Challenges in using cardiovascular medications in Sub-Saharan Africa
Berhe, Derbew Fikadu
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Berhe, D. F. (2017). Challenges in using cardiovascular medications in Sub-Saharan Africa. University of Groningen.
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Healthcare Professionals’
Level of Medication
Knowledge in Africa:
A Systematic Review
Derbew Fikadu Berhe Katja Taxis
Flora M Haaijer-Ruskamp Peter GM Mol
Objective: Understanding how much healthcare professionals (HCPs) know
about medication can help to devise strategies to improve rational medica-tion use. This study aimed to synthesis informamedica-tion on the level of medicamedica-tion knowledge of HCPs in Africa.
Method: We performed a systematic literature study in Embase and PubMed.
We included original studies quantifying HCPs’ medication knowledge, pub-lished between 2012 and 2016. We extracted disease focus, country, number and type of HCPs included and all medication-related knowledge questions and scored the quality of papers. The outcome measure was the percentage HCPs who correctly answered medication knowledge questions. Data were analysed using descriptive statistics and analysis of variance (ANOVA) tests were used to analyse differences between subgroups
Results: We identified 64 studies from 12 African countries,
compris-ing 13,911 HCPs, mostly nurses/midwifes and physicians. We extracted 306 medication- related knowledge questions, and only 52% (SD 28) of HCPs correctly answered them. Knowledge questions were mainly about medication prescribed for communicable diseases (70%), followed by non-communicable diseases (11%), Family Planning/Gynecology (10%) and 9% questions with no specific disease focus. Percentage of HCPs who correctly answered questions were not statistically different across these knowledge domains nor across type of HCPs or countries. It varied signif-icantly across: sample size, question type (benefit-harm), and quality score of paper. Most papers concluded that there was a considerable medication knowledge gap among HCPs.
Conclusion: We found a low level of medication knowledge across different
disease areas, countries and HCPs. This underlines the continuous need to strengthen the undergraduate and postgraduate education in (clinical) phar-macology and therapeutics in Africa.
2
Background |
Background
Medication knowledge encompasses the understanding of (clinical) pharmacology and therapeutics and the skills to apply that knowl-edge in daily practice [1–3]. According to the European Association of Clinical Pharmacology and Therapeutics, the basic elements are “sufficient knowledge of commonly prescribed medications, the ability to adequately treat the most common diseases, a rational approach to medication selection, and the ability to write a prescription safely and unambiguously’’ [4]. In a conceptual framework model for knowledge, attitude and practice [5]; knowledge is a first step towards rational medi-cation use. However, there is no universally accepted level of medimedi-cation knowledge physicians and other health care professionals responsible for prescribing, dispensing and administering medication need to have. Simonsen et al in Norway used a 60% cut-off value for nurses’ med-ication knowledge [3, 6], and a higher threshold (80–90%) was used in a study that involved final year medical students from 15 European countries [4].
In Africa, there is a strong need for appropriate and efficient use of scarcely available medicines; over 50% of the population in the region does not have access to essential medicines (8, 9). Health Care Pro-fessionals (HCPs) are the principal source of information for patients. Other sources of information (patient information leaflet, drug infor-mation centers and internet) are much less accessible or affordable and many patients are illiterate [7, 8]. This situation emphasizes the great need for good medication knowledge of African HCP’s. Understanding the level of medication knowledge can help to identify gaps, and serve as the basis for focused knowledge improvement plans by policy makers and training institutes. Studies on medication knowledge in Africa are mostly limited in size and the scope of papers is usually on overall dis-ease management not just medication [9–12]. However, many studies seem to indicate that there is a lack of medication knowledge among HCPs. We aim to perform a systematic literature review to provide a comprehensive overview of the level of medication knowledge among HCPs in Africa and to identify specific gaps in medication knowledge.
We explored if knowledge differed across harm subgroups of specials interest; such as HCP specialism, country and disease group.
Method
Search strategy
Following the PRISMA guidelines [13], we performed a systematic lit-erature search in Embase and PubMed. Search terms were grouped into four queries, using the boolean operators, ‘or’ [within a query] / ’and’ [between the four main queries]; Africa with list of countries, type of HCPs, knowledge and medication terms (Supplement Table 1). Studies published in a five-year time span from January 01, 2012 to December 31, 2016 were included without language restrictions.
Eligibility criteria
We included original research articles that evaluated HCPs’ medication knowledge using a quantitative survey / score in Africa. Medication knowledge was defined as outlined in the introduction [1–3]. We ex-cluded reviews, opinion pieces, letter to editors, conference abstracts and commentaries. We also excluded papers on traditional medicine, and substance abuse.
Study selection and data extraction
Embase and PubMed search results were combined and duplicates re-moved. Titles were independently screened by DFB and PGM and all potentially relevant papers were selected for abstract review. These ab-stracts were screened by DFB and double-checked by PGM. Full text screening was performed by DFB and PGM. DFB abstracted data using a customized data extraction tool. PGM independently cross-checked
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Method |
the abstraction. Any differences in article screening, selection and data abstraction were resolved in consensus between PM, DFB and where needed KT. From each article, we extracted the following study char-acteristics: type of HCPs, sample size, country where the study was performed, the main disease focus, if the questions focused on benefits and/or harms of medications, and finally we assessed the quality of the in-cluded papers. Differences were resolved by consensus (DFB, PGM, KT). Information about profession was classified into physicians, pharma-cists, nurses/midwifes, and ‘other HCPs’. ‘Other HCPs’ included drug-gists/pharmacy technicians, nurse assistants/vocational nurses, or phys-iotherapists. For studies that also involved patients or non-HCPs such as community healthcare workers, we extracted medication knowledge only for the HCPs. Based on the medication knowledge questions papers were classified into four main disease categories; i.e. commu-nicable diseases (CDs), non-commucommu-nicable diseases (NCDs), family planning or gynecological indications (FP/Gyn), or ‘no specific disease focus’. Papers in the group ‘no specific disease focus’ included studies on knowledge of e.g. dose calculation, and prescribing errors. We ex-cluded, however, knowledge questions related to the healthcare system; such as whether the HCP knew how to report adverse drug reactions. Vaguely presented knowledge questions with terms like “heard of’’ or attitude questions like ‘how much do you agree that medicine X is safe’, were also excluded. We classified medication knowledge questions as testing knowledge about medication benefits, harms, both or on basic medication- knowledge issues. Examples are knowledge on indications of emergency contraceptives (medication benefit), knowing/aware of safe period for artemether-lumefantrine use during pregnancy (medication harm), knowledge on the correct dose of specific medication correctly (both medication benefit-harm), knowledge of different types of emer-gency contraceptive (basic medication knowledge); supplement file 2. We also extracted an excerpt of the conclusion and recommendations provided by the authors themselves.
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Assessment of the quality of the included studies
We developed and pretested a nine-item tool to score the quality of the studies (Supplement 3a). The tool contained items on representative-ness of the HCP population included in the studies (sampling method, sample size, response rate and demographics), the methods used to test the HCPs’ medication knowledge (clarity of the knowledge ques-tions, definition of appropriate answers and validation of knowledge questionnaires) and finally on the presentation of results (descriptive statistics and missing data). This score was based on a modified version of the STROBE checklist [14]. The sum score of all 9 items was set at 10. We grouped the quality into low (0 to 5), medium (> 5 to 8) and high (> 8) scores.
Outcome measure
Medication knowledge questions were extracted from each study. We computed the ‘knowledge score’ by dividing sum of HCPs with a cor-rect answer divided by all HCPs who completed the question. This was defined as
We followed the definitions for a correct answer as indicated in the pa-pers and/or cited references. We dichotomized all answers into correct or incorrect answers. If papers used a dichotomous answer (correct/in-correct, yes/no), this meant we could use the knowledge score as re-ported in the paper. In studies, where the number of respondents with a wrong answer were presented, we calculated the number of respondents with a correct answer. If answers to questions were presented on a three or more-point Likert scale (e.g. low, medium, or high knowledge score), we dichotomized these answers by grouping medium and high scores as correct answers. Finally, if respondents had to choose between mul-tiple answers and there could be more than one correct answer, each answer was counted separately. In intervention studies with several Chapter 2
modified version of the STROBE checklist [14]. The sum score of all 9 items was set at 10. We grouped the quality into low (0 to 5), medium (>5 to 8) and high (>8) scores.
