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Erschienen in: Malaria Journal 1/2019

Open Access 01.12.2019 | Research

Dispensing practices for anti-malarials in the La Nkwantanang-Madina municipality, Greater Accra, Ghana: a cross-sectional study

verfasst von: Charles Enyaah Amankwa, Harriet Affran Bonful, Kofi Agyabeng, Priscillia A. Nortey

Erschienen in: Malaria Journal | Ausgabe 1/2019

Abstract

Background

Despite recent strides made towards reducing the emergence of artemisinin resistance, inappropriate dispensing practices for anti-malarials in both private and public sectors affect treatment outcomes negatively. In Ghana, private retail pharmacies are the most accessible health facilities for managing diseases of common occurrence. However, there is growing concern about the number of patients harmed by dispensing errors in the management of malaria in retail pharmacies. Although considerable work has been done in this area, several questions regarding dispensing practices remain unanswered. This study, therefore, sought to investigate the predictors of appropriate dispensing practices for anti-malarials in community pharmacies in the La Nkwantanang-Madina municipality of Greater Accra, Ghana.

Methods

A cross-sectional analytic study was conducted in sixty-one randomly selected community pharmacies in the La Nkwantanang-Madina. Data from 230 clients and 106 dispensers were analysed. It was checked for internal consistency and completeness then entered and analysed using STATA I/C version 14.0. Frequencies, Chi square tests, and logistic regression analyses were conducted, accounting for clustering.

Results and discussion

Of the 106 dispensers interviewed, 71.4% were medicine counter assistants. The mean age of dispensers was 30.4 years (SD 8.8). Over 88.0% of clients were advised to complete the full course of their anti-malarials. However, the 8-h loading dose principle for artemether-lumefantrine was not explained to 88.3% of the clients. More than half of the clients (52.2%) were given appropriate dispensing information on anti-malarial use. Most clients (66.1%), were dispensed anti-malarials without malaria tests. Dispensers with more than a 10-years experience were less likely to dispense artemisinin-based combinations appropriately relative to dispensers with less than 2 years experience (AOR = 0.04, 95% CI 0.002–0.802 p-value = 0.036) while pharmacy interns were about 19 times more likely (AOR = 18.5, 95% CI 1.40–245.6 p-value = 0.03) to dispense artemisinin-based combinations appropriately compared to pharmacists.

Conclusion

Dispensing practices for anti-malarials is unsatisfactory. There is a need to enforce existing legislation with educational programmes directed towards dispensers especially those with more than 10 years experience. Specific adherence to the World Health Organization Test, Treat and Track initiative should be encouraged to ensure effective use of anti-malarials.
Hinweise

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Abkürzungen
ACT
artemisinin-based combination therapy
AL
artemether–lumefantrine
CI
confidence interval
NMCP
National Malaria Control Programme
RDT
rapid diagnostic test
LCS
Licensed Chemical Sellers
PC
Pharmacy Council
NHI
National Health Insurance
MCM
Malaria Case Management
MCA
Medicine Counter Assistants
AOR
adjusted odds ratio
WHO
World Health Organization

