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 town’s 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%, p=0.001] and the control group significantly increased [RR=18.7%, p=0.0018] post-intervention. While the DSV stores showed a moderate relative reduction in this practice, the change was not significant RR= -11.0%, p=0.1317].

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 [OR=0.27, (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%, p=0.0046]. The DSV and control drugstores also reduced their recommendations [RR= -2.1%, p=0.7389 and RR= -7.3.0%, p=0.2207] 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 [OR=12.54, (95%CI: 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 1.Pharmacy law. Manila: Bureau of Printing, 1969. 2.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. 3.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. 4.IMS Health. Manila: IMS, 2003.