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

Non-prescription antibiotics dispensing by community pharmacies: implications for antimicrobial resistance

Introduction

The non-prescription antibiotics dispensing (NPAD) from pharmacies is on the rise in low- and middle-income countries, which contributes to the emergence of antimicrobial resistance (AMR). This study was conducted with the objective to determine the community pharmacy personnel's perspectives on NPAD and its implications for AMR.

Methods

A questionnaire-based cross-sectional survey was conducted in Pakistan among 336 pharmacies. The data were analyzed using SPSS v21 and MedCalc for Windows v12.3.0. Modified Bloom's cut-off point was utilized to categorize the participants' overall knowledge, attitude, and practice. For univariable logistic regression analyses, odds ratio (OR) was calculated at 95% confidence interval (CI). For multivariable logistic regression analyses, adjusted OR was calculated at 95% CI. Spearman's rank correlation coefficient test was used to assess the relationships among knowledge, attitude, and/or practice scores.

Results

The majority of the respondents were staff pharmacists (45.5%). About four-fifths (78.9%) and half (50.9%) of the participants demonstrated moderate to good knowledge and practice, respectively. However, about only one-third (33.1%) had a moderate to good attitude. Staff pharmacists had higher odds of moderate to good knowledge (OR: 2.4, 95% CI: 1.2-4.7) and practice (OR: 2.3, 95% CI: 1.4-3.8). Total knowledge and practice (Spearman's ρ: 0.280; P <0.001) and total attitude and practice (Spearman's ρ: 0.299; P <0.001) scores were significantly correlated.

Conclusion

The qualified pharmacists had satisfactory knowledge, attitude, and practices toward antibiotics. However, non-pharmacist staff lacked knowledge and had probable NPAD practice, which has a negative impact on public health. Regular refresher training, seminars, and strict enforcement of rules and regulations are essential.

Private pharmacies as healthcare providers in Odisha, India: analysis and implications for universal health coverage

INTRODUCTION

In India, as in many low-income and middle-income countries, the private sector provides a large share of health care. Pharmacies represent a major share of private care, yet there are few studies on their role as healthcare providers. Our study examines: (1) What are the characteristics of and services provided by private pharmacies and how do these compare with other outpatient care providers? (2) What are the characteristics of patients who opted to use private pharmacies? (3) What are the reasons why people seek healthcare from private pharmacies? (4) What are the quality of services and cost of care for these patients? Based on our findings, we discuss some policy implications for universal health coverage in the Indian context.

METHODS

We analyse data from four surveys in Odisha, one of India's poorest states: a household survey on health-seeking behaviours and reasons for healthcare choices (N=7567), a survey of private pharmacies (N=1021), a survey of public sector primary care facilities (N=358), and a survey of private-sector solo-providers (N=684).

RESULTS

17% of the households seek outpatient care from private pharmacies (similar to rates for public primary-care facilities). 25% of the pharmacies were not registered appropriately under Indian regulations, 90% reported providing medical advice, and 26% reported substituting prescribed drugs. Private pharmacies had longer staffed hours and better stocks of essential drugs than public primary-care facilities. Patients reported choosing private pharmacies because of convenience and better drug stocks; reported higher satisfaction and lower out-of-pocket expenditure with private pharmacies than with other providers.

CONCLUSION

This is the first large-scale study of private pharmacies in India, with a comparison to other healthcare providers and users' perceptions and experiences of their services. To move towards universal health coverage, India, a country with a pluralistic health system, needs a comprehensive health systems approach that incorporates both the public and private sectors, including private pharmacies.

Physicians' attitudes, knowledge, and practices regarding antibiotic prescriptions

OBJECTIVES

Inappropriate and overuse of antimicrobials, incorrect dosing, and extended duration are some of the leading causes of antibiotic-resistance that have led to the development of antimicrobial resistance (AMR). We aimed to evaluate knowledge, attitudes, and practices regarding rational antibiotic prescribing among physicians in a teaching hospital in Oman, with the goal of identifying knowledge gaps and interventions that could lead to judicious use of antimicrobials and reduce the emergence of resistant organisms METHODS: A cross-sectional study assessing physicians' knowledge of and attitudes towards prescribing antibiotics was conducted at the Royal Hospital from 15 January to 31 March 2020. Likert scales were used to evaluate physicians' awareness and perception of personal performance regarding the care of patients with infections and rational use of antibiotics.

RESULTS

Inadequate hand washing was regarded as the most important factor contributing to AMR (51.6%), followed by widespread use of antibiotics (49%), prescribing broad-spectrum antibiotics (47.3%), lack of effective narrow-spectrum antibiotics (47.3%), inappropriate duration of antibiotic therapy (46.2%), inappropriate empirical choice of antibiotics (45.1%), poor access to information on local antibiotic resistance patterns (40.8%), and inadequate restrictions on antibiotic prescribing (34.4%). Other factors contributing to AMR such as lack of local hospital guidelines on antibiotic usage, random mutations in microbes, patient demands and expectations for antibiotics, and the role of pharmaceutical companies in advertising and promoting use of antibiotics were deemed important by 33.3%, 26.8%, 22.5% and 20.4%, respectively.

CONCLUSIONS

AMR is a global health threat with significant effect on the health system and the economy. Misuse and overuse of antimicrobials remain the main drivers for the development of drug-resistant pathogens. Identifying knowledge gaps and planning interventions that could lead to judicious use of antimicrobials including establishing an Antimicrobial Stewardship Program are of paramount importance in reducing AMR in the twenty-first century and beyond.

Role of community pharmacy professionals in child health service provision in Ethiopia: a cross-sectional survey in six cities of Amhara regional state

BACKGROUND

Community pharmacy professionals have great potential to deliver various public health services aimed at improving service access, particularly in countries with a shortage of health professionals. However, little is known about their involvement in child health service provision in Ethiopia.

OBJECTIVE

The purpose of this study was to evaluate the level of involvement of community pharmacy professionals in child health service provision within Ethiopia.

METHODS

A multi-center cross-sectional survey was conducted among 238 community pharmacy professionals from March to July 2020 in Amhara regional state of Ethiopia. Independent samples t-test and one way Analysis of Variance (ANOVA) was used to test the mean difference.

RESULTS

Most community pharmacy professionals were 'involved' in providing child health services related to 'advice about vitamins/supplements' (46.6%), 'advice about infant milk/formulas' (47.1%) and 'responding to minor symptoms' (50.8%) for children. The survey revealed that, community pharmacy professionals were less frequently involved in providing childhood 'vaccination' services. Further, level of involvement of community pharmacy professionals differed according to participants' licensure level, setting type, responsibility in the facility and previous training experience in child health services.

CONCLUSION

Community pharmacy professionals have been delivering various levels of child health services, demonstrating ability and capacity in improving access to child health services in Ethiopia. However, there is a need for training and government support to optimize pharmacist engagement and contribution to service delivery.

Interventions to improve dispensing of antibiotics at the community level in low and middle income countries: A systematic review

BACKGROUND

Inappropriate antibiotic dispensing is one of the key drivers of antibiotic resistance. This review documents the effectiveness of interventions aimed at improving antibiotic dispensing practices at the community level by drug dispensers in low and middle income countries (LMIC).

METHODS

We conducted a systematic search in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science (November 11, 2019). Studies were included if they reported data on the outcome measure: appropriate dispensing of medicine including antibiotics. The effectiveness of studies was assessed based on quantitative results reported in the studies included.

RESULTS

A total of 1158 papers were screened. Thirteen studies from Asia (6), Africa (5), South America (one) and one study from both Africa and Asia were included in this review. Nine (69.2%) studies reported significant effectiveness of interventions on all or more than 50% of antibiotic related outcomes. Cochrane Effective Practice and Organization of Care interventions frequently applied were educational meetings (9/13), distribution of educational materials (7/13), educational outreach meetings (7/13), reminders (6/13), local consensus processes (6/13), distribution of supplies (6/14) and clinical practice guidelines (4/14), Nine studies reported on stakeholder involvement.

CONCLUSION

This review shows that it is possible to improve antibiotic dispensing practices at the community level in LMIC. Stakeholders' involvement was key in the design and implementation of interventions.

