Re-imagining adherence to treatment from the “other side”: local interpretations of adverse anti-malarial drug reactions in the Peruvian Amazon

Joan Muela Ribera, Susanna Hausmann-Muela, Charlotte Gryseels, Koen Peeters Grietens

Patients' adherence to malaria treatment is a key issue in malaria control and elimination efforts. Previous studies have reported on problems with adherence to anti-malarials, which in part can be related to adverse drug reactions (ADRs) of anti-malarials. However, there has been a relative inattention to the cultural and social aspects of these anti-malarial side-effects and, more broadly, to how cultural representations of body functions may affect people's behaviour. In this article, an in-depth analysis is presented of the cultural logics underlying local interpretations of adverse drug reactions to anti-malarials in the Peruvian Amazon. Ethnographic fieldwork was carried out during two periods of 3 months in 2007 and 2008. Fieldwork was carried out in 10 communities in the department of Loreto, the administrative area corresponding to the Peruvian Amazon. Thirty in-depth interviews of key and general informants, focusing on perceived adverse anti-malarial drug reactions, were carried out in Spanish, recorded, transcribed and analysed. Informants reported surprisingly elevated problems of adverse drug reactions. Frequent statements about medication that "shocked", "cut the blood" or provoked "allergic reactions" are difficult to interpret from a biomedical perspective, and only make when considering the underlying cultural logics. The logic of maintaining a 'temperate' physical and moral balance by avoiding excesses of 'hot' or 'cold' or sudden changes of 'body heat' can explain the locally constructed adverse drug reactions to anti-malarials. Adherence is a continuous process during which the patient evaluates and re-evaluates the course of his illness and the perceived benefits and risks of the treatment. What counts are the processes, the interpretations and the logics which underlie the decisions to adhere to or to abandon treatment. Adherence can only be adequately addressed if such interpretations are understood and taken into account.