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  • 1.
    Buchner, Denise Lynn
    et al.
    Univ Calgary, Cumming Sch Med, Dept Community Hlth Sci, Calgary, AB, Canada.
    Kitutu, Freddy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Pharm Dept, Kampala, Uganda.
    Cross, Donall Eoin
    Aberystwyth Univ, Inst Biol Environm & Rural Sci, Aberystwyth, Dyfed, Wales.
    Nakamoga, Esther
    Makerere Univ, Sch Publ Hlth, Kampala, Uganda.
    Awor, Phyllis
    Makerere Univ, Sch Publ Hlth, Kampala, Uganda.
    A cross-sectional study to identify the distribution and characteristics of licensed and unlicensed private drug shops in rural Eastern Uganda to inform an iCCM intervention to improve health outcomes for children under five years2019In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 1, article id e0209641Article in journal (Refereed)
    Abstract [en]

    Introduction: Malaria, pneumonia and diarrhea are leading causes of death in young children in Uganda. Between 50-60% of sick children receive treatment from the private sector, especially drug shops. There is an urgent need to improve quality of care and regulation of private drug shops in Uganda. This study was conducted to determine the distribution, the licensing status and characteristics of drug shops in four sub-districts of Kamuli district.

    Methods: This study was part of a pre-post cross sectional study that examined the implementation of an integrated Community Case Management (iCCM) intervention for common childhood illness in rural private drug shops in Kamuli District in Eastern Uganda. This mapping exercise used a snowball sampling technique to identify licensed and unlicensed drug shops and collect information about their characteristics. Data were collected using a questionnaire. GPS data were collected for all drug shops.

    Analysis: Quantitative data were analyzed using SPSS for descriptive statistics. Open ended questions were entered into NVivo 10 and analyzed using thematic analysis strategies.

    Results: In total, 215 drug shops in 284 villages were located. Of these, 123 (57%) were open and consented to an interview. Only 12 (10%) drug shops were licensed, 93 (76%) were unlicensed, and the licensing status of 18 (15%) was unknown. Most respondents were the owner of the drug shop (88%); most drug sellers reported their qualification as nursing assistants (70%). Drug sellers reported licensing fees and costs of contracting an "in-charge" as barriers to licensing. Nearly all drug shops sold drugs for malaria (91%) and antibiotics (79%).

  • 2.
    Johansson, Emily White
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kitutu, Freddy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere University School of Public Health, College of Health Sciences.
    Mayora, Chrispus
    Makerere University School of Public Health, College of Health Sciences.
    Awor, Phyllis
    Makerere University School of Public Health, College of Health Sciences.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wamani, Henry
    Makerere University School of Public Health, College of Health Sciences.
    Hildenwall, Helena
    Karolinska Institutet, Global Health - Health Systems and Policy Research Group.
    "It could be viral, but you don't know. You have not diagnosed it": Health worker challenges in managing non-malaria pediatric fevers in the low transmission area of Mbarara District, Uganda2016In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 15, article id 197Article in journal (Refereed)
    Abstract [en]

    Background: In 2012, Uganda initiated nationwide deployment of malaria rapid diagnostic tests (RDT) as recommended by national guidelines. Yet growing concerns about RDT non-compliance in various settings have spurred calls to deploy RDT as part of enhanced support packages. An understanding of how health workers currently manage non-malaria fevers, particularly for children, and challenges faced in this work should also inform efforts.

    Methods: A qualitative study was conducted in the low transmission area of Mbarara District (Uganda). In-depth interviews with 20 health workers at lower level clinics focused on RDT perceptions, strategies to differentiate non-malaria pediatric fevers, influences on clinical decisions, desires for additional diagnostics, and any challenges in this work. Seven focus group discussions were conducted with caregivers of children less than five years in facility catchment areas to elucidate their RDT perceptions, understandings of non-malaria pediatric fevers and treatment preferences. Data were extracted into meaning units to inform codes and themes in order to describe response patterns using a content analysis approach. 

