research open access exploring provider and community ... · management of malaria in si and...

RESEARCH Open Access

Exploring provider and community responses tothe new malaria diagnostic and treatment regimein Solomon IslandsRushika S Wijesinghe1*, Jo-An M Atkinson1, Albino Bobogare2, Lyndes Wini2, Maxine Whittaker1

Abstract

Background: Improvements in availability and accessibility of artemisinin-based combination therapy (ACT) formalaria treatment and the emergence of multi-drug-resistant parasites have prompted many countries to adoptACT as the first-line drug. In 2009, Solomon Islands (SI) likewise implemented new national treatment guidelines formalaria. The ACT, Coartem® (artemether-lumefantrine) is now the primary pharmacotherapy in SI for Plasmodiumfalciparum malaria, Plasmodium vivax malaria or mixed infections. Targeted treatment is also recommended in thenew treatment regime through maintenance of quality microscopy services and the introduction of RapidDiagnostic Tests (RDTs). Ascertaining the factors that influence community and provider acceptance of andadherence to the new treatment regime will be vital to improving the effectiveness of this intervention andreducing the risk of development of drug resistance.

Methods: In order to understand community and prescriber perceptions and acceptability of the new diagnostic andtreatment interventions, 12 focus group discussions (FGDs) and 12 key informant interviews (KII) were carried out inrural and urban villages of Malaita Province, Solomon Islands four months subsequent to roll out of these interventions.

Results: Lack of access to microscopy or distrust in the accuracy of diagnostic tools were reported by someparticipants as reasons for the ongoing practice of presumptive treatment of malaria. Lack of confidence in RDTaccuracy has negatively impacted its acceptability. Coartem® had good acceptability among most participants,however, some rural participants questioned its effectiveness due to lack of side effects and the larger quantity oftablets required to be taken. Storing of left over medication for subsequent fever episodes was reported as common.

Conclusion: To address these issues, further training and supportive supervision of healthcare workers will beessential, as will the engagement of influential community members in health promotion activities to improveacceptability of RDTs and adherence to the new treatment regime. Exploring the extent of these issues beyond thestudy population must be a priority for malaria programme managers. Practices such as presumptive treatment andthe taking of sub-curative doses are of considerable concern for both the health of individuals and the increased riskit poses to the development of parasite resistance to this important first-line treatment against malaria.

BackgroundSince first proposed by the World Health Organizationin the early 1990s, the strategy of early diagnosis andprompt effective treatment of malaria illness has been acornerstone of malaria control [1,2]. In recent times, theRoll Back Malaria Partnership has set the target for

2010 of “80% of malaria patients to be diagnosed andtreated with effective anti-malarial medicines within oneday of the onset of illness” [3]. To achieve this, manyinterventions have been developed and strategiesemployed to improve accuracy of diagnostic testing andreporting of results. This has the additional benefit ofreducing the waste and cost of anti-malarial medicationand improving treatment of alternative causes of fever[3,4]. It has also been recommended that programmesaim to build health system capacity to increase coverage

* Correspondence: [email protected] University of Queensland, School of Population Health, Pacific MalariaInitiative Support Centre, Australian Centre for International and TropicalHealth, Brisbane, AustraliaFull list of author information is available at the end of the article

Wijesinghe et al. Malaria Journal 2011, 10:3http://www.malariajournal.com/content/10/1/3

© 2011 Wijesinghe et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

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of services and improve the prescription and dispensingpractices of providers [5].Malaria is the predominant cause of febrile illness and

a major public health problem in Solomon Islands (SI)[6]. In 2009, there were 40,136 reported malaria cases inthe country, with an annual incidence rate of 77/1,000population, of which Plasmodium falciparum accountedfor 72% and Plasmodium vivax 28% [6]. There were 13deaths due to malaria in 2009. However, malaria hospitaladmissions showed a significant decline in 2009 com-pared to the two previous years and there is evidence of agradual decline in malaria cases over the period 2001 to2009. There has also been a general decline in malariaannual incidence rates over the period of 2003 - 2009 [6].Malaita Province, where the current study was carriedout, had a malaria incidence rate of 82.9/1,000 populationin 2009, which was amongst the top three provinces formalaria incidence reported in that year [6]. In 2008, SIraised the goal of their National Malaria Programme(NMP) to intensified control and progressive elimination.In line with the current global strategy, a key componentof the programme is capacity building for early diagnosisand prompt and effective treatment [7].Concerns about emerging resistance to the previously

existing regime of chloroquine and sulphadoxine-pyrimethamine (Fansidar®), prompted a review of themanagement of malaria in SI and subsequently, the newnational treatment guidelines for malaria were imple-mented [8]. The new drug regime recommendsartemisinin-based combination therapy (ACT) with arte-mether-lumefantrine (Coartem®) as first-line pharma-cotherapy for P. falciparum malaria, P. vivax malariaand mixed infections. The new regime also recommendstreatment after definitive diagnosis and aims to reducepresumptive treatment. This can be achieved by increas-ing diagnostic capability of peripheral-level health ser-vices either through use of good quality microscopy orthrough the introduction of Rapid Diagnostic Test(RDT) kits [8].RDTs can be used as a stop-gap when microscopy ser-

vices are not operating (e.g. evenings/weekends/publicholidays) or as a primary diagnostic tool for rural/remote areas without microscopy services [8]. MalariaRDTs have being suggested to improve diagnostic effi-ciency, which is important for preventing indiscriminateuse of ACT, thereby preventing or delaying the develop-ment of parasite resistance to this new first-line drug[9]. Several studies have shown that using RDTs todirect the use of ACT has the added advantage of allow-ing more accurate treatment of fever, which is impor-tant for improving patient care and minimizing costs formalaria control programmes [9-13]. A study in Zanzibarin 2009 found the introduction of RDTs resulted inimproved management of patients presenting with fever

without increasing cost per patient, leading authors tosuggest RDTs as an important tool for improving fevermanagement in peripheral health care settings [9].Furthermore, Lubell et al [11] found that at moderate

and low levels of malaria transmission in Tanzania,RDTs were more cost beneficial than microscopy, andboth more so than presumptive treatment, but onlywhere treatment response was consistent with testresults. In cases where prescriptions of anti-malarialdrugs were given to patients with negative tests results,neither microscopy nor RDTs were found to be costbeneficial. Depending on transmission rate, theseauthors reported that the cost of treatment inconsistentwith diagnostic outcome was 10 - 250% higher thantreatment that was consistent with test results [11].Investment in building diagnostic capacity to minimiseindiscriminate presumptive treatment with ACT will beconsiderably less costly than dealing with the conse-quences of the development of parasite resistance tothis important first-line treatment against malaria [12].Realizing the potential of RDTs and ACT for intensi-