Evaluating novel engagement mechanisms, yields and acceptability of tuberculosis screening at retail pharmacies in Ho Chi Minh City, Viet Nam

Pharmacies represent a key health system entry point for people with TB in Viet Nam, but high fragmentation hinders their broader engagement. Professional networking apps may be able to facilitate pharmacy engagement for systematic TB screening and referral. Between September and December 2019, we piloted the use of a social networking app, SwipeRx, to recruit pharmacists for a TB referral scheme across four districts of Ho Chi Minh City, Viet Nam. We measured chest X-ray (CXR) referrals and TB detection yields at participating pharmacies and fielded 100 acceptability surveys, divided into pharmacists who did and did not make a CXR referral. We then fitted mixed-effect odds proportional models to explore acceptability factors that were associated with making a CXR referral. 1,816 push notifications were sent to pharmacists via the SwipeRx app and 78 indicated their interest in participating; however, only one was within the pilot's intervention area. Additional in-person outreach resulted in the recruitment of 146 pharmacists, with 54 (37.0%) making at least one CXR referral. A total of 182 pharmacy customers were referred, resulting in a total of 64 (35.2%) CXR screens and seven people being diagnosed with TB. Compared to pharmacists who did not make any CXR referrals, pharmacists making at least one CXR referral understood the pilot's objectives more clearly (aOR = 2.6, 95% CI: 1.2-5.8) and they believed that TB screening increased customer trust (aOR = 2.7, 95% CI: 1.2-5.8), benefited their business (aOR = 2.8, 95% CI: 1.3-6.2) and constituted a competitive advantage (aOR = 4.4, 95% CI: 1.9-9.9). They were also more confident in using mHealth apps (aOR = 3.1, 95 CI%: 1.4-6.8). Pharmacies can play an important role in early and increased TB case finding. It is critical to highlight the value proposition of TB referral schemes to their business during recruitment. Digital networking platforms, such as SwipeRx, can facilitate referrals for TB screening by pharmacists, but their ability to identify and recruit pharmacists requires optimization, particularly when targeting specific segments of a nation-wide digital network.

The knowledge of community pharmacists about appropriate dosing of antibiotics among paediatrics: A national study from Jordan

OBJECTIVE

Paediatric patients are highly exposed to medication errors especially dosing errors. This study assessed the community pharmacists' knowledge about appropriate dosing of antibiotics among paediatric patients, factors affecting community pharmacists' knowledge and barriers that lead to inappropriate dosing of antibiotics.

METHODS

A self-administered questionnaire was distributed to 1283 Jordanian pharmacists who worked in community pharmacies. Descriptive statistics and multivariate regression were conducted.

RESULTS

The response rate was 87.1%. The majority of pharmacists (86.4%) were non-knowledgeable about appropriate dosing of antibiotics among paediatrics. The monthly income of the pharmacist was positively associated with pharmacists' knowledge. The case of azithromycin dosing in acute bacterial pharyngitis was answered correctly by the highest percentage of community pharmacists (55.8%) while the case of trimethoprim-sulfamethoxazole dosing in lower urinary tract infection was answered correctly by the lowest percentage (15.7%). Poor scientific knowledge about dose calculation was the most reported barrier by the participants (54.7%).

CONCLUSION

Most community pharmacists were non-knowledgeable about appropriate dosing of antibiotics in paediatrics and the level of knowledge was affected by monthly income. Implementing adequate and appropriate educational programmes, constructing specific guidelines that regulate antibiotics practice among community pharmacists are highly recommended.

Comparison of the Knowledge and Practices in Medicine Dispensing between Retail Medicine Shops and Model Pharmacies in Dhaka Metropolis

Model pharmacy has been adopted recently to upgrade the healthcare delivery system in Bangladesh. This study was aimed to analyze and compare the effectiveness of drug dispensing patterns, practices, and knowledge of both clients and dispensers of model pharmacies over traditional retail medicine shops. Two established methods, namely, client simulated method (CSM) and provider interview method (PIM), were employed to determine the practice differences in 90 retail medicine shops and 90 model pharmacies in and around Dhaka city. The results are represented primarily in comparison with corresponding percentages. The survey results did not fully support the findings obtained from the observations of the CSM as PIM contrasted these to some extent, and the differences are statistically significant ( $p<0.0001$ ). According to CSM, the presence of A-grade pharmacists during working hours in retail medicine shops was 0%, and 63% in model pharmacies. As reported by PIM, in the retail medicine shops, 36% of clients were ignorant of visiting doctors before purchasing medicine. On the other hand, only 18% of clients could visit doctors. As per CSM, 40% of clients did not follow doctors' recommendations for completion of the full dose of antibiotics bought from retail medicine shops and 51% did not finish full antibiotic courses collected from model pharmacies. Additionally, CSM revealed that 28% of the clients administered leftover drugs following old and obsolete prescriptions of retail medicine shops and 21% of clients followed the same practices in terms of model pharmacies. The report of CSM revealed that 95% of dispensers of retail medicine shops sold medicine without prescription except over-the-counter (OTC), and in the model pharmacies, the percentage was 77%. The qualitative findings revealed substandard practices and dispensing pattern too. Model pharmacies were established to prevent aberrant medicine dispensing patterns and ensure proper medication dispensing practices and medicine intake. This research could not verify the situation that pharmacists or owners of model pharmacies were fully abiding by the guidelines set for them by the Directorate General of Drug Administration (DGDA).

Regulatory compliance among over-the-counter medicine sellers facilities within the Upper East Region of Ghana

Background

Easy access to medicines provided by private medicine retailing facilities including that of over-the-counter medicine retailers, have gained prominence in sub-Saharan Africa. Although over-the-counter medicine-sellers (OTCMS) facilities play an indispensable role in healthcare delivery, there is inadequate information about their regulatory environment and whether their operations conform to regulatory provisions. Hence, this study sought to investigate the characteristics and predictors of regulatory practices among over-the-counter medicine sellers in Ghana.

Methods

This was a cross-sectional study involving participants from 208 OTCMS facilities in eight (8) municipalities and districts (MDA’s) of the Upper East Region of Ghana. An initial census of facilities in the region was conducted between May and August 2016 and a follow-up conducted between December 2016 and March 2017. This ensured the identification and location of all OTCMS facilities within the selected MDA’s for study planning and data collection. The main outcome variable was regulatory compliance which is a composite of three indicators for regulatory practices (retention of medicine supplier’s invoices and receipts on-premises), licensing and registration requirements (appropriate signage), and equipment and material requirements (availability of reference material). Regulatory compliance was assessed using bivariate and multivariate logistic regression analyses.

Results

In this survey, 21.5%, 38.2%, and 23.1% of the facilities surveyed had a good state of repair, had the owner of the facility available on the premises, and had received regulatory visit(s) in less than 12 months, respectively. Only 29.2% of facilities were regulatory compliant. After statistical adjustment, OTCMS facility location (compared with Rural: Urban, AOR = 4.2, 95% CI 1.74–10.17, p = 0.001) and staff trained in less than 1 year (AOR = 2.78, 95% CI 1.02–7.62, p = 0.046) were significantly associated with regulatory compliance.

Conclusions

Regulatory compliance was low in the Upper East Region of Ghana, particularly across rural locations, where most of the facilities failed to meet the laid down provisions of the Pharmacy Council regarding practice, staff and premises requirements. This could be attributed to the fact that these areas are poorly resourced. Policymakers are been called on to put in place pragmatic measures in relation to OTCMS facility’s location and regulatory requirements to address the inequities in compliance.

What are the most effective community-based antimicrobial stewardship interventions in low- and middle-income countries? A narrative review

Antimicrobial resistance (AMR) is a major global issue and antimicrobial stewardship is central to tackling its emergence. The burden of AMR disproportionately impacts low- and middle-income countries (LMICs), where capacity for surveillance and management of resistant pathogens is least developed. Poorly regulated antibiotic consumption in the community is a major driver of AMR, especially in LMICs, yet community-based interventions are neglected in stewardship research, which is often undertaken in high-income settings and/or in hospitals. We reviewed the evidence available to researchers and policymakers testing or implementing community-based antimicrobial stewardship strategies in LMICs. We critically appraise that evidence, deliver recommendations and identify outstanding areas of research need. We find that multifaceted, education-focused interventions are likely most effective in our setting. We also confirm that the quality and quantity of community-based stewardship intervention research is limited, with research on microbiological, clinical and economic sustainability most urgently needed.

Behavioural interventions to address rational use of antibiotics in outpatient settings of low-income and lower-middle-income countries

Objectives

To explore the current evidence on interventions to influence antibiotic prescribing behaviour of health professionals in outpatient settings in low‐income and lower‐middle‐income countries, an underrepresented area in the literature.

Methods

The systematic review protocol for this study was registered in PROSPERO (CRD42020170504). We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies relating to antibiotic prescribing of health professionals in outpatient settings in low‐income and lower‐middle‐income countries. Behavioural interventions were classified as persuasive, enabling, restrictive, structural or bundle (mix of different interventions). In total, 3,514 abstracts were screened and 42 studies were selected for full‐text review, with 13 studies included in the final narrative synthesis.

