1. Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012 ISSN: 2141 - 4149
© Wilolud Journals, 2012 http://www.wiloludjournal.com
` Printed in Nigeria
EVALUATION OF DRUG USE AND PATIENT CARE PRACTICES IN A REFERRAL HEALTH
FACILITY IN YENAGOA, BAYELSA STATE, NIGERIA
Ifeanyi E. Chima1, Olatunji S. Obidiya2 and Chibuike V. Mc Abraham3
1
Department of Clinical Pharmacy & Pharmacy Practice, Faculty of Pharmacy, Niger Delta University,
Wilberforce Island, Bayelsa State, Nigeria.
2
Department of Clinical Pharmacy & Pharmacy Practice Niger Delta University, Wilberforce Island, Bayelsa
State, Nigeria.
ABSTRACT
Background: Evaluation of drug use and patient care practice is a very vital aspect of patient care. It also
measures the quality of care provided by health practitioners for patients. Data from this study is very essential
in healthcare management and planning.
Objectives: To assess drug use and patient care practices at the outpatient section of a referral hospital in
Yenagoa, south-south, Nigeria, using WHO drug use indictors.
Methods: The study was conducted at Federal Medical Centre, Yenagoa, Bayelsa State. A total of 2450
prescriptions from the outpatient pharmacy were selected by systematic sampling and retrospectively studied. A
prospective study of the patient care practices and health facility indicators, which include consultation and
dispensing times, revenue time, Patient’s knowledge of their medications and availability of key essential drugs,
was also undertaken. Data collected was analyzed using WHO guideline for assessment of drug use in healthy
facilities.
Results: The average number of drugs prescribed per encounter was 3.4; Percentage of encounters with at least
an antibiotic prescribed was 35.5%. Injections were prescribed in 22% of encounters. 62% of drugs were
prescribed by generic name while 87% of drugs prescribed were from the essential drug list. The mean
consultation and dispensing times were 11.5 and 3.5 minutes respectively. Two out of every three patients
interviewed knew both the names and the duration of their medications while four out of every five knew the
correct dosage of their medications.
Conclusion:
Many of the prescribing and patient care indicators assessed were found to be inappropriate and need to be
improved upon. . There was high tendency of poly- pharmacy and over prescription of antibiotics. The patients’
knowledge of vital aspects of medication management was found to be inadequate. The overall picture of drug
use suggests that the indicators at this facility are not yet at the optimal level.
KEYWORDS: Drug use indicators, rational drug use, WHO guideline, patient care, essential drug list.
INTRODUCTION
Drugs are very vital in health care delivery. Drug therapy is the most commonly used method for disease
treatment in general practice. Hence, the availability and affordability of good quality drugs, coupled with
rational use is fundamental to effective health care delivery in any country (Enato and Chima 2011). Rational
drug use refers to the use of the right drug for the right indication in the right dosage and dosing frequency and
for the correct duration. However, inappropriate use of drugs abounds especially in developing countries due to
irrational prescribing, dispensing and administration of medications (WHO, 1985, 1993; Bashrahil, 2010).
In a bid to improve drug use practices globally, the World Health Organization developed a set of objective
indicators for measuring health facility drug use practices in outpatient settings (WHO, 1993; Hogerzeil et al,
1993).
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2. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012
The best way to investigate drug use in health facilities is by the usage of indicators created and validated by the
World Health Organization (WHO, 1993).
The following WHO Core drug use indicators are used to evaluate drug use and patient care practices globally:
a. prescribing indicators-
Average number of drugs per encounter, percentage of drugs prescribed by generic name, percentage of
encounters with an antibiotic prescribed, percentage of encounters with an injection prescribed, percentage of
drugs prescribed from essential drug list or formulary.
b. WHO patient care indicators: Average consultation time, average dispensing time, Percentage of drugs
actually dispensed, percentage of drugs adequately labeled, patient’s knowledge of correct dosage. Others
indicators are: Availability of a copy essential drug list or formulary and availability of key essential drugs in
the facility.
