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Primary care training for patent medicine vendors in rural Nigeria
SOC. Sci. Med. Vol. 35, No. 12, pp. 1477-1484, 1992 Printed in Great Britain. All rights reserved
PRIMARY
Copyright 0
CARE TRAINING FOR PATENT VENDORS IN RURAL NIGERIA
0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
MEDICINE
FREDERICK 0. OSHINAHB’ and WILLIAM R. BRIEGER~* ‘Nigeria Drug Enforcement Agency, Counselling Unit, Lagos, Nigeria and 2African Regional Health Education Centre, Department of Preventive and Social Medicine, University of Ibadan, Nigeria Abstract-The provision of essential drugs and the involvement of various potential and existing health care providers (e.g. teachers and traditional healers) are two important primary health care strategies. One local group that is already actively supplying the medication needs of the community is the patent medicine vendors (PMVs), but the formal health establishment often views their activities with alarm. One way to improve the quality of the PMVs’ contribution to primary care is through training, since no formal course is required of them before they are issued a license by government. Primary care training was offered to the 49 members of the Patent Medicine Sellers Association of Igbo-Ora, a small town in western Nigeria. Baseline information was gathered through interview, observation and pre-test. A training committee of Association members helped prioritize training needs and manage training logistics. Thirty-seven members and their apprentices underwent the 8 weekly 2-hr sessions on recognition and treatment (including non-drug therapies) for malaria, diarrhoea, guinea worm, sexually transmitted diseases, respiratory infections, and malnutrition, plus sessions on reading doctor’s prescriptions and medication counseling. The group scored significantly higher at post-test and also showed significant gains over a control group of PMVs from another town in the district. The Igbo-Ora experience shows that PMVs can improve their health care knowledge and thus increase their potential value as primary health care team members. Key words-patent
medicine vendors, primary health care training
INTRODUCTION The treatment of common health problems and the provision of essential drugs are two interrelated essential services of a primary health care (PHC) programme [l]. In keeping with PHC emphasis on
community participation, one approach to providing these services is the revolving drug fund managed by community members and their volunteer community health workers [2]. In reality money generated through community financing has often been insufficient to maintain health services, hence a need for government supplementation [3,4]. Government health planners are currently emphasizing cost sharing and cost recovery in local health services [5], a move that has been formalized in the Bamako Initiative launched by UNICEF in 1987, and is based on the belief that people will pay for public services since they already pay for private and traditional health care [6]. Unfortunately the general picture for government health services has been chronic drug shortages [7,8]. Planners have often underestimated requirements for distribution networks in maintaining community based services [8-lo], giving rise to a natural fear that medicine supplies will be siphoned off into the informal sector [ll]. While attention to these management issues is part of the solution, a deeper problem is the politicization of health care, that inhibits many govern*To whom correspondence
should be addressed.
ments in developing countries from retreating from the role of ultimate provider of free care [6]. While governments try to sort out their policies and plan their programmes, people in local communities continue to meet their illness care needs (and demonstrate daily their willingness to pay) by patronizing patent medicine vendors (PMVs), as they have been doing for decades [7, 121. In poor rural areas private expenditure for health care through drug shops is considerable [ 131.A survey in rural Indonesia found that only 17% of illness treatment contacts were made at government health services. Nearly half (45%) were with the informal sector, 88% of which were village medicine shops, the cheapest source of care [14]. Though their ethics and competence have been challenged [15, 161, the ability of PMVs to provide accessible services, even in remote areas, can not be doubted [14]. It is ironic that while government doctors and medical assistants are more knowledgeable about medication use and correct prescribing practices than private medicine vendors, the PMVs spend more time with and display a friendlier attitude toward their clients than do staff of the formal health sector [ 171. APPROACHES TO MEDICINE VENDING
Three approaches to the ubiquitous PMV exist. Generally they have been ignored by the formal health sector in hopes that governments will
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eventually eliminate drug shortages. “It is significant that most countries working on an essential drugs policy seem to exclude the private sector” [1 11. In the meantime government health workers continue to write prescriptions that they know can not be filled in their own dispensaries [12, 161. Law enforcement is a second, but ineffectual approach. “Few developing countries have succeeded in imposing any meaningful controls on private drug sales” [lo], because few ministries have enough trained personnel to monitor the numerous, dispersed and often mobile private medicine sellers [ 16, 171. A third option, training PMVs, would address concerns about competence. PHC philosophy is noted for advocating incorporation of local human resources, such as village volunteers, traditional healers and religious leaders, into health care efforts. The PMV, who already has motivation and experience, is another likely candidate. In Ghana, PMVs have been trained on use of oral rehydration salts and birth control pills, so extended training on dispensing practices generally might be feasible [17]. Unfortunately, positive recognition is feared by some health professionals who believe that training would create a band of dangerous pseudo-doctors [16]. The training option has been explored by a team from the Ibarapa Community Health Programme, Department of Preventive and Social Medicine, University of Ibadan, Nigeria, based at its rural training site in the town of Igbo-Ora in southwestern Oyo State. A participatory approach, in keeping with PHC philosophy, was used whereby the local PMV association was involved in determining training needs, designing the training sessions and organizing training logistics. An assessment of pre- and posttraining knowledge among the Igbo-Ora PMVs was compared with PMVs in another community who were not trained. The processes of training design, delivery and immediate evaluation are presented herein. DEFINING THE MEDICINE
VENDOR
Before presenting the Igbo-Ora study, it is necessary to define briefly who are patent medicine vendors and the nature of the work they perform. This includes legal, functional and cultural perspectives as well as group self-identity. Since much of the controversy over PMV practice is couched in legal terms, it is necessary to see what the law says about their status. In Nigeria a definition of PMV can be implied from Pharmacy Law as a person duly licensed by a state Ministry of Health to sell patent and proprietary medicines [18]. Three types of licenses distinguish whether the owner may sell prescription or proprietary medications. The former could be termed poisonous, addictive or dangerous if used without professional guidance (e.g. antibiotics, opiate derivatives), while the latter are prepackaged preparations, sold under trade names
and considered relatively safe for use by the general public (e.g. cough mixtures and some pain relievers). Holders of license ‘C’ can sell only proprietary or patent medicines; those with ‘B’ may in addition sell selected ‘poisons’ such as disinfectants; while only trained pharmacists receive license ‘A’, and sell the full range of medications [18]. No other distinguishing requirements are written into the law, but by custom the PMV is expected to have completed primary school. No formal job training is demanded or organized, although licensees are given a pamphlet outlining relevant aspects of Pharmacy Law. It is possible to define the PMV by observing his/her practice. Van der Geest [19] distinguishes five functional categories of PMVs in southern Cameroon: (1) general shop keepers who also sell patent medicines, (2) traders in the periodic markets who sell medicines along with other merchandise, (3) drug peddlers who go from village to village, (4) merchants who specialize in the sale of medicines and (5) health workers who sell the medicines obtained from their institutions. While all forms are known to exist in the Ibarapa District of Oyo State, Nigeria, previous field study has looked more closely at peddlers and medicine shop keepers. In Ibarapa both primary and secondary school leavers are among licensed PMVs. Some learned the work as apprentices, while others had worked in the formal health sector as pharmacy technicians, clerks and aids [20]. Most PMVs have shops in towns, often located near markets or busy intersections. Many sell small provisions like tinned milk and detergent powder, but the main commodity in their shops is medicine. Sale of prescription and expired drugs has been documented [2,21]. Just as many learned the trade through apprenticeship, many also left their shops in the hands of their own apprentices, especially since PMVs often engage in farming and other businesses [21]. Medicine peddlers on motorcycle were found to provide the bulk of western health care to remote hamlets. They also set up shop at periodic farm markets where quantities sold relate more to ability to pay than to any medical regimen [2]. Another definition of the PMV relates to cultural perceptions of appropriate illness behaviour. Selftreatment is a pervasive human behaviour because of the intrinsic value, seen by most all cultures, in an immediate, low-cost and self-controlled response to sickness [22,23]. In this context the community defines and refines its ideas about what medicines are ‘essential,’ and members act on these definitions with the aid of friends, relatives, patent medicine sellers and other health care providers [ll]. While the primary source of information and influence on selfmedicine usually comes from within the family, physician’s prescribing practices may, by way of example, ‘teach’ local people about drug selection [24]. Consumer requests in turn inform the PMVs,