Results

Of the 13 included studies, five were conducted in Vietnam, two in Sudan, two in Tanzania, two in India and two in Kenya. All studies were conducted in the outpatient or ambulatory setting: eight took place in primary health centres, two in private clinics and three in pharmacies. Our review found that enabling or educational interventions alone may not be sufficient to overcome the ingrained incentives to link revenue generation to sales of antibiotics, and hence, their inappropriate prescription or misuse. Bundle interventions appear to be very effective at changing prescription behaviour among healthcare providers, including drug sellers and pharmacists.

Conclusions

Multi‐faceted bundle interventions that combine regulation enforcement with face‐to‐face education and peer influence may be more effective than educational interventions alone at curbing inappropriate antibiotic use.

Assessment of community pharmacy management towards self-medication requests of tetracyclines for pregnant women: a simulated client study in Upper Egypt

Background Self-medication is a worldwide phenomenon of using medications without medical supervision. It is even more prevalent in low-income countries, where individuals seek community pharmacies because of accessibility and affordability. Although self-medication is associated with an increased risk of medication errors, few studies have been conducted to examine the quality of community pharmacy management towards self-medicating individuals of at-risk populations such as pregnant women. Objective We sought to investigate the quality of community pharmacies management of self-medication requests of tetracyclines for pregnant women. Setting The study was conducted in community pharmacies in Minya, Egypt. Methods A random sample of 150 community pharmacies was chosen from the urban areas of five districts of Minya, Egypt. To evaluate the actual practice, a simulated client was trained to visit pharmacies and purchase doxycycline for a pregnant woman. In a random subset of the sampled pharmacies (n = 100), interviews were conducted to evaluate pharmacy staff knowledge and attitudes regarding information gathering and dispensing practice. Main outcome measure Dispensing rate of doxycycline for pregnant women. Results From simulated client visits, almost all pharmacy staff (99.1%) dispensed doxycycline without requesting a prescription or collecting any information. About 25% of staff members did not abstain from dispensing even after knowing about pregnancy. On the other hand, most interviewed pharmacy staff (91.5%) reported that they ask about pregnancy before dispensing. Conclusion Our findings show that the current community pharmacy practice puts pregnant women at high risk of experiencing harmful self-medication outcomes. Therefore, strict legislative measures and pharmacy education programs should be considered in Egypt to lessen inappropriate dispensing rates in community pharmacies.

Good pharmacy practice assessment among community pharmacies in Lebanon

Objective

This study aims to assess good pharmacy practice (GPP) aspects and compare GPP scores among community pharmacies in Lebanon, using a tool developed jointly by the International Pharmaceutical Federation (FIP) and the World Health Organization (WHO) to improve and maintain standards of pharmacy practice.

Methods

Data collection was carried out between July and October 2018 by a team of 10 licensed inspectors who work at the Lebanese Order of Pharmacists (OPL) and visited community pharmacies across Lebanon. The questionnaire was adapted to the Lebanese context and included 109 questions organized under five sections: socio-demographics, Indicator A (data management and data recording), Indicator B (services and health promotion), Indicator C (dispensing, preparation and administration of medicines), and Indicator D (storage and facilities). The value of 75% was considered as the cutoff point for adherence to indicators.

Results

Out of 276 pharmacies visited, a total of 250 (90.58%) pharmacists participated in the study with one pharmacist being interviewed in every pharmacy. Results showed that 18.8% of pharmacists were generally adherents to GPP guidelines (scores above the 75% cutoff): 23.3% were adherent to indicator A, 21.6% to indicator B, 14.8% to indicator C and 13.2% to indicator D. Moreover, comparison of GPP scores across geographical regions revealed a higher adherence among community pharmacists working in the Beirut region compared to the North region, the South region, Mount Lebanon, and the Bekaa.

Conclusions

Our study shows that community pharmacists in Lebanon do not fulfill GPP criteria set by FIP/WHO, and that this poor adherence is a trend across the country's geographical regions. Therefore, efforts should be made to raise awareness among pharmacists about the necessity to adhere to GPP guidelines and standards, and train them and support them appropriately to reach that goal. This is the first indicator-based comprehensive pilot assessment to evaluate GPP adherence in community pharmacies across Lebanon. Working on the optimization of this assessment tool is also warranted.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use.Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known.Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals.Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.

The impact of law enforcement on dispensing antibiotics without prescription: a multi-methods study from Saudi Arabia

Background: Dispensing of antibiotics without a prescription (DAwP) has been widely practised among community pharmacies in Saudi Arabia despite being illegal. However, in May 2018, the law and regulations were enforced alongside fines. Consequently, we wanted to evaluate the impact of these changes.Methods: A study was conducted among 116 community pharmacies in two phases. A pre-law enforcement phase between December 2017 and March 2018 and a post-law enforcement phase one year later. Each phase consisted of a cross-sectional questionnaire-based survey and a simulated client method (SCM) approach. In the SCM, clients presented with either pharyngitis or urinary tract infections (UTI). In SCM, for each phase, all 116 pharmacies were visited with one of the scenarios.Results: Before the law enforcement, 70.7% of community pharmacists reported that DAwP was common with 96.6% and 87.7% of participating pharmacies dispensed antibiotics without a prescription for pharyngitis and UTI respectively. After the law enforcement, only 12.9% reported that DAwP is still a common practice, with only 12.1% and 5.2% dispensing antibiotics without prescriptions for pharyngitis and UTI respectively.Conclusion: law enforcement was effective. However, there is still further scope for improvement. This could include further educational activities with pharmacists, physicians and the public.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

"I can make more from selling medicine when breaking the rules" - understanding the antibiotic supply network in a rural community in Viet Nam

Background

As in many other low and middle income countries (LIMCs), Vietnam has experienced a major growth in the pharmaceutical industry, with large numbers of pharmacies and drug stores, and increasing drug expenditure per capita over the past decade. Despite regulatory frameworks that have been introduced to control the dispensing and use of prescription-only drugs, including antibiotics, compliance has been reported to be strikingly low particularly in rural parts of Vietnam. This qualitative study aimed to understand antibiotic access and use practices in the community from both supplier and consumer perspectives in order to support the identification and development of future interventions.

Methods

This qualitative study was part of a project on community antibiotic access and use (ABACUS) in six LMICs. The focus was Ba Vi district of Hanoi capital city, where we conducted 16 indepth interviews (IDIs) with drug suppliers, and 16 IDIs and 6 focus group discussions (FGDs) with community members. Drug suppliers were sampled based on mapping of all informal and formal antibiotic purchase or dispensing points in the study area. Community members were identified through local networks and relationships with the field collaborators. All IDIs and FGDs were audio-taped, transcribed and analysed using content analysis.

Results

We identified a large number of antibiotic suppliers in the locality with widespread infringements of regulatory requirements. Established reciprocal relationships between suppliers and consumers in drug transactions were noted, as was the consumers’ trust in the knowledge and services provided by the suppliers. In addition, antibiotic use has become a habitual choice in most illness conditions, driven by both suppliers and consumers.

Conclusions

This study presents an analysis of the practices of antibiotic access and use in a rural Vietnamese setting. It highlights the interactions between antibiotic suppliers and consumers in the community and identifies possible targets for interventions.

Assessing the impact of law enforcement to reduce over-the-counter (OTC) sales of antibiotics in low- and middle-income countries; a systematic literature review

BACKGROUND

Many low- and middle-income countries (LMIC) are moving towards enforcing prescription-only access to antibiotics. This systematic literature review aims to assess the interventions used to enforce existing legislation prohibiting over-the-counter (OTC) sales of antibiotics in LMICs, their impact and examine the methods chosen for impact measurement including their strengths and weaknesses.

METHODS

Both PubMed and Embase were systematically searched for studies reporting on impact measurement in moving towards prescription only access to antibiotics in LMICs. The PRISMA methodological review framework was used to ensure systematic data collection and analysis of literature. Narrative data synthesis was used due to heterogeneity of study designs.

RESULTS

In total, 15 studies were included that assessed policy impact in 10 different countries. Strategies employed to enforce regulations prohibiting OTC sales of systemic antibiotics included retention of prescriptions for antibiotics by pharmacies, government inspections, engaging pharmacists in the design of interventions, media campaigns for the general public and educational activities for health care workers. A variety of outcomes was used to assess the policy impact; changes in antimicrobial resistance rates, changes in levels of antibiotic use, changes in trends of antibiotic use, changes in OTC supply of antibiotics, and changes in reported practices and knowledge of pharmacists, medicine sellers and the general public. Differences in methodological approaches and outcome assessment made it difficult to compare the effectiveness of law enforcement activities. Most effective appeared to be multifaceted approaches that involved all stakeholders. Monitoring of the impact on total sales of antibiotics by means of an interrupted time series (ITS) analysis and analysis of pharmacies selling antibiotics OTC using mystery clients were the methodologically strongest designs used.

