Key words |
| Drug utilization, Artemisinin combination therapy (ACT),Patent Medicine Vendors
(PMV), Rural area, Antimalarias, Nigeria. |
Introduction |
| The public health and economic challenges of malaria in Nigeria has been well documented in
literatures.1, 2 In an effort to stem the bleak situation, the Federal Ministry of Health (FMOH) in
Nigeria changed the malaria treatment policy from chloroquine (CQ) and
sulfadoxine/pyrimethamine (SP) to Artemisinin combination therapy (ACT),2 with preference for
Artemether/lumefantrine (ALU) and Artesunate/Amodiaquine (AS+AQ) combinations.3
Meanwhile, the movement of malaria medications from prescription only medication (POM) to
over the counter medication (OTC) and the dearth of standard health facilities in Sub Saharan
Africa (SSA) has led to the growth of the Patent Medicine Vendors (PMV) as sources for malaria
treatment4 in most parts of Africa especially Nigeria. PMVs thrive because of the factors that
have been enumerated in studies5, 6; consequently, policy makers have recognized that the PMVs
can provide an opportunity for effective coverage of malaria treatment.7 However, concerns
abound on the appropriateness of care that PMVs provide.8 It therefore becomes relevant to
assess the knowledge and utilization of ACTs by the PMVs in communities in Nigeria. This
study set out to evaluate the knowledge of the PMVs’ on malaria especially on FMOH
recommended first line drug for uncomplicated malaria. The outcome of this study will help
design policy measures to strengthen the treatment component of the malaria control strategy. |
Methods |
Study Design and Study Sites |
| The study was conducted in some rural communities in Anambra state, south east Nigeria. |
| The study was a descriptive cross-sectional study. A minimal sample size of 237 PMVs was
determined using the formula for descriptive studies9 based on 19 % PMVs who stock ACT in
Nigeria10. Purposive sampling method was used to select the study sites and 290 PMVs were
selected for the study using random sampling method. |
| The survey instrument was an interviewer-administered questionnaire. The questionnaire
enquired on the socio demographic characteristics of the respondent, knowledge and perception
about malaria, issue of side effects, dosing, precaution and adherence to ACTs. |
| Adherence is crucial to scaling up ACT. The likelihood that the PMVs will help promote
adherence to the therapy was evaluated by noting the PMVs’ understanding of the drugs’ side
effects and their ability to counsel their patients about the expected side effects. |
| The questionnaires were pretested among ten (10) PMVs in a different community not involved
in the study and adjusted after the pretest. The study recruited four (4) research assistants (RA) in
each community who were given an in-house training prior to the research. All the PMVs who
consented to the study were informed that it was voluntary, strictly academic and that their
responses will be treated with utmost confidentiality. |
Data Analysis |
| The descriptive statistics of the variables were analysed using Statistical Program for Social
Sciences (SPSS) version 18. Data presentation was in the form of pie charts. |
Ethical Clearance |
| Ethical clearance was obtained from the Ethics committees of Anambra state University
Teaching Hospital, Awka, Anambra State, Nigeria. |
Results |
| The result showed that 48.9 % of the respondents were males while 51.1 % were females as
shown in figure 1. Figure 2 shows that approximately 73.3 % of the respondents had secondary
education, 14.4 % had tertiary education and 12.2 % had only primary education. Ninety-one
percent (91 %) were engaged full time in the patent medicine business and the rest did it on part
time basis as shown in figure 3. The age range of the PMVs as illustrated in figure 4 were 31-40
(36.7 %), 21-30 (28.9 %), 41-50 (23.3 %), 51-60 (5.6 %), >60 (3.3 %) and <21(2.2 %). The
average years of experience of the interviewed PMVs was found to be 11 years. The study also
showed that 86.7 % of respondents were store owners while 13.3% were sales clerk. |
| Only eight percent (8 %) of the PMVs interviewed correctly mentioned the vector organism
implicated in malaria transmission and all the respondents (100 %) diagnosed malaria
presumptively. However, 94 % mentioned correctly at least three symptoms of uncomplicated
malaria and only about 13.3 % were aware of FMOH recommended malaria preventive
measures. Within the last 3 years, 38.9 % of our respondents indicated participating in trainings
on malaria control. Meanwhile, 15.6 % were trained by government agencies, 13.3 % by Nongovernmental
organizations (NGO’s), 6.7 % by profit- oriented organizations and 1.1 % by both
