The impact of community-based teaching on drugs: an experience from western Uganda
Adome RO, Whyte SR, Ortenblad L, Nsabagasani X, Turinde AK
Objective: To assess the impact of community-based training on proper use of chloroquine, mebendazol, paracetamol, aspirin, magnesium trisilicate and ORS.
Design: This was a cross-sectional comparative study of two communities.
Setting: Kishami is served by two government health units which are fifteen kilometres away. The Uganda Red Cross Society was training the community on use of drugs. Kaberebere, which is seven kilometres away from one of the health units, lacked such an initiative.
Study Population: Kishami has nine villages with around 5,652 people and 1,074 households; 93 of these completed the follow-up interviews whereas in Kaberebere 90 households completed. In both cases, households with pre-school children were conveniently selected because they were likely to have more illness episodes.
Outcome Measures: These were based on process, coverage, effectiveness, appropriateness and sustainability of the intervention.
Intervention: Training of community representatives/community health workers on rational use of some selected common drugs to treat common diseases (malaria, worms, cough and diarrhoea). CRs and CHWs in turn educated community members.
Results: The training was highly appropriate, and well appreciated. There were some positive effects on knowledge and use of drugs compared to the control community. However, there were problems of sustainability, lack of coordination, consistent supervision and follow-up. Only consumers were sensitized during the study period although it had been planned to sensitize informal providers as well.
Conclusions: There is no doubt that the training of CRs on the use of some
essential drugs is useful. However, only about one third of households in the sample were
visited by the CRs. Knowledge about the proper dose of chloroquine was better in the
intervention community, but was still low at 19%. There is need to create and consolidate
the local capacity to sustain the training. The evaluation raised several questions of
general significance for the planning of community education on drugs.
The increasing sale of drugs by private retailers coupled with weakness in the formal sector of health care has led to a high rate of self-medication in Uganda. The community drug use study, of which the present research formed a part, found that 69% of treatments for four tracer conditions were taken without the advice of a health worker. These included drugs that are supposed to be regulated: 67% of antibiotic medications and 64% of chloroquine treatments were self medicated.1 Most interventions aimed at improving drug use in the country have been directed to government health units.2 They have not attempted to teach the public (or the retailers) specific indications or dosages. The underlying principle has been that self-medication should not be encouraged. In 1993 the Uganda Red Cross (URC) undertook a unique intervention that integrated instructions on a few simple drugs in community health education.
1Adome RO, Whyte SR, Hardon A. 1996. Popular Pills: Community Drug Use in Uganda. Amsterdam: Het Spinhuis.
2Kafuko, J., Zirabamuzaale C, Bagenda D. 1996. Rational Drug Use in Rural Health
Units of Uganda: Effect of National Standard Treatment Guidelines on Rational Drug Use.
Entebbe: Ministry of Health
To evaluate the URC training intervention in terms of its process appropriateness, coverage effectiveness and sustainability. To gain insight into issues of importance for designing further drug use interventions.
This evaluation had a cross-sectional comparative design. Kishami Parish, where the intervention took place, was compared with the similar neighbouring area of Kaberebere, where no intervention occurred.
As part of the overall study, qualitative research was carried out by two researchers, who resided in the area over a period of 18 months in 1993-1994. Focus group discussions, key informant interviews, and informal conversations were held with community health workers, local leaders, and URC officials. A weekly illness recall survey of 50 households in each area was done in late 1993.
In order to evaluate the intervention, the training sessions, which took place in 1993,
were observed by the field researchers. A structured interview on knowledge of drugs was
administered to a sample in each parish in May 1994. For this purpose, 93 households in
the intervention area of Kishami and 90 in the control area of Kaberebere were selected.
Only households with children under 5 were taken and the method was convenience sampling
starting at a given geographical point and taking every household where there was an adult
at home at the time of the survey.
The study was undertaken in Ntungamo District in southwestern Uganda. The two parishes are rural areas about 40 km. from the nearest town. The population depends on subsistence farming and small scale trading. Fertility rates are high at 8 children, as are infant mortality rates at 145/1000.3 The disease pattern is similar to that of most of southern Uganda: malaria, diarrhoea, respiratory infections, worms, malnutrition, eye infections, tuberculosis, and AIDS are major health problems. The areas are poorly served by formal health units. The people of Kishami had to go 15 km to the nearest health centre, while those of Kaberebere had a distance of 7 km.
Self-medication is the common mode of treatment. The household illness recall survey found that:
90% of treatments for fever, cough, worms, and diarrhoea were taken without advice from a
trained health worker.
25% of treatments included antibiotics.
Drug retailers were the main sources of treatment.
The Uganda Red Cross had identified Kishami as a primary health care intervention area and made a plan to integrate teaching about essential drugs into other PHC activities. Their needs assessment survey had revealed many malpractices in the use of drugs, including misuse of antibiotics. Although participants wanted to learn about antibiotics, URC explained that they could not teach about them because such drugs should not be used without professional advice.
Intervention activities were as follows:
Training of 71 community representatives (CRs) and community health workers (CHWs) for 5 days with 4 follow-up sessions of 4 days each.
Teaching of other community members by the CRs and CHWs (each was assigned 20 homes). Screening video shows on health problems.
Training a drama group in a play on use of drugs (not performed during the evaluation period).
Training of 15 drug retailers (planned but not done until 1995).
Training facilitators consisted of:
A core group of staff from the URC National Office in Kampala: a medical assistant, a nurse, and a teacher.
A URC regional officer and field officer.
A member of the district health team.
A midwife from the local government health unit.
A person from Radio Uganda who trained the drama group.
