Primary care drug therapy training : The solution for PHC nurses ? KEY WORDS Primary Health Care Primary Care Drug Therapy Primary Health Care Nurse Essential drugs Primary Health Care training Nursing Pharmacology Competency-based training

The priority of the National Health Sys­ tem in South Africa is primary health care (PHC). The approach involves a health system led by PHC services and includes personal and curative services for acute minor ailments delivered by PHC nurses. The nurses are also re­ sponsible for the treatment of these ail­ ments with essential drugs according to protocols as proposed in the Essen­ tial Drugs List. A before-after experi­ mental research design was used to evaluate the effect of a competencybased prim ary care drug therapy (PCDT) training programme for PHC nurses in the treatment of acute minor ailments. An experimental group (n=35) and control group (n=31) consisting of registered nurses undergoing training in PHC at Gold Fields Nursing College were randomly selected. The results showed a significant increase in pre­ scribing outcomes and medicine utilisa­ tion.


ABSTRACT
The priority of the National Health Sys tem in South Africa is primary health care (PHC).The approach involves a health system led by PHC services and includes personal and curative services for acute minor ailments delivered by PHC nurses.The nurses are also re sponsible for the treatment of these ail ments with essential drugs according to protocols as proposed in the Essen tial Drugs List.A before-after experi mental research design was used to evaluate the effect of a competencybased p rim a ry care d ru g th e ra p y (PCDT) training program m e fo r PHC nurses in the treatment of acute minor ailments.An experimental group (n=35) and control group (n=31) consisting of registered nurses undergoing training in PHC at Gold Fields N ursing C ollege were random ly selected.The results showed a significant increase in pre scribing outcomes and medicine utilisa tion.

OPSOMMIHG
Primêre gesondheidsorg (PGS) is die prioriteit van die nasionale gesondheidstelsel in Suid-Afrika.Die benadering behels 'n omvattende gesondheidsisteem en sluit genesingsdienste vir akute g e rin g e o n g e s te ld h e d e d e u r PGSverpleegkundiges in.PGS-verpleegkundiges is ook verantwoordelik vir die behandeling van hierdie ongesteldhede m et v a s g e s te ld e p ro to k o lle so os voorgeskryf in die Essensiële Medisyne Lys.'n Tw eegroep e ks p e rim e n te le navorsingsontw erp is gebruik om die effek van die bevoegdheidsgebaseerde p r im ê r e s o r g g e n e e s m id d e lte r a p ie o p le id in g s p ro g ra m in akute gerin g e ongesteldhede vir PG S-verpleegkundiges te evalueer.'n Eksperimenteleg ro e p (n = 35) en 'n k o n tro le g ro e p (n= 3 1 ) bestaande uit geregistreerde verpleegkundiges wat opleiding in PGS aan die Gold Fields V erpleegkollege ondergaan, is ewekansig geselekteer.The vast majority of medical problems seen in primary health care (PHC) con sist of commonly occurring conditions.Most of these conditions are easy to rec ognise and for which basic treatment is reasonably standard (Evian, 1989:36).In the PHC setting only approximately 10% of all the medical problems encountered are of a more complex nature and re quire more sophisticated management approaches.Evian (1989:36) argues that an adequately trained PHC nurse can more than adequately diagnose and treat 90% of the clinical PHC load which include personal curative services for acute minor ailments and the provision of e s s e n tia l d ru g s (S outh A fric a , 1997:37).
Registered nurses in general have inad equate and sometimes even little knowl edge of pharmacology.To ensure the rational use of essential drugs on PHC level in South Africa PHC nurses should be tra in e d in b a s ic p h a rm a c o lo g y (O elofse, 1996:1).The PHC nurse should therefore receive adequate and competent training in all the aspects of treatment with essential drugs, such as drug indication, contra-indication, dose, interaction, adverse effects, overdoses, special precautions and good dispens ing practices (Dreyer, 1996:i;Irwig etal., 1985:92;Oelofse, 1996:1).The World Health Organisation (1995:1) em pha sises these training objectives but sug gests that the approach in pharmacol ogy training should not be drug-centred but diagnosis-centred, thus from diag nosis to the drug, in order to enhance the therapeutic skills and competence of the prescriber.