CONCLUSIONS

The published literature describing activities to enforce prescription-only access to antibiotics in LMICs is sparse and offers limited guidance. Most likely to be effective are comprehensive multifaceted interventions targeting all stakeholders with regular reinforcement of messages. Policy evaluation should be planned as part of implementation to assess the impact and effectiveness of intervention strategies and to identify targets for further activities. Robust study designs such as ITS analyses and mystery client surveys should be used to monitor policy impact.

Practice of over-the-counter dispensary of antibiotics for childhood illnesses in Addis Ababa, Ethiopia: a simulated patient encounter study

Background

Dispensary and use of antibiotics without prescriptions from qualified providers is a common practice in countries with poor pharmaceutical regulations and where due focus is not given to rational use. This practice is a main factor for the spread of antimicrobial resistance due to its non-reliance on pre-treatment microbiologic work-up, improper indications and dosing errors. This study was conducted to determine the rate of over-the-counter dispensary of antibiotics for common childhood illnesses among privately owned medicine retail outlets in Addis Ababa, Ethiopia.

Methods

Pre-determined simulated patient visits depicting common childhood illnesses were employed to request antibiotics without prescriptions. A simple random sampling was used to select medicine retail outlets within Addis Ababa city. Trained data collectors filled structured data forms (including antibiotic requested, reasons for denial of dispense and details enquired by pharmacist) shortly after each patient enactment. Multi-variable logistic regression analysis was employed to explore factors associated with over-the-counter sales of antibiotics.

Results

A total of 262 simulated encounters were surveyed. Of the 262 verbal antibiotic requests, 63.4% were dispensed. Close to 60% of encounters were accompanied by questions about a doctor's visit or the child's symptomatology while a past history of drug allergies was enquired in only 11.1% of visits. Over-the-counter dispensary was more likely when dispenser queried about symptoms was made (AOR: 2.412, 95%CI: 1.236, 4.706), for requests for more than one antibiotics (AOR: 2.988, 95%CI: 1.258, 7.095) and for simulated patient demands for oral antibiotics for children with acute diarrhea (AOR: 3.297, 95%CI: 1.248, 8.712) and parenteral antibiotics for those reported to receive in-patient care for pneumonia (4.516, 95% CI: 1.720, 11.857).

Conclusions

The prevalence of providing antibiotics over-the-counter for pediatric illnesses in Addis Ababa is markedly high. Further studies into factors encouraging this malpractice are required. Enhancing education of personnel dispensing antibiotics and strict enforcement of national regulations are needed.

'Working to stay healthy', health-seeking behaviour in Bangladesh's urban slums: a qualitative study

Background

Kamrangirchar and Hazaribagh are the largest slum areas in Dhaka, Bangladesh. In 2013, Médecins Sans Frontières initiated an urban healthcare programme in these areas providing services for factory workers and responding to the sexual and reproductive health needs of young women. Little in-depth information is available on perceptions of health and health seeking behaviour in this population. We aimed to provide a better understanding of community perceptions toward health and health care in order to inform programme strategies.

Methods

In-depth interviews were conducted with women (n = 13); factory workers (n = 14); and key informants (n = 13). Participants were selected using purposive maximum variation sampling and voluntarily consented to take part. Topic guides steered participant-led interviews, which were audio-recorded, translated and transcribed from Bangla into English. By comparing cases, we identified emerging themes, patterns and relationships in the data. NVivo11© was used to sort and code the data.

Results

Emerging themes indicated that in Kamrangirchar and Hazaribagh, health is seen as an asset necessary for work and, thus, for survival. Residents navigate a highly fragmented health system looking for ‘quick fixes’ to avoid time off work, with the local pharmacy deemed ‘good enough’ for ‘common’ health issues. Health care seeking for ‘serious’ conditions is characterised by uncertainty, confusion, and unsatisfactory results. Decisions are made communally and shaped by collective perceptions of quality care. People with limited socio-economic capital have few options for care. ‘Quality care’ is perceived as comprehensive care ‘under one roof,’ including predictive biomedical diagnostics and effective medication, delivered through a trusting relationship with the care provider.

Conclusions

Health seeking behaviour of slum dwellers of Kamrangirchar and Hazaribagh is based on competing priorities, where quick and effective care is key, focussed on the ability to work and generate income. This takes place in a fragmented healthcare system characterised by mistrust of providers, and where navigation is informed by word-of-mouth experiences of peers. Improving health in this context demands a comprehensive and integrated approach to health care delivery, with an emphasis on rapid diagnosis, effective treatment and referral, and improved trust in care providers. Health education must be developed in collaboration with the community to identify knowledge gaps, support decision-making, and be channelled through existing networks. Further research should consider the effectiveness of interventions aiming to improve the practice of pharmacists.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6750-0) contains supplementary material, which is available to authorized users.

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems

This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.

Antibiotic prescribing and dispensing for acute respiratory infections in children: effectiveness of a multi-faceted intervention for health-care providers in Vietnam

Background: Appropriate antibiotic use is vital to effectively contain antibiotic resistance and improve global health. Acute respiratory infections (ARIs) remain the leading cause of disease and death in children under five in low-income countries.

Objective: To evaluate a multi-faceted intervention targeting health-care-providers’ (HCPs) knowledge, practical competences and practices regarding antibiotic use for ARIs.

Methods: A multi-faceted educational intervention with a two-armed randomised controlled design targeting HCPs treating ARIs in children was conducted in Bavi district, a rural district in Northern Vietnam in 2010–2011. Thirty-two communes of the district were randomized into two arms, with 144 HCPs in the intervention arm and 160 in the control arm. The intervention, conducted over seven months, comprised: (i) education regarding appropriate-antibiotic use, (ii) case scenario discussion and (iii) poster distribution. Questionnaires to assess knowledge and dispensing/prescribing forms to assess practice were completed before-and after interventions. The main outcome measures were differences in improvement in knowledge and practice in the intervention and control group, respectively.

Results: Knowledge improved in the intervention group for ARI aetiology by 28% (Δ_{Decrement control arm} 10%), antibiotic use for mild ARIs by 15% (Δ_{Decrement control arm} 13%) and for severe ARIs by 14% (Δ_{Improvement control arm} 29%). Practical competence for a mild ARI case scenario improved in the intervention and control groups by 20% and 11%, respectively. Total knowledge score increased statistically in the intervention group (Δ_{mean improvement} 1.17); less so in the control group (Δ_{mean improvement} 0.48). Practice regarding antibiotics for mild ARIs improved by 28% in the intervention group (Δ_{Decrement control arm} 3%).

Conclusions: The intervention significantly improved HCPs’ knowledge of ARIs and practice of antibiotic use in treatment of ARIs. We suggest mixed method assessment and long-term follow-up of these interventions to enable better appreciation of the effects and effect sizes of our interventions.

Interventions for improving pharmacist-led patient counselling in the community setting: a systematic review

BACKGROUND

Pharmacist counselling is an important service that has been associated with improved outcomes. The primary aim of this review was to identify, describe, and determine the effectiveness of interventions for improving the counselling practice of community pharmacists.

METHODS

We searched PubMed (from January 1990 to June 2017) and the Cochrane Library (June 2017). To supplement our database searches, we searched Google Scholar for papers that cited the identified studies. We included only studies that reported the impact of the intervention on pharmacists' behaviour during counselling. We searched for data from studies with randomised trials, non-randomised trials, controlled before-after studies, or interrupted time series study designs. Parameters including selection bias, performance bias, detection bias, and attrition bias were assessed. The data were narratively synthesised.

RESULTS

We screened 2335 abstracts and 59 full-text articles and included 17 RCTs. Overall, three studies were determined to have a high risk of bias, and 14 studies were determined to have an unclear risk of bias. Fifteen studies investigated multifaceted interventions that included two or more components. The most commonly used interventions were educational meetings (n = 14), educational materials (n = 9), educational outreach visits (n = 5), feedback (n = 5), guidelines (n = 5), and local opinion leaders (n = 2). Outcomes were measured using simulated patient visits (n = 10), and the self-reported outcomes of patient or pharmacists (n = 6). Most of the included studies (n = 11) reported some degree of improvement in counselling practices.

CONCLUSIONS

The included studies showed that educational meetings combined with educational materials, outreach visits, and feedback can improve pharmacist counselling in community settings. However, the unclear risk of bias and poor quality of reporting intervention components necessitate caution in interpreting the findings. Recommendations for future studies based on the evidence gap identified in this review are presented.

