Malaria constitutes a major Public Health burden in sub Saharan Africa particularly
Nigeria. The disease, caused by sporozoan genus Plasmodium and ably transmitted
by female anopheles mosquitoes commonly presents with fever, headache, chills,
rigors, vomiting and poor appetite. About 15% of Nigeriaís population is exposed
to malaria infection at least once in a year (RBM, 2005).
Nigeria is responsible for 25% of malaria burden in Africa (DFID,
2009). Half of world population is exposed to the risk of malaria with annual
global incidence of 250 million cases resulting in 860,000 deaths mostly involving
children from African continent (WHO, 2010). In Nigeria,
it accounts for 30 and 11% of childhood and maternal mortalities, respectively
and 60% of out-patient consultations are for malaria. Before the advent of Artemesinin-based
Combination Therapy (ACT) chloroquine has been on the fore front in the treatment
of uncomplicated malaria. However, due to the development of widespread chloroquine
resistance in malaria endemic areas in 2004 the federal government of Nigeria
adopted ACT as first line treatment for uncomplicated malaria in line with the
recommendation of the WHO (Onwujekwe et al., 2009).
Artemesinin-based combination therapy drugs were supposed to be provided free
in all government health facilities and
75.00 charged across private pharmacies and medicine stores in Nigeria.
Primary health centres are the first health facilities from which patients seek assistance when they are sick especially in rural and peri urban areas where majority of the populace leave. Therefore, this pre-intervention study is aimed at determining the awareness as well as the compliance of primary level health care providers to WHO recommendation for ACT as first line treatment of uncomplicated malaria. Availability and affordability of ACTs in the primary health care facilities were also assessed. To the best of the knowledge, no similar studies have been carried out in the study area.
MATERIALS AND METHODS
Instruments of data collection: Pre-validated questionnaires were used.
The items of interest included demographic characteristics of the respondents,
qualification of respondent, number of malaria cases seen per month, knowledge
of the respondents about the first line and second line drugs in the treatment
of malaria generally and in first trimester of pregnancy, methods of malaria
diagnosis as well as second line drugs and awareness of ACT (Table
|| Qualifications of respondents
|MBBS: Bachelor of Medicine Bachelor of Surgery; RN: Registered
Nurse; CHO: Community Health Officer; SCHEW: Senior Community Health Extension
Worker; JCHEW: Junior Community Health Worker
The respondents were also asked for free comments on issues not included in
the questionnaire. A pilot study was carried out prior to the on set of the
study in Yar akija and Arkilla Primary Health centres.
Selection of study area and respondents: The study was a cross-sectional in design that involved multi-stage sampling techniques. Total number of primary health care centres in the state 37 was obtained from the state ministry of health. These centres were stratified along the 3 senatorial districts, namely Sokoto East, Sokoto South and Sokoto Central using simple random sampling techniques. From each of the three zones, five (a total of 15) health centres were also randomly selected to be enrolled into the study (by ballot). The survey was targeted only at staff involved in managing the patients. The questionnaires were self administered and collected there and then and for those respondents who were unable to fill the questionnaire at the spot it was left with him/her to be collected at the next visit. Each senatorial zone was manned by two trained assistants that were knowledgeable in all aspects of the study. The data collected were analysed using soft-ware program for Social Sciences (SPSS).
RESULTS AND DISCUSSION
As shown in Table 2, exclusive use of clinical features for diagnosis of malaria was significantly more frequent (69.23% vs. 30.77%, p = 0.027) among the staff having lower qualifications (SCHEW, JCHEW and Pharm Tech) compared with officers having higher qualifications (doctor, nurses, CHO).
The 25 eligible respondents (mean age: 34.3 years; male: female ratio: 5.3:1),
working in 15 primary health centres were surveyed. The pattern of anti-malarial
prescription was shown in Table 3.
|| Qualifications and methods of malaria diagnosis PHCC
|| Pattern of anti-malaria prescription in PHCC
|PHCC: Primary Health Care Centre
The two most frequently prescribed drugs (singly or in combination with other
anti-malarials) were artemether-lumefantrine and chloroquine being mentioned
by 44 and 40% of the respondents, respectively (Table 3).
The 14 (56%) respondents mentioned either effectiveness or recommendation by
World Health Organisation (WHO) as reasons for their prescription while for
the remaining 11 (44%) their prescriptions were determined by availability and
affordability of the drugs.
The 12 (48%) prescribed first line drugs because of effectiveness, 6 (24%) because the drugs were easily available, 5 (20%) because the drugs were cheap and 2 (8%) due to WHO recommendation. The 15 (60%) of respondents were aware of ACT while 10 (40%) were not. However, none of the respondents was able to give the meaning of ACT or itís various recommended regimens. Three respondents (12%) mentioned treatment of multi-drug resistance malaria when asked importance of ACT. When respondents were asked to comment freely, 9 responded. The 4 (16%) said ACT drugs were expensive while 5 (20%) claimed availability was a problem.
Nurses and senior community health extension workers were the main category
of health care givers at these centres (80%). This was reassuring considering
the fact that it was level I health care where village health workers (VHW),
Junior Health Extension Workers (JCHEW) and trained patent medicine vendors
belong to this category of health facilities. The finding in this study of 40%
prescription ACT of all anti malaria prescribed as first line therapy in uncomplicated
malaria is >26.2% reported in Lagos (Oshikoya, 2007).
Respondentsí knowledge of ACT was very poor as only 8 and 12% of them were aware
of ACT recommendation by the WHO and the fact that ACT was recommended as a
result of chloroquine resistance, respectively (WHO and FMOH) and none of the
respondents could mention correctly full meaning of ACT and the its recommended
|| Treatment of malaria at first trimester of pregnancy
These findings were indications that the prescription pattern of the healthcare
providers was influenced not by evidence but mainly by availability of the drugs.
This was supported by fact that ACT drugs were donated free to most of these
health facilities. Chloroquine ranked second after fixed dose Lumefantrine +
Artemether combination (28%) despite its non recommendation for treatment of
malaria probably because it was cheaper and more available especially in the
rural areas. Another important finding was the use of ineffectient combination
(e.g., Artemether + Pyrimethamine + Sulphadoxine) and the use of artemisin-based
monotherapy (as artesunate alone and artemether only) which is associated with
serious danger for emergence of resistance to artemesinin based combination
therapy. Another disturbing finding of this study was the treatment of pregnant
women at first trimester shown in Table 4. Only 4% of the
respondents prescribed quinine (plus chloroquine) for malaria treatment in this
category of patients which was the recommended therapy at this stage of pregnancy.
However, in the absence of quinine, Lumefantrine + Artemether fixed dose was
recommended but only 8% of the respondents prescribed it. This showed 88% of
pregnant women at first trimester were not properly treated with consequent
negative impacts on both maternal and child health. The data on affordability
and availability of ACT in these centres may not necessarily reflect true situation
on ground because the drug was freely donated to these facilities by donor agencies
and the state government and may account for the favorable responses as against
what obtained in tertiary level health facilities where no such donations were
given (Olurishe et al., 2007).
This study found that chloroquine was still prescribed at the primary health care centres despite the ban on its use by WHO and Nigerian National Policy on Malaria Treatment. Knowledge of ACT among primary health care providers was very low and there was need for health education intervention at this level of health care on ACT to acquaint the respondents with basic knowledge of ACT.
The researchers are very grateful to Dr. Umar Ango of Sokoto State Ministry of Health for his contribution to this research.