Transcript Poster presentation

Abstract
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 and Tomson G
Karolinska Institutet, Sweden; Management Sciences for Health (
MSH); Chulalongkorn University, Thailand; Hanoi Medical University, Vietnam;
Nordic School of Public Health, Sweden
Problem Statement: Private pharmacies are the first line of health care in many
communities, commonly selling antibiotics in too small doses and prescription-only
drugs such as steroids without medical supervision.
Objectives: To study the effectiveness of a multi-faceted intervention on the dispensing
practices of drug sellers within Hanoi and Bangkok.
Design: A randomized, controlled trial.
Setting: Private pharmacies in Hanoi and Bangkok
Study Population: 34 intervention private pharmacies in Hanoi and 39 in Bangkok and an
equal number of controls were randomly selected and assigned. In Hanoi, 28
intervention and 27 control pharmacies completed the study, as did 34 intervention
and 35 control pharmacies in Bangkok
This is where
a large
or sequentially
chart canwith
go.four
Intervention: Three three-month
interventions
weregraphic
implemented
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 effectively compulsory in Hanoi.
Outcome Measures: Behaviour was assessed by five simulated client visits per pharmacy
per dispensing practice, at baseline and a month or more after each intervention.
Whether the requested antibiotic or steroid was dispensed and whether relevant
questions were asked and advice given were recorded.
Results: In Hanoi, significant improvements compared to controls was shown after the
educational intervention, reducing the dispensing of illegal steroids (29% v 62%) and
low dose antibiotics (69% v 90%), sustained by means of the peer review (17% v 57%
steroids and 71% v 95% antibiotics), and in fewer dispensers asking no questions and
giving no advice (11% v 30% steroids and 51% v 81% antibiotics). The only
significant improvement in Bangkok was the reduction in illegally dispensing steroids
(25% v 44%) after the regulatory intervention which was not sustained. 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% v
81%).
Conclusions: A multi-component intervention can have a profound
effect in changing dispensers’ behaviour, but the effect is
dependent on the context and the method of implementation.
Possible reasons for differences between the cities are discussed.
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
Study Aim
To study the effectiveness of a multifaceted intervention on dispensing practices
of drug sellers in Hanoi and Bangkok on two
critical behaviors: :
 Selling antibiotics in small doses without
prescription (which is particularly
dangerous for the spread of antimicrobial
resistance)
 Selling prescription only drugs (steroids)
without prescription
Study Design: Randomized
Controlled Trial
SAMPLE
PHARMACIES
Intervention
Pharm acies
Control
Pharm acies
Intervention
1
RegulatSCM
ory
Enforcement
Dec-97 Aug-98
SCM
Intervention
2
SCM
Educational
Nov-98
Jan-99
SCM
Intervention
3
SCM
Peer
Influence
May-99 Aug-99
SCM
SCM = Simulated Client Method
Monitoring by Simulated Client Visits, 5
visits per pharmacy for each tracer
condition. 4 times: Baseline & after each
intervention. The Clients asked for:
1) A small dose of an antibioitic
2) Steroids for a bad back
SCM
Dec-99
SCM
Interventions
1: Enforcement of Regulations
Focusing on dispensing of prescription only drugs
Hanoi: 2 visits giving a summary of px only regulations
with a letter from the Provincial Health Bureau
Bangkok: Checked steroids & steroid pxs, Gave a
warning of violation of the regulations and gave
instruction to the seller on the respective regulations
2: Education
Hanoi: Academic detailing: 2 visits, 45 mins each by 2
people one visit steroids, and one antibiotics
 Questions, advice and treatment (QAT) stressed with
written and verbal info.
Bangkok: Owners and counter attendants invited to 2 day
workshops; included steroids, and antibiotic requests.
