INTERVENTION TEST OF TRAINING AND SUPERVISION ON PRESCRIBING...

INTERVENTION TEST OF TRAINING

AND

SUPERVISION ON PRESCRIBING PRACTICES

Submitted to

USAID/RPM/JSI, Nepal

August, 1995

Kathmandu, Nepal

CONTENTS

Page No

CONTENTS i-ii

ACKNOWLEDGEMENT iii

PERSONNEL INVOLVED iv

EXECUTIVE SUMMARY v-vi

INTRODUCTION

1. BACKGROUND 1

2. PURPOSE AND SIGNIFICANCE 2

2.1 Study Objectives 2

2.2 Significance of the Study 2

METHODS

3. OVERALL APPROACH AND DESIGN 3

4. DETAILED METHODOLOGY 3

4.1 Sample Selection 3

4.2 Instruments 5

4.3 Intervention Strategy and Implemention 6

4.4 Recruitment, Orientation and Supervision of 7

Survey Team

4.5 Secondary Coding 7

4.6 Data analysis 11

i

Page

RESULTS

5. PRESCRIBING PRACTICES 12

5.1 Percentage of Prescriptions Inaccordance with SDTS 12

5.2 Percentage of Encounter With an Injection 12

5.3 Average Consultation Time 13

5.4 Percentage of Encounter with an Antiabiotic 13

Prescribed

5.5 Average Number of Drugs Prescribed 13

5.6 Percentage of Drugs Prescribed by Generic Name 14

5.7 Percentage of Drug Prescribed on EDL 14

5.8 Percentage of Drugs Actually Dispensed 14

5.9 Percentage of Reviewed Cases With Adequate 15

Examination

5.10 Percentage of Availability of Key Drugs 15

5.11 Avability of EDL, SDTS and other

Impartial Information 15

6. PRESCRIBER KNOWLEDGE

6.1 Diarrhoea 16

6.2 ARI 16

6.3 Peptic Ulcer 16

6.4 Anaemia 17

6.5 Scabies 17

6.6 Conjunctivitis 17

6.7 Ascariasis 17

6.8 UTI 17

6.9 Referral 17

CONCLUSION 18

REFERENCES 19

ANNEXE ii

ACKNOWLEDGEMENT

We express sincere thanks to Dr P.C Karmacharya, Dean, Institute

of Medicine for administrative support.

We are grateful to USAID/JSI particularly, Mr. Mathew Friedman,

Mr. Brice Atkinson and Dr. Penny Dowson, for financial support and

for having study done through INRUD, Nepal.

We are grateful to RPM Team member, particularly Mr James Bates,

Dr. R.O.Laing, and Dr. Budiono Santoso for valuable guidance and

support.

Thanks are also due to Department of Health Services, Department

of Drug Administration (DDA) in particular, Dr. Asfaq Sheak,

Chief Drug Administrator, and Nepal Chemist and Druggist

Association for their valuable help in carrying out this study.

We express thanks to District Health Officers, particularly Dr.

T.N.Jha, Late Dr.G.R. Karki, Dr. R.L. Karwa, Dr. V.K.Singh, Dr.

S.S. Jha, Dr.(Mrs) S. Verma, Dr. G.P. Ojha, and Dr. B.R. Bhatta;

District Public Health Officers, in particular, Mr. H.N. Yadav and

Mr. S.B. Verma and members of research team for their co-

operation, and hard and sincere work.

Lastly but not the least, we would like to thank Ms. Jeanne Madden

for helping us in developing the proposal, Mr. Iswor Bahadur

Shrestha and Mr. Arjun Pandey for statistical work, Mrs.Jyoti

Shrestha of HLMC for language editing and Mr. Kumar Prasad Baral

for data compilation, analysis and report typing.

Research Team

INRUD, Nepal

iii

PERSONNEL INVOLVED

1. Principal Investigator

Prof. Kumud Kumar Kafle

2. Co-principal Investigator

Mr. Ananda Dev Shrestha

Mr. Shiba Bahadur Karkee

Dr. B.P. Yadav

Mr. Radha Raman Prasad

3. Assistant Investigator

Mr. Naveen Shrestha

Mr. Prabhakar Lal Das

4. Consultant

Dr. Yogendra Man Singh Pradhan

5. Resource Person

- Dr. Tara Nanda Jha ( DHO, Jhapa)

- Dr. Shiva Shanker Jha ( DHO, Sarlahi)

- Dr. Bhoj Raj Bhatta (DHO, Kanchanpur)

iv

EXECUTIVE SUMMARY

Study Objective

The objective of the study was to evaluate :

- the impact of interventions - regular supervision/

monitoring and training using SDTS on the prescribing

patterns in HPs and SHPs.

Sample and Technique

The study was conducted in Nine Terai districts grouped into

control, intervention I and II; each group comprised of 21 health

facilities (3 X 4 HPs and 3 X 3 SHPs) from three districts.

Intervention group I was assigned training.

The training to prescribers was to be provided by UNICEF but it

could not take place during the study.

Intervention group II was assigned supervision/monitoring with

feedback .

Group III was control group having no intervention.

All three groups were evaluated for practices by observation

technique using WHO indicators.

For evaluating the knowledge, an interview was conducted using

structured questionnaire in post-test only.

Results

Prescribing Practices

The following results were obtained following supervision/

monitoring:

- Consultation time increased significantly .

- Prescriptions in accordance with Standard Drug Treatment

Schedule (SDTS) increased significantly.

- Injection encounter decreased significantly.

In the case of intervention I, consultation time decreased,

injection encounter increased and prescription in accordance with

SDTS decreased .

v

Prescribing Knowledge

The following results were obtained in the post-test:

- The correct knowledge of history taking for diarrhoea ,

peptic ulcer, ARI, aneamia, scabies and conjunctivitis

was less in intervention II than in control group.

- The knowledge of adequate examination for peptic ulcer

was more in intervention II than in control group.

- The knowledge of drug use for ARI and ascariasis was

more in intervention II than in control group .

- The appropriate knowledge of referral for UTI and

rheumatic fever was less than control group in

intervention II .

- The correct knowledge of history taking for diarrhoea,

peptic ulcer and anaemia was more than control group in

intervention I.

- The knowledge of adequate examination for ARI, peptic

ulcer and scabies was more than control group in

intervention I .

- The knowledge of drug use for ARI and peptic ulcer was

more than control group in intervention I.

- The appropriate knowledge of referral for rheumatic

fever was less in intervention I than in control group.

vi

INTRODUCTION

1. BACKGROUND

The study conducted in health posts of Kathmandu, Patan and

Bhaktpur showed most of the prescribing inconsistent with Standard

Drug Treatment Schedule (SDTS) for health post . The same study

showed only 56% of patients had knowledge of dosing [1,5]. The

study in other district also had similar findings [2]. However,

the practice of prescribing and dispensing is affected by several

factors.