fied malaria control and elimination depends upon pro-vider and community response to and utilisation ofthese new tools for diagnosis and treatment. Acceptabil-ity of RDTs and ACT can be affected by perceptionsand misconceptions of their accuracy, safety and effec-tiveness. Studies carried out in Tanzania and Ugandafound that despite recognising their potential to improveclinical diagnosis, RDTs were suspected by the commu-nity of being used to test for HIV (Human Immunodefi-ciency Virus) status, that they could infect children withHIV and that the blood samples could be used forwitchcraft [14,15]. Community acceptability of RDTswas also found to be influenced by the education levelof healthcare workers which affected community confi-dence in their expertise [15]. Furthermore, healthcareworker non-adherence to RDT use has been found tobe a consequence of inconsistencies in training mes-sages, insufficient technical supervision and inadequaciesin logistical support for their consistent supply [15].Factors affecting healthcare worker prescription of

ACT have been reported to include patient tolerance ofthe drug, its effectiveness, adequate drug supply andstaffing, training messages that are consistent withrecommended guidelines and follow-up supervision [16].Factors influencing community acceptability of ACT aresuggested to be inter-related and include provider-patient relationship and trust in the quality of care,patient expectations, beliefs regarding illness aetiologyand perceived effectiveness of treatment [17]. Theseissues can have a significant impact on patient adher-ence to the ACT treatment regime. A study carried outin Sierra Leone found as little as 48.3% of patients hadprobable adherence to artesunate and amodiaquine


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therapy provided through community health centres[18]. This was attributed to side effects after the firstdose, food not being available to accompany drugintake, forgetting to take doses and incorrect instruc-tions given by the health centre [18].It is vital to evaluate local factors that influence RDT

and ACT acceptability and use early in the post-imple-mentation period in order to rapidly address communityand provider concerns and misconceptions. This wouldprevent issues of mistrust of interventions and of health-care workers which can otherwise result in a costlywaste of valuable resources and more critically, canundermine malaria control and elimination programmes.This qualitative study was, therefore, carried out toinvestigate community and prescriber perceptions andacceptability of the new diagnostic and treatment inter-ventions in SI. The results will be used to inform qualityimprovement of the newly implemented treatmentregime and to assist with planning for national scale-upof RDTs and ACT in SI.

MethodsStudy area and target populationThis study was conducted in March 2010 in MalaitaProvince, SI (Figure 1). This Province was purposefullyselected as it has one of the highest incidences ofmalaria in SI [6], and hence intensified control activitiesthere had included training of healthcare workers androll-out of RDTs and ACT four months prior to com-mencement of the study. Designed as an exploratorystudy, in-country public health and research officersguided the selection of one rural and one urban villagewithin one hour of the Provincial Capital, Auki, in orderto capture potential differences in provider and commu-nity attitudes and perceptions. A convenience methodwas used to recruit study participants from villagechurch groups, womens’ clubs and youth groups in con-sultation with local village leaders.

ProcedureThe field work was carried out by male and female con-tracted local research officers of the Solomon IslandsDevelopment Trust (SIDT), supported and supervised bystaff of the National Vector Borne Disease Control Pro-gramme (NVBDCP), Ministry of Health, SI and the PacificMalaria Initiative Support Centre (PacMISC) at the Schoolof Population Health (SPH), University of Queensland(UQ), Australia. The SPH team have several years ofexperience in Melanesia including SI and have been work-ing very closely with the local co-investigators of theNVBDCP who are intensively involved in the malaria pro-gramme in the country. A four-day workshop was con-ducted by SPH staff to train the field research team in

qualitative research methods, research logistics, ethicalconsiderations, equipment use and data processing.Focus Group Discussions (FGDs) were carried out

separately with men, women and youth (mixed gender)groups in order to facilitate open, unrestricted dialogue.Key Informant Interviews (KIIs) were conducted withhealthcare workers and other community leaders ineach village such as chiefs, teachers, womens’ groupactivists and religious leaders. Interviews were carriedout in Solomon Islands Pijin, were facilitated by a fieldresearch officer and supported by a local language inter-preter as required. Semi-structured interview guideswere used to direct discussions. Interviews wererecorded with consent using a digital tape recorder,backed up with manual note taking. Demographic dataof participants was also obtained including age, educa-tion, occupation and religious affiliation.Throughout the study, there were regular consulta-

tions between the field research staff and the staff ofSPH and NVBDCP. This included the SPH team review-ing a sample of early transcripts and their translationswhen the research was underway to identify any issuesin quality, method, translation and misinterpretation ofinterviews guides. Advice and feedback was given andchanges made accordingly. An additional aim of thestudy was to continue capacity building in SI by traininglocal staff in qualitative research methodologies; there-fore comprehensive feedback was provided to them dur-ing and after the work was completed.

Data analysisIn-depth analysis was carried out by the SPH researchteam at the University of Queensland. Digital record-ings of the FGDs and KIIs were directly transcribedand translated from Solomon Islands Pijin (or localdialect) to English by the field research team. Data wascoded around the main topics of the interview guidesand entered into NVivo 8 software (QSR InternationalPty Ltd, Australia). The SPH team developed an agreedcoding key through sample transcript reviews and dis-cussions of coding issues, which was then utilised bythe primary coder. The data was organized into identi-fiable themes and patterns of behaviour and subjectedto thematic analysis. Areas of consensus and diver-gence were identified and a ‘realist method’ was usedto understand participants’ realities, experiences andmeanings. This approach has previously been reportedto be appropriate for working within a participatoryparadigm particularly where research findings areinforming policy development [19]. Discussions wereheld throughout the coding and analysis process withthe SI co-investigators for clarification, back translationif required and confirmation.


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Ethical aspectsEthical approval for this study was obtained from theSolomon Islands National Health Research Ethics Com-mittee and the University of Queensland Behaviouraland Social Sciences Ethical Review Committee. Indivi-dual informed consent (written or witnessed thumbprint) was obtained from all participants prior to theFGDs and KIIs following a verbal and written explana-tion of study aims and procedures. The privacy of parti-cipants was preserved as the transcripts did not identifyindividuals by their full names. Participant information(digital recordings from FGDs, KIIs and records of parti-cipant demographic details) was securely stored in thefield and subsequently in Honiara and Brisbane.

