ABSTRACT

 

The purpose of this study was to survey antimalaria drug prescriptions and compliance to treatment among pregnant women attending antenatal clinic in the two tertiary hospitals in Enugu State. The study surveyed 92 doctors from UNTH and ESUTH Parklane, Enugu. 368 pregnant women from both hospitals (156 from ESUT and 212 From UNTH) who consented were surveyed. Purposive sampling was used to select the two tertiary hospitals. Proportionate stratified random sampling was used to select the pregnant women for the study. Convenience sampling was then used to reach the respondents. Questionnaire was used to identify the drugs prescribed by the doctors and their reason for prescription while the other questionnaire was used to elicit compliance level and factors affecting compliance from pregnant mothers. Descriptive statistics using frequency, percentages, means and standard deviations were computed for the demographic variables. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 15. The result revealed that the most frequently prescribed antimalaria  drug for pregnant women was Artemisinin combined therapy, (76.3%), (73.1%) Artemether Lumefantrine 32.9%, 56.5%, Sulphadoxine Pyrimethamine 31.8% & 42.4% for first and second choice drug, Quinine 10.6% & 3.5% for first and second choice drug, Artesunate single therapy 5,9% & 2.4%. The least prescribed drug were Amodiaquine, Chloroquine, Proguanil and Halofantrine. Their major reason was gestational age of pregnancy 67.1%, severity of signs and symptoms 38.8%, past experience 28.2%. The least reasons were age of the woman, hospital policy, cost of drug, parity of the woman, availability of drug etc. The result also showed that pregnant women comply more to taking the number of prescribed drug not more 4.31, not less 3.91, mean values. The least in the compliance is timing, saving for future use, taking another drug in place of the prescribed one. The results suggest that there is high compliance only in number of dosage prescribed but low compliance in timing, completion and sticking to the particular antimalaria drugs. The major factors affecting compliance were forgetfulness, quick recovery, side effects. Doctors prescribed more of artemisinin combination therapy in both first and second choice drug and their reasons were to consider gestational age, severity of signs and symptoms. Hypothesis was tested using Spearman’s rho correlation analysis; there was no significant association between the levels of education of women with their level of compliance. There is a relationship between doctors’ years of experience with their reasons for their choice of prescription shown using chi-square cross tabulation. It is therefore recommended that patient centred care will be vital to encourage compliance to new treatment algorithms developed in response to the changing malaria environment in Enugu. Efforts should be made by the Federal Ministry of Health and other stakeholders to organise training and refresher courses on the current and national antimalaria treatment guidelines. Lastly, behaviour change communication (BCC) programmes should be initiated to aid in awareness creation on the consequences of non compliance.

CHAPTER ONE INTRODUCTION

Background to the Study

Malaria is a major public health problem in developing countries causing considerable morbidity and mortality (Menedez, 2006). It is endemic in 103 countries with 200 million people exposed to the infection (Onwuama, 2007). Today, due to the effect of globalization and increased transportation, it has become a worldwide disease which causes more than 300 million acute illnesses and at least one million deaths annually (Onwuama, 2007).

Malaria is acknowledged to be by far the most important tropical parasitic disease causing great suffering and loss of life. More than two billion people, nearly 40% of the world’s population are at risk. The high burden of the disease is associated with morbidity and mortality despite the concerted effort of the Federal Government of Nigeria and the local partners to combat the disease. This has led to the development of newer drug regimen to keep the pace with the evolution of resistance acquired by malaria parasites. Malaria impedes human development and thus has a social consequence and is a heavy burden on economic development. Every year the nation loses over N132 billion from cost of treatment and absenteeism from work, school and farms (Pharmanews, 2007)

Malaria in pregnancy is an obstetric, social and medical problem requiring multidimensional solution. It is estimated that more than 50 million pregnancies occur in malaria endemic areas. 50% of these occur in sub-Saharan Africa (WHO, 2004). The incidence of malaria attacks is about 4.2 times higher during pregnancy than in non-pregnancy states

(Ntadom, 2007).  Four species of the parasite of the genus plasmodium are responsible for malaria in man:  plasmodium falciparium, plasmodium vivax, plasmodium Ovale and plasmodium malariae. Plasmodium falciparium causes 98% malaria in Africa while 80% of the deaths due to malaria in Africa occur in pregnant women (Fatumbi, 2007).

