Kwena, Zachary MA*; Sharma, Anjali DSc*; Wamae, Njeri PhD*; Muga, Charles MA*; Bukusi, Elizabeth PhD*†
A SOUND HEALTH CARE delivery system aspires to achieve the World Health Organization's goal of health for all.1,2 However, health care delivery systems in many sub-Saharan African countries are poor due, in part, to structural adjustment programs introduced in the early 1990s.3–5 The ensuing cost sharing limits the prompt access of the urban poor to public health care, especially for seemingly nonfatal illnesses such as STIs. When untreated, STIs prolong morbidity and increase an individual's chances of acquiring HIV.6
In poor urban settings, retail pharmacies are often the first and sometimes the only contact of poor people with the allopathic (biomedical) health delivery services where many purchasing decisions are unmediated by other medical professionals.7–9 In sub-Saharan Africa, about 50% to 80% of patients first visit private drug outlets for treatment.10,11 Such private outlets are numerous, often unregistered and outside the government's capacity to regulate. Monitoring and influencing the quality of service of pharmacies is now recognized as a key component of effective disease treatment.12 The quality of care in turn is determined by staff education level, professional training, experience, and motivation.13–16 We, therefore, sought to evaluate the provider characteristics of the retail pharmacies providing care to self-medicating STI patients in the Kibera Slum, Nairobi, Kenya. For this paper, we use the term providers to refer to both pharmacy staff and individual retail pharmacies.
We conducted a cross-sectional study in Kibera, a slum in Nairobi with an estimated 1,000,000 residents and population density of 55,000 persons/km2. Residents earn an average of Kshs. 3500 (≈US$ 50) per month. Overcrowding and lack of basic sanitary facilities, conducive to disease outbreaks and episodes of ill-health, characterize Kibera.17,18 The Kenya Medical Research Institute's National Ethical Review Committee approved the study. The consent form detailed the purpose of the research and alerted the pharmacy staff that after collection of the completed self-administered questionnaire (SAQ), 2 mystery patients would visit the pharmacy at an unspecified date.
Mapping retail pharmacies in Kibera established their number and location. We selected and distributed SAQs to a convenience sample of 50 of the 150 retail pharmacies identified using the 30% rule of sample selection19 and the willingness of the pharmacies to participate. Eleven of the retail pharmacies approached declined to participate (20% refusal rate) and were replaced by the closest neighboring pharmacy. Although we had a mutually agreed date for collection of the completed questionnaire, approximately 2 weeks after delivering of the SAQ, it took several appointments with the pharmacy staff to get the completed forms.
Approximately 2 weeks after collection of SAQ, 2 male data collectors separately visited all the 50 retail pharmacies as mystery patients seeking care for symptoms of either gonorrhea or genital ulcer disease (GUD) (100 encounters with pharmacy staff). The 2-week time lapse was necessary to reduce chances that the pharmacy staff would link the completed SAQ and the data collectors. The mystery patients observed how the retail pharmacy staff handled them and recorded their observations in a precoded observation record sheet within 10 minutes of leaving the target pharmacy. To elicit this information, the mystery patients simulated 2 scenarios.
* Simulated scenario 1: “I feel a sharp burning pain when passing urine. There is also thick yellowish discharge from my penis. What medicine should I take?” and,
* Simulated scenario 2: “I have several painful ulcers on my genitalia. They have smelly pus. What should I do?”
In cases where the mystery patients were asked for additional information they provided the following details:
* I have never had any similar symptoms before.
* I have had sexual intercourse with a few different partners in the past few weeks.
* I don't know whether any of the partners had suffered from anything like this.
* I have not seen a doctor about my problems.
* I am willing to accept any suggestion that the pharmacy staff provides.
The data were manually checked for completeness of the questionnaires and verification of the consistency of the responses given. It was then coded and double-entered into SPSS program (Version 10.0, SPSS Inc., Chicago, IL) for analysis using descriptive statistics. We also compared the treatment regimen given to mystery patients with the national guidelines for the management of STIs to establish the percentage of staff who used Government recommended treatment to manage the simulated scenarios.20 The Kenya Government Ministry of Health recommended first line treatment for gonorrhea is norfloxacin 800 mg stat and doxycycline 100 mg BD for 7 days and alternative is spectimycin 2 g stat and doxycycline 100 mg BD for 7 days. The government recommended first line treatment for GUD is erythromycin 500 mg 3 times daily for 7 days and benzathine penicillin 2.4 μm injection stat. Those allergic to penicillin are given erythromycin 500 mg QID for 14 days. The alternative treatment for GUD is ceftriaxone 250 mg stat.
