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

Community Pharmacy Professionals' Knowledge and Counseling Skills for the Treatment of Acute Diarrhea in Children in Qassim Region, Saudi Arabia: Questionnaire Based and Simulated Client Study

Objective

The study aimed to evaluate the knowledge and counseling skills of community pharmacy professionals regarding managing acute diarrhea in children in the Qassim region of Saudi Arabia.

Methods

A cross-sectional study consisting of a questionnaire and simulated client scenario was conducted to collect data from pharmacy professionals working in community pharmacies over a period of 3 months in the Qassim region of Saudi Arabia. Pharmacy professionals were assessed for evaluating cases using 5 indicators (the age of the child, the frequency of diarrhea, fever and the presence of mucus or blood) and also for their recommendations and counseling.

Results

The data were collected from 60 pharmacy professionals after site visits. In the questionnaire, 60% of the pharmacy professionals used all 5 indicators, while in the simulation, 13.3% used at least 3 indicators and 80% used 2 or fewer indicators (p = 0.35). An oral rehydration solution was recommended alone by 35% of the pharmacy professionals and with other drugs by 13.3% in the questionnaire, while in the simulation, an oral rehydration solution alone was recommended by 15% and other drugs by 48.3%. Approximately 86.7% of the pharmacy professionals did not give any dietary advice, and 50% did not counsel the simulated client on the recommended drug.

Conclusion

The community pharmacy professionals in the study did not ask enough questions to evaluate a child suffering from acute diarrhea appropriately in the simulation. More questions were asked in the questionnaire; however, the difference is not significant. Additionally, they did not provide proper dietary advice, and their recommendation of an oral rehydration solution was insufficient.

Evidence-Do Gap in Quality of Direct-To-Consumer Telemedicine: Cross-Sectional Standardized Patient Study in China

Background: The evidence-do gap between the availability of clinical guidelines and provider practice is well documented, resulting in low health care quality. With the rapid development of telemedicine worldwide, this study aimed to investigate the evidence-do gap and explore the factors for the evidence versus practice deficits as well as low quality in direct-to-consumer telemedicine. Methods: We adopted the standardized patient approach to evaluate the health worker performance and calculate the evidence-do gap in quality of the consultation process, diagnosis, and treatment in telemedicine based on China's national clinical guidelines. Moreover, we further explored the factors associated with the gap through multiple linear regression and logistic regressions. Results: Validated physician-patient interactions (N = 321) were included. On the one hand, the consultation process and treatment quality are less commendable with the huge evidence-do gap. More than three-quarters of the physicians provided low-quality care, as against standard clinical guidelines. On the other hand, the level I, specialized hospitals, doctor, associate chief physicians, and attending physicians, sponsored by Internet enterprises, more times of provider's responses and words were associated with high-quality processes; More total times of provider's responses, urticaria, and nonoffice hours of the visit were associated with high-quality diagnosis; Sponsored by Internet enterprises, more total words of provider's all responses, and urticaria were associated with high-quality treatment. Conclusions: Our findings have important implications in an era in which to better comprehend the evidence-do gap. Efforts to bridge the evidence-do gap should be focused on the important role of institutions and physicians.

Community pharmacists' treatment patterns and counselling of acute diarrhea in children: A simulation-based cross-sectional study

Background

Diarrhea is a significant global health concern, particularly among children, and its impact is particularly pronounced in countries with limited resources and ongoing conflicts, such as Yemen. Diarrheal diseases remain one of the leading causes of morbidity and mortality in children under the age of 5 years worldwide.

Objectives

The aim of our study is to assess the treatment patterns and counseling of community pharmacists regarding the management of acute diarrhea in children in Yemen.

Design

A simulation-based cross-sectional study was carried out targeting community pharmacy professionals in Sana'a city.

Methods

A questionnaire and simulated client methods were used to assess the pharmacists' evaluation of a case based on five indicators including the child's age, diarrhea frequency, presence of fever, and blood or mucus. In addition, the pharmacists' recommendations and counseling were also evaluated.

