INTRODUCTION:

Drug prescriptions are done for their therapeutic reasons. Physicians’ (prescribers) prescribing practices can influence such prescription to meet patients’ needs. Writing prescription is a very tasking activity carried out by health professionals. It is an instruction issued by a prescriber to a pharmacist as well as the patient. Proper prescription writing guarantees proper drug usage and aids in reducing errors during the dispensing process. When prescribing any drug, health practitioners must consider its appropriateness, efficacy, side effects, contraindications, and cost¹. Study by Amit et al.² revealed that majority of the prescribers assessed didn’t subscribe to the ideal art of writing prescriptions. Studies on prescribing practices are important due to the dangers associated with irrational prescription³. Rational prescription means that patients get appropriate medicine in proper dosage, at a minimal cost. Prescription writing is a practice as it captures instructions, issued by a physician or prescriber to a patient. Irrational drug utilization practices had been extensively studied and identified as a major problem in various pediatric prescription studies as this could lead to drug resistance, treatment failures and increased healthcare costs with attendant’s risks and poor objective benefits⁴. Irrational drug prescription is a common happening in clinical practice; the financial cost to the patient is enormous coupled with effects of reduced compliance⁴. Several studies carried out in developing countries like Nigeria revealed that inappropriate antimalarial utilization still continue years after Artemisinin Combination Therapy (ACT) was adopted in private and government health facilities⁵. One of the contributing factors to prescribing and medication errors is lack of knowledge of the prescribed drug, its correct dosage regimen⁶. Poor knowledge is one of the greatest hindrances to implementing health strategies to improve patients’ health conditions⁷. With the advent of the internet and other sources of drug information, it is expected that health workers should have good access to malaria treatment guidelines and succinctly adhere to recommended strategies for uncomplicated malaria⁸. Although, it has been documented that the public health facilities conform more to the policy on antimalarial utilization^{9, 10}, other reports suggest that a good number of inapproriate treatment practices still exists, such as empirical treatment, treatment of negative results, polypharmacy, monotherapy and use of low quality and expensive brands of Artemisinin Combination Therapies^{11, 12}. The outcome of these practices includes wastages and inefficient management in implementing therapy, thereby predisposing the patients to increased risk, resistance and treatment failures. ACTs were adopted in 2005 as first-line therapy instead of chloroquine due to reports of resistance¹³. Although, this policy may be effective, the mortality rate of malaria is still high¹⁴. Drug prescription is an important skill that demands continous assessment in order to identify areas of concern². Although, information exists on the prescribing practices of physicians, there is however poor information as it relates to children below five years. The few available studies that exist in the literature on prescribing pattern of antimalarials in paediatric patients are old, and as a result, it becomes important to consider the current practice across levels of health care, hence this study. This study sought to assess antimalarial utilization practices of physicians in children below five years in Delta state.

METHODS:

Study Design:

The study is a retrospective cross sectional survey to assess prescribing practices, and adherence to guidelines for the treatment of malaria in children below five years in two health care facilities in Delta State.

Study Setting:

The study was done in two health care facilities; a primary healthcare facility (PHC, Oria-Abraka) and a secondary healthcare facility (Central Hospital Warri).

Central Hospital Warri, is located along Warri/Sapele road. The hospital provides mainly primary and secondary health care services for the communities. The hospital has 30 units/departments with 14 wards listed below. The hospital has 254 beds. As at the time the study was conducted, the pharmacy has 5 subunits with 6 pharmacists, 4 corper pharmacists, 7 intern pharmacist, and 1 pharmacy technician. The nursing department had 124 nurses. The laboratory unit had 9 laboratory scientists. There were 71 doctors. The questionnaires were administered and collected within a four month period.

The primary health centre, Oria - Abraka is located beside Oria town hall in Ethiope East Local Government Area, Delta State, Nigeria. The health care centre comprises of 8 beds, 7 workers, 2 security officers, 1 Matron who most times does the prescription and a visiting physician assigned to the centre she could call for cases beyond her.

Study Population:

The study population includes physicians from Central Hospital, Warri (CH, Warri) and the primary healthcare (PHC, Oria) Delta State.

Sample Selection:

Children below the age of 5 years.

Instrumentation:

The study instrument is the World Health Organization prescribing indicator form.

Sample Size:

A total of 400 prescriptions each were collected from the primary and secondary healthcare facilities.

