Drug prescription pattern for asthma among nigerian doctors in general practice: A cross-sectional survey

Is the national health insurance scheme a pathway to sustained access to medicines in Nigeria?

OBJECTIVE

The debate surrounding access to medicines in Nigeria has become increasingly necessary due to the high cost of essential medicine drugs and the prevalence of counterfeit medicines in the country. The Nigerian government has proposed the implementation of the National Health Insurance Scheme (NHIS) to address these issues and guarantee universal access to essential medicines. Access was investigated using the 3 A's (accessibility, affordability, and availability). This paper investigates whether the NHIS is a viable pathway to sustained access to medicines in Nigeria.

DESIGN

This was a cross-sectional study using a mixed-methods design. Both qualitative and quantitative methods were utilized for the study.

SETTING

This study was conducted at NHIS-accredited public and private facilities in Enugu State.

PARTICIPANTS

296 randomly selected enrollees took part in the quantitative component, while, 6 participants were purposively selected for the qualitative component, where in-depth interviews (IDIs) were conducted face-to-face with NHIS desk officers in selected public and private health facilities.

RESULTS

The quantitative findings showed that 94.9% of respondents sought medical help. Our data shows that 78.4% of the respondents indicated that the scheme improved their access to care (accessibility, affordability, and availability). The qualitative results from the NHIS desk officers showed that respondents across all the socio-economic groups reported that the NHIS had marginally improved access to medicine over the years. It was also observed that most of the staff in NHIS-accredited facilities were not adequately trained on the scheme's requirements and that most times, essential drugs were not readily available at the accredited facilities.

CONCLUSION

The study findings revealed that although the NHIS has successfully expanded access to medicines, there remain several challenges to its effective implementation and sustainability. Additionally, the scheme's coverage of essential medicines is could be improved even more, leading to reduced access to needed drugs for many Nigerians. A focus on the 3As for the scheme means that all facility categories (private and public) and their interests (where necessary) must be considered in further planning of the scheme to ensure that things work out well.

Over-prescription of short-acting β2-agonists is associated with poor asthma outcomes: results from the African cohort of the SABINA III study

BACKGROUND

The extent of short-acting β₂-agonist (SABA) overuse in Africa remains poorly documented. As part of the SABA use IN Asthma (SABINA) III study, we assessed SABA prescriptions/clinical outcomes in 3 African countries.

METHODS

Data on disease characteristics/asthma treatments were collected from patients (≥12 years) using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma) and practice type (primary/specialist care). Multivariable regression models analyzed associations between SABA prescriptions and outcomes.

RESULTS

Data from 1778 patients (mean age, 43.7 years) were analyzed. Most patients were female (62.4%) and had moderate-to-severe asthma (63.3%), with 57.1 and 42.9% of patients treated in specialist and primary care, respectively. Asthma was partly controlled/uncontrolled in 66.2% of patients, with 57.9% experiencing ≥1 severe exacerbation in the previous 12 months. Overall, 46.5% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (over-prescription); 26.2% were prescribed ≥10 canisters. SABAs were purchased over-the-counter by 32.6% of patients, of whom 79.3% had received SABA prescriptions; 71.9% and 40.1% for ≥3 and ≥10 canisters, respectively. Higher SABA prescriptions (vs. 1-2 canisters) were associated with increased incidence rate of severe exacerbations and lower odds of having at least partly controlled asthma (except 3-5 canisters).

CONCLUSIONS

Findings from this African cohort of the SABINA III study indicate that SABA over-prescription and SABA over-the-counter purchase are common and associated with poor asthma-related outcomes. This highlights the need for healthcare providers/policymakers to align clinical practices with the latest treatment recommendations.

Nationwide survey of the availability and affordability of asthma and COPD medicines in Nigeria

OBJECTIVE(S)

To determine the availability and affordability of asthma and COPD medicines across Nigeria.

METHODS

This was a cross-sectional survey conducted in 128 pharmacies (51 in public sector hospitals, 51 private sector community pharmacies and 26 charity or big private hospitals) across the six geopolitical zones of Nigeria using the WHO/Health Action Initiative method. The proportion of pharmacies where medicines were available, the median retail prices of originator and generics and affordability were analysed. A medicine was available if found in ≥ 80% of surveyed pharmacies. Unaffordability was defined as paying> 1 day's wage (> US$1.68) for a standard 30-day supply of the medicine.

