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The effect of two educational activities
on the practices of drugstore sellers in
the Philippines
Isidro C Sia*, Rainier M Galang†, Ophelia M Mendoza†, Judith A
Reyes†, Anna Margarita A Bernardo†, Dexter T Estrada†, Cristina O
Quiroga‡, Aldrin C Santiago‡
* Department of Pharmacology, College of Medicine, University of the
Philippines Manila
† National Drug Information Center, project of the National Drug Policy Staff,,
Department of Health
‡ Drug Use Study Group, National Institutes of Health, University of the
Philippines Manila
Background
Drug dispensing, as mandated by law, has been
designated to licensed pharmacists in the
Philippines.1 In community drugstores and chains in
cities and big towns, drugstore sellers usually
dispense drugs, supposedly under pharmacist
supervision.2 Drug sellers have no formal training in
pharmacy but the high cost of seeking medical
consultation and non-availability of physicians results
in consumers seeking the advice of drug sellers.3
Drugstore sellers play a significant role in the rational
use of drugs as privately owned drugstores are the
largest source of drugs nationwide.4 There is
evidence of irrational drug dispensing by drug sellers
in the Philippines.2
Objectives
To determine the prevalence of three undesired
practices of drugstore sellers and to evaluate the effect
of two educational interventions on these practices.
The practices are:
• incomplete dispensing [as demonstrated in the
outright filling of erroneous single prescription of
rifampicin for tuberculosis (TB)];
• dispensing amoxicillin without prescription for a child
with acute respiratory tract infection (ARI) and;
• recommending antibiotics where they may not be
needed in an adult with flu symptoms.
Methods
Study Design and Setting: Non-randomized comparative, pre-post
intervention study. Study sites were two comparable provinces,
selected from the Tagalog-speaking provinces in Luzon island,
Philippines.
Interventions: After pre-testing two interventions were conducted.
Moderated Interactive Group Discussion (IGD): 10 IGDs
comprising drug store sellers and mothers were conducted.
One seller, preferably the most senior, was invited from each
drugstore. Mothers were recruited through the local government
health offices. The moderator presented a summary on the
drugstore situation. Group discussion on the rational treatment
of tuberculosis, acute respiratory tract infection and flu (as well
as of wounds) followed. Leaflets on the rational treatment for
these conditions were distributed, as well as gifts. Additional
copies of the leaflets (20 per drugstore) were distributed to
drugstore representatives with the understanding that these
would be shared with the other sellers and clients.
Methods
IGDs were held in local restaurants or the town’s administrative
building and lasted for about 2 hours. The average number of
drugstore sellers per IGD was 8.5 (range= 4 –13, some
drugstores sent more than one representative).
Drug Store Visit (DSV): Drugstores not represented at IGDs
received a 5-10 minute visit from members of the research team.
The team distributed copies of the same educational material
used in the IGD and the main educational messages were
conveyed verbally. The drugstore sellers were advised to use the
material as a guide when attending to the clients.
Outcome Measures: Data were collected before the intervention
and 1-month post intervention and were obtained through trained
surrogate clients, drawn from local townsfolk. Each surrogate
client visited a drugstore only once and each drugstore received a
surrogate client visit for each scenario before and after the
intervention.
Results
The study population comprised 271 drug stores; 85
in the IGD intervention, 52 in the DSV group, and
134 in the control group. Drugstores employed 855
drugstore sellers (average 2 to 3 sellers). Stores
were generally owned by non-pharmacists and tend
to be located in cities, or well-off municipalities. The
intervention and control groups were comparable
with respect drugstore seller characteristics. Almost
all were females and mostly in the 20-29 year age
group. The age range of sellers was 14 to 75 years.
The proportion of sellers who spent up to 10 years in
school was approximately the same as those who
were schooled longer. Only 90 sellers (10.2%) were
pharmacists and of these, 50 were the drugstore
owners.
Results
The undesired practices were highly prevalent at baseline; 99.3%
of stores filled erroneous single prescriptions of rifampicin for TB,
83.4% dispensed amoxicillin without a prescription for ARI and
73.4% recommended antibiotics for flu symptoms. There were
baseline differences between the prevalence of practices between
intervention and control groups, and this non-comparability has
been accounted for using multiple logistic regression analysis
(MLRA).
The practice of filling erroneous prescription TB was not altered by
the IGD or DSV interventions.
