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Improving Chloroquine Prescribing in PrivateClinics in Lagos State, Nigeria *Taylor O, **Momodu RO, **Odufalu O *World Health Organisation **National Agency for Food and Drug Administration and Control (NAFDAC) Introduction/Background Chloroquine has been very valuable for the chemotherapy of malaria for several decades by virtue of its safety, wide availability and affordability. However, chloroquine is fast becoming ineffective in the management of malaria due the development of chloroquine resistant plasmodium parasites. It is thought that irrational prescribing of chloroquine among other factors is responsible for the development of resistance. Studies show that less than half of chloroquine prescriptions in private and public health facilities were inappropriate in Lagos State, Nigeria. The study describes an intervention to determine the best approach to improve multiple dosing regimen such as found in chloroquine among private health facilities in Lagos State. The effect of using an aidememoire and dosing information printed on a sheet of paper was compared. Objectives/Study Questions It is hypothesised that the various dosing schedules for different ages may be difficult for prescribers to remember. The objective of the study is to test the effectiveness of an aidememoire placed on the table in comparison with the same information printed on a sheet of paper handed over to the prescriber after face to face academic detailing in improving chloroquine prescribing. METHODS The prescribing patterns of chloroquine were surveyed before and after intervention in 13 private health facilities in Lagos State, Nigeria. All chloroquine-containing prescriptions were recorded in each of the facilities between April to December 1999. Intervention was carried out in January 2000 and prescriptions were recorded for the post intervention study between February and July 2000. Improvement in the prescription of chloroquine after intervention was judged on the basis of the following outcome indicators: Increase in the percentage of prescriptions having the correct chloroquine doses. Increase in the percentage of chloroquine prescriptions with the oral dosage form Increase in the percentage of prescriptions with chloroquine injections followed up with the oral form. Decrease in the percentage of prescriptions with chloroquine injections only. INTERVENTION METHODS 13 private health facilities were randomly assigned as follows: Group 1: 5 hospitals received academic detailing and an aidememoire with the dosing schedule of chloroquine Group 2: 4 hospitals received academic detailing and printed dosing schedule of chloroquine. Group 3: 4 hospitals did not receive any information on chloroquine dosing. Academic Detailing: Two persons visited the prescribers in their health facilities. A computer notebook using the Microsoft Power Point software was used to make presentations to the physicians in their consulting rooms. The key messages were: a) Using the oral dosage form as the preferred route of administration. b) Using injections only when the oral route becomes impossible but including the oral dosage form as a follow up to injections. INTERVENTION METHODS AIDEMEMOIRE The aidememoire consists of a plastic box filled with loose sheets. These are gift items that are used by corporate bodies for publicising either their products or their organisations. The dosing schedules corresponding to different age groups were printed on plastic boxes placed on the physicians' tables after the educational encounter and the prescribers were encouraged to refer to them while prescribing. DRUG INFORMATION SHEETS The same dosing schedules printed on the plastic boxes were printed on a sheet of paper and handed over to the prescribers after the face to face training. RESULTS Baseline results Figure 1 shows that 2 (15%) of the clinics had between 50% and 80% prescriptions in the recommended dose while 11 (85%) had between 0% and 50%. Increase in the percentage of prescriptions having the correct dosing schedule of chloroquine. Figure 2 shows the percentage of chloroquine prescribed in the recommended dosage form increased by 26% in the aidememoire group. The use of drug information sheets did not elicit an appreciable improvement in prescribing since the recommended dose only increased by 4%. In the control group the recommended dose remained approximately the same. Decrease in the percentage of prescriptions with chloroquine injections only. The message, which emphasised the reduction in the use of injections alone, was heeded by the group that was given the aidememoire as a 24% decrease was recorded after the intervention. The group that received drug information sheets also recorded a decrease of 14% in the use of injections alone while the control had a 5% increase. RESULTS (CONTD) Increase in the percentage of prescriptions with chloroquine injections followed up with the oral form. Only the aidememoire group increased their use of injection followed up with the oral dosage forms by 11% while the drug information group had no appreciable increase (1%). There was a 22% reduction in the use of the injection with the oral dosage form in the control group. Increase in the percentage of chloroquine prescriptions with the oral dosage form The use of the oral form of chloroquine increased in all the groups; 16% in the aidememoire group, 13% in the drug information sheet group and 16% in the control group. PERCENTAGEOF PRESCRIPTIONS FIGURE 1: PERCENTAGE OF PRESCRIPTIONS IN RECOMMENDED DOSES 80 73 PRE 70 POST 60 50 47 51 52 44 44 40 30 20 10 0 AIDEMEMOIRE DRUG INFORMATION CONTROL PERCENTAGE OF PRESCRIPTIONS FIGURE 2 PERCENTAGE OF PRESCRIPTIONS WITH CHLOROQUINE ONLY INJECTIONS 50 45 40 35 30 25 20 15 10 5 0 PRE POST 47 42 40 33 26 9 AIDEMEMOIRE DRUG INFORMATION CONTROL PERCENTAGEOF PRESCRIPTIONS FIGURE 3: PERCENTAGE OF PRESCRIPTIONS TABLET AND INJECTIONS 50 45 PRE POST 45 40 35 34 30 30 25 20 20 19 15 9 10 5 0 AIDEMEMOIRE DRUG INFORMATION CONTROL PERCENTAGE OF PRESCRIPTIONS FIGURE 4: PERCENTAGE OF PRESCRIPTIONS AS ORAL DOSAGE FORM 60 PRE 54 POST 47 50 44 41 40 31 28 30 20 10 0 AIDEMEMOIRE DRUG INFORMATION CONTROL IMPLICATIONS/RECOMMENDATIONS There is lack of attention paid to the private sector despite the fact that about 60% of the Nigerian population use the private sector. In this study, baseline studies showed most of the facilities recorded very low percentage of prescriptions in the recommended dose. It is noteworthy that one of the facilities had not even one correct prescription. For drugs that are subject to development of resistance such as anti-infectives, it is important that monitoring of therapy should not be limited to the public sector if drug resistance is to be mitigated. Adequate attention was not paid to rational use of chloroquine and today, it is no longer effective in the malaria treatment despite its advantages. Most countries are turning to the artemisinin derivatives as first line antimalarials. It is important that efforts be made to preserve the long term use of these drugs and other new antimalarials to mitigate future development of resistance. Use of newer antimalarials need to be closely monitored in both private and public sectors and any irrational behaviour promptly corrected. Aidememoires can immediately be put into use to test their effectiveness in preventing irrational prescribing of newer antimalarials.