1. IMPACT OF TRAINING IN DRUG SUPPLY MANAGEMENT (DSM) ON DSM, DISPENSING PRACTICE AND PATIENT KNOWLEDGE AND CARE AT PRIMARY HEALTH CARE CLINICS Summers RS 1, Kruger CH 2 Abstract Problem statement: DSM training for Primary Health Care (PHC) staff was introduced as part of the Essential Drugs Programme in Mpumalanga Province of South Africa. Objectives: To determine the impact of the training on the practice of DSM, dispensing and patient knowledge Design: Randomised, controlled, pre-post intervention study Setting and Study Population: Twelve PHC clinics in the Eastern Highveld region of Mpumalanga Province of South Africa, randomly allocated to study and control groups (six in each group). Intervention: Training for DSM for PHC staff. Training materials were adapted from the WHO/BASICS DSM Training course. The three-day training workshop was part of a provincial DSM training cascade. It was presented by the researcher, two pharmacists’ assistants and a primary health care worker who had successfully completed the generic training of trainers and DSM workshops presented by MEDUNSA School of Pharmacy Training and Development Project. The study consisted of four phases: pre-intervention survey, training workshop for staff from the study group clinics, first post-intervention survey one month after the workshop and second post-intervention survey three months after the workshop. Outcome Measures: Organisation of supplies, record-keeping, ordering and stock control and goods receipts; labelling of medicines, patient knowledge and advice received and usage of medicines on the Essential Drugs List (EDL). Results: Highly significant improvements were recorded across the range of activities listed above from baseline to the first post-intervention survey. The improvements were sustained and even increased in some cases from the first to the second post-intervention surveys. Conclusions: DSM training impacted more than just the DSM indicators. It also improved patient care and raised the level of use of EDL drugs Funding source: Operating budgets of the MEDUNSA School of Pharmacy and provincial pharmaceutical services of Mpumalanga Province. The training workshop was funded by the South African Drug Action Programme (SADAP). (1) School of Pharmacy, MEDUNSA (2) School of Pharmacy, MEDUNSA and Pharmaceutical Services, Mpumalanga

2. 2 To assess the impact of Drug Supply Management training on the way in which  the drug store is prepared,  supplies are organised,  records are kept,  supplies are ordered,  supplies are received (Drug Supply Management),and  drugs are dispensed (prescribing and dispensing). Objectives of the study

3. 3 A controlled pre-intervention / post- intervention study was carried out between July and December 1998 in the Highveld region (now Ngangala) of Mpumalanga Province. Twelve clinics were chosen according to the following criteria:  DSM trainers present in the area  Enough patients for 30 interviews in a day  Pharmacists’ assistants and nurses could attend training Three-day in-service workshops for primary health care workers were organised as part of a training cascade conducted in the province. Training materials were adapted from the WHO/BASIC DSM training package (1). WHO-recommended indicators were investigated using structured questionnaires. Method

4. 4 Control group (6 clinics) Study group (6 clinics) Pre-test Training = 1 month Post-test 1 Post-test 2 Pre-test Post-test 1 Post-test 2 Study area Mpumalanga Province South Africa Study plan Study area

5. 5 Indicator group (number of indicators) - description Storage (6) - Dry medicines on top shelf, generic labels, FEFO, FIFO, stock returned on expiry, removed stock recorded Record keeping (8) - Stock levels recorded, order times defined, stock cards exist, updated with issues, destination, quantity, current stock level; regular stock checks Ordering (5) - Based on past consumption, triggered by re-order stock levels, physical stock checks when ordering, average monthly consumption calculated, stock reference number specified. Receiving (7)- : stock is signed for, checked when delivered (against order, expiry dates, possible damage), discrepancies documented Physical infrastructure of medicines store (12) - Locks on doors, access control, cleanliness, temperature control (ceiling, ventilation, windows), stock stored off floor, roof intact, pest-free, separate from dispensing area Indicator groups: DSM 1 questionnaire per clinic and survey

