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Table 2 Summary of study characteristics and findings

From: Examining characteristics, knowledge and regulatory practices of specialized drug shops in Sub-Saharan Africa: a systematic review of the literature

Ref No Author (year), country of study Number and type of shops (staff) Study design (SCM) Areas investigated Major findings
66 Abula et al (2006) Ethiopia, urban 20 Pharmacies Cross-sectional survey Drug sources, sources of information, handling of clients requesting for partial doses, and patient referral -Poor access to drug information; 80% get no up-to-date information on medicines (and rely on inserts instead)
      -All staff reported referring patients when required
      -40% accept partial dispensing
70 ACTwatch (2009) Benin, urban and rural 35 pharmacies (30 registered and 5 rural outpost pharmacies) Cross-sectional survey Availability, price, and volume of antimalarials sold -77% stocked the first-line ACT, with 87% stocking non-artemisinin antimalarials. Diagnostic tests
     Knowledge of providers - Pharmacy charged higher prices compared to other providers, but sold lower volumes overall
30 ACTwatch (2009) D.R Congo, urban and rural 31 pharmacies and 470 drug stores Cross-sectional survey Availability, price, and volume of antimalarials sold -Both shops rarely stocked first-line (only 20-25%), but most had artemisinin monotherapy in stock
      -Both shop types did not generally do diagnostic tests
     Knowledge and perceptions of providers -Pharmacies charged lowest prices for ACTs
      -Drug stores sold the most, but had least knowledge
33 ACTwatch (2009) Madagascar, urban and rural 80 registered pharmaciesand 162 rural pharmacies Cross-sectional survey Availability, price, and volume of antimalarials sold -Only half stocked the first-line; majority had non-artemisinin drugs, and did not do diagnostic tests
      -Pharmacies charged highest prices for ACTs by far
     Knowledge and perceptions of providers -They sold the highest volume of medicines, but only 59% knew the recommended first-line treatment
29 ACTwatch (2009) Nigeria, urban and rural 38 pharmacies and 305 patent medicine stores Cross-sectional survey Availability, price, and volume of antimalarials sold -74% of pharmacies had first-line, compared to 8% for PMVs
      -Both shop types did not generally do diagnostic tests
     Knowledge and perceptions of providers -Pharmacies charged highest prices for recommended ACTs
      -PMVs sold the most, but had least knowledge on treatment
32 ACTwatch (2009) Uganda, urban and rural 65 pharmacies and 188 drug stores Cross-sectional survey Availability, price, and volume of antimalarials sold -57% of pharmacies had first-line; only 4% of drug shops
     Knowledge and perceptions of providers -Both shop types rarely carried out diagnostic tests
      -Pharmacies charged highest prices for recommended ACTs
      -Drug stores sold the highest volume of medicines, but only 60% knew the recommended first-line treatment
31 ACTwatch (2009) Zambia, urban and rural 49 pharmacies and 130 drug stores Cross-sectional survey Availability, price, and volume of antimalarials sold -Most pharmacies sold ACTs, but only 6% of drug shops did –Non-registered ACT also very common in pharmacies
      -32% of pharmacies did diagnostic tests, but not drug stores
     Knowledge and perceptions of providers -Pharmacy ACT prices were higher than drug stores
      -Drug stores had much lower knowledge on first-line drug
25 Adikwu, M. U (1996) Nigeria, peri-urban 46 Patent medicine stores Cross-sectional survey Regulatory inspections, characteristics and knowledge of dispensers -All staff aware of the law governing retailers in Nigeria
      -Main suppliers were pharmaceutical representatives
      -Sales boys and girls used in patent medicine stores
68 Adisa et al (2006) Nigeria, urban 50 Pharmacies Cross-sectional survey Knowledge on characteristics, ethics and perceived responsibility with regard to phyto-pharmaceuticals -3/4 scored below 53% on knowledge about the drugs
      -1/3 had training on phyto-pharmaceuticals
      -3/4 felt such drugs need Regulatory Authority governance
      -3/4 felt pharmacists qualified to handle such medicines
56 Adu-Sarkodie et al (2000) Ghana, urban 48 pharmacies Baseline survey before intervention (SCM) -Management practices for STI clients -About half of the shops took patient history before selling
      -Only one-fifth counseled clients on partner notification
      -Only one-fifth offered the recommended medicines
      -Only 13% advised STI clients to use condoms
34 Amin et al, 2005, Kenya, rural 20 Pharmacies Cross-sectional survey -Drug sales practices -Unregistered drugs found in some pharmacies
