Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam

Private local pharmacies in low- and middle-income countries: a review of interventions to enhance their role in public health

OBJECTIVES

To review the evidence regarding the potential of pharmacy services to play an enhanced role in contributing to health care and policy initiatives in low- and middle-income countries.

METHODS

Literature search, using computer and hand searching, to identify original research reporting the results of interventions to improve services from private local pharmacies in low- and middle-income countries.

RESULTS

Eighteen studies were identified which spanned all regions: 12 evaluations of training initiatives, three studies evaluating the impact of policy of regulatory interventions, one regarding a collaboration of pharmacy services with a national TB programme, and two evaluating a pharmaceutical care initiative for patients with hypertension. A total of 14 studies used advice and recommendations to simulated clients as the primary outcome measures. Whilst most studies reported some improvements to practice, these were often small, limited to specific outcomes and believed to be short-lived.

CONCLUSION

The studies in this review demonstrate international interest in enhancing the place of pharmacy services in the provision and delivery of health care. But the small number of studies provides inadequate evidence on how to assure the quality of local pharmacy services can be assured, or how to develop them within a wider reform framework.

Low sale of antibiotics without prescription: a cross-sectional study in Zimbabwean private pharmacies

OBJECTIVES

To assess the quality of private pharmacy practice with a focus on the extent of antibiotic sales without prescription in private pharmacies in four Zimbabwean cities in relation to two tracer infectious conditions-sexually transmitted infections (STIs) among females and males, and diarrhoea in a child.

METHODS

A cross-sectional study including pharmacies in Harare and three other towns. Information about each pharmacy was collected through structured interviews. Staff were interviewed using a different structured interview guide and simulated clients were used to assess staff performance. Data were analysed statistically, and step models to evaluate pharmacist performance were developed.

RESULTS

A majority (69%) stated that they would never sell an antibiotic without a prescription and very few actually did in spite of a high patient demand. Few respondents however performed acceptably regarding provision of information and advice in relation to guidelines: 8% for the STI male, 33% for the STI female and 22% for the diarrhoea scenario.

CONCLUSIONS

The study revealed low sales of antibiotics without prescription, showing good adherence to the letter of the law. However, few respondents performed acceptably in relation to guidelines when considering information and advice for the tracer conditions.

Clinical and economic outcomes of pharmaceutical services related to antibiotic use: a literature review

AIM OF THE REVIEW

To identify and review the clinical and economic impact of pharmacists' interventions on antibiotic use.

METHOD

A literature search was conducted on Medline (1966-2003) to identify original articles measuring the impact of pharmacists' interventions on antimicrobial therapy at patient's or prescriber's level.

RESULTS

Forty-three articles were included: 20 uncontrolled before-after studies, four controlled before-after studies, five controlled trials, 12 randomized controlled trials and two interrupted time series (ITS). The described interventions were grouped into four categories: patient-specific recommendations (pharmacists' interventions concerning patient-specific drug therapy), implementation of policies, education, and therapeutic drug monitoring. These interventions were often combined to provide a multifaceted intervention, making it difficult to isolate the impact of one specific intervention. Measured outcomes were: appropriateness of prescribing (evaluated in 17 studies, 16 showing significant improvement), costs (analysed in 22 studies, nine showing a statistically significant reduction in costs after or with the intervention), and length of hospital stay (mixed results). Other measured outcomes were: drug use, prescriptions, length of treatment, dose intervals, switch to oral route, mortality rate, and treatment failure.

CONCLUSION

Over the years, the number of studies and quality of methodology has increased. The most frequently observed outcomes with a positive impact were appropriateness of prescribing and cost savings. The vast majority of studies used multiple interventions, in conjunction with pharmacists' recommendations to physicians. Coupled with the use of practice guidelines or educational strategies, these interventions demonstrated a positive impact on economic or clinical outcomes. However, the data are still sparse and sometimes contradictory; therefore, further studies with randomized controlled designs are needed.

