Tumwikirize WA., Ekwaru JP, Mohammed K., Ogwal-Okeng JW, Aupont O.

1. 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 thatdespite 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. 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

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. Results (continued) Changes in the assessment of children with ARI at the drug outlets * Significance level estimated at p-value less than 0.05

10. Results (continued) Changes in dispensing patterns of drugs used for ARI at the drug outlets * 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.