The reasons for increased malaria in pregnancy have been attributed to impaired immune system during pregnancy.  Thus the physiological changes of pregnancy and the pathological changes of malaria have a synergistic effect on the course of each other, thus making life difficult for the pregnant woman, unborn child and even the healthcare provider.  Placental parasitization is also common during pregnancy because the placenta is highly vascularized and a favourable site for parasite sequestration (Nwagha, 2007). Some pregnant women do not attend antenatal early in pregnancy and when they start, they avoid anti malaria chemoprophylaxis for fear that the fetus may be affected (Onwuama, 2007). The effect of malaria in pregnancy include high acquired immunity, anaemia, maternal morbidity, asymptomatic infections, less nutrient transmission, low birth weight, and higher infant mortality.

Medication compliance refers to how well a patient follows medical advice about his or her medication therapy. Patients who take their medications correctly as instructed by their health care providers are compliant while those patients who take their medications incorrectly or not at all are non-compliant. Medication compliance is one of the most important parts of medication therapy that is often overlooked. A medication is most effective in treating a patient’s condition if it is taken as prescribed by the health care provider.

Non compliance or failing to take medicine as prescribed is common, costly and deadly. Working with noncompliant patients is not easy, it takes an awful lot of compassion and patience and understanding (Osterberg and Terrence , 2005). It is the main reason medical therapy fails and disease worsens. It may also result in costly preventable hospital admissions and loss of productivity due to illness. The bottom line is that if one does not take his\ her medications or do not take them as prescribed, they cannot do their job and the condition may not improve and may actually worsen.

There is no foolproof solution to the pervasive problem of medication non compliance, because it has no single cause. Some noncompliant patients have trouble affording medications, while others have difficulty remembering to take them. Many do not understand the medical benefit of the drugs or the nature of the conditions for which they are being prescribed. Some patients have personal beliefs that interfere with compliance. Thus Compliance has been described as a multi-dimensional phenomenon determined by the inter play of five sets of factors which are as follows: patient related factors, and is reflected on the understanding of the fact that a person is responsible for taking his/her medication. Therapy related factor which may be due to actually or perceived unpleasant side effects. Social and economic factor which may be due to low health literacy or medication cost. Condition related factor which may be due to the severity of the symptoms and lastly provider patient health care system factor which may be due to disparity between the health beliefs of the health care provider and those of the consumer/patients. (WHO, 2003)

There can be problems with antimalarial drug use particularly where there is inadequate training of people in the use of particular drugs resulting in emergence of resistance to these drugs. Even if drugs are obtained after consultation, the ways in which they are used depend on the understanding and health seeking behaviour of individual consumer. This means that understanding of the people, their attitude and knowledge of drug, that is, drug taking behaviours are fundamental to attempts to improve drug usage. In averting drug-resistance problem, people need to be aware of the consequences of their drug use, since most malaria case-management usually ends at home.

Based on this, it is necessary to carry out a survey of drugs prescribed  for the treatment of malaria  and compliance  among pregnant women in tertiary hospitals in Enugu State, Nigeria.

Statement of problem

Malaria in pregnancy accounts for 11% maternal deaths in Nigeria (WHO, 2005). Fatumbi (2007) observed that malaria and pregnancy are mutually aggravating conditions, consequently malaria in pregnancy becomes a serious problem with devastating effects and complications such as anaemia, abortions, low birth weight and stillbirths, among others. Therefore, lack of effectiveness  of the drugs prescribed and partial or non compliance in taking these drugs in the treatment of malaria in pregnancy may  compound the problems.

Currently in Enugu state in line with its free maternal health services in which one of the cardinal focus is management of malaria in pregnancy, Intermittent Preventive Therapy ( IPT) drugs are distributed free to pregnant women from 20 weeks of gestation. This is expected to reduce the incidence of malaria in pregnancy to the lowest level. Yet from the records available in ESUT Teaching Hospital Parklane Enugu from January 2010 – December 2010, 390 pregnant women were treated for different ailments and 169 had malaria representing 43% of the population that had different ailments in pregnancy (ESUTH 2010 RECORDS). In UNTH, out of 779 pregnant women that were treated for different ailments, 230 had malaria representing 30%of the total population that had problem in pregnancy. (UNTH 2010 RECORDS) What could be the problem? Could it be due to drugs prescribed or the compliance level to the prescribed drugs by pregnant women or both? Seeking answers  to these pertinent questions led to finding out the antimalaria drug of choice from the perspective of prescribers and compliance  from the perspective of  the consumers.

