Transcript impact of an intervention program for the treatment

IMPACT OF AN INTERVENTION PROGRAM FOR THE TREATMENT OF MALARIA IN CHILDREN IN PAPUA NEW
GUINEA
†
JOSHUA IB
SUNDERLAND VB
PASSMORE PR
School of Pharmacy, Curtin University of Technology
Kent Street, Bentley, Western Australia 6102
† Currently, Discipline of Pharmacy, University of Papua New Guinea,
Port Moresby, Papua New Guinea
Abstract
Background and Setting
Study Aims
Methods
This study evaluated the impact of patient carer directed drug information on the understanding
and treatment outcomes in uncomplicated malaria in children. A pre-post intervention study
was carried out at an urban health clinic using an intervention of written and verbal
reinforcement of directions and information about treatments, drug administration, compliance
and understanding of the treatment with respect to the control group.
Malaria is still significant today with in excess of 2 million deaths
reported annually, and most are children (1). Few studies have been
reported for malaria with an aim to improve patient compliance and
understanding of their medications. One study in China initially with
inferior quality medications showed that lack of understanding of
administration instructions was improved by blister packaging and
provision of written instructions (2). A study from Cambodia found
that public education of patients by posters and videos was effective
if patients visited health practitioners rather than drug vendors (3). A
recently reported study found additional labelling and verbal
instruction of carers significantly improved compliance with
chloroquine in uncomplicated malaria in children(4). In other
disease states patient education has been shown to result in
significant and long lasting improvements in Type 1 diabetes (5).
The aims of this study were:
The trial was a pre-post intervention protocol with a control group (Control). The
intervention arm (Clinic) was at an urban clinic in the National Capital District of
PNG serving approximately 20,000 people. The control clinic was similar in size and
services provided but located about 15km distant serving a different population.
Inclusion criteria: children 0-10 years diagnosed with uncomplicated malaria and
prescribed the standard treatment protocol. Consent was required from carers.
Exclusions were children in the post-intervention phase who participated in the preintervention phase.
Patient carer understanding of basic medication administration dosage and frequency was
unchanged (P>0.05) however significant improvements were evident in patient carer
understanding of medications (P<0.05), understanding of storage of medicines (P<0.001),
reading labels and instructions (P<0.001), remembering to give medicines (P<0.001) and correct
administration timing (P<0.001). The reported improvement in treatment cure rate (health
outcome) increased from 57.9% to 92.3% (P=0.007).
Other than understanding of administration all other parameters showed marked improvements
as a result of the intervention including self-reported patient outcomes.
Table 3
(1) Evaluate the impact of an intervention program on patient
carers on the understanding of antimalarial drugs in
children for uncomplicated malaria.
(2) Evaluate the level of rational use for uncomplicated
malaria in children.
In the pre-intervention current and previously prescribed drugs, doses and frequencies
prescribed were recorded. Patients were asked to complete a standardised
questionnaire on past and present medications and issues related to compliance (6).
Patients were requested to return to the clinic after 7 days and report to the researcher
if the child had recovered or not.
Patient/Carer Understanding of
In the post-intervention phase the following were introduced:
(a) Use of the Medicine
Drug
Amodiaquine
100mg tablet
Uses
count
Incorrect
Chloroquine
150mg tablet
The demographic data (Table 1) show that the mean age for each of the groups was
approximately 2 years. There were no significant differences in any of the population
characteristics.
Quinine 300
mg tablet
Table 1. Patient demographics at the clinic pre-post and control pre-post groups
Con-pre
Con-post
Clin-pre
Clin-post
10 (45.5%)
25 (39.7%)
25 (29.1%)
22 (26.8%)
12 (54.5%)
38 (60.3%)
Incorrect
Correct
1 (100.0%)
Incorrect
1 (100.0%)
3 (100.0%)
Sample
Size
Con-post
Clin-pre
Clin-post
25 (8.3%)
75 (24.8%)
103
(34.0%)
100
(33.0%)
303
(100.0%)
1.90
1.99
2.78
2.32
2.36
SD
2.14
1.93
2.60
1.98
2.23
P-value1
0.079
Age (years) Mean
Weight (kg) Mean
Gender
10.04
10.16
11.87
11.01
11.01
SD
3.97
3.60
5.51
5.25
4.92
P-value1
0.094
Male
15 (60.0%)
Female
P-value2
P-value1
10 (40.0%)
35 (46.7%)
40 (53.3%)
from oneway-anova Test
0.184
•The carer was verbally counselled on the directions and importance of completing the
treatment
61 (70.9%)
60 (73.2%)
171 (67.6%)
2 (28.6%)
2 (100.0%)
4 (30.8%)
5 (71.4%)
0.098
Differences in pre-post elements of the study periods were evaluated using Chisquared, Kruskal-Wallis, Fisher’s Exact or Student’s - t tests as appropriate.
