Management of childhood acute respiratory infections at private pharmacies in Vietnam

Health system barriers to the implementation of the national action plan to combat antimicrobial resistance in Vietnam: a scoping review

BACKGROUND

Vietnam is among 11 countries in the Western Pacific region that has developed a National Action Plan for Antimicrobial Resistance (NAPCA).

METHODS

This scoping review characterises health system barriers to the implementation of the Vietnam NAPCA, with reference to the WHO Health Systems Framework.

RESULTS

Over 7 years, between 2013 and 2020, the Ministry of Health (MOH) of Vietnam has been implementing activities to achieve the six NAPCA objectives. They include revision of regulations needed for antimicrobial resistance (AMR) prevention programs; formation and operation of national management bodies; improvement of antimicrobial stewardship (AMS) in hospitals; maintenance of surveillance systems for AMR; provision of trainings on AMR and antibiotics use to doctors and pharmacists; and organization of nation-wide educational campaigns. Limited cooperation between MOH management bodies, shortages of human resource at all health system levels, a low degree of agreement between national and hospital guidelines on antibiotic use, low capability in the domestic supply of standardised drugs, and unequal training opportunities for lower-level health professionals present ongoing challenges. Actions suggested for the next period of the NAPCA include a final review of what has been achieved by the plan so far and evaluating the effectiveness of the different components of the plan. Different options on how to improve coordination across sectors in the development of a new NAPCA should be put forward.

CONCLUSIONS

The 6-year implementation of the Vietnam NAPCA has yielded valuable lessons for AMS in Vietnam, guiding the development of future national plans, with a central focus on scaling up AMS in hospitals and promoting community AMS programs to combat AMR.

Community Pharmacies in the Asian Countries of Developing Health System: Formation, Regulation, and Implication

Community pharmacies (CPs) in Asian countries are often the first point of contact for patients withinthe healthcare system and their preferred place to purchase medicines. The number of CPs may vary across Asian countries, and each country has developed its own design and functioning. The regulatory environment plays a crucial role in shaping and governing CPs. The aim of this study was to conduct a comprehensive literature review in order to enhance understanding of the establishment and regulation of CPs. By undertaking this review, the researchers, policymakers, and practitioners sought to gain a deeper insight into the performance and functions of CPs and the regulatory frameworks that govern them. Moreover, this review shed light on implementation strategies, effects on patient outcomes, and the barriers and challenges associated with their establishment. A narrative literature review method was adopted with specific inclusion and exclusion criteria. Significant disparities can be observed when comparing the stated intentions of regulations with their actual implementation. Recently, there has been an inclusion of public health practices. Unfortunately, pharmacy procedures conducted in such environments have been characterized by inadequate understanding and inappropriate care. This poor performance can be attributed to employees' focus on maximizing profits. Several shortcomings can arise, including incomplete patient history documentation, failure to refer patients who require medical attention, unauthorized dispensing of prescription-only medicines (POM), dispensing clinically inappropriate or excessive medication doses, selling incomplete antibiotic courses, and inadequate information and counseling services. Regulatory interventions can help strengthen these services.

Mapping access to drug outlets in Vietnam: distribution of drug outlets and the sociodemographic characteristics of the communities they serve

Background

Drug outlets are a vital first point of healthcare contact in low- and middle-income countries (LMICs), but they are often poorly regulated and counter staff may be unqualified to provide advice. This introduces the risk of easy access to potentially harmful products, including unnecessary antimicrobials. Over-the-counter antimicrobial sales are a major driver of antimicrobial resistance (AMR) in LMICs. We aimed to investigate the distribution of different types of drug outlets and their association with socio-economic factors.

Methods

We mapped the location of drug outlets in 40 randomly selected geographic clusters, covering a population of 1.96 million people. Data including type of drug outlet, context, operating hours, chief pharmacist name and qualification, and business registration identification were collected from mandatory public signage. We describe the density of drug outlets and levels of staff qualifications in relation to population density, urban vs rural areas, and poverty indices.

Findings

We characterised 1972 drug outlets. In the study area, there was an average of 102 outlets/per 100,000 population, compared to the global average of 25. Predictably, population density was correlated with the density of drug outlets. We found that drug outlets were less accessible in rural vs urban areas, and for the poor. Furthermore, for these populations, degree-qualified pharmacists were less accessible and public signage frequently lacked mandatory registration information.

Interpretation

Drug outlets appear over-supplied in Vietnam compared to other countries. Unregistered outlets and outlets without degree-qualified pharmacists are prevalent, especially in poor and rural areas, posing a risk for inappropriate supply of antimicrobials, which may contribute to AMR, and raises questions of equitable healthcare access.

Funding

This study was funded by a grant from the Australian Department of Foreign Affairs and Trade.

Impact of a multifaceted intervention on physicians' knowledge, attitudes and practices in relation to pharmaceutical incentivisation: protocol for a randomised control trial

INTRODUCTION

In settings where the private sector constitutes a larger part of the health system, profit-gathering can take primacy over patients' well-being. In their interactions with pharmaceutical companies, private general practitioners (GPs) can experience the conflict of interest (COI), a situation whereby the impartiality of GPs' professional decision making may be influenced by secondary interests such as financial gains from prescribing specific pharmaceutical brands.

METHODS AND ANALYSIS

This study is a randomised controlled trial to assess the impact of a multifaceted intervention on GPs' medical practice. The study sample consists of 419 registered GPs who own/work in private clinics and will be randomly assigned to intervention and control groups. The intervention group GPs will be exposed to emotive and educational seminars on medical ethics, whereas control group GPs will be given seminars on general medical topics. The primary outcome measure will be GPs' prescribing practices, whereas the secondary outcome measures will be their knowledge and attitudes regarding COI that arises from pharmaceutical incentivisation. In addition to a novel standardised pharmaceutical representatives (SPSR) method, in which field researchers will simulate pharmaceutical marketing with GPs, presurvey and postsurvey, and qualitative interviewing will be performed to collect data on GPs' knowledge, attitudes and practices in relation to COI linked with pharmaceutical incentives. Univariate and multivariate statistical analyses will be performed to measure a change in GPs' knowledge, attitudes and practices, while qualitative analysis will add to our understanding of the quantitative SPSR data.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Pakistan National Bioethics Committee (# 4-87/NBC-582/21/1364), the Aga Khan University (# 2020-4759-1129) and the London School of Hygiene and Tropical Medicine (# 26506). We will release results within 6-9 months of the study's completion.