6. 6 Results: DSM Indicator group (number of indicators): 0% 20% 40% 60% 80% 100% Positive responses Storage (6) Records (8) Ordering (5) Receiving (7) Physical (12) Significant differences within groups 1 : Control (C)P2 vs Pre Study (S)P2 vs Pre    between groups 2 : C vs SPre C vs SP2  Effect size: a Study P2-Pre (%)53.950.056.747.616.7 b ControlP2-Pre (%)11.16.3-3.314.312.5 a-b (%) 42.843.760.033.34.2 Significance 2  1 paired T-test, 2 independent T-test;  p<0.05 Pre (n=6)Post1 (n=6)Post2 (n=6)Control group: Pre (n=6)Post1 (n=6)Post2 (n=6)Study group:

7. 7 Labelling (10) - Generic name, strength, dosage, schedule, quantity, warnings, batch number, expiry date, dosage instructions, patient ref. number Quality of medicines (2) - I dentity of medicine, not expired Patient knowledge (3) - Dosage, frequency, duration of treatment Advice given (2) - Patient was told to keep medicines away from children, was asked to repeat dispenser’s instructions EDL medicines only were prescribed (1) Indicator groups: prescribing and dispensing 30 patient exit interviews per clinic and survey Indicator group (number of indicators) - description

8. 8 Results: dispensing Indicator group (number of indicators): Labelling (10) Med quality (2) Pt know- ledge (3) Pt instruc- tions (2) EDL meds (1) 1 paired T-test, 2 independent T-test;  p<0.05,  p < 0.001 Pre (n=198)Post1 (n=196)Post2 (n=192)Control group: Pre (n=185)Post1 (n=193)Post2 (n=201)Study group: 0% 20% 40% 60% 80% 100% Positive responses Significant differences within groups 1 : Control (C) P2 vs Pre   Study (S) P2 vs Pre      between groups 2 : C vs SPre     C vs SP2       Effect size: a Study P2-Pre (%)21.10.024.148.625.5 b Control P2-Pre (%)5.02.50.70.10.0 a-b (%) 16.1-2.523.448.525.5 Significance 2     

9. 9 Discussion Significant improvements were achieved through the training programme as shown above. This study confirms earlier findings (2,3) that this type of training can improve drug supply management and prescribing practices at Primary Care level. For Drug Supply Management, considerable average effect sizes were achieved. However, the performance of the clinics varied greatly. A general situation of understaffing might have hindered the implementation of the concepts learnt. For patient exit interviews, significant differen- ces were shown for all the indicator groups except drug quality, where both groups per- formed at a high level throughout the study. It is encouraging to note that the beneficial effects of the training were more marked at Post-test 2 than at Post-test 1, indicating a good retention effect of the training.

10. 10 Limitations The results from the study area are not necessarily representative of the entire Mpumalanga Province. The sample size for DSM indicators, where only one questionnaire was completed per clinic at each test phase, was relatively small. Certain indicators in the Facility category, like changing physical structures and purchasing locks, were not under the control of primary health care staff. Trainers who worked in the region were trained long before the first intervention and could have influenced the study. The lack of Management involvement and financial support delayed the training process.

11. 11  Ongoing in-service training relevant to conditions in the field should be presented  Trainers should attend annual refresher courses; new trainers should be trained as necessary  Training manuals should be adopted at national level  Provincial management should be involved and committed to the training programme Recommendations

12. 12 Acknowledgements Prof. HS Schoeman, for statistical consultancy Staff of the School of Pharmacy, for their support Provincial Department of Health, for permission to conduct the study Mr. Gustav Malangu Mrs. Monika Zweygarth, for data analysis and this presentation References (1) WHO Div. of Child Health Development/BASICS. Drug supply management training resources. Available on-line at http://www.who.int/child-adolescent- health/publications/CHILD_HEALTH/ WHO_CHD_98.4.htm (2) Meyer JC, Summers RS, Möller H. Randomized controlled trial of prescribing training in a South African Province. Med Ed 2001; 35: 833-840. (3) Phasha D. Strengthening District Pharmaceutical Services. MSc (Med) Dissertation. MEDUNSA: School of Pharmacy, 2002.