Results

During the study, a total of 100 pharmacists were visited and evaluated using both a questionnaire and simulation. The results demonstrated that 43.0% of the pharmacists utilized all five indicators in the questionnaire, with a mere 3.0% using all five indicators in the simulation. Oral rehydration solution (ORS) alone was recommended by 42.0% of the pharmacists and in combination with other drugs by 47.0% in the questionnaire, and the rest (11.0%) recommended only other drugs; while in the simulation, 7.0% of the pharmacists referred the patients to clinic, only 6.0% recommended ORS alone, 47.0% gave ORS plus other drugs including antibiotics, and 40.0% dispensed only antibiotics. In regards to counseling, 89.0% of pharmacists reported that they would explain to the patient regarding the recommended medicine during the questionnaire, and only 36.0% gave any sort of explanation to the simulated client.

Conclusion

In the current study, community pharmacists did not ask enough questions to accurately evaluate a child with acute diarrhea during the simulation. This finding has apparently differed from their responses in the questionnaire. Furthermore, the pharmacists failed to provide sufficient dietary advice, and their recommendation of ORS was inadequate.

Birth preparedness and complication readiness: Evaluating the "know-do" gap among women receiving antenatal care in Benin City, Nigeria

Across several African countries, birth preparedness and complication readiness (BPACR) among pregnant women is poor. The practice of BPACR, though improving in recent years, is not commensurate with the knowledge available to pregnant women. Maternal health indices remain sub-optimal. This study evaluates the determinants of this "know-do' gap among women receiving antenatal care at a secondary health facility in Benin City, Nigeria. A cross-sectional study involving 427 pregnant women was conducted between October and December 2020 using a structured interviewer-administered questionnaire. The prevalence of knowledge and practice were described, and the determinants of BPACR practice evaluated using bivariable (chi-square) analysis and multivariable ordinal logistic regression with post-estimation predictive margins analysis. About 77% of respondents had good birth preparedness practice. Multivariable regression revealed that respondents with poor knowledge and moderate knowledge of components of BPACR had statistically significant lower odds (OR:0.05 (95% CI: 0.02-0.13) and 0.10 (95% CI: 0.03-0.30) times, respectively) for greater practice of BPACR when compared to those with good knowledge. Respondents with poor knowledge of danger signs had statistically significant lower odds (OR: 0.08 (95% CI: 0.03-0.26) for greater practice of BPACR when compared to those with good knowledge. But predictive margins analyses demonstrates that knowledge, though critical to practice, is insufficient to optimize practice. The optimum number of danger signs women need to know to improve practice may be between eight to ten. Beyond this number, practice may not change significantly. Other predictors of BPACR practice include income level, parity, gravidity, and residential settings. The number of antenatal clinic visits had no statistically significant correlation with BPACR practice. Interventions to facilitate practice at the community level may be helpful to improve outcomes and bridge the know-do gap with respect to BPACR within the study context.

Using the Simulated Patient Method to Evaluate the Community Pharmacy Management of Childhood Diarrhoea: A Systematic Review

The simulated patient method has been widely used to assess community pharmacy practice in the management of childhood diarrhoea. In such a process, a community pharmacist is required to explore a patient's history, choose the right medication and provide drug-related information. The aim of this review was to evaluate the aforementioned practice. A comprehensive literature search was carried out over Sage Journal, PubMed, ScienceDirect and Google Scholar, and the analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eligible articles were those published from 2011 to 2021 and original studies that used the simulated patient method to examine the pharmaceutical services provided by pharmacists in relation to childhood diarrhoea. The eight studies that satisfied the eligibility criteria were reviewed. These investigations were undertaken in Brazil, Nigeria, Turkey, Ethiopia and Pakistan. Five of the studies focused on history taking with regard to the characteristics of diarrhoea and revealed that the evaluated pharmacists asked about patient histories. In terms of therapy, three studies indicated that the evaluated pharmacists recommended the administration of oral rehydration salts. Pharmacies should improve their history-taking process, provide drug-related information and recommend therapies to increase the knowledge of simulated patients about diarrhoea treatment in children.