TRIAL REGISTRATION NUMBER

ISRCTN12294839.

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.

Drivers of antibiotic use in Vietnam: implications for designing community interventions

INTRODUCTION

Antimicrobial resistance is a global challenge that threatens our ability to prevent and treat common infectious diseases. Vietnam is affected by high rates of antimicrobial resistant infections, driven by the overuse of antibiotics and the Vietnamese government has recognised antimicrobial resistance as a health security priority. This study aimed to understand how people in Vietnam use antibiotics in community settings, and the factors that impact their practices and decision-making regarding antibiotics.

METHODS

We conducted 43 qualitative in-depth interviews with 50 community members in two urban and two rural sites in Vietnam. We conducted iterative, inductive thematic analysis alongside data collection through a process of systematic debriefings based on detailed interview summaries. Through this process, we developed a coding framework that was then applied to transcribed interview data.

RESULTS

Frequent and indiscriminate use of antibiotics was driven by the powerful appeal that antibiotics held for many Vietnamese consumers. Consumers were discerning in making decisions in their purchase and use of antibiotics. Consumers' decisions were affected by perceptions of what constitutes high-quality medicine (effective, strong, accessible and affordable); privileging symptom control over diagnosis; social constructions of antibiotics as a trusted remedy with embodied evidence of prior efficacy, which is reinforced by advice from trusted sources in their community; and varied, generally incomplete, understanding of the concept of antibiotic resistance and its implications for individuals and for public health.

CONCLUSION

Antibiotic use at the community and primary care level in Vietnam is driven by community members' social and economic response to what constitutes effective healthcare, rather than biomedical logic. Community-based interventions to reduce unnecessary antibiotic use need to engage with the entangled socio-structural factors that 'resist' current public health efforts to ration antibiotic use, alongside biomedical drivers. This study has informed the design of a community-based trial to reduce unnecessary antibiotic use.

Factors Related to Antibiotic Supply without a Prescription for Common Infections: A Cross-Sectional National Survey in Sri Lanka

Inappropriate antibiotic use is a problem in Sri Lanka. We investigated pharmacy staff’s attitudes towards antibiotic supply for common infections in Sri Lanka. A self-reported cross-sectional survey was conducted among a random sample (n = 369) of pharmacies. We assessed staff’s beliefs and attitudes to antibiotic supplying for common infections (common cold and cough, sore throat, diarrhoea, wound and urinary tract infections (UTI)). Pharmacists (n = 210; 79%) and pharmacy assistants (n = 55: 21%) responded. About 30% (80/265) had supplied antibiotics without a prescription for common infections, including common cold (15.8%), sore throat (13.6%) and diarrhoea (10.2%). Overall, pharmacists were less likely to supply than non-pharmacists. Pharmacy staff with more positive beliefs about their professional competency to supply and monitor antibiotic use were more likely to supply antibiotics without a prescription for common cold (Adj.OR = 1.08; 95% CI: 1.01–1.15; p = 0.032), wound infections (Adj. OR = 1.06; 95% CI: 1.00–1.13; p = 0.059), and UTI (Adj.OR = 1.07; 95% CI: 0.99–1.15; p = 0.097). Pharmacy staff who believed in the effectiveness of antibiotics against common infections were more likely to supply antibiotics for common infections. Supply of antibiotics without a prescription was associated with staff’s beliefs about antibiotics’ effectiveness and their professional competency. Our findings could be used to strengthen regulatory strategies to improve practice.

Economic and social drivers of antibiotic dispensing practices among community pharmacies in Nepal

OBJECTIVE

To assess economic and social drivers of dispensing antibiotics without prescription by community pharmacies in Nepal.

METHOD

A survey was conducted among 111 pharmacy owners and managers in five districts. Information on demographic and economic characteristics of the pharmacies (e.g. revenue and profits from antibiotics) and their inclination to sell antibiotics without a physician's prescription under various scenarios (e.g. diarrhoea in a child) was collected. Univariate analysis was conducted to assess the demographic and economic characteristics. Bivariate analysis was conducted to examine the relationship between dispensing antibiotics without prescription and economic and social factors.

RESULTS

Azithromycin and amoxicillin were the most commonly dispensed antibiotics. The proportions of pharmacies reporting that they would 'most likely' or 'likely' dispense antibiotics without prescription to adult patients ranged from 36.9% (sore throat) to 67.6% (cough). The proportions for paediatric patients ranged from 62.2% (sore throat) to 80.2% (cough or diarrhoea). There was no consistent relationship between the likelihood of dispensing antibiotics and revenues, profits or the number of patients. Instead, dispensing behaviour was influenced by the pressure from the patient; the respondents were more likely to dispense antibiotics when the patient specifically asked for 'an antibiotic' rather than for 'a medicine', and 68.5% respondents ranked 'customer satisfaction' as the most important factor motivating their work.

CONCLUSIONS

In Nepal, inappropriate sale of antibiotics by community pharmacists is high, particularly for paediatric patients. Additional research is needed to establish key drivers of this behaviour and to help design effective approaches to reducing AMR.

Compliance of private pharmacies in Uganda with controlled prescription drugs regulations: a mixed-methods study

Background

Controlled prescription drug use disorders are a growing global health challenge in Sub-Saharan Africa. Effective supply chain regulations on dispensing and stock control are important for controlling this epidemic. Since compliance with these regulations in resource-limited countries is poor, there is need to understand its predictors in order to reduce the risk of prescription drug use disorders.

Methods

A mixed-methods study utilizing a structured questionnaire and a simulated client guide was undertaken in Kampala and Mbale towns in Uganda. The questionnaire recorded self-reported dispensing and verified stock control practices and their covariates from 101 private pharmacies. The guide recorded actual dispensing practices from 27 pharmacies. Snowball sampling was done to enrich the sample with pharmacies that stock opioids. The mean compliance with good dispensing and stock control practices was calculated. Multivariate logistic regression analyses were applied to identify predictors of compliance.

Results

The mean compliance with dispensing and stock control requirements was 82.9% and 23%, respectively. Twenty percent and 40% of the pharmacies dispensed pethidine without a prescription and with invalid prescriptions, respectively. Having a pharmacist on duty (OR = 5.17; p = 0.02), prior in-service training on narcotics regulations (OR = 3.51; p = 0.04), and previous narcotics audits by the regulator (OR = 5.11; p = 0.01) were independent predictors of compliance with stock control requirements. Pharmacies with a previous history of poor compliance with dispensing requirements were less likely to demonstrate good compliance (OR = 0.21; p = 0.01).