Outcome measure
Medication knowledge questions were extracted from each study. We computed the ‘knowledge score’ by dividing sum of HCPs with a correct answer divided by all HCPs who completed the question. This was defined as
𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘𝑘 𝑠𝑠𝑠𝑠𝑘𝑘𝑠𝑠𝑘𝑘 (𝑝𝑝𝑘𝑘𝑠𝑠 𝑞𝑞𝑞𝑞𝑘𝑘𝑠𝑠𝑡𝑡𝑡𝑡𝑘𝑘𝑘𝑘) =∑ 𝐻𝐻𝐻𝐻𝐻𝐻𝑠𝑠 𝑘𝑘𝑡𝑡𝑡𝑡ℎ 𝑠𝑠𝑘𝑘𝑠𝑠𝑠𝑠𝑘𝑘𝑠𝑠𝑡𝑡 𝑎𝑎𝑘𝑘𝑠𝑠𝑘𝑘𝑘𝑘𝑠𝑠 𝑘𝑘𝑜𝑜 𝑡𝑡ℎ𝑘𝑘 𝑞𝑞𝑞𝑞𝑘𝑘𝑠𝑠𝑡𝑡𝑡𝑡𝑘𝑘𝑘𝑘 ∑ 𝐻𝐻𝐻𝐻𝐻𝐻𝑠𝑠 𝑘𝑘ℎ𝑘𝑘 𝑠𝑠𝑘𝑘𝑐𝑐𝑝𝑝𝑘𝑘𝑘𝑘𝑡𝑡𝑘𝑘𝑘𝑘 𝑡𝑡ℎ𝑘𝑘 𝑞𝑞𝑞𝑞𝑘𝑘𝑠𝑠𝑡𝑡𝑡𝑡𝑘𝑘𝑘𝑘 ∗ 100% We followed the definitions for a correct answer as indicated in the papers and / or cited references. We dichotomized all answers into correct or incorrect answers. If papers used a dichotomous answer (correct/incorrect, yes/no), this meant we could use the knowledge score as reported in the paper. In studies, where the number of respondents with a wrong answer were presented, we calculated the number of respondents with a correct answer. If answers to questions were presented on a three or more-point Likert scale (e.g. low, medium, or high knowledge score), we dichotomized these answers by grouping medium and high scores as correct answers. Finally, if respondents had to choose between multiple answers and there could be more than one correct answer, each answer was counted separately. In intervention studies with several measurement points, e.g. a pre-and post-training score, we extracted the pre- intervention score. In randomized controlled trials (RCT), we used the pre-intervention medication knowledge score of the control group. We assumed the pre-intervention or control group reflects daily practice.
Statistical analysis
We conducted a descriptive analysis of the knowledge questions across the extracted study characteristics. We used analysis of variance (ANOVA) to test if the knowledge score [per question]) was significantly different among subgroups (Table 1).
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Results |
measurement points, e.g. a pre-and post-training score, we extracted the pre- intervention score. In randomized controlled trials (RCT), we used the pre-intervention medication knowledge score of the control group. We assumed the pre-intervention or control group reflects daily practice.
Statistical analysis
We conducted a descriptive analysis of the knowledge questions across the extracted study characteristics. We used analysis of variance (ANOVA) to test if the knowledge score [per question]) was signifi-cantly different among subgroups (Table 1).
Results
Study characteristics
Out of 2,379 potentially relevant publications, 64 papers met our inclu-sion criteria (Figure 1). Overall 13,911 HCPs — ranging from 16 to 2,386 (median 176) HCPs per paper — answered a total of 306 medication- related knowledge questions. In total, 5,011 nurses/midwifes, 4,892 phy-sicians, 1,455 pharmacists and 1,721 other HCPs were included in respectively 37 (58%), 38 (59%), 20 (31%) and 26 (41%) papers. Three papers mentioned the type of HCPs, but did not provide group specific numbers and two papers did not specify the type of HCPs involved in the study. The studies have been performed in 12 African countries, but 75% originated from four countries: Nigeria (n = 29 papers), Tanzania (n = 9), Kenya (n = 6) and Cameroon (n = 4), Tables 1 and 2.
Most knowledge questions (n = 215; 70%, 45 papers) were on com-municable diseases, followed by 33 (11%, eight papers) questions on non-communicable diseases, 31 (10%, five papers) questions on family planning and gynecology, and 27 (10%, 6 papers) questions with no spe-cific disease focus. The majority (n = 116; 38%) of knowledge questions were on medication benefit, the remainder of the questions were equally
on medication harm (20%), both benefit and harm (24%), or related to basic medication knowledge (19%), Table 1.
Study quality
All but three of the studies were descriptive cross-sectional surveys. Two studies assessed the impact of training or a workshop and had pre- and post-intervention knowledge scores [15, 16] and one study was a rand-omized controlled trial [17].
The mean quality score of the papers was 7.5 (SD 1.8, range 3 to 10). The included papers scored poorly with regards to sample size
calcu-lation (item 1), sampling methods (item 2) and tool validation (item 7 of our quality score tool). In all papers information was collected via interviews or self-administered questionnaires. Two papers [18, 19]
22 | P a g e
Figure 1: Review process
Most knowledge questions (n = 215; 70%, 45 papers) were on communicable diseases, followed by 33 (11%, eight papers) questions on non-communicable diseases, 31 (10%, five papers) questions on family planning and gynecology, and 27 (10%, 6 papers) questions with no specific disease focus. The majority (n = 116; 38%) of knowledge questions were on medication benefit, the remainder of the questions were equally on medication harm (20%), both benefit and harm (24%), or related to basic medication knowledge (19%), Table 1.
Study quality
All but three of the studies were descriptive cross-sectional surveys. Two studies assessed the impact of training or a workshop and had pre- and post-intervention knowledge scores [15, 16] and one study was a randomized controlled trial [17].
Excluded
• Conference abstracts & posters, reviews, letters and editorials, notes and other topics. Embase (825) and PubMed (167) • Duplicates (366)
Abstracts screened (447)
Full texts screened (185)
Included articles (64)
Knowledge questions extracted (306) Titles screened (2,379) Embase (2,370) PubMed (1,367)
Excluded (262) Excluded (1,932)
Excluded (121)
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Results |
Table 1 Knowledge score per question and sub group
Paper
n (%) Question n (%) *Knowledge score Mean (SD) (ANOVA) P-value
Overall 64 (100) 306 (100) 52 (28) Type of HCPs ¥ # 0.59 Physicians (n = 4,892) 38 (59) 175 (57) / 107 (35) 56 (31) Nurses/Midwife (n = 5,011) 37 (58) 169 (55) / 89 (29) 55 (32) Pharmacists (n = 1,455) 20 (31) 87 (28) / 55 (18) 49 (31) Other HCPs (n = 1,721) 26 (41) 97 (32) / 39 (13) 53 (32)
Sample size (n = 13,911 HCPs) three groups 0.01
≤ 120 26 (41) 127 (42) 58 (29) 121–253 19 (30) 82 (27) 43 (27) ≥ 254 19 (30) 97 (32) 51 (27) Country of study 0.07 Nigeria 29 (45) 128 (42) 49 (28) Tanzania 9 (14) 30 (10) 55 (32) Kenya 6 (9) 35 (11) 42 (26) Cameroon 4 (6) 19 (6) 58 (21) Ethiopia 3 (5) 26 (9) 56 (27) S. Africa 3 (5) 17 (6) 68 (23) Uganda 3 (5) 3 (1) 39 (20) Egypt 2 (3) 14 (5) 49 (32) Sudan 1 (2) 13 (4) 63 (27) DR Congo 1 (2) 10 (3) 56 (32) Malawi 2 (3) 8 (3) 43 (41) Zimbabwe 1 (2) 3 (1) 37 (07) Medication for 0.24 Communicable disease 45 (70) 215 (70) 54 (27) Non-communicable diseases 8 (13) 33 (11) 47 (29) Family Planning/Gynecology 5 (8) 31 (10) 44 (28) No specific disease focus 6 (9) 27 (9) 50 (30)
Question type < 0.01
Benefit 116 (38) 49 (28)
Harm 60 (20) 41 (27)
Both (benefit-harm) 73 (24) 59 (27)
Basic medication issues 57 (19) 59 (27)
Quality score 0.03
Low (0 to 5) 8 (13) 27 (9) 60 (28)
Medium (> 5 to 8) 30 (48 145(47) 47 (28)
High (> 8 to 10) 26 (41) 134 (44) 54 (28)
*Knowledge score is calculated based on average knowledge score per question. ¥The first number
(percentage) represents all questions answered by a professional group and the second number (per-centage) the questions for which knowledge scores were reported separately per type of professional. # The knowledge score is presented for only those questions for which these were reported sepa-rately per type of professional
Other HCPs: druggists/pharmacy technicians, nurse assistants/vocational nurses, or physiotherapists. Others (for disease): did not have a specific disease focus including dose calculation, and pre-scribing errors.