Pharmacists and Pharmacy Technicians' Perceptions of Scopes of Practice Employing Agency Theory in the Management of Minor Ailments in Central Indonesian Community Pharmacies: A Qualitative Study

Community pharmacy staff assist in the management of minor ailments. Agency Theory underpins relationships between health professionals and patients. This study explores pharmacists' and pharmacy technicians' perceived scopes of practice of minor ailment services in community pharmacies. Twelve one-on-one semi-structured interviews used an open-ended interview guide for each cohort of community pharmacists and pharmacy technicians, between June and July 2021. Purposive sampling selected a diversity of pharmacists and pharmacy technicians. Interviews were transcribed verbatim, thematically analysed assisted by NVivo version 20. Agency Theory aided the interpretation. Three main themes emerged: (1) inconsistencies in practice, (2) the lack of understanding of the scopes of practice of pharmacists and pharmacy technicians, and (3) provision of prescription-only medicines for some minor ailments or to fulfil patient requests. Several sub-themes included pharmacy staff involvement, education and training, provision of prescription-only medicines, and weak regulatory enforcement. Agency Theory indicated pharmacy patients (principals) delegated authority to pharmacists and pharmacy technicians (agents), which was confused by partial pharmacist absence. The lack of defined scopes of practice for pharmacists and pharmacy technicians disrupted established professional relationships. The scopes of practice and roles of the pharmacist and pharmacy technicians should be clearly defined, assisted by practice guidelines.

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.

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.

The Quality of Counseling for Headache OTC Medications in German Community Pharmacies Using a Simulated Patient Approach: Are There Differences between Self-Purchase and Purchase for a Third Party?

Background

In Germany—as worldwide—headache is one of the most frequent causes of self-medication. The dispensing of over-the-counter (OTC) medications may only be carried out by community pharmacies (CPs). In doing so, CPs have to ensure “adequate” counseling, for both self-purchase and purchase for a third party, which also occurs in everyday pharmacy practice. The aim of this study was to evaluate the quality of counseling for headache OTC medications in German CPs and, as the first study worldwide, to analyze whether and to what extent there are differences in counseling between self-purchase and purchase for a third party.

Methods

A cross-sectional study was carried out using the covert simulated patient methodology (SPM) in all 42 CPs in the German big city Potsdam. With the help of 8 trained simulated patients (SPs), each CP was visited four times by a different SP. The SPs simulated in each CP two scenarios two times with the demand for an OTC medication against headache, which differed only in whether the demand was for themselves or for their boyfriend/girlfriend.

Results

All 168 planned pharmacy visits (84 visits per scenario) were successfully carried out. Overall, the median counseling score was 3.0 out of 9 points (interquartile range [IQR 2.0]). There were no significant differences between the two scenarios (Wilcoxon signed-rank test; p=0.495, r = 0.053). In a multivariate binary logistic regression analysis, the counseling level and the different scenarios were not significantly associated (adjusted odds ratio [AOR] = 1.635, 95% CI = 0.673–3.972, p=0.278).

Conclusions

Due to the partly considerable deficits in counseling of German CPs, policy-makers and the regional chambers of pharmacists are called upon to take appropriate measures to improve the quality of counseling. It is positive that no differences in counseling between self-purchase and purchase for a third party were found, but further verifying studies with a modified methodology are recommended.

Prevalence and determinants of inappropriate antibiotic dispensing at private drug retail outlets in urban and rural areas of Indonesia: a mixed methods study

INTRODUCTION

The aim of this mixed-method study was to determine the extent and determinants of inappropriate dispensing of antibiotics by licensed private drug retail outlets in Indonesia.

METHODS

Standardised patients (SPs) made a total of 495 visits to 166 drug outlets (community pharmacies and drug stores) between July and August 2019. The SPs presented three clinical cases to drug outlet staff: parent of a child at home with diarrhoea; an adult with presumptive tuberculosis (TB); and an adult with upper respiratory tract infection (URTI). The primary outcome was the dispensing of an antibiotic without prescription, with or without the client requesting it. We used multivariable random effects logistic regression to assess factors associated with the primary outcome and conducted 31 interviews with drug outlet staff to explore these factors in greater depth.