ResultsIn total, 12 FGDs and 12 KIIs were carried out with 135participants from urban and rural villages in MalaitaProvince over four weeks. The number of participantsin each FGD ranged from 7 to 11. The age range formale participants was 22 - 80 years, for females 23 - 56years and for youth, 16 - 18 years. Participants were pri-marily members of the South Seas Evangelical Church.

Treatment-seekingTreatment-seeking practices reported by men, womenand youth were similar; however, differences emerged

when comparing responses in urban and rural villages.Participants in the urban village were more likely toidentify the importance of early treatment-seeking foradults with fever and reported accessing either the localnurse aid post or Provincial Hospital within 12 to 24hours of onset of symptoms. Participants in the ruralvillage reported waiting 2-4 days post onset of feverbefore accessing the aid post. The reasons for this differ-ence are unclear; however, a few participants reportedthat the distance to the aid post was sometimes a prohi-biting factor and one participant perceived that malariamay not be correctly diagnosed if he attended the clinicsoon after onset of fever.

‘I first observe the symptoms of malaria until itbecomes more obvious so that when I go for a test,they straight away find malaria, because, in somecases when I went early to get a test (for malaria),my result is often negative. So I have to wait untilI notice the symptoms becoming more obviousbefore I go for a test and after the test my resultconfirms malaria.’ (male participant, FGD urbanvillage)

Some participants in both rural and urban villagesreported that due to their vulnerability, children andpregnant women with fever should go to the clinic or

Figure 1 Map of location of study site.


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hospital without delay to be tested and treated. Many inthe rural village, however, stated that the usual practiceeven for these vulnerable groups was to wait until thefever becomes more serious (waiting up to four days)prior to attending the aid post or hospital. Until thatdecision point, a carer/family member of the patientthemselves would manage the fever at home, typicallyvoiced by this male participant;

‘...(people) will commonly wait until (a mother orchild) gets seriously sick before they will take them tothe clinic. This is what usually happens in ruralareas....when a child has a fever, I will treat themwith the leftover medicine at home for three daysand then if they don’t recover I will take them to theclinic.’ (male participant, FGD rural village)

Home treatment (reported by most participants in bothurban and rural villages) consists primarily of giving aperson with fever paracetamol or aspirin and spongingthem with cool water. Some participants in both villagesreported using left over malaria medication if they had itat home. This was used if they suspected malaria beforethey attended a clinic or if the clinic did not diagnosemalaria but the participants believed the diagnosis to bein error. Some less commonly reported home remediesfor fever included steaming, drinking lemon juice, eatinglots of fruit, taking custom medicine and/or praying forthe sick person.

Experiences of presenting with fever to an aid postMost participants in the urban and rural communitiesreported that when they present to an aid post withfever, a blood slide is usually taken to test for malaria.Treatment was commonly reported as directed by micro-scopy results. If the test is positive they are given malariatreatment, if the test is negative they are given paraceta-mol, aspirin or ‘Septrin®’ (cotrimoxazole, an antibiotic).Some participants in both villages also reported that if amicroscopist is not available or if a significant delay inobtaining results is expected, then presumptive treatmentfor malaria is given by the nurse on the basis of present-ing symptoms. A few participants and a key informant inthe urban village also reported that on occasions thenurse at the aid post provides presumptive treatment ifthey suspect malaria even when the microscopy resultsare negative, as expressed by a male participant;

‘...but now if you are positive or negative (formalaria) they will give you Coartem® tablets.’ (maleparticipant, FGD urban village)

The issue of lack of patient confidence in accuracy ofmicroscopy and nursing staff was raised by a few

participants in both urban and rural villages. These par-ticipants highlighted that a lack of trust in diagnosticaccuracy usually results in demands for presumptivemalaria treatment by the patient, cross checking ofresults at another clinic (or with a doctor at the Provin-cial Hospital) or taking of left over malaria medicationthey are able to obtain back at their village.

‘...some people usually force the nurse to give malariatreatment even if test result (microscopy) is negative,but if a doctor tells them (that they don’t havemalaria) they will accept treatment with Panadol®

or Septrin®.’ (male participant, FGD urban village)’Sometimes a parent will bring their child (to theclinic) and when the test result (microscopy) is nega-tive they come back to the village and give leftover(malaria) medication to the child to drink...’ (femaleparticipant, FGD urban village)’If my child was sick with a fever....and the womandoes not have any malaria treatment at home, theygo around the village and ask people if they haveany malaria treatment.’ (male youth participant,FGD rural village)

One male participant from the rural village suggestedthe potential negative impact of presumptive treatmentfor malaria by highlighting that if the fever was causedby another illness, the malaria medication will not work.Dissatisfaction with the nurses’ diagnosis of the cause offever was highlighted by a few participants in each ofthe FGDs carried out with men and youth of the ruralvillage.

‘...a few weeks later I felt sick again so I went to theclinic and they told me my test was negative, but Iknow I had malaria...so I forced the nurse to give memalaria treatment. But some nurses, if they see theresult is negative they will not give me malaria treat-ment, they would just give me Panadol® and aspirinand then they justify it by saying that the cold orfever is hidden in your lung. I am not sure whetherthey are telling the truth or not....this happened tome and I am not happy.’ (male participant, FGDrural village)

Healthcare worker perceptions of RDTsNone of the healthcare workers interviewed claimedthey had received any recent formal training in the useof RDTs. All healthcare workers interviewed reportedtheir lack of confidence in the accuracy of RDTs. Spe-cifically, they reported a concern that RDTs were notsensitive enough to detect malaria when there is lowparasite density in the blood. Negative RDTs are


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usually cross-checked with microscopy particularly forpregnant women or children. When microscopy is notavailable to confirm the negative RDT results, manyhealthcare workers reported giving presumptive treat-ment if they suspected malaria. Lack of training in theproper use of RDTs did not appear to be the only rea-son for a lack of confidence in the test results asreflected in these typical comments by many of thehealthcare workers.