used mystery client surveys, in addition to interviews. In most papers (n = 53), questionnaires were newly developed by the authors, of which four followed a ‘formal’ validation procedure, 28 conducted only a pretest, and 21 papers did not explain if or how the questionnaire was validated. The remaining 11 papers adapted a tool previously used by others; five used an adapted tool and six made some modifications (Ta-ble 2). Most papers defined how medication knowledge score was meas-ured (item 5, n = 60), Supplement 3b.
Medication knowledge questions and scores
Overall, 306 medication-related knowledge questions were identified; a mean of five (SD 4) questions per paper. Fifty-two percent (SD 28) of HCPs answered the 306 questions correctly. There was no statistically significant difference in knowledge scores for those questions that could be split out per type of HCP (p = 0.59). Physicians answered a mean of 56% (SD 31) out of 107 questions correctly, nurses/midwifes 55% (SD 32) out of 89 questions, pharmacists 49% (SD 31) out of 55 ques-tions, and other HCPs 52% (SD 35) out of 39 questions (Table 1).
The knowledge score did not vary significantly across countries, but numerically the highest proportion of correct answers (68%, SD 23) was reported in South African studies and the lowest in Zimbabwean stud-ies with (37%, SD 7) correct answers, p = 0.07 [Table 2]. The knowledge scores also did not differ across the main disease areas, p = 0.15, more detailed results are presented below and in table 2.
The highest knowledge scores were observed for questions on basic medication knowledge (59%, SD 27) and questions on both benefit- harm issues (59%, SD 27), which were higher than questions on benefits (49%, SD 28) and harm (41%, SD 27) only; p < 0.01.
Finally, papers that had the lowest quality scores reported higher medication knowledge by HCPs than the studies with medium or high quality; p = 0.03.
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Results |
Disease focus
Communicable diseases (215 questions, 45 papers)
The majority of papers and medication-related knowledge questions were for medicines used for malaria, HIV/AIDS, tuberculosis and for vaccines. Forty-eight questions in 11 papers queried HCPs about their medica-tion knowledge to treat or prevent malaria [17, 20–29]. These quesmedica-tions identified knowledge gaps across all aspects of antimalarial medication use; i.e. dosing, drug-drug (food) interactions, contraindications, appro-priate use in specific patient groups (pediatrics, pregnancy, and adults). The main finding, as reported by authors, was the lack of knowledge on rational and effective use of artemisinin-based combination therapy and implementation of recommended intermittent preventive treatment in pregnancy or medications for specific age groups.
Forty-seven questions in nine papers were on antiretroviral medica-tions for HIV/AIDS [30–38]. In these papers, it is reported that HCPs lacked knowledge on use of microbicides to prevent HIV and other sex-ually transmitted diseases, that they were unable to identify medications used for post-exposure prophylaxis (PEP) and did not know the time point to initiate PEP, duration of treatment and effectiveness of PEP. The main finding in these papers was that PEP was underused, and it was spec-ulated that this was partly due to the low level of PEP-related knowledge.
Forty-eight questions were about different types of vaccines; 23 on hep-atitis B [39–43], eight on human papilloma [44–46], three on influenza [47, 48] viruses, and 14 questions on adverse events following immuni-zation [49]. Questions were about overall awareness of different types of vaccines, and the effectiveness, what comprised a dose/full course, how long the vaccines offered protection, and about the safety of vac-cination, adverse reactions after immunization, and medication used to prevent/relief vaccination-related immune reaction. The papers on hep-atitis B reported overall good knowledge of the vaccine (56–97%), but despite this good knowledge, HCPs perceived benefit and actual use of the vaccine was low. All but one paper reported poor knowledge of vac-cines for human papilloma and influenza viruses, and also about adverse reactions following immunization.
Fourteen questions from four papers were on knowledge of medica-tion used to treat tuberculosis [50–53] focusing on child tuberculosis treatment, knowledge of the complex treatment regimens (number of medications, duration of therapy and safety concerns), and about the consequences of poor treatment adherence. Two of these papers re-ported poor knowledge on tuberculosis treatment regimens and conse-quences of medication non-compliance.
The remaining 58 questions in papers focusing on medications for communicable diseases were e.g. about medications for human African trypanosomiasis, diarrheal agents, sepsis management, general anti-microbial indications, safety, or resistance [54–63]. Topics in these papers were timing of administration and safety issues of perioperative antibiotic prophylaxis, prevention of antimicrobial resistance and contributing fac-tors, inappropriate antibiotic prescribing, and diarrhea management in children. The main findings from these papers were that HCPs had a fair knowledge of what constitutes rational antimicrobial use, but poor knowl-edge of antimicrobial resistance and especially on products for diarrhea.
Non-communicable diseases (38 questions ; 8 papers)
Non-communicable diseases medication questions were on cancer treatment and cancer-related pain management and palliative care in two papers (n = 12), medications for asthma/COPD (n = 12) in three papers, four on management of thyroid cancer and use of radioactive io-dine in one paper, and finally three papers on antipsychotics [15, 64–70]. The main knowledge questions were more general; as the papers focused
mostly on general disease management, and type of medication to be used. The main findings were knowledge gaps on palliative care, use of radioactive iodine for thyroid cancer, long active Long-acting antipsy-chotic injections, asthma/COPD, and cancer pain management.
Family planning and gynecology (31 questions; 5 papers)
Thirty-one questions in five papers were about contraceptives or med-ication used in gynecological procedures [19, 71–74]. The knowledge
2
Discussion |
questions were about appropriate use of medication for (pre-)eclampsia, neonatal resuscitation, emergency contraceptives (type, dose, indication, side effects, and time window for use), and abortifacient medication use and complications. The studies reported limited knowledge on medical abortion, pharmacotherapeutics of oral and emergency contraceptives. Many papers indicated also important attitudinal issues affecting the proper use of especially emergency contraceptives and abortifacients.
Without specific disease focus (27 questions; 6 papers)
Seven papers (14%) with 27 medication-related knowledge questions did not have a specific disease focus (grouped under “other’’ in Table 2 [16, 18, 75–78]. Questions were more general including self-medication, topical medications (anti-pain and antibiotics), dose calculation and prescribing errors. Authors reported this type of general knowledge to be poor as with other disease groups. In particular low level of knowl-edge on self-medication practices, prescribing errors, and pharmaco-therapy of dermatological products.