BACKGROUND ON THE RESEARCH
The general objective of this research was to develop and evaluate a compe tency-based primary care drug therapytraining programme in the treatment of acute m inor ailments for PHC nurses.The c o n c e p t o f p rim a ry care d ru g therapy being the use of essential drugs in the rational treatm ent of a disease making use of knowledge of the disease process as the fundamental point of de parture.A specific objective was to de termine the effect of the competencybased primary care drug therapy-training programme in acute minor ailments on PHC nurses with regard to rational prescribing and rational medicine utili sation.
A before-after research design (Arnold eta!., 1998:377) was used as an experi mental design.This design makes it pos sible is to determine the effect of the in d e p e n d e n t v a ria b le (tra in in g p ro gram m e) on the d ependent variable [knowledge and outcomes viz.rational prescribing and medicine utilisation of PHC nurses] (Huysamen, 1993:90).A pre-test was used to determine if the ex perimental and control groups differed significantly.A post-test was used to compare the change in knowledge and outcomes of the experimental and con trol groups directly after the training pro gramme.
The data was analysed by using the SAS computer package (SAS Institute, 1985).Descriptive and inferential statistics were used to analyse the research results.Paired t-tests were used to determine the differences between the pre and post tests of the experim ental and control groups (De Wet et al., 1981:188).The statistical significance (p) and practical significance (d) of the results were de termined.
The training programme was developed and presented from a trainee (Barr & Tagg, 1995) and person-centred a p proach (Bandura, 1986;1997;Rogers, 1980;1983) endorsing the principles of adult learning (Knowles, 1987:170-173) and the p h ilo s o p h y of co m p e te n ce (Dall'Alba & Sandberg, 1996).The prin ciples of competency-based training for primary care drug therapy can be sim plified as the point of departure being the nurses' experience in PHC and the PHC setting asaw ho le (See Figure 1.1).This implies that the significance of proper drug treatment must be brought in rela tion to the aspects of PHC, namely: the c lin ica l a ssessm ent of p atie nts; the sym ptom s and sign s of d ifferen t ill nesses; the differential diagnoses; and possible complications.Thus, endors ing experience in the essential parts of the practice of PHC and the integrated knowing-doing thereof.Only then can competence learning of safe treatment with drugs on PHC level be ensured.

The primary care drug therapy-training programme
The training programme (supported by a manual) was holistic in nature.The trainee (nurse) was brought into a clini cal primary health care situation to em power her/him to share and use embed ded knowledge and skills in order to achieve new knowledge and skills suffi ciently.By starting with a quick clinical assessm ent of each system, e.g. the eyes, th e p ro g ra m m e m an ag es to achieve this.The assessment was fol lowed by specific acute minor ailments for each system, e.g.conjunctivitis.The manual provided a colour picture and a definition of each condition.The symp toms, signs, differential diagnoses, com plications and treatment of each condi tion were gathered through group dis cussions and the sharing of experiences during the presentation of the course.The pharm acological aspects of each treatment, and good dispensing prac tices were emphasised during the dis cussion of each condition.At the end of each system there was a repeat discus sion on the basic pharmacology and dis pensing practices in order to ensure the proper learning of the pharmacology of the drugs used in the treatment of that specific minor ailment.
The following minor ailments/conditions were included in the program m e for treatment with essential drugs: • The eyes: conjunctivitis, dacryocysti tis, external stye, chalazion, blepharitis, dry eye, trachoma, pinguecula, ptery gium, arc eyes, subconjunctival bleed ing, lid contusion, foreign body in eye, eyelid bums, chemical burns to the eye, acute glaucoma, and general medical disorders affecting the eye.
• The ear: otitis externa, otitis media, and foreign bodies in the ear.
• The nose: hayfever, acute sinusitis, nose bleeds, and foreign bodies in the nose.
• The throat: tonsillitis and pharyngitis.
• The kidneys and bladder: cystitis and pyelonephritis.
The drugs included in the training pro gramme were taken from the Essential Drugs Programme as prescribed by the Government of South Africa (South Af rica, 1996), as well as drugs that may be included in the Essential Drugs Pro gramme in the future (Serfontein, 1997) and com m on over-the-counter drugs used/bought by patients.A differentiation was made between se rious and less serious conditions and whether treatment on PHC level was safe and sufficient or referral to a secondary level is indicated.
A medical practitioner, a dentist (oral cavity), a pharmacist and a practising PHC nurse edited the content of the training programme.