Prevalence of multiresistant Gram-negative organisms in a surgical hospital in Ho Chi Minh Cit, Vietnam

OBJECTIVE

To determine resistance patterns of multiresistant Gram-negative organisms at a surgical hospital in Ho Chi Minh City, Vietnam, in order to guide appropriate antibiotic prescribing and improve infection control procedures.

METHOD

All samples sent in for microbiological analysis over a 3-month period were included. A resource neutral double disc-diffusion test was introduced to detect the presence of extended-spectrum beta-lactamase (ESBL) production.

RESULTS

We obtained 350 bacterial isolates from clinical specimens; 87.4% were Gram-negative bacteria (GNB). Of these, 88.9% were Enterobacteriaceae, of which 14.7% produced ESBL. Fifteen (37.5%) of these were isolated within 48 h of admission. Resistance to gentamicin and ciprofloxacin occurred in 70.0% and 72.5% of those organisms that produced ESBL and in 39.5% and 38.7% of those that did not. Resistance to third-generation cephalosporins was common: 36.7% of all GNB were resistant to ceftriaxone, 34.0% to cefotaxime, 19.6% to ceftazidime and 36.7% to cefoperazone.

CONCLUSION

Multiresistant Gram-negative organisms are common and pose a challenge to antibiotic therapy. Successful implementation of a simple test to detect ESBL production allowed reporting of these organisms, appropriate antibiotic prescribing and infection control interventions. Development of antibiotic-prescribing guidelines must take into account these resistance patterns.

Sexually transmitted and reproductive tract infections in symptomatic clients of pharmacies in Lima, Peru

OBJECTIVE

To determine prevalences and predictors of sexually transmitted and reproductive tract infections among men and women seeking care at pharmacies.

METHODS

Men and women with urethral discharge or dysuria and vaginal discharge were enrolled at 12 central and 52 smaller pharmacies in Lima, Peru. All participants answered a questionnaire. Men provided urine for polymerase chain reaction (PCR) testing for Neisseria gonorrhoeae and Chlamydia trachomatis, and for leucocyte esterase testing. Women provided self-obtained vaginal swabs for PCR testing for N gonorrhoeae and C trachomatis, Trichomonas vaginalis culture and bacterial vaginosis and Candida.

RESULTS

Among 106 symptomatic men, N gonorrhoeae and C trachomatis were detected in 34% and were associated with urethral discharge compared with dysuria only (odds ratio (OR) 4.3, p = 0.003), positive urine leucocyte esterase testing (OR 7.4, p = 0.009), less education (OR 5.5, p = 0.03), and with symptoms for <5 days (OR 2.5, p = 0.03). Among 121 symptomatic women, 39% had bacterial vaginosis or T vaginalis, and 7.7% had candidiasis. N gonorrhoeae and C trachomatis were detected in 12.4% of the women. Overall, 48.8% had one or more of these infections. No factors were associated with vaginal infection, and only symptoms of vaginal discharge for <5 days were associated with N gonorrhoeae and C trachomatis (OR 4.0, p = 0.02). The main reason reported for seeking advice at pharmacies by both men and women was trust in pharmacy workers.

CONCLUSIONS

Among men and women presenting to pharmacies with urethral and vaginal symptoms, rates of urethral and vaginal infections were comparable to those found in other clinical settings. Pharmacies can contribute to the care and prevention of sexually transmitted infection in developing countries.

Antimicrobial self medication for reproductive tract infections in two provinces in Lao People's Democratic Republic

OBJECTIVES

To describe antimicrobial self medication for reproductive tract infections (RTI) including sexually transmitted infections (STI), and to explore the understanding and use of health information among the adult population self medicating with antimicrobials for RTI/STI in two provinces of Laos. This could contribute to quality improvement of RTI/STI management.

METHODS

Cross sectional community based study. Structured interviews (household survey) were conducted among 500 subjects aged 18 or more, who had used antimicrobials as self medication for RTI/STI during the past year. They were recruited among 3056 family members in Vientiane capital and Champasak province, divided equally between the two study sites, and between urban and rural areas.