Discussion
We provide a comprehensive overview of medication knowledge based on a review of 64 papers including 13,911 HCPs from 12 African coun-tries. Overall, 52% (SD 28) of HCPs answered a total of 306 knowl-edge questions correctly. Physicians, nurses and midwives were most often included, but pharmacists were also well represented. Most (70%) studies were about communicable disease medications including an-timalarial, antiretroviral medications for HIV, and different types of vaccines. The large majority of included studies were of medium to high quality but especially validation of the questionnaire was either poorly performed or described. Although, we found some variation in the level of knowledge these were only significant across studies with smaller sample sizes, with a lower study quality or for questions focus-ing on benefit/harm and basic medication issues that reported higher
Ta ble 2 S umm ar y o f s tud y c ha rac ter ist ics a nd k no w le dg e s co re Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no w le dge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns C omm uni ca bl e dis eas es / m ala ria Br uxv oo rt et al 2014 [17] T anza ni a NS 37 10 b 66 (27) Di sp en ser k no w le dg e o f co rr ec t ad vice o n a rt emi sinin l um efa n-tr in e. Di sp en ser k no w le dg e co uld b e in cr ea se d s om ew ha t b y u sin g text m es sa ges, b ut p at ien t ad her en ce wa s n ot a ffe ct ed in t hi s clu ster ra ndo mize d t ria l. ` Ka m uh ab wa et al 2013 [20] T anza ni a Pm, N, O 32 7 e 42 (21) ACT [a bs or pt io n, s af et y/p reg -na nc y, dos e/p at ien t w eig ht f or di sp en sin g a nd p res cr ib in g] Lac k o f s ufficien t k no w le dg e o n dos ag e, dr ug-dr ug (f oo d) in terac tio ns, a nd co nt ra in dic at io ns f or A CT , a nd t he n ee d f or on-t he-j ob t ra inin g a nd co nt in uin g e duc at io n. M an gh am et al 2012 [21] C am er oo n NS 447 7.5 b 61 – M al ar ia p re va len ce a nd t re at -m en t o f f eb rile p at ien ts w ith m al ar ia [A CT f or un co m plic at ed m al ar ia] Fe br ile p at ien ts m ay n ot n eces sa ril y h av e m al ar ia. R at io na l us e o f A CT s ho uld b e p ro m ot ed w ith a pp ro pr ia te t es tin g, a lso up da te d guide lin e f or n ega tiv e t es t r es ul ts. Mb ac hu et al 2013 [22] N ig er ia N/M 213 8 e 31 – M oni to rin g a nd e va lu at io n o f m al ar ia co nt ro l in ter ven tio ns [A CT g ro up in g] Kn ow le dg e ga ps o n un der sta ndin g o f d at a m an ag em en t, p er -cep tio n o f efficien t d at a t ra nsmi ssio n a nd p rac tice o f m al ar ia m oni to rin g a nd e va lu at io n. Mb on ye et al 2013 [23] U ga nd a N/M, O 65 9.5 b 43 – Tr ea tm en t o f f ev er [1 st lin e dr ug ACT] Lac k o f k no w le dg e o n C oa rt em (A CT) r es ul te d in a lo w pr op or tio n o f m al ar ia p at ien ts r ecei vin g a pp ro pr ia te A CT . I n-ter ven tio ns s ho uld addr es s t he in ade qu at e t ra inin g o n m al ar ia m an ag em en t. W atsiera h et a l 2012 [24] K en ya PM, O 288 8.5 b 69 (19) M al ar ia t re at m en t p olic y a nd dosin g r eg im en w ith A CT , quinin e a nd o th er dr ugs [dr ug ch oice , a ge b as ed dosin g, o th er iss ues] Bet ter k no w le dg e o n t re at m en t p olic y a nd dosin g r eg im en b y pu blic-s ec to r p ro vider s in p riva te .
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Discussion | Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no w le dge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns Ra biu et al 2015 [25] N ig er ia P 394 9.5 b 17 (8) M al ar ia t re at m en t in p reg na nc y Pr iva te m edic al p rac tit io ner s h av e p oo r k no w le dg e o f m al ar ia pr op hy laxi s a nd t re at m en t in p reg na nc y, a nd t he p rac tice o f m os t i s n ot co nf or m guide lin e r eco mm en da tio ns. M an nan et al 2015 [26] S ud an P, PM 119 9 e 63 (27) Kn ow le dg e o f H CP s o n A CT ACT k no w le dg e i s v er y p oo r. Thi s i s n ee d f or im pr ov in g kn ow le dg e v ia p ro vider -o rien te d t ra inin g p rog ra mm es. On wu je kw e e t al 2012 [27] N ig er ia P, PM, N 52 8.5 b 83 (11) M an ag em en t / c hem op re ven tio n fo r m al ar ia-in-p reg na nc y [IPT p gen era l, t imin g, u sef uln es s, a nd defini tio n] O vera ll, k no w le dg e o n m an ag em en t o f m al ar ia-in-p reg na nc y is s ub-o pt im al . H ow ev er , m edic at io n s pe cific k no w le dg e i s in accep ta ble ra ng e. Th e i s n ee d f or in ter ven tio ns. Ru sk et al 2012 [28] Ken ya P, N/M, O 117 7 c 65 – A nt i-m al ar ia l m edic at io n M aj or ity co uld iden tif y t he fir st-lin e t re at m en t f or un co m pli -ca te d m al ar ia b ut t hi s s til l n ee ds im pr ov em en t. M in ya liwa et a l 2012 [29] M al aw i P, N, O 16 6 e 30 (34) N ew m al ar ia t re at m en t guide -lin es Di sp en ser s h av e in ade qu at e k no w le dg e o f t he n ew m al ar ia tre at m en t guide lin es. I nv ol vin g di sp en ser s in a ll s ta ges o f guide lin e p rep ara tio n, t ra inin g, a nd co nt in uin g p ro fes sio na l ed uc at io n a re n ee de d. C omm uni ca bl e dis eas es / HIV Et ok idem et al 2014 [30] K en ya P, PM, N, O 350 9 e 29 – M icr ob icides [p re ven tin g s pr ead of S TI s/ HIV ] Th er e i s a g en era l k no w le dg e ga p o n t he u se o f micr ob icides, an d t her e i s a n ee d f or c ap aci ty b ui ldin g. M at he w os et al 2013 [31] E thio pi a P, PM, N/M, O 195 8.5 b 62 (11) Pos t exp os ur e p ro ph yl axi s/HIV [ini tia te , d ura tio n o f t hera py , a nd eff ec tiv en es s] In ade qu at e k no w le dg e a nd p rac tice o f HIV P EP . Re co mm en de d in ter ven tio ns: t ra inin g a nd s et u p a 24-h our acces sib le f or m al P EP cen ter w ith guide lin e.Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no w le dge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns M po nel a e t al 2015 [32] T anza ni a P, N, O 291 7 e 41– Pos t exp os ur e p ro ph yl axi s/HIV PEP s pe cific k no w le dg e i s lo w. A lso , lo w P EP u sa ge , lo w le ve l of k no w le dg e o n o cc up at io na l exp os ur e a nd r ep or tin g ra te . Th er e i s a n ee d f or r ep or tin g exp os ur e o n t im e s o t ha t t he pr ov ider c an r ecei ve P EP . O wo lab i e t al 2012 [33] N ig er ia P, N, O 230 8.5 b 58 (20) Pos t-exp os ur e p ro ph yl axi s/HIV [m edic at io ns u se d, d ura tio n o f th era py , a nd in dic at io n] PEP k no w le dg e a nd p rac tice w er e v er y p oo r. Th e a ut ho rs rep or t a n ee d t o s ca le u p P EP s er vices. Ru ud et al 2014 [34] S. A fr ic a N, O 102 6.5 b 79 (11) HIV a nd t re at m en t [a wa re -nes s a nd s pe cific m edic at io n kn ow le dg e] Kn ow ledg e o f HIV m edic at io ns i s fa irl y hig h. H ow ev er , H CP s lac k t he a bi lit y t o m an ag e AD Rs a nd h av e li ttle k no wle dg e o f ba rr ier s t o p at ien t ad her en ce . Th er e i s a n ee d f or t ra inin g o n m an ag em en t o f a nt iret ro vira l t hera py . Aji bo la et a l 2014 [35] N ig er ia P, N 300 7.5 b 46 (30) HIV P EP [t im e t o t ak e, d ura tio n of u se a nd m edic at io n] D es pi te r ea so na ble k no w le dg e s co re , P EP u sa ge wa s lo w. Th er e i s a n ee d f or P EP m an ag em en t p rog ra m s t o in cr ea se r e-po rt in g p ro fes sio na l/acciden ta l exp os ur e, im pr ov e co un se lin g, fo llo w u p a nd acces s t o P EP . Ogb onn a e t a l 2016 [36] S. A fri ca P, N 102 4.5 b 46 (32) Pr ev en tio n o f m ot her -to-c hi ld HIV t ra nsmi ssio n (PMT CT) Ph ysici an a nd n ur ses k no w le dg e o f HIV co un se lin g wa s b et ter th an t heir m edic at io n k no w le dg e (e .g . o n dos ag es a nd co m -bin at io n o f dr ugs t o b e u se d f or PMT CT). O ver t w o-t hir ds rep or te d f ol lo w in g PMT CT guide lin e r eco mm en da tio ns, bu t a s t heir k no w le dg e wa s limi te d t heir p rac tice m ay b e su bs tan dar d. Mu sa et al 2012 [37] N ig er ia P 74 9.5 b 13 (17) HIV p re ven tio n s tra teg y /va gin al M icr ob icides G yn eco log ist k no w le dg e o n va gin al micr ob icides i s p oo r. Th er e i s a n ee d t o cr ea te a wa ren es s o n r ecen t HIV p re ven tio n te chn olog ies, in cludin g t he r ole o f va gin al micr ob icides.
