AN EDUCATIONAL INTERVENTION ON RATIONAL PRESCRIBING OF CHLOROQUINE IN THE MANAGEMENT OF UNCOMPLICATED MALARIA IN LAGOS STATE GENERAL HOSPITALS, NIGERIA

ABSTRACT Title: An Educational Intervention on Rational Prescribing of Chloroquine in the

Management of Uncomplicated Malaria in Lagos State General Hospitals, Nigeria Authors:Aina BA, Tayo F and Taylor O Institution: Department of Clinical Pharmacy and Biopharmacy, Faculty of Pharmacy of

the University of Lagos, Idi-Araba,Lagos, Nigeria. Objective: To determine the impact of two modes of educational intervention on the

chloroquine prescribing pattern of prescribers in Lagos State General Hospitals Design: Retrospective, cross sectional, before and after study with control group Setting and Population: Ten Government General Hospitals under Lagos State

Hospitals Management Board. 100 prescriptions each for adults and children for January-December 2000 were systematically sampled. Where there were fewer than 100 prescriptions all the prescriptions available were sampled for quantitative analysis. Questionnaires were distributed to the prescribers in November - December 2001 for quantitative and qualitative analysis.

Intervention: An educational intervention took place in January-February 2002. Educational Seminar was presented in 8 out of the 10 hospitals. Among the 8 that had seminars , 4 hospitals had educational posters while the other 4 had plastic board describing correct doses of chloroquine left behind . Two hospitals served as control.

Result: There was significant increase in the percentage of prescriptions with correct dose of chloroquine post intervention.There was association between intervention and dose of chloroquine prescribed (X2 = 1276.02 and p<0.001). There was also association between the mode of intervention and dose of chloroquine prescribed. The group with plastic board had a significantly higher percentage of correct prescriptions than the group with poster(paired t = 15.00, p = 0.04238 1 month post intervention)

Conclusion: Educational intervention improved the prescribing pattern of chloroquine.

Introduction/Background I Malaria is a preventable,treatable and curable infection. It is a

major public health problem in Nigeria. Malaria may present as uncomplicated (non-severe) malaria or severe malaria. Uncomplicated malaria is not life-threatening while severe malaria is life-threatening. Treating uncomplicated malaria promptly and correctly will prevent progression to severe malaria.

There are several strategies for the control of malaria but one strategy that has been consistently used is chemotherapy. Drugs for treating malaria in Nigeria include Chloroquine, Amodiaquine, Sulphadoxine-pyrimethamine, Quinine, Artemether, Artesunate, Dihydroartemisinin, Halofantrine,Mefloquine and other combination drugs. Chloroquine is still the cheapest and safest antimalarial and it is still a first line drug of treatment in Nigeria.

Introduction/Background II Rational use of antimalaria drugs involves the appropriate

use of antimalarials at the correct/adequate dosages, availability of good quality drugs and patient compliance

Rational use of antimalarials can be determined by measuring the existing practices and identifying if any problem exists. If any problem is identified,there is need to identify the reasons for the problem(s) and then suggest possible actions to correct the problem(s).

Inappropriate prescribing, the failure to prescribe drugs in accordance with guidelines based on scientific evidence to ensure safe, effective and economic use, is an irrational drug use behaviour.

Increased benefits from chloroquine or a slowdown of progression to resistance could be achieved by improving prescribing practice, drug quality and patient compliance

Objectives/Study Questions

To determine the prescribing pattern of chloroquine in the management of non severe malaria in Lagos State General Hospitals.

To determine the factors that influence the observed prescribing pattern of chloroquine in Lagos State General Hospitals.

To determine the impact of two modes of educational intervention on chloroquine prescribing pattern of prescribers in Lagos State General Hospitals.

Methods I Antimalarial prescriptions under the “Eko Free Malaria

Programme” were studied using the WHO 1993 guidelines on ‘How to investigate drug use in health facilities’. Certain core prescribing indicators, complimentary drug use indicators and specific chloroquine indicators were analysed.

These indicators include Average number of drugs per encounter Average number of injections per encounter Percentage of encounters with injections Percentage of encounters with dipyrone Average drug cost per encounter Percentage of encounters with the different antimalarials

and other drugs prescribed with the antimalarials Percentage of encounters with the different chloroquine

dosage forms

Methods II Percentage of encounters with either correct, overdose

or underdose of chloroquine 100 prescriptions each for adults and children were

systematically sampled retrospectively in all the ten General Hospitals in Lagos State for the month of January to December 2000. Where there were a fewer than 100 prescriptions in a particular month, all the prescriptions available were sampled for quantitative analysis.