Training patent medicine vendors
who tend to monitor market forces [15,20]. Unfortunately the information passed along this chain is often based on symptomatic, expensive, excessive and sometimes dangerous prescriptions [24]. Even where traditional practitioners and home remedies and are a major source of care, the PMV has been widely accepted and often provides largest source of medications for self-treatment [25]. The integral role of self-treatment in all cultures implies that community reliance on PMVs is not solely due to drug shortages in government clinics [19]. As Northrup [26] observed in rural India, community members prefer the PMV, “not only because of convenience and personalized service, but also because they have faith in the effectiveness of his medicines. They are not sure that the worker in the government health facility will be present nor do they trust the power of the free government medicines.” Finally the licensed PMVs have defined themselves. In 1951 the PMVs in the former Western Region (the present Bendel, Lagos, Ogun, Ondo and Oyo States) of Nigeria came together to form the Nigerian Association of Patent and Proprietary Medicine Dealers, headquartered at Ibadan. The Association received a certificate of incorporation in 1962, and associations in other states have joined in accordance with a 1978 national affiliation agreement [27]. State, district and town branches have been formed. The Association serves as a mediator between members and local, state and federal governments. One effect of the association at the local level may be the relative uniformity in pricing that was found in Igbo-Ora shops [20]. Another may be the speed by which information about drugs spreads among PMVs, as was seen with the quick availability of medicine for onchocerciasis in PMV shops shortly after a group of village health workers in Ibarapa contacted one PMV to help them purchase a supply wholesale [2]. THE IGBO-ORA
COMMUNITY
Igbo-Ora, a town of 60,000 people, is the largest in Ibarapa District and base for the University of Ibadan’s rural health training programmes. The town is an amalgam of six smaller communities that grew from hunting camps formed in the nineteenth century by settlers from the nearby Oyo and Egba empires, both of which are part of the larger Yoruba ethnic group. Agriculture is the mainstay of the local economy. Twenty to thirty percent of the population live in scattered farm hamlets located between 5 and 30 km from town. Igbo-Ora is the hub for bulking produce for onward transport to nearby federal and state (Oyo and Ogun) capitals. These cities, Lagos, Ibadan and Abeokuta, are the main source of supply for the 47 licensed PMVs in Igbo-Ora town. Other health services within the town include a state general
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hospital, one private hospital, two local government dispensaries/maternity centres, two private clinics/maternity homes and numerous traditional and spiritual healers. The town has one chemist shop run by a trained pharmacist. Faculty, staff and students from the University of Ibadan’s Ibarapa Community Health Programme have been involved in training volunteer village health workers and school teachers in primary health care skills since 1978 [28,29]. The present effort with PMVs is a natural extension of that work. METHODS
The target group for developing and implementing a training curriculum was all PMVs in Igbo-Ora town. Since a participatory approach to the study of PMVs was chosen [30], the team decided to work through the Igbo-Ora Patent Medicine Sellers Association (PMSA), which presented nearly all the PMVs in town. The 49 members included 6 PMVs from the neighbouring town of Idere (distance 7 km). Four Igbo-Ora PMVs did not belong to the PMSA. The association encouraged them to join in order to participate in the training, but they declined. One was a trained nurse, while the others did not have an active business. In addition to regular members, the association asked that apprentices also attend training. Each member PMV had at least one apprentice, many of whom were informal helpers and the children of the PMV, so an exact number could not be determined. The first step in the project was establishment of a trusting relationship between the trainers and the PMSA. Because government officials and police agents often harassed individual PMVs, the association needed to be assured that the trainers were not government agents and would not use information gathered to harm members. Meetings with individual officers and an introduction to the general membership at a regular meeting were conducted before approval was given to carry out the project. Baseline data for curriculum development was gathered through five interrelated methods. First a review of existing documents and publications on patent medicines and PMVs in the community was made [2,20,21] including records of the PMSA. This was followed by key informant interviews with PMSA officers and staff at the state hospital. The former included the chairman and secretary of the PMSA, and the latter involved two medical officers, two senior nurses and the pharmacist. Thirdly observation was conducted in 28 PMV shops in all sections of Igbo-Ora by the first author. An observational checklist was used to record selling and prescribing practices, types of medicines sold and instructions given to buyers. Between 1 and 2 hr was spent in each shop during the evening hours, because PMSA officers indicated that this would be the busiest time. Observations were preceded by
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additional introductions to dispel sellers’ fears about the observer’s identity. Because of the participatory approach to the training, the fourth method was self-study. The PMSA appointed a five-member training committee charged with polling member interests and developing a list of training needs. The committee then worked together with the trainers to outline the final curriculum and manage training logistics. Based on information and interests generated from the preceding activities, the trainers developed the fifth method, a baseline knowledge questionnaire for PMSA members. Since many had only primary education, the self-administered instrument was translated into the Yoruba language. A pilot test was conducted among the ten PMVs in Igangan town 30 km away at the north end of the district. The final version was given to association members at one of their regular meetings, which conveniently held in a local school room. For comparative purposes, the questionnaire was also administered to a control group, the 16 members of the PMV association in Eruwa town, located 25 km east of Igbo-Ora. Both groups were also given the same instrument as a post-test after the training period. The results of the above processes were used to develop 8 weekly 2-hr training sessions. Each lesson plan was reviewed by hospital staff for technical content and by the training committee for adherence to PMV interests. The results obtained from each baseline method are presented next, followed by a description of the training programme. A comparison between the Igbo-Ora participants and the Eruwa control group conclude the study results. BASELINE
INFORMATION
PMSA records provided information on member characteristics. Most (78%) were male, and ages ranged from 22 to 60 years, although 67% were under 40 years old. All had at least primary education, while 53% had gone on to secondary school. Among these were two who had studied nursing and four who had completed teacher training college. Two held License B, while the majority had License C. Some (43%) learned their work as apprentices. Several (31%) had worked in health facilities as professional, clerical or auxiliary staff. The remainder simply set up the shop and learned on the job. Medicine selling was the sole business of only 20%. Most PMVs were also farmers, traders and artisans. Key informants
The two PMSA officers quizzed the trainers thoroughly on their purpose and affiliation before agreeing to cooperate with the proposed project. They noted that many people who had come to them (PMVs generally) before, turned out to be detectives or government officials. They had even been harassed