      -Majority of drugs not within the registration period
     -Regulation and registration policy framework -New first-line AL found in only 11% of pharmacies
      -Sourced drugs mainly from wholesalers, never from vendors
     -Adherence, stocking practices  
60 Berih et al (1989) Sudan, urban 63 pharmacies Cross-sectional survey (SCM) Drug dispensing practices -Only 5% recommended ORS despite wide availability, with 2/3 recommending antimicrobials which cost 4 times more
      -63% took history before treatment; these were more likely to refer child and less likely to recommend antimicrobials
      -ORS use not related to availability or history taking
47 Blanchard et al (2005) South Africa, urban 28 Pharmacies Cross-sectional survey Knowledge and attitudes of pharmacists towards providing emergency contraception -Nearly all pharmacists sold at least one of the two ECPs
      -Most were familiar with contraceptive indication and side effects, but felt they should not be given to under 18s
      -About 80% were willing to display promotional materials
62 Brieger et al (2004) Nigeria, rural and urban 149 patent medicine shops; (820 observations) Cross sectional survey Nature of interaction between patent medicine vendors and clerks and clients -Quarter of clients shared problems with staff
      -69% sold requested medicines, 30% gave treatment suggestions, 21% gave instructions on medication use, and 19% asked questions about the illness
49 Brieger et al (2007) Nigeria, rural 12 patent medicine sellers Qualitative study -Medicine sellers perceptions of consumer color preferences for medicines -Sellers linked color to effects; yellow associated with malaria because of symptoms of yellow urine and eyes
      -Sellers had low opinion of white colored medicines
73 Buabeng et al (2008) Ghana, urban and rural 35 pharmacies and 64 licensed chemical shops Cross-sectional survey -Availability of antimalarials -SPs the most available antimalarial; ACTs less available, especially in chemical shops and rural areas
     -Policy adherence when choosing drugs to dispense -Poor adherence to policy guidelines when choosing drugs
      -Unregistered and unrecommended drugs stocked
     -Types of medicines stocked  
51 Buabeng et al (2010a) Ghana, urban and rural 35 pharmacies and 64 licensed chemical shops Cross-sectional survey -Characteristics of staff -45% of pharmacies had professional staff (pharmaceutical or nursing) compared to 5% for LCSs; 24% of pharmacy staff could treat malaria with ACTs compared to 6% LCSs
     -Knowledge of staff on malaria -76% of pharmacy staff knew symptoms of complicated malaria compared to 43% in LCS
     -Practices on malaria prevention  
65 Buabeng, K. O (2010b) Ghana, urban and rural 35 pharmacies and 64 licensed chemical shops Cross-sectional survey -Suitability of premises for malaria services provision -Most pharmacies clean and well lit compared to LCSs
      -74% pharmacies had counseling area versus 19% of LCS
      -88% pharmacies had fridge versus 22% of LCSs
      -All pharmacies kept some records versus 47% of LCSs
      -More pharmacies than LCSs had reference materials
40 Cohen et al (2010) Tanzania, rural 226 part II drug shops Cross-sectional survey Range and patterns of availability of antimalarials vis-à-vis geographical and socio-economic determinants -ACTs stocked more in shops located nearer towns and/or nearer other shops and in more populous areas (p<0.01)
      -Shops near ACT-stocking facilities more likely to stock the non-recommended SP medicines (p<0.01). Remote shops more likely to sell antipyretics for fever than antimalarial
20 Fayemi et al (2010) Nigeria, rural 97 Patent medicine vendors Cross-sectional survey -knowledge, dispensing practices, and referral for emergency contraceptives -One-third not aware of ECPs; only half knew that ECPs could prevent pregnancy
      -Only half had referral systems for ECP clients
58 Goel et al (1996) Kenya, rural and urban 91 Pharmacies Cross-sectional survey (SCM used) Influence of geographical location and knowledge on prescribing practices for diarrhea -No clear relationship between knowledge and prescribing
      -Correct treatment odds higher in high SES urban areas -
      -Women more likely to receive appropriate treatment for diarrhea in their children
28 Goodman (2004) Tanzania, rural 43 Part II drug shops Cross-sectional survey Range and sources of antipyretics, antibiotics and antimalarials -Nearly all drug shops had fever and malaria medicines, and nearly two-thirds had antibiotics
      -87% got drugs from drug wholesaler or part I pharmacy