Community pharmacy and emerging public health initiatives in developing Southeast Asian countries: a systematic review

The development of health and healthcare systems in South-East Asia has influenced the practice of community pharmacy. Over the years, community pharmacy in the region has striven to expand services beyond dispensing to encompass more involvement in public health issues. Searches were conducted in Scopus, EMBASE, MEDLINE and PubMed for articles published between January 2000 and December 2014, with 21 studies in five countries meeting the inclusion criteria. The findings showed increasing interest in research into the delivery of pharmacy services and public health initiatives. Overall, the review found that provision of some health services in pharmacies was common; however, most public health initiatives appeared to be poorly implemented, had limited evidence and were not demonstrated to be sustainable across the sector. This indicates that the practice of community pharmacy in the region has not significantly changed over the past 14 years with respect to the scope and quality of pharmacy services provided, and fundamental policy changes are necessary to improve this situation.

Public stewardship of private for-profit healthcare providers in low- and middle-income countries

BACKGROUND

Governments use different approaches to ensure that private for-profit healthcare services meet certain quality standards. Such government guidance, referred to as public stewardship, encompasses government policies, regulatory mechanisms, and implementation strategies for ensuring accountability in the delivery of services. However, the effectiveness of these strategies in low- and middle-income countries (LMICs) have not been the subject of a systematic review.

OBJECTIVES

To assess the effects of public sector regulation, training, or co-ordination of the private for-profit health sector in low- and middle-income countries.

SEARCH METHODS

For related systematic reviews, we searched the Cochrane Database of Systematic Reviews (CDSR) 2015, Issue 4; Database of Abstracts of Reviews of Effectiveness (DARE) 2015, Issue 1; Health Technology Assessment Database (HTA) 2015, Issue 1; all part of The Cochrane Library, and searched 28 April 2015. For primary studies, we searched MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE Daily and MEDLINE 1946 to Present, OvidSP (searched 16 June 2016); Science Citation Index and Social Sciences Citation Index 1987 to present, and Emerging Sources Citation Index 2015 to present, ISI Web of Science (searched 3 May 2016 for papers citing included studies); Cochrane Central Register of Controlled Trials (CENTRAL), 2015, Issue 3, part of The Cochrane Library (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 28 April 2015); Embase 1980 to 2015 Week 17, OvidSP (searched 28 April 2015); Global Health 1973 to 2015 Week 16, OvidSP (searched 30 April 2015); WHOLIS, WHO (searched 30 April 2015); Science Citation Index and Social Sciences Citation Index 1975 to present, ISI Web of Science (searched 30 April 2015); Health Management, ProQuest (searched 22 November 2013). In addition, in April 2016, we searched the reference lists of relevant articles, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and various electronic databases of grey literature.

SELECTION CRITERIA

Randomised trials, non-randomised trials, interrupted time series studies, or controlled before-after studies.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility and extracted data, comparing their results and resolving discrepancies by consensus. We expressed study results as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI), where appropriate, and assessed the certainty of the evidence using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). We did not conduct meta-analysis because of heterogeneity of interventions and study designs.

MAIN RESULTS

We identified 20,177 records, 50 of them potentially eligible. We excluded 39 potentially eligible studies because they did not involve a rigorous evaluation of training, regulation, or co-ordination of private for-profit healthcare providers in LMICs; five studies identified after the review was submitted are awaiting assessment; and six studies met our inclusion criteria. Two included studies assessed training alone; one assessed regulation alone; three assessed a multifaceted intervention involving training and regulation; and none assessed co-ordination. All six included studies targeted private for-profit pharmacy workers in Africa and Asia.Three studies found that training probably increases sale of oral rehydration solution (one trial in Kenya, 106 pharmacies: RR 3.04, 95% CI 1.37 to 6.75; and one trial in Indonesia, 87 pharmacies: RR 1.41, 95% CI 1.03 to 1.93) and dispensing of anti-malarial drugs (one trial in Kenya, 293 pharmacies: RR 8.76, 95% CI 0.94 to 81.81); moderate-certainty evidence.One study conducted in the Lao People's Democratic Republic shows that regulation of the distribution and sale of registered pharmaceutical products may improve composite pharmacy indicators (one trial, 115 pharmacies: improvements in four of six pharmacy indicators; low-certainty evidence).The outcome in three multifaceted intervention studies was the quality of pharmacy practice; including the ability to ask questions, give advice, and provide appropriate treatment. The trials applied regulation, training, and peer influence in sequence; and the study design does not permit separation of the effects of the different interventions. Two trials conducted among 136 pharmacies in Vietnam found that the multifaceted intervention may improve the quality of pharmacy practice; but the third study, involving 146 pharmacies in Vietnam and Thailand, found that the intervention may have little or no effects on the quality of pharmacy practice (low-certainty evidence).Only two studies (both conducted in Vietnam) reported cost data, with no rigorous assessment of the economic implications of implementing the interventions in resource-constrained settings. No study reported data on equity, mortality, morbidity, adverse effects, satisfaction, or attitudes.

AUTHORS' CONCLUSIONS

Training probably improves quality of care (i.e. adherence to recommended practice), regulation may improve quality of care, and we are uncertain about the effects of co-ordination on quality of private for-profit healthcare services in LMICs. The likelihood that further research will find the effect of training to be substantially different from the results of this review is moderate; implying that monitoring of the impact is likely to be needed if training is implemented. The low certainty of the evidence for regulation implies that the likelihood of further research finding the effect of regulation to be substantially different from the results of this review is high. Therefore, an impact evaluation is warranted if government regulation of private for-profit providers is implemented in LMICs. Rigorous evaluations of these interventions should also assess other outcomes such as impacts on equity, cost implications, mortality, morbidity, and adverse effects.

Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector?

The private for-profit sector's prominence in health-care delivery, and concern about its failures to deliver social benefit, has driven a search for interventions to improve the sector's functioning. We review evidence for the effectiveness and limitations of such private sector interventions in low-income and middle-income countries. Few robust assessments are available, but some conclusions are possible. Prohibiting the private sector is very unlikely to succeed, and regulatory approaches face persistent challenges in many low-income and middle-income countries. Attention is therefore turning to interventions that encourage private providers to improve quality and coverage (while advancing their financial interests) such as social marketing, social franchising, vouchers, and contracting. However, evidence about the effect on clinical quality, coverage, equity, and cost-effectiveness is inadequate. Other challenges concern scalability and scope, indicating the limitations of such interventions as a basis for universal health coverage, though interventions can address focused problems on a restricted scale.

Factors influencing the current practice of self-medication consultations in Eastern Indonesian community pharmacies: a qualitative study

Background

Research has shown that the current practice of pharmacy staff when providing self-medication consultations in Indonesia is suboptimal. To improve the performance of pharmacy staff when providing self-medication consultations in community pharmacies, the factors that influence current practice need to be understood. The aim of this study is to identify the factors that influence current practice of pharmacy staff when handling self-medication consultations in Eastern Indonesian community pharmacies.

Methods

Fifteen in-depth interviews were conducted with pharmacists, pharmacy technicians, pharmacy owners, and counter attendants. Thematic analysis was used to generate findings.

Results

The current practice of pharmacy staff when handling self-medication consultations is directly influenced by the professionalism of pharmacy staff and patient responses to the consultations. These factors are in turn affected by the organisational context of the pharmacy and the external pharmacy environment. The organisational context of the pharmacy includes staffing, staff affordability, and the availability of time and facilities in which to provide consultations. The external pharmacy environment includes the number of trained pharmacy staff in the research setting, the relevance of pharmacy education to the needs of pharmacy practice, the support offered by the Indonesian Pharmacists Association, a competitive business environment, and the policy environment.

Conclusion

Complex and inter-related factors influence the current practice of pharmacy staff when providing self-medication consultations in community pharmacies in this research setting. Multiple strategies will be required to improve consultation practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1425-3) contains supplementary material, which is available to authorized users.

Performance of retail pharmacies in low- and middle-income Asian settings: a systematic review

In low- and middle-income countries (LMIC) in Asia, pharmacies are often patients' first point of contact with the health care system and their preferred channel for purchasing medicines. Unfortunately, pharmacy practice in these settings has been characterized by deficient knowledge and inappropriate treatment. This paper systematically reviews both the performance of all types of pharmacies and drug stores across Asia's LMIC, and the determinants of poor practice, in order to reflect on how this could best be addressed. Poor pharmacy practice in Asia appears to have persisted over the past 30 years. We identify a set of inadequacies that occur at key moments throughout the pharmacy encounter, including: insufficient history taking; lack of referral of patients who require medical attention; illegal sale of a wide range of prescription only medicines without a prescription; sale of medicines that are either clinically inappropriate and/or in doses that are outside of the therapeutic range; sale of incomplete courses of antibiotics; and limited provision of information and counselling. In terms of determinants of poor practice, first knowledge was found to be necessary but not sufficient to ensure correct management of patients presenting at the pharmacy. This is evidenced by large discrepancies between stated and actual practice; little difference in the treatment behaviour of less and more qualified personnel and the failure of training programmes to improve practice to a satisfactory level. Second, we identified a number of profit maximizing strategies employed by pharmacy staff that can be linked to poor practices. Finally, whilst the research is relatively sparse, the regulatory environment appears to play an important role in shaping behaviour. Future efforts to improve the situation may yield more success than historical attempts, which have tended to concentrate on education, if they address the profit incentives faced by pharmacy personnel and the regulatory system.