To improve prescribing habits a mixture of strategies has been

found to be the most effective, which includes training in the use

of Standard Treatment Protocols, a small list of necessary drugs,

structured drug ordering forms, regular supervision and in-

service education on specific diagnostic areas [3].

HMG, Nepal, has decided to implement a Community Drug Programme

(CDP) to improve supply, and prescribing and dispensing through

training.

The rational use of drugs can be measured by using WHO indicators

[4]. These indicators can be used to measure impact of

intervention. The indicators can also serve as simple supervisory

tools to detect problems in performance by individual prescriber,

dispenser or health facility.

2

2. PURPOSE AND SIGNIFICANCE

2.1 Study Objectives

The specific objective of this study was:

- to evaluate the impacts of two interventions- regular

supervision/monitoring and training using a Standard

Drug Treatment Schedule (SDTS) on the prescribing

patterns in health posts and subhealth posts.

2.2 Significance of the study

This evaluative study has identified the most appropriate way

to implement the STDS, in terms of behavioural change and

cost effectiveness to prescribers. However, training to

prescribers by UNICEF using SDTS as designed in intervention

strategy could not take place.

The study was significant in evaluating the supervision/

monitoring strategy, which could be introduced in the health

system in improving rational prescribing.

3

METHODS

3. OVERALL APPROACH AND DESIGN

The study was conducted in Nine Terai Districts and consisted of:

a. interview with prescribers;

b. interview with patients/patient attendants;

c. observation.

The unit of analysis was health institution. Prescribing, Patient

care and Facility indicators were applied.

4. DETAILED METHODOLOGY

4.1 Sample Selection

The study was conducted in Nine Terai Districts.

Three Terai districts were randomly selected from the five

initial districts where UNICEF training on the SDTS as a part

of National Drug Scheme implementation was proposed. This was

labelled Group I.

An other three Terai districts were randomly selected from 17

Terai districts. This was labelled Group II.

Another three districts were randomly selected from the

remaining Terai districts and was labelled Group III.

Altogether Nine districts, all from Terai, were covered and

grouped as given below:

Group I: Morang, Dhanusha and Kailali.

Group II: Jhapa, Sarlahi and Kanchanpur.

4

Group III: Siraha, Chitwan and Bardia.

5

Selection of Health posts and Subhealth posts

From each district four health posts (HPs) were randomly

selected. In addition, three subhealth posts (SHPs) were

selected from the nearby selected health posts, making a

total of seven facilities per district. In total, there were

21 facilities in each group.

Group I

Morang

1. Tankisinuwari HP 2. Bayarban HP

3. Haraincha HP 4. Dadarbairiya HP

5. Nochha SHP 6. Pathari SHP

7. Sanischare SHP

Dhanusha

1. Parbaha HP 2. Ghodghas HP

3. Dhalkebar HP 4. Sinurjora HP

5. Sapahi SHP 6. Bateshwore SHP

7. Bhuinchakkarpur SHP

Kailali

1. Basauti HP 2. Pahalmanpur HP

3. Chaumala HP 4. Malakheti HP

5. Pabera SHP 6. Sahajpur SHP

7. Baliya SHP

Group II

Jhapa

1.Dhulawari HP 2. Baniyani HP

3. Damak HP 4. Kumarkhod HP

5. Budhabare SHP 6. Topgachhi SHP

7. Gauradaha SHP

Sarlahi

1. Gangapur HP 2. Jamunia HP

6

3. Sisautia HP 4. Sasapur HP

5. Pipariya SHP 6. Khutauna SHP

7. Kaudena SHP

7

Kanchanpur

1. Shreepur HP 2. Jimua HP

3. Parasan HP 4. Daiji HP

5. Kalika SHP 6. Gulariya SHP

7. Laxmipur SHP

Group III

Siraha

1. Khirauna HP 2. Nayanpur HP

3. Golbazar HP 4. Malahaniya HP

5. Madar SHP 6. Chandraudayapur SHP

7. Sukhchaina SHP

Chitwan

1. Khairhani HP 2. Bharatpur HP

3. Shardanagar HP 4. Shivanagar HP

5. Gunjanagar SHP 6. Divyanagar SHP

7. Shaktikhor SHP

Bardiya

1. Shorahawa HP 2. Bagnaha HP

3. Nyaulapur HP 4. Magargadhi HP

5. Kalika SHP 6. Thakurdwara SHP

7. Thothari SHP

Prescribing, Patient Care and Facility Indicators were

applied in health institutions.

For assessment of prescribing practices, prescribing as well

as patient care WHO indicators were used.

In average, 30 encounters per health unit were collected for

Prescribing Indicators. For Patient Care Indicators ten

encounters per health unit were observed and recorded.In

addition, Facility Indicators were used to assess the drug

availability and impartial information (Table -1)

4.2 Instruments

8

For collecting data on prescribing practices; Patient care

form, Encounter form and Facility forms were developed.

Structured questionnaire was developed to assess prescriber

knowledge during post test only.

All the developed instruments were field-tested in one health

post of Bhaktapur district and modified.

4.3 Intervention Strategy and Implementation

Group I was assigned intervention strategy one ie Training.

This group was designed to receive training for prescribers

from UNICEF on SDTS focusing 5-6 common health problems.

Group II was assigned Intervention strategy two ie

supervision and monitoring with feedback .

Group III was control group ie without intervention.

Intervention strategy one ie training to prescribers by

UNICEF could not take place.

Health posts and subhealth posts prescribers in Group II

received first on-site supervision and monitoring visits by

DHO/DPHO one month after base line data collection. The

second visit was two months later. During each visit DHO/DPHO

evaluated the prescribing practices using

supervision/monitoring tools and the results were immediately

fedback to the prescribers. In the second

supervision/monitoring, DHO/DPHO were provided with data from

the first supervision/monitoring for comparative feedback.

The guidelines and tools were developed by a Research Team

and field-tested in one of the health posts of Bhaktapur

district.

DHO/DPHOs, were oriented to supervision/monitoring tools by

investigators and they were also given guidelines on how to

use tools and give feedback. The tools included the same WHO

indicators, simplified by the Research Team (see Annex).

Group three health posts and sub health posts being control

9

received no intervention.

4.4. Recruitment, Orientation and Supervision of Survey Team

The survey was conducted by six teams. Each Team comprised

of two research assistants, and one supervisor, the

investigator. Research assistants were either MBBS students

or Bachelor or Master in Public Health students. The research

assistants were oriented to instruments andinvolved in field

testing.

The baseline data was collected in October,1994 and the final

data in May, 1995.

