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Effectiveness of a Multi-Component Intervention on Dispensing Practices at Private Pharmacies in Vietnam and Thailand: A Randomized Controlled Trial
Chalker J, Ratanawijitrasin S, Chuc NTK, Petzold M & Tomson G
Karolinska Institutet, Sweden; Management Sciences for Health (MSH); Chulalongkorn University, Thailand; Hanoi Medical University, Vietnam; Nordic School of Public Health, Sweden
Funded by EU grant and WHO/EDM
Background Drug sellers are becoming the first
line of PHC in many communities Dispensing Practices are often both
bad and illegal Few attempts to change but
evidence shows multifaceted interventions best
No comparison of effectiveness of multifaceted interventions in different environments
:
To study the effectiveness of a multi-faceted intervention on dispensing practices of drug sellers in Hanoi and Bangkok on two critical behaviors: Selling antibiotics in small doses
without prescription Selling prescription only drugs such
as Steroids without a prescription
Study Aim
.
SAMPLE Interv- Interv- Interv-PHARMACIES ention ention ention
1 2 3
Intervention Regulat-Pharmacies SCM ory SCM Educat- SCM Peer SCM
Enforce- ional Influ- ment ence
Dec-97 Aug-98 Nov-98 Jan-99 May-99 Aug-99 Dec-99Control Pharmacies SCM SCM SCM SCM
SCM = Simulated Client Method
Monitoring: By Simulated Client Visits, 5 visits per pharmacy. 4 times: Asking for:1) A small dose of an antibioitic2) Steroids for a bad back
Study Design: Randomized Controlled Trial
.
Sampling Private Pharmacies (PP) for intervention (int) and control (cont) groups
4 area types
2 districts in each
Int / cont
39 cont39 int
35 cont34 int
Bangkok
789 PPs
641 fit criteria
34 pairs
34 cont34 int
27 cont28 int
Hanoi
.
Intervention 1: Enforcement of Regulations
Focusing on dispensing of prescription only drugs
Hanoi: Two visits by Inspectors giving a summary of prescription only regulations backed by a letter from the Provincial Health Bureau
Bangkok: Inspectors checked the availability of steroids & steroid prescriptions.They gave a warning of violation of the regulations and gave instruction to the seller on the respective regulations
.
Intervention 2: EducationHanoi: Academic detailing: 2 visits, 45 minutes each by 2 people Questions, advice and treatment (QAT) stressed
with written and verbal information
Bangkok: Owners and counter attendants invited to 2 day workshops, which included steroids, and antibiotic requests.
9 shops who did not attend were visited twice- for 2-hour academic detailing one steroids, and one antibiotics.
.
Interventions 3: Peer Influence Hanoi: Hanoi divided 5 area groups with 5-6 shops. Built on QAT. 5 meetings per group. Collected and
reported cases. All pharmacies attended Hanoi Private Pharmacists Association involved.
Bangkok: All intervention shop staff invited to a meeting "Techniques to increase the revenue of drugstore".
Setting up of peer groups discussed. Sent out minutes and invited for peer groups.
Groups set own agendas, with some guidance.
16/34 did NOT attend.
.
Antibiotic Results
Hanoi Bangkok Difference Int
& Control (%) P-value
Difference Int &
Control (%) P-value
Received requested Antibiotics
Baseline 2 0.1625 1 0.8925 Post Regulatory 0 0.7389 -9 0.3770
Post educational -21 0.0471 -3 0.4795 Post peer review -24 0.0125 -4 0.5525
Ask no Questions gave no Advice Baseline -3 0.6027 -4 0.4165
Post Regulatory 0 0.9597 -2 0.5526 Post educational -26 0.0025 0 0.9447 Post peer review -30 0.0028 -9 0.1927
Hanoi Bangkok Difference Int
& Control (%) P-value
Difference Int &
Control (%) P-value
Received steroids
Baseline 7 0.2930 3 0.6815 Post Regulatory -4 0.5456 -19 0.0240
Post educational -33 0.0011 -16 0.1151 Post peer review -40 <.0001 -18 0.0639
Ask no Questions gave no Advice Baseline 8 0.2488 4 0.6176
Post Regulatory 6 0.2919 -7 0.2818 Post educational -24 0.0032 -3 0.6518 Post peer review -19 0.0014 0 0.9610
Steroid Results
.
Results In Hanoi, compared to control, significant improvement was
seen for the dispensing of antibiotics and steroids as well as a reduction in those not asking relevant questions or giving advice
In Bangkok there were no significant changes by the end of
the intervention package
In Hanoi, the success of the multi-intervention package gives important evidence showing that these drug-seller
practices are changeable
.
Methodological considerations
Caution is needed in interpreting the difference in effectiveness between cities (inter-city) . Contextual factors are as likely as the details of the implementation to explain the difference in effectiveness in Hanoi and Bangkok.
Caution is needed in interpreting longitudinal trends. as
the consistency of simulated client reporting varies This does not affect the validity of the intra-city
interpretation between intervention and control groups The randomized control trial is a robust design to judge
this intra city design
.
Methodological considerations -2
The randomized controlled trial (RCT) is the cornerstone of clinical medicine for assessing the efficacy of medication or clinical intervention because of the minimizing of bias.
There are problemsTo improve drug use we know multi faceted interventions
are most likely to be effective.
It is the very nature of multi faceted complex behavioural interventions to be contextualized. This reduces their external validity
.
Conclusion and recommendations The study presented here show that improvements are
possible to achieve in the private sectors. However even with improvements major problems remain.
The successes of interventions depend on place. The search for the interventions that will universally work is therefore illusory. The art and science of developing specific strategies relevant to specific locations is needed.
If information from monitoring relevant indicators is produced in a timely manner, the data can be used to iteratively develop the success of the intervention.