These indicators enable health care planners, managers and researchers to compare situations in different
facilities or at different times (Enato and Chima, 2011).
Several studies done on medication and patient care practices in various parts of Nigeria using the above
indicators, often show irrational drug use in the form of over prescription of antibiotics and injections, poly
pharmacy and non adherence to the principles of essential drugs (Enato and Chima, 2011). The average
numbers of drugs prescribed per patient had been found to vary from 3 to 7, the prescribing rate of injection has
a range of 40-70% and antibiotic use rate exceeds 50% (Odusanya, 2004).
OBJECTIVES OF THE STUDY:
To evaluate the pattern of drug use in the facility using WHO Core Drug Use indicators.
To assess the quality of care given to patients using WHO Patient Care indicators.
METHODOLOGY
STUDY SETTING: This study was carried out in Federal Medical Centre Yenagoa, the capital city of Bayelsa
State, South-South Nigeria. Yenagoa is a Local Government Area in Bayelsa State, Nigeria. Its headquarter is in
the town of Yenagoa (the State capital) in the south of the area at 4°55′29″N 6°15′51″E4.92472°N 6.26417°E.
The LGA has an area of 706 km² and a population of 353,344 at the 2006 census.
The postal code of the area is 561.
Yenagoa is the traditional home of the Ijaw people, Nigeria's fourth largest ethnic group after the Hausa, Yoruba
and Igbo. The Ijaw form the majority of the town. English is the official language, but Epie/Atissa language, one
of the Ijaw languages, is the major local language spoken in Yenagoa.
Since attaining the status of state capital in 1996, construction and other activities have accelerated appreciably.
Yenagoa's population is estimated at about 150,000 people.
Yenagoa is the heart of the oil rich Niger Delta of Nigeria. It is bounded in the east and west by Port Harcourt
and Delta States respectively linked by the east-west road; and at the south by the Atlantic Ocean. At the time of
this study, the hospital had six wards and about two hundred bed spaces. It has an average general outpatient
attendance 13,000 cases per annum. The general practice clinic has four consulting rooms with four doctors. The
Pharmacy Department of the hospital had six registered pharmacists, six intern pharmacist, four pharmacy
technicians and four pharmacy trainee on their industrial training that dispense drugs as support staff. This type
of study to the best of our knowledge has not been done in this part of the country before now. The study was
designed essentially to assess the degree of rational use of drugs in this health facility using WHO core drug use
indicators.
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3. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012
STUDY DESIGN
The data collection process was done both prospectively and retrospectively. The pharmaceutical prescribing
pattern was retrospectively done while the patient care practices and health facility indicators were prospectively
studied. In addition, the times spent by patients to assess their prescription and make payments were also
evaluated.
DATA COLLECTION PROCESS
The prescription sheets of the previous twelve months period were collected from the pharmacy department,
sorted and systematically sampled. One in every three prescriptions was selected for the study. Three research
assistants were trained to extract the necessary information from the sampled prescriptions into data collection
forms. The information abstracted from the prescription forms are: The name of the medication, the route of
administration, the dosage form, the dose and duration of therapy.
The prescribing indicators evaluated in this study include: Total number of drugs prescribed per encounter,
percentage of drugs prescribed by generic name, percentage of encounter with an antibiotic prescribed,
percentage of encounter with an injection prescribed. The patient care indicators evaluated include: Consultation
time, dispensing time, patient’s knowledge of prescribed medications and adequacy of medication labeling.
Also, the times spent by the patients to assess their prescriptions and make payments were also evaluated. These
were all done prospectively.
The presence or absence of an essential drug list at the pharmacy unit was also noted. Classification of
antibiotics and the description of key essential drugs were based on WHO guideline.(WHO/DAP 1993)
DATA ANALYSIS
The information from the prescription forms were entered into a data collection form and sorted while data on
patient care practices were collected prospectively and entered into appropriate section of the data collection
forms.