Background

The accurate use medicines play an important role in healthcare delivery. The provision of appropriate medicines can help alleviate symptoms, prevent recurrence of disease and restore patient’s health. Nonetheless, inappropriate use of medicines remains a major public health issue globally [1, 2].
In developing and low middle income countries, there has been considerable evidence of inappropriate drug use due to poor dispensing practices, inadequate package labelling and poor instruction given to clients on usage of medicines [3, 4].
In contrast to the developed regions, private retail pharmacies and Licensed Chemical Shops play an important role in promoting access to basic health services in sub-Saharan Africa. In Ghana, for example, private retail pharmacies and Licensed Chemical Shops, who are registered suppliers of specific over-the-counter medicines are the most accessible health facilities available for managing commonly occurring diseases [5]. Empirical studies have shown that the majority of families seek treatment for mild febrile diseases in retail pharmacies as compared to public health facilities [6, 7]. Their operations are regulated by the Pharmacy Council (PC) of Ghana under the Health Professions Regulatory Bodies Act 857 [8]. Community pharmacies are typically managed by pharmacists (individuals who hold a degree in pharmacy, completed the required internship programme and passed professional qualifying examination) and other pharmaceutical support staff; Medicine Counter Assistants (MCA—support staff trained to complement the role of pharmacy technicians, owing to acute shortage of the technicians) and pharmacy technicians.
Retail pharmacies are patronized primarily because they are readily accessible, have longer opening hours and clients may spend less time to be served compared to the public health facilities [5, 9, 10]. However, they are poorly monitored and may not be operating professionally [1012]. In a study conducted by Buabeng in 2010, an alarming 77% of patients used incorrect dosage or did not complete the course of their anti-malarials [13]. The same study showed that (54%) of the patients who purchased from community pharmacies took their anti-malarials inappropriately possibly due to poor dispensing information [13]. Other researchers have rather observed that a greater proportion of patients had informed understanding of adverse effects compared to ‘how to use’ anti-malarials [11, 14]. These point to the importance of adequate dispensing and its pivotal role in preventing medication use errors [15, 16].
The dispensing process forms an integral part of the quality use of medicines and is the core professional role of a pharmacist. It ensures the safe and effective provision of medication to the general public. Dispensing involves all activities from the receipt of the prescription to the time the medicine is issued out to the patient [15]. The role of the pharmacist has traditionally been to provide patients with appropriate pharmaceutical care, to maintain the quality of pharmaceutical products and to ensure that patients take their medicines rationally [5, 8, 10, 11, 13].
In recent times, pharmacists’ role has evolved to advising physicians and other health professionals about drug therapy, its adequacy, side effects and possible interactions. In the community pharmacy setting, however, pharmacists and other support staff may not have the opportunity to interact with physicians and therefore, treat their clients empirically [13, 17]. This may have dire effects on patients once vital information is missed and often resources involved in patient care prior to dispensing may be wasted.
The introduction of rapid diagnostic testing (RDT) in the private sector in Ghana has made it easier for dispensers in community pharmacies to diagnose malaria definitively and treat confirmed malaria cases. However, in most malaria endemic areas, oral anti-malarials purchased from retail outlets are mainly obtained through client requests without laboratory confirmation [6, 18, 19]. Therapy initiated without conclusive test outcomes may not only accelerate artemisinin resistance but lead to the possible progression and aggravation of the actual cause of disease [17, 2023].
Evidence from a cross-sectional survey and other studies point to a possible link between poor dispensing practices and its effect on anti-malarial resistance [2426]. There is, therefore, a need for continuous assessment of the quality of dispensing of anti-malarials as this will inform policy makers and the National Malaria Control Programmme (NMCP) on areas to be targeted during the roll-out of interventions. Although considerable work has been done in this area, past studies on dispensing practices have primarily focused more on dispensing in public health facilities, understanding the role of pharmacists, assessing staff/patient knowledge, policy guidelines adherence among many others [13, 16, 23, 2729].
However, there is limited information on dispensing practices among community pharmacies especially in the Greater-Accra region of Ghana. This study aims to address that gap by assessing factors associated with dispenser’s practices for anti-malarials in the La Nkwantanang-Madina municipality.

