Pharmacology & Pharmacy, 2012, 3, 485-491
http://dx.doi.org/10.4236/pp.2012.34067 Published Online October 2012 (http://www.SciRP.org/journal/pp)
1
Impact of Training of Dispensers on Case Management of
Acute Respiratory Tract Infections at Community
Pharmacies in Pakistan
Azhar Hussain1,2*, Mohamed Izham Mohamed Ibrahim1,3, Madeeha Malik2
1School of Pharmaceutical Sciences, University Sains Malaysia, Penang, Malaysia; 2Hamdard Institute of Pharmaceutical Sciences,
Hamdard University, Islamabad, Pakistan; 3Social & Administrative Pharmacy College of Pharmacy, Qassim University, Qassim,
KSA.
Received June 26th, 2012; revised July 28th, 2012; accepted August 24th, 2012
ABSTRACT
Purpose: To evaluate the impact of training of dispensers on the process of case management of ARI at community
pharmacies in context to history taking and provision of advice working at community pharmacies in Islamabad, Paki-
stan. Method: A randomized, controlled, blinded intervention study was designed and implemented. Before the imple-
mentation of intervention, a baseline study was performed to assess the process of case management for ARI at com-
munity pharmacies. The study population included all community pharmacy outlets in Islamabad. After data collection,
data was analyzed. The result of the study revealed that the overall process of disease management of ARI at commu-
nity pharmacies in Pakistan is not satisfactory. Pharmacies of Islamabad which were visited in pre intervention phase
(118) were divided into two geographical regions A (intervention) and B (control). From which thirty pharmacies were
selected randomly from each region. The targeted group of the interventions was drug sellers. Keeping in view the re-
sults of the base line study an educational intervention was designed to improve the case management of ARI at com-
munity pharmacies in Pakistan. Results: No significant difference (p ≤ 0.05) was seen in the process of history taking
and advice provision in case of ARI management at community pharmacies between pre and post control groups. On
the other hand significant difference in the process of history taking and provision of advice for ARI was observed in
the intervention group before and after training. Conclusion: The study has highlighted that improvements in the cur-
rent dispensing practices at community pharmacies are possible through appropriate educational interventions. The dis-
pensers have the potential to provide fast and low cost healthcare to the masses in the country where the presence of
doctors and qualified pharmacist is low; to date they are an untapped and underutilized source in the country.
Keywords: Acute Respiratory Tract Infection (ARI); Community Pharmacies; Dispensers; Pakistan; Training
1. Introduction
Private pharmacies have become the first line contact in
health care delivery system [1-3]. Dispensing is a critical
part of the drug use process. The way drugs are dis-
pensed and the type of information given during dis-
pensing highly influences the compliance of patients with
the therapy. Staff training and education, customer de-
mand, physician practice, regulations, and economic in-
centives are the common factors affecting the pharmacy
practice [1,2]. Implementation of regulations is an im-
portant factor influencing pharmacy practice in develop-
ing countries though effective enforcement mechanisms
are still weak [3-5].
Changing the knowledge, behaviour and practices of
dispensers working at community pharmacies is a diffi-
cult and slow process but the likelihood of achieving
improvements exists [6]. Improving dispensing practices
in community pharmacies is possible by using a mix of
focused interventions. Three types of interventions are
used by researchers which include; educational, manage-
rial and regulatory interventions alone or in combination
[7]. The literature suggests that majority of dispensers are
willing to learn and contribute towards rational dispens-
ing and have also highlighted the need for training [8,9].
Uplift in social status, increase in knowledge, increased
ability to help their families and earning better profits
were few of the reasons for participation in interventions
[10].
Educational interventions are mostly used for improv-
ing the practices of drug sellers worldwide. It involves
*Corresponding author.

Impact of Training of Dispensers on Case Management of Acute Respiratory
Tract Infections at Community Pharmacies in Pakistan
486
focused small group training, one to one educational
training, peer-educators, in-service training, moderated
group discussion, large group training, feed back or peer
review [11,12]. Persuasive educational intervention en-
ables behaviour change by addressing barriers to change
[13]. Though educational interventions have been effec-
tive in some studies but variation exists depending on the
scenario. Face-to-face educational intervention did not
improve management of ARI in Uganda; the study high-
lighted the need to combine education training with
regulatory enforcement in order to ensure appropriate
management of ARI [14]. It is important to design inter-
ventions in local context to improve the practices.
