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01.12.2012 | Research | Ausgabe 1/2012 Open Access

Malaria Journal 1/2012

Relationship between treatment-seeking behaviour and artemisinin drug quality in Ghana

Malaria Journal > Ausgabe 1/2012
Eili Y Klein, Ian A Lewis, Christina Jung, Manuel Llinás, Simon A Levin
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1475-2875-11-110) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

EK and CJ developed the study design. CJ purchased the drugs, interviewed caregivers, and analysed data. EK and IL performed drug analysis. EK, IL and CJ wrote the manuscript. SL and ML reviewed and commented on the manuscript and contributed to the interpretation of the results. All authors saw and approved the final version.



Artemisinin-based combination therapy (ACT) is currently the recommended first-line treatment for uncomplicated malaria infections. However, a significant proportion of ACT is assumed to be of poor quality, particularly in Africa. In addition, little is known about how treatment-seeking behaviour of individuals or drug price is associated with drug quality.


Caregivers of children less than 5 years of age were interviewed on their knowledge of malaria and their choices for treatment. Artemisinin drugs were then purchased from sellers that caregivers preferred or had previously patronized. The active ingredients were quantified by nuclear magnetic resonance spectroscopy.


A negative relationship was anticipated between the education level of caregivers and the quality of anti-malarial drugs purchased. However, of the 33 drugs collected from 16 different shops, only one contained less than 80% of its purported active ingredient, and most drugs were within 90% of their listed amounts. No link was found between drug quality and price. Nonetheless, while ACT is the recommended first-line treatment in Ghana, 21% of the drugs collected were artemisinin monotherapy, and 27% of the ACT was not co-formulated. Among caregivers, higher education was found to be associated with both an increased likelihood of seeking treatment in a clinic first, as opposed to visiting drug shops or using herbal remedies, and with purchasing drugs from licensed sellers.


Surprisingly, drug quality was found to be uniformly high and thus no significant relationship between price, treatment-seeking behaviour and the content of the active ingredients was observed. However, artemisinin monotherapy, which the WHO considers inappropriate therapy, was still widely available in Ghana in 2010. Monotherapy was more likely to be available in unlicensed vendors where less-educated caregivers generally shopped. This linkage between education, treatment-seeking behaviour and drug availability suggests that the global subsidy to reduce the cost of co-formulated ACT can play a significant role in increasing its availability.
Additional file 1: Guided Questions for Household Interviews. Guided questions used to conduct all interviews with participants about disease awareness and treatment-seeking behaviour. (PDF 27 KB)
Additional file 2: Example comparing NMR Spectra of different compounds. One-dimensional 1H NMR spectra of artemether standard, lumefantrine standard, and Coartem®, a coformulated standard, at different concentrations. (PDF 60 KB)
Additional file 3: Example comparing NMR Spectra of different concentrations. One-dimensional 1H NMR spectra of artemether standards at different concentrations. (PDF 46 KB)
Additional file 4: Caregiver Information. Table listing detailed information about each participating caregiver. (PDF 43 KB)
Additional file 5: Drug Formulations. Detailed data on each drug collected. (PDF 48 KB)
Additional file 6: Artemether Estimated Quantity. Raw data of estimated artemether concentrations. (PDF 32 KB)
Additional file 7: Lumefantrine Estimated Quantity. Raw data of estimated lumefantrine concentrations. (PDF 32 KB)
Additional file 8: Artesunate Estimated Quantity. Raw data of estimated artesunate concentrations. (PDF 31 KB)
Additional file 9: Amodiaquine Estimated Quantity. Raw data of estimated amodiaquine concentrations. (PDF 31 KB)
Additional file 10: Dihydroartemisinin Estimated Quantity. Raw data of estimated dihydroartemisinin concentrations. (PDF 37 KB)
Additional file 11: IC50 vs. Observed Drug Quantity. Plot of estimated IC50 values vs observed drug quantity. (PDF 44 KB)
Authors’ original file for figure 1
Authors’ original file for figure 2
Authors’ original file for figure 3
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