7

Table : I Health Facilities Encounters, Tracer Diagnosis, Tracer Conditions

and Drug Prescribed in Study Districts

Morang Dhanusha Kailali Jhapa Sarlahi Kanchanpur Siraha Chitwan Bardiya

Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post

test test test test test test test test test test test test test test test test test test

Number of Health

Facility

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

Encounter 210 209 210 210 211 200 216 217 210 213 214 205 210 210 211 210 210 210

Total Drug Prescribed 476 456 536 458 417 449 484 561 469 384 466 386 492 476 361 459 436 371

Consultation Time

Encounter

70 70 71 70 70 70 70 70 70 70 70 70 70 70 70 69 70 70

Dispensing Time

Encounter

70 70 66 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70

Tracer Dignosis 81 63 81 129 99 109 62 78 58 111 96 26 113 141 71 103 137 141

Tracer Condition 27 36 32 48 56 49 35 42 29 34 34 28 34 70 33 65 34 40

8

9

4.5 Secondary Coding

Collected data were coded based on knowledge and practices.

The coding for practices were grouped into indicators among

WHO Indicators of Prescribing, Patient care and Facility

indicators.

Prescribing Indicators

1 Average Number of Drugs Per Encounter - Average

calculated by dividing the total number of

different drug products prescribed, by the number of

encounters surveyed.

2 Percentage of Drugs Prescribed by Generic Name -

Percentage, calculated by dividing the number of drugs

prescribed by generic name by the total number of drugs

prescribed, multiplied by hundred.

3 Percentage of Encounter With an Antibiotic Prescribed -

Percentage, calculated by dividing the number of patient

encounters during which an antibiotic is prescribed, by

total number of encounters surveyed, multiplied by

hundred.

4 Percentage of Encounters With an Injection Prescribed -

Percentage, calculated by dividing the number of patient

encounters during which an injection is prescribed, by

the total number of encounters surveyed, multiplied by

hundred.

5 Percentage of Drugs Prescribed From Essential Drug List

-Percentage, calculated by dividing the number of

products prescribed which are listed on the essential

drug list, by the total number of products prescribed,

multiplied by hundred.

6 Average consultation time - Average, calculated by

dividing the total time for the series of consultations,

10

by the number of consultation.

7 Percentage of Drugs Actually Dispensed - Percentage,

calculated by dividing the number of drugs actually

dispensed at the health facility by the total number of

drugs prescribed, multiplied by hundred.

11

8 Availability of Key Drugs - Percentage, Calculated by

dividing the number of specified products actually in

stock by the total number of drugs on the check list

(ORS, cotrimoxazole tablet, paracetamol tablet,

mebendazole tablet,tetracycline eye ointment, ferrous

sulphate+folic acid tablet, antacid tablet, amoxycillin

capsule, procaine penicillin and benzyl benzoate)

multiplied by hundred.

9 Availability of Copy of Essential Drug Lists - Yes or

No per facility.

10 Availability of Copy of SDTS - Yes or no per facility.

11 Availability of any Other Impartial Information -

Percentage, calculated as the number of facilities where

a listed source of impartial information is present,

divided by the number of facilities surveyed.

12 Prescription in Accordance with Treatment Guidelines -

Percentage, calculated by dividing the number of cases

receiving the chosen treatment divided by the total

number of tracer diagnosis reviewed, multiplied by

hundred. In this study accepted chosen treatment means

only correct drugs and not the correct doses and

duration for single diagnosis.

13 Adequate Examination - Percentage, calculated by

dividing the number of cases who received an examination

meeting minimum criteria for adequacy for important

tracer conditions (e.g. Diarrhoea, ARI, scabies,

hyperacidity/ PUS, conjunctivitis, and anaemia) divided

by the total number of cases reviewed, multiplied by

hundred.

12

Prescribing Knowledge

Diarrhoea

1. History Taking - was defined correct based on either /or

thirst and urination.

2. Adequate Examination - was defined adequate based on

examination of skin elasticity and tongue or fontanelle

in children.

3. Drug Use - was defined correct based on Ringer lactate

use in severe dehydration.

ARI

1. History Taking - was defined correct based on fever and

duration of cough or breast sucking.


counting respiration rate and chest indrawing or noisy

breathing.

3. Drug Use - was defined correct based on use of PPF or

Benzyl Penicillin or Amoxycillin.

Peptic Ulcer

1 History Taking - was defined correct based on either/or

relationship of pain with food and onset of pain.


palpation of epigastrium.

3. Drug Use - was defined correct based on use of Aluminum+

Magnesium Antacids.

Anaemia

13

1. History Taking - was defined correct based on patient

history relating cause.


inverting eyelid or examining tongue and examination of

nails.

Scabies

1. History Taking - was defined correct based on history of

itching.


inspection of infected area or itching spots.

Conjunctivitis

1. History Taking - was defined correct based on duration

of illness


inverting eye lid.

Ascariasis

Drug Use - was defined correct based on use of

piperazine.

UTI

Drug Use - was defined correct based on use of

cotrimoxazole.

14

Referral

1. UTI:

Referral - was defined appropriate based on

recurrent UTI or ineffective treatment.

2. Rheumatic Fever

Referral - was defined appropriate based on heart

complication or ineffective treatment.

4.6 Data Analysis

The data were entered into Lotus 123 and Excel and checked

manually several times for accuracy. Some of the data were

analysed manually also. The t-test and paired t-test were

used to compare the changes within the facility as well as

study groups.

If significant difference was not observed between groups, a

non-parametric test (X2 test) was applied to measure the

change. The level of significant difference was stated at 95%

confidence limit.

15

RESULTS

5. PRESCRIBING PRACTICES (Table 2 -3 and Annexe)

5.1 Percentage of Prescriptions Inaccordance with SDTS

There has been a decrease by 5.5% in intervention I, an

increase by 13.6% in intervention II and a decrease by 6.8%

in control.

There is significant increase in prescribing inaccordance

with SDTS with supervision/monitoring (df = 36, P< 0.1, t=

1.97).

The decrease in intervention I is not significant (t=-0.15).

There has been an increase in 39% of health institutions in

intervention I, 74% in intervention II and 42% in control.

Applying X2-test;

There is significant increase with supervision/monitoring

(df = 1, P < 0.05, X2 = 3.89).

In intervention I, there is no significant increase

(X2 = 0.04).

5.2 Percentage of Encounter with an injection Prescribed.

There has been an increase by 8.8% in a intervention I, a

decreased by 5.3% in intervention II and an increase by 4.3%

in control.

There is a decrease with supervision/monitoring but it is not

significant (t= -1.3).

There is an increase in intervention I but it is not

significant (t = 0.34).

There has been a decrease in 14% of health institutions in


16

Applying X2- test;

There is significant decrease with supervision/monitoring

(P < 0.05, X2 = 4.2).

In intervention I, there is no significant decrease (X2 =0).

5.3 Average Consultation Time

There has been a decrease by 22 seconds in intervention I, an

increase by 20 seconds in intervention II and a decrease by

71 seconds in control.

There is significant increase in consultation time with

supervision/monitoring (df = 40, P < 0.01, t = 3.43, highly

significant).