    Findings: Differential diagnosis strategies included studying fever patterns, taking histories, assessing symptoms and analyzing other factors such as child’s age or home environment. If no alternative cause was found, malaria treatment was reportedly often prescribed despite a negative result. Other reasons for malaria over-treatment stemmed from RDT perceptions, system constraints and provider-client interactions. RDT perceptions included mistrust driven largely by expectations of false negative results due to low parasite/antigen loads, previous anti-malarial treatment or test detection of only one species. System constraints included poor referral systems, working alone without opportunity to confer on difficult cases, and lacking skills and/or tools for differential diagnosis. Provider-client interactions included reported caregiver RDT mistrust, demand for certain drugs, and desire to know the ‘exact’ disease cause if not malaria. Many health workers expressed uncertainty about how to manage non-malaria pediatric fevers, feared doing wrong and patient death, worried caregivers would lose trust, or felt unsatisfied without a clear diagnosis.  

    Conclusions: Enhanced support is needed to improve RDT adoption at lower level clinics that focuses on empowering providers to successfully manage non-severe non-malaria pediatric fevers without referral. This includes building trust in negative results, reinforcing integrated care initiatives (e.g. Integrated Management of Childhood Illness) and fostering communities of practice according to the Diffusion of Innovation model.

     

  • 3.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Chrispus, Mayora
    Johansson, Emily White
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wamani, Henry
    Bigdeli, Maryam
    Shroff, Zubin Cyrus
    Health system effects of implementing integrated community case management (iCCM) intervention in private retail drug shops in South Western Uganda: a qualitative study2017In: BMJ Global Health, ISSN 2059-7908, Vol. 2, no e000334Article in journal (Refereed)
    Abstract [en]

    Background Intervening in private drug shops to improve quality of care and enhance regulatory oversight may have health system effects that need to be understood before scaling up any such interventions. We examine the processes through which a drug shop intervention culminated in positive unintended effects and other dynamic interactions within the underlying health system.

    Methods A multifaceted intervention consisting of drug seller training, supply of diagnostics and subsidised medicines, use of treatment algorithms, monthly supervision and community sensitisation was implemented in drug shops in South Western Uganda, to improve paediatric fever management. Focus group discussions and in-depth interviews were conducted with stakeholders (drug sellers, government officials and community health workers) at baseline, midpoint and end-line between September 2013 and September 2015. Using a health market and systems lens, transcripts from the interviews were analysed to identify health system effects associated with the apparent success of the intervention.

    Findings Stakeholders initially expressed caution and fears about the intervention's implications for quality, equity and interface with the regulatory framework. Over time, these stakeholders embraced the intervention. Most respondents noted that the intervention had improved drug shop standards, enabled drug shops to embrace patient record keeping, parasite-based treatment of malaria and appropriate medicine use. There was also improved supportive supervision, and better compliance to licensing and other regulatory requirements. Drug seller legitimacy was enhanced from the community and client perspective, leading to improved trust in drug shops.

    Conclusion The study showed how effectively using health technologies and the perceived efficacy of medicines contributed to improved legitimacy and trust in drug shops among stakeholders. The study also demonstrated that using a combination of appropriate incentives and consumer empowerment strategies can help harmonise common practices with medicine regulations and safeguard public health, especially in mixed health market contexts.

  • 4.
    Kitutu, Freddy Eric
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Towards a functioning retail health market: Evaluating the integrated Community Case Management Intervention for Pediatric Febrile Illness in Drug Shops in Rural South Western Uganda2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Objectives: This thesis examined the health systems effects of implementing the integrated Community Case Management (iCCM) intervention for paediatric febrile illnesses in a retail health market in South Western Uganda. More specifically, it evaluated drug seller interpretation of malaria Rapid Diagnostics Test (RDT) results (study I), adherence to iCCM guidelines (study II) and the intervention effect on households’ perceived quality of drug seller fever care and care-seeking choice. Study IV qualitatively analysed the iCCM intervention implementation and causal mechanisms for observed effects. Improved understanding of such retail health markets will inform policy decisions and interventions for Universal Health Coverage.