Data Analysis:

Analysis was done using the statistics package for social sciences (SPPS) and Microsoft Excel. Descriptive statistics of frequency and percentage as well as inferential statistics using Chi-square was done.

Ethical Consideration:

The Ethics and Research committee of the Hospitals granted the ethical clearance for the study with reference number, CHW/ECCVOLI/081.

RESULTS:

WHO Indicators:

A sum total of 400 prescriptions from each facility were evaluated. The values for WHO core indicators are shown in Table 1. A total of 1,243 and 1,313 drugs were prescribed in the Secondary Facility (CH) and primary facility (PHC) respectively giving an average of drugs prescribed per encounter (DPPE), 3.3 in PHC, Oria and 3.1 in CH, Warri with tendency to polypharmacy in PHC.

Table 1: WHO Indicators

WHO Indicators	PHC, Oria	CH, Warri	WHO
Average number of drugs prescribed per encounter	3.3	3.1	2.0
% Drugs prescribed by generic name	537(41%)	522(42%)	100%
% Drugs prescribed as antibiotics	198(15.1%)	353(28.4%)	<32%
% Drugs prescribed as injections	79(20.05%)	Nil	<1%
% Of drugs prescribed from the Essential Drug List	100%	100%	100%

Percentage of Drugs Prescribed:

Drugs prescribed are presented in Table 2. Antimalarials, analgesics/antipyretics, antibiotics were most prescribed. Antihistamines, haematinics, antiemetics, antihelmintics were the least prescribed drugs in these facilities.

Table 2: Drugs prescribed by therapeutic categories

Therapeutic Group	Primary Facility (PHC, Oria)		Secondary Facility (Central Hospital)
Therapeutic Group	Frequency	(%)	Frequency	(%)
Analgesics/ Antipyretics	320	24.4	274	22.0
*Antimalarials	594	45.1	396	31.9
Artemether /lumefantrine	309	52.0	250	63.1
Artesunate/ Amodiaquine	96	16.2	56	14.1
Quinine	50	8.4	43	10.9
Chloroquine	75	12.6	23	5.8
Artemether	64	10.8	7	1.8
Dihydroartemisinin /piperaquine	-		17	4.3
Vitamins and Minerals	162	12.3	140	11.3
Antibiotics	198	15.1	353	28.4
Antiemetics	24	1.8	1	0.1
Antihistamine	6	0.5	12	1.0
Haematinics	5	0.4	8	0.6
Antihelmintics	4	0.3	55	4.4
Antacid	Nil	-	4	0.3
Total	1,313	100%	1,243	100%

Socio-demographics and Prescribing Pattern:

Senior medical officers accounted for 50% of the prescribers with 9-11 years of experience being predominant (Table 4). ACTs were mostly used as first line drug in the treatment plan 37(84.1%). Amodiaquine plus SP was mostly prescribed as a second line drug combination 16(36.4%). Most physicians 27(40.9%) hinged their therapy on experience.

Table 3: Socio-demographics and Utilization Practices of Prescribers in Central Hospital, Warri

Variable		Frequency	%
Gender	Female	18	40.9
	Male	26	59.1
Age (years)	20-29	5	11.4
	30-39	18	40.9
	40-49	18	40.9
	50-59	3	6.8
Position	House Officer	5	11.4
	Principal Medical Officer	2	4.5
	Senior Medical Officer	22	50.0
	Medical Officer	15	34.1
Duration of Practice (years)	0-2	5	11.4
	6-8	13	29.5
	9-11	17	38.6
	12-14	9	20.5
Prescribing Practices
First Line	ACT	37	84.1
	Quinine	2	4.5
	ACT and SP	1	2.3
	Chloroquine	2	4.5
	ACT and Quinine	2	4.5
Second Line	Artemether	2	4.5
	Chloroquine	1	2.3
	Quinine	14	31.8
	SP and Mefloquine	9	20.5
	Halafantrine	2	4.5
	Amodiaquine and SP	16	36.4
Prescribing Practice	Experience	27	40.9
	WHO	13	24.5
	NATP	4	7.5
	Efficacy of Antimalarial	9	17.1

ACT: Artemisinin Combination therapy; SP: Sulphadoxine-Pyrimethamine,

Drugs Prescribed in Dosage Forms:

Most dosage form prescribed was syrup. Injection was only prescribed in PHC, Oria as against <1% specified by the WHO. Oral route of drug administration was the most preferred route. Generic prescription was practiced more in the primary facility (Fig. 1).