54 Goodman et al (2007) Tanzania, rural 30 part II drug stores Cross-sectional survey Compliance with regulations -Majority displayed permits, but some permits belonged to staff not attached to the shop. Majority also stocked and sold prescription medicines against regulatory requirements
     Likely causes of regulatory infringement -Poor compliance cause by low knowledge, inadequate inspections, and tacit permission from regulatory enforcers
22 Greer et al (2004) Nigeria, rural 245 patent medicine vendors Baseline survey before intervention (SCM) -Characteristics and knowledge of PMV on malaria and other diseases -57, 28% had secondary or tertiary education respectively
      -Stability in employment; 80% had worked there for over 1 year, 54% more than 4 years, 24% for more than 10 years
      -21% knew ITNs, but only 5% recommended to clients
22 Greer et al (2004) Uganda, rural   Baseline survey before intervention (SCM) -Management of malaria, ARI and diarrhea -Majority took basic patient history appropriately
      -Nearly all recommended wrong medicine and dose
      -Only 8% explained how drug should be taken
42 Hera (2006) Tanzania, rural and peri-urban 25 ADDOs Post-hoc ADDOs programme evaluation Availability, affordability and quality of drugs, and the quality of dispensing services Better availability but higher prices of drugs compared to public facilities. Rural shops sold at higher prices, but disparities among ADDOs in prices. Amoxicillin, quinine and ORS dispensed inappropriately
17 Hetzel et al (2006) Tanzania, rural 10 drug stores before, 19 after Cross-sectional surveys -Availability and access to drugs before and after policy change from chloroquine as first line to SP -Number of shops stocking drugs almost doubled.
      -First-line drug (SP) had better availability in 2004 than did CQ (previous first-line) in 2001 (in drug shops)
23 Hetzel et al (2008) Tanzania, rural 29 part II drug stores Cross sectional survey (SCM used) -Knowledge on malaria treatment -Drug shops had better knowledge than general shops
     -drug prescribing practices -Mystery shoppers likely to get appropriate treatment in drug shops but at higher price.
      -Adults more likely to have an anti-malarial sold to them
52 Igun (1994) Nigeria, rural 58 pharmacies and 77 patent medicine stores -Cross-sectional survey (SCM used) -Knowledge and prescribing practices for watery and bloody diarrhea -70% of staff said they would give ORT for diarrhea, but only 7% actually gave, the rest giving drugs
      -57% stated they give ORT only, but 90% of these providers gave drugs only for the diarrhea
13 Jacobs et al (2004) Uganda, rural and peri-urban 141 drug shops Cross-sectional survey -Management of urethral discharge in men, treatment outcomes, and patients’ perception of quality of care -14% of patients treated according to national guidelines, but 11% managed properly
      -55% told to use condom or refer partner
      - 38% cure rate
41 Karim et al (1996) South Africa, urban 10 pharmacies Records review -Generic substitution -45.7% of all prescription had generic equivalents
     -Cost analysis of prescriptions for branded and generic drugs - The branded price was 10% higher than the generic price
      -Pharmacists only substituted 14% of drugs for generics
      -7% of costs can be saved through generic substitution
74 Kachur et al (2006a) Tanzania, urban 29 part I pharmacies Cross-sectional survey -Availability, packaging and labeling of artemisinin-containing products - 89% of artemisinin drugs identified were monotherapies
      -All products sold as prepackaged unit doses
      -All drugs obtained in manufacturers' original packaging
69 Kachur et al, (2006b) Tanzania, rural 10 specialist drug stores Cross-sectional survey -Prevalence of malaria parasitemia among clients -17% of febrile visits resulted in buying of an antimalarial
     -Characteristics of malari -An antipyretic as obtained in 77% visits, with most clients not getting malaria-specific treatment when warranted
     a and fever medicines buyers -Education linked to better buying of antimalarials
43 Kagashe et al (2011) Tanzania, urban 70 pharmacies Cross-sectional survey -Dispensing practices for antibiotics, and other drugs -45% dispensed on client request, 32% on dispenser recommendation, and only 23% on prescription
      -Antibiotics given inappropriately and in partial doses
21 Kwena et al (2008) Kenya, urban 50 pharmacies Cross-sectional survey (SCM) -Characteristics of providers managing STI patients -Only 10% of clients were offered appropriate treatment according to the government’s STI management guidelines
     -Knowledge on management of STIs, compliance to guidelines -74% of pharmacy staff reported that some customers cannot raise all money for medicines prescribed
