Introduction
The appropriate use of medicines is critical especially in lower- and middle-income countries (LMICs) where the cost of medicines account for up to 70% of total healthcare expenditure, with potentially catastrophic implications for the family if a member becomes ill [
1,
2]. The World Health Organization (WHO) estimates that over half of all medicines are inappropriately prescribed, dispensed or sold worldwide, and a similar percentage of patients fail to take their medicine properly [
2].
In Namibia, several medicine use surveys have suggested the inappropriate use of medicines across all levels of health care [
3,
4]. This is a concern as currently in Namibia over 45% of the adult population have hypertension [
5], with cardiovascular diseases now a leading cause of death (21%) [
5,
6]. There is also a high burden of infectious disease such as HIV/AIDS, tuberculosis, malaria and acute respiratory infections in Namibia [
7‐
9]. In order to promote rational use of medicines (RUM), the Ministry of Health and Social Services (MoHSS) adopted the Essential Medicine concept with the first National Medicine Policy launched in 1998, and the first standard treatment guidelines (NSTGs) was launched in 1994, with a comprehensive update in 2012 [
9]. STGs are seen as important interventions to improve medicine use in countries including Namibia [
9‐
11]. However, compliance to the guidelines in 2014 was between 26.2 and 44.6% nationally [
12], below the target of ≥ 90% with a rate of 80% considered acceptable [
9].
Aim of the study
The objective is to investigate current trends in prescribing practices and compliance with NSTGs among different level health care facilities in Namibia. In addition, qualitatively identify key factors that may influence prescribing practices and NSTG compliance.
Ethics approval
Permission to conduct the research was granted by the University of Namibia (UNAM) and the Ministry of Health and Social Services (MoHSS, REF 17/3/3). Specific patient and prescriber identifiers and patient identifiers were not collected but rather codes were assigned to each study participant for identification.
Methodology
Study design and setting
A cross-sectional descriptive survey applying mixed methods was conducted to assess medicine prescribing patterns and drivers of compliance to NSTGs at three levels of health care in Namibia. These were the Intermediate Hospital Katutura (IHK), Katutura Health Centre (KHC) and Khomasdal Clinic (KMDC) in the Khomas Region. The Khomas region was chosen as it has a diverse cosmopolitan patient and prescriber population, a high population versus other regions in Namibia and concerns with adherence to STGs [
12]. The Khomasdal clinic was purposely selected among the ten clinics in the region based on its proximity and similarity of demographics and services to IHK and KHC.
Quantitative methods were used to assess prescribing indicators based on those recommended by the WHO [
9,
13]. Qualitative methods were applied to evaluate thematic drivers of compliance to NSTGs.
Study population and sample
The target populations included outpatient prescriptions and prescribers at the three public health facilities. Prescriptions obtained from health passports during patient exit interviews were analysed for prescribing patterns. In Namibia, outpatient prescriptions are compiled in a medical booklet, the health passport. These detail consultation records including diagnoses, medical and medication history. This study only included prescribing data on recent prescriptions at the three facilities. Consequently, a sample of 584 patient prescriptions was determined using Kish and Leslie [
14] method for a single sample estimation of proportion [
9,
14]. However, since the study was conducted at two different levels of health care, we estimated the total sample at 2 * 584 = 1168. We included an additional 6.5% to account for prescriptions that may have missing data. As a result, a maximum number of prescription records to be collected at patient exit interviews was 1243. These prescriptions were collected from 1243 patients who were sampled from daily outpatient registers at the respective outpatient pharmacies at the three health facilities. A systematic sampling method, i.e. every third patient, was used to consecutively recruit patients. Of the 7 (0.56%) prescriptions with presenting complaints but no diagnosis indicated, 5 were rectified after consultation with the respective prescribers and the two were replaced through the process of systematic sampling matched with the age and sex of the patients.