Purpose of the study 

The purpose of the study is to survey antimalaria drug prescriptions and compliance to treatment among pregnant women attending antenatal clinic in the two tertiary hospitals in Enugu state.

The specific objectives are to:

1. identify the drugs prescribed for the treatment of malaria in pregnancy in the hospitals

under study.

2. determine the prescribers reasons for choice of drugs  in the treatment of malaria in pregnancy.
3. determine the compliance level of  the pregnant women to  treatment regimen, in   the

hospitals  .

4. identify the factors that influence the pregnant women’s compliance to the prescribed

antimalaria drugs in the hospitals under study.

Research questions

• What are the anti-malaria drugs prescribed for treatment of malaria in pregnancy in the hospitals under study?
• What are the prescriber’s reasons for choice of drugs in the treatment of malaria in pregnancy?
• Do these pregnant  women comply   to   the treatment regimen ?
• What factors influence the pregnant women’s compliance to antimalaria drugs prescribed for them in the hospitals under study?

Research hypotheses

• There is no significant relationship between the level of education and compliance to taking antimalaria drugs by pregnant women in the hospitals under study.
• There is no significant relationship between the years of experience of prescribers and their reason for choice of antimalaria drugs prescribed for pregnant women in the hospitals under study.

Significance of the study

The findings from the study will give evidence based information which when published can guide the prescribers in their prescriptions of anti-malaria drugs in the treatment of malaria in pregnancy. When the effective drugs for malaria in pregnancy are prescribed, problem of frequent attacks will be reduced and patient’s recovery will increase. This will reduce work load burden on the nurses who provide direct care for these patients, thereby giving the nurses more time and opportunity to adequately care for the patients with more critical conditions in pregnancy.

It will also guide the nurses on the importance of giving enough information about drugs prescribed and how to take them, so as to avoid problems of non compliance. It will also be beneficial to consumers ie pregnant women because if it is identified that they do not comply to prescribed drugs, adequate education will be given to them on the importance of compliance. This will reduce the incidence of malaria attacks. In order words, it will improve behavior change communication which will aid  awareness creation on the consequences of non compliance.

When the relationship between anti-malaria drugs prescribed and consumed is identified, changes can be effected. The result will also help to confirm the effectiveness of those antimalaria drugs in Nigeria population and thereby promote their use.

The findings will also motivate policy makers in providing both financial and material resources to ensure regular supply of the identified effective drug for the treatment of malaria in pregnancy. This will control or reduce the devastating effects of malaria in pregnancy. The findings of this study will also add to the already existing body of knowledge in this area of study.

Scope of the Study

All the tertiary hospitals which render antenatal services in Enugu State were included in the study. These are ESUT Teaching hospital and University of Nigeria Teaching Hospital (UNTH) Ituku-Ozalla, Enugu. The study is delimited to the identification of antimalaria drugs prescribed for the treatment of malaria in pregnancy, determine the prescribers reasons for choice of antimalaria drug prescription, determine the compliance of pregnant women to the prescribed antimalaria drugs and factors that influence their compliance.

Operational definition of terms 

Survey – Survey in this study is to look at antimalaria drug, choice of prescription by prescribers, pregnant women’s compliance and factors that influence them in order to form an opinion.

Tertiary hospitals – in this study refer to all Federal and State government owned Teaching Hospitals that render antenatal care services in Enugu State. These are University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu and ESUT Teaching Hospital Parklane, Enugu.

Antimalaria Drug—in this context is the medicine or medicinal used to treat or prevent malaria in pregnancy.

Pregnancy – the physical condition of a woman carrying an unborn offspring inside her body from fertilization to birth. These women are already booked and receiving antenatal care at the two study centres.

Prescribers – in this context refers to doctors who prescribe antimalaria drugs.

Compliance – in this context is the correct use of antimalaria in terms of right timing, right dosage, right drug, completing prescribed dose.

Consumer – in this context is the pregnant women who take antimalaria drugs.