Messages on drug use included:
Cause, treatment, and prevention of common diseases (malaria, diarrhoea, worms, respiratory infections).
Indications and dosages for aspirin, panadol, chloroquine, mebendazole, magnesium trisilicate and ORS.
Dangers of drug misuse: overdose, underdose, improper storage.
Evaluation of the intervention
Training of CHWs was appropriate in view of the lack of formal health units and professional health workers in the area.
97% of respondents were positive about the programme. Few women were trained as CHWs. This was unfortunate given their key role in family care. Delaying the training of drug retailers was inappropriate since they continued to be the major suppliers of drugs. It is debatable whether excluding antibiotics was justifiable in a situation where they were commonly used and largely self-medicated.
Trainees were keen. Even people who had not been selected turned up to take part. Teaching was carried on in an atmosphere of exchange and engagement. Communication was a problem at times, since some of the facilitators did not speak the local languages.
About one third of the households in the Kishami sample reported that they had been visited at least once by a CHW. This was far below URC plans that 80% of homes would be visited 6 times in the year.
Knowledge about chloroquine was somewhat better in the intervention area: 86% knew that
it was the appropriate drug for malaria (vs. 78% in the control area) and 19% knew the
correct dose for an adult, while no one in the control sample knew the dose. Knowledge
about ORS was better in the intervention area: 61% knew it was appropriate for diarrhoea
(vs. 23% in control sample) and 46% knew how to prepare it (vs. 14% in control area). The
level of appropriate medication in defined health problems was higher in the intervention
area (26%) than in the control (14%). However appropriateness was poor overall in both
localities. Drug retailers in the intervention area reported an increase in chloroquine
sales after the training.
CHWs and community members were pessimistic about the prospects for sustainability once
the leading role of URC drew to a close. Supervision and continuing support were
insufficient. CHWs did not hold meetings among themselves to review progress and problems.
Their home visiting activities fell off sharply after the last refresher course. The
district health team had not taken responsibility for long term support and follow-up. The
CHWs were not being paid nor were they supplied with medicines to sell. In order to derive
some income from their work, several set themselves up as drug retailers.
Conclusion and implications
The Uganda Red Cross intervention in Kishami was moderately successful in terms of the measures adopted here. The training programme was appropriate in that it addressed major health problems of the area and drugs that were locally available. The process of training was reasonably carried out. The enthusiasm with which the training was received suggests that there is great interest in learning more about recommended drug use; qualitative research in the area strongly supported this impression. In terms of knowledge about chloroquine and ORS, the intervention area came out better. The evidence on practice also suggests that the training helped: the appropriateness of medication taken (most of which was self-medication) was better in Kishami. However there were also problematic aspects of the training programme from which much can be learned.
The following questions are of general concern for training programmes:
1. What is the local situation of drug provision?
In Kishami, there was no immediately accessible formal unit. The training itself did not change the fundamental situation that people continued to obtain the vast majority of their drugs from retailers. (As part of the general mobilization that URC set in motion, construction began on a local health unit in the hope that the government would staff it. But the unit has yet to be completed four years later.) Any intervention should be tailored to the local reality of drug provision, rather than assuming that one model will fit all local variations equally well.
2. Who should receive training?
The URC had the innovative plan of training both users and private providers. In the event, the training of retailers was delayed, and did not occur until after our study was completed. It would have been preferable to provide training for providers and users at the same time so that the two parties could reinforce each other's new knowledge and practices.
Public health education never reaches "the public" in general, but only those to whom channels of information flow. In Kishami information flowed most effectively to men as trainees and to a minority (one third) of households which were visited.
Training drug retailers will entail decisions about which ones to train. Should an intervention target only the legal retailers with licenses? Or should an attempt be made to reach all proprietors and shop assistants?
3. Who should provide the training?
The URC intervention in Kishami relied heavily on staff from the central office in Kampala to train community health workers and community representatives. The Kampala people did a good job, but there was no local follow-up. Although a member of the district health team and a health worker from the nearest government unit participated to some extent, they were not involved enough to carry on. The intervention remained an NGO initiative that was not an integrated part of district health care.
The trainees were also trainers in the sense that they were to provide information on drugs to their neighbours. Most of them had no drugs to provide, so the drug messages were not integrated in real situations of using drugs. In contrast training drug retailers would allow them to use the occasion of drug provision for informing users.
4. What messages should training convey?
Messages can be positive or negative. Most public education on drugs in Uganda has been of the negative type - warning against sharing drugs, asking for injections, or consulting "quack" doctors. The URC made the decision to give some positive messages as well about indications and dosages. Training can be broad or focused. Here URC decided to select a few common conditions and drugs.
The most sensitive question about training content concerns which drugs to teach about. Although antibiotics were commonly self-medicated in Kishami and people wanted to learn more about them, the URC decided that informing about indications and dosages would condone a practice that was dangerous. The community drug use project found that most health policymakers at national and international levels agreed with this view. But some members of district health teams and frontline health workers favoured educating drug sellers about the proper use of antibiotics on the pragmatic grounds that they were the main source of medication in many communities.
5. How can sustainability be promoted?
Possibilities for sustainability can be increased by institutionalizing follow-up and by motivating individuals to keep up the practices they learned about in the training. URC organized four follow-ups and they returned to Kishami for a drug retailer training session. But they have now phased out their work in Kishami and there is no reliable arrangement for continuing the follow-up.
Individual motivation is more likely to be sustained in the long run if the wish to enlighten others about safe and effective drug use can be combined with some possibility of income. For this reason, the training of community health workers to disseminate drug use messages on a purely voluntary and idealistic basis is probably not sustainable in the long run.