Sample
The objective was to develop a univer sal training programme and to evaluate its outcomes for a specific group of pri mary health care nurses.Therefore it was decided to evaluate the training pro gramme at one training institution in volved in the training of primary health care nurses in South Africa (viz.Gold Fields Nursing College).
The sample (n = 66) consisted of nurses undergoing training in prim ary health care at Gold Fields Nursing College.All of them were registered nurses with ex perience in primary health care.The college selected the nurses for this train ing throughout South Africa.The group was randomly divided into an experimen tal (n = 35) and control group (n = 31).Four participants in the control group, however, were not able to attend the p o st-te s tin g and w ere th erefore ex cluded from the study (Thus, n=31 for the control group).A comparison be tween the two groups provided the out comes of the study.

The measuring instrument
Eight case studies were used to meas ure prescribing and medicine utilisation outcom es of respondents before and after the training programme.
The case studies (see Appendix A) were developed out of constructs in the litera ture such as the Essential Drugs Pro gramme of South Africa (South Africa, 1996) and clinical textbooks (Berkow et al., 1992;Tierney et al., 1997).Support for the selection of conditions/ailments in the case studies came from experi ences the researcher had in PHC clinics as well as interview s w ith a prim ary health care nurse in charge of educa tion and training in the Potchefstroom D istrict Health D epartm ent (De Wet, 1997), and a general practitioner in the public and private sector (Muller, 1997).The conditions/ailm ents used as case studies were addressed during the fa cilitation of the course and are described in the course manual.The objectives of the case studies were: • To measure the participants' ability to recognise the selected conditions/ail ments; • to measure their ability to treat ration ally according to prescribed protocols (South Africa, 1996), thus prescribing outcomes; and • to measure medicine utilisation and prescribing patterns.
The case studies measured eight con ditions/ailments.A colour photo (except for Case study 5) and a description of the sym ptom s and signs expected to encounter in each condition/ailment ac companied each case study.The case studies were divided into a diagnosis, possible differen tia l d ia gn osis, s u g gested treatment, and suggested further diagnostic procedures (see Appendix A).Conditions selected for the case stud ies were herpes gingivostomatitis, acute g o u t, in fe c tio u s a rth ritis , a cute dacrocystitis, congestive heart failure, acute otitis media, acute tonsillitis, and pre-cancerous oral leukoplakia (De Wet, 1997;South Africa, 1996;Muller, 1997).The selection of the conditions were di vided into: • Common acute minor ailments en countered in the clinics (otitis media, ton sillitis); • acute minor ailments that are com monly confused with their differential di agnosis resulting in incorrect diagnosis and m anagem ent (herpes gingivosto matitis, gout, dacrocystitis); and • three serious conditions which are of ten confused with or treated as acute minor ailments and which needs recog nition and immediate referral in order to ensure good primary health care prac tice and prevent serious complications (infectious arthritis, congestive heart fail ure and pre-cancerous oral leukoplakia).
The case studies were administrated in a group situation.The participant read through the description on each case study and answers the four questions accordingly.The case studies were in a fill-in format.Although the researcher acknowledges that every primary health care nurse have the Essential Drugs Pro gramme at their disposal in every clinic, the embedded knowledge enhanced by the training programme could only be assessed by not supplying the book to them.No time limit was imposed.The researcher gathered the completed case studies for evaluation.
A qualitative investigation was done on the case studies to determine medicine utilisation patterns in the prescribing of drugs e.g.correct protocol and diagno sis and the unnecessary prescribing of antibiotics.For the qualitative investiga tions them es were identified from the case studies (collectively by the panel of th re e e v a lu a to rs .See S m ith & W ertheimer, 1996:125), and counted accordingly.The following themes were used: 1. Correct protocol (Drug, dose and pe riod of treatment) for specific condition.2. Incorrect protocol -medication and management of specific condition.3. Unnecessary medicine.4. Sub-therapeutic doses. 5. Overdose.6.Too short period of treatment.The researcher and an expert in the field (Pharm.D pharmacist) did the evaluation of the prescribing outcomes and medi cine utilisation of the case studies.The evaluation outcomes of each evaluator were statistically com pared with each other in order to ensure interrater reliabil ity.The intra-class coefficient was 0,99, which indicate a very good agreement betw een the e valua tion s o f the tw o evaluators (Bland & Altman, 1986:307-310;Dunn, 1989:34-35).
The validity of the case studies was en sured by developing items on the basis of the important constructs, and by ob taining the opinions of experts regard ing the constructs and items.The case studies were presented to experts (two medical practitioners, two pharmacolo g is ts and tw o p rim a ry h ealth care nurses) to determine face validity.A trial run was performed on prim ary health care nurses in primary health care clin ics in the Potchefstroom district to en sure that the case studies were clearly understood and relevant.

