Transcript Oral Presentation 1

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
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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
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
 Selling prescription only drugs such
as Steroids without a prescription
Study Design: Randomized Controlled Trial
SAMPLE
PHARMACIES
Intervention
Pharmacies
Control
Pharmacies
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. 4 times: Asking for:
1) A small dose of an antibioitic
2) Steroids for a bad back
SCM
Dec-99
SCM
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 cont
34 int
35 cont
28 int
27 cont
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: Education
Hanoi: 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 twicefor 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
Difference Int
& Control (%)
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
Bangkok
P-value Difference Int &
Control (%)
P-value
0.1625
0.7389
0.0471
0.0125
1
-9
-3
-4
0.8925
0.3770
0.4795
0.5525
0.6027
0.9597
0.0025
0.0028
-4
-2
0
-9
0.4165
0.5526
0.9447
0.1927
Steroid Results
Bangkok
Hanoi
Difference Int
& Control (%)
Received steroids
7
Baseline
-4
Post Regulatory
-33
Post educational
-40
Post peer review
Ask no Questions gave no Advice
8
Baseline
6
Post Regulatory
-24
Post educational
-19
Post peer review
P-value Difference Int &
Control (%)
P-value
0.2930
0.5456
0.0011
<.0001
3
-19
-16
-18
0.6815
0.0240
0.1151
0.0639
0.2488
0.2919
0.0032
0.0014
4
-7
-3
0
0.6176
0.2818
0.6518
0.9610
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 problems
.
To 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.