by ‘fake’ police who tried to fool them into paying bribes. They eventually expressed great interest in the training idea because they said there was no standard qualification for the job. The PMSA had even invited a trained pharmacist to lecture them at a previous meeting. They felt most current members were not very active in the association and thought that training might be a way to boost participation. A general need identified by the two officers was a better understanding of the pharmacy law. Most of the members with only primary education had difficulty reading the English language pamphlets provided by the Ministry. This was given as reason why many did not realize it is illegal to sell prescription medicines. Also mentioned was the fact that many members travel to the surrounding hamlets to sell medicines and confront complaints that they are unable to identify. In contrast the Igbo-Ora hospital staff considered the PMVs to be a nuisance. They acknowledged the fact that most people patronize the PMVs and said there was little to be done about that. Particular concern was expressed about attempts by PMVs to treat sexually transmitted diseases without being aware of the dangers of engendering antibiotic resistance. Fear was expressed that training might foster in PMVs the attitude that they are doctors. The medical staff stressed that the lessons should focus on ability to identify when to refer patients to hospital, especially for tuberculosis and other serious respiratory diseases. The health workers did concede that people must buy drugs from the PMVs, because government hospitals often run short. Therefore they suggested that PMVs should be taught to read a doctor’s prescription correctly. Medicine shop observations
As expected with evening visits to the 28 shops, all owners were found, but only 15% reported that they stay in their shops all day. Attendants and apprentices were seen in 71% of shops. In the larger shops near markets and major junctions up to 30 customers came in an hour. Shops located in the more residential sections had as few as three customers an hour. On average ten people bought medicines in an hour during this time of day. In contrast, the morning outpatient clinics at the Igbo-Ora Hospital see between 60 and 100 patients daily. No salesperson was observed to ask for a prescription form before selling. Also none were heard to give instructions on medication use. Direct sales to children were observed in six shops located near two of the town’s busiest junctions. Although no vendors had license to sell prescription drugs, all had ampicillin available. Others included Valium (in 93% of shops), tetracycline (89%), phenobarbitone (36%), ampiclox (18%) and diethyl-
Training patent medicine vendors carbamazine citrate (11%). Other prescription drugs may be sold in these shops, but were not observed because PMVs usually keep them locked in cabinets or stored in boxes, often in another room, for protection in the event of police raid. Observation also revealed that the drug sellers often take a passive role, allowing displayed medicines to sell themselves. Some customers come with their minds made up about what drug they want. They point to the desired capsule or tablet and begin bargaining. The final choice and amount depend on how much the customer can pay, not on the dose required to combat his illness. Wolf-Gould et al. [17] describe a similar experience in Ghana where they observed a PMV selling tetracycline for headache even though he had just described the correct use for that drug. “When asked about the apparent contradiction in knowledge and practice he stated that he sold what the customers wanted” (emphasis added). The training committee
The 5 PMSA members selected for the training committee included 1 woman for whom patent medicine selling was her sole business. The PMSA Secretary was also a member and chaired the committee. He was a retired records clerk from the Igbo-Ora Hospital. Another member had nursing training, but had taken up medicine selling when he could not find employment after graduation. Two other members were former school teachers. Prior to the first meeting with the trainer, the committee discussed training interests among themselves and polled other members. Thus they were able to list the following topics: cough, malaria, convulsions, guinea worm, gonorrhoea, diarrhoea and vomiting, snake bite and rheumatism. They said these items reflected the common problems brought to their shops. Based on readings and interviews with key informants, the trainers suggested additional topicsessential drug list, pharmacy law, drug storage and shelf life, nutrition, medication counselling and interpretation of doctor’s prescription. Since the PMSA had decided to limit the time to 8 weekly 2-hr sessions, the list had to be narrowed. The committee prioritized the topics and agreed to focus on-malaria (including febrile convulsions), diarrhoea, guinea worm, gonorrhoea, cough, malnutrition, medication counselling and reading prescriptions. The list was presented at a meeting of the whole PMSA and accepted by the members. The baseline questionnaire
Two-thirds of the PMSA members attended the meeting where the baseline questionnaire was administered. Their strengths and gaps in knowledge about each training topic and reported practices are summarized below. Most (94%) knew mosquitoes carry malaria. The common symptoms of fever, chills and aches were recognized by 75%, 42% and 33% respectively. The
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group was not fully aware that malaria could lead to death (52%), convulsions (48%), and anaemia (46%). Chloroquine was listed as the most appropriate medicine by 70%, but only one person answered correctly the dose to give a 3 year old child. Most (91%) included tepid sponging as part of management, and 54% mentioned fanning as another means to reduce high temperature. Nearly everyone (94%) knew that people acquire guinea worm from drinking pond water. Few could state simple management techniques like daily ulcer dressing (15%) and winding the worm out on a match stick (3%). Instead 52% recommended drugs (niridazole, diethylcarbamazine citrate, metronidazole), even though there is no real ‘cure’ for the disease [25,29]. The role of unhygienic food and water in the cause of diarrhoeal diseases was cited by 88%. Most (97%) knew diarrhoea could lead to malnutrition. Few (21%) recognized sunken fontanelle as a signal for dehydration. Only one-third listed salt-sugar solution as part of management. Instead 70% recommended various antibiotic and antidiarrhoeal drugs. Gonorrhoea was thought to present with painful urination (79%) and discharge (58%). While 46% suggested referring such a patient to hospital, 30% mentioned one of several antibiotic drugs. Others gave no response or said they would fill a prescription as presented. Only 15% suggested use of antibiotics for cough, 30% did not answer the question, while the remainder listed various patent cough mixtures. Two-thirds said they would refer the person to hospital if the cough persisted beyond 2 weeks. Although 61% were aware that malnutrition results from a lack of varied diet, 58% were willing to suggest blood tonics and vitamin tablets as the main solution. Interestingly, 18% recognized the role of intestinal parasites in malnutrition by recommending worm expellers. The PMVs knew an average of 5 out of 9 common abbreviations found on doctors’ prescription forms. The most well known (73%) was ‘tab’ for tablet. Few knew that ‘pm’ meant take when needed (21%). When asked what they would tell their customers after selling a medicine, 12 said they would mention side effects. Eleven would stress the importance of compliance. Two each said they would instruct the patient to keep drugs away from children, to store drugs properly, to eat before taking medicine and to go to hospital if there was no improvement. In response to a direct question on ensuring compliance, 42% said they would explain procedures to the patient, and 27% noted that they would mark symbols for dosage on the container or packet. Finally 39% said that they would sell medicine to a child, although they qualified their answer by saying they would give explanation or mark dosage symbols. The others would either refuse to sell or send for the child’s parents.
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FREDERICK0. OSHINAMEand WILLIAM R. BRIEGER TRAINING DESIGN
It is important to state clearly that training cannot be a panacea for solving all health management problems. The baseline study of PMVs showed that there were several areas of knowledge and skill and possibly attitudes that could be addressed through training. The basic cultural and health system issues that impel people to patronize the PMV in the first place (desire for immediate help, drugs shortages in government clinics) are not within the scope of a training intervention. The broad objective of training PMVs in Igbor-Ora was therefore increasing their competence in handling some of the common problems the community brings to them. Specific training objectives included ability of the trainees to:
Igbo-Ora trainees were taking their post-test and scored a mean of 42.2%. No significant difference was found between these two scores [t = 0.107, P > 0.901. Neither was the difference between IgboOra and Eruwa PMVs at baseline significant [t = 0.357, P > 0.701. In contrast the Igbo-Ora trainees scored significantly higher than the Eruwa control group at post-test [t = 9.015, P < O.OOl]. A few of the specific areas of improvement for the Igbo-Ora trainees are noted. After training, over three-quarters could list ulcer cleaning and worm removal as part of guinea worm disease management. The proportion of anti-helminthic drugs mentioned dropped from 54% to 35% of responses. An increase from 42% to 81% in the mention of paracetamol for malaria treatment was in keeping with training emphasis on non-aspirin products for febrile children.