RESULTS

Antibiotic dispensing without prescription occurred in 69% of SP visits. Dispensing antibiotics without a prescription was more likely in standalone pharmacies and pharmacies attached to clinics compared with drug stores, with an OR of 5.9 (95% CI 3.2 to 10.8) and OR of 2.2 (95% CI 1.2 to 3.9); and more likely for TB and URTI SP-performed cases compared with child diarrhoea cases, with an OR of 5.7 (95% CI 3.1 to 10.8) and OR of 5.2 (95% CI 2.7 to 9.8). Interviews revealed that inappropriate antibiotic dispensing was driven by strong patient demand for antibiotics, unqualified drug sellers dispensing medicines, competition between different types of drug outlets, drug outlet owners pushing their staff to sell medicines, and weak enforcement of regulations.

CONCLUSION

This study shows that inappropriate dispensing of antibiotics by private drug retail outlets is widespread. Interventions will need to address not only the role of drug sellers, but also the demand for antibiotics among clients and the push from drug outlet owners to compete with other outlets.

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.

Skills and practices of pharmacy staff for dispensing of drugs with fiscalized substances in drugstores and pharmacies

OBJETIVE

To evaluate the skills and practices of pharmacy staff during the dispensing of tramadol (drug with fiscalized substance) in drugstores and pharmacies in Medellin, Colombia.

METHODS

A cross-sectional study was performed. The simulated patient technique was used. The main outcomes included the information provided on the dispensed drug (tramadol), the use of tools to provide information, and the information provided on drug precautions and use recommendations.

RESULTS

We visited 305 drugstores and pharmacies. The average dispensing time was 2.3 min (SD 1.1 min). In nine drugstores and pharmacies (3.0%), tramadol was not dispensed because it was not in stock. In 17 drugstores and pharmacies (5.7%), the simulated patients were actively informed by the dispensing pharmacy staff; of these, 16 provided oral information and one provided oral and written information. Eight patients (2.7%) received information regarding tramadol use. However, 99% of patients were not informed about tramadol side effects such as dependence, sedation, or hypnosis, and none of the simulated female patients were informed on the precautions related to tramadol use during pregnancy or lactation.

CONCLUSIONS

Communication skills and appropriate practices of pharmacy staff are critical to patient self-care. However, this study shows their difficulty in counseling about precautions and use recommendations of drugs with fiscalized substances. These outcomes could inform future studies focusing on the rational use of these drugs in drugstores and pharmacies. It is necessary to improve the pharmacy staff competencies through continuing education programs, to facilitate access to information and training.

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.

'Know-Can' gap: gap between knowledge and skills related to childhood diarrhoea and pneumonia among frontline workers in rural Uttar Pradesh, India

OBJECTIVES

In India, frontline workers (FLWs) - public accredited social health activists (ASHAs) and private rural medical providers (RMPs) - are important for early detection and treatment of childhood diarrhoea and pneumonia. This cross-sectional study aims to measure knowledge and skills, and the gap between the two ('know-can' gap), regarding assessment of childhood diarrhoea with dehydration and pneumonia among FLWs, and to explore factors associated with them.

METHODS

We surveyed 473 ASHAs and 447 RMPs in six districts of Uttar Pradesh. We assessed knowledge and skills using face-to-face interviews and video vignettes, respectively, about key signs of both conditions. The 'know-can' gap corresponds to absent skills among FLWs with correct knowledge. We used logistic regression to identify the correlates of knowledge and skills.

RESULTS

FLWs' correct knowledge ranged from 23% to 48% for dehydration signs and 27% to 37% for pneumonia signs. Their skills ranged from 3% to 42% for dehydration and 3% to 18% for pneumonia. There was a significant 'know-can' gap in all the signs, except 'sunken eyes'. Training and supervisory support was associated with better knowledge and skills for diarrhoea with dehydration, but only better knowledge for pneumonia.

CONCLUSIONS

FLWs are crucial to the Indian health system, and high-quality FLW services are necessary for continued progress against under-five deaths. The gap between FLWs' knowledge and skills warrants immediate attention. In particular, our results suggest that knowledge-focused trainings are insufficient for FLWs to convert knowledge into appropriate assessment skills.

"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.

Quantifying antimicrobial access and usage for paediatric diarrhoeal disease in an urban community setting in Asia

Objectives

Antimicrobial-resistant infections are a major global health issue. Ease of antimicrobial access in developing countries is proposed to be a key driver of the antimicrobial resistance (AMR) epidemic despite a lack of community antimicrobial usage data.

