Introduction

Medicine is an essential tool for health care prevention, cure, and rehabilitation. Record of previous studies revealed that due to inappropriate use of drugs a constant rise both in number and in type of different medicinal products was experienced with limited funding for health services (Perez-Casas, Herranz, & Ford, 2001). More than half of all the medicine found to be prescribed, dispensed or inappropriately utilized by the consumer (Icium, 2004). Respectively, 50% of patients do not take their medications accurately; on the other hand, almost one third of the global population is deprived of access to essential medicine (Pathak, Gupta, Maurya, Kumar, & Singh, 2016). World Health Organization (WHO) has defined rational use of drugs as “Patient receives medication appropriate to their clinical needs, as in doses that meet their requirements for an adequate period of time, and at the lowest cost to them and their community” (WHO, 2002). However, apprehensions of the wrong prescription may lead to the development of many complications like, anti-microbial drugs resistance, ineffective treatment, adverse effects of drugs, and the economic burden on both patient and their society. Further insight of Irrational or misuse of drugs refers to consumption, distribution or prescribing of medicine in such a way that reduces its efficacy or in a situation where they are unlikely to have their desired effect (Siddiqi et al., 2002). Nevertheless, some highlighted factors are responsible for inappropriate utilization of medicine such as patient-related factors; which include patient’s behaviours, lack of knowledge of the disease, and certain types of illness, others are sociological impacts, psychiatric impacts, and non-adherence to treatment contribute for any disarray in rational drug utilization overall (Çelik, Şencan, & Clark, 2013). Furthermore, some of the factors related to prescribing; include a high ratio of the anti-bacterial prescription in a prescription, less prescribing of international non-proprietary names (INN) drugs and increased number of drugs in a prescription (poly-pharmacy), described as the use of multiple medicines prescribed to patients (Bushardt, Massey, Simpson, Ariail, & Simpson, 2008; Lukali & Michelo, 2015). The quality of life can be improved in the developing countries by refining the medical treatment norms at every level of the health system (Shankar, Partha, & Shenoy, 2001). To encourage appropriate use of drugs especially in developing countries this is essential to evaluate the pattern of drug use. WHO in association to International Network for Rational use of Drugs (INRUD) has provided a set of core prescribing indicators to configure and examine the mechanisms that describes the way to analyse the prescribing pattern at health facilities (Anker, Brudon, Fresle, & Hogerzeil, 1993).

^{The aim of this study was to evaluate the prescribing pattern at basic healthcare facilities of Islamabad Pakistan, to find out whether these health facilities were complying or surpassing the defined standards of WHO / INRUD.}

Materials and Methods

A non-experimental descriptive, cross-sectional study was conducted between January 2018 and July 2018, to evaluate the prescribing pattern at basic healthcare facilities of Islamabad Pakistan using WHO / INRUD core indicators in 14 Basic Health Units (BHU), 3 Rural Health units (RHC) and 3 Local Dispensaries located Islamabad Pakistan. These health facilities in Islamabad serve rural population in which most of the patients are pursuing their treatment.

Sample size and sampling method

WHO/INRUD recommends that a minimum sample of 600 prescriptions (prescribing episodes) should be comprised for a descriptive cross-sectional study of this kind, and at least twenty health facilities should be included where minimum thirty prescribing episodes could be recorded from each health facility (WHO, 1993). The selected location (Islamabad) comprised of fourteen BHUs, in order to fulfil the sample requirement three RHC and three Dispensaries were included. The principal investigator was trained by the supervisor to collect data. Retrospectively 420-prescription records from primary source were collected from all the fourteen BHUs, 90 from three RHCs and 90 from three Dispensaries. A total of 600 prescription episodes were recorded. A simple random sampling technique was used for this study to visit the facilities depending upon the time and feasibility of geographical location.

Data Analysis

The average number of drugs per encounters, calculated as dividing the total number of drugs prescribed by the number of encounters surveyed. Percentage of encounters with INN, calculated as dividing the number of drugs prescribed by generic name by the total number of drugs prescribed multiplied by 100. Percentage of encounter with Antibiotics, Injections, and Corticosteroid calculated as, dividing the number of encounters with Antibiotics, Injections, and Corticosteroid by the total number of encounters multiplied by 100. Average consultation time; calculated as dividing the time span from patient enters and exit by the total number of consultations. Average dispensing time calculated as, dividing the entire time of dispensing by the number of patient visit. Percentage availability of essential drug list calculated as, dividing the number of the facilities having EML by the total number of facilities multiplied by 100. Percentage of drugs actually dispensed; calculated as, dividing number of drugs actually dispensed in facility by total number of drug prescribed multiply with 100. Percentage of drugs adequately labelled; calculated as, dividing the number of packages at least contain name of patient, dose and interval when the drug should be taken by the total number of packages multiply with 100. Knowledge of the correct dose was assessed by pre structured close ended questions i.e.

