WHO logo




Essential Medicines and Policy Department  (EDM)

International Conferences on Improving Use of Medicines (ICIUM)


photo Ross-DegnanA controlled trial of the impact of face-to-face educational outreach on diarrhoea treatment in pharmacies in two developing countries

Ross-Degnan D, Soumerai SB, Goel PK, Bates J, Makhulo J, Dondi N, Sutoto, Adi D, Ferraz-Tabor L, Hogan R


Harvard Medical School, Management Sciences for Health, Kenya CDD Program, Indonesia CDD Program, and WHO CDD Programme

Reference: Health Policy and Planning 1996; 11(3): 308-18


Problem Statement: Private pharmacies are an important source of health care in developing countries. A number of studies have documented deficiencies in treatment, but little has been done to improve practices.

Objectives: To determine the efficacy of face-to-face education in improving communication and product sales for diarrhoea in children in Kenya and Indonesia

Design: Before-and-after comparison group design in Kenya, and a randomized controlled design in Indonesia

Setting: 107 private pharmacies in Kenya, 87 private pharmacies in Indonesia

Intervention: A training guide was developed to enable a national diarrhoea control program to identify problems in pharmacy treatment of diarrhoea, and to design, implement, and evaluate an educational intervention (brief one-on-one meetings between educators and pharmacists/ owners, followed by small group sessions with counter attendants working in the pharmacies).

Outcome measures: Using surrogates posing as mothers of children under five with diarrhoea, we measured ORS and antidiarrhoeal sales, as well as history-taking and advice to continue fluids and food. We also measured knowledge about dehydration and drugs among Kenyan pharmacy employees after training.

Results: Major discrepancies were found at baseline between reported and observed behavior. For example, 66% of pharmacy attendants in Kenya, and 53% in Indonesia, reported selling ORS, but in only 33% and 5% of surrogate patient visits was ORS actually sold. After training, there was a significant increase in knowledge about diarrhoea. ORS sales in intervention pharmacies increased by 30% in Kenya (almost a two-fold increase) and 21% in Indonesia compared to controls (p<0.05); antidiarrhoeal sales declined by an average of 15% in Kenya and 20% in Indonesia compared to controls (p<0.05). There was a trend toward increased communication in both countries, and in Kenya, we observed increases in discussion about dehydration during pharmacy visits (p<0.05).

Conclusions: Face-to-face training of counter attendants targeting knowledge gaps and problem behaviours can result in significant short-term improvements in product sales and communication with customers. Cost-effectiveness needs to be tested over a longer period, for other problems, and in other countries.




blueball.gif (959 bytes) pharmacies and drug sellers are the principal source of diarrhea treatment in most developing countries

blueball.gif (959 bytes) many studies have documented poor practices in pharmacies: failure to recommend ORS; widespread sales of antidiarrhoeals and antibiotics; and little useful advice for customers

blueball.gif (959 bytes) national CDD programs have a traditional public sector bias, with little exposure to or understanding of the public sector



Increase the Capacity of National CDD Programs

blueball.gif (959 bytes) encourage a public sector MOH program to intervene to improve a private sector public health problem

blueball.gif (959 bytes) provide a structured format (the WHO-CDD Drug Sellers Guide) with which to manage a complex intervention

blueball.gif (959 bytes) encourage the use of local technical expertise in implementing a research-oriented package of activities

blueball.gif (959 bytes) encourage involvement with other MOH divisions, and with NGOs such as professional associations and UNICEF

Change Knowledge and Sales Practices of Drug Sellers

blueball.gif (959 bytes) improve knowledge among pharmacy staff about diarrhea and specific drugs commonly used to treat it

blueball.gif (959 bytes) increase ORS sales & decrease antidiarrheal & antibiotic sales

blueball.gif (959 bytes) improve quality of communication with customers: history-taking, case management, appropriate referral, and prevention


Stages of the WHO-CDD drug sellers guide

1. Learn How Diarrhoea is Treated & Why

blueball.gif (959 bytes) identify the relevant network of retail outlets and the specific drugs they stock for treating diarrhea

blueball.gif (959 bytes) survey knowledge and reported practices of pharmacists and counter attendants

blueball.gif (959 bytes) observe actual practices of pharmacy staff using the simulated case method (mothers trained to present a standard case)

blueball.gif (959 bytes) assess staff motivations and constraints to change using key informant interviews and focus groups

2. Prepare an Effective Training Program

blueball.gif (959 bytes) design print materials targeting specific observed behaviors amenable to change

blueball.gif (959 bytes) train trainers in techniques of persuasive communication

blueball.gif (959 bytes) design a persuasive education strategy, based on one-on-one or small group interactions where feasible

