|Year : 2016 | Volume
| Issue : 4 | Page : 267-273
Patronage and perceived efficacies of artemisinin-based combination therapies and herbal antimalarials in Kumasi, Ghana
George Asumeng Koffuor1, Akua Afriyie Abruquah2, Rauf Audu3, Theresa Agyapong1, Yaa Afrakoma Amoa-Gyarteng1
1 Department of Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
2 Department of Pharmaceutical Sciences, Faculty of Health Sciences, Kumasi Polytechnic, Kumasi, Ghana
3 Department of Clinical and Social Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi; Kama Health Service, Kumasi, Ghana
|Date of Web Publication||15-Nov-2016|
Dr. George Asumeng Koffuor
Department of Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi
Source of Support: None, Conflict of Interest: None
Context: Herbal antimalarials are promising to be a sure way to offset malaria. Aim: The aim of this study was to assess the patronage and the perceived efficacies of artemisinin-based combination therapies (ACTs) and herbal antimalarials in Ghana. Methods: A cross-sectional survey on this subject was conducted in Kumasi, Ghana, between January and April 2014. Statistical Analysis: Statistical analysis was performed by Pearson's Chi-square analysis; P ≤ 0.05 was considered statistically significant. Results: Of 500 respondents (46.8% males; 53.2% females) interviewed, 75% were aged between 20 and 40 years. Majority (82.9%) had secondary education although 2.5% had no formal education. Respondents had a good knowledge of the symptoms of malaria; headache (93.8%), fever (99.1%), nausea and vomiting (93.8%), and general body weakness (88.4%) were most frequently mentioned. For malaria therapy, 73.6% use ACTs, while 47.6% use prepackaged or extemporaneous herbal antimalarials; 52.1% of the herbal users had used ACTs before. Commonly used herbs were Phyllanthus fraternus, Vernonia amygdalina, Khaya senegalensis, Azadirachta indica, and Cryptolepis sanguinolenta. Although 69.8% of ACT users recovered from malaria after a complete course, 27.2% recovered after course repetition(s) within 4 weeks. Nearly 82.8% of herbal users recovered fully after taking required quantities as stated by the manufacture, with 17.2% having recurrence. Side effects such as general malaise and dizziness reported by ACT and herbal antimalarial users were 15.3% and 10.1%, respectively. Although there was no significant relationship between preferred antimalarial type and age as well as working status, there was high significant (P ≤ 0.001) relationship with tertiary education. Conclusion: Although both ACTs and herbal antimalarials are highly patronized, a greater percentage of consumers find herbal antimalarials to be more efficacious.
Keywords: Artemisinin-based combination therapy, herbal antimalarials, Malaria, presumptive diagnosis
|How to cite this article:|
Koffuor GA, Abruquah AA, Audu R, Agyapong T, Amoa-Gyarteng YA. Patronage and perceived efficacies of artemisinin-based combination therapies and herbal antimalarials in Kumasi, Ghana. Int J Health Allied Sci 2016;5:267-73
|How to cite this URL:|
Koffuor GA, Abruquah AA, Audu R, Agyapong T, Amoa-Gyarteng YA. Patronage and perceived efficacies of artemisinin-based combination therapies and herbal antimalarials in Kumasi, Ghana. Int J Health Allied Sci [serial online] 2016 [cited 2020 Feb 25];5:267-73. Available from: http://www.ijhas.in/text.asp?2016/5/4/267/194132
| Introduction|| |
Malaria is proven to be one of the most debilitating illnesses of all time resulting in over one million deaths annually worldwide.  Its management has become complicated as the causative agents of malaria, including Plasmodium falciparum, Plasmodium ovale, Plasmodium malariae, and Plasmodium vivax, have been reported to have gained resistance to most of the safest and cheapest first-line drug treatments.  Thus, in 2004, Ghana changed its antimalarial drug policy to select artemisinin-based combination therapies (ACTs) and officially adopted it in 2005 as the first-line treatment for the management of uncomplicated malaria. The ACTs have faced their fair share of criticisms in terms of efficacy and toxicity, ,, hence a number of Ghanaians have drifted to use prepackaged or extemporaneous herbal antimalarial formulations. , The question therefore arises on the efficacy and safety of these herbal preparations, as against the ACTs. This study therefore compared the patronage and the perceived efficacy of ACTs and herbal antimalarials in Kumasi, Ghana.
| Methods|| |
The study was conducted in Kumasi, the regional capital of the Ashanti region of Ghana. It is an urban (metropolitan) area that is highly populated (a third of the region's population). Kumasi has high commercial activities and established industries. Although it is Ashanti dominated, almost all the other ethnic groups in Ghana are represented in this region, hence ethnic and cultural diversity abounds tremendously in this area [Figure 1]. The populace is however closely knit together in a harmonious relationship. 