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Discussion | Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no w le dge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns A min de et al 2015 [38] C am er oo n N 85 10 d 50 (19) HIV P EP K no w le dg e a nd P rac -tices o f N ur ses Th e k no w le dg e a nd p rac tice o f n ur ses o n P EP f or HIV i s lo w. Th er e i s a n ee d f or t ra inin g a nd w or ks ho ps t o in cr ea se a wa re -nes s, im pr ov e p rac tice , a nd r ed uce t he r isk o f HIV acq ui sit io n fro m w or k r el at ed ac tiv ities a m on g H CP s. C omm uni ca bl e dis eas es / vac cine s Ab io la et al 201 3 [39] N ig er ia P, N, O 84 8.5 b 62 (19) H ep at iti s B vaccin e [eff ec tiv e-nes s, dos e, p ro te ct io n p er io d] H CP s h ad g oo d k no w le dg e o f v ira l h ep at iti s B , b ut p oo r prac tice o n vaccin at io n. P ro vide f ur th er e duc at io n t o t ra ns la te kn ow le dg e in to g oo d p rac tice . Ab io la et a l 2016 [40] N ig er ia P, N 134 9 d 56 (20) H ep at iti s b vaccin e [dos e a nd u se] H CP s h ad fa ir k no w le dg e o f v ira l h ep at iti s B , b ut p oo r p rac -tice o n p os t vaccin at io n t es tin g. Th e n ee d f or f ur th er t ra inin g, co m pu lso ry o cc up at io na l vaccin at io n a nd p os t vaccin at io n tes tin g. Ab ej e e t al 2015 [41] Et hio pi a P, PM, N/M, O 374 7 e 67 (18) H ep at iti s B vaccin e [f ul l co ur se , us ef uln es s, s af et y, eff ec tiv en es s] Lo w le ve l o n t he inf ec tio n a nd m ode o f t ra nsmi ssio n b ut m od -era te k no w le dg e s co re a bo ut t he vaccin e. Th e n ee d o f t ra inin g on p re ven tio n a nd co nt ro l, a nd vaccin e. Ade ka nle et al 2015 [42] N ig er ia P, PM, N, O 382 9.5 b 97 – H ep at iti s B vaccin e [a wa re o f t he vaccin e] D es pi te hig h a wa ren es s o f t he vaccin e, p er cei ve d r isk o f t he inf ec tio n a nd vaccin at io n co vera ge i s lo w. C om pu lso ry s cr een -in g a nd vaccin at io n m ay b e n ee de d. No ub ia p et a l 2014 [43] C am er oo n P 49 8.5 b 80 (16) H ep at iti s B vaccin e [dos e, im -m un e r es po ns e] F air ly g oo d k no w le dg e o n t he vaccin e b ut lo w u pt ak e. Th e ne ed t o o ffer a nd ur ge r esiden ts t o t ak e t he vaccin e b ef or e beg innin g o f r esiden cy t ra inin g. Aud u et al 2014 [44] N ig er ia P, PM, N, O 602 8.5 b 44 – H um an p ap illo m a v iru s vaccin e [a wa ren es s] “lo w k no w le dg e o f a vaccin e t ha t c an p re ven t t he co mm on es t ca ncer in w om en in s ub-Sa ha ra n A fr ic a.” Th e a ut ho rs r eco m -m en d t ar get ed in ter ven tio ns: v ia t he ‘ m an o n t he s tre et ’ a nd tradi tio na l a nd r elig io us le ader s. H oq ue , 2016 [45] S. Af ric a P 320 10 c 34 (12) H um an P ap illo m av iru s vaccin e [eff ec tiv en es s a nd t yp e] D oc to rs l ac ke d k no w le dg e o f H um an P ap illo m av iru s inf ec tio n an d vaccin e. Th er e i s a n ee d f or h ea lth e duc at io n a nd o n sa fet y, effic ac y a nd t he b es t t imin g f or H um an p ap illo m a v iru s vaccin at io n.Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no wl edge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns W am ai et al 2013 [46] Ca m er oo n N 76 8 e 85 (8) H um an P ap illo m av iru s vaccin e [u se] Th er e i s hig h a wa ren es s o f t he vaccin e b ut m or e e duc at io n i s re quir ed t o f ur th er in cr ea se n ur ses ’ w illin gn es s t o r eco mm en d th e vaccin at io n. Ka m uh ab wa et al 2012 [47] T anza ni a P, PM, O 253 7 e 19 (22) Infl uenza vaccin e/p re ven tio n an d t re at m en t [a nt iv ira l m edic a-tio n a nd side eff ec ts] La rg e k no w le dg e ga p o n a nt iv ira l m edic at io ns a nd ad ver se eff ec ts. N ee d f or co nt in ue d (p os t-g rad ua te) e duc at io n a nd pr of es sio na l de ve lo pm en t. Fa tir egun et a l 2012 [48] N ig er ia P,N 255 8 e 39 – Infl uenza A (H1N1) vaccin e Po or k no w le dg e o f t he vaccin e b ut w illin gn es s t o r ecei ve t he vaccin e wa s v er y hig h. On e o f r ef us al r ea so n wa s f ea r o ver side eff ec ts. I nt er ven tio n n ee de d t o in cr ea se u pt ak e. M asi ka et a l 2016 [49] Ken ya N 274 5.5 b 33 (14) Ad ver se e ven ts f ol lo w in g imm u-niza tio n (AEFI) Th e m aj or ity o f t he r es po nden ts h ad p oo r k no w le dg e a nd prac tice le ve ls o n AEFI s ur vei lla nce; es pe ci al ly o n h ow t o in -ves tiga te , r ep or t a nd m an ag e p os t-imm uniza tio n a na ph yl axi s. Tra inin g o n AEFI s ur vei lla nce f or n ur ses. C omm uni ca bl e dis eas es / Tu be rc ul osi s Ad am s e t al 2014 [50] Ta nza ni a P, N O , 117 4.5 b 90 (2) Chi ld ho od t ub er cu losi s [t re at -m en t a nd m oni to rin g] O vera ll k no w le dg e wa s hig h a nd g oo d im plem en ta tio n o f na tio na l guide lin es. S til l t her e i s n ee d t o addr es s ga ps in di ag -nosi s, t re at m en t a nd u se o f i so ni azid p re ven tiv e t hera py . Ch uk wu et a l 2016 [51] N ig er ia P 106 9 a 27– Chi ld ho od TB [r eg im en f or ca teg or y 1 TB] G oo d o vera ll di se as e k no w le dg e b ut p oo r k no w le dg e o f ca teg or y I TB m edic at io ns. D es pi te g oo d k no w le dg e, p rac tice wa s les s a pp ro pr ia te . N ee d f or f oc us ed t ra inin g o n c hi ld ho od TB c ar e. U kwa ja et a l 2013 [52] N ig er ia P, N, O 30 5 b 77 (19) Tu ber cu losi s [r eg im en/d ura tio n an d side eff ec t] Ga ps in di se as e a nd m edic at io n k no w le dg e, b ut es pe ci al ly a ne ed t o r e-e duc at e H CP s o n inf ec tio n co nt ro l.