The decrease in intervention I is not significant.



Applying X2- test;

There is no significant increase in intervention I (X2=0.47).

5.4 Percentage of Encounter with an Antibiotic Prescribed

There has been a decrease by 4.1% in intervention I, a

decrease by 12.5% in intervention II and a decrease by 5.6%

in control.

There is a decrease with supervision/monitoring but is not

significant (t= -1.38).

There is also a decrease in intervention I and is also not

significant (t = 0.66)


intervention I, 67% both in intervention II and control.

17

Applying X2 -test;

There is no significant decrease with supervision/monitoring

and intervention I as well.

5.5 Average number of drugs Prescribed

There has been a decrease by 0.1 in intervention I, and

intervention II but an increase by 0.1 in control.

There is a decrease with supervision/monitoring but is not

significant (t = 0).

There is also a decrease in intervention I and is also not

significant (t = -0.76)



Applying X2 - test;

There is no significant decrease with supervision/monitoring

and intervention I as well.

5.6 Percentage of Drug Prescribed by Generic Name.

There has been a decrease by 3.2% in intervention I, a

decrease by 9.5% in intervention II and an increase by 4% in

control.



5.7 Percentage of Drugs Prescribed on EDL

There has been an increase by 1% in intervention I, a

decrease by 2.8% in intervention II and an increase by 0.2%

in control.

18



Applying X2- test;

There is no significant increase with supervision/

monitoring.

5.8 Percentage of Drugs Actually Dispensed

There has been a decrease by 6% in intervention I, a decrease

by 7.7% in intervention II but an increase by 3.1% in

control.


all groups.

5.9 Percentage of Cases with an Adequate Examination

There has been an increase by 30.5% in intervention I, an

increase by 13.7% in intervention II and an increase by 9.1%

in control.

There is no significant increase with supervision/ monitoring

(t =0.22).

There is no significant increase in intervention I (t=1.69).



Applying X2- test;

There is significant increase in intervention I (X2 =4.36,

P<0.05) but there is no significant increase with

supervision/monitoring (X2 = 0.86) .

5.10 Percentage of Availability of Key Drugs

19

The availability of key drugs was found slightly increased

from 70 to 74 % in intervention I, slightly decreased (69 to

66%) in intervention II and decreased from 72% to 62% in

control group.

5.11 Availability of EDL, SDTS AND other Impartial

Information

The availability of Essential drug list was found increased

both in intervention I and II, where as decreased in control

group. It was increased from 10% to 14% in intervention I, 5%

to 19% in intervention II and decreased from 5% to 0% in

control.

The availability of SDTS was found increased from 0 to 5% in

intervention II where as decreased in both intervention I and

control group from 5% to 0% .

The availability of other impartial information (which

included Where there is no Doctor, CIMS; TB. Leprosy, ARI and

Diarrhoea treatment manuals; FCHV, MCHW, and TBA Manuals)

increased in Intervention I whereas decreased in both

intervention II and control group.

6. PRESCRIBING KNOWLEDGE

6.1 Diarrhoea

The knowledge of history taking was correct in 81% of

intervention I, and 71 % of both intervention II and control.

The knowledge of adequate examination was 86% of control and

intervention II, and 81% of intervention I.

The knowledge on drug use was correct in 86%, 76% and 57 % of

control, intervention I and intervention II respectively.

20

6.2 ARI

The knowledge of history taking was correct in 52%, 47% and

28% of control, intervention I and II respectively.

The knowledge of adequate examination was 38% both of control

and intervention II, and 52% of intervention I.

The knowledge on drug use was correct in 24% of control and

52% both of intervention I and II.

6.3 Peptic Ulcer

The knowledge of history taking was correct in 67%,81% and

47% of control,intervention I and II respectively.

The knowledge of adequate examination was 38%, 47% and 52% of

control, intervention I and II respectively.

The knowledge on drug use was correct in 33%, 38% and 28% in


19

Table : 2


Control-Interventions

Group I Group II Group III Control Vs Control Vs

Intervention I Intervention II Control Intervention I Intervention II

Pre Post Pre Post Pre Post `t'-test X2-test `t'-test X2-

test

test test test test test test

Number of Facility 21 21 21 21 21 21 - - - -

1 Percentage of reviewed cases in 26.8 21.3 26.9 40.5 29.9 23.1 -0.15 0.04 1.97 3.89

accordance with Standard Drug

Treatment Schedule

2 Percentage of encounters with an

Injection prescribed

9 17.8 20 14.7 12.2 16.5 0.34 0 -1.3 4.2

3 Average consultation time 2'45'' 2'23'' 2'01'' 2'21'' 3'12'' 2'01'' 1.27 0.47 3.43 -


Antibiotic prescribed

53.4 49.3 57.7 45.2 54.2 48.6 0.66 3.44 -1.38 0

5 Average number of Drugs 2.3 2.2 2.2 2.1 2 2.1 -0.76 0.44 0 1.52

Prescribed

20

21

Table : 3


Control-Interventions

Group I Group II Group III

Intervention I Intervention II Control

Pre-t Post Pre Post Pre Post

test test test test test test

Number of Facility 21 21 21 21 21 21

1 Percentage of drug prescribed 49.4 46.2 56 46.5 45.4 45.8

by Generic names

2 Percentage of drugs prescribed 81.7 82.7 85.7 82.9 87.9 88.1

on Essential Drugs

3 Percentage of Drugs actually 79.4 73.4 83.2 75.5 79.1 82.2

Dispensed

4 Percentage of reviewed cases 30.4 60.9 45.9 59.6 38.6 46.7

with an Adequate Examination.

5 Percentage of availability of key 69.5 73.8 68.6 66.2 71.9 61.5

Drugs

6 Availability of Essential Drug

List

9.5 14.2 4.8 19 4.8 0

7 Availbility of Standard Drug 4.8 0 0 4.8 4.8 0

Treatment Schedule

8 Percentage of Impartial 33 47.6 28.6 19 23.8 9.5

20

21

6.4 Anaemia

The knowledge of history taking was correct in 28%, 57% and

9% of control, intervention I and II respectively.

The knowledge of adequate examination was 100%, 95% and 85%

of control, intervention I and II respectively.

6.5 Scabies

The knowledge of history taking was correct in 85% both of

control, and intervention I and 62% of intervention II.

The knowledge of adequate examination was 86%, 91% and 81% of


6.6 Conjunctivitis

The knowledge of history taking was correct in 38% both of

control, and intervention I and only 9% of intervention II.

The knowledge of adequate examination was 100% in control and

intervention I and 76% of intervention II .

6.7 Ascariasis

The knowledge on drug use was correct in 33%, 19% and 47% of


6.8 UTI

The knowledge on drug use was correct in 76%, 43% and 47% of


6.9 Referral

22

The knowledge on referral for UTI was appropriate in 57%

both of control, intervention I and only 33% of intervention

II.