Methods

The study was conducted in La Nkwantanang-Madina located in the Greater Accra Region, one of the ten administrative regions in Ghana at the time of the study. La Nkwantanang-Madina is located on the south-eastern part of the country along the Gulf of Guinea. It is estimated to have a population of 111,926 representing 2.8% of the region’s total population [30]. Pharmaceutical services in the district are delivered in private, public, quasi-governmental health centers and mission facilities. The provision of pharmaceutical care in the health delivery system in the municipality of La Nkwantanang-Madina is considered to be critical and is dominated by the private sector. The study population included dispensers at post in retail community pharmacies and their clients who had purchased oral anti-malarials for use and were exiting from the pharmacies. Pregnant women and individuals with cognitive disabilities who had purchased anti-malarials were excluded from the study.
This study employed an analytical cross-sectional approach among 61 selected community pharmacies in La Nkwantanang-Madina, from May to July 2017. A total of 122 retail community pharmacies and 36 wholesale outlets were obtained from Pharmacy Council, Ghana. This study employed a simple random sampling technique to select 61 community pharmacies, excluding wholesalers and licensed chemical shops. Data were gathered from three sources: dispensers, clients, and pharmacies.
Questionnaires were administered for data collection. The client and dispensers’ questionnaires were adapted from the WHO modified paper on good dispensing practices, as well as Training Manual for Licensed Chemical Sellers in Ghana [16]. Data obtained from respondents were collected, reviewed for completeness and entered using EpiData (Version 3.1). Double data entry was done to minimize errors and ensure the reliability of data collected.
The clients’ questionnaire captured data on age, gender, educational level, religion, marital status, National Health Insurance (NHI) registration status, rapid diagnostic test (RDT) check, client’s occupation, purchased drugs and dispensing information. Information on the number of times Pharmacy Council had visited the pharmacy within the last 6 months, availability of reference materials on Malaria Case Management (MCM) and availability of MCM wall chart were obtained from the dispensers in their respective pharmacies.
The client and dispenser data were merged and checked for internal consistency and completeness using simple summary statistics of the selected variables. Age of respondents (both dispensers and clients) were measured as completed years. Frequencies were used to describe the sociodemographic characteristics of dispensers and clients. Where there was evidence of skewness in the data, means were estimated for continuous variables after log transformation.
The dependent variable, dispensing practice was measured as a binary ordinal categorical variable (appropriate and inappropriate dispensing practices) (Table 1). This was assessed based on 13 key indicators for measuring dispensing practices (Table 4) [20, 27].
Table 1
Dispensing practice classification
Score (n = 13)
Dispensing practice
Less than 9
Inappropriate
At least 9
Appropriate
Chi square tests of associations were used to determine associations between the independent and independent categorical variables. Fisher’s exact tests were used when sample sizes were found to be small (< 5 per cell). Univariable and stepwise multivariable logistic regression analyses were performed to determine the predictors of dispensing practices at 95% confidence level and α-value of 0.05.

Results

Overall, client sample size of 248 and 106 dispensers were obtained after data validation. However, there were 18 missing values in the client dataset. Therefore, 230 and 106 completed questionnaires were obtained for client and dispenser data, respectively.
Table 2 shows the characteristics of dispensers in community pharmacies at the time of the survey. Although hundred and twenty-four (124) dispensers initially consented to partake in the study, only a hundred and six (106) completed questionnaires were obtained in the 61 pharmacies visited. Females constituted 72%. The mean age of these dispensers was 30.4 (SD = 8.8) years ranging from 18 years to 70 years.
Table 2
Socio-demographic characteristics of dispensers in community retail pharmacies in La Nkwantanang-Madina-2017
Characteristics
Frequency (n = 106)
Percentage (%)
Sex
 Male
34
32.1
 Female
72
67.9
Age (mean, sd)
(30.4, 8.8)
 
Age group (years)
 15–24
21
19.8
 25–34
55
51.9
 35–44
22
20.8
 > 45
8
7.6
Marital status
 Single
69
65.1
 Married
37
34.9
Highest level of education
 None
 Primary/elementary
1
0.9
 Secondary
30
28.3
 Tertiary
73
68.9
 Vocational/technical
2
1.9
Religion
 Muslim
3
2.8
 Christian
103
97.2
Ethnicity
 Ewe
19
17.9
 Akan
54
50.9
 Ga/Adangme
29
27.4
 Northerner
4
3.8
Professional category
(n = 97)
 
