A total of 2,519 valid records of patients, who had received care at the selected health facilities in Accra, were used for the study. Patient and facility level descriptive characteristics are presented (Table 1). Of patients prescribed with antibiotics, 4 out of 10 were aged above 5 years. It must be noted that 1.2% of the folders did not have age recorded in them. The proportion of females prescribed with antibiotics was 51.9%. Regarding registration with the main social health insurance scheme in Ghana, the national health insurance scheme (NHIS) or other schemes, 57.6% of patients were registered.
Table 1
Facility and patient level descriptive characteristics by antibiotic prescription
| Antibiotics prescription |
| Not Prescribed | Prescribed | Total, N = 2,519 |
| n | %a | n | %a | n | %b |
Municipality | | | | | | |
Ga South (N = 811) | | | | | | |
Ga South Municipal Hospital | 148 | 74.7 | 430 | 70.1 | 578 | 71.3 |
Ngleshie Amanfrom Health Centre | 50 | 25.3 | 183 | 29.9 | 233 | 28.7 |
La Dade Kotopon (N = 802) | | | | | | |
La General Hospital | 78 | 35.5 | 215 | 36.9 | 293 | 36.5 |
Police Hospital | 142 | 64.5 | 367 | 63.1 | 509 | 63.5 |
La Nkwantanang Madina (N = 906) | | | | | | |
Kekele Polyclinic | 145 | 43.3 | 71 | 12.4 | 216 | 23.8 |
Pentecost Hospital | 190 | 56.7 | 500 | 87.6 | 690 | 76.2 |
Patient age-group | | | | | | |
< 5 | 186 | 24.7 | 963 | 54.5 | 1149 | 45.6 |
≥ 5 | 552 | 73.3 | 788 | 44.6 | 1340 | 53.2 |
Unknown | 15 | 2.0 | 15 | 0.9 | 30 | 1.2 |
Sex | | | | | | |
Male | 343 | 45.6 | 848 | 48.0 | 1191 | 47.3 |
Female | 410 | 54.4 | 917 | 51.9 | 1327 | 52.7 |
Client on NHIS | | | | | | |
Yes | 426 | 56.6 | 1026 | 58.1 | 1452 | 57.6 |
No | 327 | 43.4 | 740 | 41.9 | 1067 | 42.4 |
ABBREVIATION: NHIS, national health insurance scheme; a: Proportion of those prescribed or not prescribed antibiotics; b: proportion based on total number seen in the municipal facility |
The distribution of symptoms of the patients by age group is presented (Table 2a). A total of 11,953 symptoms were recorded. While headache (10.5%) was generally the most frequently reported symptom, nasal congestion (11.6%), poor appetite (11.2%), cough (10.3%) and watery stool (8.4%) were more frequently reported among the children under 5.
Table 2
a: Distribution of symptoms by age-group
Symptoms | Age-group in years |
| < 5 (n = 1149) | 5–14 (n = 353) | 15–29 (n = 435) | 30–44 (n = 310) | ≥ 45 (n = 242) | Unknown (n = 30) | Total (N = 2519) |
Headache | 392 (7.3) | 215 (12.7) | 289 (13.1) | 201 (14.3) | 150 (12.2) | 11 (12.0) | 1258 (10.5) |
Poor appetite | 600 (11.2) | 160 (9.4) | 159 (7.2) | 95 (6.8) | 98 (8.0) | 8 (8.7) | 1120 (9.4) |
Nasal congestion | 619 (11.6) | 140 (8.2) | 128 (5.8) | 74 (5.3) | 68 (5.5) | 3 (3.3) | 1032 (8.6) |
