|Year : 2021 | Volume
| Issue : 1 | Page : 71-78
Practices toward presumptive tuberculosis clients among patent medicine vendors in Ebonyi State Nigeria
Cosmas Kenan Onah1, Benedict Ndubueze Azuogu2, Edmund Ndudi Ossai2, Adaoha Pearl Agu2, Lawrence Ulu Ogbonnaya2, Chika Onwasigwe3
1 Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
2 Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital; Department of Community Medicine, College of Health Sciences, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
3 Department of Community Medicine, College of Medicine, University of Nigeria Enugu, Enugu State, Nigeria
|Date of Submission||05-Jan-2021|
|Date of Acceptance||20-Jan-2021|
|Date of Web Publication||28-Feb-2021|
Cosmas Kenan Onah
Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
Background: Tuberculosis (TB) is a major cause of ill-health and death globally but a serious challenge to its control is low case notification. In low- and middle-income countries, most patients with symptoms of the disease first seek care from patent medicine vendors (PMVs) who are not formerly trained to manage TB. The practices of PMVs toward presumptive TB are pivotal to control of TB. Aim: The aim of this study was to describe the pattern of practices toward presumptive TB and assess their determinants among PMVs. Method: The study was carried out in Ebonyi State Nigeria using descriptive cross-sectional design. Through a multistage sampling, 250 PMVs were selected and interviewed. Data were collected using pretested interviewer-administered questionnaire and analyzed with IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA). Chi-square test and binary logistic regression were used to determine factors associated with practices toward presumptive TB with P value set at 0.05 for statistical significance. Results: Almost half (48.8%) of the respondents engaged in poor practices by inadequate referral of clients (45.2%), delayed referral (69.6%), and unstandardized treatment with antibiotics (56.4%). There was no statistically significant association between independent variables and practice and none of the variables significantly predicted practice. Conclusions: There were poor practices toward presumptive TB shown in inadequate referral, delayed referral, and unstandardized treatment of clients. We recommend that PMVs should be trained and regularly sensitized about TB to improve their practices and that regulatory authorities should enforce policies on antibiotics distribution and sale.
Keywords: Client referral, directly observed treatment short-course, patent medicine vendors, persistent cough, presumptive tuberculosis
|How to cite this article:|
Onah CK, Azuogu BN, Ossai EN, Agu AP, Ogbonnaya LU, Onwasigwe C. Practices toward presumptive tuberculosis clients among patent medicine vendors in Ebonyi State Nigeria. Int J Mycobacteriol 2021;10:71-8
|How to cite this URL:|
Onah CK, Azuogu BN, Ossai EN, Agu AP, Ogbonnaya LU, Onwasigwe C. Practices toward presumptive tuberculosis clients among patent medicine vendors in Ebonyi State Nigeria. Int J Mycobacteriol [serial online] 2021 [cited 2021 Apr 22];10:71-8. Available from: https://www.ijmyco.org/text.asp?2021/10/1/71/310502
| Introduction|| |
Tuberculosis (TB) remains a major cause of ill health and the leading cause of death from a single infectious agent. In 2018, the World Health Organization (WHO) estimated that 10 million people contracted the disease globally and in 2019, one quarter of the 10 million that fell ill with TB were in the WHO region of Africa. TB is among the ten leading causes of hospital admissions across public and private health institutions in Nigeria which accounts for 4% of TB global burden, and was one of the top three of ten countries that accounted for 80% of the total gap between TB incidence and reported cases.
Although the key step to diagnosis is referral of presumptive TB clients to a directly observed treatment short course (DOTS) facility where the definitive diagnosis and treatment take place, patients with symptoms suggestive of TB first seek care from a wide array of healthcare providers that are often not linked to the public sector-based National TB Control Program (NTBCP) that implement DOTS. It has been shown that a large proportion of this care for presumptive TB clients take place at pharmacy and drug shops.,, This situation is common in many resource-poor countries with high TB burden like Nigeria. This constitutes a major challenge to TB control through poor case finding and under reporting.
