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

- zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAVietnam A survey was conducted in a sample of 29 pharmacies in the Badinh district of Hanoi, Vietnam, to determine the knowledge

- zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Vietnam

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 pur-

chasers 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 man-

agement of acute diarrhoea by staff in retail

pharmacies have been reported.2-6 In these stud-

ies, a method using simulated patients was ef-

fectively applied

The objectives of our research were to assess

the knowledge and behaviour of pharmacy staff

in monitoring acute, watery diarrhoea in child-

hood

Methods

The survey was conducted in the Badinh district

of Hanoi, Vietnam A list of 132 retail pharma-

cies was provided by Badinh Health Centre This

list was then stratified according to daily drug

sales and a sample of 30 pharmacies was ran-

domly chosen using a method outlined by

Abramson.7

The survey was carried out using a simulated

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 follow- ing medical complaint: zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA“ 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 in- formation about the stool, such as if it were lien- teric (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 qual- ifications of the staff according to information given by the owners previously (This survey was part of research on the use of antibiotics in ur- ban areas in Vietnam The researcher had to vis-

it the owners of the selected pharmacies for permission to investigate the purchase of antibi- otics in these settings.)

Results

The survey was conducted from March 1 to 7,

1996 Of 30 pharmacies selected, one was no

Hanoi School of Pharmacy, Vietnam Dat Van Duong MPharm, MPH,

lecturer

Hanoi School of

Public Health, Vietnam Truyen Van Le, BPharm, PhD,

associate professor

School of Public Health, Curtin University of Technology, GPO zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Box U 1987,

Perth WA 6001, Australia Colin William Binns, MD,

MPH, head o f school

Correspondence:

Professor Binns

Int J P h a m Pract

1997:5:97-100

1997, THE 1NTERNATlONAL JOURNAL OF PHARMACY PRACTICE 97

Table 1: Questions asked by pharmacy staff (n=29)

Question Number of pharmacies (per cent)

where question asked

Medicines taken 1 (3.4)

Frequency of

longer in business at the time of the investiga-

tion As a result, 2 9 pharmacies were included in

the survey There were four categories of occu-

pation recorded in the pharmacy staff: pharma-

cist (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)

Communication The survey indicated that com-

munication between pharmacy staff and the sim-

ulated parent was poor The case of a

12-month-old child who has had acute, watery

diarrhoea for three days should have been treat-

ed seriously However, only zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA59 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 re-

lating 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 pharma-

cy staff regarding drug use was limited and in-

sufficient In all the cases, information about the

dosage was given However, information on du-

ration of treatment, advice on breast or bottle

feeding and advice to consult a doctor was pro-

vided in only one case (Table 2)

Drugs suggested zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAby pharmacy staff ORS (oral re-

hydration salts) was suggested in only one case,

while antibiotics and other antidiarrhoeal drugs

dominated (Table 3) The most commonly sug-

gested medicines were co-trimoxazole 17.2 per

cent of pharmacies, Smecta (smectite, an adsor-

bent) 17.2 per cent and Bioflor (lyophilised

Sacharornyces zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAboulardii) 13.8 per cent The five antibiotics suggested by pharmacy

staff were co-trimoxazole 480mg (five cases),

sulphaguanidine 5OOmg (three cases), nifurox-

azide (three cases), Ery-bactrim 375mg (combi-

nation of erythromycin and trimethoprim) (one

case) and Intetrix (combination of tiliquinol and

Table 2: Advice given by pharmacy staff (n=29) Nature of Number of harmacies advice (per cent) ofLrinp advice

Duration of use 1 (3.4)

Consult a doctor 1 (3.4)

Table 3: Drugs suggested by pharmacy staff (n=29) Category Number of pharmacies

I

(per cent) suggesting

Lactobacillus and similar preparations 8 (27.6) Traditional medicines 3 (10.3) Antimotility drugs 2 (6.9)

I

Table 4: Drug combinations suggested by pharmacy staff h = 2 9 )

Antidiarrhoeal drugs only 15 (51.7) Antibiotics and

antidiarrhoeal drugs 6 (20.7) Antibiotics and vitamins 1 (3.4)

ORS and antidiarrhoeal

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 4

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 antidiar- rhoeal drugs only in comparison with antibiotics only (20.7 per cent) and antibiotics and an- tidiarrhoeal drugs together (20.7 per cent)

The pharmacy staff often did not dispense a full course of antibiotics The quantity of antibi- otics 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 an- tibiotic suggested for purchase was between one and four tablets However, in two cases, sulph- aguanidine 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)

Discussion

In Vietnam, doctors and nurses are not allowed

to work in a pharmacy However, our survey found that both these groups were working in pharmacies and reference to these employees is included in this report to provide a more com-

plete picture of diarrhoea management in Hanoi,

Vietnam

To obtain the pharmacy assistant certificate,

people have to attend a training course a t a col-

lege 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 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA45 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 communica-

tion skills with customers The case of a 12-

month-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 Oth-

er significant information such as the child’s tem-

perature, medicines taken at home, diet and

health status were ignored In the worst cases,

the pharmacy staff did not ask for any informa-

tion 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 de-

ficient 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 stan-

dard treatment protocols from the World Health

Organisation,**9 this 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 an-

tidiarrhoeal 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 inap-

propriate treatment The length of antibiotic use

suggested by pharmacy staff was always too

short Of the cases where antibiotics were sug-

gested, about 83 per cent suggested the purchase

two days This is compelling evidence of antibi-

otic misuse among pharmacy staff

In Vietnam, it is difficult for pharmacists and

general practitioners to attend continuing educa-

tional programmes because of financial con-

straints and staff shortages The drug zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

~ information they receive mainly comes from

1 guidelines or from medical representatives How-

ever, some guidelines are out of date and infor- mation from medical representatives can be sub- jective 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, cost- ing 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 percent- age of sales

Other studies have also shown that the treat- ment of diarrhoea is often inappropriate Zamo- ra-Gutierrez zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAet zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA UP in their survey in 498

pharmacies in Bolivia found that fewer than 2

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 Howev-

er, this research contained a possible source of

bias because the sample was purposively select-

ed 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 pos- ing 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 treat- ing acute diarrhoea in children This inappropri- ate 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 ap- propriate treatment of diarrhoea in children

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

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6