 Pharmacist
14
14.4
 M.C.A
71
73.2
 Pharmacy technician
3
3.1
 Pharmacist Intern
8
8.3
 Other (manager/owner)
1
1.0
The characteristics of the study participants (clients) are presented in Table 3. More than half of the clients (60.9%) were females. The mean age was 33.70 (SD = 10.3) years and ranged from 15 years to 69 years. The majority (53.6%) were married. About thirty-nine percent (38.7%) had completed secondary school whereas primary and tertiary had nearly equal proportions of 25.0% and 25.4% respectively. Seventy-two (29.4%) clients were traders while 26.6% were artisans (Table 3).
Table 3
Socio-demographic characteristics of clients who patronize retail pharmacy services in the La Nkwantanang-Madina-2017
Characteristics
Frequency (n = 248)
Percentage (%)
Sex
 Male
96
38.7
 Female
151
60.9
Age (mean, sd)
(33.7, 10.3)
Marital status
 Single
102
41.1
 Married
133
53.6
 Separated/divorced
5
2.0
 Widow/widower
8
3.2
Highest level of education
 None
8
3.2
 Primary/elementary
62
25.0
 Secondary
96
38.7
 Tertiary
63
25.4
 Vocational/technical
19
7.7
Religion
 Muslim
35
14.1
 Christian
211
85.1
 Traditional
2
0.8
Ethnicity
 Ewe
64
25.8
 Akan
100
40.3
 Ga/Adangme
43
17.3
 Northerner
36
14.5
 Other
5
2.0
Occupation
 Trader
72
29.0
 Artisana
66
26.6
 Professionalb
34
13.7
 Office workerc
27
10.9
 Unemployed
11
4.4
 Student
35
14.1
 Other
3
12.0
aTo a worker in a skilled trade especially one that involves making things by hand. Eg hairdressers, painters, etc.
bIncludes skilled professionals such as nurses, teachers, etc.
cMainly people who work in offices e.g. bankers
More than half (58%) of the clients were given accurate directions on the use of their ACT’s with 88.7% being advised to complete the full course. However, most dispensers (88.3%) did not explain the 8-h loading dose principle to their clients (Table 4).
Table 4
Distribution of areas of assessment during dispensing and post-dispensing advice
Areas of assessment (advise)
Frequency (n = 248)
Percentage (100%)
Advice on how to take anti-malarials
 Accurate direction
103
58.5
 Inaccurate direction
145
41.5
Taking after meals
 After meals
237
95.6
 Before meals
11
4.4
Completion of full course
 Advised
220
88.7
 Not advised
28
11.3
Risk of side effects
 Advised
53
21.4
 Not advised
195
78.6
Labelling
Labelling in ink
 Yes
230
92.7
 No
18
7.3
Clear instruction
 Clear
216
87.1
 Not clear
32
12.9
Legibility to client
 Legible
223
89.9
 Illegible
25
10.1
Label captured
 Quantity of drugs dispensed
  Yes
226
91.1
  No
22
8.9
 Frequency of administration
  Yes
219
88.3
  No
29
11.7
 Exact time to take the drug
  Yes
29
11.7
  No
219
88.3
 Duration of administration
  Yes
191
77.0
  No
57
23.0
Assessment was from clients exit interviews
Chi square test for trends (Table 5) showed significant associations between each of the following variables: NHIS status (chi = 5.69, p < 0.05), dispenser’s marital status (chi = 6.55, p < 0.05), access to reference materials (chi = 9.59, p < 0.05), type of recommender (chi = 16.54, p < 0.05), awareness of guidelines (chi = 5.38, p < 0.05) and dispensing practices.
A crude analysis of the association between dispensing practices and the predictor variables showed that marital status, access to reference materials, dispenser’s awareness of guidelines, National Health Insurance Scheme registration status and number of supervisory visits within the last 6 months were associated with the outcome of dispensing practices. However, adjusting for all other variables, dispenser’s age, level of education, professional category and level of experience were significant predictors of dispensing practices (Tables 5, 6).
Table 5
Chi square test of association of socio-demographic characteristics of dispensers and dispensing practices
Variables
Dispensing practices
χ2
p-value
Appropriate
Inappropriate
Frequency
%
Frequency
%
Age group
 15–24
14
11.6
11
10.0
8.05
0.184
 25–34
59
49.2
58
52.7
 35–44
29
24.2
36
32.7
 45+
18
15.0
5
4.6
 Total
121
100.0
110
100.0
  
Sex
N = 120
 
N = 110
   
 Male
34
28.3
33
30.0
0.08
0.802
 Female
86
71.7
77
70.0
Educational level
N = 120
 
N = 110
   
 None
1.47
0.577
 Primary
1
0.8
 Secondary
42
35.0
36
32.7
 Tertiary
76
63.3
72
65.5
 Vocational/technical
1
0.8
2
1.8
  
