1. International Conference on Improving Use of Medicines
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

2. 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.

3. 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.

4. 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

5. 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)

6. Face to Face Educational Training Material distribution
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
Training of counter attendants on appropriate management of ARI in children covering:
Appropriate assessment of child’s condition
Appropriate management and dispensing for ARI
Information and instructions to give with dispensed drugs
Material distribution
Written materials (posters and brochures) targeting drug outlet personnel and clients were distributed
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

7. 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.

8. 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

9. Practices asking about specific questions
Results (continued)
Changes in the assessment of children with ARI at the drug outlets
Types of ARI
Types of questions
Intervention (n=84)
Control (n= 87)
Group Comparison
Practices asking about specific questions
Pre
Post
Difference
Sig.*
MILD ARI
Age of child
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
Previous medication
50%
53.6%
41.3%
48.5%
-3.6%
0.77
Presence of fever
26.2%
16.7%
13.8%
19.6%
-15.3%
Difficulty in breathing
4.8%
1.1%
5.7%
-9.4%
n/a
Nature of cough
21.4%
13.1%
26.6%
27.7%
0.27
SEVERE ARI
96.5%
100%
93.8%
-1.5%
75.3%
67.1%
71.6%
77.8%
0.15
11.7%
16.5%
7.4%
-7.5%
0.26
54.1%
48.2%
53.1%
-17.9%
0.10
28.2%
35.3%
23.5%
35.8%
-5.2%
0.58
4.7%
7.1%
6.2%
3.6%
0.49
21.2%
24.7%
12.4%
32.1%
-16.2%
0.04
* Significance level estimated at p-value less than 0.05

10. Practices dispensing a particular drug
Results (continued)
Changes in dispensing patterns of drugs used for ARI at the drug outlets
Types of ARI
Drug type
Intervention (n=84)
Control (n= 87)
Group Comparison
Practices dispensing a particular drug
Pre
Post
Difference
Sig.*
MILD ARI
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%
0.90
Cough syrup
59.5%
58.3%
49.4%
58.6%
-10.4%
0.28
SEVERE ARI
58.8%
70.6%
55.6
79%
-11.6%
0.21
17.6%
36.5%
28.4
29.6%
17.7%
0.06
25.6%
18.8%
13.6
35.8%
-29%
0.00
9.4%
8.2%
11.1
7.4%
2.5%
0.70
40%
48.2%
50.6
37%
21.8%
0.05
* Significance level estimated at p-value less than 0.05

11. Summary and conclusion
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.

12. Summary and conclusion
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.