Transcript Poster presentation

IMPACT OF FACE-TO-FACE EDUCATIONAL
INTERVENTION ON IMPROVING THE
MANAGEMENT OF ARI IN PRIVATE PHARMACIES
AND DRUG SHOPS IN UGANDA:
Tumwikirize WA., Ekwaru JP, Mohammed K.,
Ogwal-Okeng JW, Aupont O.
International Conference on Improving
Use of Medicines
Chiang Mia, Thailand 2004
INRUD Uganda and Makerere University
Project supported as part of the Joint Initiative on Improving
Use of Medicine under a grant from ARCH
Abstract
Problem statement: In Uganda, though private retail pharmacies and drug shops are the commonest
source of drugs for a big proportion of the population, there is a high level of irrational dispensing. It is
believed that lack of adequate knowledge is an important underlying factor to such practices.
Objectives: To assess the impact of a small group face-to-face educational intervention aimed at
improving management of ARI in the under-fives, at private pharmacies and drug shops.
Study design: The study used a non-randomized quasi-experimental research design with comparison
groups to analyze counter attendants’ management of ARI before and after an intervention.
Study setting and population: The study was conducted in Kampala District, and used a sample of
191 counter attendants from 191 registered drug outlets (27 Pharmacies and 164 drug shops), which
were stratified into two groups: 1) An experimental group that received an educational intervention; 2)
A comparison group that was not exposed to the training. Data on the practices in the drug outlets
were collected at two time-points: 7 months before the intervention, and at 1-month after the
intervention.
Outcome measures: Two main outcome measures were considered: a) Assessment of the child’s
condition. b) The dispensing practices of counter attendants.
Results: The study found that despite the intervention, the assessment of the child’s condition
remained inadequate in both groups where the child’s age was the only question asked in more than
90% of cases. High levels of irrational dispensing for both mild and severe ARI were still persistent in
both groups after the intervention. Antibiotic prescribing for both mild and severe ARI was very
common, and barely no information or advice was given with the dispensed drugs. The main reported
barriers were clients’ demand for particular drugs, competition among drug outlets, and the
recommended dose being unaffordable to most clients
Conclusions: The face-to-face educational intervention did not improve management of ARI. The
study suggests the need to combine education training with regulatory enforcement in order to ensure
that counter attendants acquire the necessary skills so as to appropriately manage ARI in drug outlets.
BACKGROUND
─
Private pharmacies and drug shops are important sources
of drugs in Uganda
─
High level of consumer preference for these outlets.
─
Outlets characterized by high level of inappropriate
dispensing practices.
─
Limited knowledge of outlet staff identified as a major
contributor to sub-optimal practice
─
Face-to face interaction with counter attendants is believed
to be amongst strategies capable of improving dispensing
practices at drug shops and pharmacies.
OBJECTIVES
General objective:
To assess the impact of an educational intervention
aimed at improving the management of ARI in
children under-five by counter attendants at
private pharmacies and drug shops in Uganda.
Specific Objectives:
To evaluate the impact of the intervention on :
.
counter attendants’ assessment of child’s illness.
.
Prescribing and dispensing practices
.
Counter attendants’ advices given on home care
management
METHODS
-
Quasi-experimental research design with comparison
groups
-
Survey of 191 drug outlets in Kampala District:
- 27 pharmacies & 164 drug shops
Use of simulated clients and case scenarios of a children
with either mild or severe ARI
-
-
An educational intervention targeting counter attendants
at the drug outlets
-
Two waves of data collection
. At baseline (7 months before intervention)
. At follow-up (1 month post-intervention)
METHODS (continued)
Intervention Description
2 components:
Three morning sessions of face-to-face educational training of
counter attendants conducted over a 3-week period
-
Distribution of written materials
Face to Face Educational Training
Material distribution
Training of counter attendants on
appropriate management of ARI in
children covering:
Written materials (posters and
brochures) targeting drug outlet
personnel and clients were distributed
Appropriate assessment of child’s
condition
- Appropriate management and
dispensing for ARI
- Information and instructions to give
with dispensed drugs
-
-
Materials for drug outlet personnel
provided information on appropriate
management of sick children with ARI
- Materials for clients contained
information on danger signs of ARI and
referrals
Results
-
Questioning about age of the child received most attention during
assessment of illness.
-
Very little improvement observed for assessment of child condition after
the intervention
-
For both conditions of ARI, smaller improvement in counter attendants’
inquiry about duration of illness and history of previous medication
observed for intervention.
