Management Of Diseases

INTRODUCTION
Diseases are diverse in nature and affect a vast proportion of the population in any setting. In disease conditions, there is lack of total well being in an individual. Diseases could be either communicable or non-communicable. Occurrence of diseases varies in different regions of the world. Earlier studies revealed that communicable diseases constituted a huge health burden in Africa and developing countries as opposed to the western countries where non-communicable diseases accounts for a greater part of the mortality and morbidity1. More recently, there has been a shift with non-communicable diseases being a greater cause of mortality and morbidity and also accounting for most hospital visits/admissions in Africa (2,3). There has been a noted increase in prevalence of some non communicable diseases in Africa. Such diseases include diabetes mellitus, cardiovascular diseases and renal disease (4 Ansa VO, Ekott, 5,Ayanwu AC et al). Also, a study carried out in Port Harcourt, South-South Nigeria revealed that diseases of the cardiovascular, endocrine and renal systems were the most prevalent non-communicable diseases among medical admissions(6DI AGomuoh CN Unachukwu).

In the management of diseases, drug therapy is mostly used in practice. Appropriate drug utilization will improve health care delivery and reduce global morbidity and mortality rates. However, the patterns of drug prescribing and utilization are often inappropriate. The World Health Organization (WHO) describes ration drug use as prescribing the right drug for the right indication in the right dosage and dosing frequency for the correct indication (7 WHO, 2002). Irrational drug use and inappropriate prescribing result in drug therapy problems which are a huge burden in the delivery of health care.(8 Guino and Fadare). In Nigeria, WHO reports that about 60% of antibiotics prescribed are unnecessary and physicians prescribe drug therapy when not indicated (WHO Ref 9). The identification of disease trends, patterns of drug use and common drug therapy problems in a locality is essential for effective health care planning. This study seeks to determine the prevalent diseases in Amassoma community and its environs presenting to the hospital and also the drug utilization patterns/ drug therapy problems occurring the general Hospital of Amassoma.
METHODS
The study was conducted at Amassoma General Hospital which is the main health facility servicing the Amassoma community and its environs. It is located on Wilberforce Island, southern Ijaw Local Government of Bayelsa State. It is the main Hospital in Amassoma Community with xyx functional bed spaces and xyv annual patients' turnover.
Following ethical approval, a retrospective review of randomly selected case notes of patients who attended the outpatients department of the general hospital between January 1st to December 31st, 2012 was undertaken. The sample size, 504 (inclusive of overage) was determined with the aid of the sample size calculator at 95 % confidence interval and 5 % margin of error (Research Advisor, 2006). The patients' attendance register was used as a guide. A data collection form was employed for the gathering of requisite patients' information which include; patients' demographics, disease condition(s), information on prescribed drugs such as name (generic/brand), dosages, duration of therapy and associated drug therapy problems.
Data analysis
Statistical Package for Social Sciences (SPSS) version 16.0 and GraphPad Instat 3.10 for windows (GraphPad Software, San Diego California USA) were employed for data analysis. Data presentation was by descriptive statistics with categorical variables reported as simple percentages. Drug therapy problems were however determined manually.
RESULTS
A sample of five hundred and four(504)patient's case files were assessed retrospectively. One hundred and ninety four (38.5%) were males while 310 (61.5 %) were females. Most of the patients that frequented the hospital within the period considered were the young adults within the age range 12 ' 49 years (58.7%). This was followed by the children (26.4 %), elderly (9.7 %) and the very old patients (5.2 %). However, the average age of the patients encountered was 26.94 ?? 19.71. Additionally, (39.3%) of the patients are unemployed followed by another 114 (22.6 %) that are students. Several patients are either business owners/artisans (16.3%) or civil servant (10.7%) while others are farmers (8.7%), retired (2.2%) or working for private companies (0.2%). See Table 1.