1. Recognize the signs and symptoms for the common illness conditions prioritized for training. 2. Recommend non-drug therapy where appropriate. 3. Provide medication conseling to clients. 4. Refer patients with serious conditions such as sexually transmitted diseases and respiratory infections. 5. Describe preventive measures for target conditions.
Flow of
PMV training sessions
Opening and announcements
Thirty-seven people attended the course, 9 of whom were apprentices. Existing primary health worker training lesson plans were adapted for the PMV course. These emphasized a participatory approach and culturally appropriate methods such as story telling, role play and use of proverbs [31]. The PMSA training committee took charge of printing written and pictorial handout materials based on the lesson plans. Trainers included two nurses from the Igbo-Ora Hospital, a member of the Idere Primary Health Workers Association and a local secondary school teacher. The training process was evaluated through observation by the researchers and questions to the trainees on their post-test (see Fig. 1). POST-TRAINING RESULTS
To simplify comparison, the 101 items on the questionnaire (test) were scored and the overall results displayed in Table 1. The 33 Igbo-Ora PMVs who took the pretest averaged 43.2%. The 37 people who underwent training had a significantly higher mean score of 71.6% at post-test [t = 9.940, P < O.OOl]. Since the two sets of people were not identical, a paired t-test was calculated using the scores of the 28 individuals who took both tests. Their pretest (46.0%) and post-test (70.8%) scores were similar to the two groups generally and also showed the significant gain at post-test [t = 12.161, P < O.OOl]. The 16 Eruwa PMVs scored 41.9% at pre-test. Fourteen were located to retake the test when the
Review of session, trainee feedback, and clarification
I--
Closing, assignments, and announcements I
Fig. 1. Flow of PMV training sessions.
Training patent medicine vendors Table 1. Comparison of knowledge scores at pre- and post-test for trained and control groups Group Time Pretest Mean score N Post-test Mean score N f value P value
Igbo-Ora Trainees 43.2 33
Eruwa Controls 41.9 16
71.6 37 9.940 <0.001
42.2 14 0.107 >0.90
f value
P value
0.357
>0.70
9.015
< 0.001
Listing of the generic chloroquine for malaria treatment still topped the list at post-test, while mention of brand name drugs was cut nearly in half. The number stating that patients with suspected gonorrhoea should be referred to hospital more than doubled to 92%. Although some trainees continued to list antibiotic drugs for gonorrhoea treatment, 60% stated they would sell no drugs for the condition compared to 3% at pretest. For diarrhoeal diseases recognition of oral rehydration therapy increased to 89%, and mention of anti-diarrhoeal drugs dropped from 33% to 5%. Naming of antimicrobial drugs for diarrhoea reduced to two-fifths of previous listing. At post-test proprietary cough mixtures were still commonly suggested for patients presenting with cough, but 73% were also willing to refer the patient to clinic immediately compared to 30% at pretest. Only one trainee mentioned an antibiotic drug for cough. Knowledge of components of a balanced diet increased by 50% overall, and intention not to sell drugs as the cure for malnutrition quadrupled to 40% of post-test. Trainees could now recognize on average 8 out of 9 abbreviations used on prescription forms. Up to 73% indicated that they would now explain medication use and dose to their customers. Trainee feedback
The session on medication counseling was the most popular, mentioned by 65% as one of the best liked. Over half specifically said they enjoyed learning about the preventive aspects of the conditions covered. Various suggestions were given includingmake training compulsory for all PMVs, increase the length of training, offer training on a regular basis, involve government in training efforts. Requests for sessions on additional topics listed eye problems, skin diseases, chronic illness (e.g. hypertension) and pain/arthritis. DISCUSSION
The most important lesson that can be learned from training patent medicine vendors in Igbo-Ora is that they themselves value knowledge. This is crucial in light of the reality that many years will pass
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before government programmes will be able to supply communities with adequate supplies of essential drugs. Even if these are made available, the natural human desire for the personal sense of control and convenience offered by self-treatment will not easily be extinguished. Thus self-care, facilitated by trained PMVs, can hopefully be made safer and more appropriate. The popularity of the lesson on medication counselling shows that this is a reasonable hope. There may be concern that the profit motive might muffle the interest in medication counselling, i.e. that business as usual may continue whenever the customer requests a specific drug, even though the PMV may know that the particular drug is not needed or appropriate. The independent drug seller in a small town like Igbo-Ora, is also a neighbour and friend, and therefore most likely shares prevailing community values. Is he or she any less ethical than the private physician from the city who sets up ghost a practice (of which two currently exist in Igbo-Ora) run by nurses and aides? The training did also address ethical issues; for example, trainees were asked to discuss what to do if a small child tries to buy medicine. These practical issues are what made the session on medication counselling interesting. This short training can not hope to change values quickly, but the commitment of the PMSA does offer hope that the environment might exist for the continual reinforcement needed to build some sort of ‘professional values.’ The enthusiasm for training was engendered in large part because the trainees themselves were involved in needs assessment, planning and management of the course. There was initial skepticism because others who had approached the PMVs had questionable motives (harassment, extortion and research that extracted information while giving nothing in return). Later the PMSA became committed to making the programme successful because they had ownership in the project. The involvement of the association may have two longer term benefits. First the organization now has the experience and skills to tap local health resource people and to implement its own ‘continuing education’ programme. As noted the association executives felt that training would make the membership more active. Also the involvement of apprentices shows that the association is looking toward the future. Secondly the association may provide peer support for higher levels of performance. In conclusion, training PMVs is not offered as a panacea for addressing the whole issue of essential drugs. But it is one avenue for improving community knowledge about medications and strengthening the quality of natural self-care tendencies. The Igbo-Ora pilot training has shown that with mutual trust, the formal health sector and the private medicine seller can collaborate in primary care.
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24. Hardon A. P. The use of modern pharmaceuticals in a Filipino village: doctors’ prescription and self-medication. Sot. Sci. Med. 3, 277-292, 1987. 25. Brieger W. R., Ramakrishna J. and Adeniyi J. D. Self-treatment in rural Nigeria: a community health education diagnosis. Hygie (Int. J. Hlth Educ.) $4146, 1986.
1977.
10. Mamdani M. and Walker G. Essential drugs in the developing world. Hlth Policy Planning 1, 187-201, 1986. 11. van der Geest S., Hardon A. and Whyte S. R. Planning for essential drugs: are we missing the cultural dimension? Hlth Policy Planning 5, 182-185, 1990. 12. Egboh A. A. Pharmacy Laws and Practice in Nigeria. LGeramed Publications, Ikeja, 1984. 13. Kleczkowski E. M.. Ellina R. H. and Smith D. L. Health
17. Wolf-Gould C. S., Taylor N., Horwitz S. M. and Barry M. Misinformation about medications in rural Ghana. Sot. Sci. Med. 33, 83389, 1991. 18. Nigeria. Pharmacy Law, Chap. 92. Federal Ministry of Health, Lagos, 1946. 19. van der Geest S. Self-care and the informal sale of drugs in south Cameroon. Sot. Sci. Med. 25, 293-305, 1987. 20. Abiola A. B., Adeyinka A. F., Alhassan M. R., Famuyide A. O., Nwaorgu 0. G. B., Olojohungbe A. B. K. and Uche F. N. A qualitative assessment of medicine sellers in Igbo-Ora. A project report submitted to the Department of Preventive and Social Medicine, Universitv of Ibadan. Nigeria. in oartial fulfilment of the requirements of the-M.B.B.S.-Degree, 1983. 21 Akinde J. A., Effiong C., Obiejosie J. 0. A., Ogun J. B., Oloye S. D. and Temiye E. 0. Survey of patent medicine stores in Igbo-Ora. A project report submitted to the Department of Preventive and Social Medicine, University of Ibadan, Nigeria, in partial fulfilment of the requirements of the M.B.B.S. Degree, 1982. 22. Levin L. S. Patient education and self-care: how do they differ? In Patient Education: an Inquiry into the State of the Art (Edited by Squyres W. D.) pp. 205-216. Springer, New York, 1980. 23. Levin L. S. Self-care in health: potentials and pitfalls.