Factors Influencing Access to Sexual Health Care Among Behaviorally Bisexual Men in Vientiane, Laos: A Qualitative Exploration

In Laos, men who have sex with men (MSM) are disproportionately affected by HIV, and bisexual behavior among men is common. We conducted a qualitative study to explore access and influences on sexual health care seeking among bisexual men in Vientiane. In 2013, behaviorally bisexual men were recruited from bars, clubs and dormitories for 5 focus group discussions and 11 in-depth interviews. Participants (aged 18-35 years) commonly reported high-risk sexual behaviors, yet most had never been tested for HIV, and none reported testing for sexually transmitted infections. Common barriers to testing were low perception of risk, expectation of symptoms, fear of HIV, shyness, perceived stigma, confidentiality concerns, and waiting times. Many men were unaware of available services. Most clinics cannot provide comprehensive HIV and sexually transmitted infection services. Strategies are needed to generate demand for testing, improve the capacity of sexual health care providers, and promote available services among behaviorally bisexual men in Vientiane.

A meta-analysis of the proportion of animal Salmonella isolates resistant to drugs used against human salmonellosis in Ethiopia

Background

The emergence and spread of drug resistant Salmonellae of both human and animal origins are global concerns and worrisome in countries where the risk of infection is high and treatment options are limited. The objective of this study was to estimate the proportions of animal isolates resistant to antimicrobials used against human salmonellosis in Ethiopia.

Methods

Published studies on the antimicrobial resistance features of Salmonellae isolated from food animals of Ethiopia were searched in Medline, Google Scholar and the lists of references of articles. Eligible studies were selected by using inclusion and exclusion criteria and data were extracted. The extracted data included the host species, the numbers of isolates and the numbers of ampicillin, co-trimoxazole, chloramphenicol, ceftriaxone and ciprofloxacin resistant isolates. The risks of bias were assessed and the percentages of the variations of the estimates attributable to heterogeneities were quantified. Pooled proportions were estimated by the DerSimonian and Laird random effects model.

Results

Five hundred and fifty four Salmonellae isolated from cattle, camels, sheep, goats and pigs were tested with a variety of antimicrobials. The percentages of the variations attributable to heterogeneities were low for chloramphenicol and ceftriaxone (I² = 0) and high for ampicillin, co-trimoxazole and ciprofloxacin resistance estimates (I² > 75%). The pooled estimate of ampicillin resistant isolates was higher in slaughtered ruminants (17.28%) than in pigs (3.95%), (p < 0.001). The pooled estimates of co-trimoxazole resistant isolates in true ruminants (4.35%) and pigs (1.12%) were not significantly different (p > 0.05). The overall pooled estimates of chloramphenicol and ceftriaxone resistant isolates were 2.24% and 1.25%, respectively. Seven serotypes have been reported to be resistant to antimicrobials uncommonly used in veterinary clinical practice in Ethiopia.

Conclusions

Among Salmonellae of farm animals, there exist strains that are resistant to drugs used in the therapeutic management of human salmonellosis in Ethiopia. Intervention measures should be taken to ensure the prudent use of antimicrobials and curb the spread of high risk strains across the country.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-0835-x) contains supplementary material, which is available to authorized users.

Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Background

Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings.

Methods

We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011.

Results

We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively.

Conclusion

The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.

Improved knowledge and reported practice regarding sexually transmitted infections among healthcare providers in rural Vietnam: a cluster randomised controlled educational intervention

BACKGROUND

Healthcare providers (HCPs) play a critical role in controlling the spread of sexually transmitted infections (STI) through early and accurate diagnosis, appropriate treatment and prevention counselling. This study aimed to assess the effectiveness of an educational intervention about STI on knowledge and reported practice among HCPs and to explore which determinants may influence the intervention's effects.

METHODS

A cluster randomized controlled educational intervention was carried out in a rural district, Vietnam. 32 communes of the district were randomized into two arms, with 160 HCPs in an STI intervention arm and 144 in a control arm. The STI intervention comprised interactive training with basic STI knowledge, case scenarios, and poster distribution. Questionnaires to evaluate knowledge and reported practice were completed three times: before, during and after the intervention. Correct answer was scored as 1; "do not know", incorrect answer was scored as 0. Univariate and multilevel multivariate analyses were applied.

RESULTS

Of the maximum 56 points, the mean knowledge score increased significantly in the STI intervention arm and in the control arm post-intervention (37.2 to 48.4, and 32.7 to 41.7, respectively). In multivariate regression analysis, knowledge improvement in the intervention arm was significantly higher than that in the control arm (regression coefficient = 2.97, p = 0.008). Other factors which positively influenced the increase in knowledge were being between 35 and 50 years old, having intermediate professional training, being a pharmacist or working at a village level (regression coefficient: 2.81, 4.43, 5.53 and 7.91, respectively). Post-intervention, the mean reported practice score increased significantly in the STI intervention arm (from 17.6 to 21.8) and insignificantly in the control arm (maximum 36 points). Factors which positively influenced the increase in reported practice were being between 35 and 50 years old, having intermediate professional training, or working at a pharmacy/drugstore (regression coefficient: 2.15, 3.33 and 3.22, respectively).

CONCLUSIONS

This study indicates that an educational intervention including interactive training and multi-faceted interventions may be effective in improving STI knowledge and reported practice of HCPs at grassroots level, particularly among pharmacists, HCPs who work in villages or pharmacies/drugstores, and who initially have low STI knowledge.

The policy-practice gap: describing discordances between regulation on paper and real-life practices among specialized drug shops in Kenya

BACKGROUND

Specialized drug shops (SDSs) are popular in Sub-Saharan Africa because they provide convenient access to medicines. There is increasing interest in how policymakers can work with them, but little knowledge on how their operation relates to regulatory frameworks. This study sought to describe characteristics and predictors of regulatory practices among SDSs in Kenya.

METHODS

The regulatory framework governing the Kenya pharmaceutical sector was mapped, and a list of regulations selected for inclusion in a survey questionnaire. An SDS census was conducted, and survey data collected from 213 SDSs from two districts in Western Kenya.

RESULTS

The majority of SDSs did not comply with regulations, with only 12% having a refrigerator and 22% having a separate dispensing area for instance. Additionally, less than half had at least one staff with pharmacy qualification (46%), with less than a third of all interviewed operators knowing the name of the law governing pharmacy.Regulatory infringement was more common among SDSs in rural locations; those that did not have staff with pharmacy qualifications; and those whose operator did not know the name of the pharmacy law. Compliance was not significantly associated with the frequency of inspections, with over 80% of both rural and urban SDSs reporting an inspection in the past year.

CONCLUSION

While compliance was low overall, it was particularly poor among SDSs operating in rural locations, and those that did not have staff with pharmacy qualification. This suggested the need for policy to introduce levels of practice in recognition of the variations in resource availability. Under such a system, rural SDSs operating in low-resource setting, and selling a limited range of medicines, may be exempted from certain regulatory requirements, as long as their scope of practice is limited to certain essential services only. Future research should also explore why regulatory compliance is poor despite regular inspections.

A meta-analysis of the proportion of antimicrobial resistant human Salmonella isolates in Ethiopia

BACKGROUND

Antimicrobial resistant Salmonella is a global problem and recently, a strain on the verge of pan-resistance was reported. In Ethiopia, the therapeutic management of Salmonellosis is difficult because drug sensitivity tests are not routinely carried out and treatment alternatives are not available in most health care facilities. The objectives of this study were to estimate the temporal changes and proportions of drug resistant isolates in Ethiopia.

METHODS

Published studies on drug resistant Salmonella isolates were searched in Medline, Google Scholar and the lists of references of articles. Eligible studies were selected by using inclusion and exclusion criteria. Generic, methodological and statistical information were extracted from the eligible studies. The extracted data included the proportions of ampicillin, co-trimoxazole, chloramphenicol, ceftriaxone, ciprofloxacin and multi-drug resistant isolates. Pooled proportions were estimated by a random effects model.

