Towards good pharmacy practice in Hanoi : a multi-intervention study in private sector

Sammanfattning: This thesis describes the quality of private pharmacy practice and assesses the effects of an intervention package on knowledge and practice of private pharmacy staff in Hanoi, Vietnam. The study types used were a case study and a randomised controlled trial. In the case study, two private pharmacies were included. Interviews, observations and drug inventory were used for data collection. In the intervention study, 68 private pharmacies participated. A Simulated Client Method was conducted to assess practice, interviews with a questionnaire were used to assess knowledge. The four-tracer conditions in the intervention study were for STD, the management of urethral discharge in an adult man, for ARI, the management of acute upper respiratory tract infection in a child under 5 years of age, the request without a prescription for 2-5 capsules of an antibiotic (cefalexin) and for 2-5 steroid tablets (prednisolone). Three interventions were applied sequentially: regulatory enforcement, education and peer influence. Results from the case study showed that less than 1% of customers came with prescriptions. Antibiotics were sold to 17% of clients and 90% were broad spectrum. According to pharmacy staff, antibiotics gave them the best financial benefit. The pharmacy staff had poor awareness of Good Pharmacy Practice. In the baseline survey 74% of the pharmacy staff knew that they should not treat STD patients, 84% actually did. None of these provided correct syndromic treatment. To recommend condom use was very rare, both in stated and real practice. Twenty percent of pharmacy staff said that they would dispense antibiotics for the ARI and 53% said that they would ask questions regarding the breathing. In practice, 83% of the pharmacies dispensed antibiotics and only 10% of the encounters asked about breathing. Cefalexin and prednisolone were dispensed without a prescription for 95% and 76% of the encounters, respectively. The intervention package resulted in improved knowledge and practice of pharmacy staff in the intervention pharmacies. For STD, more drug sellers stated that they would ask about the health of the partner (p=0.03) and more said they would advise to use a condom (p=0.01) and partner notification (p=0.04). In practice, advice to go to the doctor and dispensing the correct syndromic treatment increased (p=0.01). For ARI, more pharmacy staff stated that they would ask questions regarding fever (p=0.01), fewer would give antibiotics (p=0.02) and more would give traditional medicines (p=0.03). In practice, antibiotic dispensing decreased (p=0.02) and questions regarding breathing increased (p=0.01). For antibiotic and steroid requests, more said that they would not sell a few capsules of cefalexin (p=0.02). In practice, the dispensing of steroids and cefalexin decreased (p<0.01) and prescription requests increased for prednisolone and cefalexin (p<0.01). This study shows that it is possible to improve the knowledge and practice of pharmacy staff with a multi-component intervention. Knowledge was often better than practice. It also shows that if pharmacy staff gets appropriate support to fulfil their public health role, more rational provision of drugs may follow. The impact of this for the control of antibiotic resistance, prevention of the spread of STD including HIV, and avoiding waste of scarce resources, cannot be underestimated considering the high utilization of private pharmacy services.