Methods

Using a mixed-methods approach (geospatial mapping, simulated clients, healthcare utilization, longitudinal cohort) we assessed antimicrobial access in the community and quantified antimicrobial usage for childhood diarrhoea in an urban Vietnamese setting.

Results

The study area had a pharmacy density of 15.7 pharmacies/km² (a pharmacy for every 1316 people). Using a simulated client method at pharmacies within the area, we found that 8% (3/37) and 22% (8/37) of outlets sold antimicrobials for paediatric watery and mucoid diarrhoea, respectively. However, despite ease of pharmacy access, the majority of caregivers would choose to take their child to a healthcare facility, with 81% (319/396) and 88% (347/396) of responders selecting a specialized hospital as one of their top three preferences when seeking treatment for watery and mucoid diarrhoea, respectively. We calculated that at least 19% (2688/14427) of diarrhoea episodes in those aged 1 to <5 years would receive an antimicrobial annually; however, antimicrobial usage was almost 10 times greater in hospitals than in the community.

Conclusions

Our data question the impact of community antimicrobial usage on AMR and highlight the need for better education and guidelines for all professionals with the authority to prescribe antimicrobials.

A systematic review of the use of simulated patient methodology in pharmacy practice research from 2006 to 2016

OBJECTIVES

Simulated patient (SP) methodology (mystery shopping) is used increasingly to assess quality of pharmacy services, and evaluate impact of interventions. Our objective was to review papers reporting on the use of SP methodology in pharmacy practice research 2006-2016 in community pharmacies worldwide.

METHODS

We searched EMBASE and MEDLINE for papers reporting on the use of mystery shopping in pharmacy settings, using a wide range of terms for SPs, based on previous review. We removed irrelevant papers, duplicates, papers not written in English, and review papers and reviewed remaining papers. Two reviewers carried out data abstraction, using the same tool as the previous review and inserting data into Excel, focusing on how the SP methodology is used.

KEY FINDINGS

A total of 148 papers from 52 countries from all regions of the world were included in the review. A wide range of terms described the method, and simulated patient was the most common (49 papers). Most studies were cross-sectional (124), and most investigated only community pharmacies (115). The most common aim was to evaluate some aspect of pharmacists' or other staff's advice and counselling (94). Number of visits is 2-7785. Many papers did not cover details, such as number of visits planned, and carried out, scenario used, training and background of SPs, and ethical approval for the study.

CONCLUSIONS

The use of SP methodology has increased substantially in the field of pharmacy over the past decade. This is a useful method in a wide range of countries and settings. Greater detail is required in reporting.

Effectiveness of a short training program for community pharmacists to improve knowledge and practice of asthma counselling - A simulated patient study

OBJECTIVE

Community pharmacists can make significant contributions and be an indispensable member in the asthma therapy chain. The present study aimed to investigate the current knowledge level of Vietnamese community pharmacists in asthma counselling and the impact of a short training program on asthma knowledge and practice.

METHOD

300 community pharmacists participated in the study. A knowledge questionnaire about asthma medications and a standardized inhaler checklist were designed to evaluate their knowledge before and after a 4-h training program. Six to eight weeks later, 10 simulated patients were sent to the community pharmacies to evaluate the pharmacists' knowledge and practice.

RESULTS

The training program significantly improved the asthma knowledge score of pharmacists from 5.3 to 17.2 out of a maximum score of 20 (p < 0.001). After the training, the percentage of pharmacists performing correctly inhaler devices increased significantly (0% vs.∼50%, p < 0.001). In the simulated patient study, pharmacists who attended the training demonstrated better asthma knowledge with higher scores (5.4 vs 1.7 out of a maximum score of 7.0, p < 0.001), as well as much better inhaler technique scores (6.1 vs 4.3, out of a maximum score of 8, p < 0.001). These pharmacists achieved higher scores in all aspects encompassing distinguishing controllers and relievers, counselling correctly about adherence, and common side effects.

CONCLUSION

Our results revealed significant knowledge deficiency about asthma among Vietnamese community pharmacists. However, a short training program was effective in upskilling the pharmacists to effectively counsel asthmatic patients about the management of their condition and medications.