• Can you identify the name of medicine(s)?

• Do you know the purpose of this medicine (s)?

• Do you ascertain the dose of drug (s)?

• Do you know this treatment undergoes for how long? Do you know the administration method and dose frequency of the drugs?

• Are you aware of the side effects of the drugs? (Mathew, Gadde, Nutakki, & Doddayya, 2013).

The interpretation of answers was marked as (0/1). “0” described that a patient did not answer all the questions correctly while “1” described that patient has answered all the questions correctly. After a successful data collection, the data was cleaned, coded and analysed on the data consolidation form provided in the WHO manual (WHO, 1993). Meanwhile we did not evaluate correlations between the prescribers and diagnosing information only descriptive statistical analysis was carried out through Microsoft Excel for percentages, means, averages and frequencies.

Ethical Considerations

The approval of Ethical Review Boards and Ethical Committees of Hamdard University ref (HU/IC/DIR/HIPS/2018/141) and District Health Office Islamabad ref (5/24-Health/ICT/84-1154) was acquired prior to carrying out the survey. Study aim and protocols of the research were explained through consent to the person in charge of institutions involved.

Results and Discussion

A total of six hundred episodes of patient prescribing records retrospectively were collected randomly from BHUs, RHCs and Dispensaries were assessed for WHO given indicators. There were three major patient age groups, 35 (5.83%) were >5 years, 202 (33.6%) were 5 to 12 years, 363 (60.5%) <12 years, out of them 354 (59%) were male and 246 (41%) were female. It was found that 415 (69.16%) were uneducated, 47 (7.83%) prevailed matriculation, 41 (6.83%) were graduated and 97 (16.16%) were student Table 1.

The results of the current study highlighted that out of 600 episodes 1608 drugs were prescribed ranges between one and seven drugs in various prescriptions. The average number of drugs prescribed was 2.751 from all health facilities, where the lowest average number was 1.63 at local dispensary and highest was 3.3 at BHU and RHC. The results of the study highlighted that INN prescribing was 41.15%, the least reported at BHU was 6% and highest 86% at local dispensary.

The results of the study highlighted 48.6% of antibiotics episodes at 20 health facilities, the lowest percentage of antibiotic reported at dispensary 13% and highest 87%, 67% were present at BHUs and RHCs setting. Different type of antibiotics were found at various settings, Cephalosporin 83 (28.62%), Penicillin 73 (25.12%), Quinolone 69 (23.79%), Metronidazole 48 (16.55%), Macrolide 14 (4.82), Gentamycin 3 (1.03%) Table 2.

The results of the study showed that 7.68% Corticosteroids were prescribed at primary healthcare facilities and other common classes of the drugs that our study highlighted are, NSAIDs (n=300) 18.72%, Multivitamins (n=330) 20.59%, Anti-tussive syrups (n=140) 8.73%, Anti allergic drugs (n=186) 11.61% and Oral rehydration salt (n=239) 14.16% Table 3.

The results of the study emphasized that 16.05% of injections were prescribed at primary healthcare facilities. 75.08% of the drugs were prescribed from essential drug list; the highest percentage prescribed from EDL was 81%, 89% and 92% at different settings Table 4.

According to this study, the reported average consultation and dispensing time was 2.699 minutes and 1.479 minutes. Percentage of drugs actually dispensed was 70.45% while percentage of drugs adequately labelled was 56.14% and only 18.79% of the patients in all the facilities were aware of the correct dose Table 5.

Rational use of medicine is a fundamental parameter for the provision of better healthcare to the community. Inappropriate prescribing, dispensing, and use of medicine can lead to increase morbidity and mortality. This practice can increases health care cost and wastage of resources and also contributes to antibiotic resistance (Atif et al., 2016). The results of this study showed that the average number of drugs prescribed at BHU, RHC, and Dispensaries of Islamabad was 2.751 overall, which have/had surpassed the Who is a given standard range.

According to WHO the prescription should have an average number between the ranges of 1.6 to 1.8 drugs per prescription. In several individual prescriptions that we have explored, there was a propensity towards increased number of average drugs in a prescription with at least five to seven drugs. This might be due to certain factors like ‘the need of the patient or decreased adherence to standard treatment guidelines or due to the financial incentives provided by pharmaceutical industries. This shows the polypharmacy (increased number of drugs) which needs enhancement as the possibility of drug toxicity, decreased adherence to patients, greater therapy costs and greater chances of drug interactions are addressed due to this practice.

In a relevant research, finding from Pakistan the result reported 2.3 of average number of drugs prescribed and comparatively another survey conducted in India Goa includes an optimal range of medicines prescribed per prescription as compared to this study (Azeem et al., 2015; Chandelkar & Rataboli, 2014).

