title: The influence of customer-medicine seller transactional dynamics on childhood diarrhoea management: a qualitative study in Ghana.
abstract: In 2004, the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) jointly revised the recommended treatment for acute paediatric diarrhoea to specify supplementing reduced osmolarity oral rehydration salts (ORS) with zinc. In many countries, however, a significant knowledge-practice gap persists in appropriate diarrhoea management among private healthcare providers. For example, the United States Agency for International Development (USAID)-funded Strengthening Health Outcomes through the Private Sector (SHOPS) project recently demonstrated that over-the-counter medicine sellers (MS) in Ghana recommended inappropriate diarrhoea treatments, despite their demonstrated knowledge of appropriate treatment protocols. To explore and explain these results, we conducted 26 focus groups with MS and their customers using an indirect elicitation approach, presenting simulated drug shop transaction scenarios for each group to analyze and discuss. Through inductive and deductive data analysis, we found that the pattern of customer-MS interactions within the transactional context plays a critical role in shaping dispensing outcomes, not only in diarrhoea management but in other contexts as well. MS who engaged and negotiated with their customers were better able to introduce and promote the appropriate diarrhoea treatment protocol. Several factors hinder optimal interactions. Although MS in fact serve as frontline medical providers, they lack the perceived status of a clinician. Moreover, the need to maintain their customer base creates a power imbalance that favours accommodating customer requests and discourages educational interaction. Finally, many MS lack a complete understanding of the recommended treatment, limiting their ability to educate and negotiate. These findings have important implications for efforts to position community-level private providers to improve outcomes across a number of health areas; the study recommends three broad approaches related to training design, marketing, and professional linkages. More generally, behaviour change initiatives should recognize the potential impact of provider interaction dynamics in facilitating or impeding desired health outcomes.
authors.affiliation: Abt Associates Inc., 4550 Montgomery Ave Suite 800N, Bethesda, MD, USA.
authors.forename: Lauren
authors.initials: L
authors.lastname: Rosapep
authors.affiliation: Edge Research, 1560 Wilson Blvd, Suite 475, Arlington, VA, 22209.
authors.forename: Emily
authors.initials: E
authors.lastname: Sanders
authors.affiliation: The Bill and Melinda Gates Foundation, 440 5th Ave N, Seattle, WA, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Banke
mesh_terms: D002648:Child; D000067576:Child Health; D003967:Diarrhea / Q000188:drug therapy*; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D017144:Focus Groups; D005869:Ghana; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D010596:Pharmacy Technicians / Q000523:psychology*; D017149:Private Sector; D036301:Qualitative Research; D015032:Zinc / Q000627:therapeutic use*
chemical_list: D015032:Zinc
keywords: Child health; diarrhoea; drug shops; ghana; informal sector; medicine sellers; oral rehydration salts; private sector; qualitative research; transactional dynamics; zinc