Knowledge, attitudes and practices related to tuberculosis in pharmacy workers in a cross-sectional survey in El Agustino, Peru

Introduction

Although the worldwide incidence of tuberculosis (TB) is slowly decreasing, annual infection rates in Peru remain among the highest in the Americas. Pharmacies could play an important role in facilitating early detection of TB. However, the awareness, expertise and cooperation of pharmacy workers is fundamental. This study explored the TB-related knowledge, attitudes and practices of pharmacy workers in a district with one of the highest incidences of TB in Peru.

Methods

This cross-sectional study applied a questionnaire that was administered face to face using smartphones with one pharmacy worker at each of 45 randomly selected pharmacies in the El Agustino district of Lima, Peru.

Results

Participants were primarily female (78%) and had an average age of 31.3 years old (range 18–57 years old). Only 11% of participants were pharmacists with complete university training. The pharmacy workers’ knowledge was adequate; however, workers had important knowledge gaps and myths regarding prevention of TB transmission. Most pharmacy workers (77%) reported they would send a client with a history of cough for more than two weeks to a healthcare center, while 23% reported they would offer them antitussive medication or antibiotics. Almost all workers reported talking with clients about diseases and reported respiratory symptoms as one of the most common causes for consultation (60%). Most participants expressed interest in learning more about TB and expanding their involvement in the fight against TB in their community.

Conclusion

Pharmacy workers have adequate knowledge about TB. However, we identified gaps in knowledge with respect to prevention of TB transmission. Pharmacy workers commonly see patients with respiratory symptoms and some offer recommendations, including for treatment. Pharmacy workers are willing to learn more and contribute to TB control and could be a valuable asset in the control and prevention of TB in Peru. To achieve this integration of pharmacy workers into TB control and prevention, more research is needed.

A Double-blind, Randomized, Placebo-controlled Trial of Lactobacillus acidophilus for the Treatment of Acute Watery Diarrhea in Vietnamese Children

BACKGROUND

Probiotics are the most frequently prescribed treatment for children hospitalized with diarrhea in Vietnam. We were uncertain of the benefits of probiotics for the treatment of acute watery diarrhea in Vietnamese children.

METHODS

We conducted a double-blind, placebo-controlled, randomized trial of children hospitalized with acute watery diarrhea in Vietnam. Children meeting the inclusion criteria (acute watery diarrhea) were randomized to receive either 2 daily oral doses of 2 × 10 CFUs of a local probiotic containing Lactobacillus acidophilus or placebo for 5 days as an adjunct to standard of care. The primary end point was time from the first dose of study medication to the start of the first 24-hour period without diarrhea. Secondary outcomes included the total duration of diarrhea and hospitalization, daily stool frequency, treatment failure, daily fecal concentrations of rotavirus and norovirus, and Lactobacillus colonization.

RESULTS

One hundred and fifty children were randomized into each study group. The median time from the first dose of study medication to the start of the first 24-hour diarrhea-free period was 43 hours (interquartile range, 15-66 hours) in the placebo group and 35 hours (interquartile range, 20-68 hours) in the probiotic group (acceleration factor 1.09 [95% confidence interval, 0.78-1.51]; P = 0.62). There was also no evidence that probiotic treatment was efficacious in any of the predefined subgroups nor significantly associated with any secondary end point.

CONCLUSIONS

This was a large double-blind, placebo-controlled trial in which the probiotic underwent longitudinal quality control. We found under these conditions that L. acidophilus was not beneficial in treating children with acute watery diarrhea.

Interventions to enhance effective communication during over-the-counter consultations in the community pharmacy setting: A systematic review

BACKGROUND

Easy access to effective over-the-counter (OTC) treatments allows self-management of some conditions, however inappropriate or incorrect supply or use of OTC medicines can cause harm. Pharmacy personnel should support consumers in their health-seeking behaviour by utilising effective communication skills underpinned by clinical knowledge.

OBJECTIVE

To identify interventions targeted towards improving communication between consumers and pharmacy personnel during OTC consultations in the community pharmacy setting.