Conclusions

There is suboptimal compliance to controlled prescription drug regulations among Uganda’s pharmacies. A previous history of poor compliance to dispensing requirements predicted low compliance in subsequent assessments. Training and regulatory audits increased compliance in stock control but not dispensing. Expansion of training and audits to more pharmacies and/or incentives for compliance are necessary.

"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.

Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia

BACKGROUND

Global attention to antimicrobial resistance has increased interest in tackling the widespread inappropriate dispensing of antibiotics by informal, for-profit healthcare providers (HCPs). We provide new evidence on an understudied group of informal HCPs: invisible medicine sellers (IMS) who operate without any marked facility. We investigated factors that influence community decisions on which HCPs to purchase medicines from, focusing on reasons for using IMS, and compared different HCPs' knowledge of antibiotic use.

METHODS

We conducted community focus group discussions (FGDs) in seven purposively selected villages representing high and low informal HCPs use in two peri-urban districts in Phnom Penh, Cambodia. Using information from the FGDs to identify HCPs that sell medicines, we interviewed 35 participants: 21 HCPs (including five IMS) and 14 key informants, including government HCPs and village leaders. We adopted an interpretative approach and conducted a thematic analysis.

RESULTS

Community members typically knew of several formal and informal HCPs selling medicines nearby, and IMS were common, as were doctors that sell medicines covertly. Two factors were most salient in influencing the choice of HCP for medicine purchasing. The first was trust in the effectiveness of medicines provided, judged by the speed of symptomatic relief. This pushed HCPs to provide several medicines, including antibiotics, at the first consultation. The second was the convenience offered by IMS and other informal HCPs: supplying medicines when other facilities are closed, accepting delayed payments, providing incomplete courses of medication and selling human antibiotics for animal use.

CONCLUSION

This first study focusing on IMS indicates that it is important, but challenging, for public health agencies to engage with them to reduce inappropriate use of antibiotics. Although public health facilities must fill some gaps that informal HCPs are currently addressing, such as access to medicines at night, reducing demand for unnecessary antibiotics is also critical.

The provision of advice by pharmacy staff in eastern Indonesian community pharmacies

Background:

Indonesian community pharmacies hold a strategic position from which to promote the rational use of medicines by providing appropriate advice for patients requesting self-medication. To date, published studies related to the provision of advice in Indonesian community pharmacies are limited and have been conducted only in more developed western Indonesia. No studies have been undertaken in eastern Indonesia, which is less developed than and culturally different from the western region.

Objectives:

This paper aims to: (1) describe the types and amount of advice provided by pharmacy staff for three scenarios in a patient simulation study and for two scenarios in pharmacy staff interviews; and (2) ascertain the frequency of appropriate advice given in response to the scenarios.

Methods:

A patient simulation study was conducted at community pharmacies in an eastern Indonesian provincial capital. Four weeks after completing a patient simulation study, structured interviews with pharmacy staff were conducted. Two cough scenarios and one diarrhoea scenario were developed for the patient simulation study. Meanwhile, two scenarios (an ACE inhibitor-induced cough and a common cough and cold) were developed for pharmacy staff interviews. The types and amount of advice provided by pharmacy staff were recorded on paper and assessed for its appropriateness. The determination of appropriate advice was based on the literature and by consensus of two Indonesian experts.

Results:

In patient simulation, the most common type of advice provided in all scenarios was product recommendations. In interviews, medical referrals and recommending cough and cold medicine were the most common types of advice provided for ACE inhibitor-induced cough and common cough and cold scenarios respectively. Appropriate advice was provided in less than 0.5% in the patient simulation study, but two-third of participants in the interviews responded to the scenarios appropriately.

Conclusions:

Pharmacy staff did not provide appropriate advice in practice, although they may have adequate knowledge. A contributing factor was insufficient information gathered in patient encounters. Optimising information-gathering practice by pharmacy staff is needed.

Effectiveness of an educational intervention to improve antibiotic dispensing practices for acute respiratory illness among drug sellers in pharmacies, a pilot study in Bangladesh

BACKGROUND

Inappropriate dispensing of antibiotics for acute respiratory illness (ARI) is common among drug sellers in Bangladesh. In this study, we evaluated the impact of an educational intervention to promote guidelines for better ARI management among drug sellers.

METHODS

From June 2012 to December 2013, we conducted baseline and post-intervention surveys on dispensing practices in 100 pharmacies within Dhaka city. In these surveys, drug sellers participated in 6 standardized role-playing scenarios led by study staffs acting as caregivers of ARI patients and drug sellers were blinded to these surveys. After the baseline survey, we developed ARI guidelines and facilitated a one-day educational intervention about ARI management for drug sellers. Our guidelines only recommended antibiotics for children with complicated ARI. Finally, we conducted the six month post-intervention survey using the same scenarios to record changes in drug dispensing practices.

RESULTS

Only 2/3 of participating pharmacies were licensed and few (11%) of drug sellers had pharmacy training. All the drug sellers were male, had a median age of 34 years (IQR 28-41). For children, dispensing of antibiotics for uncomplicated ARI decreased (30% baseline vs. 21% post-intervention; p = 0.04), but drug sellers were equally likely to dispense antibiotics for complicated ARI (15% baseline vs. 17% post-intervention; p = 0.6) and referrals to physicians for complicated ARIs decreased (70% baseline vs. 58% post-intervention; p = 0.03). For adults, antibiotic dispensing remained similar for uncomplicated ARI (48% baseline vs. 40% post-intervention; p = 0.1) but increased among those with complicated ARI (44% baseline vs. 78% post-intervention; p < 0.001). Although our evidence-based guidelines recommended against prescribing antihistamines for children, drug sellers continued to sell similar amounts for uncomplicated ARI (33% baseline vs. 32% post-intervention; p = 0.9).

CONCLUSIONS

Despite the intervention, drug sellers continued to frequently dispense antibiotics for ARI, except for children with uncomplicated ARI. Pairing educational interventions among drug sellers with raising awareness about proper antibiotic use among general population should be further explored. In addition, annual licensing and an reaccreditation system with comprehensive monitoring should be enforced, using penalties for non-compliant pharmacies as possible incentives for appropriate dispensing practices.

