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.
pharmacies and drug sellers are the principal source of diarrhea treatment in most developing countries
many studies have documented poor practices in pharmacies: failure to recommend ORS; widespread sales of antidiarrhoeals and antibiotics; and little useful advice for customers
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
encourage a public sector MOH program to intervene to improve a private sector public health problem
provide a structured format (the WHO-CDD Drug Sellers Guide) with which to manage a complex intervention
encourage the use of local technical expertise in implementing a research-oriented package of activities
encourage involvement with other MOH divisions, and with NGOs such as professional associations and UNICEF
Change Knowledge and Sales Practices of Drug Sellers
improve knowledge among pharmacy staff about diarrhea and specific drugs commonly used to treat it
increase ORS sales & decrease antidiarrheal & antibiotic sales
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
identify the relevant network of retail outlets and the specific drugs they stock for treating diarrhea
survey knowledge and reported practices of pharmacists and counter attendants
observe actual practices of pharmacy staff using the simulated case method (mothers trained to present a standard case)
assess staff motivations and constraints to change using key informant interviews and focus groups
2. Prepare an Effective Training Program
design print materials targeting specific observed behaviors amenable to change
train trainers in techniques of persuasive communication
design a persuasive education strategy, based on one-on-one or small group interactions where feasible
3. Carry Out Training & Evaluate Results
mount intervention on a pilot scale (50-75 pharmacies)
measure changes in knowledge resulting from training, and in specific target behaviors using simulated visits
revise & establish ongoing training, ideally in conjunction with pharmacy association or ORS manufacturers
Sample Characteristics and Selection
design is pre-post with comparison group
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
randomized controlled trial
87 pharmacies from Jakarta and neighboring towns, randomly assigned to intervention (n=43) and control (n=44) groups
Characteristics of the Intervention
targeted messages and themes (see examples of materials)
one-on-one visits to "detail" pharmacists and enlist support
all pharmacy staff invited to attend small group training (8-10 counter attendants per group) with high participation
one short, interactive session per group (1.5-2.0 hours) conducted in local restaurant or hotel by trained educators
feedback data on actual practices from baseline assessments
attractive pre-tested print materials for counter attendants and pharmacy customers (see examples)
involve and feature credible sponsors (such as WHO, UNICEF, or the national pharmacists association)
FGD Findings with Kenya Drug Sellers
Information about therapy
pharmacy staff model treatment practices of local MDs
drug company information has high credibility
great interest in learning about "scientific" therapy
Attitudes about drugs
ORS is known, but seen as only "good first aid"
feel need to "stop diarrhea quickly" and treat the cause
poor knowledge about possible dangers of other drugs
selling expensive drugs important, but not overwhelming
pharmacy staff have strong desire to be seen as "competent"
Effects of Training (see Table and Figures)
Success of the intervention
Can This Intervention Model Be Sustained?
Can This Model Succeed Elsewhere or for Other Problems?