METHODS

Systematic review and narrative analysis. Databases searched were MEDLINE, EMBASE, Psycinfo, Cochrane Central Register and Cochrane Database of Systematic Reviews for literature published between 2000 and 30 October 2014, as well as reference lists of included articles. The search was re-run on 18 January 2016 and 25 September 2017 to maximise the currency. Two reviewers independently screened retrieved articles for inclusion, assessed study quality and extracted data. Full publications of intervention studies were included. Participants were community pharmacy personnel and/or consumers involved in OTC consultations. Interventions which aimed to improve communication during OTC consultations in the community pharmacy setting were included if they involved a direct measurable communication outcome. Studies reporting attitudes and measures not quantifiable were excluded. The protocol was published on Prospero Database of Systematic Reviews.

RESULTS

Of 4978 records identified, 11 studies met inclusion criteria. Interventions evaluated were: face-to-face training sessions (n = 10); role-plays (n = 9); a software decision making program (n = 1); and simulated patient (SP) visits followed by immediate feedback (n = 1). Outcomes were measured using: SP methodology (n = 10) and a survey (n = 1), with most (n = 10) reporting a level of improvement in some communication behaviours.

CONCLUSION

Empirical evaluation of interventions using active learning techniques such as face-to-face training with role-play can improve some communication skills. However interventions that are not fully described limit the ability for replication and/or generalisability. This review identified interventions targeting pharmacy personnel. Future interventions to improve communication should consider the consumer's role in OTC consultations.

Barriers and Facilitators for Information Exchange during Over-The-Counter Consultations in Community Pharmacy: A Focus Group Study

Consumers are confident managing minor ailments through self-care, often self-medicating from a range of over-the-counter (OTC) medicines available from community pharmacies. To minimise risks, pharmacy personnel endeavour to engage in a consultation when consumers present with OTC enquiries however they find consumers resistant. The aim was to determine stakeholder perspectives regarding barriers and facilitators for information exchange during OTC consultations in community pharmacies and to understand the elicited themes in behavioural terms. Focus groups were undertaken with community pharmacist, pharmacy assistant and consumer participants. Independent duplicate analysis of transcription data was conducted using inductive and framework methods. Eight focus groups involving 60 participants were conducted. Themes that emerged indicated consumers did not understand pharmacists' professional role, they were less likely to exchange information if asking for a specific product than if asking about symptom treatment, and they wanted privacy. Consumers were confident to self-diagnose and did not understand OTC medicine risks. Pharmacy personnel felt a duty of care to ensure consumer safety, and that with experience communication skills developed to better engage consumers in consultations. They also identified the need for privacy. Consumers need education about community pharmacists' role and responsibilities to motivate them to engage in OTC consultations. They also require privacy when doing so.

Support and performance improvement for primary health care workers in low- and middle-income countries: a scoping review of intervention design and methods

Primary health care workers (HCWs) in low- and middle-income settings (LMIC) often work in challenging conditions in remote, rural areas, in isolation from the rest of the health system and particularly specialist care. Much attention has been given to implementation of interventions to support quality and performance improvement for workers in such settings. However, little is known about the design of such initiatives and which approaches predominate, let alone those that are most effective. We aimed for a broad understanding of what distinguishes different approaches to primary HCW support and performance improvement and to clarify the existing evidence as well as gaps in evidence in order to inform decision-making and design of programs intended to support and improve the performance of health workers in these settings. We systematically searched the literature for articles addressing this topic, and undertook a comparative review to document the principal approaches to performance and quality improvement for primary HCWs in LMIC settings. We identified 40 eligible papers reporting on interventions that we categorized into five different approaches: (1) supervision and supportive supervision; (2) mentoring; (3) tools and aids; (4) quality improvement methods, and (5) coaching. The variety of study designs and quality/performance indicators precluded a formal quantitative data synthesis. The most extensive literature was on supervision, but there was little clarity on what defines the most effective approach to the supervision activities themselves, let alone the design and implementation of supervision programs. The mentoring literature was limited, and largely focused on clinical skills building and educational strategies. Further research on how best to incorporate mentorship into pre-service clinical training, while maintaining its function within the routine health system, is needed. There is insufficient evidence to draw conclusions about coaching in this setting, however a review of the corporate and the business school literature is warranted to identify transferrable approaches. A substantial literature exists on tools, but significant variation in approaches makes comparison challenging. We found examples of effective individual projects and designs in specific settings, but there was a lack of comparative research on tools across approaches or across settings, and no systematic analysis within specific approaches to provide evidence with clear generalizability. Future research should prioritize comparative intervention trials to establish clear global standards for performance and quality improvement initiatives. Such standards will be critical to creating and sustaining a well-functioning health workforce and for global initiatives such as universal health coverage.