Communicable diseases including gastroenteritis, res-
piratory infections, congenital abnormalities, tuberculosis,
malaria, and typhoid fever are the most prevalent and
leading causes of morbidity and mortality in Pakistan.
Hospital-based studies have reported ARI to be one of
the major causes of hospitalization i.e. usually 30% -
60% of patients in a hospital OPD out of which (80%
acute upper respiratory infections and 20% acute lower
respiratory infections) in Pakistan. Malnutrition, vitamin
A deficiency, low-birth weight, lack of immunizations,
lack of breast-feeding, crowding and exposure to indoor
pollutants (from wood or cow dung combustion or
smoking) have been identified as major risk factors for
development of severe ARI in Pakistan which needs to
be addressed as foremost public health challenge [15,16].
In current health care scenario community pharmacies
are looked upon for their potential in disease manage-
ment. This requires knowledge and skills by the dispens-
ers for the treatment of common ailments and their un-
derstanding of patient referral. This can be achieved
through effective history taking and counselling of the
patients regarding their disease and drug therapy. Ex-
perience from developing countries shows that dispens-
ers working at community pharmacies do not posses
adequate understanding about the process of effective
disease management, though they are extensively in-
volved in it [17,18]. The community pharmacies in Paki-
stan are known to be managed by a diversity of dis-
pensers in terms of their qualification, knowledge and
experience. The qualification of dispensers vary from
qualified pharmacist (degree of B-pharm/pharm D),
pharmacy assistant (diploma in pharmacy), diploma
holder (certified course of drug dispensing), to medical
doctors, nurses and to the salesmen (persons having no
dispensing related education) and majority constitutes of
this group [19-21]. These dispensers have minimal for-
mal education with 10 to 12 years of schooling and with
little or no professional training. Even this nominal edu-
cation of primary or secondary level is seen as a com-
mercial necessity and not as a legal requirement to be
followed. A number of studies have documented in-
adequate knowledge of the dispensers and deficiencies in
dispensing practices at community pharmacies in Paki-
stan but little has been done to improve so far [19,20,
22,23]. Increasing market competition, perceived eco-
nomic incentives and customer demand has an increasing
influence on pharmacy practice at community pharma-
cies [18,23]. Educational intervention for improving
pharmacy practices was employed in a study carried in
rural Sindh, Pakistan. The results of the study highlighted
that provision of education to drug sellers and expansion
of education program for drug sellers across the country
can be beneficial in promoting rational drug use [17].
However, there is no research published combining dif-
ferent types of interventions for improving the commu-
nity pharmacy practice in Pakistan. The present study is
unique in this aspect that educational intervention was
targeted at dispensers working in community pharmacies
and was conducted by involving regulators, chemist and
druggist association along with provision of job aids to
improve the practice. To evaluate the impact of training
of dispensers on the process of case management of ARI
at community pharmacies in context to history taking and
provision of advice working at community pharmacies in
Islamabad, Pakistan.
2. Methodology
2.1. Baseline Study
A randomized, controlled, blinded intervention study was
designed and implemented. Before the implementation of
intervention, a baseline study was performed to assess
the process of case management for ARI at community
pharmacies. The study population included all commu-
nity pharmacy outlets in Islamabad selling allopathic
medicines (western or modern medicines excluding tra-
ditional, herbal and homeopathic medicines), or homeo-
pathic or herbal medicines if sold alongside allopathic
medicines. Any shop meeting this definition constituted
the sampling unit.
2.2. Sampling of Pharmacies
A list of pharmacies was obtained from respective Dis-
trict Health Offices. The total population of pharmacies
in Islamabad was 169. The sample size was calculated at
95% confidence interval by using Cochrane formula
which came out to be 118. Simple random sampling was
used to select the pharmacies from the list. A total of 118
simulated patient visits were conducted from April to
June 2008 at these 118 pharmacies.