‘RDT can detect the high fever but the lower fever itdoesn’t detect.’(healthcare worker 1, KII, urban village)‘...for hard cases to do with Pv, given that the proto-zoa are so tiny, they need cross checking (with micro-scopy) especially for pregnant mothers and childrenor middle age group.’ (healthcare worker 1, KII, ruralvillage)’During the first introduction of RDTs, I was involvedin using them for some time but one thing I foundout is that (the RDT) is not as accurate as we wouldexpect. We found that the same (blood sample) thatwas negative in RDT, is positive in microscopy. Sonow we don’t use RDT.’ (healthcare worker 3, KII,urban village)

Other commonly reported disadvantages of RDTswere their variable and often insufficient supply as wellas their inability to visually detect the parasite andtherefore support prescribing of treatment.

‘(Microscopy) is always available here because wehave power, but for RDTs, when it runs out of stockwe have to wait for a long period of time before wehave it in our stock, whereas microscopy is alwaysavailable.’ (healthcare worker 1, KII, urban village)’I prefer microscopy because it is visual where I cansee the parasite and identify the real parasite, notlike RDTs where there is only chemical detection ofthe parasite. I don’t really trust the RDT.’ (Health-care worker 2, KII, urban village)

Despite these perceived disadvantages, RDTs werecommonly recognized as being potentially useful in ruraland remote areas where there is no microscopy service aswell as in urban and less remote rural clinics for use onweekends and evenings when the microscopist is notavailable. RDTs were also reported as being provided freeof charge to patients (compared to microscopy whichreportedly incurs a charge to patients), provides fasterresults and were identified as useful when there is nopower to use electric microscopes.

Community perceptions of RDTsNone of the participants in the urban village and only afew participants in the rural village (primarily thewomen) reported knowing what RDTs are or hadexperienced this test. Once this test was brieflyexplained to participants they reported their perceptionsof the potential advantages and disadvantages. Most par-ticipants in both villages reported the advantage of theRDT as its ability to provide prompt test results. A fewparticipants also identified that they were useful in poorweather when community microscopes are not opera-tional and that they are a way of avoiding human error.For these reasons, some participants in both villagesindicated perceived acceptability of RDTs.Despite these advantages and nominal acceptability

expressed by some participants, in most interviews parti-cipants, particularly those that had experienced theiruse, expressed their doubts regarding the accuracy of a‘rapid’ test. These doubts would reportedly promptdemands for presumptive malaria treatment, crosscheck-ing with microscopy (through attendance at multipleclinics) or the taking of left over malaria medicationthat may be available at their home or village.

‘I think I would doubt this new test (RDT) because itis very fast and might not properly diagnose theblood, whereas the microscope takes time for diagnos-ing and might be more accurate than the new test.’(male participant, FGD urban village)’I was uncertain whether it gave a true result becauseat least with the microscope they actually look at theblood. I think this is the true one, because it takes along time and they look at the blood.’ (female partici-pant, FGD rural village)

The lack of trust expressed in RDT and in negativeresults of microscopy appears to arise from the incon-gruence between the diagnosis provided by the aid postnurse and the patient’s self diagnosis of malaria andexpectations for malaria treatment. The majority of thecommunity members strongly voiced their expertise inclinical diagnosis of malaria given their history ofexperience with this disease.

‘...my expectation is that my child will be positive butinstead she was negative so I suggest that this RDTgave a false result so I don’t trust this sort of test.’(male participant, FGD rural village)’Almost everybody in every house knows how to diag-nose themselves of which sickness they have, whetherit is malaria or other diseases.’ (male participant,FGD urban village)


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Healthcare worker perceptions of ACTHealthcare worker attitudes to Coartem® (artemether-lumefantrine, AL) differed between the urban and ruralvillage. Healthcare workers in the urban village reportedthat AL has better acceptability than chloroquineamongst their patients, there are fewer complaints andthere has been better compliance with completion ofthe full dose as it has no side effects. Although somecriticisms included its occasional lack of supply and thatit is not available as an injection for the treatment ofmore severe malaria cases, overall AL has good accept-ability among healthcare workers in this village and theyperceived a reduction in the number of malaria casessince its introduction.

‘Yes...we have seen change take place, that is, thenumber of cases of malaria has decreased due to theintroduction of Coartem®. Not like before during thetime of chloroquine where we had a lot of positivecases. In one day we now only see 60 slides whereasbefore in one day we usually read 200 slides. ’(healthcare worker 2, KII urban village)

In contrast, healthcare workers in the rural villagereported problems with patients complying with thetiming of doses (i.e. some forgetting to take eveningtablets) of AL and one aid post worker reported that itis less effective than chloroquine (with anecdotal reportsof AL resistance based on poor response of presentingsymptoms to the AL treatment). Due to these reasons,one healthcare worker reported that some of his patientswill no longer accept AL for malaria treatment.

‘...the problem patients have is to drink the medicinestwice a day. If they don’t have a watch they just takethe medicines anytime they feel they want to take it.....at least 10% of the population of the catchment area Ilook after don’t want Coartem®. After taking the med-icine they would come back and check and they stillhave malaria. So for this reason they don’t want Coar-tem®.’ (healthcare worker 2, KII rural village)

Community perceptions of chloroquineUse of chloroquine was frequently mentioned bypatients, and was often compared with the new drugCoartem®; therefore these perceptions were recordedand analysed, even though chloroquine is not part ofthe new treatment regime. Perceptions and experienceswith malaria medication did not appear to differbetween the rural and urban village nor by gender orage. Chloroquine was the most well-known and com-monly used malaria treatment reported among partici-pants. Although some participants in both rural and

urban villages stated the importance of completing anentire dose of chloroquine provided by the nurse ordoctor in order to cure malaria, these participants weremostly those that held positions of leadership in theircommunities.

‘It is tambu (forbidden) to give the medicine to any-one. If I don’t complete my dose the sick will con-tinue.’ (village elder, KII rural village)

Reasons provided by the majority of the participantsfor poor adherence to the chloroquine dosage regimewere the bitter taste, experience of other side effects(commonly reported were body itchiness and dizziness)or the habit of ceasing its use once malaria symptomsare relieved.

‘...I usually experience body scratch so I just stop tak-ing (chloroquine) and put the rest aside. If I noticethis feeling following the first dose, I will straightaway put aside the rest of the tablets.’ (male youthparticipant, FGD urban village)

Less commonly reported side effects were abdominaldiscomfort, weakness and tiredness.

‘Another thing about that medicine (chloroquine) is itaffects your body and makes it weak, by the time itcomes to the second day you feel like you are drunkso I don’t finish the medicine.’ (male youth partici-pant, FGD rural village)

Despite these side effects, chloroquine was perceivedto be effective by most participants. Chloroquine tabletsnot used were commonly reported to be kept by house-holds for subsequent episodes of fever for themselves,other family members (including children) or occasion-ally for others in their community.