General Body pains | 360 (6.7) | 130 (7.7) | 213 (9.7) | 152 (10.9) | 134 (10.9) | 6 (6.5) | 995 (8.3) |
Watery stool | 448 (8.4) | 126 (7.4) | 134 (6.1) | 77 (5.5) | 74 (6.0) | 1 (1.1) | 860 (7.2) |
Dizziness | 356 (6.7) | 119 (7.0) | 176 (8.0) | 92 (6.6) | 94 (7.6) | 4 (4.3) | 841 (7.0) |
Cough | 548 (10.3) | 94 (5.5) | 70 (3.2) | 57 (4.1) | 47 (3.8) | 12 (13.0) | 828 (6.9) |
Fatigue | 364 (6.8) | 107 (6.3) | 160 (7.3) | 88 (6.3) | 83 (6.7) | 2 (2.2) | 804 (6.7) |
Dysuria | 366 (6.8) | 112 (6.6) | 146 (6.6) | 80 (5.8) | 76 (6.2) | 4 (4.3) | 784 (6.6) |
Nausea | 354 (6.6) | 105 (6.2) | 136 (6.2) | 72 (5.2) | 79 (6.4) | 1 (1.1) | 747 (6.2) |
Other | 937 (17.5) | 389 (22.9) | 588 (26.7) | 403 (29.0) | 327 (100.0) | 40 (43.5) | 2684 (22.5) |
Total | 5344 (100.0) | 1697 (100.0) | 2199 (100.0) | 1391 (100.0) | 1230 (100.0) | 92 (100.0) | 11953 (100.0) |
Table 2b shows the distribution of diagnoses by age group. On average, 4 (10,026/2519) diagnoses were made per patient. Generally, the predominant diagnosis was ARTI (11.0%). Among the under 5 age group, this pattern of ARTI being the most frequently diagnosed condition was observed (12.7%). However, for all the other age groups, malaria was the most frequently diagnosed condition; 10.7%, 5–14 years; 11.1%, 15–29 years; 10.4%, 30–44 years; 10.4%, ≥ 45 years.
Table 2
b: Distribution of diagnoses by age-group
Diagnoses | Age -group in years |
| < 5 (n = 1149) | 5–14 (n = 353) | 15–29 (n = 435) | 30–44 (n = 310) | ≥ 45 (n = 242) | Unknown (2 = 30) | Total (N = 2519) |
ARTI | 618 (12.7) | 136 (9.4) | 157 (9.5) | 101 (9.8) | 85 (8.6) | 9 (22.0) | 1106 (11.0) |
Malaria | 423 (8.7) | 156 (10.7) | 184 (11.1) | 148 (10.4) | 103 (10.4) | 15 (36.6) | 1029 (10.3) |
UTI | 401 (8.3) | 119 (8.2) | 143 (8.6) | 81 (7.8) | 71 (7.2) | 4 (9.8) | 819 (8.2) |
Typhoid fever | 357 (7.4) | 113 (7.8) | 138 (8.3) | 84 (8.1) | 79 (7.4) | 1 (2.4) | 772 (7.7) |
Enteritis | 371 (7.7) | 122 (8.4) | 127 (7.7) | 72 (7.0) | 73 (7.4) | 1 (2.4) | 766 (7.6) |
Pneumonia | 379 (7.8) | 103 (7.1) | 117 (7.1) | 65 (6.3) | 68 (6.8) | 0 (0.0) | 732 (7.3) |
Ear infection | 387 (8.0) | 104 (7.2) | 113 (6.8) | 59 (5.7) | 68 (6.8) | 0 (0.0) | 731 (7.3) |
Tonsilitis | 368 (7.6) | 114 (7.8) | 114 (6.9) | 65 (6.3) | 65 (6.5) | 0 (0.0) | 726 (7.2) |
Anaemia | 344 (7.1) | 109 (7.5) | 122 (7.4) | 70 (6.8) | 67 (6.7) | 3 (7.3) | 715 (7.1) |
Eye infection | 360 (7.4) | 107 (7.4) | 109 (6.6) | 60 (5.8) | 66 (6.6) | 0 (0.0) | 702 (7.0) |
Others | 841 (17.3) | 271 (18.6) | 331 (20.0) | 229 (22.1) | 248 (25.0) | 8 (19.5) | 1928 (19.2) |
Totals | 4849 (100.0) | 1454 (100.0) | 1655 (100.0) | 1034 (100.0) | 993 (100.0) | 41 (100.0) | 10026 (100.0) |
ABBREVIATION: ARTI, Acute Respiratory Tract Infection; UTI, Urinary Tract Infection |