TABLE 1: DEMOGRAPHIC DATA OF PATIENTS STUDIED
GENDER N (%)
Female 310 (61.5)
Male 194 (38.5)
AGE
12-49years(young adult) 296 (58.7)
0-11years (children) 133 (26.4)
50-64years(elderly) 49 (9.7)
' 65 (very old) 26 (5.2)
Average age(mean ?? SD) 26.94 ?? 19.71
OCCUPATION
Unemployed 198 (39.3)
Students 114 (22.6)
Business/Artisan 82 (16.77)
Civil servant 54 (10.7)
Farmer 44 (8.9)
Retired 11 (2.2)
Private company 1 (0.2)

A total of 937 disease states were encountered in the 504 patient's case file assessed. Of these, malaria (34.8 %) accounted for the most frequently treated ailment at the study center. It was somewhat followed by typhoid fever (17.1 %), urinary tract infection (9.7 %), cardiovascular disorders (5.3 %), Helminthiasis (5.2 %) and peptic ulcer disease (4.4 %) respectively. Others were respiratory tract infection (3.6 %), diabetes mellitus (2.1 %) and diarrhea to mention a few of them. The average disease state per patient was observed to be 1.89 ?? 0.86 (Table 2).
TABLE 2: DISEASESENCOUNTEREDS IN PATIENTS STUDIED
DISEASE STATE N (%)
Malaria 326 (34.8)
Typhoid Fever 160 (17.1)
Urinary Tract Infection 91 (9.7)
Cardiovascular diseases 54 (10.7)
Helminthiasis 49 (5.2)
Peptic Ulcer disease 41 (4.4)
Respiratory Tract Infection 34 (3.6)
Diabetes mellitus 20 (2.1)
Threatening abortion 15 (1.6)
Appendicitis 12 (1.3)
Diarrhea 11 (1.2)
Prolactinaemia 10 (1.1)
Chicken pox 10 (1.1)
Allergic reaction 9 (0.9)
Gastroenteritis 8 (0.9)
Musculoskeletal pain 8 (0.9)
Arthritis 7 (0.8)
Anxiety 6 (0.6)
Asthma 6 (0.6)
Anemia 5 (0.5)
Dysentery 5 (0.5)
Hemorrhoids 4 (0.4)
Fibroid 4 (0.4)
Eye diseases 3 (0.3)
Amenorrhea 3 (0.3)
Sexually Transmitted disease 2 (0.2)
Menstrual disorder 2 (0.2)
Others 37 (3.9)
Average disease per patient(mean ?? SD) 1.89 ?? 0.86

A total of 2088 drugs were prescribed for the patients most of which were multivitamins (20.9%). Next to this were409 (19.59%) analgesic/antipyretic, followed by380(18.20%) antibiotics, then 333(15.59%) anti malaria, 107 (5.12%) antihelmintic,77(3.7%) benzodiazepine, 66(3.16%) cardiovascular drugs, 63(3.02%) cough syrup, 52 (2.49%) non steroid anti inflammatory drugs, 45 (2.16%) anti ulcer drugs, 35 (1.68%) antihistamin and many others .The average number of drug prescribed per patient was observed to be 5.46 ?? 1.61 (Table 3).

TABLE 3: DRUGS PRESCRIBED FOR PATIENTS
DRUGS PRESCRIBED N (%)
Multivitamins 437 (20.93)
Analgesic/Antipyretic 409 (19.59)
Antibiotics 380 (18.20)
Anti malaria drugs 333 (15.95)
Antihelmintic 107 (5.12)
Benzodiazepine 77 (3.69)
Cardiovascular drugs 66 (3.16)
Cough Syrup 63 (3.02)
Non Steroidal Anti Inflammatory Drugs 52 (2.49)
Anti ulcer drugs 45 (2.16)
Antihistamin 35 (1.68)
Anti diabetes drugs 18 (0.86)
Asthma drugs 13 (0.62)
Oxytocic drugs 9 (0.43)
Antifungi 8 (0.38)
Antiprolactinaemia 7 (0.34)
Anti diarrhea 3 (0.14)
Eye drops 3 (0.14)
Other drugs 23 (1.10)
Average drug per patient (mean ?? SD) 5.46 ?? 1.61

One hundred and six (5.1%) of all the drugs prescribed were in form of injectables. Of these, analgesics (38.1 %), notably paracetamol were the most encountered and closely followed by the antibiotics (13.5 %).Others were 13 (10.32%) antimalaria drugs, 11(8.7%) antihistamins, 9 (7.14%) B.complex, and 7 (5.56%) cardiovascular drugs (Table 4).

