Introduction

Effective altruism is an ideology that applies evidence and reason to determine the most effective ways to benefit others.[1] It encourages individuals to consider all causes and actions and to act in a way that brings about the greatest positive impact based upon their values. The concept of effective altruism has been widely studied and used in different areas health interventions [2,3] such as community distribution of mosquito nets and health care services. Successful introduction and implementation of altruism in paediatric in-patient care in resource-poor countries have the potential of decreasing the gap between antibiotic prescription and commencement of antibiotic treatment for indigent paediatric patients especially with the existing high level of poverty and low coverage of social health insurance.[4,5]

Millions of children receive antibiotic treatment annually in Nigeria and higher prevalence among in-patient care.[6-11] Timely commencement of these antibiotic therapies is paramount but often not the reality, especially among indigent caregivers who are expected to pay out of pocket. This often limits the healthcare providers' antibiotic's treatment options.[12,13] These challenges affect the adequate implementation of antibiotic stewardship (ABS).[14-17]

The concept of ABS is commencing appropriate antibiotics where indicated in the appropriate dose, route, and duration and discontinuing the antibiotic treatment once considered no longer necessary. Interventions to improve ABS has always focused on changing healthcare provider prescribing behavior, researchers have failed to consider the problem of providing the prescribed antibiotics especially in places where OOP is highly due to lack of implementation of formal sector social health insurance programme (FSSHIP) and poverty level is high.[4,5]

One area that has not been considered as a solution to these is the area of humanitarian and charity. Studies have shown that majority of individuals who identify their capabilities to help always utilizes the opportunity and become of great help, and this is the principle of altruism and has been widely explored in the health sector. One question that deserves an answer is, "can well-to-do caregivers of paediatric patients on admission providing antibiotics altruistically for the care of indigent paediatric patients? To providers answer to this question was the aim of this study. The outcome will inform policy reform towards designing intervention that can improve antibiotic availability, especially for indigent children.

Materials and Methods

Study Area

The study took place in three southeastern states in Nigeria: Abia, Ebonyi, and Enugu. Three tertiary health facilities which render paediatric health care services in these states were randomly selected. These hospitals have wide catchment areas and are accessed by households of different socio-economic status. They are all public facilities, and user fees are paid at the point where care was received.

Study design and population

The study was cross-sectional, and the period study was from March 2017 to May 2017. Simple random selection was used in the selection of the respondents. Healthcare workers and the parents/caregivers of in-patient children in the hospitals were interviewed.

Sampling and data collection

A total of three (3) Focus Group Discussions (FGDs) with the children's caregivers and 16 In-depth interviews (IDIs) with healthcare workers (HCWs) were used to collect data. A sociologist developed the interviewer's guides that were used for IDIs and FGDs. The guide was further translated to the native language (Igbo) for better comprehension. The guides were designed to obtain information on HCWs' antibiotics usage, ability to promptly provide antibiotics, willingness-to-donate antibiotics for other children use, and their willingness to allow their children to receive antibiotic reconstituted for other children. An inventory of remnants drugs of discharged patients in the hospital refrigerator was conducted. This is to evaluate the drug wastage due to discontinuation of antibiotic or discharge.

The IDIs were for doctors, nurses, and pharmacists. Three to four doctors, one nurse, and one pharmacist were identified and selected through random sampling for the IDI from each hospital. Information sheets were provided for them prior to the commencement of the interviews. Sixteen (16) IDIs were conducted in total.

The FGDs: A list of all the mothers/caregivers of children who had been on admission for a minimum of three days in the paediatric wards were used to develop a frame of random numbers; a minimum of eight subjects were randomly selected for each FGD. One FGD was conducted in each of the selected facilities, making it a total of three FGDs. The FGDs involved 8 - 10 caregivers per session to allow for an opportunity to get opinions from many mothers. A participant's biodata form was filled and signed by the participants before commencing each of the FGDs.

The participants in the FGD were mainly females (24) and a few males (3). Their occupations were diverse: banker, businessmen/women, civil servants, housewives, and petty traders. Sex balance could not be achieved because most caregivers were mothers. Each FGD lasted between 55 and 70 minutes. Light refreshment was provided for the respondents after the discussions. With the consent of the interviewees and FGD participants, the interviews were recorded.

Pilot and pre-testing of the FGD and IDI guides. The guide was pilot-tested among health care workers and parents that brought their children to a health center. This helped improve the comprehension and clarity of the lead questions and informed some modifications that were made before the survey. The information given was as follows: for the FGDs, the respondents were asked their experiences with antibiotic change in the first 48 hours, which was considered to be a challenge. They were asked where they purchased the antibiotics used for their children. After which they were asked whether they could donate antibiotic for indigent children as well as whether they can willingly relinquish any remaining reconstituted antibiotics for other children to use. They were also asked that even when they can provide their children drugs, whether they are willing to allow their children to receive treatment from already reconstituted antibiotics used for a discharged patient.

Data Management and Analysis

Quantitative analysis: The medical records of children on admission were reviewed. A proforma was used to document the quantity and estimate the cost of the remnant antibiotics in the refrigerator.

The costs of the different antibiotics were obtained through market survey. The average of the different prices was obtained. The estimated cost of the remnant antibiotics was calculated using the formula:

Average price = x; the proportion of the remnant antibiotic =a/b, where "a" is the quantity/dosage remaining and "b" is the total amount of dose in "mg" in one vial x.a/b

The cost estimates were in the local Nigerian currency (Naira) and converted to U.S. dollars (USD) at the official rate of 350 naira according to Central Bank of Nigeria (CBN) 2017. The discrepancies in the cost structure and purchasing power of the Naira and USD were adjusted using purchasing power parity.

The education and occupation of the parent were used to estimate the socioeconomic class and grouped into three groups: 1 - 2 high class, 3 middle and 4 - 5 low class.

Qualitative data: The audio recordings were transcribed verbatim into Microsoft Word documents (Microsoft, Redmond, WA) for analysis. To ensure transcription quality, all transcriptions were independently checked against the original audio recordings. A deductive approach was used to develop thematic headings. Parent and child nodes were developed to aid coding into the Nvivo software (QSR International, Melbourne, Australia) for the analysis.

Ethical Considerations

The approval to carry out this study was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, Enugu (Nigeria) Informed written consents were obtained from participants.

Results

Antibiotics Prescription Pattern

The proportion of the in-patients on parental antibiotics were 45 (84.2%), and in all cases, 7 (15.5%) were able to commence the prescribed antimicrobials within 1hour the prescription was made. (Table 1). The mean value of the remnant antibiotics was USD 2.1.