INFLUENCE OF LOCATION AND STAFF KNOWLEDGE ON QUALITY OF RETAIL PHARMACY PRESCRIBING FOR CHILDHOOD DIARRHEA IN KENYA

Background: Retail pharmacies are important sources of advice on pharm aceuticals in developing countries, where many purchasing decisions ar e unmediated by medical professionals. For childhood diarrhea, choice of drug sales in pharmacies has been found to be consistently poor, wh ether with or without prescription, as evidenced by a low use of effec tive oral rehydration salts (ORS) and high use of marginally effective or ineffective products such as antimotility agents, adsorbents, and antimicrobials. Little information is available about factors influenc ing prescribing by pharmacy personnel in these settings. This paper re ports results of an analysis which examined the influence of rural ver sus urban location, neighborhood socio-economic status (SES), and clin ical knowledge of pharmacy assistants on quality of prescribing in ret ail pharmacies in Kenya. Methods: Using WHO treatment guidelines, we m easured quality of prescribing in childhood diarrhea as: (1) the propo rtion of client encounters in which ORS is prescribed (indicating high er quality practice); and (2) the proportion of visits in which an ant idiarrheal product is prescribed (lower quality practice). We obtained data on prescribing in a simple case of childhood diarrhea using surr ogate patient visits to 91 pharmacies located in the major urban area of Kenya Nairobi) and four rural towns. Multivariate logistic regressi on was used to examine the association between pharmacy predictor vari ables and the quality of prescribing. Results: No consistent relations hip was found between the clinical knowledge of pharmacy assistants an d quality of prescribing. Controlling for number of products prescribe d, gender of the assessor, and level of knowledge, multivariate analys es indicated that in comparison to rural pharmacies, the odds of presc ribing ORS were significantly higher in parmacies located in high SES (OR 4.7; 95% CI = 1.4,16.1) or middle SES (OR = 4.5; CI = 1.9,10.6) ur ban neighborhoods; the odds in low SES urban pharmacies were similar t o those in rural areas (OR = 2.0; CI = 0.6,6.2). The odds of prescribi ng antidiarrheal products did not differ significantly in any geograph ic area. Conclusions: Location of a retail pharmacy in a rural area or in a low-income urban neighborhood was associated with suboptimal qua lity of prescribing as evidenced by lower use of ORS. No relationship between clinical knowledge and quality of practice was detected. Futur e research is needed to examine such factors as the influence of intra -pharmacy authority structure, perceived efficacy of pharmaceuticals, local patterns of physician practice, and economic incentives on the q uality of prescribing. Copyright (C) 1996 Elsevier Science Ltd.