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Discussion | Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no wl edge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns Ru tta et a l 2014 [53] Ta nza ni a PM, O 295 6.5 b 37 (23) Tu ber cu losi s c ar e [co ns eq uen ces of p oo r ad her en ce] Po or k no w le dg e o n co ns eq uen ces o f in ade qu at e m edic at io n ad her en ce b y r et ai l dr ug o ut let s ta ff. I nt er ven tio n im plem en t-ed t o im pr ov e iden tific at io n o f TB p at ien ts a nd r ef er ra l t o pr op er h ea lth faci lit ies. C omm uni ca bl e dis eas es / othe r Ab era et al 2014 [54] et a l 2016 E thio pi a P, N 385 9.5 b 47 (30) A nt imicr ob ia l r esi sta nce [co nt rib ut in g fac to rs f or r esi st-an ce a nd exa m ples] Po or k no w le dg e o n diff er en t a sp ec ts o f a nt imicr ob ia l r esi st-an ce . I nt er ven tio ns s ho uld f oc us o n [r ed ucin g] s elf-m edi -ca tio n, ra ise a wa ren es s o n r esi sta nce a nd im pr ov e acces s t o an tib iog ra m s Aji bade et al 2014 [55] N ig er ia N 67 3 e 61 (25) Per io pera tiv e a nt ib io tic p ro ph -yl axi s [admini stra tio n a nd s af et y] N ur se-a naes th esi st h ad fa ir k no w le dg e o f ra tio na l s ur gic al an tib io tic p ro ph yl axi s. F ur th er a tten tio n t o p er i-p ro ce dura l pr op hy laxi s n ee de d, es pe ci al ly w ith r ega rd s t o t imin g o f an tib io tic dosin g. Ch uk wu O .A l 2016 [56] N ig er ia P, PM, N 221 6 e 50 (31) Pr ob io tics [a wa ren es s, b en efi t, an d micr ob e s ta tu s] H CP s a re n ot a wa re o f ad va nt ag es o f u sin g p ro bio tics f or m an ag in g e .g . di ar rh ea. K no w le dg e o f H CP s m ay b e im pr ov ed thr oug h s emin ar s, w or ks ho ps a nd u sin g p ha rm aci sts a s m es -sen ger s a s t he y s eem ed m or e inf or m ed . Fa thi et a l 2016 [57] Eg yp t P 319 7 d 69 (31) A nt imicr ob ia l t hera py a nd r esi st-an ce [dos e, s pe cific a gen t] O vera ll fa irl y g oo d k no wle dg e b ut limi ted a wa ren es s o f s pe cific iss ues: e .g. n ee d f or dos e ad ju stm en ts in p atien ts w ith r en al im pa irm en t o r a bo ut lo ca l r esi sta nce p att er ns, o r n ee d t o co un cil pa tien ts o n p ro per u se . A nt imicr ob ial s tewa rd shi p p rog ra m s a re re co mm en de d f or E gyp tia n h os pi ta ls. Mb on ye et al 2016 [58] U ga nd a P, O 170 7.5 b 18 – A nt ib io tics [A m oxici llin/ c hi l-dr en p neum oni a] M or e t ha n 80% o f H CP s did n ot k no w a m oxici llin a s fir st lin e th era py f or p neum oni a. Th e n ee d t o r egu la te dr ug s ho ps. M wa na ka sa le et al 2013 [59] Z im ba bw e P, N/M, O 28 3 e 37 (7) Th e c ha llen ges to co nt ro l H um an A fr ic an T ryp an os omi asi s In addi tio n t o p oo r m edic at io n k no w le dg e o f H CP s, es pe ci al ly sh or ta ges o f t ra in ed h ea lth w or ker s, in ade qu at e di ag nos tic (la bo ra to ry) a nd t re at m en t faci lit ies, a nd s ho rt ag e o f t ryp an o-so micides n ee d t o b e addr es se d t o im pr ov e c ar e.Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no w le dge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns Ogb o et al 2014 [60] N ig er ia P 186 7.5 b 22 (14) M an ag em en t o f ac ut e di ar rh ea in c hi ldr en [p ro duc t r eco m -m en de d] Po or k no w le dg e o n p ro duc ts t o m an ag e di ar rh ea, w ith o nl y 15% o f co mm uni ty p ha rm aci sts f ol lo w in g WH O guide lin es. Au th or s in dic at e a n ee d f or a c am pa ig n o n t he m an ag em en t o f ac ut e wa ter y di ar rh ea. Om uem u et al 2012 [61] N ig er ia P, N/M 59 9.5 b 38 (32) Zin c s up plem en ta tio n in t he m an ag em en t o f c hi ld ho od di ar rhe a [typ es o f di ar rh ea t re at ed w ith zin c s up pl y a nd b en efi t] H CP s l ac k ade qu at e k no w le dg e o n h ow t o s up plem en t zin c. So ci al m ar ket in g c am pa ig ns a re p ro pos ed t o p ro m ot e zin c su pp lem en ta tio n in c hi ldr en w ith di ar rh ea. Pe lto la et al [62] M ala wi O 115 7 e 63 (52) Sepsi s m an ag em en t Kn ow le dg e o n p rac tic al m an ag em en t wa s r el at iv ely g oo d, b ut ‘Sur vi vin g S epsi s C am pa ig n’ t hera peu tic s tra teg ies w er e p oo rly kn ow n. S epsi s guide lin es n ee d t o b e ad ap te d t o h ea lth ca re str uc tur es in un der de ve lo pe d co un tr ies. Thr iem er et al 2013 [63] D R C on go P 184 8 d 56 (32) A nt ib io tic p res cr ib in g [sim ul at ed ca ses b as ed o n s af et y o f m edi -ca tio n f or p reg na nc y, r esi sta nce iss ue , a nd admini stra tio n r ou te] Lo w t o m edio cr e k no w le dg e o f H CP s, es pe ci al ly o f lo ca l resi sta nce p at ter ns a nd l ac k o f in dep en den t dr ug inf or m at io n. Th e a ut ho rs in dic at ed a n ee d f or lo ca l a nt ib io tic guide lin es an d co ur ses o n ra tio na l u se . N on-c omm uni ca bl e dis eas es Ad eye ye et al 2015 [15] N ig er ia N 78 3 e 68 (16) kn ow le dg e, s ki lls a nd co m pet en -cy o f n ur ses in t he t re at m en t o f as th ma . Th e k no w le dg e o f n ur ses a bo ut dr ug de liv er y de vices a nd p ea k flo w m et er s wa s p oo r. N ee d f or s tr uc tur ed co ur ses o n a sthm a m an ag em en t, in cludin g h an ds-o n t ra inin g w ith va rio us de vic -es a nd p ea k flo w m et er s. Ja m es et al 2012 [65] N ig er ia P 128 7 c 26 (21) Lo ng-ac tin g a nt ipsy ch ot ic in je ct io ns (L AI s) [m edic at io n sa fet y, effic ac y/in dic at io n a nd pr es cr ib in g] H CP s h ad (t oo) p osi tiv e a tti tudes t o in je ct ab le a nt ipsy ch ot ics bu t t heir k no w le dg e o n ad ver se eff ec ts wa s lo w a nd n ee ds t o be im pr ov ed a s did p at ien t co un se lin g.