    Methods: The study used mixed-methods design with an intervention and comparison arm, and pre-test assessment in both study arms. Data collection methods included care-seeker drug shop exit interviews and household surveys using structured questionnaires, focus group discussions, in-depth interviews, review of secondary data and a laboratory analysis of finger-prick capillary blood samples.

    Results: Among those tested for malaria parasites, there was 93% (95% CI 88.3, 96.2) agreement between drug sellers and laboratory scientist re-reading and with a kappa value of 0.84 (95% CI 0.75, 0.92) (Study I). The drug seller compliance with the reported malaria RDT results was 92.5% (95% CI 87.9, 95.7) (Study I). The iCCM intervention improved appropriate treatment for uncomplicated malaria by 34.5% (95% CI 8.6, 60.4), for pneumonia symptoms by 54.7% (95% CI 28.4, 81.0) and reduced appropriate treatment for non-bloody diarrhoea -11.2% (95% CI -65.5, 43.1), after adjusting for extraneous variables (Study II). Implementing the iCCM intervention in drug shops decreased the odds of households perceiving drug seller fever care as good but increased the household odds of choosing to seek care from private health facilities versus within the community (Study III). Drug sellers operated in a retail market system influenced by knowledge and actions of care-seekers, CHWs, government health workers and regulators, and also how formal and informal rules and norms were applied (Study IV). Implementation of the iCCM intervention at drug shops was modified and shaped by the emerging actor perceptions and behaviours (Study IV).

    Conclusions: This thesis demonstrates the implementation, causal mechanisms and contextual factors of the iCCM intervention in a rural retail health market. Fidelity and quality of iCCM intervention by drug sellers was acceptably high, probably as a result of co-interventions. Interventions in retail health markets should comprise of components that target the multiple actors or influences that shape that market. Multi-component health system interventions are complex to implement and also create complexity in their evaluation. When technologies are involved, their analysis should go beyond their substance as products and view them as items that encapsulate interests of different actors, some of which maybe converging with or competing against societal goals.

  • 5.
    Kitutu, Freddy Eric
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Kalyango, Joan Nakayaga
    Mayora, Chrispus
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Wamani, Henry
    Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda: a quasi-experimental study.2017In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 16, no 1, article id 425Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Fever case management is a major challenge for improved child health globally, despite existence of cheap and effective child survival health technologies. The integrated Community Case Management (iCCM) intervention of paediatric febrile illnesses though adopted by Uganda's Ministry of Health to be implemented by community health workers, has not addressed the inaccess to life-saving medicines and diagnostics. Therefore, the iCCM intervention was implemented in private drug shops and evaluated for its effect on appropriate treatment of paediatric fever in a low malaria transmission setting in South Western Uganda.

    METHODS: From June 2013 to September 2015, the effect of the iCCM intervention on drug seller paediatric fever management and adherence to iCCM guidelines was assessed in a quasi-experimental study in South Western Uganda. A total of 212 care-seeker exit interviews were done before and 285 after in the intervention arm as compared to 216 before and 268 care-seeker interviews at the end of the study period in the comparison arm. The intervention effect was assessed by difference-in-difference analysis of drug seller treatment practices against national treatment recommendations between the intervention and comparison arms. Observed proportions among care-seeker interviews were compared with corresponding proportions from 5795 child visits recorded in patient registries and 49 direct observations of drug seller-care-seeker encounters in intervention drug shops.

    RESULTS: The iCCM intervention increased the appropriate treatment of uncomplicated malaria, pneumonia symptoms and non-bloody diarrhoea by 80.2% (95% CI 53.2-107.2), 65.5% (95% CI 51.6-79.4) and 31.4% (95% CI 1.6-61.2), respectively. Within the intervention arm, drug seller scores on appropriate treatment for pneumonia symptoms and diagnostic test use were the same among care-seeker exit interviews and direct observation. A linear trend (negative slope, - 0.009 p value < 0.001) was observed for proportions of child cases prescribed any antimicrobial medicine in the intervention arm drug shops.

