Ellen Abrafi Boamah on behalf of Kintampo Health Research Centre, Ghana Health Service .

1. THE KNOWLEDGE, PERCEPTIONS AND PRACTICES OF PRESCRIBERS ON ANTIBIOTIC USE AND RESISTANCE INTHE BRONG AHAFO REGION OF GHANA Ellen Abrafi Boamah on behalf of Kintampo Health Research Centre, Ghana Health Service.

2. Background • Infectious diseases account for most morbidities and mortalities in developing countries • These infections are managed/ treated with antibiotics. • There is however a surging antibiotic resistance in most developing as well as developed countries • Resistance to antibiotics has become a public health challenge. • Ghana is in the process of developing an Antibiotic Resistance policy. (KAPP to provide empirical data to inform the policy)

3. Objectives • To assess the knowledge of prescribers on rationale antibiotics use • To evaluate current practices (trend of antibiotic prescription) by prescribers . • To explore the perceptions of antibiotic resistance among prescribers • To determine stock levels of essential antibiotics.

4. Methods • Study Design Cross-sectional survey among doctors, medical assistants , nurses and patient folder review. • Study site Brong Ahafo Region of Ghana (B/A) • All 27 districts in B/A 27 district and municipal hospitals in B/A. 1 private hospital / Clinic in each district 1 Regional hospital • Data Collection Quantitative and qualitative data collection methods. • Data Analysis STATA version 11 for quantitative data and QSR Nvivo version 10 for qualitative data.

5. Methods contd. • Sample size and sampling procedure • 379 Health professionals (Random sampling if more than number required per facility) • 2661 Patient folder review (systematic sampling) Approvals • Scientific and ethical clearance from KHRC SRC/IEC • Ghana Health Service ERC • B/A regional health directorate and various health facilities.

6. Table 1 Demographic characteristics of prescribers interviewed

7. Table 2 Demographic Characteristics of patients whose folders were reviewed.

8. Table 3 Prescriber’s knowledge on antibiotic use and resistance.

9. Prescriber’s knowledge on antibiotic use and resistance contd.

10. Sources of knowledge about antibiotic use and resistance Electronic media, Prints, Meetings are sources of information on antibiotics. “Aside my knowledge from school, I also learn from the BNF- British National Formulary, it has all the medications that we prescribe so, if you want to check the dose, you just refer to it and also from our standard treatment guide and also from senior colleagues”(IDI, MD, BE) “We have worked in various facilities under various consultants and physicians, specialists, professors and what have you. So from there you tap it. And sometimes these days you can even go on net and then you learn a lot”(IDI, MA, AA)

11. Prescription practices • 3 visits reviewed per folder. 7982 total visits recorded. • At visit 1, 1976 antibiotics were prescribed • On average, each patient received 0.7 antibiotics. • Doctors prescribed 21%, MAs, 50.2% and Nurses 28.2%. • At visit 2, 1526 antibiotics were prescribed. • On average, each patient received 0.5 of antibiotics • Doctors prescribed 22.6% , MAs 46.2%, Nurses, 31.2%

12. Prescription practices continued. • At visit 3, 1,539 antibiotics were prescribed • On the average, each patient received 0.6 antibiotics • Of this, doctors prescribed 21.6%, MAs, prescribed 48.3% and nurses, 30.1%. • The over all average number of prescriptions per patient was 1. • Most prescribed antibiotics from the folder review was amoxicillin 27.3%(1374/5041)

13. Prescription practices continued. Diagnosis based on history and physical examination Upper Respiratory and Urinary Tract Infections were used as case studies for prescribers to demonstrate how they would manage these cases “URTI” let me say usually the history and examination unless may be you are suspecting bronchiolitis or broncho pneumonia then we do the chest X-ray we don’t often do the chest x-ray for all the URTI”(IDI, MD, DC)

14. Opinion on levels of antibiotics Prescription I think it is quite high. People prescribe antibiotics centre right, centre left, I mean, I do not think it is that low, I think it is quite high (IDI,MD,AS) I actually think that, any slight thing, they just put the fellow on antibiotics…some people will not give and those who give, the patients prefer that one. It is over prescribed (IDI, MA, TX) Factors that influence antibiotic prescription ..another thing is the availability of medicine at our facility. Also if they are insured and you prescribe a particular antibiotic which is not immediately available and the patient cannot afford to buy in the open market at times we need to change it looking at the kind of antibiotic it is. (IDI,MD, AZ)

15. Factors that influence antibiotic prescription continued ..it has a social connotation in the sense that some people just want the clients to think that their good clinicians and therefore will load antibiotics for them and then in the long run when everybody comes he is looking Mr. C or Mr. D”(IDI, MA, AA) Patient demand driven “Patients should not decide for me what to prescribe because I’m doing my work, you can’t dictate to me what I should do”(IDI, MD, AA) “You will have that problem of influence with patients who are educated and also the health staff themselves …but for the general population, they rely on what we prescribe for them. ”(IDI, MD, JN)

16. Reasons for preference for prescribed antibiotics “The reasons for my preference are usually cost and effectiveness of the drugs and the ability of the client to pay for the particular drug. (IDI, MD, TX) “The number one reason is the insurance. You always want to prescribe what the patients will get in your facility; the second factor is affordability of the patient, if the patient can afford some of the high ones you can prescribe for them and the third factor will be previous drug history, what has the patient taken before coming to you. You don’t want to continue on the same line. The other factor will be patient choice, sometimes you have to agree with the patient” (IDI, MD, JN)

17. Perception of the burden of antibiotic resistance “Resistance is very serious because if somebody is resistant to a drug which is commonly used in Ghana here, it means if he is sick, there will be no other drug and the patient can die..”(IDI, MA, SC) “… “That is the most dangerous thing that can happen to mankind. We may move to the last limit where we cannot get any antibiotics to treat certain diseases..” (IDI, MA, DC)

19. Stock levels • Patients mostly get their prescribed drugs. • Fifty percent (50%) of the 27 facilities had a stock out of at least one essential antibiotics. Reasons…. “….we are short of some of the drugs because the insurance scheme has not paid the hospital about 6 month ago and the suppliers also need their money to be able operate”(IDI, Nurse, JS)

20. Conclusion • Marked differences exist in the perceptions and prescription practices among the various cadres of prescribers on the use of antibiotics in health care. • There is an urgent need to develop and sustain a formal platform from which rational prescription, use and antibiotic resistance information can be disseminated for improved services delivery, regarding the management of microbial infections.

21. Recommendation 1 Prescribers • Prescribers should prescribe and dispense antibiotics only when they are needed. • Prescribers should prescribe and dispense the right antibiotic(s) to treat illnesses.

22. Recommendation 11 Policymakers • Policymakers should regulate and promote appropriate use of medicines • Policymakers should strengthen resistance tracking and laboratory capacity; • Policymakers should promote cooperation and timely sharing of information among all stakeholders • Policymakers should foster innovation and research and development of new tools towards antibiotic use and resistance.

23. Acknowledgment • Ministry of Health • ReAct • Ghana Health Service • Ghana Antimicrobial resistance working group • Regional Health Directorate BAR • All health facilities in BAR • All study participants • Management and Staff of KHRC

24. Thank you