2.3. Data Collection Tool
Structured observation form was adapted from WHO
manual “How to investigate drug use in health facilities

Impact of Training of Dispensers on Case Management of Acute Respiratory
Tract Infections at Community Pharmacies in Pakistan
487
and was modified accordingly. Two Focus group discus-
sions were carried out at different time intervals with
four different groups of community pharmacist, drug
inspectors (Government officials who inspect quality of
drugs and legal requirements at community pharmacies
by drug law 1976 Pakistan), academia and members of
consumer groups (NGO) each group comprising of three
to four participants for the development, finalization,
face and content validity of the data collection tool. Pilot
testing was carried out on 12 pharmacies (10%) of total
sample size before execution of the final study. The
value of cronbach’s alpha was 0.69 which was applied to
assess the reliability and internal consistency of the tool.
The observation form included a total of twenty four
questions which included history obtained regarding
demographics of patients, history of illness, medication
and medical history, advice regarding dose, frequency,
duration, use and side effects of drug. Data collection
was planned and permission for survey was obtained
from relevant drug inspectors.
2.4. Ethical Considerations
As such there is no ethical committee for approval of
such studies in Pakistan. The study was approved by the
Research & Development wing of Drug Control Organi-
zation at Ministry of Health, Government of Pakistan.
Local chapters of PCDA (Pakistan chemist and druggist
association), DHO (District Health Officer) and Drug
inspectors were also informed and approval was taken.
2.5. Data Collection
Trained data collectors performed simulated patient visits
at each selected pharmacy to document the management
of Acute Respiratory tract Infection. The data collectors
presented as a simulated patient of ARI. They wanted to
buy some drugs to treat these conditions. Other then the
complaint/symptoms, no information was presented unless
asked by the dispenser. The data collectors spoke to the
dispensers at the time of the visit and later recorded the
encounters at the end of each visit using a structured ob-
servation form. Any product that was finally recom-
mended was purchased in quantities offered.
2.6. Data Analysis
After data collection, data was analyzed. The result of the
study revealed that the overall process of disease man-
agement of ARI at community pharmacies in Pakistan is
not satisfactory. The finding of the study supports the
assumption that the community pharmacies in Pakistan
have been converted into a place of medical practice
which is being carried out by untrained dispensers. The
process of history taking and provision of advice had
been ignored by the pharmacies either situated in rural or
urban settings, irrespective of the provider type and loca-
tion of pharmacies. The study results highlighted that
90% of drug sellers felt that they require training while
84% showed their willingness to participate if such op-
portunity arises.
2.7. Designing & Execution of Interventional
Study
Pharmacies of Islamabad which were visited in pre in-
tervention phase (118) were divided into two geographi-
cal regions A (intervention) and B (control). From which
thirty pharmacies were selected randomly from each re-
gion. The targeted group of the interventions was drug
sellers. Keeping in view the results of the base line study
an educational intervention was designed to improve the
case management of ARI at community pharmacies in
Pakistan. The results of the baseline study were shared
with representatives of chemist and druggist association,
drug inspectors, academia, drug sellers and community
pharmacist. The focus, targets, contents and format of
intervention was designed after a series of discussions
with the above mentioned stakeholders. The contents of
the training materials were developed from Drug Law,
Good Pharmacy Practice guidelines, dispensing practice
standards and discussion with drug inspectors. The for-
mat of a formal workshop was selected for training be-
cause it is the most common method used across the
world for training drug sellers. After discussion with dif-
ferent stakeholders the name of the training workshop
was recommended to be “Modern Concepts of Dispens-
ing and Patient Handling”. The training workshop was
intended to be conducted over two days but due to busy
schedule of drug sellers it was restricted to one day and
was divided into three sessions; duration of each session
was of 2.5 hours. The workshop was focused on issues
including standard prescription/patient handling and
dealing with patients of ARI without prescription. Dif-
ferent components of history taking and counseling were
also highlighted and importance of referral and POM
diseases were also discussed. The training workshop in-
cluded presentations, video clips and group tasks. The
trainees were provided with list of responsibilities of
dispensers, essential documents to be kept in pharmacy,
daily checklist for pharmacy, dispensing list, list of con-
trol drugs, sample of prescription, checklist for prescrip-
tion and list of commonly used abbreviations and were
requested to share the same with their colleagues work-
ing in pharmacies.
