THE IMPACT OF FACE-TO-FACE EDUCATIONAL OUTREACH ON DIARRHEA TREATMENTIN PHARMACIES

Private pharmacies are an important source of health care in developin g countries. A number of studies have documented deficiencies in treat ment, but little has been done to improve practices. We conducted two controlled trials to determine the efficacy of face-to-face educationa l outreach in improving communication and product sales for cases of d iarrhoea in children in 194 private pharmacies in two developing count ries. A training guide was developed to enable a national diarrhoea co ntrol programme to identify problems and their causes in pharmacies, u sing quantitative and qualitative research methods. The guide also fac ilitates the design, implementation, and evaluation of an educational intervention, which includes brief one-on-one meetings between diarrho ea programme educators and pharmacists/owners, followed by one small g roup training session with all counter attendants working in the pharm acies. We evaluated the short-term impact of this intervention using a before-and-after comparison group design in Kenya, and a randomized c ontrolled design in Indonesia, with the pharmacy as unit of analysis i n both countries (n = 107 pharmacies in Kenya; n = 87 in Indonesia). U sing trained surrogate patients posing as mothers of a child under fiv e with diarrhoea, we measured sales of oral rehydration salts (ORS); s ales of antidiarrhoeal agents; and history-taking and advice to contin ue fluids and food. We also measured knowledge about dehydration and d rugs to treat diarrhoea among Kenyan pharmacy employees after training .Major discrepancies were found at baseline between reported and obser ved behaviour. For example, 66% of pharmacy attendants in Kenya, and 5 3% in Indonesia, reported selling ORS for the previous case of child d iarrhoea, but in only 33% and 5% of surrogate patient visits was ORS a ctually sold for such cases. After training, there was a significant i ncrease in knowledge about diarrhoea and its treatment among counter a ttendants in Kenya, where these changes were measured. Sales of ORS in intervention pharmacies increased by an average of 30% in Kenya (almo st a two-fold increase) and 21% in Indonesia compared to controls (p < 0.05); antidiarrhoeal sales declined by an average of 15% in Kenya an d 20% in Indonesia compared to controls (p < 0.05). There was a trend toward increased communication in both countries, and in Kenya we obse rved significant increases in discussion of dehydration during pharmac y visits (p < 0.05). We conclude that face-to-face training of pharmac y attendants which targets deficits in knowledge and specific problem behaviours can result in significant short-term improvements in produc t sales and communication with customers. The positive effects and cos t-effectiveness of such programmes need to be tested over a longer per iod for other health problems and in other countries.