RESULTS
For the sake of this article only the tabu lated results of the first case study (her pes gingivostomatitis) will be presented.The prescribing and medicine utilisation outcomes of the other seven case stud ies will, however, be 1 summarised from the research.

Case study l -Primary herpes gingivostomatitis
The p resence o f b liste rs, fever and lymphnodes differentiate the condition from ailments such as oral thrush.The condition is self-limiting and continues over a period of seven to ten days.Man agem ent includes sym ptom atic relief and good patient information.Compli cations such as dehydration may de velop and should be addressed and ex plained to the mother.The correct man agement includes an anti-pyretic agent, e.g.paracetamol syrup, gentian and vio let a p p lica tio n s, oral re h y d ra tio n /in creased fluid intake, e.g.ice lollies, a soft diet, and no force feeding of the baby.Multivitamins may be given as support ive therapy.Antibiotic therapy has no value in the treatment of this condition (a virus), unless secondary infection is present, which is rare (Bannister ef al., 1996:79;Berkowefa/., 1992Berkowefa/., :202 & 2478;;Tierney ef al., 1997:223).The results for this case study is presented in Table 1: The results of the pre-tests indicate that only 14,29% of the experimental group were able to make the correct diagnosis (theme 22) while all the respondents in the control group made an incorrect di a g n o sis.The re s p o n d e n ts o f both groups who made an incorrect diagno sis suggested oral thrush and treated the condition accordingly with antimicrobials such as nystatin, miconazole gel and some even with amoxycillin (theme 13).Of the 14,29% in the experimental group only 8,57% were able to treat the condi tio n ra tio n a lly (them e 1).However, 14,29% of the experimental group and 16,13% of the control group suggested no treatment (theme 14) whatsoever.In adequate advice (theme 17) and a lack of the provision of supportive medication (in this case for the treatment of fever) -theme 18 -were also apparent during the pre-testing.The provision of unnec essary medication (theme 3) was also common in both groups.
During the post-testing it was found that there were a significant improvement in the experimental group towards the cor rect diagnosis (theme 22), 74,29% of the participants were able to make the di agnosis for primary herpes gingivosto matitis although only 60% applied the correct protocol.This change of 54,29% was statistical significant with a large practical significance.There was also a significant decrease in the provision of antim icrobials for the treatm ent of the condition (theme 13) and only 17,14% still provided antimicrobials.The per centage improvement towards the cor rect protocol was 54,29% which was sta tistical as well as practical (large effect) significant.The provision of good pa tient inform ation (theme 20) also im proved for the better with 34,29%.
The results for the control group stayed approximately the same during the pre and post testing, with no practical or sta tistical significant differences.

Summary of the results of: Case study i -Acute gout
The essentials of diagnosis for acute gout include the acute nocturnal onset, inflammatoric monarticular involvement of the first metatarsophalangeal joint and the drám atic therapeutic response to colchicine.A low-grade fever, support the diagnosis of acute gout.The condi tion is not self-limiting and may result in chronic gout with enormous cost impli cations.Management includes colchi cine, which is only effective against gouty arthritis, has a rapid onset of action, is cheap and may be diagnostic for the condition, a short course of non-steroidal anti-inflammatory drugs, and good pa tie nt inform ation and d ietary advice.Serum uric acid should be measured which is necessary for further follow-up and preventative treatment (allopurinol).This condition is often confused with cellulitis, trauma and other arthritis con d itio n s su ch as rh e u m a to id or osteoarthritis (Berkow ef al., 1992(Berkow ef al., :1346(Berkow ef al., -1349;;South Africa, 1996:71;Tierney ef al., 1997:753-757).
During the pre-testing the respondents of both groups confused the clinical presentation with traum a or cellulitis.Only 17,41% of the experimental group made the correct diagnosis (theme 22) while only 2,86% of them were able to 1. Obtain tabulated results from the researcher.E-mail : rothmann@iafrica.comor Tel 018-2906866