Characteristics of Pharmacy Staff
Among the 50 respondents, 56% were male and half were below 28 years old. The majority (93%) had at least 12 years of formal schooling, which is equivalent to completion of 4 years of secondary school education, and 96% of the 50 respondents had some professional training. Almost all (96%) had professional training that was related to medicine (Table 1).
Men constituted 90% of the trained pharmaceutical technologists and 90% of the trained nurses were women. The length of time the staff had trained ranged from 1 to 6 years but most training lasted for 2 years. The time spent in training depended on the level of training namely: degree, higher diploma, diploma, and certificate. For instance, one pharmacy staff had graduated after 6 years of training at the University of Nairobi as a medical doctor whereas another had a certificate as nurse aid after 1 year.
The staff with professional training attended 24 different institutions. About 66% trained in government-affiliated institutions whereas 30% had trained in private institutions mostly Mission hospitals. The highest institution of learning attended was University leading to a degree in Medicine. Other qualifications included Diplomas and Higher Diplomas (from National Polytechnics) and Diplomas and Certificates (from middle level colleges).
About half of the pharmacy staff earned less than USD 71 per month, 56% of whom were on temporary employment whereas the rest were assisting the pharmacy owner (16%), were self-employed (16%), or on attachment (8%) with only 4% in permanent employment. While 26% of the pharmacy staff was related to the owner of the pharmacy, 16% owned the pharmacy themselves, 56% were employees, and 2% did not respond. The majority (93%) of those on temporary employment earned up to USD 143 compared with those on attachment who earned less than USD 71 per month. Half of the staff had worked with their current employer for over 2 years. However, slightly more than half had worked in pharmaceutical establishments for less than 2 years.
Characteristics of Retail Pharmacies
About 70% of the retail pharmacies reported between 10 and 30 customers per day. All sampled pharmacies reported stocking analgesics. The class of drugs least stocked was steroids (8%). Antihelminthics, antiemetics, antidiarrheal, and antipyretics were stocked by at least 50% of the pharmacies (Table 2). The reasons for stocking the specific classes of drugs include: high demand, treatment for common and multiple infections, affordable and licensed over the counter drugs. Two-thirds of the retail pharmacies mentioned STIs as a common illness for which customers sought care.
Three-quarters (74%) of the pharmacy staff reported that some of their customers cannot raise all the money required for medicines prescribed. Thirty percent said that customers buy some medicines and return for other medicines when they can afford it whereas 19% said that the customers purchase all the medicines in small quantities until they complete the treatment regimen.
Although 80% of the pharmacies get their medicine stock from wholesalers, one-third reorder their drug stock on a monthly basis and about half reorder their stock after 2 weeks. About 65% of the retail pharmacies reported that their customers do not present with prescriptions, with approximately 45% requesting specific drugs while being open to advice and about 36% using the pharmacy as the first stop for care. Ten percent of the pharmacy staff thought that their customers do not comply with instructions on the use of drugs and 26% reported that customers come back regularly either for the same or different conditions. Ninety-four percent of the pharmacy staff agreed to provide partial treatment to the patients who did not have money for the full dose. Most of the pharmacy staff advised patients to purchase half dose and return for the second half when they get the rest of the money.
Adequate Treatment of Mystery Patients
Of the pharmacy staff who had the correct gonorrhea diagnosis, 27% (8 of 30) offered a regimen that included government recommended medicines of norfloxacin 800 mg stat and doxycycline 100 mg twice a day for 7 days. Also, 5% (1 of 20) who had incorrect gonorrhea diagnosis, nonetheless, offered a regimen that included recommended medicines. Therefore, only 18% (9 of 50) of the staff offered the mystery patients appropriate treatment for gonorrhea even if their diagnosis was not correct. The pharmacy staff who had correct gonorrhea diagnosis had a trend towards offering correct treatment [OR: 6.91 (95% CI: 0.97–60.37)] when compared with those with incorrect diagnosis. Only 3% (1 of 40) of the staff who had correct GUD diagnosis offered a regimen that included government recommended treatment for those allergic to penicillin of erythromycin 500 mg 4 times daily for 14 days. Overall, only 10% (10 of 100) of the pharmacy staff offered appropriate treatment for gonorrhea and GUD combined. All pharmacy staff offered counseling except one. The counseling mostly centered on contact treatment (84%), proper and consistent condom use (77%), and completion of the dose (59%). They also counseled on seeking prompt treatment in future cases (56%), being faithful to one partner (47%), abstinence (19%), correct use of medications (17%), and going for laboratory testing and to see a doctor (9%).