‘I stop taking the tablets (chloroquine) when I start toget better...The left over medication I keep in thehouse for next time if I get sick...or for some timewhen family come and ask for medicine I will give itto them.’ (female participant, KII urban village)’If I had left over medicine I would keep it, becausesometimes it is hard to get to the clinic, so you needto keep some medicine.’ (male youth participant,FGD rural village)

Community perceptions of ACTSome participants in both rural and urban villagesreported having taken the recently introduced ACT,Coartem® (artemether - lumefantrine, AL). Good


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acceptability was reported by most of those who hadused AL due to its effectiveness, the lack of side effectsand its pleasant taste. It was also perceived to be safe touse for pregnant women and children if prescribed andprovided by a healthcare worker.

‘This one (Coartem®) is nice. It wins over the old one,it tastes sweet and it is easy to take.’ (female youth,FGD rural village)‘...so after I completed 2 treatments (Coartem®), I feltbetter and I left out the last treatment...I found itseffect to be faster than chloroquine.’ (male partici-pant, FGD urban village)

A few participants of the male and youth FGDs in therural village however, perceived the lack of side effectsof AL and the larger quantity of tablets needing to betaken as evidence of its potential ineffectiveness or lackof strength.

‘The old one was 12 tablets and the new one is 24tablets. You have to take four in the morning andfour in the evening. This is three times more than theold type of pill. I am worried; do the new ones havesimilar strength for curing malaria as the old ones?’(male participant, FGD rural village)‘I like the old treatment because I know when itmakes me feel drunk that the treatment is so strongso it must be working. According to the new one, youhave to take 8 tablets for three days but you stillnever feel drunk, so the medicine must be weak/inef-fective.’ (male participant, FGD rural village)

Reports of storing of left over AL in households forsubsequent fever episodes emerged during the discus-sions with a few participants admitting to have donethis themselves. However, due to differences betweenpackaging (loose tablets are provided for chloroquineand pre-packaged blister strips for AL) one participantreported the storing of AL to be more difficult thanchloroquine.

‘It is important that when you open the packet of thenew tablets (Coartem®) that you take them straightaway so they are not exposed to the air, otherwisethe strength is reduced. But the old medicine is differ-ent; you can just keep the left over tablets in the bot-tle.’ (male participant, FGD rural village)

Participant recommendationsMost participants (both healthcare workers and villa-gers) recommended that further awareness be carriedout to improve community knowledge of the new

diagnostic and treatment interventions. Many of the vil-lage participants suggested that this awareness will mosteffectively be carried out by healthcare workers ortrained volunteers through regular visits to communitiesas this will allow villagers to receive education, ask ques-tions and have their concerns addressed.

‘They should set up programs to come down to thecommunity to provide awareness and health serviceto the village people so that they will not find it diffi-cult to go to the clinics.’ (youth participant, FGDurban village)‘...They must show the community how to use thetreatment. People have a lot of questions. They mustexplain the medicines well...In order to clear peoples’minds there is a need for nurses to go around andtalk to people rather than people only being able toask questions when they come to the clinic only.’(elder, KII rural village)

Particularly in the rural village, some participantsrequested education regarding the different types ofmalaria, why the new drug AL is being introduced andwhen and how it should be used.

‘The nurse did not come to the village to explain. Wedon’t know why we need to use the new treatmentnot the old treatment. How come? Is it because it isbad? They need to come to the village and explainwhy we need to take the new one.’ (male participant,FGD rural village)

DiscussionThis study was carried out to investigate communityand prescriber perceptions and acceptability of the newdiagnostic and treatment interventions in SI. Determin-ing malaria status has been advocated as an importanttool for reducing overuse of the more expensive ACT,to improve the management of non-malarial febrile ill-ness and to prevent emergence of parasite resistance tothis new first line drug [9]. However, the use of RDTshas elucidated a number of human behavioural chal-lenges which can negatively impact the acceptability anduse of RDTs and jeopardize the cost-effectiveness oftheir implementation.

Lack of healthcare worker confidence in RDT useHealthcare workers in the current study reportedinadequate training in the use of RDTs. Although apre-rollout training program for Provincial healthcareworker representatives did occur in the SI capital(Honiara), the ‘cascade training’ system implementedby the malaria programme had not reached many of


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the healthcare workers of the villages that participatedin this study. This approach to training refers to thedissemination of knowledge through multiple levelsuntil it reaches peripheral healthcare workers, but hasbeen criticized as being ineffective due to the dilutionof key messages and its lack of continuation [20]. Aprevious study on the effectiveness of ‘cascade training’has shown that although initially it is more cost-effec-tive and can provide some improvements in quality ofcare and access, it had less impact than supportivesupervision to reinforce guideline dissemination overtime [21]. The extent of Provincial-level training ofhealthcare workers in RDT use is not known andhence it is recommended that this be reviewed prior tonational scale-up of this intervention.Manufacturer’s instructions for RDT use have been

found to be insufficient to ensure their safe and accurateuse [22]. Given that the accuracy of RDT results candepend on factors such as storage and end-user perfor-mance, it is vital to implement an adequate training sys-tem and provision of ongoing supervision, technical/logistic support and feedback of quality control resultsfor RDTs [22-24]. Significantly higher accuracy in usingRDTs have been demonstrated in a Zambian studythrough the use of pictorial instructions (kept for refer-ence as a ‘job aid’) and a brief training session (3 hours)when compared to the use of manufacturer’s instruc-tions alone [22]. Other suggested content for a trainingcurriculum for RDTs are unambiguous guidelines, train-ing in alternative causes of disease and strategies toimprove healthcare worker - patient relationships [24].As well as ensuring accurate results, adequate trainingcan help foster healthcare worker confidence in the useand results of RDTs and improve their acceptability bythe community, which may reduce the practice of pre-sumptive treatment for malaria using ACT [15,22].