Summary of the results of: Case study ^ -Infectious arthritis
The essentials of diagnosis for infectious arthritis include the sudden onset of acute arthritis that is monarticular and in a large weight-bearing joint.There is a positive history of joint damage or recent urethritis or haemorrhagic vesicular skin lesions.The presence of fever and signs of inflammation in the joint, support the diagnosis.The condition is a medical em ergency and the join t may be de stroyed if not promptly treated.Manage ment includes immediate treatment with penicillin G or benzylpenicillin IMI and ur gent referral to secondary level (Bannis ter et al., 1996:339;Berkow et al., 1992Berkow et al., :1342Berkow et al., -1343;;Tierney e t al., 1997:790-791).
The result regarding the correct diagno sis and the management of the condi tion were catastrophic during the pre testing.Only 8,57% of the experimental group and 9,86% of the control group were able to make the correct diagno sis, while none of them managed the condition correctly.Although 34,29% of the experimental group and 35,45% of the control group suggested immedi ate treatment (mostly non-steroidal anti inflammatory drugs) supported by refer ral to secondary level.
During the post-testing, however, the experim ental group im proved sign ifi cantly (statistical as well as practical) to w ards the correct diagnosis (88,57% improvement) and the application of the correct protocol (82,86% improvement).No statistical significant improvem ent was found for the control group.

Summary of the results of: Case study 4 -Acute dacrocystitis
Pain, redness and oedema about the lacrimal sac, epiphora, and conjunctivi tis are essentials of diagnosis for this acute minor ailment.A dry nose and raised temperature are supportive signs for diagnosis.Management includes an oral antibiotic, such as amoxycillin, tet racycline eye ointm ent, paracetam ol syrup, and oxymetazoline nasal drops.Patient information and advice should in clude the recommendation of hot com presses and massaging of the lacrimal system (from the nose upwards) after every feed.C o m p lica tio n s such as chronic dacrocystitis or dacrostenosis m ay develop if not treated p ro m p tly (Berkow et al., 1992(Berkow et al., :2376;;Elkington & Khaw, 1988:7-8;Tierneyef al., 1997:178-179).
Only 17,14% of the experimental group and 22,85% of the control group were able to make the correct diagnosis dur ing the pre-testing.Most of the respond ents diagnosed the condition as a sty or bacterial conjunctivitis.None of the ex perimental group, who made a correct diagnosis, was able to manage the con dition correctly while only 6,45% of the control group com ply with the correct protocol.The provision of good advice and information were also found to be inadequate.None of the experimental group and only 3,23% of the control group provided patient information or advice that could improve the condition.
On completion of the primary care drug therapy-training programme there was a 74,29% improvement within the experi mental group towards the correct diag nosis and the same im provem ent to wards the correct management of the c o n d itio n .Also an im p rove m e nt of 57,14% occurred towards the provision of good patient information and advice.All these results were statistical and prac tical significant (large effect).The results of the control group during the post-testing did not change with any significance.

Summary of the results of: Case study 5 -Congestive heart failure
The essentials of diagnosis for CHF in clude exertional dyspnoea, cough, rales, orthropnoea, tachycardia, hypotension, reduced pulse pressure, signs of in creased sympathetic nervous system ac tivity, e.g.cold extremities and diaphore sis, hepatomegaly, dependent oedema and elevated venous pressure.Support for the diagnosis includes the absence of dyspnoea during rest, a negative his tory regarding asthm a or COPD and worsening of symptoms in the recum bent position.Managem ent on PHC level includes immediate referral to sec ondary level for further investigation and the initiation of treatment and manage ment.STAT treatment with a diuretic, e.g.hydrochlorthiazide is also regarded as correct (Berkow et al., 1992:446-454;South Africa, 1996:48-49;Tierney et al., 1997:387 The results during the pre-testing were distressful.Only 25,71% of the experi mental group and 25,84% of the control group made the correct diagnosis, while only 14,29% and 12,9%, retrospectively, managed the condition correctly.The co n d itio n was overall confused with asthma, bronchitis or COPD.In the ex perim ental g ro u p 34,29% of the re spondents treated the co ndition with antibiotics and sent the patient home (the same was true for 19,39% of the control group).Theophyllin (which may aggravate the condition) as only treat ment (theme 9), was supplied by 22,86% of the experimental group and 25,84% of the control group.
However, during the post-testing the ex perimental group improved significantly (statistically and practically) regarding all the above results.The improvement to wards the correct diagnosis was 60% (85,71% were able to make the correct diagnosis) and the correct management was 57,14% (68,57% managed the con dition correct).Only 5,71% of the experi mental group suggested theophyllin for the treatment of the condition.There were no statistical or practical significant differences within the control group.