RESULTS

Among the 500 respondents reporting self medication for RTI/STI, 91% had bought the antimicrobials from local private pharmacies without a physician's prescription. 58% of those were advised to buy the drugs from drug sellers. Ampicillin (not recommended as syndromic treatment for RTI/STI) was used in 83% of all cases, in 28% combined with tetracycline. 79% of respondents used antimicrobials for a non-recommended duration of time. Most respondents had access to health messages for RTI/STI, largely from radio/television and drug sellers. However, only 17% of all respondents reported that they had ever used a condom.

CONCLUSIONS

More than three quarters of respondents, self medicating for RTI/STI with antimicrobials, used inappropriate drugs bought from private pharmacies. There is a need to improve RTI/STI management, including health promotion, through interventions at community level, and to health providers, including private drug sellers.

Home and community management of acute respiratory infections in children in eight Ugandan districts

BACKGROUND

Acute respiratory infections (ARI), especially pneumonia, are the second largest child killer in sub-Saharan Africa. Symptoms, including cough and difficult/rapid breathing, frequently overlap those of malaria. In Uganda, the Home-Based Management (HBM) strategy treats all childhood fevers as malaria in the community, ignoring the pneumonia symptom overlap.

AIM

To determine the extent of overlap of fever and ARI symptoms at community level, the timeliness of care-seeking and the treatments sought for ARI with or without fever.

METHODS

From eight districts, 3223 households with 3249 children aged <2 years were randomly selected through two-stage cluster sampling and their primary caretakers were interviewed regarding the child's most recent illness episode using 2-week recall.

RESULTS

Of the 1682 children <2 years who had been sick, 19% reported overlapping symptoms of fever, cough and "difficult/rapid breathing". Of these, 45% were given antimalarials alone. Use of health facilities was low and 42% of antibiotics used were obtained from drug shops or home-stocks.

CONCLUSIONS

Given the large overlap of fever and ARI symptoms and the reported practice of using primarily antimalarials, the implications of HBM might be the continued or increased mismanagement of pneumonia. Community drug distributors' ability to identify rapid breathing and make a presumptive diagnosis of pneumonia based on respiratory rate should be tested.

Antimicrobial resistance in developing countries. Part II: strategies for containment

The growing threat from resistant organisms calls for concerted action to prevent the emergence of new resistant strains and the spread of existing ones. Developing countries have experienced unfavourable trends in resistance-as detailed in part I, published last month--and implementation of many of the containment strategies recommended by WHO is complicated by universal, as well as developing country-specific, factors. The control of selective pressure for resistance could potentially be addressed through educational and other interventions for orthodox and unorthodox prescribers, distributors, and consumers of antimicrobials. At national levels, the implementation of drug use strategies--eg, combination therapy or cycling--may prove useful to lengthen the lifespan of existing and future agents. Programmes such as the Integrated Management of Childhood Illnesses (IMCI) and directly observed short-course therapy (DOTS) for tuberculosis are prescriber-focused and patient-focused, respectively, and have both been shown to positively influence factors that contribute to the selective pressure that affects resistance. The institution of interventions to prevent the transmission of infectious diseases could also lead to beneficial effects on the prevalence of resistance, as has vaccination against Haemophilus influenzae type B and Streptococcus pneumoniae. There has been an upsurge in the number of organisations and programmes that directly address issues of resistance, and collaboration could be one way to stem the dire trend. Additional factors such as unregulated drug availability, inadequate antimicrobial drug quality assurance, inadequate surveillance, and cultures of antimicrobial abuse must be addressed to permit a holistic strategy for resistance control.

Diagnosis and treatment of pulmonary tuberculosis at basic health care facilities in rural Vietnam: a survey of knowledge and reported practices among health staff

One fundamental element needed for tuberculosis control programmes to succeed is that health staff should adequately manage persons with both suspected and confirmed tuberculosis. This study assesses the level of knowledge and reported practices regarding tuberculosis among health staff at basic health care facilities in a rural district in Vietnam. A questionnaire consisting of 17 multiple-choice questions, 6 open questions, and five case-studies was completed by 253 health staff. Nearly half of the respondents (47%) answered at least 17 out of 23 questions correctly. The mean knowledge score was 15.59 +/- 3.78 (range 5-23). The mean practice score was 2.03 +/- 1.28 (range 0-5). Health staff knowledge of theoretical aspects was better than knowledge related to patient management. Even staff members who had attended TB training courses had inadequate TB knowledge, particularly in the area of TB control. District hospital staff reported surprisingly lower knowledge scores than community health care staff. Practice competency related to the management of tuberculosis patients during treatment course was low. The importance of targeted education using multiple educational methods needs to be emphasized within the National Tuberculosis Programme.