Fig 1: Percentage of Drugs Prescribed in different dosage forms and form in which prescribed

DISCUSSION:

This study highlighted the utilization practices in two levels of health care facilities (HFs) in Delta State, Nigeria; a secondary facility (CH, Warri) and a primary facility (PHC, Oria). The index of the study indicated that polypharmacy was seen more in PHC, Oria compared to CH, Warri (Table 1). This finding indicates more rational prescribing pattern in CH, Warri. This according to Okoli et al.¹⁵ could emanate from the fact that doctors in CH, Warri may have been exposed to regular seminars, continuous medical education as well as regular update in malarial therapy. This finding is similar to the research work conducted by Enwere et al.¹⁶ at the University College hospital, Ibadan where the value stood at 3.2+1.47. However, the lowest mean drug prescribed per encounter in Central hospital is above the

WHO recommended limits of 2.0 drugs per prescription¹⁷. This is actually in contrast with the works of Okoli el.¹⁵ which revealed that half of the prescriptions contain six (6) drugs prescribed per patient. No prescription in the facilities contained only one drug. Okoli et al.¹⁵ suggested that the reason for this poly pharmacy are the uncertainties associated with empirical diagnosis, paucity of functional diagnostic equipment making the doctors to resort to empirical treatment and hence prescribe many drugs in a bid to cover different pathological condition in a single prescription. As posited by Mahalakshmi and Sudha¹⁸, one of the most deadly childhood infectious diseases ravaging the world is malaria and therefore, accurate diagnosis necessary for rational drug treatment becomes imperative. Few patients were asked to carryout diagnostic test in the facilities. Thus, this would justify the reason highlighted by Okoli et al.¹⁵ and may eventually be disadvantageous due to reduction in compliance especially in children, increase in drug interactions and antimalarial resistance. Other drugs prescribed alongside the antimalarials revealed the following trend in PHC, Oria: Antimalarials > Analgesics > Multivitamins and Minerals > Antibiotics. In CH, Warri, the trend was quite different with Antimalaria > Antibiotics > Analgesics > Multivitamins and Minerals. The use of antibiotic in pediatrics is a public health concern. This is because infants and children are one of the vulnerable group especially those below five years to contract illness and as a result antibiotic prescription has become a popular practice in the treatment of paediatric illnesses such as malaria¹⁹. All other drugs that were prescribed were less than 5%. No antacid was prescribed in PHC, Oria. Antacid was least prescribed (Table 2).

Furthermore, in the secondary facility, ACT accounted for a large number of the prescriptions as first line drug in the treatment of uncomplicated malaria falciparum (Table 3). This agrees with the studies of Fadare et al.²⁰. Amodiaquine plus SP accounted for a few prescriptions as second line treatment with very low artemisinin monotherapy. The WHO²¹ recommends the utilization of ACT and dissuades the use of artemisinin as montherapy as this would lead to the emergence of resistance. In the light of the above, most of the physicians in this study believed that antimalarial treatment in children is based on experience, with one-quarter reported to have followed the WHO guideline, less than one-quarter based their prescription on the efficacy of the antimalarial with only few reported to have followed the National Antimalarial Treatment Policy (NATP) guidelines.