Summary of the results of: Case study 6 -Acute otitis media
This case study represents acute otitis media (secondary to upper respiratory infection).Essentials of diagnosis in clude fever, red and bulging tympanic membrane, symptoms of upper respira tory infection, and nausea, vomiting and diarrhoea occur com m only in infants.Com plications include rupture of tym panic membrane, acute mastoiditis, and meningitis.Suggested treatment is as follows: an antibiotic such as amoxycillin or co trim oxa zole and an a n tip y re tic agent.Supportive treatm ent includes syste m ic or local s y m p a th o m im e tic d ru g s , e .g. p s e u d o e p h e d rin e or oxymetazoline nasal drops (Berkow et al., 1992(Berkow et al., :2331;;South Africa, 1996:43;Tierney et al., 1997:205-206).
The results of the pre-testing were much more satisfactory.71,43% of the experi m ental group and 74,23% of control group were able to make the correct di agnosis although only 60% of the experi mental group manage the condition cor rectly.The entire control group, who made the correct diagnosis, managed the condition correctly.However, 57,14% of the experimental group and 58,06% of the control group did not supply any supportive medication (theme 18) such as an antipyretic that would have im proved patient comfort.
The primary care drug therapy-training programme added to a 25,71% improve m ent to w a rd s the c o rre c t d ia gn osis within the experimental group.During the post-testing 94,29% of the respond ent were able to make the correct diag nosis and 91,43% applied the correct management protocol, thus an improve ment of 34,29%.These results were both statistical and practical (large effect) sig nificant.Although there were an im provement towards the provision of sup portive medication the results were not significant.The results of the control group during the post-testing also did not improve significantly.
The outcomes of this case study were even better than in the otitis media case study.It was apparent that the nurses felt comfortable with this condition and 94,29% of the experimental group and 80,65% of the control group made the correct diagnosis although only 71% of both groups were able to treat the con dition according to the correct protocol during the pre-testing.The primary care drug therapy-training programme con tribute to a better application of the man agement protocol in the experimental group but the results were not statistical significance when compared to the con trol group.

Summary of the results of: Case study & -Pre-cancerous oral leukoplakia
The condition is often confused with oral thrush but unlike oral thrush the white le s io n s c a n n o t be rem oved w ith a spatula and the condition is painless.There is normally a positive history of heavy smoking especially pipe smoking.This condition should be referred imme diately for further investigation.No treat ment on PHC level can improve the con dition but patient information and advice is recom m ended (Berkow e f a l., 1992(Berkow e f a l., :2491;;Tierney ef al., 1997:221-222).
The results of the pre-testing showed that only 22,86% of the experim ental group and 16,01% of the control group were able to make the correct diagno sis.The entire experimental group who made the correct diagnosis managed the condition correctly while only 12,94% of the control group who made the cor rect diagnosis supplied the correct man agement.The condition was generally confused with oral thrush and treated with antim icrobials.The training pro gram m e contributed to a 62,86% im provement towards the correct diagno sis and a 31,34% improvement towards the correct management within the ex perimental group.These results were both statistical and practical (large effect) significant.The results of the control group did not improved with any signifi cantly.
The p re -tra in ing p ro gram m e results (pre-tests of both groups and the post tests of the control group) indicate that the groups were able to diagnose and treat common apparent conditions such as acute otitis media and acute tonsilli tis satisfactory.It was, however, evident that acute minor ailments such as her pes gingivostomatitis, acute gout, and acute dacrocysititis were confused with other common and more apparent ail ments such as oral thrush, trauma, and a sty or bacterial conjunctivitis.The re sult is irrational management of these conditions, which may contribute to poor patient outcomes and escalating costs.A n othe r concern re g ardin g the o u t comes of the pre-training program m e results was that all three serious and lifethreatening conditions (infectious arthri tis, congestive heart failure, and pre-cancerous leukoplakia) were managed by m ost of the respondents as an acute minor ailment (trauma, asthma, and oral thrush).These serious conditions were in most cases not even mentioned as a possible differential diagnosis.
The post-test results of the experimen tal group indicated that there was a sig nificant improvement towards the correct diagnosis and management of the con ditions; there was a decrease in the un necessary use of antibiotics; an improve ment towards the rational provision of supportive medication; and a substan tial improvement in the provision of good patient information and advice.These results were of statistical as well as of practical significance fo r all the case studies except acute otitis m edia and acute tonsillitis.In the latter there was an improvement but the condition was well managed before and after the train ing programme by most of the respond ents.
The com petency-based prim ary care drug therapy-training program m e has proved to be successful and was per ceived as such by the participants.The participants stated, in a reaction evalua tion, that the most im portant learning experience was that they were able to make a connection between the diag nosis and treatment including the differ ence between serious and less serious and when to treat and when to refer.One participant summarised the success of the training programme as follows: "Theory and practice is well related -it is the reality of PHC and the common prob lems that we encounter and experience in PHC.Everyone of use cannot wait to go back and implement what we have gained."