63 Liambila et al (2010) Kenya, urban 20 pharmacies Survey before intervention (SCM) -Counseling and dispensing practices for clients seeking emergency contraception -About half of staff gave additional information on EC
      -Only 12.5 gave regular family planning advice
      -Only 5% talked about STIs/HIV
26 Maiga et al (2003) Mali, urban 11 Pharmacies Records review Drug prescription and selling practices -Most purchases made without prescription were generics
      -Transactions were more costly in pharmacies than public health facilities (prices higher by 68%)
72 Maiga et al (2010) Mali, urban 30 Private drug stores Survey before intervention Availability and prices for essential medicines - Availability of 49 essential drugs was 66.1% among the retail pharmacies
      -Retail prices were 25% higher than recommended
35 Manirakiza et al (2010) Central African Republic, urban 15 Private drug stores and 60 non-official drug shops Cross-sectional survey -Availability of antimalarials -87% of drug stores sold artemisinin monotherapy
     -Performance of staff in management of malaria -70 and 93% of drug stores and unofficial drug shops sold the unrecommended chloroquine
      -Chloroquine was not supplied by the official wholesalers
      -SP, the official treatment, was available in all drug stores, but unavailable in 84% of unofficial drug shops
44 Massele et al (1993) Tanzania, urban 20 drug shops Cross-sectional survey -Knowledge and treatment practices for malaria -Knowledge of drug sellers on sign and symptoms was adequate, but 45% did not know the correct drug dose
      -Only 30% of patients knew the correct dose
61 Mayhew et al (2001) Ghana, urban 248 pharmacies Survey before intervention (SCM) -Characteristics of shops, staff and clients -Only 34% of staff had university qualification
     -STI management of clients -60% of STI clients visit without a prescription
      -Only 17% used national guidelines to treat STIs
27 Mazzilli et al, 2009 Somaliland, urban and rural 83 pharmacies Cross-sectional survey -Characteristics of shops, staff -No pharmacists found. Nurses own most pharmacies
      -Pharmacies offered injections and diagnostic tests
     -Knowledge about drugs -Majority knew drugs through self study and experience
     -Services and drugs offered -Majority sold medicines without prescription
7 Minzi et al (2008) Tanzania, urban 551 pharmacies Cross-sectional survey -Types of antimalarials stocked at the pharmacies -None of had been involved in preparation of guidelines
      -Poor knowledge on pediatric dosages
     -Awareness on new malaria treatment guidelines -49% of pharmacies still stocked chloroquine
      -Only 30/7% knew dose regimen of SP/AL respectively
18 Murray et al (1998) Eritrea (rural) 59 rural drug vendors Cross-sectional survey (SCM) -Knowledge and treatment practices for diarrhea and respiratory infection -41% gave correct treatment for respiratory infection
      -Only 38% of clients knew correct dosing for antibiotics
      -63% knew how to treat diarrhea, but only 10% did so
14 Nakyanzi et al (2010) Uganda, urban 32 pharmacies Cross-sectional survey -Range and characteristics of medicines that expire within pharmacies -75% had gotten low-price/donations of near-expiry drugs; 56% had disposed of expired drugs; 44% had returned drugs to suppliers, and 28% had customers return drugs
      -Policy change in treatment linked to expiry of medicines
36 Noor et al (2009) Somalia, rural 194 pharmacies Cross-sectional survey -Availability of malaria drugs and diagnostic services -Over 30% do diagnosis; CQ found in 53% of shops, with 9% providing SP. Artemisinin monotherapy was found in 14% of shops, with one area having 42% availability
     -Prescribing for malaria -ACT only found in 9% of shops (2 years after new policy)
45 Nshakira et al (2002) Uganda, rural 2 drug shops Cross –sectional survey -Drugs and instructions given to children under five - 75% of medication was bought in shops in community
     -Instructions given to caretakers about dosage -All study sites had a range of ant malarial drugs in stock -An average of 3.2 drugs was dispensed per child
59 Nsimba (2007) Tanzania, rural 4 pharmacies and 39 drug stores Cross-sectional survey (SCM used) -Dispensing practices for ORS, antimalarials and antibiotics -Antibiotics overused in both urban and rural settings
      -Use of branded drugs more common than generics
     -Training on selectively prescribing -ORS rarely prescribed. Antibiotics inappropriately dispensed for watery diarrhea in almost half of the cases
8 Ntambwe et al (1994) Zaire (now D.R. Congo), rural 44 pharmacies Cross-sectional survey -Characteristics of premises, staff, and availability of permit -None run by pharmacist or assistant. 30% run by nurses; 71% run by untrained persons; all shops owned by traders