RESULTS

The available medicines were oral corticosteroids and oral salbutamol which are not on the WHO Essential Medicine List. Medicines were found more frequently in private than public pharmacies and in the southern than northern zones. Inhalable corticosteroid was not available at any public pharmacy nationwide. None of the EML medicines were affordable. The least number of days' wages for a 30-day supply of any inhalable corticosteroid-containing medication was 3.5 days.

CONCLUSIONS

There are very limited availability and affordability of recommended asthma and COPD medicines across Nigeria with disparity across regions. Medicines that were available and affordable are not recommended and are harmful for long-term use. This underpins the need for engagement of all stakeholders for the review of existing policies regarding access to asthma and COPD medicines to improve availability and affordability.

Development of a framework for increasing asthma awareness in Chitungwiza, Zimbabwe

Background

Asthma accounts for significant global morbidity and health-care costs. It is still poorly understood among health professionals and the general population. Consequently, there are significant morbidity and mortality rates throughout the globe. The aim of this study was to develop a framework to increase asthma awareness at Chitungwiza Hospital, Zimbabwe.

Methods

A modified Delphi model was used to collect data to develop a framework for increasing asthma awareness. At baseline (round 1) in-depth interviews with 44 medical doctors were carried out to understand the level of asthma awareness. Round 2 data collection was in the form of a workshop involving a total of 15 doctors, 30 nurses, four public relations officers, and two health education and promotion officers. The same participants who were engaged in round 2 were also involved in the third round where consensus was achieved by the health professionals.

Results

Our study showed that awareness to asthma among health care providers was affected by mimicry of symptoms and lack of continuous education on asthma. Our study showed lack of Information Education and Communication (IEC) material and lack of use of bulk messages affected asthma awareness. Our study showed that clinical meetings on asthma, having asthma training manuals, (IEC) materials and guidelines for asthma diagnosis and management could improve health care providers' awareness of asthma. Bulk messages on asthma through network providers, social media and bill boards, commemorating world asthma day, edutainment, asthma ambassadors and multimedia were suggested as means of improving awareness of asthma among the public.

Conclusion

We concluded that awareness of asthma can be improved using a framework. Such a framework ultimately improves the quality of asthma care.

Implementation of GINA guidelines in asthma management by primary care physicians in Vietnam

Background

Asthma control is suboptimal in Vietnam. Lack of knowledge of primary care physicians (PCPs) for asthma management may potentially be one of the causes.

Purpose

The aim of this study was to assess the knowledge and practice of PCPs’ asthma management based on the Global Initiative for Asthma (GINA) guidelines (2015 update).

Methods

A cross-sectional study with convenience sampling was conducted among PCPs in an urban and rural area of Vietnam using questionnaires related to asthma patients daily practice: use of spirometry and the asthma control test (ACT), prescription of asthma medications, and frequency of consultations. Five asthma case scenarios were also used to ask participants to classify GINA-defined levels of asthma control and to choose the initial or adjusted treatment options based on the current situation. All scenarios are common in Vietnam, ie, three cases for adults, one case for children, and one case for pregnant women.

Results

Of the 327 completed questionnaires, 201 questionnaires could be analyzed. Most PCPs consulted their asthma patients on a weekly to monthly basis. Approximately 50% used spirometry for asthma care and only 25% used ACT. For asthma treatment, oral short-acting beta agonists and oral steroids were still commonly used and long-acting beta agonists alone were prescribed by 70%. Regarding GINA-defined levels of asthma control, 24% of the responders had ≥50% of correct answers, 21% had no correct answers, 2% had all five correct answers, and 20–42% had a correct answer for each of the five questions. Regarding treatment choice, 22% had ≥50% of correct answers, 14% had a wrong answer for all nine questions, and no respondent had a correct answer for ≥8 questions.

Conclusion

The percentage of PCPs in Vietnam who had implemented GINA 2015 was low. Some drugs with a high risk of side effects were still being prescribed. There is a need to improve both knowledge and daily practice. Additional studies should determine why these guidelines are not largely adopted by PCPs in Vietnam.

Knowledge and perceptions of asthma in Zambia: a cross-sectional survey

BACKGROUND

Zambia is currently experiencing an epidemiological transition, from communicable to non-communicable diseases. The annual rate of physician-diagnosed asthma is estimated at 3 %. However, the general public's knowledge of asthma symptoms and signs, and their perception of asthma remain unknown. A survey was conducted aiming to determine knowledge and perceptions of asthma among Zambians.

METHODS

Adults and adolescents attending four clinics in the capital, Lusaka, were surveyed using a standardized questionnaire from July 2011 to March 2012.