    CONCLUSIONS: The iCCM intervention improved appropriate treatment for uncomplicated malaria, pneumonia symptoms and diarrhoea. Drug seller adherence to iCCM guidelines was high, without causing excessive prescription of antimicrobial medicines in this study. Further research should assess whether this effect is sustained over time and under routine supervision models.

  • 6.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Martensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Wamani, Henry
    Makerere University School of Public Health.
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kalyango, Joan
    Makerere University College of Health Sciences, Department of Pharmacy.
    Perceived quality of paediatric fever care from private drug shops and care-seeking choice in South Western Uganda: data from household surveys.In: Article in journal (Refereed)
    Abstract [en]

    Background

    Child mortality is influenced by interventions beyond the health sector such as adequate access to education, quality water and sanitation, transport and general socio-economic wellbeing. Child mortality due to febrile illnesses remains unevenly distributed within countries. The role of context and variables that act at a higher level such as a geographical location has been largely under-examined. Factors that act at group level are commonly described in literature as neighbourhood factors. The aim of the study was to investigate whether contextual differences in choice of childhood fever care-seeking in South Western Uganda remain after relevant individual and household characteristics have been taken into account, for three outcome variables, namely, choice of care-seeking in private versus government health facilities, choice of care-seeking in private health facilities versus community level and perceived quality of childhood fever care at drug shops, among households in Mbarara and Bushenyi districts.

    Methods

    Two household surveys were conducted at different time periods in Bushenyi and Mbarara districts. The first survey of 2261 households was conducted from July to October 2013 before implementation of an adapted integrated Community Case Management (iCCM) intervention for paediatric febrile illness in drug shops in Mbarara district. The second survey of 3073 households was done from April to May 2015 after the intervention. These data were analysed for effect of contextual factors, the iCCM intervention and other predictors on choice of care-seeking and perceived quality of care among the households in Mbarara and Bushenyi.

     

    Results:

    In the pre-intervention survey , more households in both Mbarara and Bushenyi reported time required to travel to either a private clinic (31%) or drug shop (43%) of 15 minutes or less as compared to a government health facility (12%). The crude second level (neighbourhood) variance of the odds ratio for care-seeking in private versus government health facility was 0.446 (SE, 0.089). The intra-neighbourhood correlation and median odds ratio were 11.9% and 1.89, respectively, for the crude model. After adjusting for covariates that were kept in the prediction model, the estimates of neighbourhood variance, intra-neighbourhood correlation and mean odds ratio decreased to 0.241 (0.069), 6.8% and 1.6, respectively.

     

    Conclusion:         

    In addition to individual factors, contextual characteristics of the neighbourhoods predict the choice of care-seeking from private versus government health facilities, private health facilities versus in the community and perceived quality of pediatric fever care at drug shops.

  • 7.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Coll Hlth Sci, Pharm Dept, Kampala, Uganda.
    Wamani, Henry
    Makerere University School of Public Health.
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Katabazi, Fred
    Makerere University College of Health Sciences, Department of Medical Microbiology.
    Kuteesa, Ronald
    Makerere University College of Health Sciences, Infectious Disease Institute.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Coll Hlth Sci, Pharm Dept, Kampala, Uganda; Makerere Univ, Coll Hlth Sci, Infect Dis Inst, Kampala, Uganda.
    Kalyango, Joan
    Makerere University College of Health Sciences, Department of Pharmacy.
    Mårtensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Can malaria rapid diagnostic tests by drug sellers under feld conditions classify children 5 years old or less with or without Plasmodium falciparum malaria?: Comparison with nested PCR analysis2018In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 17, article id 365Article in journal (Refereed)
    Abstract [en]

    Background

    Malaria rapid diagnostic tests (RDTs) available as dipsticks or strips, are simple to perform, easily interpretable and do not require electricity nor infrastructural investment. Correct interpretation of and compliance with the malaria RDT results is a challenge to drug sellers. Thus, drug seller interpretation of malaria RDT strips was compared with laboratory scientist re-reading, and PCR analysis of Plasmodium DNA extracted from malaria RDT nitrocellulose strips and Fast Transient Analysis (FTA) cards. Malaria RDT cassettes are also assessed as potential source of Plasmodium DNA.