RESULTS

The odds of multi-drug resistant isolates in the 2000s was higher than before the 1990s (OR =18.86, 95% CI = 13.08, 27.19). The pooled proportions of ampicillin, co-trimoxazole, chloramphenicol, ciprofloxacin and multi-drug resistant isolates in the 2000s were 86.01%, 68.01%, 62.08%, 3.61% and 79.56% respectively. S. Concord (>97%) was resistant to ampicillin, co-trimoxazole, chloramphenicol and ceftriaxone.

CONCLUSION

The proportion of drug resistant isolates has increased since the 1970s. All drugs currently used for the treatment of Salmonellosis but ciprofloxacin are not reliable for an empirical therapy. Alternative drugs should be included in the essential drug list and measures should be taken to re-enforce the drug use policy.

Improving pharmacy staff knowledge and practice on childhood diarrhea management in Vietnam: are educational interventions effective?

BACKGROUND

In many developing countries, private pharmacies play an important role in providing health information and services to local communities for common health issues. The aim of this study was to ascertain medium-term impact of educational interventions on knowledge and practice of pharmacy staff regarding management of childhood diarrhea in Vietnam.

METHODS

This was a pre- and post-intervention study with 32 and 44 months difference from the time of the baseline survey to the conclusion of trainings and the time of the end-line survey, respectively. Interventions included in-class training for pharmacy staff, printed materials at the pharmacy, and supportive supervision. Knowledge/reported practice and actual practice of pharmacy staff were measured before and after interventions.

RESULTS

After interventions, significant improvements (p<0.01) were observed for all indexes related to pharmacy staff's knowledge about childhood diarrhea; for instance, 31% and 60% of surveyed staff asked about weight of the child and accompanying symptoms of childhood diarrhea, respectively, an increase from 11% and 45% at the baseline. Oral rehydration solution (ORS) was the most frequently reported product recommended (97% to 99%), but probiotics and antidiarrheals were the products most frequently prescribed at pharmacies. Public health facilities remained the preferred choice for referrals from pharmacies, but the use of private clinics was increasing. Consultations and advice provided to caregivers also improved, but considerable gaps between knowledge and actual practice of staff in real pharmacy settings remained.

CONCLUSIONS

Educational interventions were effective in improving pharmacy staff knowledge and practice regarding management of childhood diarrhea. Knowledge and actual practice of staff in real pharmacy settings did not always correlate; there is need for a stronger regulatory and law enforcement system. Interventions to improve pharmacy practice in developing countries should be focused, comprehensive, and evidence-based.

Intervention research to enhance community pharmacists' cognitive services: a systematic review

BACKGROUND

Positive impact of community pharmacists' cognitive pharmaceutical services (CPS) is well documented. However, community pharmacists have been slow to expand CPS roles. This systematic review explores how community pharmacy intervention research can help inform efforts to expand cognitive pharmaceutical service delivery.

OBJECTIVES

To: 1) identify community pharmacy CPS intervention studies that report data on pharmacist behaviors, either as a final study outcome itself or as a fidelity measure in patient outcome studies, and 2) describe the state of this research to help frame future research agendas.

METHODS

Empirical articles examining improvement or expansion of community pharmacist cognitive services published through December 2010 were searched using various search engines, bibliography searches and authors' libraries. Studies were included if they: 1) reported findings on pharmacist behaviors during cognitive service delivery, 2) employed a minimum of pre-post design or two study arms for pharmacists/pharmacies, and 3) were in community-based pharmacies.

RESULTS

A total of 50 studies evaluated impact of community pharmacy based CPS delivery; however, only 21 included a pharmacist behavior outcome measure as a final outcome or as a fidelity measure. The majority (14 out of 21) of studies used a randomized controlled trial design. Nearly half (10 of 21) addressed asthma or tobacco cessation. Limited details were provided about interventions to prepare pharmacists for CPS delivery. The most frequent measures of pharmacist behavior were patient surveys and observation of pharmacists' behavior by secret shoppers; electronic data sets were rarely used.

CONCLUSIONS

There is a need for well-designed intervention research that evaluates how interventions impact on pharmacist cognitive service behavior. Positive findings from this review reinforce that planned interventions have the potential to improve and expand pharmacist cognitive service delivery; however, more detail is needed in study publications for this potential to be fully realized.

Strengthening pharmacy practice in vietnam: findings of a training intervention study

OBJECTIVE

To assess the effectiveness of a training and supportive supervision intervention in strengthening the capacity of pharmacy staff in Vietnam to deliver client-oriented, accurate healthcare information and appropriate services for childhood diarrhoea and emergency contraceptive pills (ECP).

METHODS

Pre- and post-intervention study using a cross-sectional design. Pharmacy staff participated in 3 days of training on customer relations, good pharmacy practice, childhood diarrhoea and ECP over a period of 1 month, consisting of lectures, discussion, question-and-answer sessions and role-playing. We compared baseline and 6-month post-intervention surveys to ascertain changes in knowledge, attitudes and practice of pharmacists, using univariate statistics to find significant differences.

RESULTS

More than 1200 pharmacists received training and supportive supervision. After interventions, pharmacy staff knowledge was significantly improved on most of the measured indicators. Knowledge of dehydration symptoms for diarrhoea increased from 19% to 88%, and for side effects of ECP increased from 27% to 77%. While assessment of actual practice revealed that this knowledge was not always used, significant improvement was observed. Before interventions, 12% gave information on dehydration symptoms but 45% did so afterwards. The proportion giving information on side effects of ECP increased from 13% to 54%.

CONCLUSIONS

Providing a programme of training and supportive supervision is an effective way to improve knowledge and practice of pharmacists at private pharmacies in Vietnam. These improvements have the potential to lead to better community health care.

The conflicts between professional and non professional work of community pharmacists in Indonesia

Objective

The study aimed to determine the type of professional and non professional work of community pharmacists in Surabaya Indonesia and find the difference between time spent for performing both works in actual (current) situation and ideal (expected) situation.

Methods

A cross sectional study was conducted by combining purposive sampling for selecting the community pharmacists. Afterwards, the data was analyzed using SPSS v16 to provide the descriptive results and completed with Wilcoxon signed rank test to find the difference between time spent in actual and ideal situation. The sample size was 100 respondents of 300 pharmacists who have been practicing in Surabaya.

Results

From 100 participants just 30 participants gave response to the questionnaire, 67% was female who 20-30 years old at most (53%) with working experience as pharmacist less than 3 years (60%) and working 30 hours per week (60%) in pharmacy. Significant difference between time spent in actual and ideal situation was found.

Discussion

The time spent for performing professional and non professional work in ideal situation was significantly higher than in actual situation except for preparing medicines activity. This finding illustrated that the respondents did not have adequate time to provide ideal services in their daily practice. Therefore, they expected to improve their time and level of work in more professional manner. Surprisingly, they were also willing to provide more time and higher level of work in some non professional work.

Conclusions

The Indonesian community pharmacists spent little time on both professional work and non-professional work in their daily activities. This indicated that the pharmacists did not focus on delivering quality professional work.

Frequently used healthcare services in urban slums of Dhaka and adjacent rural areas and their determinants

BACKGROUND

To compare patterns of healthcare service user preference between urban slums in Dhaka and adjacent rural areas and to identify key determinants of those preferences.

METHODS

The data were collected through baseline surveys conducted in 2008 and 2009. A total of 3207 subjects aged 10-90 years were systematically selected from 12 big slums in Dhaka and 3 rural villages outside Dhaka.

RESULTS

Two frequently used healthcare sources utilized in 1 month preceding the baseline survey were pharmacies (slum, 42.6%; rural, 30.1%) and government hospitals/clinics (GVHC; slum, 13.5%; rural, 8.9%). According to the multilevel logistic regression analysis adjusted for age, sex and marital status, the likelihood of using pharmacies and GVHC were higher for those subjects who used non-hygienic toilets, who reported food deficiency at a family level, who expressed dissatisfaction about family income and who stated poor health status. Some more factors namely overweight, living in permanently structured house, smoking bidis and less frequency of watching TV were associated with higher likelihood of using GVHC.

CONCLUSIONS

Pharmacy was the most dominant healthcare service in both areas. As persons running pharmacies often provide poor quality of healthcare services, they need continuous training and back-up supports to improve their quality of services and to strengthen the overall healthcare system in Bangladesh.

Perspectives on child diarrhoea management and health service use among ethnic minority caregivers in Vietnam

BACKGROUND

In Vietnam, primary government health services are now accessible for the whole population including ethnic minority groups (EMGs) living in rural and mountainous areas. However, little is known about EMGs' own perspectives on illness treatment and use of health services. This study investigates treatment seeking strategies for child diarrhoea among ethnic minority caregivers in Northern Vietnam in order to suggest improvements to health services for EMGs and other vulnerable groups.