These results show that while most of retail pharmacy staff in Kibera may have medical training, majority of the outlets do not offer adequate treatment to self-medicating patients even though prompt STI treatment is an important HIV prevention.20,21 A previous study in Nairobi indicated that approximately half of the pharmacy staff surveyed offered correct treatment to self-medicating STI patients.22 The pharmacies surveyed were, however, not slum based. Our results are slightly better than the results from Peru and Nepal, where the percentage of mystery patients who received correct syndromic treatment in the pharmacies was only 1%.14,23 Given that only 10% of the pharmacy staff could correctly diagnose and treat gonorrhea or GUD raises concerns over appropriate treatment of self-medicating patients in this setting.
Studies in Botswana and Nigeria associate inappropriate treatment patients receive at retail pharmacies to knowledge and qualifications levels of the pharmacy staff.24,25 In this study, we cannot link the training/qualification data to the diagnosis and treatment because some of the pharmacies had up to 3 staff each, and as such, we cannot be sure that the person who filled the SAQ was also the one attended to the data collectors (mystery patients). Also, since only one SAQ was completed per pharmacy, we cannot assume that the treatment offered represents the collective knowledge of all the staff in the participating pharmacy. However, since pharmacy staffs are able to consult with each other, there was presumed to be adequate opportunity for seeking advice from colleagues if needed.
One important provider characteristic in providing quality care is the relevance and quality of the training received. We could not verify the certification of the pharmacy staff and relied on self-reports. However, one third of the staff reported receiving training in the mushrooming private medical colleges, which try to meet the high demand for training in the “marketable” medical profession. Although private colleges were encouraged to supplement government colleges in Kenya, the quality of their training cannot be guaranteed except where there is strict government monitoring.26 The Kenyan government has well designed curricula for various courses offered in the public medical training colleges. Although private medical training institutions are supposed to follow the same curriculum, this is not guaranteed without strict enforcement of regulations with frequent monitoring and standardized examinations regardless of the training institutions. Periodic in-service training courses as demonstrated in Peru14 coupled with regular inspections by pharmaceutical inspectorate27 would not only strengthen the compliance with storage and dispensing, but also improve services to self-medicating patients.
Appropriate financial remuneration attracts and retains competent and experienced staffs who are dedicated to their work. In poor neighborhoods, such as the Kibera slum, where residents' initial reaction to illnesses is often unmediated by clinical staff, the need for competent, dedicated staff cannot be over emphasized. However, good remuneration of the staff is dependent on the performance of the pharmacy, the number of customers, purchasing power and rate of stock turnover. It is unlikely, given the reported number of customers (10–30 per day), that the majority of the retail pharmacies in Kibera Slum generate enough money to engage the services of highly qualified and experienced staff. Compounding this is the reported number of patients (36%) who use pharmacy as the first stop for care and the high number (74%) who is unable to purchase doses as prescribed. As a result, the retail pharmacies may be unable to attract and retain qualified and experienced staffs to serve their clientele who probably most need these services.
It is likely that a majority of countries in sub-Saharan Africa share the same challenges of inadequate treatment for self-medicating patients who depend on care from retail pharmacies.24,25,28–30. These countries should assess the quality of care provided by these pharmacies and take the opportunity that they provide for good pharmaceutical care, health promotion, and delivery. These efforts should not ignore training in the management of STI given its strong association with HIV acquisition and as such should be treated as a matter of urgency.
Despite majority of pharmacy staff in this informal settlement reporting medical training and some experience, a very low proportion offered appropriate treatment for 2 common STIs. This may negate the efforts of STI treatment as a HIV prevention mechanism in these settings. Nevertheless, since pharmacy staff can consult coworkers, we can recommend confirmation by regulatory authorities of their certificate for practice and in addition such pharmacy staff be encouraged to attend in-service training on STI recognition and management. Mandatory courses and tests targeting the staff of retail pharmacies and provision of the recommended National guidelines for STI treatment may also help improve care.
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