    Methods

    A total of 212 children aged between 2 and 60 months, 199 of whom had complete records at two study drug shops in south west Uganda participated in the study. Duplicate 5μL samples of capillary blood were picked from the 212 children, dispensed onto the sample well of the CareStartTM Pf-HRP2 RDT cassette and a fast transient analysis (FTA), WhatmanTM 3MM filter paper in parallel. The malaria RDT strip was interpreted by the drug seller within 15 to 20 minutes, visually re-read centrally by laboratory scientist and from it; Plasmodium DNA was recovered and detected by PCR, and compared with FTA recovered P. falciparum DNA PCR detection.

    Results

    Malaria positive samples were 62/199 (31.2% 95% CI 24.9 - 38.3) by drug seller interpretation of malaria RDT strip, 59/212 (27.8% 95% CI 22.2 – 34.3) by laboratory scientist, 55/212 (25.9% 95% CI 20.0 – 32.6) by RDT nitrocellulose strip PCR and 64/212 (30.2% 95% CI 24.4 – 37.7). The overall agreement between the drug seller interpretation and laboratory scientist re-reading of the malaria RDT strip was 93% with kappa value of 0.8 (95 % CI 0.7, 0.9). The drug seller compliance with the reported malaria RDT results and kappa value were 92.5% and 0.8 (95% CI 0.7, 0.9), respectively. The performance of the three diagnostic strategies compared with FTA PCR as the gold standard had sensitivity between 76.6% and 86.9%, specificity above 90%, positive predictive value ranging from 79% to 89.8% and negative predictive value above 90%.

    Conclusion:

    Drug sellers can use of malaria RDTs in field conditions and achieve acceptable accuracy for malaria diagnosis, and they comply with the malaria RDT results. Plasmodium DNA can be recovered from malaria RDT nitrocellulose strips even in the context of drug shops. Future malaria surveillance and diagnostic quality control studies with malaria RDT cassette as a source of Plasmodium DNA are recommended.

  • 8. Lalani, Mirza
    et al.
    Kitutu, Freddy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Clarke, Siân E
    Kaur, Harparkash
    Anti-malarial medicine quality field studies and surveys: a systematic review of screening technologies used and reporting of findings2017In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 16, no 1, article id 197Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Assessing the quality of medicines in low-middle income countries (LMICs) relies primarily on human inspection and screening technologies, where available. Field studies and surveys have frequently utilized screening tests to analyse medicines sampled at the point of care, such as health care facilities and medicine outlets, to provide a snap shot of medicine quality in a specific geographical area. This review presents an overview of the screening tests typically employed in surveys to assess anti-malarial medicine quality, summarizes the analytical methods used, how findings have been reported and proposes a reporting template for future studies.

    METHODS: A systematic search of the peer-reviewed and grey literature available in the public domain (including national and multi-national medicine quality surveys) covering the period 1990-2016 was undertaken. Studies were included if they had used screening techniques to assess the quality of anti-malarial medicines. As no standardized set of guidelines for the methodology and reporting of medicine quality surveys exist, the included studies were assessed for their standard against a newly proposed list of criteria.

    RESULTS: The titles and abstracts of 4621 records were screened and only 39 were found to meet the eligibility criteria. These 39 studies utilized visual inspection, disintegration, colorimetry and Thin Layer Chromatography (TLC) either as components of the Global Pharma Health Fund (GPHF) MiniLab(®) or as individual tests. Overall, 30/39 studies reported employing confirmatory testing described in international pharmacopeia to verify the quality of anti-malarials post assessment by a screening test. The authors assigned scores for the 23 criteria for the standard of reporting of each study.