     -Compliance with dispensing and recording regulations -None had a permit, and none kept prescription registers
      -87% sold drugs without prescription
64 Nyazema et al (2007) Zimbabwe, urban 63 pharmacies Cross –sectional survey (SCM used) Sale of antibiotics without prescription, and provision of treatment advice according to acceptable standards -69% said they can’t sell antibiotics without prescription
      -Actual sale of antibiotics without prescription was low
      -Few respondents performed well regarding provision of information and advice in relation to treatment guidelines
9 Ojuawo et al (1993) Nigeria, urban 75 Patent medicine sellers Cross –sectional survey (SCM used) -Knowledge, treatment and referral practices for diarrhoea -33% were owners. 30% of employees were primary school children. Majority of staff did not ask questions about diarrhea, and lacked knowledge on ORT
      -Diarrhea drugs were recommended by all respondents
48 Okeke et al (2006) Nigeria, rural 13 patent medicine sellers Survey before intervention Knowledge, beliefs, treatment practices, and referral for mild and severe malaria -Majority of sellers not health professionals
      -Poor knowledge, dispensing, and referral for malaria
      -Advice and information rarely given to care-givers
      -62% dispensed what clients demand; only 15% took history
37 Onwujekwe et al (2010) Nigeria, rural 11 pharmacies and 137 patent medicine sellers Cross-sectional survey -Characteristics of providers -14% of PMVs sold medicines without any diagnostic steps compared to 5% for pharmacies. A high proportion of both shops used history to confirm diagnosis for malaria
     -Knowledge and management of malaria -More pharmacies sold artemisinin monotherapies
53 Oreagba et al (2010) Nigeria, urban 400 pharmacies Cross-sectional survey -Knowledge, perceptions and practice around pharmacovigilance -55% had heard of pharmacovigilance; 18% could define it
      -Only 3% reported adverse drug reactions to the authority
      -45% did not report because they did not know how
46 Oshiname et al (1992) Nigeria, rural 37 patent medicine vendors Baseline before intervention -Knowledge on symptoms, counseling and management of malaria and other diseases - 70% knew the correct malaria drug, but only one knew the correct dosage for a 3 year old child
      -39% would sell medicine to a child
19 RPM Plus (2006), Tanzania urban and rural 58 ADDOs Cross –sectional survey (SCM) Knowledge and management of major childhood illnesses, and availability of key drugs -Poor knowledge on treatment choices for diarrhea and ARI
      -Low adherence to national guidelines for treating ARI, malaria and diarrhea
16 Russo et al (2010) Mozambique urban 34 private pharmacies Cross-sectional survey -Prices for generic and branded medicines -Huge price variations across pharmacies despite price regulation
      -Pharmacies adjust prices depending on the market demand
38 Sabot et al (2009) Tanzania, rural   Baseline survey before intervention -Availability and dispensing practices for ACTs -Nearly none of the shops stocked the recommended ACTs before the intervention (subsidy) was introduced
      -As a result, most shops did not suggest/offer ACTs to clients, choosing to instead offer SPs
11 Tumwikirize et al (2004) Uganda, urban 28 pharmacies and 169 drug stores Cross-sectional survey -Characteristics, knowledge and dispensing practices for ARIs -Most staff had training background in nursing
      -Low knowledge on ARI symptoms and management
      -Inappropriate dispensing of antibiotics very common
39 van den Boogaard et al (2010) Tanzania, rural 14 pharmacies and 15 drug shops Cross-sectional survey -Availability and sale of floroquinolones and other antibiotics -All drug shops illegally stocked and sold antibiotics
      -Floroquinolones widely available in shops, raising concerns over resistance
24 Viberg et al (2009) Tanzania, rural 94 pharmacies, drug stores, and ADDOs Cross –sectional survey (SCM used) -STI management practices -74% of drug sellers stated they had no STI-related drugs in the stock, but 78% and 63% gave male and female simulated clients the medicines, mostly antibiotics
     -Knowledge on dose, side effects  
     -Drug dispensing practices -Most drugs dispensed were the recommended, though incomplete management, incorrect dosages, lack of advice, and poor history-taking were common
     -Knowledge on regulation  
50 Viberg et al (2010) Tanzania, rural 75 drug sellers Cross-sectional survey -Knowledge and perceptions on antibiotic use and resistance -79% of drug sellers knew antibiotics treat bacterial infections; 24% of these sellers also thought antibiotics could treat viral infections
      -72% had heard about antibiotic resistance