METHODS

The study obtained qualitative data from eight months of field work among four EMGs in lowland and highland villages in the Northern Lao Cai province. Triangulation of methods included in-depth interviews with 43 caregivers of pre-school children (six years and below) who had a case of diarrhoea during the past month, three focus group discussions (FGDs) with men, and two weeks of observations at two Communal Health Stations (CHGs). Data was content-analyzed by ordering data into empirically and theoretically inspired themes and sub-categories assisted by the software NVivo8.

RESULTS

This study identified several obstacles for EMG caregivers seeking health services, including: gender roles, long travelling distances for highland villagers, concerns about the indirect costs of treatment and a reluctance to use government health facilities due to feelings of being treated disrespectfully by health staff. However, ethnic minority caregivers all recognized the danger signs of child diarrhoea and actively sought simultaneous treatment in different health care systems and home-based care. Treatments were selected by matching the perceived cause and severity of the disease with the 'compatibility' of different treatments to the child.

CONCLUSIONS

In order to improve EMGs' use of government health services it is necessary to improve the communication skills of health staff and to acknowledge both EMGs' explanatory disease models and the significant socio-economic constraints they experience. Broader health promotion programs should address the significant gender roles preventing highland mothers from seeking health services and include family elders and fathers in future health promotion programs. Encouraging existing child health care practices, including continued breastfeeding during illness and the use of home-made rehydration solutions, also present important opportunities for future child health promotion.

Community perceptions and treatment-seeking behaviour regarding reproductive tract infections including sexually transmitted infections in Lao PDR: a qualitative study

Creating community awareness of reproductive tract infections (RTI), including sexually transmitted infections (STI), and how to prevent them is essential to minimize their spread. Data on people's views about RTI/STI are entirely lacking in Laos. The aim of this study was thus to explore people's perceptions, treatment-seeking behaviour and understanding of information about RTI/STI, in urban and rural communities in two provinces in Laos. Fourteen focus group discussions and 20 in-depth interviews were held with 76 women and 56 men, selected purposively to provide diversity of socio-demographic backgrounds. Qualitative content analysis was employed for the data analysis. The major finding was that both male and female participants had a variety of misconceptions about the causes and symptoms of RTI/STI and their cure, and a reluctance to seek health care, which could cause delay in appropriate diagnosis and treatment. The most common treatment-seeking behaviour was self-medication through private pharmacies, following advice mostly given by friends and drug sellers. The main reasons for not going to health facilities were fear of social discrimination or shyness of genital examination. Complaints were also made about clinicians' negative attitudes towards 'dirty disease'. Although condom use was mentioned as a way to prevent RTI/STI, an unwillingness to use condoms was commonly expressed. The main media sources of RTI/STI information were radio and television, and access to health information was more difficult in rural areas. The health messages provided were mostly understood, except for some technical terms. The findings indicate that strengthening health education and promotion through interventions at the community level is recommended to improve quality of RTI/STI management. Health education messages should be more accessible in rural areas. There is also an urgent need to improve communication between RTI/STI patients and clinicians.

Knowledge, legitimacy and economic practice in informal markets for medicine: a critical review of research

Current debates and market based interventions in international public health seek to bring about explicit improvements in the quality of care offered by informal providers. In this paper we examine how informal providers are framed as problematic and question assumptions about what constitutes appropriate knowledge and expectations of how economic actors in the medical marketplace will behave. We argue that existing portraits of informal providers tend to establish clear cut distinctions between different kinds of practitioner; 'dis-embed' biomedical transactions from the broader relationships within which they take place; freeze or anatomise what are dynamic economic relationships between stakeholders, and obscure or ignore the position of informal providers in a global pharmaceutical supply chain.

Client and pharmacist factors affecting practice in the management of upper respiratory tract infection presented in community pharmacies: a simulated client study

Objectives

To assess the quality of care provided by community pharmacists for simulated clients (SCs) with upper respiratory tract infection (URI) and to examine the effects of gender and appearance of socioeconomic status (SES) of the SCs on the practice.

Setting

Thirty-two community pharmacies in the south of Thailand with four male and four female SCs.

Method

Each SC visited eight community pharmacies twice, 1month apart, once with moderate and once with an appearance of low SES, in random order. Key outcome variables were history-taking, advice-giving, and antibiotic-dispensing, based on international guidelines. Descriptive statistics and mixed-effects models with nesting of SCs and community pharmacies were conducted.

Key findings

The mean scores for history-taking and advice-giving were low. The proportions of 128 encounters ending up with antibiotics, corticosteroids and nonsteroidal anti-inflammatory drugs were 87.5, 12.5 and 7.8%, respectively. Pharmacist practice did not differ by SC gender or appearance of SES.

Conclusion

Such practice by pharmacists needs improvement. Further studies to confirm the lack of effect of clients' gender and SES are needed.

Continuing education meetings and workshops: effects on professional practice and health care outcomes

BACKGROUND

Educational meetings are widely used for continuing medical education. Previous reviews found that interactive workshops resulted in moderately large improvements in professional practice, whereas didactic sessions did not.

OBJECTIVES

To assess the effects of educational meetings on professional practice and healthcare outcomes.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Effective Practice and Organisation of Care Group Trials Register and pending file, from 1999 to March 2006.

SELECTION CRITERIA

Randomised controlled trials of educational meetings that reported an objective measure of professional practice or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Studies with a low or moderate risk of bias and that reported baseline data were included in the primary analysis. They were weighted according to the number of health professionals participating. For each comparison, we calculated the risk difference (RD) for dichotomous outcomes, adjusted for baseline compliance; and for continuous outcomes the percentage change relative to the control group average after the intervention, adjusted for baseline performance. Professional and patient outcomes were analysed separately. We considered 10 factors to explain heterogeneity of effect estimates using weighted meta-regression supplemented by visual analysis of bubble and box plots.

MAIN RESULTS

In updating the review, 49 new studies were identified for inclusion. A total of 81 trials involving more than 11,000 health professionals are now included in the review. Based on 30 trials (36 comparisons), the median adjusted RD in compliance with desired practice was 6% (interquartile range 1.8 to 15.9) when any intervention in which educational meetings were a component was compared to no intervention. Educational meetings alone had similar effects (median adjusted RD 6%, interquartile range 2.9 to 15.3; based on 21 comparisons in 19 trials). For continuous outcomes the median adjusted percentage change relative to control was 10% (interquartile range 8 to 32%; 5 trials). For patient outcomes the median adjusted RD in achievement of treatment goals was 3.0 (interquartile range 0.1 to 4.0; 5 trials). Based on univariate meta-regression analyses of the 36 comparisons with dichotomous outcomes for professional practice, higher attendance at the educational meetings was associated with larger adjusted RDs (P < 0.01); mixed interactive and didactic education meetings (median adjusted RD 13.6) were more effective than either didactic meetings (RD 6.9) or interactive meetings (RD 3.0). Educational meetings did not appear to be effective for complex behaviours (adjusted RD -0.3) compared to less complex behaviours; they appeared to be less effective for less serious outcomes (RD 2.9) than for more serious outcomes.

AUTHORS' CONCLUSIONS

Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients. The effect is most likely to be small and similar to other types of continuing medical education, such as audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings. Educational meetings alone are not likely to be effective for changing complex behaviours.

Pharmacy workers' sexually transmitted diseases/human immunodeficiency virus knowledge in Fuzhou, China: implications for human immunodeficiency virus testing, treatment, and prevention strategies

BACKGROUND

Pharmacies play a special role in providing treatment services for patients with sexually transmitted diseases (STDs) in China. There is a need to study the STD/human immunodeficiency virus (HIV) knowledge among pharmacy workers in retail pharmacies.

METHOD

A total of 200 pharmacy workers were recruited from 120 randomly selected retail pharmacies in Fuzhou, China. A self-administrated questionnaire was used to collect information of demographics, working experience, pharmacy structure and clientele profile, and pharmacy workers' attitudes toward traditional Chinese folk remedies and their STD/HIV knowledge.

RESULTS

Work-related training during the past 6 months, holding pharmacist license, and years of being a pharmacy worker showed significant association with STD/HIV knowledge. Work-related training also significantly associated with provision of consultation. Years of education and medical training, however, failed to show significant association with STD/HIV knowledge.

CONCLUSIONS

In order to improve service quality and avoid misdiagnosis and inappropriate treatment of STD/HIV, on-the-job training or continuous education for pharmacy workers should be required, implemented, and monitored as part of the national effort for STD control and treatment.