9 (69.2%)
1 (100.0%)
Carers were advised to return to the clinic after 7 days and report if the child was well
or not. The pre-intervention stage was maintained for the whole period of the study at
the control clinic.
0.157
1 (50.0%)
Diagnosis and treatment was from national standard treatment guidelines which
require any child with fever to be treated for malaria. The first line treatment was
amodiaquine with chloroquine or Fansidar®(7).
59 (57.3%)
44 (42.7%)
51 (51.0%)
49 (49.0%)
(b) Dosage of the Medicine
Drug
Amodiaquine
100mg tablet
Chloroquine
150mg tablet
160
(52.8%)
Dose
count
143
(47.2%)
Quinine 300
mg tablet
Subgroups
Total
Con-pre
Con-post
Clin-pre
Clin-post
Incorrect
4 (18.2%)
14 (22.2%)
25 (29.1%)
30 (36.6%)
73 (28.9%)
Correct
18
(81.8%)
49 (77.8%)
61 (70.9%)
52 (63.4%)
180 (71.1%)
Incorrect
2 (28.6%)
1
(100.0%)
P-value
0.175
In contrast to the specific directions recall patient carers in the intervention (clinic)
group showed much improved understanding about the storage and usage of their
medicines as shown in Table 4
Table 4
Incorrect
Correct
0.455
P-value2
P-value
Total
Con-pre
N
82 (32.4%)
1 (50.0%)
Correct
Subgroups
Total
The same questionnaire was administered.
Correct
Results and Discussion
Subgroups
•A dispensing label providing directions for use and the importance of completing the
course
3 (100.0%)
1
(100.0%)
5 (71.4%)
1 (50.0%)
1 (50.0%)
1 (100.0%)
3 (23.1%)
Patient Carers responses to aspects of knowledge about
medicines
0.545
10 (76.9%)
Group
Activity
Sub-group
N
Mean rank
P-value
Control
groups
Store the
medicines
Con-pre
25
47.40
0.014
Con-post
75
51.50
Read label /
understand
instructions
Con-pre
25
56.36
Con-post
75
48.55
Remember to
give the
medicines
Con-pre
25
51.00
Con-post
75
50.33
To give the
medicines on
time
Con-pre
25
49.78
Con-post
75
50.74
Store the
medicines
Clin-pre
102
77.48
Clin-post
100
126.00
Read
Clin-pre
label/understa
Clin-post
nd
instructions
102
69.64
100
134.00
Remember to
give the
medicines
Clin-pre
102
60.37
Clin-post
100
143.45
To give the
medicines on
time
Clin-pre
102
60.37
Clin-post
100
143.45
2 (100.0%)
Correct
from Pearson Chi-Square Test
(c) Frequency of Dosage
The appropriate drug prescribing (Table 2) according to the PNG guidelines for malaria (7) showed no
change in either setting over the course of the study. No intervention occurred in relation to prescribing.
Table 2: Levels of appropriate prescribing in accordance with the PNG prescribing guidelines
Count
Subgroup
Total
Clin-pre
Clin-post
Not appropriate
36 (36.0%)
27 (27.8%)
63 (32.0%)
All aspects
appropriate
64 (64.0%)
70 (72.2%)
134 (68.0%)
P-value
0.141
Subgroup
Total
Con-pre
Con-post
14 (58.3%)
37 (52.1%) 51 (53.7%)
10 (41.7%)
34 (47.9%) 33 (46.3%)
Drug
Frequency
count
Amodiaquine Incorrect
100mg tablet
Correct
Subgroups
Con-pre
4 (18.2%)
24 (27.9%)
24 (29.3%)
67 (26.5%)
18 (81.8%) 48 (76.2%)
62 (72.1%)
58 (70.7%)
186 (73.5%)
2 (28.6%)
2 (100.0%)
4 (30.8%)
Incorrect
Correct
1 (100.0%) 3 (100.0%)
5 (71.4%)
9 (69.2%)
Quinine 300
mg tablet
Incorrect
1 (100.0%)
1 (100.0%)
2 (100.0%)
Overall the intervention seems to have had a significant improvement on reported cure
rates and therefore patient outcomes which is a significant community benefit.
Days
count
Amodiaquine
100mg tablet
Chloroquine
150mg tablet
Total
Con-pre
Con-post
Clinpre
Incorrect
4 (18.2%)
13 (20.6%)
24
24 (29.3%)
(27.9%
)
65 (25.7%)
Correct
18 (81.8%)
50 (79.4%)
62
58 (70.7%)
(72.1%
)
188 (74.3%)
2
2 (100.0%)
(28.6%
)
4 (30.8%)
5
(71.4%
)
9 (69.2%)
1
(100.0
%)
2 (100.0%)
Incorrect
Correct
Quinine 300
mg tablet
Subgroups
Incorrect
1 (100.0%)
3 (100.0%)
1 (100.0%)
Correct
0.519
0.000
0.000
0.000
0.000
0.098
It is evident from the above data that the education elements of the intervention
were valued when compared with the control group
Follow-up data for patients carers returning after 7 days to provide information on the
treatment outcome is provided in Table 5.
