The effect of two educational activities on the practices of drugstore sellers in the Philippines

1
The effect of two educational activities on the
practices of drugstore sellers in the Philippines 

• Isidro C Sia, Rainier M Galang, Ophelia M
  Mendoza, Judith A Reyes, Anna Margarita A
  Bernardo, Dexter T Estrada, Cristina O
  Quiroga, Aldrin C Santiago
• Department of Pharmacology, College of
  Medicine, University of the Philippines Manila
  National Drug Information Center, project of the
  National Drug Policy Staff,, Department of Health
• Drug Use Study Group, National Institutes of
  Health, University of the Philippines Manila

2
Background

• Drug dispensing, as mandated by law, has been
  designated to licensed pharmacists in the
  Philippines.1 In community drugstores and chains
  in cities and big towns, drugstore sellers
  usually dispense drugs, supposedly under
  pharmacist supervision.2 Drug sellers have no
  formal training in pharmacy but the high cost of
  seeking medical consultation and non-availability
  of physicians results in consumers seeking the
  advice of drug sellers.3 Drugstore sellers play a
  significant role in the rational use of drugs as
  privately owned drugstores are the largest source
  of drugs nationwide.4 There is evidence of
  irrational drug dispensing by drug sellers in the
  Philippines.2  

3
Objectives

• To determine the prevalence of three undesired
  practices of drugstore sellers and to evaluate
  the effect of two educational interventions on
  these practices. The practices are
• incomplete dispensing as demonstrated in the
  outright filling of erroneous single prescription
  of rifampicin for tuberculosis (TB)
• dispensing amoxicillin without prescription for a
  child with acute respiratory tract infection
  (ARI) and
• recommending antibiotics where they may not be
  needed in an adult with flu symptoms.

4
Methods

• Study Design and Setting Non-randomized
  comparative, pre-post intervention study. Study
  sites were two comparable provinces, selected
  from the Tagalog-speaking provinces in Luzon
  island, Philippines.
• Interventions After pre-testing two
  interventions were conducted.
• Moderated Interactive Group Discussion (IGD) 10
  IGDs comprising drug store sellers and mothers
  were conducted. One seller, preferably the most
  senior, was invited from each drugstore. Mothers
  were recruited through the local government
  health offices. The moderator presented a summary
  on the drugstore situation. Group discussion on
  the rational treatment of tuberculosis, acute
  respiratory tract infection and flu (as well as
  of wounds) followed. Leaflets on the rational
  treatment for these conditions were distributed,
  as well as gifts. Additional copies of the
  leaflets (20 per drugstore) were distributed to
  drugstore representatives with the understanding
  that these would be shared with the other sellers
  and clients.

5
Methods

• IGDs were held in local restaurants or the
  towns administrative building and lasted for
  about 2 hours. The average number of drugstore
  sellers per IGD was 8.5 (range 4 13, some
  drugstores sent more than one representative).
• Drug Store Visit (DSV) Drugstores not
  represented at IGDs received a 5-10 minute visit
  from members of the research team. The team
  distributed copies of the same educational
  material used in the IGD and the main educational
  messages were conveyed verbally. The drugstore
  sellers were advised to use the material as a
  guide when attending to the clients.
• Outcome Measures Data were collected before the
  intervention and 1-month post intervention and
  were obtained through trained surrogate clients,
  drawn from local townsfolk. Each surrogate client
  visited a drugstore only once and each drugstore
  received a surrogate client visit for each
  scenario before and after the intervention.

6
Results

• The study population comprised 271 drug stores
  85 in the IGD intervention, 52 in the DSV group,
  and 134 in the control group. Drugstores employed
  855 drugstore sellers (average 2 to 3 sellers).
  Stores were generally owned by non-pharmacists
  and tend to be located in cities, or well-off
  municipalities. The intervention and control
  groups were comparable with respect drugstore
  seller characteristics. Almost all were females
  and mostly in the 20-29 year age group. The age
  range of sellers was 14 to 75 years. The
  proportion of sellers who spent up to 10 years in
  school was approximately the same as those who
  were schooled longer. Only 90 sellers (10.2)
  were pharmacists and of these, 50 were the
  drugstore owners.