Table 3 presents a summary of the prescriber-patient interactions regarding antibiotics prescriptions at the health facilities during the period when the records were taken. Overall, the prevalence of antibiotics prescription was 70.1% (95% CI: 67.7% − 72.4%). Age-group stratified analyses showed that prevalence of antibiotic prescription was 83.8% (95% CI: 81.3–86.1) among patients under 5 and 58.8% (95% CI: 55.7–61.9) among patients aged 5 years or more. Of the 1766 prescriptions that had antibiotics prescribed, approximately half (49.2%) were written by physician assistants, 43.9% by medical doctors and 5.7% by nurse prescribers. Regarding the number of years they had been practising, 31.4% of the patients were seen by prescribers who had been practising for less than 3 years, a little over a third (37.7%) had been practising for 3 to 5 years, and 30.9% had been practising for 6 years or more. The largest proportion of the prescriptions with antibiotics were written by prescribers who had been practising for 3 to 5 years (37.4%). While 79.4% of the prescriptions with antibiotics were written by prescribers who had never been trained on integrated management of neonatal and childhood illnesses (IMNCI), 87.9% of the prescriptions without antibiotics were written by those with no training on IMNCI.
Medicines prescribed other than antibiotics included antimalarials, analgesics, haematinics, cough remedies, antacids. The proportion of those prescribed antimalarials was 54.2% (408/753) among those who were not prescribed antibiotics and 35.6% (628/1766) among those who were prescribed antibiotics.
Table 3
Prescriber-patient interactions by antibiotics prescription
Prescriber Characteristic | Antibiotics prescription |
| Not prescribed | Prescribed | Total, N = 2519 |
| n | % | n | % | n | % |
Prescriber's Profession | | | | | | |
Medical Doctor | 289 | 38.4 | 776 | 43.9 | 1065 | 42.3 |
Physician Assistant | 432 | 57.4 | 869 | 49.2 | 1301 | 51.6 |
Nurse prescriber | 24 | 3.2 | 100 | 5.7 | 124 | 4.9 |
Other | 8 | 1.1 | 21 | 1.2 | 29 | 1.2 |
Total | 753 | 100.0 | 1766 | 100.0 | 2519 | 100.0 |
Prescriber’s years of practice | | | | | | |
< 3 | 279 | 37.7 | 500 | 28.7 | 779 | 31.4 |
3–5 | 284 | 38.4 | 652 | 37.4 | 936 | 37.7 |
6–9 | 99 | 13.4 | 289 | 16.6 | 388 | 15.7 |
≥ 10 | 78 | 10.5 | 300 | 17.2 | 378 | 15.2 |
Total | 740 | 100.0 | 1741 | 100.0 | 2481 | 100.0 |
Ever trained on IMNCI | | | | | |
Yes | 91 | 12.1 | 363 | 20.6 | 454 | 18.0 |
No | 662 | 87.9 | 1403 | 79.4 | 2065 | 82.0 |
Total | 753 | 100.0 | 1766 | 100.0 | 2519 | 100.0 |
IMNCI - Integrated management of childhood illnesses. |
A total of 1109 (44.0%) of patients were referred for laboratory investigations, 1007 (40.0%) were tested for malaria, 909 (36.1%) took the full blood count test, 9 (0.4%) took the stool routine examination, and 146 (5.8%) took the urine routine examination.