RESULTS

Data from 1,540 participants (mean age 30.7 years, 65% female) were collected. Most patients (74%) were living in low-cost housing. One hundred and sixteen (7.6%) participants reported either a medical diagnosis of asthma or currently taking asthma medications. The most frequent asthma symptoms reported were wheezing (88%), and waking up at night with either shortness of breath (85%), chest tightness (85%), or cough (67%). Medications used to treat asthma were mostly oral short-acting beta-agonists (SABA) (59%), inhaled SABA (30.2%) and antibiotics (29.8%). Inhaled steroids were only used by 16.4% while less than 1% were on long-acting beta-agonists (LABA). Many misconceptions were identified among the entire surveyed population with only 54.7% believing hospitalisations are not preventable, 54.7% believing asthma symptoms can be prevented with the right medications and 37% believing inhalers are addictive. Nearly 60% thought that people with asthma cannot exercise or play hard. Significantly more individuals with asthma compared to those without thought tablets are better than inhalers for the treatment of asthma (46% vs 30%).

CONCLUSIONS

We conclude that knowledge on asthma is poor in Zambia, where there remains many misconceptions on asthma and its management.

Gaps in capacity for respiratory care in developing countries. Nigeria as a case study

There are unmet needs for respiratory medical care in developing countries. We sought to evaluate the quality and capacity for respiratory care in low- and lower-middle-income countries, using Nigeria as a case study. We obtained details of the respiratory practice of consultants and senior residents (fellows) in respiratory medicine in Nigeria via a semistructured questionnaire administered to physician attendees at the 2013 National Congress of the Nigerian Thoracic Society. Out of 76 society-registered members, 48 attended the congress, 40 completed the questionnaire, and 35 provided complete data (73% adjusted response rate). Respondents provided information on the process and costs of respiratory medicine training and facility, equipment, and supply capacities at the institutions they represented. Approximately 83% reported working at a tertiary level (teaching) hospital; 91% reported capacity for sputum smear analysis for acid alcohol-fast bacilli, 37% for GeneXpert test cartridges, and 20% for BACTEC liquid sputum culture. Only 34% of respondents could perform full spirometry on patients, and none had the capacity for performing a methacholine challenge test or for measuring the diffusion capacity for carbon monoxide. We estimated the proportion of registered respiratory physicians to the national population at 1 per 2.3 million individuals. Thirteen states with an estimated combined population of 57.7 million offer no specialist respiratory services. Barriers to development of this capacity include the high cost of training. We conclude that substantial gaps exist in the capacity and quality of respiratory care in Nigeria, a pattern that probably mirrors most of sub-Saharan Africa and other countries of similar economic status. Health policy makers should address these gaps systematically.

Knowledge of Asthma among Doctors Practicing in Three South Eastern States of Nigeria

Background:

Asthma is a chronic airway disease that has a significant impact on patients with substantial global socioeconomic burden. Appropriate knowledge by health care practitioners is important in the management of asthma.

Aim:

The aim was to assess the knowledge of asthma among doctors practicing in health care facilities in three South-Eastern states of Nigeria.

Subjects and Methods:

This was a descriptive cross-sectional study. The participants were selected using multi-staged sampling method and interviewed with structured, self-administered questionnaires. Comparison of the different outcome variables using the Chi-square (categorical) and Student's t-test (noncategorical) with the characteristics of the participants were done.

Result:

A total of 283 doctors were interviewed. Eighty-eight percent of them identified asthma as a common disease in our environment, (P = 0.04) but unrelated to socioeconomic status. Knowledge of epidemiology was poor among medical officers and registrars (P = 0.04). Most of the doctors (80%)(226/283) recognized the pathogenic significance of bronchospasm in exacerbation, while 58.6% (166/283) of them considered chronic inflammation as a significant factor in asthma pathogenesis P < 0.001. Majority of the doctors (84.1%) (238/283) were aware of the use of steroids in acute exacerbation, while 59.4% (168/283) considered aminophylline as the first line medication in exacerbation (P = 0.02). Knowledge about the use of steroids as controller medication was noted in 1.7% (5/283) of the respondents. Only 47.3% (134/283) of the participants were aware of the Global Initiative on Asthma guideline, (P = 0.03).

Conclusion:

There was good knowledge of epidemiology and clinical features of asthma, but a small number of the doctors had knowledge of pathophysiology and treatment of the disease. For best practices in asthma management, there is a need for further education.

Risk factors for asthma exacerbation in patients presenting to an emergency unit of a national referral hospital in Kampala, Uganda

BACKGROUND

Asthma exacerbations are caused by a variety of risk factors. Reducing exposure to these risk factors improves the control of asthma and reduces medication needs. Knowledge of the particular risk factors is essential in formulating controlling and treatment protocols. This study set out to determine the risk factors for asthma exacerbations in patients presenting to the emergency unit of Mulago Hospital.

