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

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

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!

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 10-14 days

• Antimicrobials – ONLY for

complicated diarrhea

• Antidiarrheals – NEVER

3

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

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.

59%22%

11%

8%

Sources of Diarrhea Treatment

Private pharmacy/Medicineseller

Public hospital/facility

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).

• 2014 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).

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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)

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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?

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Examining the Know-Do Gap Qualitatively:

Focus and Aims

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Drug

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Medicine Seller

Motivations

Barriers

Context

Customer

Motivations

Barriers

Context

Medicine

Seller and

Customer

Engagement

Dia

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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

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“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

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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?

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Findings

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“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)

Some [customers] don't

even tell you the condition,

they just tell you what they

want to buy (Medicine

Seller)

At the chemical shop,

we are patient and

friendly and so

[customers] are able to

confide in us (Medicine

Seller)

15

Where the rubber meets the road…

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

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

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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

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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

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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

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’

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Group Discussion: What would you do?

What should be done to close the know-

do gap?

What would you do to improve private provider

behavior?

What would you do to improve customer behavior?

23

Our Recommendations

Optimal Outcomes

Re-tool training

Re-think zinc promotion

Create convincing convincers

Look up the chain: improve coordination with hospitals

Thank you!

www.shopsproject.org