Generic prescribing is needed for correct drug use and reduce cost of therapy and this was practiced more in PHC, Oria (Fig. 1). These figures were far lower than those of Kanakambal et al.²², Karande et al.²³ in India but above that of Enwere¹⁵. This contradicts previous studies carried out by Igboeli et al.²⁴ which highlighted the poor use of generic name in antimalarial prescriptions. This finding is in concert with the WHO recommendations in promoting correct utilization of drugs that states that drugs should be prescribed in their international proprietary names¹⁷. Rational drug utilization is simply the prescription of the right drug for the right indication, the right dose, route and dosing frequency and for the correct duration¹⁷. This indicates that the practice of prescribing drugs in their generic names was adhered to in both facilities. The difference observed, according to Okoli et al.¹⁵, may be as a result of excessive influence by drug companies in the health facilities whose primary source of drugs could be contractors with powerful political influence on the government. Injections was only encountered in the PHC with chloroqiune and gentamicin accounting for less than half and this was below the results obtained by Ohaju-Obodo et al.²⁵ who reported a range of 57.4%-62.4% injections’ use in private hospitals. Oral administration was the most frequent method of drug administration with syrups the most prescribed dosage form (Fig. 1). Study by Niharika and Choudhary²⁶ revealed that majority of the nurses who administer injections had good injection administration practices. This is an important component in paediatric care. Drug utilization studies had been carried out in various disease states and diverse populations. In another study by Sumithra and Avantika²⁷, oral route was the most preferred route of administration in patients with gastritis. The design of an appropriate pharmaceutical dosage form in the treatment of infants and very young children is still a challenge. Several physiological and developmental changes occurring within the few weeks after birth and throughout childhood may impact significantly on drug pharmacokinetics²⁸. This is because, how they absorb, metabolize, distribute, excrete drugs in response to drug therapy differs²⁹. Thus, the selection of an appropriate pharmaceutical dosage form in infants becomes imperative to ensure compliance.

CONFLICT OF INTEREST:

The authors have no conflict of interest regarding this study.

REFERENCES:

1. Rahul DK. Mayur B. Dheraj C. Current Scenario of Prescription Writing. Asian Journal of Pharmacy and Technology. 2017; 7(3): 144-146. DOI: 10.5958/2231-5713.2017.00023.X

2. Amit B. Prashant B. Avinash K. Prospective cross-sectional study in evaluation of prescribing pattern of doctors for oncology treatment. Research Journal of Pharmacy and Technology. 2011; 4(4): 634-637.

3. Nwolisa CE. Erinaugha EU. Ofoleta SI. Prescribing practices of doctors attending to under-fives in a children’s outpatient clinic in Owerri. Journal of Tropical Pediatric. 2006; 52(3): 197-200. doi.org/10.1093/tropej/fmi095

4. Hersh AL. Jackson AM. Lauri A. Hicks and the Committee on Infectious Disease. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013; 132(6): 1146–1154. DOI: https://doi.org/10.1542/peds.2013-3260

5. Hensen B. Paintain SL. Shretta R. Bruce J. Caroline J. Webster J. Taking stock; provider prescribing practices in the presence and absence of ACT stock. Malaria Journal. 2011; 10:218.

6. Liya John. Medication Error. International Journal of Nursing Education and Research. 2016; 4(4): 502-505.

7. Minu S. Gurpreet K. Jhag DP. Jyoti S. Lalita T. Monika S. Mandip MK. Mary S. Manjot K. Rupashree DG. Knowledge of under five children's’ mothers regarding the six killer diseases. Asian Journal of Nursing Education and Research. 2018; 8(1): 159-162. doi: 10.5958/2349-2996.2018.00033.2

8. Mangham LJ. Cundill B. Ezeoke O. Nwala E. Uzochukwu BS. Wiseman V. Onwujekwe O. Treatment of uncomplicated malaria at public health facilities and medicine retailers in southeastern Nigeria. Malaria Journal 2011; 101:55.

9. Onwujekwe O. Uzochukwu B. Dike N. Uguru N. Nwobi E. Shu E. Malaria treatment perceptions, practices and influences on provider behaviour: comparing hospitals and non-hospitals in south-east Nigeria. Malaria Journal. 2009; 8:246. doi.org/10.1186/1475-2875-8-246

10. Ezenduka CC. Ogbonna BO. Ekwunife O. Okonta MJ. Esimone CO. Drugs use pattern for uncomplicated malaria in medicine retail outlets in Enugu urban, southeast Nigeria: implications for malaria treatment policy. Malaria Journal. 2014; 13:243. DOI: 10.1186/1475-2875-13-243

11. Mangham LJ. Cundill B. Ezeoke O. Nwala E. Uzochukwu BS. Wiseman V. Onwujekwe O. Treatment of uncomplicated malaria at public health facilities and medicine retailers in southeastern Nigeria. Malaria Journal 2011; 101:55.

12. Chuma J. Abuya T. Memusi D. Juma E. Akhwale W. Ntwiga J. Andrew N. Tetteh G. Shretta R. Amin A. Reviewing the literature on access to prompt and effective malaria treatment in Kenya: implications for meeting the Abuja targets. Malaria Journal. 2009; 8:243.