NHIS status
N = 120
 
N = 110
   
 Have NHIS
59
49.2
37
33.6
5.69
0.048*
 Not have NHIS
62
51.2
73
66.4
Professional category
N = 120
 
N = 110
   
 Pharmacist
14
11.8
15
13.6
6.51
0.239
 Medicine Counter Assistant
85
71.4
88
80.0
 Pharmacy Technician
6
5.0
2
1.8
 Pharmacy Intern
11
9.2
3
2.7
 Other
3
2.5
2
1.8
Years of experience
N = 119
 
N = 110
   
 < 2 years
28
25.0
14
14.6
3.73
0.535
 3–5 years
41
36.6
39
40.6
  
 6–9 years
31
27.7
29
30.2
  
 > 10 years
12
10.7
14
14.6
  
Marital status
N = 112
 
N = 96
   
 Single
82
68.3
57
51.8
6.55
0.046*
 Married
38
N = 120
31.7
53
N = 110
48.2
  
Access to wall chart
 Yes
13
10.8
24
21.8
5.13
0.095
 No
107
89.2
86
78.2
Access to reference material
N = 120
 
N = 110
   
 Yes
53
44.2
71
64.5
9.59
0.02*
 No
67
55.8
39
35.5
Supervisory visits
N = 120
 
N = 110
   
 Once
48
40.0
58
52.7
10.71
0.127
 Twice
40
33.3
20
18.2
 Three times
3
2.5
5
4.6
 More than 3
3
2.5
0
0
 Can’t remember
26
21.7
27
24.6
  
Recommender
N = 120
 
N = 110
   
 Dispenser
67
55.8
63
57.3
16.54
0.024*
 Relative
16
13.3
5
4.6
 Friend
2
1.7
0
0
 Self
16
13.3
30
27.3
 Media
0
0
2
1.8
 Unspecified
19
15.8
10
9.1
Awareness of guidelines
N = 120
 
N = 110
   
 Yes
112
93.3
92
83.6
5.38
0.019*
 No
8
6.7
18
16.4
  
In-service training (last 12 months)
N = 120
 
N = 110
   
 Yes
24
20.0
36
32.7
4.86
0.259
 No
70
58.3
53
48.2
  
 Can’t remember
26
N = 120
21.7
21
N = 110
19.1
  
Statistically significant associations are marked with *
Table 6
Univariate and multivariate logistic regression estimates of the socio-demographic predictors of appropriate dispensing practices of dispensers
Characteristics
Crude OR (95% CI)
p-value
Adjusted OR (95% CI)
p-value
Age group
 15–24 (reference)
1
 
1
 25–34
0.80 (0.24–2.72)
0.714
1.97 (0.31–12.61)
0.465
 35–44
0.63 (0.17–2.32)
0.482
7.76 (0.89–67.37)
0.063
 > 45
2.82 (0.53–15.10)
0.218
15.23 (25.91–5893.9)
0.001*
Sex
 Male (reference)
1
   
 Female
1.08 (0.57–2.07)
0.80
0.95 (0.35–2.64)
0.927
Educational level
 None (reference)
1
 
1
 Primary
1 (omitted)
1 (omitted)
 Secondary
7.83e−7
8.5e−7 (4.3e−8–1.7e−5)
0.001*
 Tertiary
7.03e−7
9.2e−7 (5.4e−8–1.6e−5)
0.001*
 Vocational/technical
3.36e−7
5.8e−6 (1.22e−7–3e−4)
0.001*
Professional category
 Pharmacist (reference)
1
 
1
 MCA
1.03 (0.33–3.22)
0.952
1.64 (0.43–6.25)
0.461
 Pharm. Technician
3.21 (0.42–24.71)
0.255
1.90 (0.39–9.33)
0.421
 Pharm. Intern
3.93 (0.53–29.08)
0.176
18.5 (1.40–245.6)
0.03*
 Other
1.61 (0.54–4.75)
0.383
4.91 (0.40–60.40)
0.208
Marital status
 Single
1
1
 Married
0.49 (0.25–0.99)
0.047*
0.20 (0.040–1.01)
0.051
NHIS status
 Have NHIS (reference)
1
 
1
 
 Don’t have NHIS
0.52 (0.27–0.99)
0.050*
0.41 (0.12–1.07)
0.067
Access to wall chart
   