    CONCLUSIONS: There is considerable heterogeneity in study design and inconsistency in reporting of field surveys of medicine quality. A lack of standardization in the design and reporting of studies of medicine quality increases the risk of bias and error, impacting on the generalizability and reliability of study results. The criteria proposed for reporting on the standard of studies in this review can be used in conjunction with existing medicine quality survey guidelines as a checklist for designing and reporting findings of studies. The review protocol has been registered with PROSPERO (CRD42015026782).

  • 9.
    Mayora, Chrispus
    et al.
    Univ Witwatersrand, Sch Publ Hlth, 27 St Andrews Rd, ZA-2193 Johannesburg, South Africa;Makerere Univ, Dept Hlth Policy Planning & Management, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Kitutu, Freddy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Makerere Univ, Dept Pharm, Coll Hlth Sci, POB 7062, Kampala, Uganda.
    Kandala, Ngianga-Bakwin
    Univ Witwatersrand, Sch Publ Hlth, 27 St Andrews Rd, ZA-2193 Johannesburg, South Africa;Northumbria Univ, Fac Engn & Environm, Dept Math Phys & Elect Engn, Newcastle Upon Tyne NE1 8ST, Tyne & Wear, England.
    Ekirapa-Kiracho, Elizabeth
    Makerere Univ, Dept Hlth Policy Planning & Management, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Swartling Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Karolinska Inst, Dept Publ Hlth Sci, Hlth Syst & Policy Res Grp, SE-17177 Stockholm, Sweden.
    Wamani, Henry
    Makerere Univ, Dept Community Hlth & Behav Sci, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 532Article in journal (Refereed)
    Abstract [en]

    Background: Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda. Methods: Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013. Results: Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin (R) syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients' finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification. Conclusion: Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.

  • 10.
    Tabernero, Patricia
    et al.
    Mahosot Hosp, Lao Oxford Mahosot Hosp Wellcome Trust Res Unit, Viangchan, Laos.;WorldWide Antimalarial Resistance Network, Oxford, England.;Univ Oxford, Ctr Trop Med & Global Hlth, Oxford, England..
    Parker, Michael
    Univ Oxford, Ethox Ctr, Oxford, England..
    Ravinetto, Raffaella
    Inst Trop Med, Dept Clin Sci, B-2000 Antwerp, Belgium.;Katholieke Univ Leuven, Dept Pharmaceut & Pharmacol Sci, Leuven, Belgium..
    Phanouvong, Souly
    US Pharmacopeial Convent Inc, Promoting Qual Med Program, US Pharmacopeia, Rockville, MD USA..
    Yeung, Shunmay
    London Sch Hyg & Trop Med, Fac Publ Hlth & Policy, Dept Global Hlth & Dev, London WC1, England..
    Kitutu, Freddy E.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Coll Hlth Sci, Dept Pharm, Kampala, Uganda.;Makerere Univ, Coll Hlth Sci, Sch Publ Hlth, Kampala, Uganda..
    Cheah, Phaik Yeong
    Univ Oxford, Ctr Trop Med & Global Hlth, Oxford, England.;Univ Oxford, Ethox Ctr, Oxford, England.;Mahidol Univ, Mahidol Oxford Trop Med Res Unit, Bangkok 10700, Thailand..
    Mayxay, Mayfong
    Mahosot Hosp, Lao Oxford Mahosot Hosp Wellcome Trust Res Unit, Viangchan, Laos.;Univ Oxford, Ctr Trop Med & Global Hlth, Oxford, England.;Univ Hlth Sci, Fac Postgrad Studies, Viangchan, Laos..
    Guerin, Philippe J.
    WorldWide Antimalarial Resistance Network, Oxford, England.;Univ Oxford, Ctr Trop Med & Global Hlth, Oxford, England..
    Newton, Paul N.
    Mahosot Hosp, Lao Oxford Mahosot Hosp Wellcome Trust Res Unit, Viangchan, Laos.;WorldWide Antimalarial Resistance Network, Oxford, England.;Univ Oxford, Ctr Trop Med & Global Hlth, Oxford, England.;London Sch Hyg & Trop Med, Fac Infect & Trop Dis, London WC1, England..
    Ethical challenges in designing and conducting medicine quality surveys2016In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 21, no 6, p. 799-806Article in journal (Refereed)
    Abstract [en]