Patent medicine vendors (PMVs) constitute the first port of call for most persons with symptoms of TB such as cough, fever, night sweats, and weight loss,,,,,,,, and provide medicines and services for other health needs. Accordingly, PMVs are pivotal to TB control in low- and middle-income countries such as Nigeria and as the first point of contacts of TB patients with the health system, they could become opportunities for linkage of presumptive TB clients to DOTS facilities for standardized care. Indeed their potential role in TB control efforts has been widely reported.,,,,,
However, reports showed that PMVs have poor knowledge of TB,,, and engaged in bad practices about the disease such as sale of unstandardized anti-TB medicine,, poor referral of presumptive TB clients to DOTS facilities,, and unstandardized treatment of TB cases. These poor practices are capable of undermining the TB control efforts. Despite this documented evidence, their pattern and predictors of practices, remain inadequately investigated in Ebonyi State Nigeria. This study described the determinants and pattern of practices of PMVs toward presumptive TB clients.
| Method|| |
The study was conducted among all registered PMVs in Ebonyi State which is one of the 36 States of Nigeria. There are 557 registered public and private health facilities in Ebonyi State and these include 2 tertiary health institutions, 13 General Hospitals, 6 Mission Hospitals, 417 Primary Health Care facilities, and 119 private hospitals and clinics. There are also informal private health service providers such as PMVs, Traditional Birth Attendants and Traditional Bone Setters. By April 2019, there were 1843 PMVs registered with the National Association of Patent and Proprietary Medicine Dealers (NAPPMED), the Association of operators of PMVs.
Unpublished data obtained from Ebonyi State TB Control Programme Office Abakaliki showed that as of January 2019, there were 148 DOTS centers spread across the 13 Local Government Areas (LGAs) of the state.
A minimum sample size of 250 PMVs was calculated using Finite Population Correction of the Cochran formula for estimating sample proportions as was reported by Singh and Masuku thus:
n is the desired sample size when the population is 10,000 and above and nf is the desired sample size when the population is < 10,000.
Z = standard normal deviate at 95% confidence interval = 1.96.
p = reported average proportion of PMVs who referred any client with a long lasting cough in a previous study; P = 18.2% (0.182).
q = 1– P = 1-0.114 = 0.818
d = desired 95% accuracy = 5% (0.05)
N = estimated population size of PMVs in Ebonyi State = 1843.
Applying these values to the formulae:
With anticipated nonresponse rate of 20% based on pretest of the data instrument, the minimum sample size was made up to 250.
Using a multi-stage sampling technique, the LGAs were first stratified into urban and rural locations and 4 out of the 13 LGAs in the state were selected by balloting. In the second stage, 4 NAPPMED branches, comprising one per LGA, were selected. Sampling frames of PMVs were generated using membership registers of the selected NAPPMED branches and selection of 250 PMVs was concluded by using a table of random numbers. The number of respondents selected from each NAPPMED branch was based on proportionate allocation.
Data collection took place during the monthly meetings of NAPPMED between April and May 2019, with the help of research assistants using a pretested structured interviewer-administered questionnaire (with 5 sections) developed by the researchers. Recruited PMVs who were absent during the meeting were reached in their shops shortly after the meeting days.
Data were analyzed using IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA) and Microsoft Excel Spread Sheet version 2016. Chi-square and binary logistic regression tests were used for tests of statistical significance at P < 0.05 and confidence interval of 95%.
The respondents' level of knowledge was assessed by assigning a score of one mark for each correct answer and zero mark for each incorrect answer to a set of 10 questions. A composite score was computed and expressed as percentage to categorize knowledge arbitrarily into “poor knowledge” for scores <50% and “good knowledge” for scores of 50% and above.
The attitude section was assessed on a 5-point Likert Scale using a set of 5 questions with a minimum score of 1 and a maximum of 5 marks on a range of 5–25 marks. A mean score for the attitude was computed and categorized into “negative attitude” for mean scores of 1–12.5 marks and “positive attitude” for mean scores of 12.6–25 marks.
The practice was similarly assessed with eight questions, each with one best option answer with 1 mark allocated for correct option to a maximum of 8 marks. A composite index was also computed, converted to a percentage and used to arbitrarily categorize practice into two thus: Poor practice for scores <50% and good practice for scores of 50% and above. Then, the determinants of practices were assessed first, by cross-tabulating the independent variables for inclusion into the binary logistic model. The variables that met the inclusion criterium (cut off in P ≤ 0.2) were then inputted into the model for the determination of predictors of practice toward presumptive TB clients.
Ethical approval was obtained from the Research and Ethics Committee of Alex Ekwueme Federal University Teaching Hospital Abakaliki. Permission was obtained from the leadership of Ebonyi State and LGA chapters of NAPPMED, and written informed consent was obtained from the participants.
| Results|| |
The sociodemographic characteristics of the respondents are presented in [Table 1]. The mean age of our respondents was 30.2 ± 8.7 years and the predominant age group was the 30 years and more category. Majority (160: 64.0%) of them were females and up to 37 (14.8%) schooled up to tertiary level. Majority (155: 62.0%) of the respondents had not operated patent medicine shop for up to 5 years and only 97 (38.8%) of them had received training on TB.
|Table 1: Sociodemographic and other characteristics of respondents (n=250)|
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Knowledge of tuberculosis
Majority of our respondents knew that TB is caused by a germ (203: 81.2%) which can spread from one person to another (214: 85.6%) and may manifest with symptoms such as cough of up to 2 weeks' duration (207: 82.8%) [Table 2]. Majority of the respondents also knew that using wrong drug to treat TB patients promotes the spread of the disease (170: 68.0%) but most of them neither knew that cure for TB takes a minimum of 6 months (134: 53.6%) nor about the existence of any DOTS facility in their LGA of practice (128: 51.2%). Overall, majority (215: 86.0%) of the respondents had good knowledge of TB.
