In the remote villages of Bugoye sub-county at the foot of Uganda’s Rwenzori Mountains a rolling landscape stretches across lush river valleys and steep hillsides. It’s the kind of terrain that might make for a beautiful and strenuous weekend hike for visitors but not necessarily for the people who live there. Residents of this region walk up and down the steep mountainsides throughout their days, at times descending over 1,000 feet to collect water in valley rivers and streams. A visit to the closest clinic or health center can be an arduous journey. This is also malaria country.
“To get to a health center, you may have to hike down a mountain, then take a motorcycle, then walk, perhaps for hours, depending on where you’re coming from,” said Victoria Shelus, PhD, who conducted her dissertation research as a Fulbright-Fogarty Fellow last year through a partnership between Mbarara University of Science and Technology (MUST) and UNC-Chapel Hill.
“Even when they do reach the health center, the necessary tests, procedures, or medications are often not available.”
That’s why private drug shops have become the first point-of-call for health care delivery, selling over-the-counter medications, including antimalarials.
“Drug shops are much more flexible than the public health centers which close in the afternoon and frequently run out of medications. Drug shops are typically located in the villages, are always open, and can offer relatively quick and personalized care.”
Drug shops also sell rapid diagnostic tests for malaria. Because there are many other causes of fever, including viral infections, the World Health Organization and Uganda’s Ministry of Health recommend that all suspected malaria cases be confirmed prior to treatment, a policy known as “test and treat.” Overtreatment drives malaria resistance and wastes limited resources. It can also delay treatment for other causes of fever.
Building on the work of Dr. Ross Boyce through the UNC Institute for Global Health & Infectious Diseases, Victoria set out to understand client and vendor health behaviors and practices at the drug shops. A previous study had confirmed more than half of all antimalarials administered in the sub-county were coming from drug shops.
“Malaria symptoms can start very general and nonspecific, with fever, chills and muscle aches. And there are many things that can cause these symptoms. We wanted to know more about drug shop practices, and specifically how many people who were buying antimalarials there were getting tested first, and then how many people who bought these medications actually had malaria, rather than something else.”
Starting in the Bugoye Village
For eight months in 2021, Victoria made her home at Bugoye Health Center, a tidy compound of one-story buildings on a dirt road lined with small shop stalls and mud-thatched homes. It was here that Victoria shared living space with other visiting students and faculty and got to know the research team she would be working with for the study.
The Bugoye Health Center is one of the keystone partnership sites of what is informally known as the MUST-UNC Research Collaboration. Led by Drs. Ross Boyce and Professor Edgar Mulogo, chair of the MUST Department of Community Health, the collaboration has been conducting research on malaria and other infectious diseases in rural western Uganda since 2013. The collaboration also works closely with a local non-profit P-HEALED (People’s Health and Economic Development), a partner organization that provides needed clinical services and advises institutions about local issues and priorities to ensure that academic research and programs are rooted in the population’s needs.
“Victoria’s research, which required the researchers and the participants to trust and respect each other, is the perfect example of the type of work we hope to catalyze,” said Dr. Boyce.
“I don’t think she could have accomplished all that she did without being on the ground every day. It’s a credit to her – I suspect she didn’t have a warm shower for months – but also the unique nature of our relationship with the local community. None of that would be possible without the infrastructure investments we’ve made to accommodate students and trainees in the community.”
Training shop vendors
The work began with training sessions for drug shop vendors on study data collection methods and instruction on how to draw blood samples. Then, between July and September 2021, each drug shop collected data from clients. Finger-prick blood samples were collected from clients who purchased antimalarials for themselves without rapid diagnostic testing.
“The data collected by vendors allowed us to estimate the proportion of clients who purchased a diagnostic test, and among those with a test, the proportion who adhered to the result. Because the vendors collected blood samples, we also estimated the proportion of clients who received antimalarials without having laboratory-confirmed malaria,” said Victoria.
“The initial finding was very low use of diagnostic tests. Nearly all drug shops sold rapid diagnostic tests, but only 25% of drug shop clients with suspected malaria bought one. Another finding was that a lot of people who tested negative for malaria purchased antimalarials anyway, suggesting clients didn’t trust the test result.”
The third finding came from the collected blood samples. Victoria says vendors could only collect blood samples if the person who was sick was actually presenting at the drug shop, which was commonly not the case. A lot of times, a family member would buy medicine for someone at home which meant the drug shop vendor couldn’t see how sick the patient was.