Results of the multivariable logistic regression analyses (Table 4a) identified the following as significant non-clinical factors of antibiotic prescription: location of facility (municipality), age of patient and prescriber’s professional category, years of practice, and training in IMNCI, Compared to prescribers who had practised for less than 3 years, those who had 6 to 9 years of practice experience and those who had practiced for 10 years or more had 3 times (AOR = 2.97; 95% CI: 1.99–4.44) and 1.6 times (AOR = 1.60; 95% CI: 1.12–2.27) higher odds of prescribing antibiotics, respectively. Patients treated by clinicians with 3 to 5 years of practice experience were not significantly different from those treated by clinicians with less than 3 years of practice. Prescribers who had ever been trained on IMNCI had 2.3 times greater odds of prescribing antibiotics than those who had never been trained (AOR = 2.33; 95% CI: 1.54–3.53). After adjusting for all the other covariates, children aged 5 years or above were 60% (AOR = 0.40; 95% CI: 0.32–0.51) less likely to be prescribed antibiotics than those under 5.
Table 4
a: Crude and adjusted logistic regression of factors associated with antibiotic prescribing
| Crude OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
Prescriber's Profession (Ref: Medical Doctor) | 0.001*** | | 0.029* |
Physician Assistant | 0.75 (0.60, 0.94) | | 0.83 (0.58, 1.20) | |
Nurse Prescriber | 1.55 (1.06, 2.27) | | 1.30 (0.70,2.41) | |
Other | 0.98 (0.44, 2.19) | | 8.33 (1.32, 52.41) | |
Prescriber's years of practice (Ref: < 3) | < 0.001*** | | < 0.001*** |
3–5 | 1.28 (0.98, 1.67) | | 1.12 (0.84, 1.48) | |
6–9 | 1.63 (1.15, 2.31) | | 2.97 (1.99, 4.44) | |
≥ 10 | 2.15 (1.50, 3.06) | | 1.60 (1.12, 2.27) | |
Prescriber ever trained on IMNCI (Ref: No) | < 0.001*** | | < 0.001*** |
Yes | 1.88 (1.38, 2.56) | | 2.33 (1.54, 3.53) | |
Municipality (Ref: Ga South) | | < 0.001*** | | < 0.001*** |
La Dade Kotopon | 0.64 (0.49, 0.84) | | 0.16 (0.09, 0.27) | |
La Nkwantanang Madina | 1.17 (0.89, 1.54) | | 0.88 (0.56, 1.40) | |
Sex of patient (Ref: Male) | | 0.235 | | 0.627 |
Female | 0.90 (0.77, 1.07) | | 1.05 (0.87, 1.27) | |
Age of patient in years (Ref: < 5) | < 0.001*** | | < 0.001*** |
≥ 5 | 0.28 (0.23, 0.34) | | 0.40 (0.32, 0.51) | |
P < 0.05*, p < 0.01**, p < 0.001***, significance levels; CI, Confidence Interval; OR, odds ratio; Ref, Reference. |
The significant clinical factors as identified from the multivariable logistic regression (Table 4b) include laboratory investigation, symptoms including cough, dizziness, difficulty in swallowing, watery stool, and diagnoses including urinary tract infection, typhoid fever, and skin disease. Patients who presented with cough were 3.54 times more likely to be prescribed antibiotics than those who did not cough (AOR = 3.54; 95% CI: 2.54–4.92). Patients for whom laboratory investigations were requested were 29% (AOR = 0.71; 95% CI: 0.57–0.89) less likely to be prescribed antibiotics than those for whom laboratory investigations were not requested. Sex of patient, symptoms including general body pains, nasal congestion and diagnoses including ARTI and pneumonia were not significant factors of antibiotic prescribing (p < 0.05).