2.8. Conduction of Training Workshop
The training was conducted in collaboration with District
Health Office, Chemist and druggist association and

Impact of Training of Dispensers on Case Management of Acute Respiratory
Tract Infections at Community Pharmacies in Pakistan
488
Hamdard University, Islamabad. District Health Officer
nominated Drug Inspector for coordination of training
workshop. Randomly selected drug sellers were con-
tacted through formal letter inviting for training and fol-
lowed on phone for the confirmation of participation.
Keeping in view the influence of opinion leaders; doctors,
pharmacist from academia, drug inspectors and commu-
nity pharmacist were engaged as trainers. Smooth run-
ning of workshop and attendance of drug sellers was en-
sured due to the group effort with DHO office.
2.9. Data Collection & Data Analysis
After four weeks of training a letter along with a small
poster and a sample of drug label was sent to the partici-
pants of training and were reminded of the request to
share the information with colleagues. Post intervention
data was collected after two months of training using
simulated patient visits. Neither the participants nor the
data collectors and the data entry persons were aware of
the intervention and control groups. Same data collection
tools were utilized to collect post intervention data as
were used in pre data collection. The data was cleaned
coded and entered in SPSS 16 version. Wilicoxon and
Man Whitney tests were used to compare the pre and
post data.
3. Results
3.1. Impact of Training of Dispensers on the
Process of History Taking and Advice
Provision in ARI Management at
Community Pharmacies
It was observed that while treating ARI at community
pharmacies in 16.7% of the cases history of medication
was asked, weight of the patient, history of past illness
and medical history was not inquired in any of the case
from the patient before training. While after training in
30% of the cases weight of the patient, 46.7% of the
cases history of medication and 23.3% of the cases
medical history was asked from the patients. In 83.3%
cases remedy was suggested for ARI before training
while after training it was decreased to 56.7% of the
cases. An increase in referral from 10% to 40% was seen
in case of ARI after training. It was observed that while
treating ARI at community pharmacies in 11.1% of the
cases duration of drug, in 7.4% of the cases what drug
does and in none of the case side effects were told before
training. While after training in 22.2% of the cases dura-
tion of drug, 50% of the cases what drug does and 11.1%
of the cases side effects were told. While an increase in
communication of correct dose and frequency ranging
from 55.6% to 100% and 37% to 72.2% was observed
after training (Table 1).
3.2. Comparison of Case Management of ARI at
Community Pharmacies between Pre-Post
Control and Pre-Post Intervention Groups
No significant difference (p ≤ 0.05) was seen in the
process of history taking and advice provision in case of
ARI management at community pharmacies between pre
and post control groups. On the other hand significant
difference in the process of history taking and provision
of advice for ARI was observed in the intervention group
before and after training (Table 2).
3.3. Comparison of Case Management of ARI at
Community Pharmacies among Control and
Intervention Groups
A significant difference in the overall process of history
taking and advice provision of ARI was observed at
Table 1. Impact of training of dispensers on the process of history taking of ARI at community pharmacies.
Provision of advice
Pre-intervention n = 30 Post-intervention n = 30 Percentage difference
Information provided
F ARI treated cases = 27% F ARI treated cases = 18% %
Age of patient was asked 3 10 3 10 0
Weight of patient was asked 0 0 9 30 +30
History of illness was asked 13 43.3 11 36.7 −6.6
History of medication was asked 5 16.7 14 46.7 +30
Medical history was asked 0 0 7 23.3 +23.3
Correct dose 15 55.6 18 100 +44.4
Correct frequency 10 37 13 72.2 +35.2
Correct duration 3 11.1 4 22.2 +11.1
What drug does 2 7.4 9 50 +42.6
Side effects/caution 0 0 2 11.1 +11.1

Impact of Training of Dispensers on Case Management of Acute Respiratory
Tract Infections at Community Pharmacies in Pakistan
489
Table 2. Comparison of case management of ARI at community pharmacies between pre-post control and pre-post interven-
tion groups.
Case management of ARI
Control Intervention
Sub scales
Pre-control
median (IQR) Post-control median (IQR) p-value Pre-intervention median (IQR) Post-intervention median (IQR) p-value
History taking 10 (9 - 10) 10 (9 - 10) 0.500 9 (9 - 10) 9 (7 - 10) 0.040
Advice provision 9 (9 - 10) 9.5 (5 - 10) 0.954 9 (8 - 10) 8 (7 - 8) 0.000
Wilcoxon test p ≤ 0.05.
community pharmacies where dispensers received train-
ing as compared to those pharmacies where dispensers
did not receive any training. The pharmacies where dis-
pensers received training were better in the process of
history taking and advice provision (Table 3).