The survey involved 500 suspected malarial patients aged between 20 and 60 years. This age limit was considered based on the ability to decide on their type of malarial treatment. The study which was a simple random and cross-sectional survey was conducted between January and April, 2014. The research was done according to the Helsinki Declaration on research regarding human subjects and approved by the Departmental Ethics Committee (reference No: FPPS/PCOL/015/2013). Consent of the respondents was sought for by giving detailed explanation of the aim and objectives of the study. Taking part in this survey was not obligatory. No incentives were given to entice individuals into this study. Confidentiality was ensured by random coding of the questionnaires. Data collection (mainly quantitative) was done using semi-structured interviews and a guided open- and close-ended questionnaire. The interviews were conducted using a checklist of questions and were held with individuals who have ever been infected with malaria. The questionnaire was tested in a pilot study before used in this survey. In addition, observations on issues relevant to the study objectives, such as various herbs used for the treatment of malaria, were also made. The questions were translated into Akan (Twi), the principal language spoken in the study area, where necessary.
Data collected included the knowledge of malarial symptoms, patronage of ACTs and herbal antimalarials, perceived efficacy and side effects of these antimalarials, preference of antimalarials, and antimalarial combination therapy, among others. The following were excluded from the survey:
- Individuals below the age of 20 and those above the age of 60 years
- Health workers and traditional medicine practitioners were excluded because of the possibility of being influenced by their professional background
- Individuals who appeared dissatisfied with the study and unable to mention the symptoms of malaria
- Individuals with no experience of malarial treatment with either ACTs of herbal antimalarial preparations or products.
Deductions made from this study were based on presumptive/clinical diagnosis which relied only on presenting signs and symptoms and not test-based diagnoses. Data were summarized using the SPSS software V19 (IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.) and presented in figures and tables. Pearson's Chi-square analysis was used where comparison to determine significance was required. A 95% confidence limit was chosen; P ≤ 0.05 was considered statistically significant.
| Results|| |
Of the 500 respondents, 234 (46.8%) were males and 266 (53.2%) were females. Majority of the respondents (75%) were aged between 20 and 40 years. Most participants (59.2%) had secondary education. Most of the respondents were either self-employed (41.2%), i.e., traders, drivers, hawkers, farmers, market women etc., or were salaried workers (35.4%), i.e., teachers and office staff [Table 1].
|Table 1: Age, level of education, and employment status of the 500 respondents enrolled in this comparative study |
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Headache, fever, joint pains, anorexia, diarrhea, nausea and vomiting, general body weakness, cough and cold, bitter taste in mouth, dizziness, and drowsiness were mentioned as the signs and symptoms of malaria by at least 40% of the respondents. The most common ones, however, were headache (93.8%), fever (99.1%), nausea and vomiting (93.8%), and general body weakness (88.4%) [Table 2].
The use of ACTs or herbal antimalarials was investigated to ascertain the level of patronage of these drugs. Three hundred and eighty-six (73.6%) respondents had used ACTs previously while 114 (26.4%) claimed never to have used ACTs before. A total of 238 respondents (47.6%) had used herbal antimalarials previously; of these 124 (52.1%) had also used ACTs previously. Most (77%) of the consumers of herbal antimalarials patronized prepackaged herbal preparations, while 23% prepared, extemporaneously, antimalarials from parts (i.e., leaves, bark, and roots) of two to five medicinal plants. Active medicinal plants used in the preparation of prepackaged herbal antimalarial products (as found on the product labels) and those mentioned of extemporaneous antimalarials are shown in [Table 3]. Prominent among these were Phyllanthus fraternus, Vernonia amygdalina, Khaya senegalensis, Azadirachta indica, Cryptolepis sanguinolenta, and Morinda lucida.
|Table 3: Medicinal plants with antimalarial activity used in the preparation of prepackage antimalarial products and those mentioned by respondents as plants used in extemporaneous preparations of antimalarials |
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Two hundred and sixty-six (69.8%) of the 386 respondents who had ever used ACTs reported that they recovered from the symptoms of malaria after taking one complete course; thus had no recurrence of the disease. However, 105 (27.2%) recovered only after repetition of ACT courses (71.4% of this number taking it two times and 28.6% taking it three times) within 4 weeks [Table 4]. Fifteen individuals (4.0%) claimed that they did not recover after three complete courses of ACTs. Forty-three of the 105 individuals (i.e., 41%) switched over to use herbal antimalarials the next time they showed symptoms of malaria as a result of perceived ineffectiveness of the ACTs. For individuals using the herbal antimalarials for 5-7 days as stated by manufacturers, 197 (82.8%) of 238 recovered from the disease, without relapse. However, 41 (17.2%) had relapse within 4 weeks after the treatment [Table 4]. Nine (36%) respondents using herbal antimalarials switched on to use ACTs upon treatment failure. Pearson's Chi-square value obtained indicated high significant (P ≤ 0.001) association between the perceived efficacy of the ACTs and the herbal antimalarials used.
