Where Rubber Meets the Road:

Transcription

1 Where Rubber Meets the Road: How the customer-medicine seller dynamic shapes childhood diarrhea management Lauren Rosapep and Emily Sanders Abt Associates March 2, 2015 SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with: Banyan Global Jhpiego Marie Stopes International Monitor Group O Hanlon Health Consulting

2 Agenda 1. Global guidelines for pediatric diarrhea management 2. Barriers to changing healthcare provider behavior: the know-do gap 3. Our qualitative study: examining the know-do gap in Ghana Group exercise! 4. What we found 5. Implications and recommendations Group exercise! 2

3 WHO Recommends ORS and zinc WHO/UNICEF Joint Statement 2004 revises recommendation for the treatment of uncomplicated diarrhea in children under 5: Low osmolarity oral rehydration solution (ORS) 10 or 20 mg zinc for days Antimicrobials ONLY for complicated diarrhea Antidiarrheals NEVER 3

4 Global Know-Do Gap Diarrhea management campaigns/education efforts can increase knowledge/awareness, but behavior change is more tricky: Bangladesh, Indonesia, Kenya, Nigeria, and Peru. (Path 2014; Simpson et al, 2013; Zwiser et al, 2013; Larson et al 2012; Parades et al 1996) Private providers from 29 sub-saharan African countries were less likely to provide ORS and more likely to provide other treatments. (Sood and Wagner, 2014) 4

5 Ghana Context SHOPS flagship diarrhea program began in 2011 with objective to introduce ORS and zinc through the private sector focusing on over-the-counter medicine sellers. Sources of Diarrhea Treatment 11% 8% Private pharmacy/medicine seller Public hospital/facility 22% 59% Private hospital/facility Other Source: SHOPS 2011 Ghana household survey 5

6 Ghana s Know-Do Gap 2012 RCT showed knowledge-practice gap in diarrhea management practices of medicine sellers. 94% say they don t dispense antimicrobials and knew ORS and zinc was the right treatment (face-to-face survey). 46% sold or recommended antimicrobials (mystery client survey) follow-up survey of medicine sellers shows much less antibiotic dispensing 2014 (29%). But more than half still aren t doing the right thing (i.e. dispensing ORS and zinc separately or with another inappropriate treatment). 6

7 If They Know It, Why Don t They Do It? 1. Retailers believe there is less risk to both the client s health and the seller s professional image in selling antimicrobials than in recommending an alternative. (Zwisler et al, 2013; Viberg et al, 2010) 2. Many retailers believe that their competitors continue to sell antimicrobials. (Igun,1994; Radyowijati and Hilibrand, 2002) 3. Private providers in particular perceive or experience patient/community pressures to provide inappropriate treatments. (Brugha and Zwi, 1998; Das and Hammer, 2007) 7

8 Examining the Know-Do Gap Qualitatively: Research Question Why do medicine sellers in Ghana continue to recommend and sell antimicrobials and antidiarrheals in addition to ORS with zinc for treatment of uncomplicated pediatric diarrhea? 8

9 Examining the Know-Do Gap Qualitatively: Focus and Aims Medicine Seller Motivations Barriers Context Customer Motivations Barriers Context Medicine Seller and Customer Engagement Medicine Seller Recommendation Customer Drug Purchase Diarrhea Management Outcomes 9

10 Examining the Know-Do Gap Qualitatively: Methods and Data Sources Describe how and why different customer-medicine seller interactions can result in optimal and sub-optimal dispensing outcomes 17 focus group discussions with medicine sellers 9 focus group discussions with caregivers who patronize medicine seller shops Conducted during rainy season when diarrhea cases are most prevalent 10

11 Activity-Enhanced Focus Groups Use group examination of illustrative vignettes to anchor the discussion Indirectly probe specific topics of interest Each vignette was trying to address different theories that literature/common sense made us think were factors including: Insufficient information on either customers or medicine sellers' side Direct request vs. request for advice Price sensitivity Sending someone other than primary caregiver 11

12 Group Discussion: Let s see how this worked Examine the vignette handout (we ll read it out loud too) and consider the following questions: What are some of the factors that influenced the outcome here? Why do you think the medicine seller recommended/ dispensed multiple treatments? How might have things been different if the customer was the girl s primary caregiver rather than the student? 12

13 Findings 13

14 The Three Faces of the Medicine Seller First Line Provider Advisor Retailer The drug store is usually my first place of contact before resorting to the hospital if the case gets worse (Customer) At the chemical shop, we are patient and friendly and so [customers] are able to confide in us (Medicine Seller) Some [customers] don't even tell you the condition, they just tell you what they want to buy (Medicine Seller) 14

15 Where the rubber meets the road 15

16 A Doctor in the Community, But Not a Doctor Medicine sellers are accessible, approachable first-line treatment providers, but lack the status of a clinician, and are motivated to maintain their client base. Leads to power imbalance favoring customer requests. Knowing that if I sent the child to the hospital with the condition, I would be verbally reprimanded for coming to the facility with such a seemingly trivial condition, [so] I went to the drug store where the owner gave me some medicine. Customer 16

17 A Doctor in the Community, But Not a Doctor Medicine Sellers are accessible, approachable first-line treatment providers, but lack the status of a clinician, and are motivated to maintain their client base. Leads to power imbalance favoring customer requests. What happens is that they believe that the doctors are more learned than the medicine seller and also, when you are sick and you go to the hospital, you don t see drugs lined up in the doctor s office, so what the doctor says is final. But at the drugstore they see a whole lot of drugs lined up and so they end up challenging what the medicine seller says --Medicine Seller 17

18 Low Depth of Knowledge Medicine sellers are aware that ORS and zinc are the best/recommended treatment, and that antibiotics are not recommended. But they lack sufficient understanding of why ORS and zinc are recommended in order to negotiate with their customers or make recommendations. ORS and zinc are the recommended drugs for the treatment of diarrhea -Medicine Seller 18

19 Low Depth of Knowledge Medicine sellers are aware that ORS and zinc are the best/recommended treatment, and that antibiotics are not recommended. But they lack sufficient understanding of why ORS and zinc are recommended in order to negotiate with their customers or make recommendations. "Imodium stops the diarrhea and Flagyl also does the same thing. Zinc and ORS also helps to restore the child s strength. - Medicine Seller 19

20 Zinc Can Be a Hard Sell Perceived limitation of ORS and zinc (by both medicine sellers and their customers) can make it a hard sell. The pervasive habitual use of antibiotics in diarrhea treatment is hard to change. "In most cases when they come with diarrhea cases, they want medicines that will stop the running fast, so they see the ten days to be too long -Medicine Seller 20

21 Zinc Can Be a Hard Sell Perceived limitations of ORS and zinc (by both medicine sellers and their customers) can make it a hard sell. The pervasive habitual use of antibiotics in diarrhea treatment is hard to change. When our children have diarrhea and we go to the drugstore to get treatment, we often buy school uniform that s amoxicillin. We call it school uniform 21

22 Group Discussion: What would you do? What should be done to close the knowdo gap? What would you do to improve private provider behavior? What would you do to improve customer behavior? 22

23 Our Recommendations Re-think zinc promotion Create convincing convincers Re-tool training Optimal Outcomes Look up the chain: improve coordination with hospitals 23

24 Thank you!