Transcript Poster presentation

IMPACT OF TRAINING IN DRUG SUPPLY MANAGEMENT
(DSM) ON DSM, DISPENSING PRACTICE AND PATIENT
KNOWLEDGE AND CARE AT PRIMARY HEALTH CARE
CLINICS
Summers RS1, Kruger CH2
(1) School of Pharmacy, MEDUNSA
(2) School of Pharmacy, MEDUNSA and Pharmaceutical Services, Mpumalanga
Abstract
Problem statement: DSM training for Primary Health Care (PHC) staff was
introduced as part of the Essential Drugs Programme in Mpumalanga Province of
South Africa.
Objectives: To determine the impact of the training on the practice of DSM,
dispensing and patient knowledge
Design: Randomised, controlled, pre-post intervention study
Setting and Study Population: Twelve PHC clinics in the Eastern Highveld
region of Mpumalanga Province of South Africa, randomly allocated to study and
control groups (six in each group).
Intervention: Training for DSM for PHC staff. Training materials were adapted from
the WHO/BASICS DSM Training course. The three-day training workshop was
part of a provincial DSM training cascade. It was presented by the researcher, two
pharmacists’ assistants and a primary health care worker who had successfully
completed the generic training of trainers and DSM workshops presented by
MEDUNSA School of Pharmacy Training and Development Project. The study
consisted of four phases: pre-intervention survey, training workshop for staff from
the study group clinics, first post-intervention survey one month after the workshop
and second post-intervention survey three months after the workshop.
Outcome Measures: Organisation of supplies, record-keeping, ordering and
stock control and goods receipts; labelling of medicines, patient knowledge and
advice received and usage of medicines on the Essential Drugs List (EDL).
Results: Highly significant improvements were recorded across the range of
activities listed above from baseline to the first post-intervention survey. The
improvements were sustained and even increased in some cases from the first to
the second post-intervention surveys.
Conclusions: DSM training impacted more than just the DSM indicators. It also
improved patient care and raised the level of use of EDL drugs
Funding source: Operating budgets of the MEDUNSA School of Pharmacy and
provincial pharmaceutical services of Mpumalanga Province. The training
workshop was funded by the South African Drug Action Programme (SADAP).
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Objectives of the study
To assess the impact of Drug Supply
Management training on the way in which
 the drug store is prepared,
 supplies are organised,
 records are kept,
 supplies are ordered,
 supplies are received
(Drug Supply Management),and
 drugs are dispensed
(prescribing and dispensing).
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Method
A controlled pre-intervention / postintervention study was carried out between
July and December 1998 in the Highveld
region (now Ngangala) of Mpumalanga
Province.
Twelve clinics were chosen according to the
following criteria:
 DSM trainers present in the area
 Enough patients for 30 interviews in a day
 Pharmacists’ assistants and nurses
could attend training
Three-day in-service workshops for primary
health care workers were organised as part of
a training cascade conducted in the province.
Training materials were adapted from the
WHO/BASIC DSM training package (1).
WHO-recommended indicators were
investigated using structured questionnaires.
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Study area
Study area
Mpumalanga
Province
South Africa
Study plan
Control group
(6 clinics)
Pre-test
Study group
(6 clinics)
Pre-test
Post-test 1
Training
Post-test 1
Post-test 2
Post-test 2
= 1 month
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Indicator groups:
DSM
1 questionnaire
per clinic and survey
Indicator group (number of indicators) description
Storage (6) - Dry medicines on top shelf, generic
labels, FEFO, FIFO, stock returned on expiry, removed
stock recorded
Record keeping (8) - Stock levels recorded, order
times defined, stock cards exist, updated with issues,
destination, quantity, current stock level; regular stock
checks
Ordering (5) - Based on past consumption, triggered
by re-order stock levels, physical stock checks when
ordering, average monthly consumption calculated,
stock reference number specified.
Receiving (7)- : stock is signed for, checked when
delivered (against order, expiry dates, possible
damage), discrepancies documented
Physical infrastructure of medicines store
(12) - Locks on doors, access control, cleanliness,
temperature control (ceiling, ventilation, windows),
stock stored off floor, roof intact, pest-free, separate
from dispensing area
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Results: DSM
Pre (n=6)
Pre (n=6)
Post1 (n=6)
Post1 (n=6)
Post2 (n=6)
Post2 (n=6)
80%
60%
40%
within groups1:
Control (C) P2 vs Pre
Study (S) P2 vs Pre

between groups2:
C vs S
Pre
C vs S
P2

Effect size:
a Study P2-Pre (%) 53.9
b Control P2-Pre (%) 11.1
a-b (%)
42.8
Significance2