Attitude about tuberculosis
The attitude of the respondents is presented in [Table 3]. Majority (218: 87.2%) of them agreed that PMVs should screen all clients with cough for TB by asking for the duration of the symptom, and refer those eligible to DOTS centers for diagnosis. Majority (233: 93.2%) of the respondents were also in agreement that referring clients will not make them loose their clients to rivals, rather it will help the clients to be cured of the disease. They also agreed that TB patients should be treated with empathy (222: 88.8%) and that it is a wrong practice to treat clients with persistent cough without referring them to DOTS center (208: 83.2%). Overall, majority (239: 95.6%) of the respondents showed positive attitude about TB.
Practices towards presumptive tuberculosis
Practice in this study is categorized as good and poor in [Table 4]. Overall, almost half (122: 48.8%) of the respondents engaged in poor practices and only 113 (45.2%) had referred a client to DOTS center within 3 months preceding interview. However, individual components of practice showed that majority (195: 78.0%) asked their clients with cough about the duration of the symptom, 136 (54.4%) of them referred all clients with persistent cough (cough lasting ≥2 weeks) to DOTS centers after sale of cough medicines to them. More than half (141: 56.4%) of the respondents had sold antibiotics with anti-TB activity to their clients for the treatment of cough and this was done without doctor's prescription in 39 (27.7%) of the cases. Of the anti-TB medicines sold for treatment of cough, streptomycin (39.6%), rifampicin (16.0%), and ethambutol (11.6%) were the most common [Figure 1].
|Figure 1: Reported sale of antibiotics with anti-tuberculosis activity for the treatment of cough among patent medicine vendors|
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|Table 4: Reported practices toward presumptive tuberculosis by patent medicine vendors (n=250)|
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Factors associated with practices toward presumptive tuberculosis
Respondents gave various reasons that influenced their decisions to refer or not to refer clients with persistent cough. Among the reasons given, perceived nonseriousness of client's clinical condition (100%), lack of client referral forms (99.2%), not being formally recognized as community TB worker (97.6%), client's clinical improvement following treatment with cough medicines (95.2%), and lack of incentives for clients referred (90.0%) were the most common [Figure 2]. In cross tabulation of independent variables with practice, there was no statistically significant association between independent variables and practice toward the disease [Table 5]. In addition, although five of the independent variables met the criterium for inclusion in the binary logistic regression model, none significantly predicted practice.
|Figure 2: Reported reasons for non-referral of clients with persistent cough by patent medicine vendors|
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|Table 5: Predictors of practice about presumptive tuberculosis among patent medicine vendors|
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| Discussion|| |
This study examined pattern and determinants of practices toward presumptive TB clients among PMVs in Ebonyi State Nigeria. We found overall poor practices toward presumptive TB clients among the respondents. One good practice among majority (78.0%) of the respondents is their act of asking for the duration of symptom from their clients presenting with cough. This is necessary as the first step in screening and identification of presumptive TB clients. This reported practice, however, did not translate to the referral practice of the respondents as much lower proportion (54.4%) of them always referred their clients to DOTS center after selling cough medicines to them. The poor referral activity among the respondents is further shown in the fact that within 3 months preceding the interview, only 45.2% of them had referred a client to a DOTS facility. This proportion is higher than the 8.5% reported previously in a study done in southern Nigeria but lower than 71.1% referral rate reported in Oshogbo Osun State and 78.9% referral reported in Badagry Lagos State both in south-western Nigeria.
The discrepancy between the proportions may be as a result of recall and reporting biases, lack of knowledge of the implication of clients having persistent cough or outright refusal to refer clients for fear of losing them and the income they would have generated from selling medicines to their clients. These findings suggest a need for more objective assessment of their referral activities and to build the capacity of PMVs to be able to screen, identify, and refer clients through training them on TB and best practices concerning management of presumptive TB clients.
