The failure of patients to adhere to recommended treatment guidelines is a major driver of widespread pathogen resistance, making diseases like malaria, pneumonia and HIV increasingly difficult and expensive to treat. Currently, Artemisinin Combination Therapies (ACTs) are the only effective treatment remaining for malaria. Although ACTs have a short three-day dosing regimen, over 35 percent of patients do not complete the full course of drugs. We conducted a randomized controlled trial in Central Uganda, with 2,500 households, designed to understand the reasons for poor adherence to the ACT treatment regimen. We also experimented with specially designed packaging and targeted messages to boost adherence. We find that a very strong predictor of adherence is how the patient is feeling (their symptom severity) when they are halfway through the treatment course. We hypothesize that patients who feel better mid-course are assuming their malaria is cured and discontinue treatment. Consistent with this hypothesis, a sticker affixed to standard ACT packaging that informs people that "malaria is not gone until all tablets are finished" significantly (though modestly) increases adherence, particularly for those patients whose symptoms were resolving early. On the other hand, a message designed to discourage saving pills for future malaria episodes had no significant effect on adherence. We also test a common approach to increasing adherence to ACTs in Africa by using specialized packaging that includes pictorial instructions for illiterate patients and information designed to raise patients' confidence in the effectiveness of the medication. While this special packaging increases the cost of ACTs by 10 to 50 percent, we find that it has no significant effect on medication taking behavior or on comprehension of instructions.
About the Speaker:
Dr. Jessica Lee Cohen is Assistant Professor at the Harvard School of Public Health and Faculty Affiliate at the Jameel-Poverty Action Lab (J-PAL). She uses behavioral and health economics and impact evaluation methods to improve maternal and child health programs in sub-Saharan Africa. Dr. Cohen's work has included field experiments to increase coverage of malaria prevention and treatment products, increase the reach of pharmaceutical supply chains to remote regions, and remove financial and behavioral barriers to safe delivery and neonatal health. She co-edited the book "What Works in Development?: Thinking Big and Thinking Small" and has published work in major economics and public health journals. She also has conducted research on financing vehicles to reduce aid volatility and the feasibility of malaria elimination. Her work has been discussed in media such as the Economist, the Boston Globe and the New York Times. She advised the government of Zanzibar on its malaria control program and the Canadian International Development Agency on its child survival programs. Dr. Cohen received her bachelor's degree in economics from Wesleyan University and was a National Science Foundation Graduate Research Fellow at MIT, where she received her doctorate in economics.