-
Overall assessment of sign and symptoms worsened in the intervention
group.
-
For mild ARI, antibiotic use decreased in post intervention in both groups
-
For severe ARI, greater increase of antibiotic use was observed for
comparison group.
Results (continued)
-
For mild and severe ARI, co-trimoxazole was the most frequently
prescribed antibiotic
-
Greater increase of the recommended first line antibiotic for severe ARI
was found in the intervention group
-
For both cases, most prescriptions contained a cough syrup
Information on daily dose was the only instruction given with dispensed
drugs.
-
-
Giving plenty of oral fluids was the main advice given for home care for
both ARI conditions, and was higher in the intervention group
-
More advices on referral were provided in the comparison group for mild
ARI while decreasing in both for severe ARI
Results (continued)
Changes in the assessment of children with ARI at the drug outlets
Intervention (n=84)
Types of
ARI
MILD ARI
SEVERE
ARI
Types of questions
Control (n= 87)
Group Comparison
Practices asking about specific questions
Pre
Post
Pre
Post
Difference
Sig.*
Age of child
98.8%
98.8%
93.2%
95.5%
-2.3%
0.79
Duration of illness
20.2%
25%
62.2%
74.8%
-7.8%
0.62
Previous medical visits
22.6%
10.7%
17.2%
19.7%
-14.4%
0.08
50%
53.6%
41.3%
48.5%
-3.6%
0.77
Presence of fever
26.2%
16.7%
13.8%
19.6%
-15.3%
0.08
Difficulty in breathing
4.8%
0
1.1%
5.7%
-9.4%
n/a
Nature of cough
21.4%
13.1%
26.6%
27.7%
-9.4%
0.27
Age of child
96.5%
100%
93.8%
98.8%
-1.5%
Duration of illness
75.3%
67.1%
71.6%
77.8%
-14.4%
0.15
Previous medical visits
11.7%
16.5%
7.4%
19.7%
-7.5%
0.26
Previous medication
67.1%
54.1%
48.2%
53.1%
-17.9%
0.10
Presence of fever
28.2%
35.3%
23.5%
35.8%
-5.2%
0.58
Difficulty in breathing
4.7%
7.1%
7.4%
6.2%
3.6%
0.49
Nature of cough
21.2%
24.7%
12.4%
32.1%
-16.2%
0.04
Previous medication
* Significance level estimated at p-value less than 0.05
Results (continued)
Changes in dispensing patterns of drugs used for ARI at the drug outlets
Intervention (n=84)
Types of
ARI
MILD ARI
SEVERE
ARI
Drug type
Control (n= 87)
Group Comparison
Practices dispensing a particular drug
Pre
Post
Pre
Post
Difference
Sig.*
An antibiotic
40.5%
36.9%
52.9%
47.1%
2.2%
0.75
Co-trimoxazole
23.8%
17.9%
31%
23%
2.1%
0.82
Amoxycillin
10.7%
21.4%
10.3%
18.4%
2.6%
0.65
Ampicillin
7.1%
2.4%
11.5%
3.4%
3.4%
0.90
Cough syrup
59.5%
58.3%
49.4%
58.6%
-10.4%
0.28
An antibiotic
58.8%
70.6%
55.6
79%
-11.6%
0.21
Co-trimoxazole
17.6%
36.5%
28.4
29.6%
17.7%
0.06
Amoxycillin
25.6%
18.8%
13.6
35.8%
-29%
0.00
Ampicillin
9.4%
8.2%
11.1
7.4%
2.5%
0.70
Cough syrup
40%
48.2%
50.6
37%
21.8%
0.05
* Significance level estimated at p-value less than 0.05
Summary and conclusion
─
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High level of inappropriate dispensing persistent in
both categories of outlets.
Overall assessment of the child’s condition remained
inadequate for both mild and severe ARI
Treatment of ARI in those outlets did not follow the
recommended treatment guidelines
An antibiotic and a cough syrup were the most
frequently dispensed drugs for both mild and severe
ARI.
Summary and conclusion
─
─
─
─
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Information given with dispensed drugs and advice on home
care were inadequate at the outlets
Though rated highly, the intervention did not result in quality
improvement at the targeted outlets
Pharmacies and drug shops will remain a major source of
care in Uganda
Several factors must be addressed if changes are to occur
Possibly a combination of regulatory and educational
interventions will lead to improved management of ARI in
drugs shops and pharmacies.