A bad practice among the respondents is the habit of prolonged treatment which leads to delay in referral of clients with prolonged cough. Only very few of the respondents deemed it necessary to refer clients with prolonged cough to DOTS center immediately after selling cough medicines to them. This approach had also been reported among PMVs in previous studies., This penchant to treat prolonged cough for too long before considering referral is a dangerous trend that should be discouraged. Successful treatment of chronic cough depends on etiologic diagnosis. Although empirical treatment is an alternative in cases where conditions for etiologic diagnosis are limited, this should be practiced by trained health-care professionals who can make diagnosis with their sound clinical judgment of cases. Prolonged empirical treatment of persistent cough with non-specific medicines leads to delay in diagnosis and contributes to increased cost of care, emergence of antimicrobial resistance, and loss of lives. The prolonged treatment of chronic cough and delay in referral of clients by PMVs are challenges to TB control efforts that need to be addressed. This suggests a need for regular sensitization of PMVs on the implications of such unstandardized approach and the benefits of early referral to the clients and the community.
The sale of antibiotics with anti-TB activity for the treatment of cough and without doctor's prescription in some of the cases, as noted among our respondents, is another bad practice engaged on by the PMVs. Previous studies have shown that drug vendors have poor knowledge of health care and drugs and often dispense drugs improperly.,, More so, the treatment of cough with antibiotics by PMVs is empirical since there is no laboratory confirmation of diagnosis. This practice is most undesirable in that most causes of chronic cough are not related to infection and therefore, antibiotic abuse should be avoided during empirical treatment. Furthermore, empirical use of antibiotics is beyond the knowledge and skills of PMVs; it is exclusively for trained health-care professionals who know the pros and cons of their usage and are further authorized to make prescriptions based on sound clinical judgments. In empirical treatment of cough with anti-TB medicines, as shown in our study, PMVs may use the drugs for inadequate period and in inadequate doses on the patients with cough. This practice is capable of temporarily relieving the symptom but promote emergence of antimicrobial resistant mycobacterial organisms.
Reports of sale of anti-TB medicine by PMVs have also been documented in previous studies in Nigeria,, and Kenya. In Nigeria, PMVs are prohibited by law from sale of prescription-only medicines including antibiotics. They are permitted to only sell a set list of pre-packaged, over-the-counter medicines in the approved list of Federal Ministry of Health for the PMVs in line with the national drug policy., The act of selling antibiotics by PMVs suggests that there may be inadequate enforcement of regulations guiding prescription, sale and use of antibiotics and this is dangerous in view of the role of antibiotic abuse in emerging and reemerging diseases., These findings suggest a need for improvement in enforcement of policies on antibiotics distribution and sale by the regulatory authorities.
Interestingly, the overall knowledge of majority of our respondents about TB was good. Majority of them also showed a positive attitude about the disease. There were discrepancies in knowledge of our respondents with those in previous studies with our respondents having lower knowledge than was reported in a study done in southern Nigeria but higher knowledge in other studies also done in Nigeria, and in Kenya. The differences in knowledge between our respondents and those of previous studies may be due to differences in educational attainments, level of participation in previous training on TB and differences in possession of some form of medical training among the respondents. In Nigeria for instance, a report of census of PMVs in 16 states of the country showed that an average of 34.6% of all persons in charge of patent medicine shops had some form of medical training, ranging from 29.7% in LGAs in southern to 52.6% in LGAs in northern states of the country.
Regrettably however, the high knowledge of TB and positive attitude shown by the respondents did not correspond with their poor practices shown in inadequate referral activities. The disconnect between good knowledge and positive attitude from practice is possibly a result of the so many reasons given by the respondents which made them not to be referring clients including their perception of nonseriousness of client's condition, not having client's referral forms and their belief that they could handle all cases of chronic cough. Other reasons include lack of incentives for clients referred, fear of losing client's confidence, lack of knowledge of referral process and desire to maintain income from sale of drugs. These reasons given by the respondents resemble those earlier reported among PMVs in a previous study in Nigeria.
Every patient with persistent cough should be screened for TB and other causes of chronic cough before treatment that could suppress the symptom is initiated. The reasons given by our respondents further buttress the need for training and regular sensitization of PMVs to improve their understanding about TB, change their perception and improve their practices.
| Conclusions|| |
Practices toward presumptive TB clients among PMVs were poor as shown in their inadequate referral of clients with persistent cough to DOTS facilities, prolonged treatment of clients with persistent cough with antibiotics which have anti-TB activity and untimely referral of clients for diagnosis and treatment. We recommend that PMVs should be motivated with incentives, trained, and regularly sensitized about TB by NTBCP to improve their understanding, change their perception and improve their referral practices about presumptive TB clients and that regulatory authorities should ensure regular enforcement of policies on antibiotics distribution and sale to avoid unstandardized practices.
The authors are grateful to Tobechukwu Alo and Chukwudi Agbor for their roles during data collection process.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]