3. Carry Out Training & Evaluate Results

blueball.gif (959 bytes) mount intervention on a pilot scale (50-75 pharmacies)

blueball.gif (959 bytes) measure changes in knowledge resulting from training, and in specific target behaviors using simulated visits

blueball.gif (959 bytes) revise & establish ongoing training, ideally in conjunction with pharmacy association or ORS manufacturers



Sample Characteristics and Selection


blueball.gif (959 bytes) design is pre-post with comparison group

blueball.gif (959 bytes) 2-stages of training: Wave 1 (Nairobi pharmacies, n=58) with all other pharmacies (n=49) as control; Wave 2 (Nakuru and Kisumu, n=24) with Mombasa pharmacies (n=25) as control


blueball.gif (959 bytes) randomized controlled trial

blueball.gif (959 bytes) 87 pharmacies from Jakarta and neighboring towns, randomly assigned to intervention (n=43) and control (n=44) groups

Characteristics of the Intervention

 Persuasive Education

blueball.gif (959 bytes) targeted messages and themes (see examples of materials)

blueball.gif (959 bytes) one-on-one visits to "detail" pharmacists and enlist support

blueball.gif (959 bytes) all pharmacy staff invited to attend small group training (8-10 counter attendants per group) with high participation

blueball.gif (959 bytes) one short, interactive session per group (1.5-2.0 hours) conducted in local restaurant or hotel by trained educators

Supporting Components

blueball.gif (959 bytes) feedback data on actual practices from baseline assessments

blueball.gif (959 bytes) attractive pre-tested print materials for counter attendants and pharmacy customers (see examples)

blueball.gif (959 bytes) involve and feature credible sponsors (such as WHO, UNICEF, or the national pharmacists association)



FGD Findings with Kenya Drug Sellers

Information about therapy

blueball.gif (959 bytes) pharmacy staff model treatment practices of local MDs

blueball.gif (959 bytes) drug company information has high credibility

blueball.gif (959 bytes) great interest in learning about "scientific" therapy

Attitudes about drugs

blueball.gif (959 bytes) ORS is known, but seen as only "good first aid"

blueball.gif (959 bytes) feel need to "stop diarrhea quickly" and treat the cause

blueball.gif (959 bytes) poor knowledge about possible dangers of other drugs


blueball.gif (959 bytes) selling expensive drugs important, but not overwhelming

blueball.gif (959 bytes) pharmacy staff have strong desire to be seen as "competent"

Effects of Training (see Table and Figures)

blueball.gif (959 bytes) in Kenya, significant improvement in knowledge about bacterial diarrhea, role of antibiotics, and reasons for referral

blueball.gif (959 bytes) following training, ORS sales increased by 32% (p<0.05) in Kenya Wave 1, 26% (p<0.10) in Kenya Wave 2, and 21% (p<0.05) in Indonesia pharmacies compared to controls

blueball.gif (959 bytes) antidiarrheal sales decreased by 19% ((p<0.05) in Kenya Wave 1, 7% (NS) in Kenya Wave 2, and 20% (p<0.05) in Indonesia pharmacies; antibiotic sales low in both countries

blueball.gif (959 bytes) poor communication with customers about all topics; no improvements in Indonesia, and only significant increase in Kenya is in discussing dehydration



Success of the intervention

blueball.gif (959 bytes) CDD program directors can manage a complex intervention in the private sector in collaboration with outside organizations

blueball.gif (959 bytes) persuasive training does improve knowledge about diarrhea and drugs, as well as increase ORS sales and decrease antidiarrheal sales during simulated customer visits

blueball.gif (959 bytes) no improvement in communication with customers, either because practice does not change or measures are unreliable


Unanswered questions

 Can This Intervention Model Be Sustained?

blueball.gif (959 bytes) unknown if improvements will persist over time, especially in light of changing pharmacy staff

blueball.gif (959 bytes) MOH staff may not be motivated to continue to implement this type of training or reinforce its effects

blueball.gif (959 bytes) taking this model to regional or national scale may be difficult without participation from NGOs or ORS manufacturers


Can This Model Succeed Elsewhere or for Other Problems?

blueball.gif (959 bytes) some national CDD programs may lack structure or capacity to manage this intervention effectively

blueball.gif (959 bytes) a number of steps in the process depend on availability of local technical support (e.g., focus groups, interactive training)

blueball.gif (959 bytes) approach may be useful for problems like ARI or malaria

blueball.gif (959 bytes) success or failure in different environments and for different problems need to be understood before promoting widely


Indonesia counter flip chart: Front (side visible to customers)


Back (used to educate customers about ORS)


Brochures for Kenya counter staff

Case management brochure cover and sample page




Front and rear covers from brochure about antidiarrheal drugs


Kenya poster directed at customers