Questionnaires were designed and distributed from November to December 2001 to the prescribers that manned the Out Patient (OPD) section of these hospitals to corroborate the baseline data from the prescription survey and to address the KAP of the prescribers which influenced their prescribing pattern and this information was used to design intervention

Methods III Educational intervention took place in January to February

2002. Educational seminars were presented in 8 out of the 10 hospitals. 2 Hospitals served as control.Among the 8 hospitals that had the seminars, 4 hospitals had educational posters describing the correct doses of chloroquine for the different age groups and having pictures left behind whereas the other 4 had a plastic board printed with the correct doses.

Post intervention prescribing pattern was carried out retrospectively after 1, 3, 6 and 12 months to determine short, intermediate and long term impact of the intervention.

Chi square distribution, ANOVA , Kruskal-Wallis test and Paired t test were used to test for association or independence or differences of some indicators. Results were considered to be statistically significant if p < 0.05

Data were analysed using Epi6 Info statistical software

Results I Chloroquine was widely prescribed and it was the first

choice of most prescribers not just because it is a first line drug or the drug that is available in the hospital but because it was believed to be effective (73.1 %)

Underdose was predominant when injection chloroquine only was prescribed (prescriptions & questionnaires).

Correct dose was predominant when tablet chloroquine only was prescribed (prescriptions & questionnaires).

Underdose prescribing was more common for children than for adults probably due to different age groups(about 4) for children (prescriptions & questionnaires).. It may not be easy to recall the different doses for these different age groups. There is only one dose for adults.

There was association between intervention and dose of chloroquine prescribed (X2 = 1276.02 , p< 0.001). There was association between the mode of intervention and dose of chloroquine prescribed (X2 = 429.08 and p< 0.001).

Results II There was significant increase in the percentage of

prescriptions with correct dose of chloroquine post intervention, 45.3%, 72.3%, 70.4%, 65.3% and 68.6 % at pre-intervention, 1month, 3 months, 6 months and 12 months post intervention respectively

The group with plastic board had a significantly higher percentage of prescription with correct dose than the group with poster

There was no statistically significant difference in percentage of correct prescriptions between 1 month post intervention and throughout the duration of study post intervention hence it is hereby implied that the intervention was sustained

FIG 1: DOSE OF CHLOROQUINE PRESCRIBED AT PRE,1,3,6 AND 12 MONTHS POST INTERVENTION

0

10

20

30

40

50

60

70

80

PRE 1 POST 3 POST 6 POST 12 POSTINTERVENTION

CORRECT OVERDOSE UNDERDOSE

FIG 6: CORRECT DOSE OF CHLOROQUINE FOR DIFFERENT MODE OF INTERVENTION AT PRE, 1, 3, 6 AND

12 MONTHS POSY INTERVENTION

0

10

20

30

40

50

60

70

80

90

P RE 1 P OST 3 P OST 6 P OST 12 P OST

P E R I OD OF I NT E R V E NT I ON

CONTROL SEMI+P OST SEMI+BP AD

FIG 2: DOSE OF CHLOROQUINE PRESCRIBED IN ADULTS AT PRE, 1,3,6 AND 12 MONTHS POST INTERVENTION

0

1020

3040

5060

7080

90

PRE 1 POST 3 POST 6 POST 12 POST

PERIOD OF INTERVENTION

CORRECT OVERDOSE UNDERDOSE

FIG 3: DOSE OF CHLOROQUINE PRESCRIBED IN CHILDREN AT PRE,1,3,6 AND 12 MONTHS POST

INTERVENTION

0

10

20

30

40

50

60

70

PRE 1 POST 3 POST 6 POST 12 POSTPERIOD OF INTERVENTION

CORRECT OVERDOSE UNDERDOSE

FIG 4: PERCENTAGE OF CHLOROQUINE DOSAGE FORMS PRESCRIBED AT PRE, 1, 3, 6 AND 12 MONTHS POST

INTERVENTION

0

10

20

30

40

50

60

PRE 1 POST 3 POST 6 POST 12 POST

PERIOD OF INTERVENTION

INJ ECTION INJ + SYRUP INJ + TABLET SYRUP TABLET

PERCENTAGE OF PRESCRIPTIONS WITH CORRECT DOSE OF CHLOROQUINE PRESCRIBED IN EACH HEALTH

FACILITY AT PRE, 1,3,6 AND 12 MONTHS POST INTERVENTION

01020304050

60708090

100

A B C D E F G H I JHEALTH FACILITY

P RE 1 P OST 3 P OST 6 P OST 12 P OST

Implication/Conclusion Educational intervention improved the prescribing pattern of

chloroquine in Lagos State General Hospitals. There is still room for improvement since 100% correct dose

was not achieved. There is need to stress on limiting the use of injection to

patients that can not swallow or that are vomiting In order to sustain/maintain correct prescribing habit there

may be need to reward prescribers or health facilities that have higher

correct prescribing habit have a managerial intervention such as structured drug

order forms and /or course-of-therapy packaging have reminders sent to prescribers and pharmacists have a prescriber and a pharmacist as facilitators or

monitoring team in each health facility