Improving Primary Care Pharmaceutical Use
of other health problems, care for adults, other types of prescribing problems, and private sector practices were infrequently studied.
Overall, authors reported at least one large impact (>25% improvement in a targeted outcome relative to controls) in 42.8% and moderate impacts (10-25% improvement) in 35.7% of 42 interventions carried out in the 36 studies with adequate designs; only 21.4% of interventions had very low or no impact (<10% improvement). Dissemination of printed materials was the only type of intervention which consistently had no impact. The impact of training was higher in interventions which employed multiple training modalities (lectures, group problem-solving, role playing, opportunity to practice skills); repeated sessions; focus on one clinical problem at a time; training at the work site; and using opinion leaders or district-level staff as trainers. Community case management interventions for ARI and diarrhea were clearly successful in reducing mortality; their overall effects on appropriateness of drug use, especially for ARI interventions, were not well studied. Administrative interventions based on group process, effective supervision or monitoring, and regular audit and feedback achieved consistently moderate to large impacts on target practices; issues of the effects of these strategies on a broader range of problem practices and the sustainability of improvements remain to be explored.
Conclusion: The results of this review are encouraging. High quality studies of interventions to improve primary care drug use in developing countries are increasing in frequency, and there is consistent evidence for the effectiveness of various strategies for improving behavior. However, many questions remain unanswered, especially how to improve drug use for chronic illness, in adults, in the private sector, and which strategies are the most cost-effective. In addition, much more attention needs to be paid to measuring the impacts of national essential drugs programs over time. However, based on these findings, we know enough now to recommend specific types of promising training programs and administrative interventions to national policymakers.