Improving Primary Care Pharmaceutical Use
Fourteen interventions tested educational strategies such as training or workshops. Three (21.4%) of these interventions achieved large improvements, 7 (50.0%) showed moderate effects, and 4 (28.6%) had little impact. What characteristics of training were associated with greater improvements? Two of the three interventions which had large impacts did not measure changes in prescribing; one examined the impact of problem-oriented pharmacotherapy training on medical students= ability to manage hypothetical cases (de Vries 1995), while the other looked at changes in community drug use resulting from multi-faceted interventions delivered by CHWs following intensive training on ARI, diarrhea, and nutrition (Lopez Linares 1991). These two interventions were carried out training in large groups using multiple, problem-oriented sessions aimed at communicating practical skills. The third intervention in a Pakistan teaching hospital (Qazi 1996) achieved 31% reductions in outpatient antibiotic use for ARI using small group training in case management followed by refresher seminars and ongoing supervision. All three interventions are notable for the use of multiple sessions to reinforce training.
Seven interventions tested in six studies (one study compared two types of training) had moderate impacts. Five of these studies focused on a single health problem, either ARI (Naivalulevu 1990, Gonzalez Ochoa 1996) or diarrhea (Chowdhury 1995, Gani 1996, Santoso 1996), while one study focused not on health problems but on specific prescribing performance indicators (Kafuko 1996). All the studies targeted reductions in antibiotic use, in addition to other prescribing indicators.
Which training approaches were effective? District-level workshops using multi-method training approaches (problem focused, role playing, practical skills development) were successful in four studies, while there were three successful examples of small, problem-focused groups conducted on-site at health facilities by district staff. Santoso (1996) compared large district workshops with small group, on-site training and found that, while either approach improved prescribing for diarrhea at three months follow-up, only the improvements in prescribing from small groups were sustained after two years in comparison to controls (unpublished data); furthermore, training in small groups proved to be far more cost effective in the Indonesia context. Gonzalez Ochoa (1996) found that reductions in community antibiotic use were twice as large (18.9% vs. 8.9%) when multi-method training and supervision for local physicians on ARI management was combined with intensive community