1 paired
Ordering
(5)
Indicator group
(number of
indicators):
Significant differences
Records
(8)
Storage
(6)
0%


Physical
(12)
20%
Receiving
(7)
Positive responses
Control group:
Study group:
100%


47.6
14.3
33.3

16.7
12.5
4.2

50.0
6.3
43.7
56.7
-3.3
60.0

T-test, 2 independent T-test;  p<0.05
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Indicator groups:
prescribing
and dispensing
30 patient exit interviews
per clinic and survey
Indicator group (number of indicators) description
Labelling (10) - Generic name, strength, dosage,
schedule, quantity, warnings, batch number, expiry
date, dosage instructions, patient ref. number
Quality of medicines (2) - Identity of medicine,
not expired
Patient knowledge (3) - Dosage, frequency,
duration of treatment
Advice given (2) - Patient was told to keep
medicines away from children, was asked to repeat
dispenser’s instructions
EDL medicines only were prescribed (1)
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Results: dispensing
Pre (n=198)
Pre (n=185)
Post1 (n=196)
Post1 (n=193)
Post2 (n=192)
Post2 (n=201)
80%
60%
40%
1 paired
EDL meds
(1)
Indicator group
(number of
indicators):
Significant differences
within groups1:
Control (C) P2 vs Pre  
Study (S) P2 vs Pre  
between groups2:
C vs S
Pre

C vs S
P2

Effect size:
a Study P2-Pre (%) 21.1
b Control P2-Pre (%) 5.0
a-b (%)
16.1
Significance2








24.1
0.7
23.4

48.6
0.1
48.5

25.5
0.0
25.5

Pt knowledge (3)
Labelling
(10)
0%
Pt instructions (2)
20%
Med quality
(2)
Positive responses
Control group:
Study group:
100%

0.0
2.5
-2.5
T-test, 2 independent T-test;  p<0.05,  p < 0.001
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Discussion
Significant improvements were achieved
through the training programme as shown
above. This study confirms earlier findings
(2,3) that this type of training can improve drug
supply management and prescribing practices
at Primary Care level.
For Drug Supply Management, considerable
average effect sizes were achieved. However,
the performance of the clinics varied greatly. A
general situation of understaffing might have
hindered the implementation of the concepts
learnt.
For patient exit interviews, significant differences were shown for all the indicator groups
except drug quality, where both groups performed at a high level throughout the study.
It is encouraging to note that the beneficial
effects of the training were more marked at
Post-test 2 than at Post-test 1, indicating a
good retention effect of the training.
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Limitations
The results from the study area are not
necessarily representative of the entire
Mpumalanga Province.
The sample size for DSM indicators, where
only one questionnaire was completed per
clinic at each test phase, was relatively small.
Certain indicators in the Facility category, like
changing physical structures and purchasing
locks, were not under the control of primary
health care staff.
Trainers who worked in the region were trained
long before the first intervention and could
have influenced the study.
The lack of Management involvement and
financial support delayed the training process.
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Recommendations
 Ongoing in-service training relevant to
conditions in the field should be presented
 Trainers should attend annual refresher
courses; new trainers should be trained as
necessary
 Training manuals should be adopted at
national level
 Provincial management should be involved
and committed to the training programme
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Acknowledgements
Prof. HS Schoeman, for statistical consultancy
Staff of the School of Pharmacy, for their support
Provincial Department of Health,
for permission to conduct the study
Mr. Gustav Malangu
Mrs. Monika Zweygarth,
for data analysis and this presentation
References
(1) WHO Div. of Child Health Development/BASICS.
Drug supply management training resources.
Available on-line at http://www.who.int/child-adolescenthealth/publications/CHILD_HEALTH/
WHO_CHD_98.4.htm
(2) Meyer JC, Summers RS, Möller H. Randomized
controlled trial of prescribing training in a South
African Province. Med Ed 2001; 35: 833-840.
(3) Phasha D. Strengthening District
Pharmaceutical Services. MSc (Med) Dissertation.
MEDUNSA: School of Pharmacy, 2002.