|Table 4: Time of recurrence of symptoms of malaria in individuals after completing a course of antimalarial |
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In individuals using ACTs, 59 (15.3%) experienced some side effects while 327 (84.7%) had no side effects. The most prominent side effects were general malaise (32%) and dizziness (32%) [Figure 2]a. In individuals using herbal antimalarials, 214 (89.9%) did not experience any side effect while 24 (10.1%) individuals reported side effects: diarrhea (16.7%) and general malaise (33.3%) being the most prominent. Some of the herbals resulted in sedation while others enhanced appetite [Figure 2]b. In general, the number of side effects of users of ACTs was more than that of users of herbal antimalarials. It is noteworthy that the two categories of antimalarial medicines had common side effects such as diarrhea, headache, and general malaise. There was a high significant (P ≤ 0.001) association between side effects (safety) as assessed by the respondents and their preferred choice of antimalarials.
|Figure 2: Side effects experienced by the consumers of artemisinin-based combination therapies (a) and herbal antimalarials (b). Association between side effects and their preference of antimalarials; P ≤ 0.001 (Pearson's Chi-square analysis). H: Headache, GM: General malaise, S: Sedation, AS: Appetite suppression, D: Diarrhea, DZ: Dizziness, I: Insomnia, N: Nausea|
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From the survey, 85 (17%) respondents took both the herbal and ACT antimalarial products. This was because the ACTs could not give satisfactory relief of malaria. All these individuals claimed to have recovered on using the two antimalarials together. No noticeable side effects were recorded on combination of these drugs.
Four hundred and two, i.e., 80.4% of the respondents preferred ACTs, the reasons being an orthodox medicine (formulated under Good Manufacturing Practice [GMP]), defined strength and dose regimen, obtained from a reputed health institution (under the National Health Insurance Scheme), less bitter, and portable to carry along. On the ability to relieve symptoms, 311 (62.2%) selected ACTs, while 178 (35.7%) selected herbal antimalarials. Comparing the pattern of preference of both ACTs and herbal antimalarials in relation to occupation, 75.5% of the students preferred ACTs. Twenty-two percent of respondents who were salary workers preferred herbal antimalarials while 72.4% of the respondents from the tertiary education category preferred ACTs [Figure 3]. Chi-square value obtained showed no statistical significance between demographics and preferred antimalarial drugs. However, there was a significant relationship between tertiary education and preferred antimalarial drugs at P ≤ 0.001.
|Figure 3: Artemisinin-based combination therapies or herbal antimalarial preference based on (a) age, (b) employment status, and (c) educational level, for the 500 respondents. There was a high significant relationship (P ≤ 0.001) between tertiary education and the preferred antimalarial (Pearson's Chi-square analysis)|
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| Discussion|| |
An assessment of the patronage and the perceived efficacies of ACTs and herbal antimalarials was undertaken. In this study, almost as many males as females were involved to ensure gender balance. Age was fairly distributed with the majority being 20-40 years. Individuals within this age bracket fall within the working class and are usually independent and economically viable, and therefore make decisions on their preferred antimalarial medications. Research has indicated that age influences decision-making.  In Ghana, it is presumed that herbal medicines are the preserve of the elderly probably due to their in-depth knowledge in the use of herbal preparations in the treatment of various disease conditions. Older persons have been noted to have high tolerance for bitter medicines because of the assumption that the bitter the medicine, the more efficacious it is.
A number of studies have shown that people in lower socioeconomic status have less access to education and resources. ,, These limitations therefore influence their decision-making with regard to health care. It is therefore assumed that the preference for orthodox or herbal products for the less endowed is influenced by their limited knowledge base and economic viability.  Majority of respondents had secondary school education, and therefore were adequately enlightened to make informed decisions on medications based on their educational background.
Again in Ghana, people are of the notion that herbal medicines are for the poor and downtrodden in society. Sometimes, herbal medicines are formulated through unorthodox processes which may lack GMP standards. This could account for less patronage of herbal products by the educated folks. Poor plant material processing also leads to less hygienic products and possible destruction of active ingredients.  However, due to innovative means of processing herbal drugs, high-quality products are being approved for use by the Food and Drug Administration nationwide.  These evaluation processes are capital intensive and usually affect the cost of the final product. Therefore, preference of antimalarial medications could also be influenced by cost of products. It is known that the cost of a prepackaged herbal antimalarial or the cost of getting the ingredients to prepare a herbal antimalarial is higher than the ACT; besides, the ACTs could be obtained virtually free of charge under the National Health Insurance Scheme. However, because of the seemingly ineffective experience with the ACTs, patients tend to shift to herbal antimalarials even if they had to acquire these at a higher cost. Majority of the respondents were self-employed and salaried workers which suggest their possible ability to purchase either the ACTs or herbal antimalarials.