Each prescription included information on patient demographics, diagnosis, medication and prescriber. Prescribers (both nurses or doctors) are required by law to indicate the diagnosis on the prescriptions as classified in the NSTGs. For prescriptions without a clear diagnosis, a team consisting of a pharmacist, doctor and nurse reviewed the prescriptions to link the diagnosis with the disease categories in the NSTG.
Secondly, prescribers who were on duty during the 6 months study period, 1st February to 31 July 2015, were interviewed for drivers for compliance to NSTGs. The sample of prescribers was determined purposively. A total of 74 prescribers working at the three public health facilities at the time of data collection were included. Of these, 44 were employed at IHK, 21 at KHC and 9 at KMDC. At any given time, 12 prescribers worked at OPD in IHK, 8 at KHC and 5 at KMDC.
We used the duty rosters to identify prescribers working at out-patient departments in the selected three sites to include them in the sample. Using the roster, 40 prescribers were expected to work in three sites at OPD during the data collection period. All 40 prescribers were selected for prescriber interviews. We did not include any prescribers in the inpatient department of IHK or any working in specialised clinics. Responses were broken down by prescriber type for further analysis.
Data collection procedure
Data were collected in two phases; patient exit interviews on medicine prescribing patterns and prescriber interviews using a structured questionnaire for drivers of compliance to NSTGs.
Patient exit-interviews
Patients were recruited into the study using a systematic sampling technique, i.e. every third patient registered at the outpatient’s pharmacy.
Only patients that gave written informed consent were subsequently interviewed and prescriptions analysed. The 1243 patients/patients were stratified by health facility, with the allocation calculated on the basis of patient turnover resulting in KMDC (10%), KHC (35%) and IHK (55%). Only prescriptions from the general outpatient department were selected. Prescribing data were abstracted from patients’ prescription booklets (i.e. health passports) by the researchers (QN and DK) and a team of three experienced data collectors using the WHO recommended tool for medicine use evaluation [
13]. We also excluded prescriptions with incomplete information such as missing diagnosis or missing details of the patient. Two patients’ prescriptions had missing data on diagnosis. Data were quantitatively analysed to determine the prescribing indicators [
9].
Survey of prescribers
A questionnaire (Annex 1) was administered to prescribers at the selected health facilities to assess for drivers of compliance to NSTGs. The tool was piloted with the help of two intern doctors at IHK and standardized before being rolled out. Prescribers’ details were also collected.
Data to determine the level of compliance and the use of NSTGs in the prescribing of medicines was collected using a self-administered questionnaire. Only prescribers whose names appeared on the prescriptions evaluated in the first phase of the study were assessed. During the collection of the questionnaire, a structured interview was conducted with the prescribers to assess the availability and access to NSTGs as well as gain further insight on key factors that might impact on their prescribing practices and compliance to NSTGs. The interviews were structured in such a way that the answers could be thematically analysed and/or quantified for ease of analysis. All interviewees gave their informed consent before being interviewed.
Data analysis
The main outcome measures were medicine prescribing practices and qualitative determinants of compliance to NSTGs among public health care facilities in Namibia. Quantitative data from the patient exit and prescriber interviews were entered into Epidata 3.1 for management and exported to SPSS v24 for descriptive analysis of the indicators and compliance to NSTGs.
Prescribing practices were analysed using descriptive statistics as per the WHO/INRUD indicators [
9,
13]. The five indicators and the MoHSS targets include:
-
Average number of medicines per out-patient prescription
-
The percentage of medicines prescribed by generic name
-
Percentage of prescriptions with an antibiotic
-
Percentage of prescriptions with an injection
-
The level of compliance to STGs
Quantitative and qualitative methods were applied to identify the drivers of compliance of NSTGs. Descriptive statistical analysis was used to determine the level of awareness, availability, access, use, and training on NSTGs. The drivers of compliance to STGs were also quantitatively determined using the χ2 test with the level of significance (α) set at p = 0.05 and a 95% confidence interval, with qualitative data analysis conducted using thematic content analysis to identify the themes and subthemes of drivers of compliance to the NSTGs. Thematic content analysis was performed manually from data obtained from the interviews. The content or responses to the question items were colour coded and organized into sub-themes. The significant drivers of compliance to NSTGs were subsequently converged during the analysis to support the themes.