    ObjectivesIn this paper we discuss the main ethical challenges related to the conduct of medicine quality surveys and make suggestions on how to address them. MethodMost evidence-based information regarding medicine quality derives from surveys. However, existing research ethical guidelines do not provide specific guidance for medicine quality surveys. Hence, those conducting surveys are often left wondering how to judge what counts as best practice. A list of the main ethical challenges in the design and conduct of surveys is presented. Results and conclusionsIt is vital that the design and conduct of medicine quality surveys uphold moral and ethical obligations and analyse the ethical implications and consequences of such work. These aspects include the impact on the local availability of and access to medicines; the confidentiality and privacy of the surveyors and the surveyed; questions as to whether outlet staff personnel should be told they are part of a survey; the need of ethical and regulatory approvals; and how the findings should be disseminated. Medicine quality surveys should ideally be conducted in partnership with the relevant national Medicine Regulatory Authorities. An international, but contextually sensitive, model of good ethical practice for such surveys is needed. ObjectifsIdentifier et discuter les principaux enjeux ethiques lies a la conduite des surveillances et formuler des suggestions sur la facon de les aborder. MethodeLa plupart des informations fondees sur des preuves en ce qui concerne la qualite des medicaments decoule des enquetes. Cependant, les directives ethiques de recherche existantes ne fournissent pas d'indications precises pour les enquetes sur la qualite de la medecine. Par consequent, ceux menant des enquetes sont souvent laisses a se demander comment juger ce qui compte comme la meilleure pratique. Une liste des principaux defis ethiques dans la conception et la conduite des enquetes est presentee. Resultats et conclusionsIl est essentiel que la conception et la conduite des enquetes sur la qualite de la medecine respectent les obligations morales et ethiques et analysent les implications ethiques et les consequences d'un tel travail. Celles-ci sont: l'impact sur la disponibilite locale et l'acces aux medicaments, la confidentialite et la protection de la vie privee des enqueteurs et des enquetes, des questions quant a savoir si les membres du personnel de sortie doivent etre informes quils font partie d'une enquete, la necessite d'approbations reglementaires et d'ethique et la facon dont les resultats devraient etre diffuses. Les enquetes sur la qualite de la medecine devraient idealement etre menees en partenariat avec les autorites relevantes de reglementation des medicaments nationaux. Un modele international, mais contextuellement sensible, de bonne pratique ethique pour ces enquetes est necessaire. ObjetivosIdentificar y discutir los principales retos eticos relacionados con la realizacion de encuestas y hacer sugerencias sobre la forma de abordarlas. MetodoLa mayor parte de la informacion basada en la evidencia en lo que respecta a la calidad de los medicamentos se obtiene a traves de encuestas. Sin embargo, las guias eticas de investigacion existentes no proveen una guia especifica para las encuestas de calidad de medicamentos. Por lo tanto, aquellos que llevan a cabo las encuestas a menudo no saben como definir lo que se considera como la mejor practica. Aqui se presenta una lista de los principales retos eticos en el diseno y en la realizacion de encuestas. Resultados y conclusionesEs vital que el diseno y el pase de encuestas de calidad de medicamentos apoyen obligaciones eticas y morales, asi como el analisis de las implicaciones y las consecuencias eticas de dicho trabajo. Estas son: el impacto sobre la disponibilidad local de y el acceso a las medicinas; la confidencialidad y la privacidad de los encuestados y encuestadores; preguntas sobre si los trabajadores del punto de entrega deberian ser avisados de que estan formando parte de un estudio; la necesidad de aprobaciones eticas y regulatorias; y como diseminar los hallazgos obtenidos. Las encuestas sobre la calidad de los medicamentos deberian idealmente realizarse junto con las autoridades nacionales relevantes en regulacion de medicamentos. Se requiere un modelo internacional, pero contextualmente sensible, de buenas practicas eticas.

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