Transcript Poster presentation - WHO archives

Abstract ID: MA026
Author Name: Jackson A.K. Lauwo
Email: [email protected]
Presenter Name: Jackson A.K. Lauwo
Authors: Lauwo JAK, Hombhanje FW, Tulo SP, Maibani G, Bjorge S
Institution: School of Medicine and Health Sciences, University of Papua New Guinea;
National Department of Health, PNG
Title: Impact of Pre-Packaging Antimalarial Drugs and counseling on Compliance with
Treatment at Port Moresby General Hospital Adult Outpatient Department
Problem Statement: Malaria medications are commonly dispensed to patients in loose
packaging after being repacked from a bulk container. Patients frequently fail to adhere to the
correct 3-day dosage regimen recommended by Papua New Guinea’s adult Standard
Treatment Guidelines (STGs).
Objectives: To contribute to the improvement of malaria treatment at Port Moresby General
Hospital’s Outpatient Department through pre-packaging of the prescribed antimalarial drugs
into an organized regimen with clearly delineated daily doses, and special counseling
instructions in order to promote patient compliance. In addition, the study examines the
acceptability of the pre-packaging by the hospital prescribing and dispensing health workers
involved in patient health care.
Intervention: An appropriately labeled pre-packaging was designed featuring three clearly
partitioned sectors, each containing medication quantities required for each of the three days,
as specified in the adult STGs for uncomplicated malaria. The impact of the pre-packaging
and accompanying special instructions on patient compliance were investigated and compared
to the standard practice of loose packaging over a 15-week period from March 2003.
Results: This study demonstrated an 18% increase in compliance, when an intervention prepackaging coupled with special instructions were applied compared to a Control Group that
was neither given a pre-packaging nor additional special instructions. The increase in
compliance was comparable to compliance rates obtained from similar studies elsewhere in
the world.
Conclusion: The pre-packaging linked with clear printed and verbal instructions improved
patient compliance in taking antimalarial drugs. In addition, it was felt that pre-packaging will
eliminate contamination of the products inherent in the common practice of uncontrolled
extemporaneous repacking of patient regimens from bulk products. Product stability will also
be enhanced by the pre-packaging system. Blister packaging should be employed in its final
design. We strongly recommend to key health administrators and policy makers in Papua New
Guinea to seriously consider the benefits of the new antimalarials pre-packaging system and
implement it in the entire country.
Study Funding: By the University of Papua New Guinea and the World Health
Organization, Western Pacific.
1
Background & Settings

Malaria is a major health problem in the
world, and it is the second cause of
morbidity and mortality in Papua New
Guinea (PNG) . [The PNG Health Plan
2001- 2010]

Resistance of P. falciparum to
chloroquine & amodiaquine, led to new
Standard Treatments Guidelines
(STGs) for malaria in PNG [PNG DOH
New STGs, 2000]

Patients frequently fail to adhere to the
correct 3-day dosage regimen
recommended by PNG Adult STGs
2
Study Objectives

To contribute to the improvement
of malaria treatment at Port
Moresby General Hospital (PMGH)
Outpatient Department (OPD)
through intervention by prepackaged regimens with clearly
delineated daily doses and special
counselling instructions.

To examine acceptability of the prepackage by prescribing and
dispensing health workers.
3
Methods
Setting:
Port Moresby General Hospital
(PMGH), PNG’s referral hospital.
Study patients: Consenting Adult
outpatients with uncomplicated malaria.
Intervention: An appropriately labelled
pre-package with partitioned, coloured
sectors, each containing medications for
each of the 3-days specified in the STGs.
Design of pre-package & packaging
A transparent polyethylene bag was
partitioned into three sectors and names of
the drugs, and instructions for use were
clearly printed on a card under each sector
of the bag, which was also differently colour
coded. The three major languages; English,
Pidgin and Motu were separately employed
in the instructions. The Figure below
shows a pre-package with English
instructions.
4
P/N_____
Patient’s
Address:__________________ Sex: F [
Age: Adult [ ] years [ ] / Child [
Date ______
Day 1
Day 2
CHLOROQUINE CHLOROQUINE
CHLOROQUINE
TABLETS
TABLETS
TABLETS
Name:___________
] M[
]
] Wt. [ ]
Day 3
CHLOROQUINE
TABLETS
FANSIDAR
TABLETS
Directions
Directions
Directions
Take the above
tablets in the
first day
Take the above
tablets in the
second day
Take the above
tablets in the third
day
Figure 1. Design of the Pre-package and
Packaging
5
Methods
(Continued)
Documentation from Interviews & Patient cards
Each patient was interviewed &a questionnaire
was completed including the following:




Patient characteristics: Gender, language spoken,
diagnosis and drug treatment given.
Other medicines prescribed
Whether the patient was informed (instructed)
about malaria.
The patient’s understanding of instructions about
antimalarial drug use.
Data Analysis:
Tabulations of specific characteristics and
responses of intervention and control groups were
made with the help of Excel spreadsheets. Chisquare analysis was performed, and the level of
significance was set at p < 0.05
6
Special counseling Instructions
Special instructions explained to the
patient:
1. the need for early treatment of
uncomplicated malaria,
2.
Possible side effects of antimalarials
3.
The need to report serious side effects
of the antimalarial drugs
The Intervention group was compared
with two Control Groups A and B.
Control Group A: Standard package with
special instructions.
Control Group B: Standard package
without special instructions
7
Methods
(Continued)
Patient Review on the Fourth Day
Follow-up reviews on the fourth day were
to
elicit whether the patient:



was cured
took all drugs as prescribed
could recall information about the
disease and instructions on malaria
drug usage as given in the first visit.
A separate questionnaire sought the
views of Prescribing and Dispensing
Health Workers on their acceptability of
the prepackage and whether they thought
it would :
 improve patient compliance
 improve Patient drug management
 improve Clarity of directions to patients
 reduce waiting time and treatment costs
 be suitable to present other standard
8
treatments.
Results ( Tables 1 – 4)
Table 1. Number of patients enrolled in intervention and
control groups and their basic characteristics.
Intervention
(N=129)
Contr Gr A
(N=151)
Contr Gr B
(N=156)
p – value
Males
73 (56.6)
78 (51.7)
91 (58.7)
Females
56 (43.4)
73 (48.3)
65 (41.7) p > 0.05
English
57 (44.2)
57 (37.7)
77 (49.4)
129 (100)
143 (94.7)
153 (98.1)
Pidgin Lang.
Motu Lang.
38 (29.5)
10 (6.6)
52 (33.3) p < 0.001
Clinical
35 (27.1)
43 (28.5)
35 (22.5)
MPS +ve
29 (22.5)
45 (29.8)
42 (26.9)
Clin+MPS-ve
65 (50.4)
63 (41.7)
79 (50.6)
(n=112)
(n=119)
Pts.reviewed
(n = 91)
Males
51 (56.0)
59 (52.7)
69 (58.0)
Females
40 (44.0)
53 (47.3)
50 (42.0)
Figures in parenthesis are percentages
p > 0.05
p > 0.05
9
Table 2. Patients’ understanding about malaria and
instructions on drug usage as compared among
Intervention and Control Groups A and B.
Understood:
Intervention
(N=129)
Contr Gr A
(N=151)
Contr Gr B
(N=156)
Yes
85 (65.9)
116 (76.8)
9 (5.8)
No
44 (34.1)
36 (23.8)
147 (94.2)
Yes
122 (94.6)
142 (94.0)
113 (72.4)
No
7 (5.4)
9 (6.0)
- about malaria 1.
- instructions on
drug usage 2.
43 (26.6)
Figures in parenthesis are percentages
1.
Intervention vs. Control Group A: p > 0.05
Intervention vs. Control Group B: p < 0.001
2.
Intervention vs. Control Group A: p > 0.05
Intervention vs. Control Group B: p < 0.001
10
Table 3. Number of patients reviewed, and their
compliance ratings (%) among all groups.
Compliance Intervention
(%)
(n=91)
Control Gr A
(n=112)
Control Gr B
(n=119)
Good
86 (94.5)
104 (92.9)
91 (76.5)
Poor
5 (5.5)
8 (7.1)
28 (23.5)
Intervention vs. Control Group A : p > 0.05;
Intervention vs. Control Group B : p < 0.001
Control Group A vs. Control Group B : p < 0.001
Good: Patient’s ability to remember instructions, and to
complete regimen as directed
Poor: Inability to recall instructions, and non adherence
to prescriber’s directions.
Table 4. Views Of Prescribing & Dispensing Health
Workers on the New Pre-package.
Approvals of
Pre-package
(Yes)
None approvals
Of pre-package
(No)
p - value
Yes / No
38 (95)
2 (5)
Free
comments
28 (70)
12 (30)
p < 0.01
Figures in parenthesis represent percentages of (N = 40)
11
Discussion
 This study demonstrated an 18% increase in
compliance when an intervention prepackage
linked with special instructions were applied,
compared to control group B that was neither
given a prepackage nor additional special
instructions.
 Increase in compliance was comparable to
findings of similar studies elsewhere.
– In Ghana, pre-packaging of antimalarial tablets
and syrups increased compliance by 21.5% &
22.1% resp. (Yeboah-Antwi. K et al., 2001)
– In China, organized blister prepackaging
improved patient compliance by 20% (Quinjun
L et al., 1998)
 verbal information about the disease, and
instructions pertinent to the effects of drug(s) used
showed impact on compliance.
 Majority (70%) of health workers interviewed
supported the introduction of the new prepackage, while 30% were doubtful or undecided.
12
Conclusion and Recommendations





The pre-package linked with clear printed and
verbal instructions significantly improved patient
compliance in taking antimalarial drugs.
Pre-packaging could eliminate contaminations of
the products inherent in the existing extemporaneous repacking of patient regimens from bulk
products.
Product stability may also be enhanced by the
pre- package system.
Blister packaging should be employed in its final
design.
We recommend to the appropriate health
authorities in Papua New Guinea to consider the
implementation of the new antimalarials prepackaging system.
References
1.
Papua New Guinea National Health Plan 2001 – 2010, Vol III 1999.
Department of Health, Papua New Guinea.
2.
Department of Health. Announcement of new combination treatments
for all malaria in Papua New Guinea. August 2000.
3.
K Yeboah-Antwi, J O Jyapon, I K Asare, G. Barnish, D B Evans& S.
Adjei. Impact of pre-packaging antimalarial drugs on cost to patients
and compliance with treatment. Bulletin of the World Health
Organization, 2001, 79 (5) 394 – 39
4.
Li Quingjun, Duan Jihui, Tang Laiyi, Zhang Xiangjun, Liang Jun, A.
Hay, S. Shires, & V. Navaratham. The effect of drug packaging on
patient’s compliance with treatment for plasmodium vivax malaria 13
in
China. Bulletin of the World Health Organization, 1998, 76 (Suppl. 1):
21 – 27