Are pharmacists' good knowledge and awareness on antibiotics taken for granted? The situation in Albania and future implications across countries

OBJECTIVES

Irrational use of antibiotics is a major driver of antimicrobial resistance (AMR), exacerbated by dispensing of antibiotics without a prescription especially for typically viral infections. Such dispensing is common despite legislation. Pharmacists play a key role in advising on medicines, especially in countries where most patients seek pharmacist help as they cannot afford both physician fees and medicines. Consequently, our objective was to ascertain pharmacists' skills and knowledge regarding antibiotics when patients present to them with typically viral infections.

METHODS

This was a qualitative cross-sectional survey among 370 community pharmacists in Albania, with carefully selected and validated topics. The main outcome measure was knowledge of antibiotics and current legislation.

RESULTS

Variable knowledge regarding antibiotics among community pharmacists. 55% knew colds are caused by viruses and 93% that antibiotics are ineffective against influenza. However, 18% believed if colds last >4 days an antibiotic can bring a patient back to work, and only 13% stated antibiotics are ineffective against viruses. Encouragingly, 93% knew penicillins can cause anaphylactic shock, 74% that antibiotics kill bacteria causing infections, and only 7% that antibiotic misuse cannot cause AMR. However, 13% stated the main disadvantage of antibiotics is that they are ineffective against viruses and 93% admitted they had no treatment protocols to consult in their daily work to direct patient care.

CONCLUSION

Encouraging signs regarding pharmacists' knowledge of antibiotics in Albania; however, concerns. Instigating educational programmes among patients and pharmacists and greater enforcement of legislation should reduce AMR rates in Albania and across countries.

Do chain pharmacies perform better than independent pharmacies? Evidence from a standardised patient study of the management of childhood diarrhoea and suspected tuberculosis in urban India

Introduction

Pharmacies and drug stores are frequently patients’ first point of care in many low-income and middle-income countries, but their practice is often poor. Pharmacy retailing in India has traditionally been dominated by local, individually owned shops, but recent years have seen the growth of pharmacy chains. In theory, lower-powered profit incentives and self-regulation to preserve brand identity may lead to higher quality in chain stores. In practice, this has been little studied.

Methods

We randomly selected a stratified sample of chain and independent pharmacies in urban Bengaluru. Standardised patients (SPs) visited pharmacies and presented a scripted case of diarrhoea for a child and suspected tuberculosis (TB). SPs were debriefed immediately after the visit using a structured questionnaire. We measured the quality of history taking, therapeutic management and advice giving against national (Government of India) and international (WHO) guidelines. We used Pearson’s χ² tests to examine associations between pharmacy type and case management.

Findings

Management of childhood diarrhoea and suspected TB was woefully substandard. History taking of the SP was limited; unnecessary and harmful medicines, including antibiotics, were commonly sold; and advice giving was near non-existent. The performance of chains and independent shops was strikingly similar for most areas of assessment. We observed no significant differences between the management of suspected TB in chains and independents. 43% of chains and 45% of independents managed the TB case correctly; 17% and 16% of chains and independents, respectively, sold antibiotics. We found that chains sold significantly fewer harmful antibiotics and antidiarrhoeals (35% vs 48%, p=0.029) and prescription-only medicines (37% vs 49%, p=0.048) for the patient with diarrhoea compared with independent shops. Not a single shop managed the patient with diarrhoea correctly according to guidelines.

Conclusion

Our results from Bengaluru suggest that it is unlikely that chains alone can solve persisting quality challenges. However, they may offer a potential vehicle through which to deliver interventions. Future intervention research should consider recruiting chains to see whether effectiveness of interventions differ among chains compared with independents.

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.

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.

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.

Systematic review on irrational use of medicines in China and Vietnam

Background

Irrational use of medicines has been an issue concerned all over the world and the outlooks in developing countries are more severe. This study aimed to assess the different patterns of irrational use of medicines and its influential factors in China and Vietnam.

Methods

A systematic review was performed on both published and grey literatures in English, Chinese and Vietnamese languages between 1993 and 2013 based on the WHO framework. Quality assessment was conducted on the basis of the Critical Appraisal Skills Programme. Key indicators were analyzed to compare the irrational use of medicines in two countries.

Results

A total of 67 published works about China and 29 about Vietnam were included, the majority of which were cross-sectional prescription studies in both China and Vietnam. Irrational use of medicines was found in both the countries but issues with polypharmacy as well as overuse of antibiotics were more severe in Vietnam while overuse of injections was unique to China. Various patterns of irrational use were also indicated between urban and rural areas, and among different levels of hospitals. Rarely does literature focus on the analysis of influential factors of irrational use of medicines. While lack of proper knowledge from both providers and patients were the most recognized influential factors in both countries, economic incentives from pharmaceutical companies in China, and weak control and regulation over prescriptions in Vietnam were the main factors attributed to this issue.

Conclusion

Severe irrational use of medicines has been abundantly evidenced in both China and Vietnam, highlighting the importance of policy interventions on the issue. However, limited evidence on the appropriateness or its compliance (conformity) to guidelines of prescription has been found. In addition, convincing evidence on the underlying explanation of this issue is lacking, although economic incentives, health insurance coverage, and knowledge of service providers and users have been implied to be factors influencing irrational drug use.

A review of the provision of appropriate advice by pharmacy staff for self-medication in developing countries

BACKGROUND

Patients in developing countries often prefer to self-medicate via community pharmacies. Pharmacy staff are therefore in a strategic position to optimize the health of the public by providing appropriate advice to patients who self-medicate.

OBJECTIVE

To determine the proportion of pharmacy staff who provide appropriate advice when handling self-medication requests in developing countries.

METHOD

A literature search was undertaken via MEDLINE, EMBASE, CINAHL Plus, Web of Science and International Pharmaceutical Abstracts. Studies that reported on the proportion of pharmacy staff providing appropriate advice when handling self-medication requests in developing countries were included. The appropriateness of advice was determined by each author's definition in the original studies.

RESULTS

Twenty-eight studies met the inclusion criteria. There were variations in methods, scenarios, how the authors reported and defined appropriate advice, and study populations. The proportion of pharmacy staff providing appropriate advice varied widely from 0% to 96%, with a minority providing appropriate advice in 83% of the scenarios performed.

CONCLUSION

There was considerable variation in results, with the majority of studies reporting that inappropriate advice was provided by pharmacy staff when handling self-medication requests in developing countries. Consistent and robust methods are required to provide comparisons across practice settings. There is also a need to identify contributing factors to poor provision of advice for developing intervention strategies for practice improvement.

