharan Africa, is plagued by malaria, particularly the plasmodium falciparum species. The annual number of diagnosed and confirmed cases in Zambia in 2012 was 4.7 million, 2.3% of the total global cases, with an estimated 11,000 deaths (World Health Organization [WHO], 2013). Although effective treatment for P. falciparum malaria is available, the problem of poor pharmacoadherence remains a significant barrier to malaria control and elimination (Mace et al., 2011; White & Olliaro, 1996; White et al., 2009). Current statistics for malaria pharmacoadherence rates in sub-Saharan Africa vary widely in their methods and definitions, resulting in a range between 36.5% and 91% (M = 61.2; SD = 20.0). Nonadherence not only impacts the patient through suboptimal blood concentrations resulting in increased morbidity and mortality, but also impacts the community through the development of parasitic resistance, disease relapse, and increased disease occurrence (Mace et al., 2011; White & Olliaro, 1996; White et al., 2009). Recent advancements in mobile phone technology and availability hold promise for health research application in sub-Saharan Africa. Eighty-seven percent of urban Zambian households and 52% of rural households had access to at least one mobile phone in 2008, with expectations for a continued rapid rise as the wave of technology floods the continent (Chirwa, Minnie, & Bussiek, 2010).Purpose of the StudyThe primary aim of this study was to assess the efficacy of a program to increase the pharmacoadherence rate of the six-dose artemesinin-based combination therapy (ACT) treatment of P. falciparum malaria in the Copperbelt Province of Zambia using short message service (SMS) reminders through the mobile phone.MethodsIntroduction and DesignThis article presents a prospective, quantitative, randomized controlled trial with an experimental, betweengroups design. Pharmacoadherence was the dependent variable and the SMS intervention was the independent variable.Sample and SettingThe convenience sample was composed of individuals who presented to the public clinic in Fisenge, Zambia, tested positive for uncomplicated P. falciparum malaria, and met inclusion criteria. Fisenge has a population of 13,000, with a household income below the national average of US$1,200/year (Zambia Census of Population and Housing, 2000). Fisenge is representative of rural villages in the Copperbelt Province, with the majority of citizens educated in the public schools, where all education was delivered in English. This site was chosen based on the large number of patients diagnosed with malaria according to clinic records during a site visit in 2012.Population. The target population of this study was rural Zambians over 18 years of age who were at least minimally literate in English, and who were diagnosed with uncomplicated P. falciparum malaria. The term minimally literate used in this study indicates an ability to read sample phrases similar to those that were to be sent by SMS.Inclusion/exclusion criteria. To be included in the study, participants must have been at least 18 years of age; had continuous access to a mobile phone for the 3 days following their clinic visit; were able to communicate via SMS; and were able to read three health-related phrases chosen from a selection of those that were sent by SMS. Participants were excluded if another member of the household was already a part of the study. In addition, if potential subjects had been treated for malaria in the 2 weeks immediately prior to their presentation, they were excluded.Sample size. For the purpose of this study, a small effect size for a chi-square analysis and bivariate linear regression was assumed for the intervention. An a priori power analysis was conducted using G* Power (version 3.1.6; University of Dusseldorf, Dusseldorf, Germany) to determine sample size to provide a small effect size (. …