METHODS

An unmatched case-control study involving 43 cases and 43 controls was conducted from November 2011 through February 2012. Asthma patients with exacerbations presenting to Mulago hospital's emergency unit were chosen as cases. The controls were asthma patients recruited from the hospital's outpatient department who had not had an exacerbation in the past 7 days. The study variables were age, sex, level of education, adherence to treatment, exercise, upper respiratory tract infections, household pets, smoking, strong emotions, exposure to in house wood or charcoal burning, weather, use of corticosteroids, beta-blockers and non-steroidal anti-inflammatory drugs. Univariate and multivariate statistical analysis was done using SPSS version 16 to identify independent risk factors for exacerbations.

RESULTS

Lack of corticosteroid use (OR = 22.109; 95% Confidence interval 6.952 to 70.315; p < 0.001) and presence of upper respiratory tract infections (OR 4.516; CI 1.258-16.213; p = 0.018) were significantly associated with exacerbations.

CONCLUSION

Lack of corticosteroid use and upper respiratory tract infections are associated with exacerbations in asthma patients presenting to the Emergency unit of Mulago Hospital.

Challenges in the management of bronchial asthma among adults in Nigeria: a systematic review

Inadequate attention given to the management of asthma and ways of improving bronchial asthma control could be an important factor for the rising morbidity and mortality from asthma despite major advances in our understanding of the disease process. There is a paucity of data concerning the challenges faced in the management of asthma in Africa. This review was aimed at highlighting the challenges facing asthma management and to discuss various strategies in improving asthma control in Nigeria. Data were sourced from PubMed, Medline, African Journals Online, Google Scholar, SCOPUS, and by reviewing the references of relevant literature. Additional articles were obtained via communications with colleagues and reviewing the Abstract Books of Nigeria Thoracic Society Annual Scientific Conference from 2005 to 2012. The data search was up-to-date as of December 31, 2012. Challenges in asthma management were found during diagnosis, treatment, and follow-up. There are wide variations in diagnostic criteria for bronchial asthma and lack of standard diagnostic equipment leading to under or misdiagnosis. Treatment challenges include poor communication gap between the health-care providers and the patients, a high-cost and unavailability of essential asthma medications. Poor technique uses for medication devices, especially the inhalational drugs and Lack of National/hospital protocol or guidelines for treating asthma. Several challenges affect asthma management in developing countries, which borders on poverty, inadequate resources, weak health systems, and poor infrastructure. Efforts should be made to address these challenges by the Nigerian government, Nigerian Thoracic Society, pharmaceutical industries, and the health-care workers in general.

Unmet needs in asthma treatment in a resource-limited setting: findings from the survey of adult asthma patients and their physicians in Nigeria

Introduction

The prevalence of asthma in our society is rising and there is need for better understanding of the asthma patients’ perception and treatment practice of physicians. The study was aimed at determining asthma attitudes and treatment practices among adult physicians and patients in Nigeria, with the goal of identifying barriers to optimal management.

Methods

To assess asthma attitudes, treatment practices and limitations among adult physicians and patients in Nigeria, a questionnaire survey was conducted among 150 patients and 70 physicians.

Results

Majority (66.7%) of the patients reported their asthma as moderate to severe, 42.7% had emergency room visit and 32% had admission due to asthma in the previous 12 months. Physicians and patients perceptions significantly differed in the time devoted to educational issues (31.4% vs.18.7%) and its contents: individual management plan (64.3% vs.33.3%), correct inhaler technique (84.0% vs.71.0%), medication side effects (80.0% vs.60.0%) and compliance 100% of time (5.7% vs. 18.7%). Patients reported that non-compliance with medication causes increased symptoms (67.0%), exacerbations (60.0%), bronchodilator use (56.0%), urgent physician visit (52.0%) and hospitalizations /ER visits (38.7%). Asthma medication in patients caused short term (10.7%) and long term side effects (20.0%). Due to side effects, 28.0% skipped and stopped their medications. Most physicians (85.7%) and patients (56.0%) agreed on the need for new medication options. The need for new medication in patients was strongly related to asthma severity, limitation of activities, side effects, cost and lack of satisfaction with current medication. With the exception of pulmonologists, physicians did not readily prescribe ICS and their prescriptions were not in line with treatment guidelines.

Conclusion

This study has highlighted the gaps and barriers to asthma treatment which need to be addressed to improve the quality of care in Nigeria.