Activity
Are they
cured
Follow up data comparing control pre-post and clinic pre-post
Count
1.
www.emro.who.int/ accessed 5th March 2004
2.
QingjunL, Duan J, Tang L, Zhang X, Liang J, Hay A, Shires S, Navaratnam V, The effect of
drug packaging on patients’ compliance with treatment for Plasmodium rival malaria in
China. Bulletin of the World Health Organisation 1998; 79 (suppl 1): 21-27.
4.
This study has demonstrated that a targetted intervention has shown significant
improvements in aspects of patients understanding of medicines in relation to compliance. It
has demonstrated no impact on the understanding of the basic issues of medicine
administration. A significant improvement occurred in patient outcomes.
Okonkwo PO, Akpala Co, Okafor HU, Mbah AU, Nwaiwo O. Compliance to correct dose
of chloroquine in uncomplicated malaria correlates with improvement in the condition of
rural Nigerian children, Transactions of the Royal Society of Tropical Medicine and
Hygiene 2001; 95: 320-324.
5.
Loveman E, Cave C, Green C, Royle P, Dunn N, Waugh N. The clinical and costeffectiveness of patient education models for diabetes: a systematic review and economic
evaluation. Health Technology Assessment 2003; 7: No 22.
6.
Avarstad BL, Chewping BA, Steath BL, Claesson C. A brief medication questionnaire: A
tool for screening patient adherence and barriers to adherence. Patient Education and
Counselling 1999; 37:113-124.
7.
Standard treatment for common illnesses of children in Papua New Guinea. A manual for
nurses, health extension officers and doctors. 7th Edn. Port Moresby: National Department of
Health, 2000.
Are they
cured
Subgroup
Total
P-value
0.570
Con-pre
Con-post
No
3 (27.3%)
9 (31.0%)
12 (30.0%)
Yes
8 (72.7%)
20 (69.0%)
28 (70.0%)
Clin-pre
Clin-post
No
16 (42.1%)
3 (7.7%)
19 (24.7%)
Yes
22 (57.9%)
36 (92.3%)
58 (75.3%)
References
Conclusions and Recommendations
The provision of liquid medications rather than the crushing of tablets should be trialled in
children who have difficulties with medication administration.
0.836
P-Value from Kruskal-Wallis Test
Table 5
Denis MB. Improving compliance with quinine + tretracycline for treatment of malaria:
Evaluation of health education interventions in Cambodian villages. Bulletin of the World
Health Organisation 1998; 79 (suppl 1): 43-49.
Improved packaging and labelling of medications and procedures to be followed when a dose
was vomited should be incorporated into routine patient carer information.
P-value
0.884
Clin-post
3.
The study found that less than 75% of patients received treatment in accordance with the
guidelines.
0.098
(d) Duration of Treatment
The “not appropriate” category usually occurred from prescribing additional drugs
such as primaquine and antibiotics which were not according to the guidelines.
The intervention had a marked improved influence on patients knowledge relevant to
compliance such as the understanding of instructions, remembering to give the
medications and giving the medications on time.
0.699
Clinic
groups
Correct
Drug
The populations enrolled into this study were homogeneous. This study has shown that
a simple intervention of providing detailed information on a label regarding exact
dosage, storage and use of medicines together with verbal reinforcement provided no
improvement in patient reported understanding the basics of medicine dosage
administration. Correct response levels in all cases were approximately 70% in all pre
and post categories. This may indicate a ceiling effect or other barriers (e.g. literacy)
limiting improvement of this finding. Additional underlying information would need to
be collected to provide an understanding of the basis of this lack of improvement. In
both control and clinic groups the pre-intervention group had a history of greater
numbers of previous prescribed medications from earlier consultations than the post
intervention period for both groups. This would indicate both “post” groups would be
less experienced in medication based upon previous prescribing.
P-value
Clin-post
15 (23.8%)
P-value from Fisher’s Exact Test
Discussion
Clin-pre
Chloroquine
150mg tablet
0.387
It is evident that carers had a reasonable understanding of their medicines. (Table 3)
Approximately 70% understood the dosing schedules for antimalarial
medication. It is evident the intervention provided no improvement in patients
ability to describe their understanding of these requirements.
Con-post
Total
0.153
0.000
P-value from Fisher’s Exact Test
As expected the response rate was not high (approximately 40%) as it required the patient
carer to report back. There does seem to be sufficient evidence in the clinic-post (postintervention) group to indicate the overall simple intervention had a significant effect on
the numbers cured.