Lack of trust in negative diagnostic resultsIn this study, suspicions of inaccuracy of negativeresults of RDTs by both healthcare workers and com-munity members were found to adversely affect theiracceptability and result in practices of confirmingresults with microscopy, provision of presumptivetreatment or the taking of un-prescribed left-overmedication available in the community. These prac-tices, if widespread, have the potential to significantlyundermine the cost-benefit of RDTs as an adjunct oralternative to microscopy in SI [11].Although double checking of results was reported

more often with the use of RDTs in this study, micro-scopy results were also questioned by some communitymembers and would result in similar practices of doublechecking of results, self-medication or demands for pre-sumptive treatment. This seemed to occur when their

self-diagnosis was inconsistent with the diagnostic con-clusions made by the healthcare worker and hence theirexpectations of service were not met. Additionally in SI,community members are familiar with microscopyexamination of blood smears taking some time to “heatthe blood and look at it” when diagnosing malaria. Thelesser duration taken for diagnosis by RDT needs morecareful explanation to the community both at the timeof consultation, as well as at community level healthpromotion to facilitate its acceptability. The sustainabil-ity of ACT use as a first-line drug will be threatened ifthese practices cannot be sufficiently addressed [25].Previous studies carried out in Tanzania have indi-

cated that approximately 50% of patients who werenegative by microscopy or RDTs were prescribed anti-malarial drugs [25,26]. It is uncertain from the currentstudy the extent of over-prescription of anti-malariamedication in SI. In addition, it is unclear as to whetherpresumptive treatment is occurring as a result of com-munity expectations and hence pressure to prescribe ordue to a lack of healthcare worker trust of negativediagnostic results or both. Therefore, the SI NationalMalaria Program will benefit from addressing the issuefrom both perspectives.Patients living in malaria endemic areas that have

experienced multiple episodes and recognize their keyphysical symptoms as malaria are less likely to accept anegative RDT result. Travelling further to seek addi-tional testing using a more sensitive diagnostic tool orretesting using an RDT by another healthcare workersome time after the initial test could potentially result ina positive diagnosis for malaria. This process, which wasdescribed by participants of the current study, could sig-nificantly undermine the confidence community mem-bers have in the expertise of their local healthcareworkers, due to their lack of understanding how RDTswork and how changing levels of parasitaemia over timecan affect the results. Whilst health promotion activitiesshould focus on encouraging early diagnosis and treat-ment, it should also reiterate that a negative RDT resultcould potentially occur due to low parasite densities atthe early stage of the disease. Therefore, patients shouldalso be advised to return to the health facility for arepeat RDT/microscopy if symptoms do not resolve, orworsen. In designing messages to address this in SI, caremust be given not to contradict messages encouragingearly treatment-seeking for fever management.Studies carried out in Africa have shown that patient

demands for presumptive malaria treatment were lesslikely to occur where the community had confidence inthe education level of community healthcare workersusing RDTs [15,27]. In SI, particularly at the peripherallevel, there are very few physicians, with the majority ofhealth service providers being nurses and nurse aids.


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Community acceptability and trust in diagnostic resultsas well as confidence in their healthcare workers’ clinicaldiagnostic capabilities will need to be enhanced in SI.This can be done through a broader health systemstrengthening approach that includes adequate trainingin diagnosis and management of a range of febrile ill-nesses. This will need to be followed up with regularsupportive supervision.

Challenges relating to the use of ACTMost malaria endemic countries in Africa and Asia havenow adopted ACT into their anti-malarial drug policy[28]. However, in order to maximize their effectiveness,behavioural factors affecting early and complete treat-ment need to be addressed. In the current study ACTswere well accepted and reported as favourable by mostcommunity and healthcare workers interviewed. Theiracceptability was primarily a result of their lack of sideeffects when compared to chloroquine. Similar findingswere noted in a study investigating community accept-ability and perceptions of ACT in Tanzania [29]. Despitetheir high acceptability, delays in treatment-seeking andnon-completion of doses, both reported in our study aswell, can limit the impact of the drug and increase therisk of resistance emerging [29]. However, there werealso concerns expressed in our study population thatACT is not strong enough. Ironically, the side effectscomplained regarding chloroquine are also perceived bySolomon Islanders as evidence of them being strongenough to rid the body of malaria and that they areworking effectively. The bitterness of chloroquine, acharacteristic of traditional medicines used to treatmalaria in SI, is a sign of efficacy for malaria treatment,transmitted verbally through generations.Delays in treatment-seeking (of 2-4 days) were primar-

ily reported by participants in the rural village. The rea-sons for this remain unclear; however as noted, oneparticipant discussed differences in the accessibility ofservices as a cause. Alba et al (2010) reported in theirstudy in the rural areas of Ifakara, Tanzania that theavailability of outlets (health facilities or drug shops)was the most important determinant of whether patientsreceive prompt and effective treatment, whereas afford-ability and accessibility contributed to a lesser extent[30]. Similarly, in the poorest areas of four malaria ende-mic districts in Kenya, facility opening hours, organisa-tion of health care services and staff shortages wereidentified as barriers for availability to prompt and effec-tive treatment [17]. Importantly, in the rural communityof the current study, an increase in the severity of feverseemed to signify malaria and motivate treatment-seek-ing. This misconception, combined with reports of lessconvenient access to a healthcare worker, lack of confi-dence in healthcare workers’ diagnosis of fever and the

availability of left-over medication in the villageappeared to be the barriers to early treatment-seeking inthis rural village.A few participants including a healthcare worker

reported poor acceptability of ACT resulting in somerefusals, as they were perceived to lack strength andeffectiveness compared to chloroquine. This may be aresult of reported problems with adherence to thedosage regime or incorrect presumptive malaria treat-ment for a non-malarial fever. Although reported byonly a few participants, these issues highlight the nega-tive impact human behavioural factors can have on thesuccess of malaria control interventions, particularly inneglected rural communities.A concerning practice described in the study popula-

tions was the sharing of malaria medicines within thefamily or from other community members. This waslikely more easily done when medicines were providedin loose form compared to needing to physically “pop”the ACT from the blister packs in which they are pro-vided. Although this practice is concerning regardless ofthe type of medication that is shared, Coartem® is speci-fically weight/age prescribed and packaged and also sen-sitive to deterioration if removed from the packaging.The need to focus on informing the community of theseconcerns and of the rationale for correct use of pre-scribed medicines is highlighted by these findings.Another issue raised in the study are the reported dif-

ficulties by community members in taking Coartem®

according to the recommended dosing regimen (i.e. onedose immediately, second dose after 8 hours, then every12 hours for the rest of the three-day course). Conveni-ently, the dosing regimen of Coartem® is similar to Sep-trin® which is a widely used and familiar antibiotic inSI. Healthcare workers could therefore harness thisexisting knowledge to guide patients in completing thenew ACT dosing regime.The National Malaria Programme in SI has recognized

the need to ensure that the central level health staff whoare influential both as educators for nurses and nurseaides as well as community role models must be con-vinced of and support the new treatment regime. In theearly stages of the introduction of the new treatmentregime there were anecdotal reports that senior nursesat the National Referral Hospital were continuing to usechloroquine as they had more confidence in this drug.Special efforts have since been made to convince influ-ential health staff to become advocates for the change.It is hoped that this will improve confidence in the useof the new treatment regime by both peripheral healthstaff and their communities.Ensuring that all individuals suffering from malaria

have prompt access to effective treatment remains achallenge for resource constrained health systems [17].