INN prescribing practice addressed as it leads to an effective communication between physician and pharmacist and it reduces the chances of wrong interpretation of prescription and decreases the cost of therapy. According to this study there was little mode of INN use reported as 41.15% in primary healthcare facilities of Islamabad. Out of 600 episodes, the least INN reported at BHU was 6% and highest 86% at local dispensary. This might be due to the lack of legal restrictions on brand prescribing in Pakistan and influence of pharmaceutical industries. Based on a survey reported in the USA and Pakistan in 2013 and 2016 respectively suggested the frequent meeting of physicians with medical marketing representatives increased the like hood of prescribing brands in the presence of INN (Atif et al., 2016; Campbell, Pham-Kanter, Vogeli, & Iezzoni, 2013). Respectively, prescribing of antibiotics for a minor ailment can lead to increase prevalence of antibiotic resistance which is observed worldwide, especially the use of antibiotics without its need, can lead to major complications, such as Clostridium difficile infection (Shiva et al., 2018). This investigation showed that every health facility had elevated antibiotic prescription, overall 48.6% reported besides WHO suggested the optimal antibiotic prescription should be between 20% - 25.40%. In 2014, correspondingly, a relevant study from Pakistan, Peshawar also reported an elevated antibiotic prescription pattern at healthcare centres (Raza, Khursheed, Irfan, Abbas, & Irfan, 2014).

Similarly, excessive use of Corticosteroids is responsible for various side effects and its use must be cautioned in the presence of other efficient alternative approaches such as non-steroidal anti-inflammatory drugs. Both physicians and patients may abuse and mistreat corticosteroids (Imam & Halpern, 1994). However, this was encouraging that the results of our study highlighted that prescribing of steroid was low at primary health care facilities, which was only 7.6% out of 600 prescriptions, besides; study conducted in Iran showed 26.75% (Safaeian et al., 2011). A decline in injectable use can help to reduce the chances of infections and cost of medical treatments. This study demonstrated that injection use was within limits (10.1% - 17%) as prescribed by WHO. In that order, a reference study from Pakistan showed 15%, the optimal use of injection at teaching hospitals (Jan, 2016).

Percentage of drugs prescribed from Essential Drug List was 75.80%, least percentage reported was 44% at BHU and highest was 92%. The principle of essential drugs has been highly helpful to address the health requirements of the masses. Thus, the result of this study is useful up to 75 percent, but WHO advises 100%. Regardless, the selection of essential drugs is an ongoing process that must be taken into consideration for the development of therapeutic and medicinal knowledge. In support of our research we explored in a reference study from Pakistan where percentage of drugs prescribed from EDL was less than 100% while in Sri Lanka 98.6% reported (Azeem et al., 2015; Menik, Isuru, & Sewwandi, 2011).

Monitoring of patient care indicators is essential for determining the extent of rational use of drugs. Adequate consultation time is necessary for effective history taking, diagnosis and counselling of patient. This study revealed that the average consultation time spent with patient was 2.699 minutes over all. This might be due to the lack of adequate number of qualified person and increased number of patients. A research in Bangladesh has shown less average consultation time I.e. 2 minutes (Alamgir & Ahmed, 2015). Respectively, average dispensing time reported by this study was 1.47 minutes. An adequate dispensing time is also necessary for rational dispensing and effective counselling to patients regarding the proper use and storage of medicine. This research indicated the low time intake for efficient dispensing in healthcare facilities, but comparatively we considered better than results of study conducted in Pakistan at public sector health facilities, which reported 38.9 seconds for dispensing (Hafeez et al., 2004). Our study explained that the level of the stock in the indoor pharmacies at BHUs was not optimum to facilitate the patients, which is described as only 70.45 percent of drugs actually dispensed to the patients. In accordance to another study reported 97.3% of the prescribed drugs were actually dispensed (Atif et al., 2016). The dispensed drugs must be appropriately labelled for the rational utilization of medicine, as our study highlighted 56.14 percent of the drugs were adequately labelled, which seems to be poorly resulted according to the WHO guidelines but seems to be better than the reportage of another surveys which showed 38.35% of the drugs labelled adequately (Mathew et al., 2013). Patient knowledge of a correct dose and administration considered as a most critical point in medical cure, while insufficient knowledge is a major hindrance towards rational use of drugs. Our study demonstrated poor knowledge of the patients for the correct dose. This might be due to the fact that most of the BHUs and RHUs are located in the rural areas with low literacy level Table 1. Similar outcomes were seen in the study reported in Pakistan (Atif et al., 2016).

Conclusions

This study concluded that prescribing Pattern at primary healthcare facilities of Islamabad Pakistan was poorly complaint in accordance to WHO references. Increased number of average drugs in prescription, brand prescribing (Less INN), and higher antibiotic percentages were observed. Consultation and dispensing time was not up to sufficient for a proper counselling to patient about disease and proper use of drugs. However, the use of corticosteroids and injections was moderate. A detailed research is required to assess the root causes of the problems in these settings. A continuous Drug use evaluation approach can be effective to improve the prescribing practices at Basic Health Facilities.