Discussion
We believe this is the first study to qualitatively identify key factors influencing prescribing practices and NSTG compliance across disease areas building on assessments of guideline adherence in specific treatment and disease areas as well as ways to improve the content and pragmatism of national STGs among sub-Saharan African countries [
10,
16‐
18]. This is a concern given the high prevalence of both infectious and non-infectious diseases in sub-Saharan Africa and their impact on morbidity, mortality and costs [
5,
19‐
27].
The prescribing indicators were typically sub-optimal compared with the Namibia and WHO/INRUD standards, similar to other African countries [
9,
15]. However, 73% of prescriptions were compliant to NSTG recommendations, an improvement on previous studies in Namibia [
12], comparing favourably with recent studies among PHCs in Botswana and other LMICs [
28‐
31]. However, lower than the compliance level set at 85% for Namibia [
9], with ongoing concerns that antibiotic prescribing remains suboptimal [
9].
Encouragingly, there was a high level of awareness and availability (94.6%) of the NSTGs among prescribers (Table
2), similar to the previous study by Akpabio et al. in Namibia and Matsitse et al. in South Africa [
12,
31]. This compares with variable availability of STGs among PHCs in Botswana [
32]. However, 8.1% of prescribers in Namibia had never seen a copy of the NSTG (Fig.
1) and never made reference to the NSTG in their prescribing. Encouragingly as well, 32.4% of prescribers routinely referred to the NSTG on a daily basis when making prescribing decisions with 18.9% referring the NSTG once a week, higher than the previous study by Akpabio et al. [
12]. In addition, a high number of prescribers (82%) found it easy to refer to the NSTGs when needed although concerns with the lack of training (Table
2) similar to South Africa [
31].
The prescribers reported using a wide variety of reference sources when prescribing medicines (Table
1, Fig.
2). Most prescribers used printed guidelines in the form of STGs, as well as treatment and algorithms charts (Fig.
2), similar to Uganda [
33]. Encouragingly, there was no mention of pharmaceutical companies as a source of information different to some LMICS [
34‐
38], with the potential for biased information affecting subsequent prescribing and patient care [
38‐
41].
The high use of the STGs appeared to be due to a number of factors including their comprehensiveness, simple and well-structured STGs, availability, relevance, objectivity and portability (Table
3). Training on STGs has reduced the prescribing of antibiotics and over use of injections in other countries [
42,
43]. Objectivity and trust in prescribing guidance resulted in high adherence rates to the ‘Wise List’ in Stockholm County Council in Sweden [
44‐
46].
Recommendations on drivers for compliance to NSTGs (Table
4) included increasing access to STGs and essential medicines at health facilities, continuous professional training, regularly updating, and continuously auditing and monitoring prescribing against NSTGs. These findings are also in line with a similar previous study conducted in a number of regions of Namibia [
12].
Limitations
We are aware of a number of limitations with this study. The principal limitation is that the study was carried out in only one region of Namibia and with a limited number of health facilities. However, we believe our findings are robust based on the nature of the chosen sites and their representational characteristics. As a result, providing future guidance on ways to improve medicine use throughout Namibia and wider.
Conclusion
Whilst the overall awareness of STGs is high among prescribers in Namibia, their use can be limited. The main factors driving the use of the STGs in Namibia are their access, the availability of medicines recommended by the STG, the simplicity and objectivity.
The findings suggest that STGs should be regularly revised, routinely made available to all health professionals, and the treatment options described in STGs should be available and in stock at all times. Pharmacists can also play a key role here. These are considerations for the future along with the introduction of a prescribing performance management system including agreed quality indicators. Pharmacists can play a key role in their development. The introduction of electronic prescribing systems can help with real time auditing of prescribing as seen with the Wise List in Sweden [
46,
47].
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
http://creativecommons.org/licenses/by/4.0/.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.