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.

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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

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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.