The prescribing, patient care and facility indicators were calculated using WHO guidelines (WHO/DAP 1993).
The prescribing indicators were calculated as follows:
Average number of drugs prescribed per encounter = Total no of drugs for all encounters
Total no of encounters
Percentage of drugs prescribed by generic name = Total no of drugs prescribed as generics
Total no of drugs prescribed
Percentage of encounters with an antibiotic prescribed =
Total no patients who received one or more antibiotics
Total no of encounters
Percentage of encounters with an injection prescribed =
Total no of encounters with one or more injections
Total no of encounters
Percentage of drugs prescribed from the EDL = Total no drugs from the EDL
Total no of drugs prescribed
Also, the mean consultation time, the mean dispensing time, the mean assessment and revenue times were all
calculated by dividing the total time spent by the patient for each of the above activities by the number of
encounters assessed. Other patient care indicators that were evaluated include: percentage of drugs actually
dispensed, the percentage of drugs adequately labeled and the percentage of patients with adequate knowledge
of their medications.
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4. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012
RESULTS
A total of two thousand four hundred and fifty (2450) prescriptions were used for the evaluation of the
prescribing pattern. A total of forty (40) patients participated in the study regarding consultation and dispensing
times. Thirty (30) persons participated in the study of revenue and waiting times while ninety (90) persons
participated in the study of the knowledge of dispensed medications.
Table 1 shows that the average number of drugs per encounter was 3.4. The percentage prescribed by generic
name was 62% and the percentage of encounter with an antibiotic prescribed was 35.5%. The percentage of
encounter with an injection prescribed was 22.4% and 87% percent of drugs prescribed from the essential drug
list.
Table 2 shows that the mean consultation time was 11.5 minutes. The mean assessment and revenue times were
48.2 seconds and 3.5 minutes respectively. The mean dispensing time was 5.0 minutes. The percentage of drugs
actually dispensed and the percentage adequately labeled were 80.3% and 84.55 respectively.
Table 3 shows that 66% of respondents knew the names and duration of their dispensed medications. Four out of
every respondent knew the dosage of prescribed medications. Only 2% of respondents knew the side effects of
the dispensed medications.
TABLE 1. WHO PRESCRIBING INDICATORS
S/N INDICATORS % REF.
STD
1. Average number of drugs per encounter 3.4 1.6-1.8
2 Percentage of encounter with an antibiotic prescribed 35.5% 20-25.4%
3. Percentage of encounter with an injection prescribed 22.4% 10.0-
17.0%
4. Percentage of drugs prescribed by generic name 67% 100%
5 Percentage of drugs prescribed from EDL 87% 100%
WHO- World Health Organization.
REF. STD- Reference Standard.
EDL- Essential Drugs.
TABLE 2: WHO PATIENT CARE INDICATORS
S/N PARAMETER
1. Mean Consultation time (mins) 11.5
2. Mean assessment time (secs) 48.2
3. Mean Revenue time(mins) 3.5
4. Mean dispensing time (mins) 5.0
5. Percentage of drugs actually dispensed 80.3%
6. Percentage of drugs adequately labeled 84.5%
TABLE 3 RESPONDENTS’ KNOWLEDGE OF DISPENSED MEDICATIONS
S/N PARAMETER PERCENTAGE
1. Knowledge of names of dispensed medications 66%
2. Knowledge of correct dosage of dispensed medications 80%
3. Knowledge of duration of dispensed medications 66%
4. Knowledge of side effects of dispensed medications 2%
DISCUSSION
Study of drug use patterns in health facilities is used to describe treatment practices and to assess performance of
health care providers. This allows healthcare planners, managers and researchers to make basic comparisons
between health facilities and also evaluate situations at different times in a particular health facility following
interventions.
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5. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012
The average number of drugs prescribed per encounter obtained from this study was 3.4.
