No. 18, November 1994
Improving the practices of pharmacists and licensed drug sellers
In this issue:
Pharmacists as health care workers
Successful training methods
What field tests show
The importance of the private sector
If diarrhoea in children is to be managed correctly, there is need to look
beyond public sector health facilities. Good management has to be promoted
in the home, and there is also a need to improve the practices of all providers
of care, particularly in the private sector.
Retail drug businesses are particularly important providers of care
in most countries, pharmacies and over-the-counter drug stores are widely
they are the most frequently visited of all health-related facilities;
for purposes of training, drug retail outlets are relatively easy to reach;
products sold and advice given to customers for treating diarrhoea are
generally inappropriate and, in some cases, dangerous.
What WHO/CDD is doing
Over the past few years, WHO's Diarrhoeal Disease Control (CDD) programme
has developed a project to address this problem.
This was done through a contract with the Management Sciences for Health
Drug Management Programme and Harvard Medical School's Drug Policy Research
The project has tested ways of using training interventions to change
the practices of pharmacists and their employees.
The project's approach is incorporated in a guide that is intended for
use by national diarrhoeal disease control programme staff.
The Guide for Improving Diarrhoea Treatment Practices of Pharmacists
and Licensed Drug Sellers has been field-tested in Kenya and Indonesia.
It is now available as a WHO document.
The Guide includes the following steps:
Stage 1 Learn how drug sellers treat diarrhoea and why
Stage 2 Design and plan a training intervention
Study the drug retail system (identify drug sales outlets and drug sellers,
map out the retail drug distribution system, identify the top-selling oral
rehydration salts [ORS] and antidiarrhoeal products, clarify optimum treatment
Choose a target audience (consult local experts about the best opportunities
for working with drug sellers, identify the type of drug outlet and geographic
area in which to work).
Learn about the drug sellers' current knowledge and practices through a
Identify factors influencing drug sellers' practices (consult local experts,
identify key questions, develop a focus group moderator's guide, plan and
conduct focus groups for drug sellers, analyse findings).
Stage 3 Carry out the intervention and evaluate results
Decide on the intervention (form implemen-tation teams, specify behaviour
to change, describe possible interventions, select most appropriate inter-vention).
Develop a work plan, including schedule.
Develop printed materials (choose central motivating theme, decide on individual
materials, follow communica-tion principles in drafting and pre-testing
Train staff and pilot-test the intervention.
Develop a monitoring and evaluation plan (specify indicators for evaluating
knowledge and behavioural changes, specify process measures to be monitored,
choose assessment methods).
Implement and assess the intervention (implement, monitor, evaluate, draw
conclu-sions and decide on future steps).
The Kenya field-test experience
A typical urban retail pharmacy in Kenya is visited each day by up to 100
customers with health problems but without a p˙˙scription from
a doctor. In small towns with fewer doctors, the number of such customers
may be even greater.
Kenya's diarrhoeal disease control programme used the WHO Guide to develop
and carry out a training programme to improve advice given by pharmacists
and their assistants on how to manage diarrhoea.
From the start, the diarrhoeal disease control programme involved the
Pharmaceutical Society of Kenya, the Kenya Medical Training Centre and
the University of Nairobi.
Kenya's capital, Nairobi, and five other towns were chosen as sites
for the training programme. Training methods included one-to-one discussions
with opinion leaders within pharmacies (e.g. pharmacy owners), one-to-one
discussions with pharmacists, and small group training sessions for pharmacy
Four types of printed materials were used after pre-testing: two pamphlets
for pharmacy staff (one on ORS and one on antidiarrhoeals), a general pamphlet
for customers and a wall poster.
Small group sessions were found to b˙˙the most effective training
method because, unlike large seminars, they allowed attention to be given
to the concerns of individuals. Importantly, small groups allowed participants
to discuss constraints in applying recommendations. Role-play was used
to simulate the giving of advice to customers.
The pilot phase of the training has been completed; 162 pharmaceutical
assistants in 90 pharmacies have received training. Initial evaluation
showed promising results.
Questionnaires given to partipants before and after training indicated
that training increased overall knowledge.
Purchase surveys in five towns showed that ORS sales increased by 24-32%
while sales of antidiarrhoeals decreased by 6-12%.
A number of important conclusions can, at least preliminarily, be drawn
from the work done thus far on this project:
Lack of knowledge and skills is one of the main reasons why drug sellers
act as they do. Thus training which changes knowledge and skills can, in
itself, cha˙˙e behaviour, at least initially. The project has
not tried to change other important influences on behaviour, such as drug
prices, national drug regulations, drug company retailing practices, physicians'
prescribing practices, or customer demands. Further activities to address
these influences are clearly needed.
Experience of changing the behaviour of care providers in industrial countries
appears to be relevant to work in developing countries. The approach to
behaviour change that is presented in the Guide (use of well-targeted printed
materials paired with face-to-face communication) was originally developed
and tested by the Harvard team members for rationalizing the drug prescribing
practices of physicians.
Qualitative research methods, such as focus group studies, can be useful
in developing interventions that will change inappropriate health care
Staff of national CDD programmes can manage the complex process of assessing
current treat-ment practices, designing in˙˙rventions for change,
and then implementing and evaluating them.
Staff of national CDD programmes from the public sector can work constructively
with others in the private sector, such as local consultants, advertising
firms, pharmaceutical distributors and the drug sellers themselves.
WHO/CDD plans to extend this project to include acute respiratory infections
as well as diarrhoeal diseases, to help expand activities in Kenya to the
entire country, and to begin further field-˙˙sting in an additional
country. The Guide is available to all countries that wish to consider
undertaking a major effort to train pharmacists and drug sellers.
What the international experts have to say:
A Joint WHO/UNICEF Statement "There is NO need for pharmaceuticals
other than ORS in the routine treatment of diarrhoea. Selected antibiotics
should be judiciously used ONLY for the treatment of severe dysentery and
WHO: "ANTIMOTILITY DRUGS like Opiates, Codeine, Loperamide, Diphenoxylate
with Atropine are NOT indicated in the treatment of diarrhoea. They greatly
slow intestinal peristalsis, delay the elimination of causative organism
and can be very dangerous (even fatal) in infants."
BRITISH NATIONAL FORMULARY: "ANTISPASMODICS & ANTIEMETICS should
be avoided in young children with gastroenteritis as they are rarely effective
and have troublesome side effects."
AMERICAN MEDICAL ASSOCIATION:"ABSORBENTS, like Kaolin, Pectin, Charcoal
have adverse side effects and their use is unwarranted."
For further information, contact:
The Director, Division of Diarrhoeal and Acute Respiratory Disease
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 791-2632, Fax: +41 22 791-4853,