government agencies and NGO’s. However, 36 of the respondents representing 13.3 % correctly mentioned the FMOH recommended first-line drugs for uncomplicated malaria and 71 % knew
signs of severe malaria where as 4 % knew the FMOH recommended measures pertaining to the
condition. Approximately, 78 % of our respondents were conversant with the ACTs and 71 % of
the PMVs stock ACTs in their shops. Data showed that while 20 % were knowledgeable on the
generic names of the therapy, 23 % knew the distinction between the mono- and the combination
therapies. Furthermore, 16.7 %, 20 %, and 25.6 % respectively mentioned the dosing, at least 3
side effects and 2 contra indications to a stated ACT. |
Discussion |
| Understanding malaria, signs and symptoms of malaria, treatment options and most importantly,
the current drugs recommended for malaria tratment is crucial to effective treatment of this
disease. Drug resistance in plasmodium falciparium is a major threat to malaria control and poor
knowledge of malaria and/or utilization of these drugs may help promote the development of this
resistance strains. Recently, combination therapy including ACTs have been advocated to help
improve efficacy and reduce resistance development. Hence, adequate information and
understanding of the ACTs will help prevent losing this new agents to resistance and therefore,
understanding the current knowledge and utilization of these ACTs by drug distributors
particularly, the PMVs forms the basis of this study. |
| About 98 % of our respondents were above 21 years of age which is in line with the requirement
of the pharmacy law in Nigeria, which requires that the PMVs’ licensee should be at least 21
years of age11. Though, minimum educational requirement is not specified in Nigeria12, we found
that 73.3 % of the PMVs had post primary education. However, there has been call to raise the
requirement to tertiary level.13 A high number (91.1 %) of the respondents engaged full time in
the patent medicine business. Studies 12, 14 have shown that whether a PMV is engaged full or
part time in the business does not affect quality of health services rendered to patients. The
PMVs have on the average 11 years of experience. This parameter may correlate positively with
improved quality of health services.15 |
| Treatment seeking behaviours relating to causation, transmission, prevention and treatment are
the main socio-cultural factors that influence malaria control16. Incorrect beliefs or inappropriate
behaviour can have strong implications on treatment outcomes and preventive measures17. We
found that approximately only 8 % of our respondents mentioned bites from infested mosquito as
a cause of malaria while 92 % mentioned other causes like exposure to rain waters, stagnant
water, poor hygiene, ingesting contaminated food and water, high alcoholic intake and exposure
to searing sun. Although these might seem inconceivable, the association between rain and
mosquito and by extension malaria may have informed some of these thoughts18. Moreso,
contaminated food, impure water, excess alcohol consumption and stress due to intense heat
from the sun can compromise the immune status which may explain the reasons for some of the
misconceptions. However, poor knowledge of aetiology of malaria has been documented in other
studies.17,18 These misconceptions are pointers that the PMVs’ malaria control measures may be
grossly inappropriate. Early treatment of childhood malaria is dependent among other factors on
prompt recognition of symptoms.16, 19 Our respondents demonstrated high knowledge (94.4 %) of
at least 3 of the classical symptoms of uncomplicated malaria. On further investigation, we found that most of our respondents recognised convulsion especially in children, jaundice and anaemia
as signs that require referral. This may be an indication that our respondents may know the
importance of prompt treatment.21 On the issue of diagnosis, all the PMVs interviewed admitted
treating malaria presumptively. Meanwhile, FMOH malaria treatment guideline20 is specific on
timely parasite –based diagnosis of malaria prior to treatment. Since shortcomings of
presumptive diagnosis are well documented21, this may imply failure of the PMVs to identify
and treat malaria appropriately22 and as such irrational use of antimalarials.23 |
| It has been shown that FMOH malaria preventive measures are effective in reducing the
prevalence of malaria.24 One reason for demand for preventive health care is the increasing
patronage of inappropriate health care providers.25 Our findings showed that 13.3 % of the drug
sellers could mention at least two FMOH recommended preventive strategies. A previous study
