Improving Primary Care Pharmaceutical Use
clinical officers, or other paramedics were the focus in 36 (61.0%) of these interventions (Table 2). Twenty-one of the interventions (35.6%) targeted some type of community health worker, such as volunteer village health workers, lady health visitors, or village midwives. Virtually all studies targeted health workers involved in clinical activities; only three studies targeted pharmacists or dispensers.(Kafle 1995a, Kafuko 1996, ZEDAP 1995)
The range of health problems addressed in the identified interventions has been quite limited. Overall, 26 studies focused on the treatment of ARI, and 21 were designed to improve diarrhoea treatment (Table 2). Virtually all of these studies emphasized appropriate treatment in children under five. Only six studies, all of which were in Africa, focused on interventions to improve treatment of malaria, despite the importance of this health problem as a leading cause of morbidity and mortality in many parts of the developing world.
Only one‑third of the 59 studies targeted issues other than ARI, diarrhoea, or malaria treatment. Only four studies (8.5%) targeted other specific health problems: worms and immunization (Curtale 1995); lack of appetite (Lopez‑Linares 1991); hypertension (Agyepong 1996); and treatment of STDs (ZEDAP, 1995). Sixteen interventions focused on prescribing practices that were not problem-specific, such as use of injections, prescribing of antibiotics, or polypharmacy. To a great extent, improving the use of medicines in adult populations, as well as in the treatment of chronic diseases, have been neglected as targets for intervention.
Whatever their health problem focus may be, interventions are typically designed to change a few specific aspects of drug prescribing. By far the most common practice addressed has been the prescribing of antibiotics. Forty-five of the 59 interventions (29 of the 36 with acceptable study designs) had improvement in antibiotic use as either a direct or an indirect focus. The desired outcome was most commonly a reduction in unnecessary prescribing of antibiotics, but in the interventions to improve compliance with ARI guidelines, an increase in the prescribing of a preferred antibiotic for pneumonia was the recommended behavior.
Two other prescribing practices that have received frequent attention are the unnecessary prescribing of multiple drugs (polypharmacy) and the overprescribing of injections, both of which have been the focus in 8 methodologically acceptable studies. Along with antibiotic prescribing, these two prescribing practices are included in the core WHO drug prescribing indicators, which is one reason they have received attention. Other important