The knowledge on referral for Rheumatic Fever was appropriate

in 57%, 43% and 19% of control, intervention I and II

respectively.

23

CONCLUSION

The research has found significant increase in consultation time

and prescriptions in accordance with Standard Drug Treatment

Schedule (SDTS) and significant decrease in injection encounter

with supervision/ monitoring.

Other prescribing indicators eg antibiotic encounter, average

number of drug prescribed, and drugs prescribed on Essential Drug

List (EDL), also have shown improvement with supervision/

monitoring, though not significant.

On the other hand, a few indicators eg prescription by generic,

cases with adequate examination, and drugs actually dispensed, did

not indicate improvement with supervision/monitoring which might

have been affected by other factors eg knowledge and drug supply .

Recommendations

. Implement supervision/monitoring and feedback for

improving use of SDTS in health institutions.

. Implement the strategy ie supervision/monitoring to

improve rational prescribing in health institutions.

. Supervision/monitoring is feasible with existing

structure in the District Health Office with some

motivation and orientation to DHO/DPHO. During study

DHOs expressed great satisfaction in using indicators as

it provided them opportunity to see the quality of

service. The motivation will have great impact to

improve rational prescribing in HP and SHP reducing the

drug cost in the district.

. Supervision/monitoring should be implemented in a few

districts initially as a pilot project .

24

. The facilities which perform most poorly eg 30% or more,

less than district average for any indicator should get

supervision/monitoring focussed on that specific

indicator.

REFERENCES

1. Kafle, K.K; Pradhan, Y.M.S; Shrestha, A.D; Karkee, S.B; :

Drug Use in PHC facilities of Kathmandu. J.INST. MED, 14,

NO.4, 318-326, 1992.

2. Kafle, K.K; Pradhan, Y.M.S; Shrestha, A.D; Karkee, S.B;

:INRUD Drug Use Indicators in Nepal: practice pattern in

health posts in four districts. INRUD News, Vol. 3, No.1,

1992.

3. Quick, J; Laing, R; Ross, Degnan D; : Intervention research

to promote clinically effective and economically efficient

use of Pharmaceuticals: International Network for Rational

Use of Drugs (INRUD). J.of Clinical Epidemiology, 44 supp 11,

pp 578-668, 1991.

4. Action Programme on Essential Drugs: How to Investigate Drug

Use in Health Facilities: WHO/DAP, 1993.

5. Hogerzeil, H, V; Bimo; Ross-Degnan, D; Laing, R.O; et al :

Field tests for Rational Drug Use in twelve developing

Countries. The Lancet, 342 (1), 1408- 1410, 1993.

1

Prescribing Indicators Annexe: 1 Morang

No Health Facility T.Sinuwari HP Haraicha HP Dadarbairiya HP Bayarban HP Sanischare SHP Nocha SHP Pathari SHP

Pre Post `t' Pre Post `t' Pre Post `t' Pre Post `t' Pre Post `t' Pre Post `t' Pre Post `t'

test test value test test value test test value test test value test test value test test value test test value

1 Average number of drugs prescribed 2.2 2.2 ns 2.2 2.8 ns 2.5 2.1 ns 2.5 2.3 ns 2 1.4 ns 1.8 2.2 ns 2.3 2.7 ns

2 Percentage of drug prescribed by

Generic names

58.7 49.2 ns 58.2 50.6 ns 32.9 51.6 s 57.5 22.1 s 47.6 53.5 ns 52.8 56.9 ns 70.1 46.3 s

3 Percentage of encounters with an Antibiotic

prescribed

58.6 58.6 ns 63.3 63.3 ns 53.6 53.3 ns 69 53.3 ns 43.3 46.7 ns 40 43.3 ns 70.6 66.8 ns

4 Percentage of encounters with an 0 20.7 - 40 36.7 ns 3.6 23.3 s 0 6.7 - 0 10 - 16.7 0 - 0 0 -


5 Percentage of drugs prescribed on Essential

drugs

87.3 76.9 ns 89.6 79.5 ns 81.4 81.3 ns 69.9 79.4 ns 93.4 93 ns 100 100 ns 76.6 95 s

6 Average consultation time 1'19'' 1'25'' ns 2'36'' 1'13'' ns 2'41'' 2'15'' ns 1'18'' 4'12'' ns 1'30'' 1'16'' ns 1'40'' 1'27'' ns 3'32'' 4'24'' ns

7 Percentage of drugs actually 66.7 66.2 ns 83.6 71.1 ns 84.3 68.8 ns 90.4 54.4 s 75.4 93 s 96.2 98.5 ns 96.1 92.5 ns

Dispensed

8 Percentage of availability of key 80 100 - 100 80 - 100 60 - 70 50 - 70 80 - 80 70 - 70 80 -

indicator drugs

9 Percentage of reviewed cases 50 66.7 ns 60 100 ns 28.6 57.1 ns - 14.3 - 16.7 0 - 77.8 0 - 20 50 ns

with an adequate examination.

10 Percentage of reviewed cases in 33.3 25 ns 25 28.6 ns 9.1 - - 6.7 - - 33.3 46.7 ns 40.9 0 - 0 13.3 -

accordance with Standard Drug

Treatment Schedule

11 Availability of Essential Drug List 0 0 - 0 1 - 1 0 - 0 1 - 0 0 - 1 0 - 0 0 -

12 Availbility of Standard drug 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 -

Treatment Schedule

13 Availability of other impartial 1 1 - 1 1 - 1 1 - 1 1 - 0 0 - 0 0 - 0 0 -

Information

s = Significant ns = Not significant

2

3


Annexe :2 Dhanusa

No Health Facility Sinurjora HP Ghodghas HP Dhalkabar HP Parbaha HP Bhuichakarpur SHP Shapahi HP Batteshwor SHP



1 Average number of drugs prescribed 2.5 2.2 ns 3 1.6 ns 2.5 3.2 ns 2.9 1.7 ns 1.1 2 ns 3 2 ns 2.8 2.5 ns

2 Percentage of drug prescribed by generic names

60.8 57.8 ns 44 40.4 ns 72 50 s 57.5 57.6 ns 72.7 56.7 ns 18.7 55.7 s 35.3 13.3 s


antibiotic prescribed

40 46.7 ns 63.3 40 ns 56.7 66.7 ns 70 56.7 ns 13.3 23.3 ns 80 53.3 s 50 63.3 ns

4 Percentage of encounters with an 6.7 6.7 ns 6.7 3.3 ns 46.7 50 ns 13.3 30 ns 0 3.3 - 26.7 23.3 ns 3.3 3.3 ns

injection prescribed

5 Percentage of drugs prescribed 85.1 82.1 ns 64.8 87.2 s 93.3 72.9 s 66.7 84.6 s 100 91.7 s 68.1 90.2 s 82.4 53.3 s

on essential drugs


7 Percentage of drugs actually dispensed 85.1 86.6 ns 64.8 87.2 s 89.3 63.5 s 60.9 88.5 s 100 70 s 55 62.3 ns 58.8 33.3 s