Table 4
b: Crude and adjusted logistic regression of factors associated with antibiotic prescribing
| Crude OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
Cough (Ref: No) | | < 0.001*** | | < 0.001*** |
Yes | 3.28 (2.57, 4.19) | | 3.54 (2.54, 4.92) | |
Dizziness (Ref: No) | | 0.033* | | < 0.001*** |
Yes | 0.81 (0.66, 0.98) | | 0.48 (0.33, 0.71) | |
Difficulty in swallowing (Ref: No) | 0.001** | | < 0.001*** |
Yes | 2.87 (1.51, 5.44) | | 7.78 (3.43, 17.64) | |
Watery stool (Ref: No) | | 0.044* | | 0.031* |
Yes | 1.24 (1.01, 1.53) | | 1.56 (1.04, 2.34) | |
General body pain (Ref: No) | | 0.019* | | 0.104 |
Yes | 0.79 (0.65, 0.96) | | 0.79 (0.59, 1.05) | |
Nasal congestion (Ref: No) | | < 0.001*** | | 0.11 |
Yes | 1.67 (1.36, 2.04) | | 1.30 (0.94, 1.80) | |
Laboratory investigations (Ref: No) | < 0.001*** | | 0.003** |
Yes | 0.62 (0.51, 0.74) | | 0.71 (0.57, 0.89) | |
Pneumonia (Ref: No) | | 0.035* | | 0.147 |
Yes | 1.27 (1.02, 1.60) | | 1.57 (0.85, 2.88) | |
Acute respiratory tract infection (Ref: No) | < 0.001*** | | 0.728 |
Yes | 1.80 (1.44, 2.25) | | 0.95 (0.70, 1.28) | |
Typhoid fever (Ref: No) | | 0.015* | | < 0.001*** |
Yes | 1.32 (1.06, 1.66) | | 3.78 (2.28, 6.26) | |
Urinary tract infection (Ref: No) | < 0.001*** | | < 0.001* |
Yes | 1.51 (1.20, 1.89) | | 3.53 (2.23, 5.60) | |
Skin disease (Ref: No) | | 0.02* | | 0.020* |
Yes | 1.54 (1.07, 2.20) | | 1.82 (1.10, 3.02) | |
P < 0.05*, p < 0.01**, p < 0.001***, significance levels; CI, Confidence Interval; OR, odds ratio; Ref, Reference. |
The age-stratified analyses in both crude and adjusted models showed that prescriber training on IMNCI was not significantly associated with antibiotic prescription in patients under 5 years but significantly associated among patients who were 5 years or more (Table 5).
Table 5
Crude and adjusted odds ratio of association between prescriber training on IMNCI and antibiotic prescribing
Less than 5 years |
| COR | p-value | AOR | p-value |
Prescriber ever trained on IMNCI (Ref: No) | | | |
Yes | 1.36 (0.86, 2.13) | 0.189 | 2.05 (0.99, 4.25) | 0.055 |
5 years or more |
Prescriber ever trained on IMNCI (Ref: No) | | | |
Yes | 1.93 (1.31, 2.84) | 0.001 | 2.44 (1.47, 4.05) | 0.001 |
The most prevalent diagnosis among the patients was ARTI (Fig. 1). The diagnoses not found to be significantly associated with antibiotic prescription were malaria, diarrhoeal diseases, anaemia, ear infection, eye infection, enteritis, trauma and tonsillitis (Table 2b). The other diagnoses that were not included in the analyses include hypertension, bacteraemia, nephritis, mastitis, diabetes mellitus.
Diagnoses of interest: all diagnoses which had a prevalence of at least 5% in the database
The variance inflation factor (VIF) for the exposure variables in the model were all less than 10 (Table 6), as such none of the variables were considered collinear with any other.
Table 6
Variance Inflation Factor for independent variables in the adjusted logistic model
Variable | Variance Inflation Factor |
Profession | 1.51 |
Years of Practice | 1.07 |
Prescriber ever trained on IMNCI | 1.23 |
Prescriber sex | 1.04 |
Municipality | 1.61 |
Age | 1.33 |
Cough | 1.83 |
Dizziness | 3.94 |
Difficulty in swallowing | 1.05 |
Watery stool | 3.26 |
General body pain | 2.60 |
Nasal congestion | 2.33 |
Laboratory investigation | 1.07 |
Pneumonia | 6.89 |
Acute Respiratory Tract Infection | 1.57 |
Typhoid fever | 4.58 |
Urinary tract Infection | 2.91 |
Skin infection | 1.10 |