CONCLUSION
The pre-testing results of this research indicate that most of the nurses were able do diagnose and treat the two com mon acute minor ailments (acute otitis media and tonsillitis) rationally.A con cern, however, is that the same is not true when confronted with the selected dif ferential diagnoses for com m on acute minor ailments encountered daily in PHC clinics.The primary care drug therapytraining programme, however, contrib uted significantly to the outcomes of the experimental group in this regard, result ing in the improvement of the following: • the correct diagnosis; • the application of the correct manage ment protocol; • a decrease in the unnecessary pre scribing of antibiotics; • a decrease in the mistreatment of con ditions resulting in serious com plica tions; • the provision of good patient informa tion and advice; and • the rational and correct prescribing of necessary supportive medication such as an anti-pyretic.
Because the PHC nurse is for most pa tients the first line of health care, it is im perative that she/he should be able to differentiate between serious conditions that necessitates referral and less seri ous conditions that is manageable on PHC level in order to ensure positive pa tient outcomes.The researchers, there fore, recommend that more emphasis should be placed on the PHC manage ment (diagnosis and treatment) of the differential diagnoses of acute minor ail ments and serious conditions that may present as acute minor ailments during the training of PHC nurses.By achiev ing a high level of knowledge and skills in this regard, PHC services in South Af rica will triumph as being comprehensive and excellence-driven.

ACKNOWLEDGEMENTS
• Gold Fields Nursing College, for their hospitality, the use of their facilities and their pro-active support and involvement.
• Boehringer Ingelheim (Pty) Ltd (Self-Medication Division) for their financial co n trib u tio n , invaluable su pp ort and trust in me.
• The participants in the research (ex perimental and control group), for their willingness to participate and the enthu siasm and support they had for the re search.You all were wonderful!
Die re s u lta te het g e to o n d a t d ie opleidingsprogram beduidend bygedra het to t d ie ra s io n e le v o o rs k ry f en benutting van essensiële medisyne.Sleutelwoorde: Primêre gesondheid sorg, Primêresorg-geneesmiddelterapie, Farmakologie, Primêre gesondheidsorgv e rp le e g k u n d ig e , B e v o e g d h e id g eb a s e e rd e o p le id in g , L eerdergesentreerde benadering.
The following drugs were included in the training pro gra m m e: a lb e n d a z o le , a m in o g ly c o s id e s , a m in o p h y llin e , amoxycillin, antacids, anthelmintics, an tihistam ines, aspirin, beclom ethasone inhaler, bismuth suppositories and oint m ent, c h lo rh e x id in e m o u th w a sh , ciprofloxacin, colchicine, cold and flu p re p a ra tio n s , c o rtic o s te ro id s , cotrimoxazole, cough syrups, cyclizine, diclophenac, doxycycline, electrolytes, erythromycin, fluorescein sodium min ims 2%, gentian violet, hydrocortisone in je ctio n , h yoscine N b u tylb ro m id e , ib u p ro fe n , laxatives, liq u id paraffin, lo p e ra m id e , m e b e n d a zo le , m etoclopram ide, methenamine hippurate, m e th e n a m in e m a n d e la te , m ethylsalicylate ointm ent, m etronida zole, miconazole oral gel, mist pot cit, naproxen, niclosam ide, nitrofurantoin, nose drops, nystatin suspension, para cetamol, penicillin, piperazine, povidone Io d in e m o u th w a sh , p re d n is o lo n e , salbutamol inhaler, senna, tetracycline eye ointment, theophylline, urinary tract antiseptics, and urinary alkalinizers.

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ab le 1 : A com parison of th e m edicine u tilisatio n in case study 1 b etw een th e pre and post-testing for th e exp erim en tal and control group.