Management of children's acute diarrhea by community pharmacies in five towns of Ethiopia: simulated client case study

BACKGROUND

Acute diarrhea is the major cause of child morbidity and mortality in low-income nations. It is the second most common cause of death among children <5 years of age globally. The indispensable role of community pharmacists is clearly observed in the prevention and treatment of diarrhea. However, there is a paucity of data on how community pharmacies manage acute childhood diarrhea cases in Ethiopia. This study aimed to evaluate the experience of community pharmacies in the management of acute diarrhea in northern Ethiopia.

METHODS

A simulated case-based cross-sectional study was conducted in community pharmacies from five towns of northern Ethiopia between April 2015 and September 2015. Convenience sampling technique was used to select sample towns. A structured questionnaire was organized to collect the information. Descriptive statistics, chi-squared test, one-way analysis of variance, and binary logistic regression were performed to describe, infer, and test for association between the variables. SPSS for Windows Version 21 was used to enter and analyze the data. A 95% confidence interval and P-value of 0.05 were set to test the level of significance.

RESULTS

Approximately 113 community pharmacies were visited to collect the required data from five towns. Majority (78, 69%) of them were located away from hospitals and health care areas. Nine components of history taking were presented for dispensers. Regarding the patient history, "age" was frequently taken, (90.3%), whereas "chief complaint" was the least to be taken (23%), for patients presenting with diarrhea. Approximately 96 (85.0%) cases were provided with one or more medications. The remaining 17 (15%) cases did not receive any medication. A total of six pharmacologic groups of medications were given to alleviate acute diarrheal symptoms. Majority (66, 29.6%) of the medications were oral rehydration salts with zinc. The mean number of medications was 1.99 per visit. Components of advice, such as dose, frequency, duration, drug action, and adverse drug reactions, were found to vary among the five towns at a statistically significant level.

CONCLUSION

Community pharmacies provided inadequate treatment for acute childhood diarrhea. Inappropriate history taking and incorrect drug and food instructions have been frequently encountered during acute diarrhea management. Practitioners working in northern Ethiopia should receive proper training on the management of acute childhood diarrhea.

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.

The Association between Provider Practice and Knowledge of ORS and Zinc Supplementation for the Treatment of Childhood Diarrhea in Bihar, Gujarat and Uttar Pradesh, India: A Multi-Site Cross-Sectional Study

Introduction

Programs aimed at reducing the burden of diarrhea among children under-five in low-resource settings typically allocate resources to training community-level health workers, but studies have suggested that provider knowledge does not necessarily translate into adequate practice. A diarrhea management program implemented in Bihar, Gujarat and Uttar Pradesh, India trained private sector rural medical practitioners (RMPs) and public sector Accredited Social Health Activists (ASHAs) and Anganwadi workers (AWWs) in adequate treatment of childhood diarrhea with oral rehydration salts (ORS) and zinc. We used cross-sectional program evaluation data to determine the association between observed diarrhea treatment practices and reported knowledge of ORS and zinc among each provider cadre.

Methods

We conducted principal components analysis on providers’ responses to diarrhea treatment questions in order to generate a novel scale assessing ORS/zinc knowledge. We subsequently regressed a binary indicator of whether ORS/zinc was prescribed during direct observation onto the resulting knowledge scores, controlling for other relevant knowledge predictors.

Results

There was a positive association between ORS/zinc knowledge score and prescribing ORS and zinc to young children with diarrhea among private sector RMPs (aOR: 2.32; 95% CI: 1.29-4.17) and public sector ASHAs and AWWs (aOR 2.48; 95% CI: 1.90-3.24). Controlling for knowledge score, receipt of training in the preceding 6 months was a good predictor of adequate prescribing in the public but not the private sector. In the public sector, direct access to ORS and zinc supplies was also highly associated with prescribing.

Conclusions

To enhance the management of childhood diarrhea in India, programmatic activities should center on increasing knowledge of ORS and zinc among public and private sector providers through biannual trainings but should also focus on ensuring sustained access to an adequate supply chain.