Chalker J, Ratanawijitrasin S, Chuc NTK, Petzold M & Tomson G

2. Effectiveness of a Multi-Component Intervention on Dispensing Practices at Private Pharmacies in Vietnam and Thailand: A Randomized Controlled Trial

3. 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

4. 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

5. Study Aim • 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 :

6. Study Design: Randomized Controlled Trial . 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

7. Bangkok Hanoi 4 area types 789 PPs 2 districts in each 641 fit criteria Int / cont 34 pairs 39 cont 39 int 34 int 34 cont 34 int 35 cont 28 int 27 cont Sampling Private Pharmacies (PP) for intervention (int) and control (cont) groups .

8. 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 .

9. 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 twice- for 2-hour academic detailing one steroids, and one antibiotics. .

10. 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. .

11. Antibiotic Results .

12. Steroid Results

13. 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 .

14. 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 .

15. 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 .

16. 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. .