The value is higher than some values obtained in Nigeria by Enato and Chima (2011) in Lokoja (2.94), Nwolisa
et al., (2005) (3.13). A similar result was obtained in a secondary health facility in Lagos, Nigeria (Odusanya,
2004) (3.5).
This value indicates a relatively high level of poly pharmacy practice in prescription pattern. This may have a
very negative effect on therapeutic outcome in patients. Among the likely negative effects this may pose are
increased incidences of side effects, drug-drug interactions, confusion where aged patients are involved, non
compliance by the patients as a result of the large number of drugs to be taken at a time (Babalola et al., 2011)
Sixty two percent of the drugs from the study were prescribed by generic name. Higher values had been obtained
in some other studies. For instance, Babalola et al.,(2011) (69.81%), Nwolisa et al. (2006) (63.8%). The value is
higher than that reported by Enato and Chima (2011) (37%). This value is low and does not comply with the
WHO recommendation that 100% of drugs should be prescribed using the International Non-proprietary Name,
INN. Prescribing by non generic name is a form of irrational prescribing (prescribing a more costly brand when
cheaper and equally effective alternatives are available). Factors that have been identified as contributing
immensely to this trend are the influence of drug promotional activities as well as pressure from pharmaceutical
manufacturers’ representatives or detail men on prescribers.
Antibiotics were prescribed in 35.5% of patient encounters. This value was lower than those obtained from
studies done in some health facilities in Nigeria. For instance, 51% was obtained in a study done by Enato and
Chima (2011), 50.1% was obtained in a study by Babalola et al (2011) and 54.8% by Odusanya (2004). Though
this value is lower than that from other studies, it still indicates overprescribing of antibiotics because it is higher
than the range given by WHO (20%-25.4%). Over prescription of antibiotics often arise from prescribing
antibiotics for presumed infections. High rate of antibiotic prescribing has a number of implications. Firstly, it
can result to non compliance when unaffordable antibiotics are prescribed. Secondly, it tends to promote
antibiotic resistance.
The prescription rate for injections from this study(22.4%) was lower than that from some previous studies. For
instance, in a study done by Babalola et al (2011) in some primary health institutions the rate of injection
prescribing was 71.74%. This relatively low rate of prescription of injection is encouraging as injection – related
hazards and infections such as HIV/AIDS, hepatitis and tissue necrosis.
Eighty seven percent of drugs in this study were prescribed from the Essential drug list (EDL). Higher values
had been obtained from other studies in Nigeria (94%) (Babalola et al, 2011). Ninety two percent and 100%
were obtained in two studies done in Edo state (Ozemoya, 1997). The value from this study, though lower than
the WHO benchmark (100%) value, is an indication that the prescribers have a fair knowledge of the drugs in
the essential drug list. Though lower than the WHO benchmark (100%). However, improvement should be made
It was observed that the pharmacy department had a copy of the EDL but none of the prescribers.
It has been noted that patient care patient care practices impact on the quality of health care delivered and
appropriate use of time influences the health seeking behavior of clientele (Isah et al, 1998) Contrary to findings
from various studies in different parts of the nation (Enato and Chima, 2011) (Isah et al, 1997), the mean
consultation time of 11.5 minutes obtained in this study was considered adequate for making appropriate
diagnosis. An important factor that affects consultation time is the number of patients to attend to. Adequate
consultation time is an indication of adequate clinical care for the clientele; which directly impacts positively on
patients’ satisfaction.
The time spent to assess their prescription for payment was so short and was considered
quite satisfactory considering the fact that sick patients are attended to almost immediately they arrive without
necessarily queuing before their prescriptions are assessed for payment. The time spent to make payment for
medications could be further reduced for the benefit of the patient.
The mean dispensing time (5 minutes) obtained was considered satisfactory and adequate for a meaningful
pharmacist- patient interaction to take place. The dispensing time is a measure of the quality of care given to
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6. Ifeanyi E. Chima et al.,: Continental J. Pharmaceutical Sciences 6 (1): 10 - 16, 2012
patients by the pharmacist in providing information about the dispensed drug. This interaction results in
appropriate use of prescribed medications and ultimately a positive therapeutic outcome. The value obtained
showed good quality of care. Inappropriate and unsuitable environment impacts negatively on dispensing time.
