Factors Influencing Compliance With The National Antimalarial Treatment Guidelines By Facility based Secondary Health Care Physicians In Oyo State, Nigeria

ABSTRACT

The National Antimalarial Treatment Guidelines (NATG) stipulates treatment actions for

the management of malaria using Artemisinin Combination Therapy (ACT). Available

evidence indicates that adoption of treatment guidelines are not matched with

corresponding levels of comprehension and compliance. An investigation of practice gaps

will generate information which will guide future policy formulation and implementation.

The aim of this study was to determine the factors influencing compliance of facilitybased

secondary health care physicians in Oyo state with NATG.

This descriptive cross-sectional study involved 94 out of 124 physicians on full-time

employment from all 36 secondary health care facilities offering malaria management

services in Oyo state. They were interviewed using a semi-structured intervieweradministered

questionnaire to elicit information on awareness of and perceived challenges

relating to implementation of the NATG. This included a 60-point knowledge scale on

diagnosis and treatment of malaria with knowledge scores of 0-20, >20-40 and >40-60

rated as poor, fair and good respectively. Case notes of malaria patients seen on the day of

interview were stratified into three categories; under-five children, pregnant women and

adults. A minimum of one and maximum of three case notes were randomly selected

across the strata per physician. Overall, 44, 74 and 128 case notes belonging to pregnant

women, under-five children and adults respectively were assessed using a check-list which

included an 11-point compliance scale on patient’s history documented, laboratory

assessment and drug prescribed by dosage. Compliance scores of 0-3, >3-7 and >7-11

were rated poor, fair and good respectively. Data were analysed using descriptive statistics

and t-test at p=0.05.

Age of respondents was 40.0±8.6 years, 70.2% were males and mean years of experience

was 9.4±3.4. Majority (84.0%) of the respondents had ever received training on NATG,

91.5% of the respondents had heard of the NATG mainly from medical conferences.

However, 48.9%, 37.2% and 11.7% had seen, read and have personal copies of NATG

respectively. Knowledge score was 32.4±6.4 with 8.5% and 90.4% of respondents having

good and fair knowledge of the NATG respectively. Compliance score was 4.3±1.9 with

4.5%, 63.4% and 32.1% of physicians having good, fair and poor compliance respectively.

Only 0.8% of case notes had complete history documented, 54.0% had prescription for

iv

ACT, 19.1% Sulphadoxine Pyrimethamine and 26.9% non-recommended Anti-Malarial

Drugs. Recommended dosage of ACT was correctly prescribed in 26.0% and 47.8% of

case notes belonging to children and adults respectively. Only 24.2% of adults and 5.6%

of children had both clinical and laboratory assessments before prescription. High cost

(31.4%), unavailability (14.9%) and treatment inefficacy (9.1%) of ACTs were identified

as perceived hindrances to compliance with NATG. A statistically significant higher

compliance score (4.4±1.7) was observed amongst respondents ever trained on NATG

than those never trained (3.7±1.3).

An interplay of factors influenced physician’s compliance with the national antimalarial

treatment guidelines. Continuing professional training programmes on compliance with

current malaria treatment approaches and adequate supervision are recommended.