26. Northrup
R. Editorial comment.
Update on Diarrhea
(PRITECH)
Technical Literature S,(7), 2, 1990.
27. Adeosun P. Brief Historv of the National Association of Patent/Proprietary Medicine Dealers. Presented at the Silver Jubilee Celebration of the National Association of Patent/Proprietary Medicine Dealers, Lagos, Nigeria, 11 May 1988. 28 Akpovi S. U., Johnson D. C. and Brieger W. R. Guineaworm control: testing the efficacy of health education in primary health care. Int. J. Hlth Educ. 24, 229-237,
1981.
29 Brieger W. R., Ramakrishna J. and Adeniyi J. D. Primary schools: making teaching relevant to local health issues. Educ. Hlth (WHO) 2,(l), 3946, 1985. 30 van der Geest S. and Harden A. Drug use: methodological suggestions for field research in developing countries. Hlth Policy Planning 3, 1522158, 1988. 31 Brieger W. R. and Akpoui Sr U: A health education approach to training village health workers. Inf. Q. Community
Hlth Educ. 3, 145-152,
1982.
PRIMARY
Copyright 0
CARE TRAINING FOR PATENT VENDORS IN RURAL NIGERIA
0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
MEDICINE
FREDERICK 0. OSHINAHB’ and WILLIAM R. BRIEGER~* ‘Nigeria Drug Enforcement Agency, Counselling Unit, Lagos, Nigeria and 2African Regional Health Education Centre, Department of Preventive and Social Medicine, University of Ibadan, Nigeria Abstract-The provision of essential drugs and the involvement of various potential and existing health care providers (e.g. teachers and traditional healers) are two important primary health care strategies. One local group that is already actively supplying the medication needs of the community is the patent medicine vendors (PMVs), but the formal health establishment often views their activities with alarm. One way to improve the quality of the PMVs’ contribution to primary care is through training, since no formal course is required of them before they are issued a license by government. Primary care training was offered to the 49 members of the Patent Medicine Sellers Association of Igbo-Ora, a small town in western Nigeria. Baseline information was gathered through interview, observation and pre-test. A training committee of Association members helped prioritize training needs and manage training logistics. Thirty-seven members and their apprentices underwent the 8 weekly 2-hr sessions on recognition and treatment (including non-drug therapies) for malaria, diarrhoea, guinea worm, sexually transmitted diseases, respiratory infections, and malnutrition, plus sessions on reading doctor’s prescriptions and medication counseling. The group scored significantly higher at post-test and also showed significant gains over a control group of PMVs from another town in the district. The Igbo-Ora experience shows that PMVs can improve their health care knowledge and thus increase their potential value as primary health care team members. Key words-patent
medicine vendors, primary health care training
INTRODUCTION The treatment of common health problems and the provision of essential drugs are two interrelated essential services of a primary health care (PHC) programme [l]. In keeping with PHC emphasis on
community participation, one approach to providing these services is the revolving drug fund managed by community members and their volunteer community health workers [2]. In reality money generated through community financing has often been insufficient to maintain health services, hence a need for government supplementation [3,4]. Government health planners are currently emphasizing cost sharing and cost recovery in local health services [5], a move that has been formalized in the Bamako Initiative launched by UNICEF in 1987, and is based on the belief that people will pay for public services since they already pay for private and traditional health care [6]. Unfortunately the general picture for government health services has been chronic drug shortages [7,8]. Planners have often underestimated requirements for distribution networks in maintaining community based services [8-lo], giving rise to a natural fear that medicine supplies will be siphoned off into the informal sector [ll]. While attention to these management issues is part of the solution, a deeper problem is the politicization of health care, that inhibits many govern*To whom correspondence
should be addressed.
ments in developing countries from retreating from the role of ultimate provider of free care [6]. While governments try to sort out their policies and plan their programmes, people in local communities continue to meet their illness care needs (and demonstrate daily their willingness to pay) by patronizing patent medicine vendors (PMVs), as they have been doing for decades [7, 121. In poor rural areas private expenditure for health care through drug shops is considerable [ 131.A survey in rural Indonesia found that only 17% of illness treatment contacts were made at government health services. Nearly half (45%) were with the informal sector, 88% of which were village medicine shops, the cheapest source of care [14]. Though their ethics and competence have been challenged [15, 161, the ability of PMVs to provide accessible services, even in remote areas, can not be doubted [14]. It is ironic that while government doctors and medical assistants are more knowledgeable about medication use and correct prescribing practices than private medicine vendors, the PMVs spend more time with and display a friendlier attitude toward their clients than do staff of the formal health sector [ 171. APPROACHES TO MEDICINE VENDING
Three approaches to the ubiquitous PMV exist. Generally they have been ignored by the formal health sector in hopes that governments will
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eventually eliminate drug shortages. “It is significant that most countries working on an essential drugs policy seem to exclude the private sector” [1 11. In the meantime government health workers continue to write prescriptions that they know can not be filled in their own dispensaries [12, 161. Law enforcement is a second, but ineffectual approach. “Few developing countries have succeeded in imposing any meaningful controls on private drug sales” [lo], because few ministries have enough trained personnel to monitor the numerous, dispersed and often mobile private medicine sellers [ 16, 171. A third option, training PMVs, would address concerns about competence. PHC philosophy is noted for advocating incorporation of local human resources, such as village volunteers, traditional healers and religious leaders, into health care efforts. The PMV, who already has motivation and experience, is another likely candidate. In Ghana, PMVs have been trained on use of oral rehydration salts and birth control pills, so extended training on dispensing practices generally might be feasible [17]. Unfortunately, positive recognition is feared by some health professionals who believe that training would create a band of dangerous pseudo-doctors [16]. The training option has been explored by a team from the Ibarapa Community Health Programme, Department of Preventive and Social Medicine, University of Ibadan, Nigeria, based at its rural training site in the town of Igbo-Ora in southwestern Oyo State. A participatory approach, in keeping with PHC philosophy, was used whereby the local PMV association was involved in determining training needs, designing the training sessions and organizing training logistics. An assessment of pre- and posttraining knowledge among the Igbo-Ora PMVs was compared with PMVs in another community who were not trained. The processes of training design, delivery and immediate evaluation are presented herein. DEFINING THE MEDICINE
VENDOR
Before presenting the Igbo-Ora study, it is necessary to define briefly who are patent medicine vendors and the nature of the work they perform. This includes legal, functional and cultural perspectives as well as group self-identity. Since much of the controversy over PMV practice is couched in legal terms, it is necessary to see what the law says about their status. In Nigeria a definition of PMV can be implied from Pharmacy Law as a person duly licensed by a state Ministry of Health to sell patent and proprietary medicines [18]. Three types of licenses distinguish whether the owner may sell prescription or proprietary medications. The former could be termed poisonous, addictive or dangerous if used without professional guidance (e.g. antibiotics, opiate derivatives), while the latter are prepackaged preparations, sold under trade names
