# Adherence to anti-malarials among patients diagnosed with malaria in East Africa: a systematic review and meta-analysis

## TL;DR

This study reviews how well malaria patients in East Africa follow their anti-malarial treatments, finding an average adherence rate of about 70%.

## Contribution

The study provides the first comprehensive and comparable regional adherence estimate for East Africa.

## Key findings

- The overall adherence rate to anti-malarials in East Africa is 70.30%.
- Adherence varies significantly between countries, with Rwanda at 100% and Tanzania at 6.99%.
- Recalling correct instructions and taking the first dose at a health facility improve adherence.

## Abstract

East Africa continues to bear a significant share of the global malaria burden, despite its commitment to the malaria elimination goal of 2030. Furthermore, reported variations in adherence to anti-malarials hamper the regional effort in malaria elimination. Moreover, the region has no comprehensive and comparable adherence estimates for policymakers to set priorities, target control strategies, and evaluate the effectiveness of interventions. Hence, this systematic review synthesized the regional adherence estimate for East Africa.

Authors searched articles from PubMed, Science Direct, CINHAL, Scopus, and Google Scholar. Two authors independently assessed retrieved studies for eligibility and risk of bias, then the adherence rate was pooled using the random effect model implemented in STATA. Publication bias was assessed using a funnel plot symmetry and the Egger test. Subgroup analysis was performed to explore the effect of the national and types of regimens on the overall estimate. Qualitative analysis was applied to explain factors that influence adherence.

A total of 29 studies with 15 927 participants were included. The overall adherence rate was 70.30% (95% CI 61.93–78.67; 29 studies; I2 = 99.76%), with the highest level reported in Rwanda (100%, 95% CI 97.28–100.00) and lowest in Tanzania (6.99%, 95% CI 0.2.81–11.17). Furthermore, adherence was high for chloroquine plus sulfadoxine-pyrimethamine (96.27%, 93.87–98.66; one study). Recalling correct instructions and taking the first dose at the health facility had a positive influence on patient adherence.

On average, about three-quarters of malaria patients in East Africa adhere to their medications. In light of these findings, further interventional studies are needed to address low adherence to anti-malarials in the region. Moreover, adherence studies with the appropriate method of measurement are still needed to obtain a robust generalizable estimate in East Africa.

Trial registration This review was registered at PROSPERO with the registration ID CRD42023410048.