7
Results

• The undesired practices were highly prevalent at
  baseline 99.3 of stores filled erroneous single
  prescriptions of rifampicin for TB, 83.4
  dispensed amoxicillin without a prescription for
  ARI and 73.4 recommended antibiotics for flu
  symptoms. There were baseline differences between
  the prevalence of practices between intervention
  and control groups, and this non-comparability
  has been accounted for using multiple logistic
  regression analysis (MLRA).
• The practice of filling erroneous prescription
  TB was not altered by the IGD or DSV
  interventions.
•  
• The proportion of IGD drugstores dispensing
  amoxicillin without a prescription for a child
  with ARI decreased significantly Relative
  Reduction (RR) 23.1, p0.001 and the control
  group significantly increased RR18.7,
  p0.0018 post-intervention. While the DSV stores
  showed a moderate relative reduction in this
  practice, the change was not significant RR
  -11.0, p0.1317.

8
Results

• Multiple logistic regression analysis (MLRA)
  indicated that among independent variables, only
  intervention type had a significant effect on the
  post-intervention dispensing practice of
  drugstores. The IGD intervention had a
  significant effect on the post-intervention
  practice of the drugstores OR0.27, (95 CI
  0.12-0.61).
• The proportion of IGD drugstores recommending
  antibiotics for flu symptoms decreased
  significantly post-intervention Relative
  Reduction (RR) 17.3, p0.0046. The DSV and
  control drugstores also reduced their
  recommendations RR -2.1, p0.7389 and RR
  -7.3.0, p0.2207 but they were not significant.
  MLRA indicated that only the pre-intervention
  practice of drugstores was found to have a
  significant effect on post-intervention practice
  OR12.54, (95CI 6.2-25.3).

9
Figure. Comparison of pre- and post-intervention
practices of drug sellers (IGD
group n  85, DSV group n 52, Control group
n 134)
Note IGD Interactive group discussion DSV
Drug store visit ARI Acute respiratory tract
infection
10
Conclusions

• The high prevalence of filling erroneous single
  prescriptions of rifampicin did not change after
  the intervention. One reason may be that in the
  Philippine cultural context, a person of lower
  knowledge (i.e. drugstore seller) may not
  question the prescribing practices of a person of
  higher knowledge (i.e. physician).
• The practice of dispensing amoxicillin without
  prescription for a child with ARI was reduced in
  the IGD intervention group. The practice change
  may be attributed to the concern of the drugstore
  seller on the possible adverse effect of the
  antibiotic on a child.
• Despite drug sellers being in full control of
  the consultation with a client with flu symptoms
  (there is no prescription from the physician nor
  the specific drug product requested by the
  client), the interventions failed to change this
  practice. This may be because of strong
  traditions of using pre-packed combinations of
  antibiotics and analgesics for the flu symptoms.
  Further, store owners encourage sellers to
  provide the combination packs as they are highly
  profitable and patients demand these products.

11
Conclusions

• The drug seller profile is worth noting. Some
  drugstores have sellers as young as 14 years old.
  In addition, half have attained, at most, a high
  school education and only 90 of the 855 sellers
  are trained pharmacists. Since there are laws
  requiring drugstores to have a pharmacist,
  theoretically, there should have been 271
  pharmacists, the number corresponding to the
  number of drugstores in the study.
• Educational methods addressing undesired drug
  practices should target health care providers
  (in formal and non-formal sectors) and patients.
  The content should have harmonized messages (eg,
  on rational use of antibiotics and rational
  dispensing) for the different target groups
  (physician, pharmacist, drugstore seller, variety
  store seller, community health worker, mother or
  other family health carer, and others). Further
  measures to strengthen drugstore sellers
  education should come from government regulatory
  authority that can outline and enforce minimum
  standards for practice.

12
References

• Pharmacy law. Manila Bureau of Printing, 1969.
• Sia IC, Murray M, Sur ALD, Valerio J, Siochi R,
  Bocala M et al. Status of drug use in Philippine
  communities education for improved use of
  medicines in the community. Paper presented
  during the Conference on Philippine National
  Drug Policy Moving Ahead. Pasay City,
  Philippines 1997 September 30.
• Lansang MA, Lucas-Aquino R, Tupasi TE, Mina VS,
  Salazar LS, Juban N et al. Purchase of
  antibiotics without prescription in Manila, the
  Philippines. Inappropriate choices and doses. J
  Clin Epidemiol 1990 43 61-67.
• IMS Health. Manila IMS, 2003.