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Nevertheless, the potential public health benefits of theintroduction of free, efficacious ACT in SI will not berealized if provider prescription practices do not con-form with the recommended guidelines or if patientsdo not adhere to treatment regimes or self-medicatewith sub-curative doses. Through a number of qualita-tive and quantitative evaluations, the SI NationalMalaria Program has demonstrated their commitmentto regular monitoring of human behavioural factorsthat impact intervention acceptability and use. Com-munity feedback provided through such investigationscontributes to informed policy decision-making andare integral to the success of the program. Based onthe results of this study, the SI National Malaria Pro-gramme is planning similar investigations into commu-nity and healthcare worker perceptions and attitudestowards ACTs and RDTs as part of their routine pro-gramme evaluation.

Study limitationsThis study was conducted to explore issues aroundacceptability and adherence to the new diagnostic andtreatment regime in SI. As with the nature of qualitativeresearch, the results are limited in their ability to begeneralized to the wider population. However, althoughthe above results reflect community and healthcareworker perceptions in one urban village and one ruralvillage in one Province, the consistency of themes thatemerged with existing published literature suggest thatthe issues may be more broadly applicable. Another lim-itation of the study may be the potential loss of nuancesthat can occur through the direct transcription andtranslation from Pijin to English by the local researchofficers. Having local co-investigators review transcrip-tions assisted in minimising this limitation.Very few participants reported knowing what RDTs

are or had seen or experienced this test prior to thestudy. Therefore, acknowledged as a potential limitationis the argument that notional acceptability is not neces-sarily congruent with actual acceptability following theuse of a particular tool or intervention [31]. Finally, theparticipants of this study were primarily of the SouthSea Evangelical Church, and it is hence unclear whetherparticipants with other religious affiliation would havediffering attitudes regarding the acceptability and use ofRDTs and ACT.

ConclusionsThis study has identified key issues around acceptabilityand compliance of using RDTs and ACT in Malaita Pro-vince, Solomon Islands. These issues have guidedrecommendations for the essential next steps to improvecompliance and confidence in the new diagnostic andtreatment interventions recently implemented in SI.

Recommendations include intensive health education toinform communities about the new treatment regime, aswell as effective refresher training of healthcare workers,with follow-on activities such as job aides and suppor-tive supervision on the use of RDTs. Attention will alsoneed to be focussed on reducing barriers to early treat-ment-seeking. Other studies have been undertaken inthe country to explore in more depth health seekingbehaviours for fever and malaria to complement thisstudy and its findings [32]. It will be essential to elicitthe support of influential community members andengage them in health promotion activities. In particu-lar, a participatory action-orientated approach will assistin building partnerships with communities and engagethem in the process of local decision-making and imple-mentation of the new treatment regime. In addition,supply lines should be streamlined for RDTs and Coar-tem® to ensure consistent stocks in the healthcarecentres.Practices such as presumptive treatment and the tak-

ing of sub-curative doses are of considerable concernfor both the health of individuals and the increased riskit poses to the development of parasite resistance to thisimportant first-line treatment against malaria. Exploringthe extent of these issues beyond the study populationsmust be a priority for malaria programme managers.These recommendations will be integral to the successand sustainability of intensified malaria control, subse-quently leading to elimination of malaria in SolomonIslands.

AcknowledgementsThis study was supported by a grant from AusAID through the PacificMalaria Initiative (PacMI). We would like to thank Catherine Sanga, John Funiand Augustine Todonga of the Solomon Islands Development Trust (SIDT)for carrying out the field research activities and Jennifer Wate (Director, SIDT)and Cate Storey (SIDT Program Adviser) for supervising and helping theresearch team in their field activities. We would also like to thank LukeMarston (PacMISC Support Officer, Honiara) and the Malaita ProvincialMalaria Team for their contribution to logistics support. Finally, the authorswould like to express their sincere gratitude to the urban and rural Malaitancommunities who participated in this study.

Author details1The University of Queensland, School of Population Health, Pacific MalariaInitiative Support Centre, Australian Centre for International and TropicalHealth, Brisbane, Australia. 2National Vector Borne Disease ControlProgramme, Ministry of Health, Honiara, Solomon Islands.

Authors’ contributionsRW, MW, JA, AB and LW participated in the conception of study design.Training of field researchers in qualitative methods and logistics was carriedout by JA and RW. The field research activities were supported andsupervised by RW, JA and MW. Data analysis was done by JA with feedbackfrom AB, LW and MW. Manuscript drafting was carried out by RW and JAwith reviews and contributions from MW, AB and LW. All authors have readand approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.


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Received: 12 October 2010 Accepted: 10 January 2011Published: 10 January 2011

References1. Smith LA, Jones C, Meek S, Webster J: Review: Provider practice and user

behavior interventions to improve prompt and effective treatment ofmalaria: do we know what works? Am J Trop Med Hyg 2009, 80:326-335.

2. WHO: Global Stratergy for Malaria Control. Geneva; World HealthOrganization; 1993.

3. RBM: Global Stratergic Plan: Roll Back Malaria 2005 - 2015. Geneva: RollBack Malaria Partnership; 2005.

4. Perkins MD, Bell DR: Working without a blindfold: the critical role ofdiagnostics in malaria control. Malar J 2008, 7(Suppl 1):S5.

5. Rieckmann KH: The chequered history of malaria control: are new andbetter tools the ultimate answer? Ann Trop Med Parasitol 2006,100:647-662.

6. NVBDCP: Solomon Islands National Vector Borne Disease ControlProgramme - Programmatic Report 2009. Honiara: Ministry of Health andMedical Services; 2009.