The proportion of IGD drugstores dispensing amoxicillin without a
prescription for a child with ARI decreased significantly [Relative
Reduction (RR)= –23.1%, p=0.001] and the control group
significantly increased [RR=18.7%, p=0.0018] post-intervention.
While the DSV stores showed a moderate relative reduction in this
practice, the change was not significant RR= -11.0%, p=0.1317].
Results
Multiple logistic regression analysis (MLRA) indicated that
among independent variables, only intervention type had a
significant effect on the post-intervention dispensing practice of
drugstores. The IGD intervention had a significant effect on the
post-intervention practice of the drugstores [OR=0.27, (95% CI:
0.12-0.61)].
The proportion of IGD drugstores recommending antibiotics for
flu symptoms decreased significantly post-intervention [Relative
Reduction (RR)= –17.3%, p=0.0046]. The DSV and control
drugstores also reduced their recommendations [RR= -2.1%,
p=0.7389 and RR= -7.3.0%, p=0.2207] but they were not
significant. MLRA
indicated that only the pre-intervention
practice of drugstores was found to have a significant effect on
post-intervention practice [OR=12.54, (95%CI: 6.2-25.3)].
Figure. Comparison of pre- and post-intervention practices of
drug sellers
(IGD group: n = 85, DSV group: n = 52, Control group: n = 134)
Fills erroneous single prescription of rifampicin for
tuberculosis
100
100
100
98.5
99.3
100
75
75
%
100
50
91.8
88.5
70.6
90.3
78.8
76.1
Post
Pre
50
25
25
0
0
Pre
Post
Pre
IGD
Post
Pre
DSV
Post
Pre
Control
Post
IGD
Pre
DSV
Post
Control
Recommends antibiotic for an adult with flu
symptoms
100
88.2
72.9
75
%
%
100
Dispenses amoxicillin without prescription for a child
with ARI
82.7
Note:
80.8
60.4
56
Pre
Post
50
25
0
Pre
Post
IGD
Pre
Post
DSV
Control
IGD = Interactive group discussion
DSV = Drug store visit
ARI = Acute respiratory tract infection
Conclusions
The high prevalence of filling erroneous single prescriptions of
rifampicin did not change after the intervention. One reason may
be that in the Philippine cultural context, a person of lower
knowledge (i.e. drugstore seller) may not question the prescribing
practices of a person of higher knowledge (i.e. physician).
The practice of dispensing amoxicillin without prescription for a
child with ARI was reduced in the IGD intervention group. The
practice change may be attributed to the concern of the drugstore
seller on the possible adverse effect of the antibiotic on a child.
Despite drug sellers being in full control of the consultation with a
client with flu symptoms (there is no prescription from the
physician nor the specific drug product requested by the client),
the interventions failed to change this practice. This may be
because of strong traditions of using pre-packed combinations of
antibiotics and analgesics for the flu symptoms. Further, store
owners encourage sellers to provide the combination packs as
they are highly profitable and patients demand these products.
Conclusions
The drug seller profile is worth noting. Some drugstores have
sellers as young as 14 years old. In addition, half have attained,
at most, a high school education and only 90 of the 855 sellers
are trained pharmacists. Since there are laws requiring
drugstores to have a pharmacist, theoretically, there should have
been 271 pharmacists, the number corresponding to the number
of drugstores in the study.
Educational methods addressing undesired drug practices should
target health care providers (in formal and non-formal sectors)
and patients. The content should have harmonized messages
(eg, on rational use of antibiotics and rational dispensing) for the
different target groups (physician, pharmacist, drugstore seller,
variety store seller, community health worker, mother or other
family health carer, and others). Further measures to strengthen
drugstore sellers’ education should come from government
regulatory authority that can outline and enforce minimum
standards for practice.
References
1. Pharmacy law. Manila: Bureau of Printing, 1969.
2. Sia IC, Murray M, Sur ALD, Valerio J, Siochi R, Bocala M
et al. Status of drug use in Philippine communities:
education for improved use of medicines in the
community. Paper presented during the ‘Conference on
Philippine National Drug Policy: Moving Ahead’. Pasay
City, Philippines; 1997 September 30.
3. Lansang MA, Lucas-Aquino R, Tupasi TE, Mina VS,
Salazar LS, Juban N et al. Purchase of antibiotics
without prescription in Manila, the Philippines.
Inappropriate choices and doses. J Clin Epidemiol 1990;
43: 61-67.
4. IMS Health. Manila: IMS, 2003.