Understanding and changing human behaviour--antibiotic mainstreaming as an approach to facilitate modification of provider and consumer behaviour

This paper addresses: 1) Situations where human behaviour is involved in relation to antibiotics, focusing on providers and consumers; 2) Theories about human behaviour and factors influencing behaviour in relation to antibiotics; 3) How behaviour in relation to antibiotics can change; and, 4) Antibiotic mainstreaming as an approach to facilitate changes in human behaviour as regards antibiotics. Influencing human behaviour in relation to antibiotics is a complex process which includes factors like knowledge, attitudes, social norms, socio-economic conditions, peer pressure, experiences, and bio-physical and socio-behavioural environment. Further, key concepts are often perceived in different ways by different individuals. While designing and implementing projects or programmes for behavioural change with respect to antibiotics for professionals or consumers it is helpful to consider theories or models of behaviour change, e.g. the 'stages of change model', including pre-contemplation, contemplation, preparation, action, and maintenance. People in different stages of change are susceptible to different behaviour modification strategies. Application of marketing principles to 'global good', so-called 'social marketing', to improve 'welfare of the individual and society' is gaining increased attention in public health. In conclusion, just providing correct knowledge is not sufficient although it is a pre-requisite for behaviour modification in the desired direction. We can never change the behaviour of any other human, but we can facilitate for others to change their own behaviour. One possibility is to implement 'antibiotic mainstreaming' as a potentially effective way for behaviour modification, i.e. to address consequences for maintaining effective antibiotics in all activities and decisions in society.

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.

Protecting the public or setting the bar too high? Understanding the causes and consequences of regulatory actions of front-line regulators and specialized drug shop operators in Kenya

The problem of poor regulatory compliance has been widely reported across private health providers in developing countries. Less known are the underlying reasons for poor compliance, especially with regards to the roles played by front-line regulatory staff, and the regulatory institution as a whole. We designed a qualitative study to address this gap, with the study questions and tools drawing on a conceptual framework informed by theoretical literature on regulation. Data were collected from specialized drug shops (SDSs) in two rural districts in Western Kenya in 2011 through eight focus group discussions, and from regulatory staff from organizations governing the pharmaceutical sector through a total of 24 in-depth interviews. We found that relationships between front-line regulators and SDS operators were a strong influence on regulatory behaviour, often resulting in non-compliance and perverse outcomes such as corruption. It emerged that separate regulatory streams operated in urban and rural locations, based mainly on differing relationships between the front-line regulators and SDS operators, and on broader factors such as the competition environment and community expectations. Effective incentive structures for regulatory staff were either absent, or poorly linked to performance in regulatory organizations, resulting in divergences between the purposes of the regulatory organization and activities of front-line staff. Given the rural-urban differences in the practice environment, the introduction of lower retail practice requirements for rural SDSs could be considered. This would allow illegally operated shops to be brought within the regulatory framework, facilitating good quality provision of essential commodities to marginalized areas, without lowering the practice requirements for the better complying urban SDSs. In addition, regulatory organizations need to devise incentives that better link the level of effort to rewards such as professional advancement of regulatory staff.

What is the role of informal healthcare providers in developing countries? A systematic review

Informal health care providers (IPs) comprise a significant component of health systems in developing nations. Yet little is known about the most basic characteristics of performance, cost, quality, utilization, and size of this sector. To address this gap we conducted a comprehensive literature review on the informal health care sector in developing countries. We searched for studies published since 2000 through electronic databases PubMed, Google Scholar, and relevant grey literature from The New York Academy of Medicine, The World Bank, The Center for Global Development, USAID, SHOPS (formerly PSP-One), The World Health Organization, DFID, Human Resources for Health Global Resource Center. In total, 334 articles were retrieved, and 122 met inclusion criteria and chosen for data abstraction. Results indicate that IPs make up a significant portion of the healthcare sector globally, with almost half of studies (48%) from Sub-Saharan Africa. Utilization estimates from 24 studies in the literature of IP for healthcare services ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement. IPs operate in a variety of health areas, although baseline information on quality is notably incomplete and poor quality of care is generally assumed. There was a wide variation in how quality of care is measured. The review found that IPs reported inadequate drug provision, poor adherence to clinical national guidelines, and that there were gaps in knowledge and provider practice; however, studies also found that the formal sector also reported poor provider practices. Reasons for using IPs included convenience, affordability, and social and cultural effects. Recommendations from the literature amount to a call for more engagement with the IP sector. IPs are a large component of nearly all developing country health systems. Research and policies of engagement are needed.

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.

A review of the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries

BACKGROUND

Currently, no review has been completed regarding the information-gathering process for the provision of medicines for self-medication in community pharmacies in developing countries.

OBJECTIVE

To review the rate of information gathering and the types of information gathered when patients present for self-medication requests.

METHODS

Six databases were searched for studies that described the rate of information gathering and/or the types of information gathered in the provision of medicines for self-medication in community pharmacies in developing countries. The types of information reported were classified as: signs and symptoms, patient identity, action taken, medications, medical history, and others.

RESULTS

Twenty-two studies met the inclusion criteria. Variations in the study populations, types of scenarios, research methods, and data reporting were observed. The reported rate of information gathering varied from 18% to 97%, depending on the research methods used. Information on signs and symptoms and patient identity was more frequently reported to be gathered compared with information on action taken, medications, and medical history.

CONCLUSION

Evidence showed that the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries is inconsistent. There is a need to determine the barriers to appropriate information-gathering practice as well as to develop strategies to implement effective information-gathering processes. It is also recommended that international and national pharmacy organizations, including pharmacy academics and pharmacy researchers, develop a consensus on the types of information that should be reported in the original studies. This will facilitate comparison across studies so that areas that need improvement can be identified.

Indicators of quality use of medicines in South-East Asian countries: a systematic review

OBJECTIVES

To identify indicators of quality use of medicines used in South-East Asian region.

METHODS

A systematic review was conducted searching MEDLINE, Embase and The International Network for Rational Use of Drugs (INRUD) and The World Health Organization (WHO) website. Original studies or reports carried out in the South-East Asian region, explicitly using indicators to measure quality use of medicines, and published between January 2000 and July 2011 were included.