Overall evaluation of drugs adequately labeled showed that 84.5% of drugs dispensed were adequately labeled.
Four out of every five patients interviewed knew the correct dosage regimen of all their dispensed drugs. This
result is lower than some results obtained from earlier drug use studies (Ozemoya, 1997). However this result
was similar to results obtained in some other studies (Massele et al, 2011). Knowledge of correct dosage of
medication is a very central factor in the therapeutic process. Lack of it could jeopardize the whole process, thus
resulting in several predictable undesirable outcomes. Two out of three respondents knew the names of all their
dispensed medications. This value is unsatisfactory, though higher than values obtained in a study in UBTH and
central hospital with values as low as 33.8% and 10.8% (Ozemoya, 1997). A researcher had observed that what
is responsible for low values of respondents who knew the names of their dispensed drugs is the practice of
some pharmacists and other health care givers not to disclose the names of the prescribed drugs. Another factor
identified in that same study was the short time spent by pharmacists in counseling patients on their medications.
This results in some vital information such as name of drugs being left out. This trend has been changed by the
fact that the new health care process encourages patients to actively participate in their care process.
Two out of every three respondents in the study knew the duration of all their medications. This indicates that
34% of the patients did not know the duration of their therapies. This entails that a patient may not complete his
therapy especially in a case where a refill is necessary, the patient may not know for how long to continue the
refills. The patient may even decide to share his drugs with another sick person who is having similar symptoms
or may even decide to save the drug for another time when he feels better. A factor that has been identified as
being responsible for the pharmacist occasionally not disclosing the duration of therapy is the fact that the total
quantity of drugs dispensed is usually equal to the quantity needed. Lower values of 30.0% and 3.5% have been
obtained in study in Edo State (Ozemoya, 1997).
Only 2% of the respondents interviewed knew the side effects of their medications. A similar result was
obtained in the study done in UBTH and Central hospital in which 1% and 0% of the respondents respectively
knew the side effects of their medications (Ozemoya, 1997). Lack of information on the side effects of a drug
could result premature discontinuation of therapy when the patient experiences the side effect, resulting in non
adherence and consequently therapeutic failure.
CONCLUSION
The findings from this study showed that pharmaceutical prescribing pattern and patient care practices were
inappropriate. There was high tendency of poly- pharmacy and over prescription of antibiotics. The patients’
knowledge of vital aspects of medication management was found to be inadequate. The overall picture of drug
use suggests that the indicators at this facility are not yet at the optimal level. Thus, the need for the training of
medical and Pharmacy practitioners on rational drug use and the incorporation of same in the undergraduate
curriculum of both professions in various universities in the country.
ACKNOWLEDGEMENTS
We wish to thank the management and staff of Federal Medical Centre, Yenagoa and the staff of the Pharmacy
Department for their support during the data collection process. We also thank Pharm (Dr) Daniel Orumwense
and Dr Suleiman, both of Clinical Pharmacy Department Niger Delta University, Wilberforce Island for their
moral and technical support in the course of the research work.
Conflict of interest:
All views expressed in this paper are simply those of the authors and does not in any way represent that of the
management of the hospital. The authors declare no conflicts of interest.
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National Population Commission. Available at : http://www.nigeriabusinessfile.com/nbf
niginfo/index.php (Access: 18/02/2012).
Received for Publication: 05/01/2012
Accepted for Publication: 02/03/2012
Corresponding Author
Ifeanyi E. Chima
Department of Clinical Pharmacy & Pharmacy Practice Faculty of Pharmacy, Niger Delta University,
Wilberforce Island, Bayelsa State, Nigeria.
E-mail: ifeanyimail@yahoo.com
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