TABLE 4: DRUGS PRESCRIBED IN INJECTION FORM
DRUGS IN INJECTION FORM N (%)
Paracetamol + analgesic 48 (38.10%)
Antibiotics 17 (13.49)
Antimalaria drugs 13 (10.32)
Antihistamin 11 (8.73)
B.complex 9 (7.14)
Cardiovascular drugs 7 (5.56)
Non Steroidal Anti Inflammatory Drugs 6 (4.76)
Others 15 (11.90)

Five hundred and ninety four drug therapy problems were encountered in this study. Drug interactions (46.6) were the most observed of the lots. Unnecessary drug therapy problems (23.4 %) came very close to this; followed by need for additional drug therapy (19.7 %), wrong drug therapy (4.2 %) among others. However, the average number of drug therapy problems per prescription was observed to be 1.19 ?? 1.10 (Table 5).
TABLE 5: DRUG THERAPY PROBLEMS ENCOUNTERED IN DRUG PRESCRIBED IN PATIENTS CASE FILE.
DRUG THERAPY PROBLEMS(DTPs) N (%)
Drug Interaction 277 (46.63%)
Unnecessary Drug Therapy 139 (23.40%)
Need for Additional Drug Therapy 117 (19.70%)
Wrong Drug 25 (4.21%)
Dosage Too High 18 (3.03%)
Dosage Too Low 17 (2.86%)
Adverse Drug Therapy 1 (0.17%)
Inappropriate Adherence 0 (0%)
Average number of DTP per patients 1.19 ?? 1.10

