Diarrhoea management by pharmacy staff in retail pharmacies in hanoi, vietnam

zyxw zyxwvutsr zyxwvutsr - Vietnam DAT V A N DUONG, TRUYEN VAN LE and COLIN WILLIAM BINNS A survey was conducted in a sample of 29 pharmacies in the Badinh district of Hanoi, Vietnam, to determine the knowledge and behaviour of pharmacy staff in dealing with cases of acute diarrhoea in children The survey found that antibiotics and antidiarrhoeal drugs were suggested in the majority of cases (45 per cent and 69 per cent, respectively) while oral rehydration salts (ORS) were suggested in only one case In about 80 per cent of the observed cases in which antibiotics were supplied, one to four tablets were given, enough for only one to two days The advice given by pharmacy staff to purchasers was poor Only about half the pharmacy staff asked for information about the stool, age of the child and frequency of diarrhoea, while questions about medicines that had already been taken, feeding and health status were rarely asked In about 10 per cent of the cases, no questions at all were asked The mean cost of the treatment was $US 0.53 (95 per cent CI = 0.37-0.68) Constraints of knowledge, time and finance could be the reasons for this inappropriate management of childhood diarrhoea ECONOMIC reforms in the early 1990s have led to a boom in private pharmacies in Vietnam As in other developing countries, retail pharmacies in Vietnam work as outpatient clinics where purchasers can ask pharmacy staff for a medical consultation However, due to many constraints such as knowledge, time, financial incentives, etc, the advice given in this consultation may not always be appropriate Diarrhoea is still a major cause of morbidity in children in developing countries In Vietnam, there were 216 reported deaths of children from diarrhoea in 1994.1 Studies conducted in both developed and developing countries on the management of acute diarrhoea by staff in retail pharmacies have been reported.2-6 In these studies, a method using simulated patients was effectively applied The objectives of our research were to assess the knowledge and behaviour of pharmacy staff in monitoring acute, watery diarrhoea in childhood Methods The survey was conducted in the Badinh district of Hanoi, Vietnam A list of 132 retail pharmacies was provided by Badinh Health Centre This list was then stratified according to daily drug sales and a sample of 30 pharmacies was randomly chosen using a method outlined by Abramson.7 The survey was carried out using a simulated 1997, THE1NTERNATlONAL JOURNAL Hanoi School of Pharmacy, Vietnam Dat Van Duong MPharm, MPH, lecturer Hanoi School of Public Health, Vietnam Truyen Van Le, BPharm, PhD, associate professor z zyxwv patient A research assistant (a female lawyer) acted as a 30-year-old mother whose child had acute, watery diarrhoea The woman went to the selected pharmacies and spoke to any member of staff In each pharmacy she reported the following medical complaint: “ M y child is 12 months old She has had diarrhoea for three days I don’t know what I should do.” If the member of staff asked her for more information about the stool, such as if it were lienteric (containing undigested food) or contained mucus or blood, or asked if the child had a fever, the research assistant said no If she was asked if the child had been given any medicines before going to the pharmacy, she also said no The response and behaviour of the staff, as well as details of any recommended medicines and their cost, were reviewed after leaving the pharmacy After the research assistant left the pharmacy, the researcher (DVD) came to the counter and identified the occupation and qualifications of the staff according to information given by the owners previously (This survey was part of research on the use of antibiotics in urban areas in Vietnam The researcher had to visit the owners of the selected pharmacies for permission to investigate the purchase of antibiotics in these settings.) School of Public Health, Curtin University of Technology, GPO Box U 1987, Perth WA 6001, Australia Colin William Binns, MD, MPH, head of school Correspondence: Professor Binns Int J P h a m Pract 1997:5:97-100 Results The survey was conducted from March to 7, 1996 Of 30 pharmacies selected, one was no OF PHARMACY PRACTICE 97 zyxwvutsrq zyxwvutsrqpon H Table 1: Questions asked by pharmacy staff (n=29) Number of pharmacies (per cent) Question where question asked Stool 17 (58.6) Medicines taken (3.4) 17 (58.6) Age of child Frequency of diarrhoea 13 (44.8) (3.4) Health status N o uestions at all (10.3) I longer in business at the time of the investigation As a result, 29 pharmacies were included in the survey There were four categories of occupation recorded in the pharmacy staff: pharmacist (45 per cent), general practitioner (10 per cent), nurse (7 per cent) and pharmacy assistant (38 per cent) A majority of the pharmacy staff who had contact with the researcher were female (21 people, 72.4 per cent) Table 2: Advice given by pharmacy staff (n=29) Number of harmacies Nature of advice (per cent) ofLrinp advice Dose 29 (100) Duration of use (3.4) (3.4) Feeding (3.4) Consult a doctor Table 3: Drugs suggested by pharmacy staff (n=29) Category Number of pharmacies (per cent) suggesting Droduct Antibiotics 13 (44.8) Adsorbents 10 (34.5) Lactobacillus and similar preparations (27.6) Traditional medicines (10.3) (6.9) Antimotility drugs Vitamins (6.9) ORS (3.4) I I zyx zyxwvuts Communication The survey indicated that communication between pharmacy staff and the simulated parent was poor The case of a 12-month-old child who has had acute, watery diarrhoea for three days should have been treated seriously However, only 59 per cent of the staff asked about the nature of the stool; 45 per cent asked about the number of times the child had diarrhoea during the day Around 60 per cent of the staff confirmed the age of the child Not much attention was paid to the current health status (hydration) of the child or whether medicines had been taken Only one pharmacy asked questions on these topics In about 10 per cent of cases, staff did not ask any questions relating to the patient (Table 1) Advice Verbal advice was the main means of communication between pharmacy staff and the parent Written advice was observed in only one instance In general, the information given by pharmacy staff regarding drug use was limited and insufficient In all the cases, information about the dosage was given However, information on duration of treatment, advice on breast or bottle feeding and advice to consult a doctor was provided in only one case (Table 2) Table 4: Drug combinations suggested by pharmacy staff h=29) Products Number of pharmacies (per cent) suggesting (20.7) Antibiotics only Antidiarrhoeal drugs only 15 (51.7) Antibiotics and antidiarrhoeal drugs (20.7) Antibiotics and vitamins (3.4) ORS and antidiarrhoeal drugs (3.4) I tibroquinol) (one case) The survey also found that antibiotics were suggested by all categories of pharmacy staff: in six cases by pharmacists, four cases by pharmacy assistants, two cases by general practitioners and one case by a nurse Further details of medicines recommended by pharmacy staff are presented in Table Antibiotics in Vietnam can only be purchased with a prescription; however this is not always the practice at many pharmacies Around 50 per cent of the pharmacy staff suggested antidiarrhoeal drugs only in comparison with antibiotics only (20.7 per cent) and antibiotics and antidiarrhoeal drugs together (20.7 per cent) The pharmacy staff often did not dispense a full course of antibiotics The quantity of antibiotics suggested was small and the duration of use short, only enough for one to two days In 83.3 per cent of the observed cases, the quantity of antibiotic suggested for purchase was between one and four tablets However, in two cases, sulphaguanidine 5OOmg was bought in a quantity of up to 10 tablets The mean cost of purchased drugs was US $0.53 (95 per cent CI=O.37-0.68) zyxwvutsr zyxwvuts Drugs suggested by pharmacy staff ORS (oral rehydration salts) was suggested in only one case, while antibiotics and other antidiarrhoeal drugs dominated (Table 3) The most commonly suggested medicines were co-trimoxazole 17.2 per cent of pharmacies, Smecta (smectite, an adsorbent) 17.2 per cent and Bioflor (lyophilised Sacharornyces boulardii) 13.8 per cent Discussion The five antibiotics suggested by pharmacy staff were co-trimoxazole 480mg (five cases), In Vietnam, doctors and nurses are not allowed sulphaguanidine 5OOmg (three cases), nifurox- to work in a pharmacy However, our survey azide (three cases), Ery-bactrim 375mg (combi- found that both these groups were working in nation of erythromycin and trimethoprim) (one pharmacies and reference to these employees is case) and Intetrix (combination of tiliquinol and included in this report to provide a more com8 THEhTERNATlONAL JOURNAL OF PHARMACY PRACTICE, JUNE 1997 plete picture of diarrhoea management in Hanoi, Vietnam To obtain the pharmacy assistant certificate, people have to attend a training course at a college for at least six months full-time However, not all assistants have this qualification Some of them are family members of the owner and have no knowledge about pharmacy In our survey, qualified pharmacists were not available at the pharmacy during working hours in 45 per cent D f the investigated settings The results of the research show that nearly all the pharmacy staff, including pharmacists and general practitioners, had poor knowledge about management of diarrhoea and poor communication skills with customers The case of a 12month-old child suffering from acute watery diarrhoea for three days did not appear to receive appropriate attention by pharmacy staff Only a few questions were asked regarding the stools, age of the child and frequency of diarrhoea Other significant information such as the child’s temperature, medicines taken at home, diet and health status were ignored In the worst cases, the pharmacy staff did not ask for any information They did only one thing: sell medicines The advice given to customers about diarrhoea treatment was generally limited to a suggestion about the dose of the purchased drugs Other important advice regarding adverse reactions, duration of use, feeding or referral to a medical doctor was not given Reasons for the poor communication between pharmacy staff and purchasers could include deficient knowledge about diarrhoea1 management, time constraints and poor communication skills In our survey, antibiotics were recommended in about 45 per cent of cases, and antidiarrhoeal drugs in 69 per cent of cases According to standard treatment protocols from the World Health Organisation,**9this treatment is not appropriate for diarrhoea ORS, the appropriate treatment, was suggested in only one case Even in this case, it was