RESULTS

A total of 17 studies conducted in 7 of 11 countries in South-East Asia were included. WHO indicators focusing on general medication use in health facilities were most widely used (10 studies). Twelve studies used non-WHO indicators for measuring quality use of medicines in clinical areas (geriatrics and obstetrics) or specific diseases, such as diarrhoea and pneumonia. In five studies, WHO indicators were used along with non-WHO indicators. There was little information available about validity, reliability and feasibility of the non-WHO indicators. The majority of indicators measured process rather than structure or outcome. There were very few indicators addressing non-communicable diseases.

CONCLUSIONS

A limited number of studies have been published explicitly using indicators of quality use of medicines across South-East Asia. Importantly, existing indicators need to be complemented with valid, reliable and feasible indicators related to non-communicable diseases, particularly those with a high financial burden to meet the current medical challenges in the region.

Drug use and self-medication among children with respiratory illness or diarrhea in a rural district in Vietnam: a qualitative study

Aims

To explore the knowledge, attitudes, and behaviors of parents in their use of drugs for respiratory illness or diarrhea among children under 5 years of age, and to understand factors influencing self-medication.

Methods

A qualitative study was conducted, using in-depth interviews with two drug sellers and three health care providers, and four focus-group discussions with mothers of children under 5 years of age. Verbatim transcriptions were analyzed, and emerging themes and categories identified, using content analysis.

Results

Use of a number of different drugs was reported, including broad-spectrum antibiotics and corticosteroids. There was poor awareness of side-effects, antibiotic resistance, and drug efficacy. Factors influencing self-medication were perceptions of the illness in the child, waiting time, and convenience, the attitudes of public health medical staff, insufficient drug supply in public health facilities, and poor control of prescribed drugs on the market.

Conclusion

Misuse and misconceptions regarding drug use gave rise to considerable problems. Mothers’ knowledge and attitudes to illness and health care services played an important role in determining the nature of self-medication. Financial barriers were not the only obstacle to adequate treatment. Health services should be more accessible and responsive to the needs of the population.

An assessment of dispensing practices in private pharmacies in Dar-es-Salaam, Tanzania

OBJECTIVES

To assess medicine dispensing practices in private pharmacies in Dar-es-Salaam, Tanzania and recommend interventions to improve practice.

METHODS

A cross-sectional survey and observational study of dispensing practices among 70 pharmacies in metropolitan Dar-es-Salaam, Tanzania.

KEY FINDINGS

There were 1479 dispensing encounters recorded across the 70 pharmacies. This translated to 1573 medicines dispensed. Of the medicines dispensed, 16% were anti-infectives; 45% of the dispensed medicines were requested by the client, 32% were recommended by the dispenser and only 23% were on prescriptions. The main reasons for pharmacy consultations were coughs (62%), general pain (62%) and 'flu and colds. Malaria constituted 21% of the private pharmacy visits. Of the cough encounters, 30% received antibiotics. In addition, oral antibiotics were given to 81% of the clients with diarrhoea and to 95% of those with eye and ear problems. Of the 628 clients who requested specific medicines without a prescription, only 29% were asked questions on why the medicines were required. Of the clients who bought antibiotics, 20% bought incomplete doses. In total, 1180 clients were interviewed. Of these, 35% could not repeat the instructions given to them by the dispenser. Of the 70 dispensers who gave dosage instructions, only 20% gave them according to guidelines.

CONCLUSION

In Tanzania, an overwhelming proportion of medicines sold in pharmacies are dispensed without a prescription. The majority of medicines dispensed without a prescription are either requested by the client or recommended by the dispenser. When dispensing medicines, dispensers seldom give dosage instructions; when they do, the instructions are often not consistent with guidelines. A high proportion of clients seeking management of coughs and colds or for diarrhoea from private pharmacies receive antibiotics. Interventions that build the capacity of dispensers, improve the rational use of antibiotics and the management of diarrhoea in private pharmacies in Tanzania are necessary to provide consistent quality services to a populace that relies heavily on the private sector for their medications needs.

Practice and attitudes regarding the management of childhood diarrhoea among pharmacies in Thailand

OBJECTIVES

to compare practice behaviour and attitudes of pharmacy personnel in the management of childhood diarrhoea between type I (requiring a pharmacist to be on duty) and type II (pharmacist not required) pharmacies, between those surveyed in 2008 and in 2001, and between new-generation (graduation ≤ 10 years) and old-generation (graduation >10 years) pharmacists.

METHODS

the setting was 115 pharmacies in a city in the south of Thailand. The study was separated into two phases: a simulated client method to evaluate history taking, drug dispensing and advice giving among pharmacy personnel and a questionnaire to measure attitudes and factors affecting diarrhoea treatment.

KEY FINDINGS

in the simulated client method study, questions asked and advice given by the providers (the pharmacists or non-pharmacists responding to the simulated clients), especially in type II pharmacies, were insufficient. Only 5.2% of pharmacies correctly dispensed for a child with viral diarrhoea, using oral rehydration salts (ORS) alone. Appropriate ORS dispensing of providers was not affected by shop type, survey time or peer generation. However, 52.2% of providers inappropriately dispensed antibiotics for such illness. In the questionnaire study, 108 completed surveys were obtained (a response rate of 93.9%). The providers working in 2008 more strongly agreed that ORS was effective, safe, used by health professionals and requested by patients, relative to those in 2001 (P < 0.05). No potential factor influencing the actual ORS dispensing was identified. Nevertheless, antibiotic dispensing was affected by beliefs in producing recovery and high profit.

CONCLUSIONS

practice and attitudes of pharmacy personnel were inappropriate in the management of childhood diarrhoea. Revision of the pharmacy curriculum did not result in improvement of practice as seen by the similarity of practice patterns among the 2001 and 2008 samples. Improvement of knowledge and practice behaviour among providers in pharmacies is needed.

"Practical knowledge" and perceptions of antibiotics and antibiotic resistance among drugsellers in Tanzanian private drugstores

Background

Studies indicate that antibiotics are sold against regulation and without prescription in private drugstores in rural Tanzania. The objective of the study was to explore and describe antibiotics sale and dispensing practices and link it to drugseller knowledge and perceptions of antibiotics and antibiotic resistance.

Methods

Exit customers of private drugstores in eight districts were interviewed about the drugstore encounter and drugs bought. Drugsellers filled in a questionnaire with closed- and open-ended questions about antibiotics and resistance. Data were analyzed using mixed quantitative and qualitative methods.