4. Discussion
Community pharmacies are looked upon for their poten-
tial in disease management in existing health care setting.
For achieving this potential, better knowledge and skills
by the dispensers and their understanding of patient re-
ferral is required. The available literature indicates that
the standards of practice are quite low at community phar-
macies in the country [20-23].
The result of the baseline study highlighted that the
overall process of disease management of ARI at com-
munity pharmacies in Pakistan is not satisfactory. Dis-
pensers attend to their customers and provide treatment
but most of them prescribe ineffective, inappropriate
drugs in inadequate doses with little or no counseling
[17]. Study from Karachi Pakistan reported that the dis-
penser working at community pharmacies have fragmen-
tary knowledge but when inquired were ready to treat
patients of diarrhoea and ARI [19].
Interventions can improve the knowledge and prac-
tices of dispensers. The results of the present intervention
study are encouraging despite the murky situation of
pharmacy practice at community pharmacies in the
country. During the training of dispensers it was empha-
sized that the case management may not be an appropri-
ate option for dispensers with the current state of knowl-
edge and training. History taking and provision of advice
were significantly improved at community pharmacies
after training. The patients were communicated with
correct dose, frequency, use and side effects for ARI.
Studies from Pakistan suggested that rational use of
medicines can be achieved by improving the knowledge
of dispensers working at community pharmacies and they
can be used effectively for disease management [17,22].
The results of the present interventional study have sup-
ported this contemplation.
Table 3. Comparison of case management of ARI at com-
munity pharmacies between post-control and post-inter-
vention groups.
Case management of ARI
Sub scalesn Median U p-value
Control = 30 Control = 10 280.500.004
History
taking Intervention = 30Intervention = 9
Control = 52 Control = 9 165.500.000
Provision of
advice Intervention = 31Intervention = 8
Mann-Whitney test p ≤ 0.05.
Intervention showed that training can improve the
knowledge and practice of dispensers working at com-
munity pharmacies. Ongoing monitoring programs and
regular audits must be designed to see the longer impact
of interventions and sustainability in the practice of the
dispensers. Training program for dispensers should be a
regular feature of District health Office and the atten-
dance of dispensers can be ensured by linking it with the
renewal of their licence. The program should also be
embedded in the National Drug Policy of the country
which aims at achieving safe use of medication through
public private partnership. Pharmacist is the best person
to perform dispensing at community pharmacies. They
shall be encouraged to come into community pharmacy
business with introduction of incentives by the govern-
ment. Due to the low number of pharmacists in the coun-
try it is difficult to ensure their presence at community
pharmacies thus in the absence of qualified person, ex-
isting dispensers at these pharmacies should be trained
for the improvement of dispensing practices. Mass media
shall also be involved to inform general public for recog-
nition of ailments, referral points and the extent of exper-
tise and help available at community pharmacies. Long
term change in the public health domain can be brought
in by the education and legislation enforcement.
5. Limitations of the Study
Financial constraint was one of the problems faced dur-

Impact of Training of Dispensers on Case Management of Acute Respiratory
Tract Infections at Community Pharmacies in Pakistan
490
ing the training. Based on the information given during
the training the dispensers might have developed an un-
derstanding on the variables which might be observed
during the post intervention data collection which might
have influence the real responses. Information provided
by the dispenser was not verified to be correct or incor-
rect during the process of prescription handling as it was
gathered through structured observation form.
6. Conclusion
The study has highlighted that improvements in the cur-
rent dispensing practices at community pharmacies are
possible through appropriate educational interventions.
The dispensers have the potential to provide fast and low
cost healthcare to the masses in the country where the
presence of doctors and qualified pharmacist is low; to
date they are an untapped and underutilized source in the
country. To effectively utilize and expand the findings of
the present study, there is a strong need of collaboration
between academia, regulatory authorities and other or-
ganizations promoting health care. Developing a larger
pool of trainers and the experience of training of trainer
from the current intervention highlights the possibility of
training a large number of dispensers thus contributing in
the achievement of millennium development goals.
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