“If the person was there and didn’t get a test, but they did agree to provide a blood sample, a blood sample was collected,” she said. “Of those people, 65% tested negative. Interestingly, those were all people who had purchased antimalarials, which suggested that there was a lot of malaria over-treatment taking place.”
Asking more questions
The next part of the study was qualitative. Over a five-day period, research assistants were trained to conduct in-depth interviews with stakeholders including vendors, clients, local community health workers, and health officials. The research assistants learned about research ethics, informed consent and interview techniques. They also practiced conducting interviews. Then, in-depth interviews were held to explain the findings, including why people were not testing.“We wanted to get them thinking about the findings of the first part of the study and what we could do about them. Given that most drug shops are unlicensed, we were particularly interested in what health officials thought were acceptable programs or interventions to implement in the future to improve these practices.”
The study team analyzed the new data using thematic and narrative techniques. While clients reportedly valued diagnostic tests, the cost limited their use. Meanwhile, mistrust in negative test results and fear about treatment options for conditions other than malaria led to nonadherence to results.
During their interviews, drug shop vendors recognized that the use of antimalarials without a test or after a negative test result was problematic, but they were torn between recommending best practices and losing business. And although clients viewed vendors as trusted health professionals, health officials distrusted them as business owners. Only one of the 46 shops was licensed by the National Drug Authority.
“All of the drug shops participated in this study, which I think is amazing, because most are operating without a license. For them to participate, we had to reassure them that this was not a government program, but a study with a goal of improving health in their communities.”
The reasons drug shops are unlicensed are varied. Annual licensing fees are difficult to pay and most vendors are nursing assistants who do not have the qualifications in Uganda to operate a drug shop. The terrain is also difficult for regulators to access, which limits enforcement. When regulators do come, word travels quickly.
“We were collecting data during one of the days regulators were inspecting drug shops. Our research coordinator had gone out to collect blood samples and found that nobody was there. The word had gotten out, and everyone had closed their shops.”
Some health officials believe better enforcement of the drug shops is needed or that they should be shut down. But for many of the villages, a drug shop is the only accessible source for health care. In fact, delays in malaria diagnosis and treatment often lead to more severe and even fatal disease, particularly in young children. Despite global progress, malaria still accounts for nearly 400,000 deaths among children each year, including in 21,000 deaths Uganda. Thus, despite the issues of licensing and overtreatment, drug shops remain important providers of life-saving care.
Dr. Jonathan Juliano, who leads malaria research through the IDEEL Lab, and is the associate director of the Institute for Global Health & Infectious Diseases, says the findings of this work are critically important.
“More of this type of research is desperately needed in Africa,” said Dr. Juliano. “Appropriate diagnostic and therapeutic stewardship is essential for both improving the clinical care of people and for the long term protection of these interventions from resistance resulting in treatment failure.”
The way forward
Public-private partnerships that incorporate drug shops into the healthcare system are seen as the best way forward, to increase opportunities for oversight and training.
Victoria adds that interventions that can address the financial barriers to diagnostic testing, as well as the quality of vendor-client counseling, could increase testing uptake and improve adherence to test results.
Other solutions could include community education, trainings for drug shop vendors, and better integration of drug shops into the public healthcare sector.
“My goal would be to continue this partnership with the drug shops which is actually bigger than these inconsistencies in malaria management. There’s also a lot of issues with antibiotic use that need to be addressed.”
“In a place where malaria is the leading cause of death, my hope is that the health care community can use these insights and build upon these recommendations, to not only improve case management of malaria and stewardship of treatment and other medications, but also to improve the use of resources that can better serve the people of Bugoye.”
In May, Victoria Shelus graduated with a doctor of philosophy in health behavior from the UNC Gillings School of Global Public Health. She is now starting a fellowship with the CDC Epidemic Intelligence Service, based in the Poxvirus and Rabies Branch.
About the Institute for Global Health & Infectious Diseases
Established in 2007, the Institute for Global Health & Infectious Diseases (IGHID) brings transformative solutions to the most important global health issues of our time, through research, training and service. IGHID has saved millions of lives and shaped policy worldwide through evidence-based research, especially in the areas of HIV, Malaria and now COVID, where UNC is the most cited university in the nation for coronavirus research. Working in over 50 countries around the globe, IGHID provides a unique pan-university framework for collaboration and access to research funding. It is this framework that continues to catalyze a global health community committed to improving health worldwide while providing critical training to thousands of health professionals.
-By Kim Morris, APR, Institute for Global Health & Infectious Diseases