 Yes
1
  
 No
2.30 (0.85–6.23)
0.10
3.32 (0.85–13.00)
0.082
Experience
   
 < 2 years (reference)
1
  
 3–5 years
0.53 (0.19–1.49)
0.219
0.47 (0.09–2.36)
0.348
 6–9 years
0.53 (0.15–1.92)
0.328
0.25 (0.026–2.50)
0.209
 > 10 years
0.43 (0.10–1.75)
0.231
0.04 (0.002–0.802)
0.036*
Awareness of guidelines
 Aware (reference)
1
   
 Unaware
0.37 (0.15–0.86)
0.022*
0.45 (0.16–1.24)
0.122
Access to reference material
 Yes
1
  
 No
2.30 (1.14–4.63)
0.020*
2.10 (0.61–7.20)
0.240
Supervisory visits
 Once
1
1
 
 Twice
2.42 (1.15–5.06)
0.020*
1.35 (0.38–4.84)
0.636
 Three times
0.73 (0.25–2.08)
0.543
0.51 (0.12–2.14)
0.345
 > Three
1 (omitted)
1 (omitted)
 Can’t remember
1.16 (0.55–2.50)
0.688
1 (omitted)
Recommender
 Dispenser
1
1
 Relative
3.00 (1.18–7.68)
0.022*
7.40 (1.03–53.41)
0.047*
 Friend
1 (omitted)
1 (omitted)
 Self
0.50 (0.25–0.99)
0.046*
0.20 (0.07–0.53)
0.002*
 Media
1 (omitted)
1 (omitted)
 
 Unspecified
1.79 (0.66–4.85)
0.248
3.22 (0.78–13.35)
0.104
Statistically significant associations are marked with *
OR odds ratio
Pharmacist interns were 18.5 times more likely to dispense anti-malarials appropriately compared to practicing pharmacists (AOR 18.50, 95% CI 1.40–245.6; p < 0.05). Also, relative to dispensers with less than 2 years working experience, dispensers with more than 10 years’ experience were less likely to dispense Artemisinin Combination Therapy (ACT’s) appropriately (AOR 0.04, 95% CI 0.002–0.802 p < 0.05). The most dispensed anti-malarial was artemether-lumefantrine (83.55), while atovaquone-proguanil was the least dispensed (Fig. 1).