This study revealed that cost-effectiveness, less side effect profile, and efficacy of antimalarials were determinants in the use of ACTs or herbal antimalarials. However, efficacy and less side effect profile were dominant factors influencing the use and preference of antimalarials. The residence of respondents affects accessibility or availability of antimalarials. It was shown that in residential areas where drug outlets were unavailable malaria patients resort to herbs to medicate themselves. Therefore, traditional medicine practitioners utilize this advantage to advance their trade in various herbal plants to manage malarial symptoms.
Assessment of the efficacy of the antimalarials was based on their ability to relieve the clinical symptoms of malaria. The malarial symptoms shown in this study were headache, fever, joint pains, anorexia, diarrhea, nausea, vomiting, general body weakness, cough, cold, bitter taste, dizziness, and drowsiness. These resonate with several research findings. , Other symptoms such as anemia, hypoglycemia, respiratory depression, seizures, abnormal behavior, and coma (cerebral malaria) were related to severe malaria due to high parasitemia. Delays in the treatment of malaria or referral of infected patients to hospitals immediately have resulted in permanent physiological disorders such as spasticity, behavioral and cognitive impairments, epilepsy, blindness, and ultimately death. There is a need to increase public health education on symptoms of both complicated and uncomplicated malaria.
The high patronage of ACTs (73.6%) could be due to the malaria treatment directives on ACTs in Ghana. The antimalarial policy (2004) indicates that uncomplicated malaria cases and pregnant women with malaria should be treated with ACTs. , Health institutions such as hospitals, pharmacies, and other licensed drug outlets stock largely ACTs because of the current health directive. The Affordable Medicine Facility-malaria, implemented by the Global Fund, was designed to increase access to quality-assured ACTs. This was done by means of subsidized pricing mechanism. , The inclusion of the ACTs in the Essential Drug List of Ghana and the National Health Insurance policy has influenced the patronage and indeed the preference of the ACTs for malarial treatment in this study.
The high cost of prepackaged herbal products indicates why students and unemployed respondents could not afford to patronize them. However, 77% of the respondents who preferred herbal products went in for the prepackaged ones. This could be attributed to massive improvement in manufacturing processes of the herbal products. Herbal products are believed to have less adverse effects than orthodox medicinal products. 
In this study, it was revealed that some patients opted for herbal products after the therapeutic failure of the ACTs. This could be related to the growing evidence of the proliferation of substandard ACTs, nonadherence to treatment regimen, and mutations of the malarial parasite to ACTs. , There is a widespread assertion that drug resistance is less in herbal preparations due to the interactions of diverse plant constituents in the formulation.  The scope of this study excluded pharmacodynamic and pharmacokinetic drug interactions. Despite the observation in this study that individuals who combined ACTs and herbal preparations reported treatment as being successful, this practice of combining orthodox and herbal medicines could precipitate unwanted side effects and drug-drug interactions. Circumstantial evidence, however, exists to show that herbs or herbal preparations should not be mixed with orthodox drugs at all. , Studies have shown the occurrence of life-threatening side effects such as marked hypokalemia, excessive bleeding, and excessive diarrhea, when orthodox medicine and herbal preparations are combined. , Synergistic effects of medicinal products have been shown to be needless with the tendency of aggravating side effects and interfering with cytochrome P450 enzyme systems which are vital to drug metabolism. 
Although 80.4% of the respondents preferred ACTs, 62.2% of these respondents based their preference on efficacy, i.e., ability to relieve malarial symptoms. One hundred and seventy-eight (35.7%) individuals preferred herbal antimalarials based on efficacy. Studying the preference pattern of ACTs and herbal antimalarials in relation to occupation, students mostly had preference for the ACTs. The possible reasons could be due to their high literacy level which encourages them to abide by the national directives on malarial treatment. Salaried workers were the majority in terms of preference for herbal antimalarials, probably because of their financial capacity to afford more expensive medications.
| Conclusion|| |
Both the ACTs and herbal antimalarials were patronized, but majority claimed that the herbal antimalarials were more efficacious. Malarial treatment using ACTs should be considered for modification to provide significantly adequate results in patients.
The authors are very grateful to Mr. Asare of the Herbal Medicine Department, KNUST, for interpreting scientific names of some of the antimalarial plants to vernacular names and vice versa.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]