Antibiotic resistance in diarrheagenic Escherichia coli and Shigella strains isolated from children in Hanoi, Vietnam

The MICs for 162 diarrheagenic Escherichia coli strains and 28 Shigella strains were determined on the basis of NCCLS guidelines. More than 75% of the strains were resistant to ampicillin, chloramphenicol (53.6% of Shigella strains), and trimethoprim-sulfamethoxazole. Multiresistance was detected in 89.5% of E. coli strains and 78.6% of Shigella strains.

Effectiveness of a multi-component intervention on dispensing practices at private pharmacies in Vietnam and Thailand--a randomized controlled trial

Private pharmacies are the first line of health care in many communities, commonly selling antibiotics in small doses and prescription-only drugs such as steroids without medical supervision. The aim was to study the effectiveness of a multi-faceted intervention on the dispensing practices of drug sellers in Hanoi and Bangkok. The study was a randomized, controlled trial with 68 Hanoi and 78 Bangkok pharmacies, randomly selected and assigned for intervention and control. Behaviour was assessed by five simulated client visits per pharmacy per dispensing practice, at baseline and a month or more after each intervention. Three three-month interventions were implemented sequentially with four months in between: enforcement of regulations with local inspectors visiting to emphasize the importance of prescription-only medicine legislation; education, performed face-to-face in Hanoi and by a large group in Bangkok; and peer review, voluntary in Bangkok and compulsory in Hanoi. The intervention resulted in significant improvements in Hanoi, reducing the dispensing of illegal steroids (29% vs. 62%) and low dose antibiotics (69% vs. 90%), sustained by means of the peer review (17% vs. 57% steroids and 71% vs. 95% antibiotics), and in fewer dispensers asking no questions and giving no advice (11% vs. 30% steroids and 51% vs. 81% antibiotics). The only significant improvement in Bangkok was the reduction in illegally dispensing steroids (25% vs. 44%) after the regulatory intervention. In Bangkok, fewer of those in the group who volunteered for the peer review asked no questions and gave no advice for low-dose antibiotics requests after the peer review (58% vs. 81%). A multi-component intervention can have a profound effect in changing dispensers' behaviour, but the effect is dependant on the context and the method of implementation. Possible reasons for differences are discussed.

Pilfering for survival: how health workers use access to drugs as a coping strategy

BACKGROUND: Coping strategies have, in some countries, become so prevalent that it has been widely assumed that the very notion of civil services ethos has completely - and possibly irreversibly - disappeared. This paper describes the importance and the nature of pilfering of drugs by health staff in Mozambique and Cape Verde, as perceived by health professionals from these countries. Their opinions provide pointers as to how to tackle these problems. METHODS: This study is based on a self-administered questionnaire addressed to a convenience sample of health workers in Mozambique and in Cape Verde. RESULTS: The study confirms that misuse of access to pharmaceuticals has become a key element in the coping strategies health personnel develop to deal with difficult living conditions. Different professional groups (mis)use their privileged access in different ways, but doctors diversify most. The study identifies the reasons given for misusing access to drugs, shows how the problem is perceived by the health workers, and discusses the implications for finding solutions to the problem.Our findings reflect, from the health workers themselves, a conflict between their self image of what it means to be an honest civil servant who wants to do a decent job, and the brute facts of life that make them betray that image. The manifest unease that this provokes is an important observation as such. CONCLUSION: Our findings suggest that, even in the difficult circumstances observed in many countries, behaviours that depart from traditional civil servant deontology have not been interiorised as a norm. This ambiguity indicates that interventions to mitigate the erosion of proper conduct would be welcome. The time to act is now, before small-scale individual coping grows into large-scale, well-organized crime.