Discussion

The over-consumption of oral anti-malarials in the private drug retail sector is a major threat to the health of the people. With concerns of overdiagnosis of malaria, poor dispensing and subsequent increase in antimicrobial resistance, key strategic options such as the distribution of rapid diagnostic test kits, peer education and training of dispensers in the private retail sector was done to scale up malaria prevention and treatment [28, 31, 32].
This study showed that dispensing practices for anti-malarials is generally unsatisfactory at the study site. With about 48% of dispensers (47.8%) dispensing anti-malarials inappropriately, a high fraction of inappropriate dispensing practices was similarly observed by Alotaibi and Abdelkarim in a survey conducted in Dawadmi, Saudi Arabia [33]. Consumers perceived that pharmacists (48%) do not give enough counselling about their medications [33]. The observation could, however, be attributed to time constraints either from the service provider or the client [34]. In connection to this, some authors have indicated interruptions during dispensing; low staff strength, inadequate knowledge, lack of training and dispenser fatigue as likely causes of inappropriate dispensing practices [35]. This high rate of inappropriately dispensed ACT medicines and poor counselling if not addressed could impede progress in the fight against anti-malarial resistance in Ghana.
This study could not clearly establish an association between in-service training and dispensing practices. In contrast, several studies have associated a positive relationship between training and dispensing practices. In a study where, dispensing practice was measured as the ability to identify the recommended anti-malarial, the odds of knowing the recommended treatment was significantly higher amongst participants with health training [28].
Dispensers with more than 10 years’ experience were less likely to dispense ACT appropriately (AOR = 0.04, 95% CI 0.002–0.802 p-value < 0.05) while pharmacy interns were about 19 times more likely (AOR = 18.5, 95% CI 1.40–245.6 p-value < 0.05) to dispense ACT appropriately compared to pharmacists. Hussein and Ibrahim, in a similar study, reported that dispensers with less than one-year work experience had a better knowledge in Lahore, thus reflecting in their dispensing practices [4]. This might be linked to a greater number of graduate pharmacists with updated knowledge on the newer trends in managing diseases of common occurrence at the community level. Cordina et al. in their study asserted that younger pharmacists identified more with current trends in the practice of pharmacy relative to their colleagues [36].
The role of accurate diagnosis with the newly introduced rapid diagnostic test kits cannot be underestimated. Ansah et al., in a cluster randomized trial conducted among LCS in the erstwhile Dangme West District of Ghana, demonstrated that providing RDT’s for malaria in the private drug retail sector significantly reduced dispensing of anti-malarials to patients without malaria [37]. However, some patients are not tested prior to initiation of treatment for malaria. Findings from this study reports that an overwhelming majority (66%) of the patients were not tested before being dispensed oral anti-malarials (Fig. 2). This finding is consistent with a similar study in Tanzania which reported that about 98% of patients were treated presumptively for malaria without performing an RDT [19]. This phenomenon has been observed in the Ghanaian public health facilities as well, as other reports suggest that over 40% of patients were treated presumptively for malaria [37, 38].
Brugha and colleagues have pointed out that motivation for profit in the private health sector may compromise the quality of care and numerous cross-sectional studies have attributed this phenomenon to inadequate training services for community pharmacy attendants, lack of supervision by regulatory authorities and the lack of confidence in the diagnostic test kits [39]. This finding illustrates the potential risk of malaria misdiagnosis which may accelerate the burden of anti-malarial resistance as has been recorded in South Eastern Asia [24, 26, 40]. Further research is, therefore, required to get the views and perception of dispensers. Monitoring and evaluation of training interventions may provide useful insights on dispensing practices. In so doing, pharmacists can introduce methods and strategies to expand their contribution in the dispensing process.

Study limitations

The study had some few limitations. Firstly, responses to dispensing practices and the last attendance to an in-service training may have been influenced by recall biases. Also, the cross-sectional nature of the study may limit the ability to infer causality.
The findings of this research may represent the reality in municipalities with comparable characteristics as the study site.

Conclusion

Community pharmacy dispensing practices were found to be unsatisfactory. Almost half of the clients (47.8%) were given inappropriate dispensing information on the use of their anti-malarials. Dispensers with more than 10 years working experience were less likely to dispense ACT medicines appropriately, while pharmacy interns were more likely to dispense ACTs appropriately. In view of this, strategies to educate and update the knowledge base of all dispensers focusing on those with more than 10 years working experience may be helpful. Education should be channeled on adherence and compliance to World Health Organization’s Test, Treat and Track initiative, as well to promote the appropriate use of anti-malarials.

Acknowledgements

The authors will like to thank all research field workers, regional and district health officers, the Pharmacy Council of Ghana and our study participants. We also recognize the assistance from Miss Doris Tsekpetse, a research assistant who helped with data entry. Pharm. Michael Mireku, RN. Henry Ofori-Duah and Dr. Paa Kwesi Blankson for editing and proofreading the manuscript. An abstract of this paper has been presented at the 83rd Conference of the Pharmaceutical Society of Ghana, in August 2018 with sponsorship from Mr. Charles Osei Amankwa, Ghana Revenue Authority, Ghana.
Ethical approval for the study was granted by the Ghana Health Service—Ethics Review Committee (Approval Number: GHS-ERC 83/02/17). Additional approval by way of informed consent (written consent) was obtained from dispensers, clients and the owners of retail facilities prior to data collection.
Not applicable.

Competing interests

The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.

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Metadaten
Titel
Dispensing practices for anti-malarials in the La Nkwantanang-Madina municipality, Greater Accra, Ghana: a cross-sectional study
verfasst von
Charles Enyaah Amankwa
Harriet Affran Bonful
Kofi Agyabeng
Priscillia A. Nortey
Publikationsdatum
01.12.2019
Verlag
BioMed Central
Erschienen in
Malaria Journal / Ausgabe 1/2019
Elektronische ISSN: 1475-2875
DOI
https://doi.org/10.1186/s12936-019-2897-5

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