7. National Vector Borne Disease Control Programme (NVBDCP) SolomonIslands & Vanuatu: Consolidated national monitoring and evaluation plan:for intensive malaria control and progressive elimination in SolomonIslands and Vanuatu 2008 - 2014. Ministries of Health and MedicalServices, Solomon Islands & Vanuatu; 2008.

8. Ministry of Health and Medical Services: Solomon Islands 2009: MalariaTreatment Protocol. Honiara: Ministry of Health and Medical Services,Solomon Islands; 2009.

9. Msellem MI, Martensson A, Rotllant G, Bhattarai A, Stromberg J, Kahigwa E,Garcia M, Petzold M, Olumese P, Ali A, et al: Influence of rapid malariadiagnostic tests on treatment and health outcome in fever patients,Zanzibar: a crossover validation study. PLoS Med 2009, 6:e1000070.

10. Lubell Y, Reyburn H, Mbakilwa H, Mwangi R, Chonya K, Whitty CJ, Mills A:The cost-effectiveness of parasitologic diagnosis for malaria-suspectedpatients in an era of combination therapy. Am J Trop Med Hyg 2007,77:128-132.

11. Lubell Y, Reyburn H, Mbakilwa H, Mwangi R, Chonya S, Whitty CJ, Mills A:The impact of response to the results of diagnostic tests for malaria:cost-benefit analysis. BMJ 2008, 336:202-205.

12. Wongsrichanalai C, Barcus MJ, Muth S, Sutamihardja A, Wernsdorfer WH: Areview of malaria diagnostic tools: microscopy and rapid diagnostic test(RDT). Am J Trop Med Hyg 2007, 77:119-127.

13. Zikusooka CM, McIntyre D, Barnes KI: Should countries implementing anartemisinin-based combination malaria treatment policy also introducerapid diagnostic tests? Malar J 2008, 7:176.

14. Williams HA, Causer L, Metta E, Malila A, O’Reilly T, Abdulla S, Kachur SP,Bloland PB: Dispensary level pilot implementation of rapid diagnostictests: an evaluation of RDT acceptance and usage by providers andpatients–Tanzania, 2005. Malar J 2008, 7:239.

15. Mukanga D, Tibenderana JK, Kiguli J, Pariyo GW, Waiswa P, Bajunirwe F,Mutamba B, Counihan H, Ojiambo G, Kallander K: Community acceptabilityof use of rapid diagnostic tests for malaria by community healthworkers in Uganda. Malar J 2009, 9:203.

16. Wasunna B, Zurovac D, Goodman CA, Snow RW: Why don’t healthworkers prescribe ACT? A qualitative study of factors affecting theprescription of artemether-lumefantrine. Malar J 2008, 7:29.

17. Chuma J, Okungu V, Molyneux C: Barriers to prompt and effective malariatreatment among the poorest population in Kenya. Malar J 2010, 9:144.

18. Gerstl S, Dunkley S, Mukhtar A, Baker S, Maikere J: Successful introductionof artesunate combination therapy is not enough to fight malaria:results from an adherence study in Sierra Leone. Trans R Soc Trop MedHyg 2010, 104:328-335.

19. Braun V, Clarke V: Using thematic analysis in psychology. QualitativeResearch in Psychology 2006, 3:77-101.

20. Petit P: Continuing education. Closing the performance gap. HealthAction1994, 4-5.

21. Stanback J, Griffey S, Lynam P, Ruto C, Cummings S: Improving adherenceto family planning guidelines in Kenya: an experiment. Int J Qual HealthCare 2007, 19:68-73.

22. Harvey SA, Jennings L, Chinyama M, Masaninga F, Mulholland K, Bell DR:Improving community health worker use of malaria rapid diagnostic

tests in Zambia: package instructions, job aid and job aid-plus-training.Malar J 2008, 7:160.

23. Moonasar D, Goga AE, Frean J, Kruger P, Chandramohan D: An exploratorystudy of factors that affect the performance and usage of rapiddiagnostic tests for malaria in the Limpopo Province, South Africa. MalarJ 2007, 6:74.

24. Chandler CI, Whitty CJ, Ansah EK: How can malaria rapid diagnostic testsachieve their potential? A qualitative study of a trial at health facilitiesin Ghana. Malar J 2010, 9:95.

25. Reyburn H, Mbakilwa H, Mwangi R, Mwerinde O, Olomi R, Drakeley C,Whitty CJ: Rapid diagnostic tests compared with malaria microscopy forguiding outpatient treatment of febrile illness in Tanzania: randomisedtrial. BMJ 2007, 334:403.

26. Reyburn H, Ruanda J, Mwerinde O, Drakeley C: The contribution ofmicroscopy to targeting antimalarial treatment in a low transmissionarea of Tanzania. Malar J 2006, 5:4.

27. Chandler CI, Mwangi R, Mbakilwa H, Olomi R, Whitty CJ, Reyburn H: Malariaoverdiagnosis: is patient pressure the problem? Health Policy Plan 2008,23:170-178.

28. Whitty CJ, Chandler C, Ansah E, Leslie T, Staedke SG: Deployment of ACTantimalarials for treatment of malaria: challenges and opportunities.Malar J 2008, 7(Suppl 1):S7.

29. Kamat VR, Nyato DJ: Community response to artemisinin-basedcombination therapy for childhood malaria: a case study from Dar esSalaam, Tanzania. Malar J 2010, 9:61.

30. Alba S, Dillip A, Hetzel MW, Mayumana I, Mshana C, Makemba A,Alexander M, Obrist B, Schulze A, Kessy F, et al: Improvements in access tomalaria treatment in Tanzania following community, retail sector andhealth facility interventions – a user perspective. Malar J 9:163.

31. Atkinson JA, Bobogare A, Vallely A, Boaz L, Kelly G, Basifiri W, Forsyth S,Baker P, Appleyard B, Toaliu H, et al: A cluster randomized controlledcross-over bed net acceptability and preference trial in Solomon Islands:community participation in shaping policy for malaria elimination. MalarJ 2009, 8:298.

32. O’Sullivan M, Kenilorea G, Yamaguchi Y: Malaria Elimination in IsabelProvince, Solomon Islands: Assessing the feasibility of a surveillanceprogramme to prevent introduction of malaria from other islands.Dissertation Brisbane: University of Queensland; 2010.

doi:10.1186/1475-2875-10-3Cite this article as: Wijesinghe et al.: Exploring provider and communityresponses to the new malaria diagnostic and treatment regime inSolomon Islands. Malaria Journal 2011 10:3.

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