and considered relatively safe for use by the general public (e.g. cough mixtures and some pain relievers). Holders of license ‘C’ can sell only proprietary or patent medicines; those with ‘B’ may in addition sell selected ‘poisons’ such as disinfectants; while only trained pharmacists receive license ‘A’, and sell the full range of medications [18]. No other distinguishing requirements are written into the law, but by custom the PMV is expected to have completed primary school. No formal job training is demanded or organized, although licensees are given a pamphlet outlining relevant aspects of Pharmacy Law. It is possible to define the PMV by observing his/her practice. Van der Geest [19] distinguishes five functional categories of PMVs in southern Cameroon: (1) general shop keepers who also sell patent medicines, (2) traders in the periodic markets who sell medicines along with other merchandise, (3) drug peddlers who go from village to village, (4) merchants who specialize in the sale of medicines and (5) health workers who sell the medicines obtained from their institutions. While all forms are known to exist in the Ibarapa District of Oyo State, Nigeria, previous field study has looked more closely at peddlers and medicine shop keepers. In Ibarapa both primary and secondary school leavers are among licensed PMVs. Some learned the work as apprentices, while others had worked in the formal health sector as pharmacy technicians, clerks and aids [20]. Most PMVs have shops in towns, often located near markets or busy intersections. Many sell small provisions like tinned milk and detergent powder, but the main commodity in their shops is medicine. Sale of prescription and expired drugs has been documented [2,21]. Just as many learned the trade through apprenticeship, many also left their shops in the hands of their own apprentices, especially since PMVs often engage in farming and other businesses [21]. Medicine peddlers on motorcycle were found to provide the bulk of western health care to remote hamlets. They also set up shop at periodic farm markets where quantities sold relate more to ability to pay than to any medical regimen [2]. Another definition of the PMV relates to cultural perceptions of appropriate illness behaviour. Selftreatment is a pervasive human behaviour because of the intrinsic value, seen by most all cultures, in an immediate, low-cost and self-controlled response to sickness [22,23]. In this context the community defines and refines its ideas about what medicines are ‘essential,’ and members act on these definitions with the aid of friends, relatives, patent medicine sellers and other health care providers [ll]. While the primary source of information and influence on selfmedicine usually comes from within the family, physician’s prescribing practices may, by way of example, ‘teach’ local people about drug selection [24]. Consumer requests in turn inform the PMVs,
Training patent medicine vendors
who tend to monitor market forces [15,20]. Unfortunately the information passed along this chain is often based on symptomatic, expensive, excessive and sometimes dangerous prescriptions [24]. Even where traditional practitioners and home remedies and are a major source of care, the PMV has been widely accepted and often provides largest source of medications for self-treatment [25]. The integral role of self-treatment in all cultures implies that community reliance on PMVs is not solely due to drug shortages in government clinics [19]. As Northrup [26] observed in rural India, community members prefer the PMV, “not only because of convenience and personalized service, but also because they have faith in the effectiveness of his medicines. They are not sure that the worker in the government health facility will be present nor do they trust the power of the free government medicines.” Finally the licensed PMVs have defined themselves. In 1951 the PMVs in the former Western Region (the present Bendel, Lagos, Ogun, Ondo and Oyo States) of Nigeria came together to form the Nigerian Association of Patent and Proprietary Medicine Dealers, headquartered at Ibadan. The Association received a certificate of incorporation in 1962, and associations in other states have joined in accordance with a 1978 national affiliation agreement [27]. State, district and town branches have been formed. The Association serves as a mediator between members and local, state and federal governments. One effect of the association at the local level may be the relative uniformity in pricing that was found in Igbo-Ora shops [20]. Another may be the speed by which information about drugs spreads among PMVs, as was seen with the quick availability of medicine for onchocerciasis in PMV shops shortly after a group of village health workers in Ibarapa contacted one PMV to help them purchase a supply wholesale [2]. THE IGBO-ORA
COMMUNITY
Igbo-Ora, a town of 60,000 people, is the largest in Ibarapa District and base for the University of Ibadan’s rural health training programmes. The town is an amalgam of six smaller communities that grew from hunting camps formed in the nineteenth century by settlers from the nearby Oyo and Egba empires, both of which are part of the larger Yoruba ethnic group. Agriculture is the mainstay of the local economy. Twenty to thirty percent of the population live in scattered farm hamlets located between 5 and 30 km from town. Igbo-Ora is the hub for bulking produce for onward transport to nearby federal and state (Oyo and Ogun) capitals. These cities, Lagos, Ibadan and Abeokuta, are the main source of supply for the 47 licensed PMVs in Igbo-Ora town. Other health services within the town include a state general
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hospital, one private hospital, two local government dispensaries/maternity centres, two private clinics/maternity homes and numerous traditional and spiritual healers. The town has one chemist shop run by a trained pharmacist. Faculty, staff and students from the University of Ibadan’s Ibarapa Community Health Programme have been involved in training volunteer village health workers and school teachers in primary health care skills since 1978 [28,29]. The present effort with PMVs is a natural extension of that work. METHODS
The target group for developing and implementing a training curriculum was all PMVs in Igbo-Ora town. Since a participatory approach to the study of PMVs was chosen [30], the team decided to work through the Igbo-Ora Patent Medicine Sellers Association (PMSA), which presented nearly all the PMVs in town. The 49 members included 6 PMVs from the neighbouring town of Idere (distance 7 km). Four Igbo-Ora PMVs did not belong to the PMSA. The association encouraged them to join in order to participate in the training, but they declined. One was a trained nurse, while the others did not have an active business. In addition to regular members, the association asked that apprentices also attend training. Each member PMV had at least one apprentice, many of whom were informal helpers and the children of the PMV, so an exact number could not be determined. The first step in the project was establishment of a trusting relationship between the trainers and the PMSA. Because government officials and police agents often harassed individual PMVs, the association needed to be assured that the trainers were not government agents and would not use information gathered to harm members. Meetings with individual officers and an introduction to the general membership at a regular meeting were conducted before approval was given to carry out the project. Baseline data for curriculum development was gathered through five interrelated methods. First a review of existing documents and publications on patent medicines and PMVs in the community was made [2,20,21] including records of the PMSA. This was followed by key informant interviews with PMSA officers and staff at the state hospital. The former included the chairman and secretary of the PMSA, and the latter involved two medical officers, two senior nurses and the pharmacist. Thirdly observation was conducted in 28 PMV shops in all sections of Igbo-Ora by the first author. An observational checklist was used to record selling and prescribing practices, types of medicines sold and instructions given to buyers. Between 1 and 2 hr was spent in each shop during the evening hours, because PMSA officers indicated that this would be the busiest time. Observations were preceded by
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additional introductions to dispel sellers’ fears about the observer’s identity. Because of the participatory approach to the training, the fourth method was self-study. The PMSA appointed a five-member training committee charged with polling member interests and developing a list of training needs. The committee then worked together with the trainers to outline the final curriculum and manage training logistics. Based on information and interests generated from the preceding activities, the trainers developed the fifth method, a baseline knowledge questionnaire for PMSA members. Since many had only primary education, the self-administered instrument was translated into the Yoruba language. A pilot test was conducted among the ten PMVs in Igangan town 30 km away at the north end of the district. The final version was given to association members at one of their regular meetings, which conveniently held in a local school room. For comparative purposes, the questionnaire was also administered to a control group, the 16 members of the PMV association in Eruwa town, located 25 km east of Igbo-Ora. Both groups were also given the same instrument as a post-test after the training period. The results of the above processes were used to develop 8 weekly 2-hr training sessions. Each lesson plan was reviewed by hospital staff for technical content and by the training committee for adherence to PMV interests. The results obtained from each baseline method are presented next, followed by a description of the training programme. A comparison between the Igbo-Ora participants and the Eruwa control group conclude the study results. BASELINE
