Effectiveness of Interventions to Increase Referral of Clients Exhibiting TB Symptoms by Pharmacies and Corner Stores in Santo Domingo, Dominican Republic

Ellen M.H. Mitchell*, 1, 2, Eddy Perez-Then3, Ivonne Orejel-Juarez4, Jeannette Baez3, Franz Gonzales1, Ana Lucia Morrobel5, Belkys Marcelino6, Netty Kamp1
1 KNCV Tuberculosis Foundation, The Hague, The Netherlands
2 Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam Institute for Global Health & Development, The Netherlands
3 Centro Nacional de Investigaciones en Salud Materna Infantil (CENISMI)
4 National Tuberculosis Program Mexico, Mexico
5 Dirección Municipal de Área IV de Salud del Distrito Nacional
6 Dominican Republic National TB Program

© 2013 Mitchell et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Correspondence: * Address correspondence to this author at the KNCV Tuberculosis Foundation, PO Box 146, 2501 CC The Hague, The Netherlands. Tel: +31 70 416 72 74; Fax: +31 70 358 40 04; E-mail:


Engagement of the private sector and community leaders are popular strategies for improving tuberculosis (TB) case detection. However the impact of engaging pharmacies and community shop keepers in TB referral varies and the best method to achieve it are unknown.

To evaluate changes in referral and TB case detection following workshops and/or motivational “detailing” visits, mystery clients visited 188 pharmacies and 103 grocery stores to seek advice for chronic symptoms reflecting pulmonary TB. Most sites (89% n=255) were exposed to “detailing” and 26.8% (76) also attended 1 hour workshops designed by the National TB program and KNCV Tuberculosis Foundation (KNCV). Sites were scored pre- and post-intervention, obtaining 1 point each for a) spontaneous recognition of TB symptoms, b) acknowledgement of symptoms as possibly TB when prompted, c) referral to medical care d) not promoting drugs e) exhibiting TB health education materials on site and f) referral of mystery clients to the TB program.

The TB recognition and referral scores of all exposed establishments increased by an average of 2.0 points (95%C.I. 1.9- 2.1) at post-test compared with an increase of 0.6 points (95%C.I. 0.4-.0.9) among those in the comparison group (p<0.001). Attempted sales of antibiotics and palliatives declined from 38.3% at baseline to 16.1%. After six months, 33.1% of pharmacies and 22.7% of grocery stores reported referring. Seven smear-positive TB cases were diagnosed from among 70 TB suspects referred by pharmacies, but none from among 30 suspects sent by groceries. TB investigations rose by 8.4% in the area for a six month period. The intervention is likely to have contributed to the doubling of TB case notifications over two years.

A simple motivation intervention led to improvement in referral and TB case detection. The National TB program introduced interventions with pharmacies to other provinces.

Keywords: Pharmacies, tuberculosis, public-private partnerships.