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Discussion | Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no wl edge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns O bumn em e-A ny im et al 2014 [67] N ig er ia P 283 6.5 b 62 (8) A sthm a [m edic at io n u se d in tre at m en t o f ac ut e exacerb at io n] G oo d k no w le dg e o n ep idemio log y a nd c linic al f ea tur es o f as thm a, b ut fa ir k no w le dg e o n t re at m en t o nl y. A n ee d f or co n-tin ue d m edic al e duc at io n t o im pr ov e k no w le dg e o n s tep-w ise co m bin at io n t hera py a nd p ut tin g k no w le dg e in to p rac tice . O zo h et al .[69] N ig er ia P 182 6 e 58 CO PD/m edic at io n Le ve l o f k no w le dg e o n C O PD m an ag em en t i s s ub-o pt im al . Th er e i s a n ee d t o de ve lo p a sys tem at ic C O PD e duc at io n pr og ra mm e t o k no w le dg e. Ogb oli-N wa so r e t al [68] 2013 N ig er ia P 82 8 a 33 (25) Ca ncer p ain m an ag em en t [guide lin e/p ro to co l f oc us ed] Elem en ta l l ac k o f k no w le dg e o f p ain m an ag em en t in c an cer pa tien ts. Thi s r eq uir es f or m al t ra inin g a s p ar t o f co nt in uo us m edic al e duc at io n in lo w-r es our ce s et tin gs. Fad ar e e t al 2014 [64] N ig er ia P, P , N, O 170 10 c 60 (32) Pa lli at iv e c ar e [m or phin e a nd pa in r elief ] Fa ir k no w le dg e o n m or phin e u se a nd p re ca ut io n b ut p oo r ov era ll p al lia tiv e c ar e k no w le dg e. I nt ro duce p al lia tiv e c ar e m an ag em en t in t he c ur ric ul um o f H CP s. M ur ila et al 2012 [66] Ken ya P, N 192 3 e 1 (0) N eo na ta l r es us ci ta tio n [m edic at io ns a nd fl uid s] In ade qu at e k no w le dg e o f r es us ci ta tio n, w ith n o k no w le dg e on r ele va nt m edicin es. Th er e i s a n ee d t o in cr ea se q ua lit y a nd dura tio n o f p re-g rad ua te t ra inin g. Sa ka fu et al 2016 [70] Ta nza ni a P 50 9 e 46 (44) M an ag em en t o f diff er en tia te d th yr oid c an cer a nd t he u se o f radio ac tiv e io din e. Th er e i s in sufficien t k no w le dg e o n p ro per m an ag em en t a nd us e o f radio ph ar m aceu tic al s. A tten tio n s ho uld b e g iv en t o n u-cle ar m edicin e in p os t-g rad ua te co nt in uo us m edic al e duc at io n. Fa mi ly p la nnin g a nd g yne co lo gy Rei ss et al 2016 [19] Ken ya 235 6.5 e 39 (28) Ab or tifacien t [r eg im en t a nd side eff ec ts, o th er u ses] Limi te d m edic al a bo rtio n k no wle dg e. T ra inin g m ay im pr ov e t he qu ali ty o f inf or m at io n a nd acces s t o s af e a bo rtio n.Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no wl edge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns A min 2016 [71] E gyp t PM 167 9 a 30 (26) Ora l co nt racep tiv es [o pt io ns fo r b re as t f ee din g m ot her , side eff ec ts, b ac ku p o pt io ns] Lo w k no w ledg e o f co nt racep tiv es. C on tin uo us m edic al e duc a-tio n s ho uld f oc us o n mi sco ncep tio ns a ro un d co nt racep tio n a nd he alt h r isks a nd o n m an ag in g mi ss ed p ill s. Ba in s e t al 2014 [72] U ga nd a PM 26 9 c 57 – M at er na l-f et al m edicin e N ot m edic at io n s pe cific. Ph ar m aci sts h ad fa ir o vera ll k no w le dg e o f m edicin es u se d dur in g p reg na nc y a nd l ac ta tio n. Th er e i s h ow ev er a n ee d t o re vi se c ur ren t p re-g rad ua te c ur ric ul a a nd in cr ea se acces s to hig h-q ua lit y dr ug inf or m at io n r es our ces, es pe ci al ly f or lo w-in co m e co un tr ies. M or ha so n-B el lo et a l 2014 [73] N ig er ia P 255 8.5 b 58 (29) Em er gen cy co nt racep tio n [t yp e, in dic at io n, r eg im en] H CP s h ad a fa ir o vera ll k no w le dg e o n em er gen cy co nt ra -cep tiv es. H ow ev er , t he y l ac ke d k no w le dg e o f em er gen cy co nt racep tio n p olic y a nd p ro per co un se lin g. U nder grad ua te an d o n-t he-j ob t ra inin g r eco mm en de d. M oh amm ed et al 2016 [74] N ig er ia P, N/M 292 6 a 43 (25) O bs tet ric k no w le dg e [s pe cific m edic at io n u se f or (p re-)e cla m p-sia, P PH a nd o th er s] N ur ses/mid w iv es h ad p oo r k no w le dg e o n m edicin es u se d in obs tet rics. P re-g rad ua te c ur ric ul a s ho uld b e f ul ly im plem en t-ed a nd co nt in uin g e duc at io n in tro duce d. G ene ra l t op ics (w itho ut s pe cifi c dis eas e) Sa va ge , AR . 2015 [16] Ta nza ni a N 242 6.5 b 33 – Dr ug dos e c alc ul at io n N ur ses h ad p oo r p re-t es t dos e c alc ul at io n s ki lls, t hes e im -pr ov ed a fter a t ra inin g p rog ra m. H ow ev er , a rit hm et ic s ki lls co uld b e s up po rt ed in les s de ve lo pe d s et tin gs b y p ro vidin g ca lc ul at ros. B ut o th er co ur se m at er ia ls m ay b e t es te d. Ka m uh ab wa et al 2015 [18] T anza ni a PM 183 6 e 95 (8) Di sp en sin g p rac tice o f p re -scr ib ed m edicin es/ m ys ter y sh op per a pp ro ac h [O TC, dr ug-dr ug/f oo d in terac tio n] Kn ow le dg e o n dr ug-dr ug (f oo d) in terac tio ns a nd p res cr ip tio n on ly dr ugs wa s hig h. H ow ev er , a ut ho rs co nc lu sio ns w er e t ha t di sp en sin g p rac tices w er e in ade qu at e, a nd p res cr ip tio n o nl y dr ugs s ho uld b e h an dle d b y t ra in ed p ro fes sio na ls o nl y.