13. Ango UM. Oche MO. Kaoje AU. Bello MM. Umar MT. Adamu A. Kalgo YF. Basakkwace SA. Musa A. (2021). Pattern of Prescription of Anti-malarial Drugs in the Primary Health Care Facilities in Sokoto State Nigeria. International Journal of TROPICAL DISEASE & Health. 2021; 42(2):30-38. doi.org/10.9734/ijtdh/2021/v42i230437

14. Salako L. Chemotherapy of malaria: a historical overview. Keynote address at the 8th Annual General and Scientific Meeting of the West African Postgraduate College of Pharmacist, Abuja. 2006; 1-16.

15. Okoli R. Isah AO. Ozolua RI. Ohaju-Obodo JO. Nwokike OC. Ovienria WA. Drug prescribing pattern in three levels of health care facilities in the north and central senatorial districts of Edo State, Nigeria. International Journal of Herbs and Pharmacological Research. 2015; 4(3):46-57.

16. Enwere OO. Falade CO. Salako BL. Drug prescribing pattern at the medical Outpatient Clinic of a Tertiary hospital in South Western Nigeria. Pharmacoepidemiology and Drug Safety 2007; 16(11):1244-9.

17. World Health Organization (WHO). How to investigate drug use in health facilities: selected drug use indicators. DAP Research, Series 1993; No. 7

18. Mahalakshmi T. Sudha R. Mosquito, Malaria and Medicines – A Review. Research Journal of Pharmacy and Technology. 2016; 9(8):1268-1276. doi: 10.5958/0974-360X.2016.00241.9

19. Maheshwari P. Manimekalai P. Anuja P. Abuk B. Antibiotic Drug Utilization and Evaluation in Pediatric Patients. Research Journal of Pharmacy and Technology. 2017; 10(8): 2704-2706. doi: 10.5958/0974-360X.2017.00480.2

20. Fadare J. Olatunya O. Oluwayemi O. Ogundare O. Drug Prescribing Pattern for Under five in a paediatric Clinic in South-Western Nigeria. Ethiope Journal of Health Science. 2015; 25(1):73-78. doi:10.4314/ejhs.v25i1.10

21. World Health Organization (WHO). Geneva. Essential Drugs. WHO Technical Report Series. Geneva, 1985.

22. Kanakambal S. Murugesh N. Shanthi M. Drug Prescribing Pattern in a Tertiary Care Teaching Hospital in Madurai (Tamilnadu). Indian Journal of Pharmacology. 2001; 2:223.

23. Karande S. Sankhe P. Kuikharni M. Patterns of prescription and drug. Indian Journal of Pediatrics. 2005; 2(7):117-121.

24. Igboeli NU. Ukwe CV. Ekwunife OI. Increasing Use of Artemisinin-based combination Therapy for the treatment of malaria infection in Nigeria Hospitals. Pharmacy Practice. 2010; 4:243-249.

25. Ohaju-Obodo JO. Isah AO. Mabadeje AFB. Perenteral use of drugs in Outpatient units of private health institutions in Nigeria. Nigerian Journal of General Practice. 2004; 7(5):20-23.

26. Niharika R. Choudhary PS. An Analytical Study on Practices Regarding injection Administration among Staff Nurses. Asian Journal of Nursing Education and Research. 2017; 7(3): 384-390. doi: 10.5958/2349-2996.2017.00077.5

27. Sumithra M. Avantika P. A Prospective Study of Drug Utilization and Evaluation of Gastro Intestinal Agents. Research Journal of Pharmacy and Technology. 2017; 10(1): 166-170. doi: 10.5958/0974-360X.2017.00036.1555. 5

28. Jagadeesan M. Harini RR. Chinnasani B. Rational Prescribing Challenges in Paediatrics: A Evidence Based Review. Research Journal of Pharmacy and Technology. 2020; 13(11): 5551-56. DOI: 10.5958/0974-360X.2020.00969.5

29. Geetha P. Kousalya M. Geetha SL. Gopi R. Prescribing Pattern of Drugs Used For Respiratory Disease in Pediatric Patients at Private Hospital. Research Journal of Pharmacy and Technology. 2016; 9(3): 251-256. doi: 10.5958/0974-360X.2016.00046.

Received on 26.06.2021 Modified on 14.11.2021

Research J. Pharm. and Tech. 2022; 15(6):2756-2760.

DOI: 10.52711/0974-360X.2022.00461