 9 shops who did not attend were visited twice- for 2hour academic detailing one steroids, and one
antibiotics
3: Peer Influence
Hanoi: Hanoi divided 5 area groups with 5-6 PPS. Built on
QAT. 5 meetings per group. Collected and reported
cases. All pharmacies attended
Bangkok: All intervention PPs 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.
Sampling Private Pharmacies
(PP) for intervention (int) and control (cont)
groups
Bangkok
Hanoi
4 area types
789 PPs
2 districts in each
641 fit criteria
Int / cont
34 pairs
39 int
39 cont
34 int
34 int
35 cont
28 int
34 cont
27 cont
Antibiotic Results
Difference Int
& Control (%)
P-value
Hanoi
Received requested Antibiotics
Baseline
2
Post Regulatory
0
Post educational
-21
Post peer review
-24
Ask no Questions gave no Advice
Baseline
-3
Post Regulatory
0
Post educational
-26
Post peer review
-30
0.1625
0.7389
0.0471
0.0125
0.6027
0.9597
0.0025
0.0028
Bangkok
Received requested Antibiotics
Baseline
1
Post Regulatory
-9
Post educational
-3
Post peer review
-4
Ask no Questions gave no Advice
Baseline
-4
Post Regulatory
-2
Post educational
0
Post peer review
-9
0.8925
0.3770
0.4795
0.5525
0.4165
0.5526
0.9447
0.1927
Steroid Results
Difference Int & P-value
Control (%)
Hanoi
Received requested steroids
Baseline
7
0.2930
Post Regulatory
-4
0.5456
Post educational
-33
0.0011
Post peer review
-40
<.0001
Ask no Questions gave no Advice
Baseline
8
0.2488
Post Regulatory
6
0.2919
Post educational
-24
0.0032
Post peer review
-19
0.0014
Bangkok
Received requested steroids
Baseline
3
0.6815
Post Regulatory
-19
0.0240
Post educational
-16
0.1151
Post peer review
-18
0.0639
Ask no Questions gave no Advice
Baseline
4
0.6176
Post Regulatory
-7
0.2818
Post educational
-3
0.6518
Post peer review
0
0.9610
Results
 In Hanoi, significant improvement
compared to control 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
 The importance of individually tailoring
interventions to the locations and
societies in which they will be
implemented through formative
research has been shown.
Methodological considerations-1
 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 intracity interpretation between intervention
and control groups
 The interventions were performed one after
the other, so there is no possibility of
isolating the effect of each individual
intervention.
Methodological considerations -2
The randomized controlled trial (RCT) is
a robust design to judge intra city effect
RCTs are the cornerstone of clinical
medicine for assessing the efficacy of
medication or clinical intervention
because of the minimizing of bias.
The RCT can also be used for assessing
the effectiveness in specific real life
situations
There are problems with RCTs
 RCTs are expensive, the results are
rarely produced within two years.
Therefore the results are not useful for
steering the design of the intervention
 To avoid bias it is necessary to
standardize the content and format of the
delivery of an intervention and with
complex behavioural interventions it is
difficult to reproduce them exactly
Methodological considerations 3
 We know Multi faceted interventions are
most likely to be effective. It is the very
nature of multi faceted interventions to be
contextualized. This reduces their
external validity
 So in our work the contextualization, all
compromise the external validity and
may be the reason for the difference
between the results in Hanoi and
Bangkok
 In Hanoi, the success of the multiintervention package gives important
evidence showing that these drug-seller
practices are changeable
 The interventions are adapted to the
opportunities of the environment and the
goal is therefore to find whether the
intervention works in that setting
Conclusion and
recommendations
 This study show that improvements are
possible to achieve in the private sectors.
However even with improvements major
problems remain.
 Isolated multi faceted interventions are
not generalisable, leave problems of
scaling up and will not solve the problems
of antimicrobial resistance.
 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.
 Both indicators and interventions have to
focus on chosen key problems.
 If information from monitoring such
indicators is produced in a timely manner,
the data can be used to iteratively
develop the intervention.