2
Discussion | Au tho r/ Pu bli ca tio n ye ar (r ef ) /C oun tr y H CPs Sa mp le siz e Qu al ity sc or e K no wl edge sc or e %, me an (S D) Ma in top ic C oncl us io n / r ec omme nd at io ns Au ta et al 2012 [75] N ig er ia O 236 7.5 b 34 – Se lf-m edic at io n [O TC, in di -ca tio n, C/I, S ide eff ec t, b ra nd/ gen er ic n am es] n ot m edic at io n sp ecific Po or k no w le dg e o n O TC, in dic at io n, co nt ra in dic at io n, side eff ec ts, b ra nd a nd g en er ic n am es. Th e n ee d f or e duc at io n o n se lf-m edic at io n. Onigb in de et a l 2012 [76] N ig er ia O 135 8 d 28 (11) To pic al p ha rm aco th era py [ac tiv e in gr edien ts, t op ic al a nt ib io tics, NSAID s, side eff ec ts a nd C/I s] Po or k no w le dg e o f t op ic al p ha rm aco th era py . Th e n ee d f or co nt in uin g p ro fes sio na l de ve lo pm en t p rog ra m/s emin ar s. Aj emigb its e e t a l 2014 [77] N ig er ia P 30 7 d 90 (4) M edic at io n p res cr ib in g er ro rs [m edic at io n u se , in dic at io n, fo rmu lat io n] G oo d k no w le dg e o n m edic at io n in dic at io n, diff er en t f or m u-la tio n a nd dos e, b ut lo w a wa ren es s f or m ak in g p res cr ib in g er ro rs. P rin ci ples o f ra tio na l pr es cr ib in g a nd o f m ak in g p res cr ib in g er ro rs s ho uld b e t aug ht in p rac tice . Ogun le ye et al 2016 [78] N ig er ia P, PM N, O 2,386 8.5 b 90 (6) M edic at io n er ro rs (g en era l) H ig h p re va len ce o f m edic at io n er ro rs, a nd k no w le dg e o f er ro rs diff er ed acr os s p ro fes sio na l g ro ups. M ul ti-facet te d in ter ven tio ns a re s ug ges te d. To ol (q ues tio nna ires) va lid at io n: a se lf-m ade w ith exp an de d / f or m al va lid at io n p ro ces s, b se lf-m ade w ith p ret es t o nl y, c ci te d p re vio us de ve lo pe d t oo l a nd u se d a s suc h, o r d ci te d p re vio us ly de ve lo pe d t oo l w ith m odific at io n, a nd e se lf-m ade w ith ou t c le ar exp la na tio n f or va lid at io n. On t he o vera ll s co re , p ap er s w ith ou t s ta nd ar d de vi at io n a re t hes e w ith o nl y o ne k no w le dg e q ues tio n. H CP s: h ea lth ca re p ro fes sio na ls P: p hysici an, PM: p ha rm aci st, N/M: N ur se mid w ife , O: O th er H CP s AC T; A rt emi sinin-b as ed C om bin at io n Th era py , IPT p; In ter mi tten t P re ven tiv e Th era py in p reg na nc y (m al ar ia c hem op re ven tio n in p reg na nc y) , H CP ; H ea lth ca re pr of es sio na ls. AD R; ad ver se dr ug r eac tio n, O TC; O ver -th e-co un ter , D M; di ab et es m el lit us, PMT CT : P re ven tio n o f m ot her -to-c hi ld t ra nsmi ssio n. Ye llo w m ar k o n t he co nc lu sio n co lumn: Th e co nc lu sio n i s dr iv en f ro m t he m edic at io n k no w le dg e q ues tio n a s t he co nc lu sio n o n t he p ap er i s m or e g en era l b ey on d m edic at io n.medication knowledge. Most papers reported as a main finding that HCP lacked sufficient medication knowledge and needed training to improve this knowledge.
Medication Knowledge
Our paper shows that using a systematic approach it is possible to syn-thetize a comprehensive overview of medication knowledge from papers that may have a wider scope, e.g. focusing on overall disease management. The overall knowledge score of 52% shows that medication knowledge continues to be a problem. The issue seems generic for all medicines across different disease areas, as medication knowledge questions were not answered differently between different disease area Although, there is no universally accepted threshold to define adequate knowledge, we think that the score found in our study is suboptimal considering the pass mark (60%) often used in medical colleges or in educational practice in general. Most papers concluded that knowledge was suboptimal despite no paper had a predefined acceptable knowledge score. Knowledge is also lower in comparison with a study conducted in 15 countries in Europe (70%), two studies in Norway (score > 60%), or one study performed in The Nether-lands (score > 70%) [1, 3, 4, 6]. The comparison with these studies should be made cautiously as the papers in our study covered a much broader range of topics, a wider variety of medication knowledge questions, had different study designs, different types of HCPs included and an emphasis on medication-related knowledge questions in the area of communicable diseases. Our results suggest that (clinical) pharmacology and therapeu-tics education may have to be strengthened in Africa.
According to Brinkman et al [4], the way (clinical) pharmacology and therapeutics are taught greatly influences prescribing competence. They showed that knowledge was significantly higher among students who attended schools using problem-based or mixed-learning methods than those attending traditional learning curricula. The ‘six steps’ approach advocated in the “Guide to good prescribing” adopted by the WHO, which is widely used in medical training programs around the globe [79],
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Discussion |
could be a good start for this. In addition, strengthening drug informa-tion services may be a way to improve medicainforma-tion knowledge as well.
Disease focus
It is not surprising that most of the articles in our review were about medications to treat or prevent communicable diseases. These diseases present the major health challenge in Africa [80]. The reported lack of knowledge on various aspects of rational medication use and drug resistance challenges, effective prevention and eradication programs. Malaria, in particular the use of artemisinin-based combinations and Prevention of Mother to Child Transmission (PMCT), HIV, especially PEP and vaccinations were the most discussed issues.
Another area that was well-studied were vaccines, where we observed knowledge gaps for different types of vaccines for hepatitis B (HBV), influenza and human papilloma viruses (HPV). Awareness of availa-ble HBV vaccines in our study (56 to 97%) was in line with a previous report [81]. Cervical cancer caused by human papillomavirus (HPV) is the leading cause of cancer mortality among women in Africa [82]. Although, the general population in the region has some knowledge of HPV and may be quite willing to get vaccinated, [83] the knowledge deficit on the efficacy and safety of the vaccines reported in our study for HCPs needs to be addressed before they are likely to support and engage in effective vaccination campaigns. Other studies on communicable diseases were on rational antimicrobial medication use and resistance, highlighting the known antibiotic use challenges that need training and continuous education of HCPs.
Even though the burden of NCDs, such as hypertension, diabetes mellitus, asthma/COPD, stroke, and cancer is increasing in Africa rela-tively little attention is still paid to these diseases by health policy mak-ers [84, 85]. It is therefore not surprising to see also few medication knowledge studies for these diseases. Cancer and asthma/COPD were most widely studied, which are diseases with complex medical treat-ments that require high levels of HCP knowledge and skills.
In developing nations, including the majority of African countries, contraceptive use remains low with obvious consequences of popula-tion growth and thus with a high unmet need for improved family plan-ning activities[86]. One of the major barriers reported for low use of family planning is inadequate knowledge about contraceptive methods and how to use them in the general population [86, 87]. Three papers included in our study substantiate these findings [71, 73, 88]. Due to cultural, religious and social influences, the role of HCPs role is crucial for improving the uptake of contraceptives. Interventions to improve HCPs knowledge may help to achieve the sustainable development goal 3 (reduce child mortality and improve maternal health) set by the United Nations [89]. The papers included in our study also suggest that attitudinal issues need to be overcome among HCPs.
Medication benefit versus harm aspect
In our study, most of the knowledge questions were on medication bene-fit. Our study suggests that the harmful aspects of medication use receive little attention, even in research. In line with this, adverse drug reaction reporting from Sub-Saharan Africa is the lowest in the world [90, 91]. Finally, we did not find important differences in knowledge between types of HCPs, disease areas and country of study. We found some var-iability depending on the sample size and quality score. These differ-ences were nonlinear, therefore difficult to interpret, but the smallest studies and studies with the lowest quality had higher knowledge scores and should be interpreted with some care.
Limitations
Our review revealed a wide range of medication and disease topics across studies. The pooled estimates should be interpreted with caution as stud-ies were highly heterogeneous, reporting a wide range of diseases that used varied measuring tools. The relation between quality of studies and
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Conclusion |
medication knowledge score should be interpreted with caution as they have non-linear relationship. In almost all papers in our review knowl-edge was measured using paper-based surveys, i.e. studies did not look at prescribing practices or outcomes. The difference between paper-based knowledge scores and practical skills need to be further explored in Af-rican settings. Our search was limited to a five-year period (2012–2016), focusing on the current situation to represent most recent findings.
Conclusion
Overall, our study indicates there continues to be a considerable lack of knowledge about medication with only half of all HCPs answered knowledge questions correctly in The African region. Our study sug-gests that there is a general need to improve education and continuous training of HCPs about medication. This indicates a continued need to improve the situation, for example by paying more attention in the edu-cation system and on the job training. In addition, more information is needed on the effects of better knowledge on the quality of prescribing and medication use, and in the end effects on health outcomes. It is also important to set up a system for monitoring HCPs training programs.
Acknowledgement
The authors wish to thank Anne-Marie Jipping for her support in the early phase of the study. The study was part of a PhD project funded by NUFFIC (Netherlands organization for international cooperation in higher education).
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