INFORMATION
PMSA records provided information on member characteristics. Most (78%) were male, and ages ranged from 22 to 60 years, although 67% were under 40 years old. All had at least primary education, while 53% had gone on to secondary school. Among these were two who had studied nursing and four who had completed teacher training college. Two held License B, while the majority had License C. Some (43%) learned their work as apprentices. Several (31%) had worked in health facilities as professional, clerical or auxiliary staff. The remainder simply set up the shop and learned on the job. Medicine selling was the sole business of only 20%. Most PMVs were also farmers, traders and artisans. Key informants
The two PMSA officers quizzed the trainers thoroughly on their purpose and affiliation before agreeing to cooperate with the proposed project. They noted that many people who had come to them (PMVs generally) before, turned out to be detectives or government officials. They had even been harassed
by ‘fake’ police who tried to fool them into paying bribes. They eventually expressed great interest in the training idea because they said there was no standard qualification for the job. The PMSA had even invited a trained pharmacist to lecture them at a previous meeting. They felt most current members were not very active in the association and thought that training might be a way to boost participation. A general need identified by the two officers was a better understanding of the pharmacy law. Most of the members with only primary education had difficulty reading the English language pamphlets provided by the Ministry. This was given as reason why many did not realize it is illegal to sell prescription medicines. Also mentioned was the fact that many members travel to the surrounding hamlets to sell medicines and confront complaints that they are unable to identify. In contrast the Igbo-Ora hospital staff considered the PMVs to be a nuisance. They acknowledged the fact that most people patronize the PMVs and said there was little to be done about that. Particular concern was expressed about attempts by PMVs to treat sexually transmitted diseases without being aware of the dangers of engendering antibiotic resistance. Fear was expressed that training might foster in PMVs the attitude that they are doctors. The medical staff stressed that the lessons should focus on ability to identify when to refer patients to hospital, especially for tuberculosis and other serious respiratory diseases. The health workers did concede that people must buy drugs from the PMVs, because government hospitals often run short. Therefore they suggested that PMVs should be taught to read a doctor’s prescription correctly. Medicine shop observations
As expected with evening visits to the 28 shops, all owners were found, but only 15% reported that they stay in their shops all day. Attendants and apprentices were seen in 71% of shops. In the larger shops near markets and major junctions up to 30 customers came in an hour. Shops located in the more residential sections had as few as three customers an hour. On average ten people bought medicines in an hour during this time of day. In contrast, the morning outpatient clinics at the Igbo-Ora Hospital see between 60 and 100 patients daily. No salesperson was observed to ask for a prescription form before selling. Also none were heard to give instructions on medication use. Direct sales to children were observed in six shops located near two of the town’s busiest junctions. Although no vendors had license to sell prescription drugs, all had ampicillin available. Others included Valium (in 93% of shops), tetracycline (89%), phenobarbitone (36%), ampiclox (18%) and diethyl-
Training patent medicine vendors carbamazine citrate (11%). Other prescription drugs may be sold in these shops, but were not observed because PMVs usually keep them locked in cabinets or stored in boxes, often in another room, for protection in the event of police raid. Observation also revealed that the drug sellers often take a passive role, allowing displayed medicines to sell themselves. Some customers come with their minds made up about what drug they want. They point to the desired capsule or tablet and begin bargaining. The final choice and amount depend on how much the customer can pay, not on the dose required to combat his illness. Wolf-Gould et al. [17] describe a similar experience in Ghana where they observed a PMV selling tetracycline for headache even though he had just described the correct use for that drug. “When asked about the apparent contradiction in knowledge and practice he stated that he sold what the customers wanted” (emphasis added). The training committee
The 5 PMSA members selected for the training committee included 1 woman for whom patent medicine selling was her sole business. The PMSA Secretary was also a member and chaired the committee. He was a retired records clerk from the Igbo-Ora Hospital. Another member had nursing training, but had taken up medicine selling when he could not find employment after graduation. Two other members were former school teachers. Prior to the first meeting with the trainer, the committee discussed training interests among themselves and polled other members. Thus they were able to list the following topics: cough, malaria, convulsions, guinea worm, gonorrhoea, diarrhoea and vomiting, snake bite and rheumatism. They said these items reflected the common problems brought to their shops. Based on readings and interviews with key informants, the trainers suggested additional topicsessential drug list, pharmacy law, drug storage and shelf life, nutrition, medication counselling and interpretation of doctor’s prescription. Since the PMSA had decided to limit the time to 8 weekly 2-hr sessions, the list had to be narrowed. The committee prioritized the topics and agreed to focus on-malaria (including febrile convulsions), diarrhoea, guinea worm, gonorrhoea, cough, malnutrition, medication counselling and reading prescriptions. The list was presented at a meeting of the whole PMSA and accepted by the members. The baseline questionnaire
Two-thirds of the PMSA members attended the meeting where the baseline questionnaire was administered. Their strengths and gaps in knowledge about each training topic and reported practices are summarized below. Most (94%) knew mosquitoes carry malaria. The common symptoms of fever, chills and aches were recognized by 75%, 42% and 33% respectively. The
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group was not fully aware that malaria could lead to death (52%), convulsions (48%), and anaemia (46%). Chloroquine was listed as the most appropriate medicine by 70%, but only one person answered correctly the dose to give a 3 year old child. Most (91%) included tepid sponging as part of management, and 54% mentioned fanning as another means to reduce high temperature. Nearly everyone (94%) knew that people acquire guinea worm from drinking pond water. Few could state simple management techniques like daily ulcer dressing (15%) and winding the worm out on a match stick (3%). Instead 52% recommended drugs (niridazole, diethylcarbamazine citrate, metronidazole), even though there is no real ‘cure’ for the disease [25,29]. The role of unhygienic food and water in the cause of diarrhoeal diseases was cited by 88%. Most (97%) knew diarrhoea could lead to malnutrition. Few (21%) recognized sunken fontanelle as a signal for dehydration. Only one-third listed salt-sugar solution as part of management. Instead 70% recommended various antibiotic and antidiarrhoeal drugs. Gonorrhoea was thought to present with painful urination (79%) and discharge (58%). While 46% suggested referring such a patient to hospital, 30% mentioned one of several antibiotic drugs. Others gave no response or said they would fill a prescription as presented. Only 15% suggested use of antibiotics for cough, 30% did not answer the question, while the remainder listed various patent cough mixtures. Two-thirds said they would refer the person to hospital if the cough persisted beyond 2 weeks. Although 61% were aware that malnutrition results from a lack of varied diet, 58% were willing to suggest blood tonics and vitamin tablets as the main solution. Interestingly, 18% recognized the role of intestinal parasites in malnutrition by recommending worm expellers. The PMVs knew an average of 5 out of 9 common abbreviations found on doctors’ prescription forms. The most well known (73%) was ‘tab’ for tablet. Few knew that ‘pm’ meant take when needed (21%). When asked what they would tell their customers after selling a medicine, 12 said they would mention side effects. Eleven would stress the importance of compliance. Two each said they would instruct the patient to keep drugs away from children, to store drugs properly, to eat before taking medicine and to go to hospital if there was no improvement. In response to a direct question on ensuring compliance, 42% said they would explain procedures to the patient, and 27% noted that they would mark symbols for dosage on the container or packet. Finally 39% said that they would sell medicine to a child, although they qualified their answer by saying they would give explanation or mark dosage symbols. The others would either refuse to sell or send for the child’s parents.
