Improving Primary Care Pharmaceutical Use
The quality of the study designs used in the educational interventions was mixed. Twelve of the 20 studies that examined the impact of training or workshops met our minimum standards of design quality. Seven were RCTs (Agunawela 1991, Bexell 1994, Chowdhury 1995, de Vries 1995, Gonzalez Ochoa 1996, Kafuko 1996, Santoso 1996); three studies used pre-post with comparison group designs (Gani 1995, Lopez Linares 1991, Ofori-Adjei 1996); and two studies employed time series or repeated measures (Naivalulevu 1990, Qazi 1996).
Twelve of the 18 CCM interventions had adequate study designs, of which 7 targeted ARI (Fauveau 1992, Khan 1990, Lucero 1994, Mtango 1986, Pandey 1991, Reddaiah 1991); 5 targeted diarrhea (Hetta 1984, Jintanganont 1988, Miller 1995, Paredes Solari 1996); one early study targeted both ARI and diarrhea (McCord 1978), and a single recent study targeted malaria (Delacollette 1996).
The remaining 21 interventions identified by our search can be broadly classified as predominantly administrative or managerial in approach, although even these interventions typically involved some form of training during implementation. These interventions tested the impact of changes in health system organization, infrastructure, or relationships among staff on the quality use of medicines.
Six interventions (5 with acceptable study designs) were based on some form of peer group interaction as a modality for behavior change. For example, five of the well-designed interventions involved facilitating a group process among staff in a health facility or district to establish standard approaches for the management of specific health problems like ARI or malaria.(Agyepong 1996, Guiscafré 1994, Hugh 1996, Perez‑Cuevas 1996) In one highly innovative study, a moderated group discussion between primary health care workers and community members was used to highlight misconceptions about community preference for injections on the part of health workers and thereby reduce their use.(Hadiyono 1996)
Another group of administrative/managerial interventions was built around improving the availability of tools for structuring treatment decisions such as written standard treatment guidelines, or on improvements in supervision and monitoring to improve the use of medicines. In total, there were 8 interventions that fell into this category, 6 of which had acceptable methodologies, often RCTs. Two of the well-designed studies tested the impact of supervision using indicators.(Kafle 1995b, Loevinsohn 1995) Two interventions were trials to contrast different