Results

Of 350 interviewed exit customers, 24% had bought antibiotics. Thirty percent had seen a health worker before coming and almost all of these had a prescription. Antibiotics were dispensed mainly for cough, stomachache, genital complaints and diarrhea but not for malaria or headache. Dispensed drugs were assessed as relevant for the symptoms or disease presented in 83% of all cases and 51% for antibiotics specifically. Non-prescribed drugs were assessed as more relevant than the prescribed. The knowledge level of the drugseller was ranked as high or very high by 75% of the respondents. Seventy-five drugsellers from three districts participated. Seventy-nine percent stated that diseases caused by bacteria can be treated with antibiotics but 24% of these also said that antibiotics can be used for treating viral disease. Most (85%) said that STI can be treated with antibiotics while 1% said the same about headache, 4% general weakness and 3% 'all diseases'. Seventy-two percent had heard of antibiotic resistance. When describing what an antibiotic is, the respondents used six different kinds of keywords. Descriptions of what antibiotic resistance is and how it occurs were quite rational from a biomedical point of view with some exceptions. They gave rise to five categories and one theme: Perceiving antibiotic resistance based on practical experience.

Conclusions

The drugsellers have considerable "practical knowledge" of antibiotics and a perception of antibiotic resistance based on practical experience. In the process of upgrading private drugstores and formalizing the sale of antibiotics from these outlets in resource-constrained settings, their "practical knowledge" as well as their perceptions must be taken into account in order to attain rational dispensing practices.

Are interventions for improving the quality of services provided by specialized drug shops effective in sub-Saharan Africa? A systematic review of the literature

PURPOSE

We set out to determine effectiveness of interventions for improving the quality of services provided by specialized drug shops in sub-Saharan Africa.

DATA SOURCES

We searched PubMed, CAB Abstracts, Web of Science, PsycINFO and Eldis databases and websites for organizations such as WHO and Management Sciences for Health. Finally, we searched manually through the references of retrieved articles.

STUDY SELECTION

Our search strategy included randomized trials, time-series studies and before and after studies evaluating six interventions; education, peer review, reorganizing administrative structures, incentives, regulation and legislation.

DATA EXTRACTION

We extracted information on design features, participants, interventions and outcomes assessed studies for methodological quality, and extracted results, all using uniform checklists.

RESULTS OF DATA SYNTHESIS

We obtained 10 studies, all implementing educational interventions. Outcome measures were heterogeneous and included knowledge, communication and dispensing practices. Education improved knowledge across studies, but gave mixed results on communication between sellers and clients, dispensing of appropriate treatments and referring of patients to health facilities. Profit incentives appeared to constrain behaviour change in certain instances, although cases of shops adopting practices at the expense of sales revenue were also reported.

CONCLUSION

Evidence suggests that knowledge and practices of pharmacies and drug shops can be improved across a range of diseases and countries/regions, although variations were reported across studies. Profit incentives appear to bear some influence on the level of success of interventions. More work is required to extend the geographical base of evidence, investigate cost-effectiveness and evaluate sustainability of interventions over periods longer than 1 year.

Pain, infection, and colds and flu: Samoan people's views about antibiotics

BACKGROUND

Samoan people have access to and use both Western and traditional forms of healing. Little is known about their perceptions and use of healing agents.

OBJECTIVES

To explore Samoan people's interpretation and use of a subset of Western medicines, namely, antibiotics, in Samoa and in New Zealand.

METHODS

Semi-structured interviews were held with a purposeful sample of 31 Samoans, recruited through informal networks. Thematic analysis focused on understanding participants' perspectives on antibiotics using a phenomenological approach. Results from these interviews were used to develop a questionnaire administered to 232 Samoans recruited in health care facilities in Samoa and New Zealand.

RESULTS

Participants were mostly females (57% of structured interview participants), and most (88%) were born in Samoa. Nearly half the sample had tertiary education. In Western terms, confusion about what antibiotics do and lack of clarity about which medicines are antibiotics were very common among the Samoan population. Antibiotics are commonly believed to be useful for colds and flu (75% of respondents) and were frequently used for these conditions. The distinctive features of the responses were the belief that antibiotics are pain killers (50%) and confusion between infection and pain. The confusion between antibiotics and pain killers may reflect a conflict between Samoan and Western concepts of illness. In the Samoan view, the lived experience of illness appears to be conflated with the illness itself; that is, pain is seen as an illness.

CONCLUSIONS

The findings have implications for attempts to promote rational use of antibiotics either with individuals or as a part of public education campaigns. Such efforts may fail in some communities if they are based on the assumption that people share Western beliefs about what antibiotics are; what they do; and which illness have microbial, bacterial, or viral causes.

Drugstore personnel's management of a tuberculosis suspect: consideration of actual and perceived management

Objective

To explore drugstore personnel's knowledge and practice on management of a suspected case of tuberculosis (TB).

Method

Seventy randomly selected drugstores in Songkhla province of Southern Thailand were visited by simulated clients (SCs) who asked for medication for relieving a one-month cough with fever. All questions asked by the drugstore personnel, advice given and drugs dispensed were noted and analysed. The drugstores were subsequently visited and the managers were interviewed.

Key findings

For the SC study, 55 out of 70 (79%) drugstore personnel took a history before dispensing drugs, but only 14 (20%) asked about cough duration. Only four drugstore personnel identified TB as a possible diagnosis for a case with one-month cough and fever, and only three recommended the SC to see a doctor. From the interviews, 46 (66%) perceived the probability of encountering TB at their workplace to be low. The knowledge on symptoms of suspected TB was poor. Sixty-eight (97%) would suspect TB if and only if the client with prolonged cough also had tiredness, weight loss, difficulty breathing or haemoptysis. In contrast to their practice with the SC, 46 (66%) claimed that they would recommend a client with one-month cough and fever to see a doctor.

Conclusions

The majority of drugstore personnel failed to detect suspected TB cases and did not give a proper referral. Interventions to educate drugstore personnel to recognise symptoms of suspected TB and to become aware in TB epidemics in this setting are urgently needed.

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.

[Knowledge and perceptions of staff working in private dispensaries in Abidjan as regards bacterial resistance]

Private dispensaries play an important role in the use of drugs such as antibiotics at community level. However, the knowledge and perceptions of staff working in these private dispensaries as regards bacterial resistance have not been sufficiently studied.

OBJECTIVES

To assess the knowledge and perceptions of staff working in private dispensaries in Abidjan as regards bacterial resistance.