8 Percentage of availability of key

indicator drugs

100 70 - 60 90 - 100 80 - 60 100 - 60 50 - 60 50 - 70 30 -

9 Percentage of reviewed cases 0 83.3 - 80 57.1 ns 28.6 77.8 ns 33.3 66.7 ns 0 57.1 - 33.3 85.7 s 0 83.3 -


10 Percentage of reviewed cases in 25 23.1 ns 21.4 42.1 ns 5.6 15.4 ns 50 28 ns 44.4 4.4 s - 33.3 - 0 0 -

accordance with Standard drug

treatment schedule

11 Availability of essential drug list 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 -


treatment schedule

13 Availability of other impartial information 0 0 - 0 0 - 0 1 - 1 1 - 0 0 - 0 0 - 0 1 -

s = Significant

ns = Not significant

4


Annexe: 3

Kailali

No Health Facility Pahalmanpur HP Malakheti HP Chaumala HP Basauti HP Sahajpur SHP Baliya SHP Pavera SHP



1 Average number of drugs prescribed 2.6 2.4 ns 2.6 2.8 ns 2.2 2.1 ns 2.1 2.2 ns 1.3 1.9 ns 1.9 2.2 ns 2 1.2 ns

2 Percentage of drug prescribed by generic

names

38.5 42.7 ns 44.7 45.7 ns 44.8 43.8 ns 59.7 47.7 ns 33.3 50 ns 51.7 65.1 ns 43.3 29.7 ns

3 Percentage of encounters with an antibiotic

prescribed

50 45.2 ns 41.4 48.3 ns 22.6 56.7 s 50 50 ns 6.3 15 ns 26.7 37.9 ns 60 20 s

4 Percentage of encounters with an injection

prescribed

3.3 22.6 s 3.5 13.8 ns 16.1 26.7 ns 3.3 23.3 s 0 0 - 6.7 12.2 ns 40 0 -

5 Percentage of drugs prescribed on essential

drugs

61.5 76 s 86.8 79 ns 91 70.3 s 87.1 63.2 s 100 100 ns 96.6 92.1 ns 88.3 100 s


7 Percentage of drugs actually dispensed 74.4 86.7 ns 100 92.6 s 94 51.6 s 95.2 96.9 ns 100 97.4 ns 84.5 96.8 s 98.3 97.3 ns

8 Percentage of availability of key indicator

drugs

40 50 - 60 90 - 90 70 - 40 80 - 60 70 - 60 90 - 80 60 -

9 Percentage of reviewed cases 33.3 100 s 40 33.3 ns 20 33.3 ns 16.7 90 s 0 14.3 - 60 80 ns 33.3 33.3 ns


10 Percentage of reviewed cases in 5.6 20 ns 0 0 - 15.8 8.3 ns 70 17.7 s 53.3 33.3 ns 36.4 11.8 ns 13.3 66.7 s


treatment schedule



treatment schedule

13 Availability of other impartial 0 0 - 0 1 - 1 1 - 1 1 - 0 0 - 0 0 - 0 0 -

information

s = significant

ns = not significant

5

6


Annexe: 4 Jhapa

No Health Facility Damak HP Baniyani HP Dhulabari HP Kumarkhod HP Budhabare SHP Gauradaha SHP Topgachhi SHP



1 Average number of drugs prescribed 1.3 2.6 ns 2.7 2.6 ns 2.6 3.1 ns 2.5 2.8 ns 2.5 3.4 ns 1.7 1.8 ns 2.2 1.9 ns


names

67.5 29.4 s 67.1 58.4 ns 60.3 6.5 s 42.1 35.7 ns 26.8 9.8 s 23.1 41.8 s 68.9 55.2 ns


prescribed

19.4 44.4 s 83.3 83.3 ns 66.7 50 ns 83.3 66.7 ns 80 36.7 s 74.2 63.3 ns 76.5 25.8 s


prescribed

0 2.8 - 63.3 13.3 s 6.7 3.3 ns 36.7 46.7 ns 20 13.3 ns 0 6.7 - 0 0 -


drugs

80 72.8 s 90.2 89.6 ns 84.6 57 s 85.5 83.3 ns 70.7 43.1 s 98.1 74.6 s 98.7 89.7 s


7 Percentage of drugs actually dispensed 82.5 54.4 s 89 79.2 ns 68 47.3 s 85.5 64.3 s 40.2 28.4 ns 92.3 45.5 s 98.7 91.4 ns


drugs

50 60 - 60 50 - 60 30 - 90 60 - 70 60 - 70 40 - 70 70 -

9 Percentage of reviewed cases 60 20 ns 50 0 - 50 83.3 ns 50 16.7 ns 60 20 ns 85.7 100 ns 50 0 -


10 Percentage of reviewed cases in 70 50 ns 0 33.3 - 10 12.5 ns 0 11.1 - 0 0 - 100 18.2 s 14.3 43.5 ns


treatment schedule



treatment schedule


s = significant


7

8


Sarlahi

Annexe: 5

No Health Facility Jamuniya HP Sasapur HP Ganga Pur HP Sisautiya HP Piparia SHP Kaudena SHP Khutauna SHP



1 Average number of drugs prescribed 2.9 2.1 ns 2.6 1.8 ns 2.1 2.5 ns 1.9 2.2 ns 2 1.4 ns 1.8 1.4 ns 2.3 1.2 ns


names

72.7 71.2 ns 62.4 49.1 ns 76.6 60.5 ns 79 68.2 s 66 63.4 ns 66 69.8 ns 20.3 89.2 s


prescribed

63.3 50 ns 75.8 43.3 s 53.3 70 ns 53.3 53.3 ns 85.2 26.7 s 30 19.4 ns 36.7 23.3 ns

4 Percentage of encounters with an 56.7 43.8 ns 51.5 0 - 33.3 43.3 ns 0 40 - 81.5 3.3 s 0 0 - 3.3 0 -



drugs

93.2 98.5 ns 83.5 80 ns 85.9 85.5 ns 63.2 81.8 ns 96.2 100 ns 86.8 100 s 76.8 94.6 s


7 Percentage of drugs actually dispensed 85.2 95.5 s 69.4 98.2 s 82.8 85.5 ns 87.7 93.9 ns 96.2 95.1 ns 81.1 97.7 s 60.9 78.4 ns


indicator drugs

9 Percentage of reviewed cases 50 100 s 50 75 ns 0 60 - 75 100 ns 0 100 - 75 100 ns 80 100 ns


10 Percentage of reviewed cases in 0 41.7 - 50 60 ns 50 28.6 ns 0 30 - 0 47.4 - 0 68.2 - 16.7 68.4 s


treatment schedule


12 Availbility of Standard drug treatment

schedule

0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 1 - 0 0 -


s = significant


9


Kanchanpur

Annexe: 6

No Health Facility Jimuwa HP Daiji HP Parasan HP Shree Pur HP Laxmi Pur SHP Kalika SHP Gularia SHP