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It is important to state clearly that training cannot be a panacea for solving all health management problems. The baseline study of PMVs showed that there were several areas of knowledge and skill and possibly attitudes that could be addressed through training. The basic cultural and health system issues that impel people to patronize the PMV in the first place (desire for immediate help, drugs shortages in government clinics) are not within the scope of a training intervention. The broad objective of training PMVs in Igbor-Ora was therefore increasing their competence in handling some of the common problems the community brings to them. Specific training objectives included ability of the trainees to:
Igbo-Ora trainees were taking their post-test and scored a mean of 42.2%. No significant difference was found between these two scores [t = 0.107, P > 0.901. Neither was the difference between IgboOra and Eruwa PMVs at baseline significant [t = 0.357, P > 0.701. In contrast the Igbo-Ora trainees scored significantly higher than the Eruwa control group at post-test [t = 9.015, P < O.OOl]. A few of the specific areas of improvement for the Igbo-Ora trainees are noted. After training, over three-quarters could list ulcer cleaning and worm removal as part of guinea worm disease management. The proportion of anti-helminthic drugs mentioned dropped from 54% to 35% of responses. An increase from 42% to 81% in the mention of paracetamol for malaria treatment was in keeping with training emphasis on non-aspirin products for febrile children.
1. Recognize the signs and symptoms for the common illness conditions prioritized for training. 2. Recommend non-drug therapy where appropriate. 3. Provide medication conseling to clients. 4. Refer patients with serious conditions such as sexually transmitted diseases and respiratory infections. 5. Describe preventive measures for target conditions.
Flow of
PMV training sessions
Opening and announcements
Thirty-seven people attended the course, 9 of whom were apprentices. Existing primary health worker training lesson plans were adapted for the PMV course. These emphasized a participatory approach and culturally appropriate methods such as story telling, role play and use of proverbs [31]. The PMSA training committee took charge of printing written and pictorial handout materials based on the lesson plans. Trainers included two nurses from the Igbo-Ora Hospital, a member of the Idere Primary Health Workers Association and a local secondary school teacher. The training process was evaluated through observation by the researchers and questions to the trainees on their post-test (see Fig. 1). POST-TRAINING RESULTS
To simplify comparison, the 101 items on the questionnaire (test) were scored and the overall results displayed in Table 1. The 33 Igbo-Ora PMVs who took the pretest averaged 43.2%. The 37 people who underwent training had a significantly higher mean score of 71.6% at post-test [t = 9.940, P < O.OOl]. Since the two sets of people were not identical, a paired t-test was calculated using the scores of the 28 individuals who took both tests. Their pretest (46.0%) and post-test (70.8%) scores were similar to the two groups generally and also showed the significant gain at post-test [t = 12.161, P < O.OOl]. The 16 Eruwa PMVs scored 41.9% at pre-test. Fourteen were located to retake the test when the
Review of session, trainee feedback, and clarification
I--
Closing, assignments, and announcements I
Fig. 1. Flow of PMV training sessions.
Training patent medicine vendors Table 1. Comparison of knowledge scores at pre- and post-test for trained and control groups Group Time Pretest Mean score N Post-test Mean score N f value P value
Igbo-Ora Trainees 43.2 33
Eruwa Controls 41.9 16
71.6 37 9.940 <0.001
42.2 14 0.107 >0.90
f value
P value
0.357
>0.70
9.015
< 0.001
Listing of the generic chloroquine for malaria treatment still topped the list at post-test, while mention of brand name drugs was cut nearly in half. The number stating that patients with suspected gonorrhoea should be referred to hospital more than doubled to 92%. Although some trainees continued to list antibiotic drugs for gonorrhoea treatment, 60% stated they would sell no drugs for the condition compared to 3% at pretest. For diarrhoeal diseases recognition of oral rehydration therapy increased to 89%, and mention of anti-diarrhoeal drugs dropped from 33% to 5%. Naming of antimicrobial drugs for diarrhoea reduced to two-fifths of previous listing. At post-test proprietary cough mixtures were still commonly suggested for patients presenting with cough, but 73% were also willing to refer the patient to clinic immediately compared to 30% at pretest. Only one trainee mentioned an antibiotic drug for cough. Knowledge of components of a balanced diet increased by 50% overall, and intention not to sell drugs as the cure for malnutrition quadrupled to 40% of post-test. Trainees could now recognize on average 8 out of 9 abbreviations used on prescription forms. Up to 73% indicated that they would now explain medication use and dose to their customers. Trainee feedback
The session on medication counseling was the most popular, mentioned by 65% as one of the best liked. Over half specifically said they enjoyed learning about the preventive aspects of the conditions covered. Various suggestions were given includingmake training compulsory for all PMVs, increase the length of training, offer training on a regular basis, involve government in training efforts. Requests for sessions on additional topics listed eye problems, skin diseases, chronic illness (e.g. hypertension) and pain/arthritis. DISCUSSION
The most important lesson that can be learned from training patent medicine vendors in Igbo-Ora is that they themselves value knowledge. This is crucial in light of the reality that many years will pass
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before government programmes will be able to supply communities with adequate supplies of essential drugs. Even if these are made available, the natural human desire for the personal sense of control and convenience offered by self-treatment will not easily be extinguished. Thus self-care, facilitated by trained PMVs, can hopefully be made safer and more appropriate. The popularity of the lesson on medication counselling shows that this is a reasonable hope. There may be concern that the profit motive might muffle the interest in medication counselling, i.e. that business as usual may continue whenever the customer requests a specific drug, even though the PMV may know that the particular drug is not needed or appropriate. The independent drug seller in a small town like Igbo-Ora, is also a neighbour and friend, and therefore most likely shares prevailing community values. Is he or she any less ethical than the private physician from the city who sets up ghost a practice (of which two currently exist in Igbo-Ora) run by nurses and aides? The training did also address ethical issues; for example, trainees were asked to discuss what to do if a small child tries to buy medicine. These practical issues are what made the session on medication counselling interesting. This short training can not hope to change values quickly, but the commitment of the PMSA does offer hope that the environment might exist for the continual reinforcement needed to build some sort of ‘professional values.’ The enthusiasm for training was engendered in large part because the trainees themselves were involved in needs assessment, planning and management of the course. There was initial skepticism because others who had approached the PMVs had questionable motives (harassment, extortion and research that extracted information while giving nothing in return). Later the PMSA became committed to making the programme successful because they had ownership in the project. The involvement of the association may have two longer term benefits. First the organization now has the experience and skills to tap local health resource people and to implement its own ‘continuing education’ programme. As noted the association executives felt that training would make the membership more active. Also the involvement of apprentices shows that the association is looking toward the future. Secondly the association may provide peer support for higher levels of performance. In conclusion, training PMVs is not offered as a panacea for addressing the whole issue of essential drugs. But it is one avenue for improving community knowledge about medications and strengthening the quality of natural self-care tendencies. The Igbo-Ora pilot training has shown that with mutual trust, the formal health sector and the private medicine seller can collaborate in primary care.
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