MATERIALS AND METHODS

A survey was carried out among 123 members of staff working in private dispensaries, during a horizontal study conducted in 18 private dispensaries selected at random in the town of Abidjan in the Ivory Coast. Group meetings were also held to better understand the perceptions of staff working in these private dispensaries as regards bacterial resistance.

RESULTS

Four antibiotics out of five bought in these private dispensaries in Abidjan were dispensed by pharmacy assistants. However, they were less informed than the pharmacists as regards bacterial resistance and the factors involved in its emergence. All the pharmacists interviewed in the study showed a good theoretical knowledge of bacterial resistance. However, the group meetings revealed that the risks of emergence of bacterial resistance in the case of antibiotics being dispensed without a prescription, and the threat of this resistance in terms of public health, were less perceived by the pharmacists.

CONCLUSIONS

Assistants in dispensaries are less well-informed about bacterial resistance and the factors determining its emergence even though they dispense the most antibiotics to customers. Pharmacists have theoretical knowledge of bacterial resistance but are less conscious of its impact in terms of public health. Information campaigns on bacterial resistance are highly recommended as regards staff working in private dispensaries in Abidjan.

The quality of private pharmacy services in low and middle-income countries: a systematic review

AIM OF THE REVIEW

In low and middle income countries private pharmacies are considered a valuable resource for health advice and medicines in many communities. However the quality of the service they provide has often been questioned and is unclear. This paper reviews the evidence regarding the quality of professional services from private pharmacies in low and middle-income countries.

METHOD

A literature search (computer and hand searches) was undertaken to identify all studies which included an assessment of the quality of some aspect of private pharmacy services in low and middle income countries.

RESULTS

30 studies were identified which spanned all regions in the developing world. These included 9 which examined the scope and/or quality of a range of professional services, 14 which assessed the quality of advice provided in response to specific symptoms and 7 which investigated the supply of medicines without a prescription. A range of methods were employed, in particular, questionnaire surveys with staff and/or clients and assessment of practice using simulated client methodology. Whilst many authors identified a potential for pharmacies to contribute more effectively to primary health care, virtually all studies identified deficiencies in the quality of current professional practice. In particular authors highlighted the lack of presence of pharmacists or other trained personnel, the provision of advice for common symptoms which was not in accordance with guidelines and the inappropriate supply of medicines.

CONCLUSION

The evidence-base regarding the quality of professional services from pharmacies in low and middle income countries is limited, but indicates that standards are often deficient. If pharmacists are to contribute effectively to health care, the barriers to the provision of higher quality care and ways in which these might be overcome must be identified and examined.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Etiology and epidemiology of diarrhea in children in Hanoi, Vietnam

OBJECTIVES

This paper provides a preliminary picture of diarrhea with regards to etiology, clinical symptoms, and some related epidemiologic factors in children less than five years of age living in Hanoi, Vietnam.

METHODS

The study population included 587 children with diarrhea and 249 age-matched healthy controls. The identification of pathogens was carried out by the conventional methods in combination with ELISA, immunoseparation, and PCR. The antibiotic susceptibility was determined by MIC following the NCCLS recommendations.

RESULTS

Of those with diarrhea, 40.9% were less than one year old and 71.0% were less than two years old. A potential pathogen was identified in 67.3% of children with diarrhea. They were group A rotavirus, diarrheagenic Escherichia coli, Shigella spp, and enterotoxigenic Bacteroides fragilis, with prevalences of 46.7%, 22.5%, 4.7%, and 7.3%, respectively. No Salmonella spp or Vibrio cholerae were isolated. Rotavirus and diarrheagenic E. coli were predominant in children less than two years of age, while Shigella spp, and enterotoxigenic B. fragilis were mostly seen in the older children. Diarrheagenic E. coli and Shigella spp showed high prevalence of resistance to ampicillin, chloramphenicol, and to trimethoprim/sulfamethoxazole. Children attending the hospitals had fever (43.6%), vomiting (53.8%), and dehydration (82.6%). Watery stool was predominant with a prevalence of 66.4%, followed by mucous stool (21.0%). The mean episodes of stools per day was seven, ranging from two to 23 episodes. Before attending hospitals, 162/587 (27.6%) children had been given antibiotics. Overall, more children got diarrhea in (i) poor families; (ii) families where piped water and a latrine were lacking; (iii) families where mothers washed their hands less often before feeding the children; (iv) families where mothers had a low level of education; (v) families where information on health and sanitation less often reached their households.

CONCLUSIONS

Group A rotavirus, diarrheagenic Escherichia coli, Shigella spp, and enterotoxigenic Bacteroides fragilis play an important role in causing diarrhea in children in Hanoi, Vietnam. Epidemiological factors such as lack of fresh water supply, unhygienic septic tank, low family income, lack of health information, and low educational level of parents could contribute to the morbidity of diarrhea in children.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative quality of private and public health services in rural Vietnam

BACKGROUND

Private health care services were officially recognized in Vietnam in 1989, and for the last 15 years have competed with the public health system in providing primary curative care and pharmaceutical sales to rural populations. However, the quality of these private and public health care services has not been evaluated and compared.

METHODS

A community-based survey was conducted in 30 of the 160 communes in Hung Yen, which were selected by probability proportional to population size (PPS) sampling. All commune health centres (CHCs) and private health care providers in the selected communes were surveyed on human resources, services provided, availability of medical equipment and pharmaceuticals, knowledge and clinical performance for acute and chronic problems. Patient satisfaction and cost of care associated with recent illness were measured using a random household survey covering 30 households from each of the selected communes.

RESULTS

There were 11.5 private providers per 10,000 population, compared with 6.7 public providers per 10,000. A quarter of private providers were employees of the public health sector. Less than 20% of the private providers had registered their practice with the government system. Eleven per cent (26/234) had no professional qualifications. Fifty-eight per cent (135/234) provided treatment as well as selling medications. Public sector infrastructure was superior to that of the private providers. The quality of services provided by public providers was poor but significantly better than that of private providers. Patient satisfaction and costs of care were similar between the two groups.

CONCLUSIONS

Private providers are successfully competing with the public health centre system in rural areas but not because they provide cheaper or better services. The quality of private health care services is not controlled and is significantly poorer than public services. Current practice in both systems falls below the national standard, especially for the management of chronic health problems. The low quality of health care services at a community level may help explain the previously observed phenomena of high levels of self-medicating, low utilization of commune health centres and over-utilization of tertiary health care facilities.

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

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