1 Average number of drugs prescribed 2.2 2 ns 1.6 2 ns 2.1 2.1 ns 2.5 1.9 ns 2 1.7 ns 2.2 1.8 ns 2.6 1.7 ns


names

73.5 42.4 s 44.7 65.6 ns 55.9 56.3 ns 45.5 60 ns 57.4 37.3 s 59.1 49 ns 45.6 34 ns


prescribed

64.5 33.3 s 26.7 56.7 s 59.4 46.7 ns 61.3 63 ns 60 36.7 ns 16.7 32.1 ns 40 26.7 ns

4 Percentage of encounters with an 12.9 13.3 ns 3.3 10 ns 21.9 16.7 ns 29 18.5 ns 6.7 26.7 ns 0 3.6 - 0 3.3 -



drugs

92.7 93.2 ns 91.5 95.1 ns 85.3 90.6 ns 77.9 90 ns 73.8 92.2 s 100 100 ns 86.1 92 ns


7 Percentage of drugs actually dispensed 100 88.1 s 100 88.5 s 88.2 87.5 ns 75.3 76 ns 91.8 84.3 ns 100 84.3 s 93.7 98 ns


drugs

80 80 - 80 80 - 70 100 - 60 70 - 80 60 - 60 70 - 60 80 -

9 Percentage of reviewed cases 33.3 0 - 10 50 ns 66.7 40 ns 33.3 100 s 16.7 100 s 33.3 20 ns 66.7 57.1 ns


10 Percentage of reviewed cases in 57.9 - - 52.9 66.7 ns 27.3 42.9 ns 22.2 50 ns 16.7 40 ns - 0 - 15.4 0 -


treatment schedule



treatment schedule


s = significant

10



Siraha

Annexe: 7

No Health Facility Khirauna HP Gol Bazar HP Nayanpur HP Malahaniya HP Sukhachaina SHP Madar SHP Chandra Ud. SHP



1 Average number of drugs prescribed 1.8 1.7 ns 2.5 2 ns 3.2 3.3 ns 3.8 2.9 ns 2 2.4 ns 1.6 1.8 ns 1.5 1.7 ns


names

61.8 48.1 ns 50 19.7 s 24 38.8 s 33.3 27.6 ns 48.3 54.8 ns 61.7 58.2 ns 47.7 58 s


prescribed

26.7 46.7 ns 76.7 26.7 s 60 53.3 ns 66.7 43.3 ns 66.7 10 s 3.3 13.3 ns 56.7 33.3 ns


prescribed

3.3 0 - 33.3 0 - 6.7 23.3 ns 10 3.3 ns 0 10 - 0 0 - 0 3.3 -

5 Percentage of drugs prescribed 89.1 80.8 ns 93.4 95.1 ns 76 70.4 ns 82.5 73.6 ns 96.7 100 ns 97.9 94.6 ns 100 98 ns

on essential drugs


7 Percentage of drugs actually dispensed 89.1 94.2 ns 76.3 78.7 ns 59.4 49 ns 63.2 46 s 100 98.6 ns 97.9 89.1 ns 100 94 ns


drugs

80 70 - 70 70 - 90 60 - 60 30 - 70 80 - 70 70 - 70 60 -

9 Percentage of reviewed cases 50 90 ns 33.3 30 ns 33.3 100 s 75 50 ns 20 100 s 0 80 - 0 40 -


10 Percentage of reviewed cases in accordance

with Standard drug treatment schedule

45.5 47.1 ns 5.9 52.9 s 0 4.8 - 11.1 14.3 ns 13.3 3.6 ns 30 31.3 ns 80 47.6 s



treatment schedule


s = significant

11



Annexe: 8 Chitawan

No Health Facility Shardanagar HP Khairahani HP Bharatpur HP Shivanagar HP Gunjnagar SHP Shaktikhor SHP Divyanagar SHP



1 Average number of drugs prescribed 1.7 2.2 ns 1.8 2.2 ns 1.6 2.3 ns 1.5 2.1 ns 1.8 2 ns 1.8 1.9 ns 1.8 2.5 ns


names

36.5 56.7 s 70 37.3 s 72.9 30.4 s 51.1 31.3 s 32.7 59 s 43.9 64.9 s 53.7 52.7 ns


prescribed

63.3 60 ns 78.6 60 ns 54.8 36.7 ns 46.7 76.7 s 43.3 76.7 s 56.3 63.3 ns 66.7 63.3 ns


prescribed

16.7 16.7 ns 25 36.7 ns 41.9 6.7 s 16.7 23.3 ns 3.3 30 s 12.5 33.3 s 26.7 33.3 ns

5 Percentage of drugs prescribed 86.5 82.1 ns 98 82.1 s 95.8 85.5 s 97.8 70.3 s 76.4 93.4 s 89.5 98.3 s 96.3 94.6 ns

on essential drugs


7 Percentage of drugs actually dispensed 90.7 88.1 ns 98 80.6 s 87.5 87 ns 97.8 67.2 s 76.4 96.7 s 100 96.5 ns 98.2 96 ns


drugs

90 90 - 80 80 - 90 90 - 90 90 - 80 40 - 90 80 - 90 80 -

9 Percentage of reviewed cases 66.7 0 - 40 33.3 ns 66.7 22.2 ns 40 40 ns 100 60 s 40 30 ns 60 10 s



with Standard drug treatment schedule

45.5 28.3 ns 28.6 29.4 ns 33.3 7.1 s - 13.3 - 28.4 20 ns - 23.5 - 66.7 11.1 s



treatment schedule


12

s = significant


13

Prescribing Indicators Bardiya

Annexe: 9

No Health Facility Bagnaha HP Nyaulapur HP Sorahawa HP Magargadhi HP Dhodhari SHP Thakurdwara SHP Kalika SHP



1 Average number of drugs prescribed 2.8 1.8 ns 2.3 1.7 ns 2.6 1.7 ns 1.6 2.2 ns 1.7 1.7 ns 1.8 1.6 ns 1.8 1.6 ns

2 Percentage of drug prescribed by Generic

names

48.2 76.4 s 28.6 41.2 ns 37.1 37.3 ns 67.3 40 s 40 34.6 ns 35.8 47.9 ns 52.8 67.4 ns