26 has reported a positive correlation between poor knowledge of preventive strategies and low
practice. The low figure we reported could be attributed to inadequate training especially on the
aetiology of malaria.19, 27 Poor knowledge of malaria preventive measures similar to this study
has also been reported in previous studies.28, 29 Although, PMVs have been recognised as crucial
in scaling up the malaria treatment policy pertaining to uncomplicated malaria, many of their
practices have been reported to be inappropriate.5 Training community level providers is a
strategy for strengthening the therapy.30 Our finding showed that 38.9% only of drug vendor
received trainings on malaria management in the previous three years. Majority of the drug
sellers were trained by government agencies (15.6 %) and NGOs (13.3 %). This finding is not
encouraging since it is a pointer that malaria management at that level will likely be of minimal
standard.31 On the issue of malaria treatment, only 13.3 % of the respondents prescribed at least
one correct FMOH recommended ACT. A dismal result comparable to this was reported in a
study in north western Nigeria.32 However, other studies cited 33, 34 reported high utilization of
ACTs. The low number (13.3 %) as reported in this study is an indication of high treatment
failures. It is probable that the presumptive diagnosis used in all cases may have also contributed
to the dismal result.35 Accessibility and utilization of appropriate health services is another factor
that determines early treatment of childhood diseases16, 19. A high number (71 %) of our
respondents were conversant with signs that require patient referral and only 4 % were aware of
FMOH recommended treatment measures for severe malaria prior to referral. This result
contrasts with those of Anberber et al36 and Idro et al37, where poor referral practice was
documented. |
| A high number (78 %) of our respondents were conversant with the artemisinin combinations. It
would be pertinent to note that awareness does not necessarily translate to true knowledge as
many drug sellers could not identify ACTs’ by generics. The high awareness figure we reported
may probably be due to patient demand38, 39. Other studies have also documented high awareness
levels of ACTs.34,40 Similarly, a high number (71.1 %) of respondents stock ACTs in their shops.
A study has shown that availability of ACT is a predictor of utilization34. However, utilization of
ACTs in our study was only 13.3 %. This anomaly may probably be explained by a
consideration of the consumer demands 38, 39 and advertisement by drug firms41. It has also been
shown that side effects are predictors of adherence42, and as such, poor knowledge of side effects
may correlate positively to non adherence to the drug. This study showed that only 26.7 % of our
medicine sellers could mention at least three side effects of a stated ACT and this percentage
affirmed that they counsel the patients on side effects. We also noted that only 23 % could draw a distinction between artemisinin deriviatives monotherapies and their combination therapies.
This is disturbing since it is an indication that artemisinin monotherapy may be dispensed as
combination therapy, as reported in a study in North West Nigeria.43 This practice may likely
predispose to treatment failure3 and resistance development. A comparable result (24.4 %) to
ours was reported among health providers in Enugu state, South east Nigeria.34 Studies by Dodoo
et al35 and Adisa et al33 meanwhile documented higher figures. |
| Patient knowledge of the ACT dosing regimen is the strongest predictor of adherence44.
Increasing caregivers' and patients' understanding of the ACT dosage regimen could influence
optimal outcome.38, 45 Our findings showed that 68% of our drug sellers correctly mentioned the
dosage regimen of a stated ACT. Other factors crucial in ensuring clinical efficacy and
prevention of adverse events to ACTs include understanding of the contra indication(s) and
precaution(s). Our study showed that only 26 % of the respondents knew at least two contra
indications and precautions to a stated ACT. Low knowledge of this parameter will compromise
the efficacy of the combination treatment and increase the incidence of severe adverse drug
reaction. |
Conclusion |
| The outcome of our study showed inadequate knowledge and low utilization of ACTs in our
study population. We recommend education programs on FMOH malaria treatment policy to
ensure that we do not lose ACTs to resistance. |
 |
| Figure 1: Gender distribution of respondents |
 |
| Figure 2: Educational attainment |
 |
| Figure 3: Time dedicated |
 |
| Figure 4: Age distribution of respondents |
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