suggested that it was used with an antidiarrhoeal drug Although the Diarrhoea1 Diseases Control Program was introduced in Vietnam some years ago, the knowledge of pharmacy staff is still poor In our study, nearly all pharmacists and general practitioners investigated gave an inappropriate treatment The length of antibiotic use suggested by pharmacy staff was always too short Of the cases where antibiotics were suggested, about 83 per cent suggested the purchase of two to four tablets, enough for only one to two days This is compelling evidence of antibiotic misuse among pharmacy staff In Vietnam, it is difficult for pharmacists and general practitioners to attend continuing educational programmes because of financial constraints and staff shortages The drug information they receive mainly comes from guidelines or from medical representatives How- ever, some guidelines are out of date and information from medical representatives can be subjective Nearly all drugs suggested by pharmacy staff in our research were introduced in Vietnam after economic reforms in the early 1990s These drugs have been widely advertised by medical representatives and through the mass media Financial constraint could also be a reason for this inappropriate, prescribing pattern in retail pharmacies ORS is a very cheap medicine, costing about dong 1,500 (about US cents 12) while antibiotics and antidiarrhoeal drugs are much more expensive and they can bring more benefit to the owners of the pharmacies In our survey, most purchased drugs were imported, with cheap domestic products accounting for a low percentage of sales Other studies have also shown that the treatment of diarrhoea is often inappropriate Zamora-Gutierrez et UP in their survey in 498 pharmacies in Bolivia found that fewer than per cent of the pharmacists recommended using ORS, increasing fluid intake, or consulting a physician Most recommended antimicrobials, antidiarrhoeals, or some combination of the two In research in three Asian countries (Bangladesh, Sri Lanka and Yemen), Tomson and Sterky6 found that, of 75 pharmacies studied, only 16 gave the appropriate advice, recommending use of ORS or consulting a medical doctor However, this research contained a possible source of bias because the sample was purposively selected and the simulated patient was Caucasian and unable to speak native languages Thamlikitkuls found that in Thailand, 50-100 per cent of drug stores inappropriately dispensed antibiotics for six conditions, including acute watery diarrhoea Igun3 concluded that most retail pharmacies in his research did not recommend ORS for watery diarrhoea A similar experience in Britain was reported by Goodburn et UP These authors found that half of the pharmacists interviewed and 70 per cent of pharmacists visited by a researcher posing as a parent recommended inappropriate treatment of childhood diarrhoea and only 30 per cent at interview stated that they would ask the age of the child Our research confirmed that antibiotics were commonly suggested by pharmacy staff for treating acute diarrhoea in children This inappropriate use could be life threatening to severely ill children and could contribute to reported widespread bacterial resistance to antibiotics There is an obvious need to educate further both pharmacy staff and the general public on the appropriate treatment of diarrhoea in children zyxwvuts zyxwvu zyxwv ~ zyxwvutsr zyxwvu JUNE 1997, THEINTERNATIONAL ACKNOWLEDGMENTS: We are grateful to lawyer Mien Tuyet Duong for her collaboration in the survey and to pharmacist Thang Nhat Nguyen, from Badinh District Health Centre, for providing a list of retail pharmacies JOURNAL OF PHARMACY PRACTICE 99 References zyxwvutsr 1.Vietnam Ministry of Health Health katistical Year Book 1994 Hanoi, 1995 Zamora-Gutierrez AD, Aguilar-Liendo AM, Cordero-Vadivia D Attitudes of Bolivian pharmacists in dealing with diarrhea cases Bull Pan Am Health Organ 1995;29:322-7 Igun UA Reported and actual prescription of oral rehydration therapy for childhood diarrhoea by retail pharmacist in Nigeria SOC Sci Med 1994;39:797-806 Goodburn E, Mattosinho S, Mongi P, Waterston T Management of childhood diarrhoea by pharmacists and parents: is Britain lagging behind the Third World? BMJ 100 1991;302: 440-3 Thamlikitkul V Antibiotic dispensing by drug store personnel in Bangkok, Thailand J Antimicrob Chemother 1987;21:125-3 Tomson G, Sterky G Self-prescribing by way of pharmacies in three developing countries Lancet 1986;2:620-2 Abramson JH Survey methods in community medicine Edinburgh:Churchill Livingstone, 1994 The rational use of drugs in the management of acute diarrhoea in children Geneva: World Health Organisation, 1990 Merson HM Proper treatment of diarrhoea: role of the pharmacist Int Pharm J 1987;1:526 THEINTERNATIONAL JOURNAL OF PHARMACY PRACnCE, JUNE 1997, ... between pharmacy staff and the parent Written advice was observed in only one instance In general, the information given by pharmacy staff regarding drug use was limited and insufficient In all... cases by pharmacy assistants, two cases by general practitioners and one case by a nurse Further details of medicines recommended by pharmacy staff are presented in Table Antibiotics in Vietnam. .. THEhTERNATlONAL JOURNAL OF PHARMACY PRACTICE, JUNE 1997 plete picture of diarrhoea management in Hanoi, Vietnam To obtain the pharmacy assistant certificate, people have to attend a training course at a