3 Percentage of encounters with an 86.7 73.3 ns 63.3 36.7 s 56.7 33.3 ns 53.3 50 ns 36.7 56.7 ns 53.3 40 ns 23.3 66.7 s

Antibiotic prescribed

4 Percentage of encounters with an 16.7 46.7 ns 16.7 20 ns 3.3 16.7 ns 0 6.7 - 10 0 - 10 13.3 ns 3.3 23.3 s


5 Percentage of drugs prescribed 86.7 94.6 ns 64.3 98 s 89.7 90.2 ns 95.9 81.5 s 94 100 ns 94.3 91.7 ns 98.1 100 ns

on Essential drugs


7 Percentage of drugs actually dispensed 49.4 89.1 s 62.9 88.2 s 56.4 90.2 ns 83.7 63.1 s 74 98.1 s 77.4 79.2 ns 94.3 100 ns


indicator drugs

9 Percentage of reviewed cases 60 0 - 0 33.3 - 50 66.7 ns 0 66.7 - 33.3 80 ns 0 14.3 - 42.9 42.9 ns



with Standard Drug Treatment Schedule

0 28.6 - 12.5 30.8 ns 4.6 22.7 ns 25.9 14.3 ns 52.2 25 s 38.1 16.7 ns 30 23.5 ns


12 Availbility of Standard Drug 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 -

Treatment Schedule


s = significant


1

Annexe: 10

Control Intervention

I (%)

Intervention

II (%)

Diarrhoea

History taking

Examination

Drug use

71.4

85.7

85.7

80.9

80.9

76.2

71.4

85.7

57.2

ARI

History taking

Examination

Drug use

52.4

38.1

23.8

47.6

52.4

52.4

28.6

38.1

52.4

Peptic Ulcer

History taking

Examination

Drug use

66.7

38.1

33.3

80.9

47.6

38.1

47.6

52.4

28.6

Anaemia

History taking

Examination

28.6

100.0

57.1

95.2

9.5

85.7

Scabies

History taking

Examination

85.7

85.7

85.7

95.5

61.9

81.0

Conjunctivitis

History taking

Examination

38.1

100.0

36.1

100.0

9.5

76.2

Ascariasis

Drug use

33.3

19.0

47.6

UTI

Drug use

76.2

42.9

47.6

2

Referral

UTI

Rheumatic fever

57.1

57.1

57.1

42.9

33.3

19.1

Annexe: 11

QUESTIONNAIRE

Name of Health Worker: ................... Post:...............

HP/SHP:................... District:...........

Interviewer:.................. Date:...............

Instruction: Put tick [ ] or specify the first response (Do not

prompt).

1. Which drug you think, should be prescribed for severe

dehydration ?

[ ] ORS [ ] Normal Saline

[ ] Dextrose Saline [ ] Ringers Lactate

[ ] Others (specify) [ ] Don't Know

2. Which drug you think, should be prescribed for

Ascariasis ?

[ ] Piperazine [ ] Mebendazole

[ ] Albendazole [ ] Pyrental Pamoate

[ ] Other (specify) [ ] Don't Know

3. Which drug you think, should be prescribed for UTI ?

3

[ ] Nitrofurantoin [ ] Nalidixic Acid

[ ] Cotrimoxazole [ ] Tetracycline


4. Which drug you think, should be prescribed for

Pneumonia?

[ ] PPF [ ] Benzyl Penicillin

[ ] Tetracycline [ ] Amoxycilin


5. Which drug you think, should be prescribed for Peptic

Ulcer ?

[ ] Aluminiun+ Magnesium Antacid

[ ] Sodium bicarbonate

[ ] Aluminum Hydroxide


Instruction: Put the tick [ ] or specify more than one answer.

6. In your opinion, what should be examined to diagnose a

case of dehydration ?

[ ] Skin elasticity [ ] Pulse

[ ] Inspection of Tongue

[ ] Examining Frontanalle in children

[ ] Other (specify) [ ] Don't Know.


case of ARI ?

4

[ ] Respiration Rate [ ] Chest Indrawing

[ ] Cyanosis [ ] Noisy Breathing



case of Anaemia ?

[ ] Inverted Eyelid [ ] Tongue

[ ] Nails [ ] Blood Investigation



case of Scabies ?

[ ] Inspection of Infected Area

[ ] Itching Spots



case of Conjunctivitis ?

[ ] Inverted Eyelid

[ ] Inspection of Eye with Torch light



case of Peptic Ulcer ?

[ ] Epigastrium [ ] Whole Abdomen


12. In your opinion, what history should be taken to find

5

out seveirity of diarrhoea ?

[ ] Frequency of Loose Motion [ ] Vomiting

[ ] Thirst [ ] Urination


13. In your opinion, what history should be taken to

diagnose a case of ARI ?

[ ] Duration of Cough [ ] Breast Sucking

[ ] Fever [ ] Other (specify)

[ ] Don't Know


diagnose a case of Anaemia ?

[ ] History of illness [ ] Duration



diagnose a case of Scabies ?

[ ] Duration [ ] Time of Itching

[ ] Itching [ ] Family History


6


diagnose a case of Conjunctivitis ?

[ ] Duration [ ] Itching



diagnose a case of Peptic Ulcer ?

[ ] Pain relation with Food

[ ] Onset of Pain [ ] Appetite

[ ] Site of Pain


18. In your opinion, when should a case of UTI be referred?

[ ] Recurrent UTI [ ] Ineffective Treatment

[ ] All Patients [ ] Children


19. In your opinion, when should a case of Rheumatic fever

be referred ?

[ ] Heart Complication [ ] Ineffective Treatment

[ ] All Patients [ ] Children


Annexe: 12

Supervision/Monitoring Form

7

PRESCRIBING INDICATOR

#

Patient Identifier

(Name)

Consulting

time

(Min)

Adequate exam

Problems 0/1

1

2

3

4

5

6

7

8

9

10

Case count (#)

Sum

Average

Percent of exam

Ilaka/Subhealth Post ............... District: ............

Supervisor: ....................... Date: ................

8

Annexe: 13 Supervision/Monitoring Form

ENCOUNTER FORM

# Patient Indicator

(Name)

Age

Sex

Prescriber Date

Health

Problems Health Problem Discription/Diagnosis

1

2

3

Prescription Character Patient drug knowledge Label

Drugs name, strength and

dose

Dispensed

Quantity

When

(0/1)

How

much (0/1)

Knowl

edge

(0/1)

Patient

name

(0/1)

Drug

name (0/1)

when

(0/1)

1

Drugs 2

3

4

5

6

7

8

9

10

Ilika/Sub Health Post: ...... District: .......

Private Dispenser :........ Date: ........

Supervision: ...........

9

Annexe: 14

Supervision/Monitoring Form

ENCOUNTER SUMMARY FORM

#

# Drugs

Prescription

Antibiotics

(0/1)

Injectio

ns (0/1)

#

Generics

#

on EDL

#

Drug

Dispensed

Standard

Treatment

(0/1)

1

2

3

4

5

6

7

8

9

10

Case

count

Sum

Average

Percent of encounters of

encounters

Of total

drugs

of total

drugs

of total

drugs

of diagnosis

Ilaka/Subhealth Post ............... District: ............

Supervisor: ....................... Date: ................

10

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