DISCUSSION

This study revealed that malaria, typhoid fever and urinary tract infections were the commonly treated cases at the Amassoma general hospital studied. Multivitamins, analgesics, antimalarials as well as antibiotics were the most prescribed drugs at the center. Also noted is the fact that more females compared to males frequented the center for treatments within the period considered. This observation is similar to that observed by (Adebisi et al.,2003). This may be an indication that health seeking behavior is more of a female issue. The average age of all the patients which was observed to be 26.94 ?? 19.71 years is influenced by the location of the hospital which is in a university community with higher population of younger adults.
Among the disease state of patients study, it was discovered that Malaria and Typhoid fever were more predominant. This may be due to the poor hygiene of the people of Amassoma Community which predispose them to Typhoid fever(enteric fever) as a result of dirty water which surround the environment. Waterlogged nature of the environment could also serves as a breeding ground for mosquitoes which causes malaria. It can also be due to the fact that most of the indigenous population of the community has low immunity against malaria parasite due to lack of balanced diet and lack of vitamins. Urinary Tract Infection was also reported in an appreciable number of the subjects. It could also be due to poor hygiene of their toilet and bathroom, unprotected sexual intercourse. Most of the patients that visited the hospital within the period considered presented with at least a disease condition.
Multivitamins were the most commonly prescribed drug. The high rates of their prescribing could have been for the purpose of supplementation of their diets which comprise majorly plantain and fish (Suleiman et al., 2013). Analgesic/antipyretic (19.59%) was the second most commonly prescribed and among the analgesic/antipyretic, paracetamol was commonly prescribed. This might be the reason that paracetamol is not just analgesic but also help to augment some other drugs like diclofenac, antimalaria etc. The third most commonly prescribed drug was antibiotics (18.20%).This may be due to high incidences of typhoid fever, urinary tract infections as well as other forms of infections observed in the patients. Therefore, antibiotics were used for the treatment of these disease states. The percentage of encounters in which antibiotics were prescribed at Amassoma General Hospital was 18.2 % and is satisfactory compared to the standard (20.0%-26.8%) using WHO indicator. Drug use evaluations are necessary to evaluate whether the antibiotics were prescribed appropriately or not. A study conducted at Hawassa University Teaching and referral hospital in south Ethiopia reported 58.0 % antibiotics encounter which is very high compared to this finding. In the drug use pattern study in 12 developing countries, the percentage of encounters in which an antibiotic was prescribed was high in Sudan(63%), Uganda(56%), and Nigeria (48%) and relatively better in Zimbabwe(29%) (Desalegn, 2013).
The fourth most commonly prescribed drugs were antimalarials. This was due to the fact that malaria was the predominant disease state. The average number of drugs per prescription which was observed to be 5.46 ?? 1.61 at Amassoma General Hospital was very high and unacceptable compared with the standard (1.6-1.8) according to World Health Organization(WHO) indicators. This was in contrast to the study in Yenagoa (Chima et al., 2012) in which an average of 3.4 drugs was reported per prescription. In a similar study performed in South West Ethiopia at Jimma Hospita, the average number of drug per encounter was 1.59, which was also in the acceptable range (Desalegn, 2013). But in a study done on evaluation of prescription pattern in Osun state (Babalola et al., 2010)the average number of drugs prescribed per encounter was 6.11, which was higher than the values obtained in this finding and extremely higher than the values obtained in majority of previous studies from developing countries. A high average number of drugs might be due to financial incentives to prescribe more, lack of therapeutic training of prescribers (Desalegn, 2013). The low values might mean there is constraint in the availability of drugs, or prescribers have appropriate training in therapeutics (Desalegn, 2013). Also the higher value in this study is a pointer to the high level of poly pharmacy practice in prescription pattern which in turn may have serious negative effects on the therapeutic outcome in patients (Babalola et al., 2011). Among the likely negative effects this can pose are incidences of side effects, drug-drug interactions, confusion where aged patients are involved, non-compliance by patients to the drug regimen as a result of the large number of drugs to be taken at a time and for prolonged periods in most cases (Babalola et al., 2011).
Amassoma General Hospital has no essential drug list, which might also contribute to the reason why the average number of drugs per prescription was very high. The percentage of encounters in which an injection was prescribed at Amassoma General Hospital was 5.1%, which is lower than the standard (13.4%-24.1%).The study showed that injection were under prescribed in Amassoma General Hospital when compared with results from previous studies elsewhere such as in Osun state (Babalola et al.,)which was too high when compared with the result from Tanzania, Iran. The percentage of encounters with Drug Therapy problems was high. Among the drug therapy problems encountered, drug interaction were most common, especially in the case where anti-malaria containing artemesinin combination were prescribed simultaneous with vitamin C and multivitamin containing vitamin C and other antioxidants which normally lead to drug interaction. The reasons for these particular drug therapy problems might be due to the fact that so many prescribers are unaware that anti-malaria containing artemesinin combination interacts with vitamin C and multivitamin containing antioxidants. Unnecessary drug therapy was the second most commonly encountered drug related problems. The reasons might be that some prescribers, prescribed drugs without appropriate indication and diagnosis for their usage. Also, some prescribers may not actually know all the indication of some drugs. Thus, they might prescribe three or more drugs for a disease state which may be effectively managed with just one drug. Also, some physicians believe that using more than one drug for one disease state produce quick therapeutic response. Need for additional drug therapy was the third most common drug therapy problem. The reasons are similar to that of unnecessary drug therapy such as inappropriate diagnosis, prescription without appropriate indication for such. Lack of knowledge of the appropriate drug for some disease state, limited knowledge of prescribers about the therapeutic limitation of drugs has also been noted. Inappropriate adherence to drug therapy was not determined. There is therefore an urgent need to reduce drug therapy problems in health care centers in order to prevent drug therapy problems-related hazards such as therapeutic failure, increase side effect of drug, toxicity and death.
Limitation of this study included non-inclusion of non-adherence to drug therapy as part of the DTPs evaluated. This was partly because of the retrospective nature of the study coupled with the fact that the patients were not interviewed. Also statements on adherence to therapy were not documented in patient's case files.
CONCLUSION
More patients presented with malaria, typhoid fever and urinary tract infections at the center of study. Multivitamins, analgesics, antimalarials as well as antibiotics were the most prescribed drugs. Incidence of drugs therapy problems was high, with drug interactions, unnecessary drugs therapy and need for additional drug therapy been the most encountered drug related problems.

REFERENCES
Research advisor. Sample Size Table (2006). Available at http://www.research-advisors.com (Accessed July 22nd, 2011).

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