An assessment of dispensing practices in private pharmacies in Dar-es-Salaam, Tanzania.

OBJECTIVES: To assess medicine dispensing practices in private pharmacies in Dar-es-Salaam, Tanzania and recommend interventions to improve practice. METHODS: A cross-sectional survey and observational study of dispensing practices among 70 pharmacies in metropolitan Dar-es-Salaam, Tanzania. KEY FINDINGS: There were 1479 dispensing encounters recorded across the 70 pharmacies. This translated to 1573 medicines dispensed. Of the medicines dispensed, 16% were anti-infectives; 45% of the dispensed medicines were requested by the client, 32% were recommended by the dispenser and only 23% were on prescriptions. The main reasons for pharmacy consultations were coughs (62%), general pain (62%) and 'flu and colds. Malaria constituted 21% of the private pharmacy visits. Of the cough encounters, 30% received antibiotics. In addition, oral antibiotics were given to 81% of the clients with diarrhoea and to 95% of those with eye and ear problems. Of the 628 clients who requested specific medicines without a prescription, only 29% were asked questions on why the medicines were required. Of the clients who bought antibiotics, 20% bought incomplete doses. In total, 1180 clients were interviewed. Of these, 35% could not repeat the instructions given to them by the dispenser. Of the 70 dispensers who gave dosage instructions, only 20% gave them according to guidelines. CONCLUSION: In Tanzania, an overwhelming proportion of medicines sold in pharmacies are dispensed without a prescription. The majority of medicines dispensed without a prescription are either requested by the client or recommended by the dispenser. When dispensing medicines, dispensers seldom give dosage instructions; when they do, the instructions are often not consistent with guidelines. A high proportion of clients seeking management of coughs and colds or for diarrhoea from private pharmacies receive antibiotics. Interventions that build the capacity of dispensers, improve the rational use of antibiotics and the management of diarrhoea in private pharmacies in Tanzania are necessary to provide consistent quality services to a populace that relies heavily on the private sector for their medications needs.

The quest for universal access to effective malaria treatment: how can the AMFm contribute?

Access to quality assured artemisinin-based combination therapy (ACT) has remained very low in most malaria endemic countries. A number of reasons, including unaffordable prices, have contributed to the low accessibility to these life-saving medicines. The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured ACT. The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives: replacing older and increasingly ineffective anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displacing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the likelihood of resistance to artemisinin.Access to medicines frameworks paint a broad picture of dimensions of access to medicines and juxtapose components that enhance or hinder access to medicines. Access requires various activities--funding, institutions, interventions, and thinking--from public and private actors at global, national, and local levels. This paper examines, within access to medicines frameworks, the role of the AMFm across and within each dimension and discusses how the AMFm can help to solve access bottlenecks.

Knowledge of medicine outlets' staff and their practices for prevention and management of malaria in Ghana.

OBJECTIVE: To obtain information about the staff resources available in licensed medicine outlets, assess their knowledge about malaria illness, current policy initiatives for malaria control, and the practices for prevention and management of malaria. SETTING: Hospitals/clinics and retail medicine outlets (community pharmacies and licensed chemical shops) from urban and rural areas in Southern and Northern Ghana. METHOD: A cross section of medicine outlets (n = 121) in the two geographic and socio-economically diverse settings in Ghana were sampled. Data on staff resources, their knowledge about malaria, and current initiatives for malaria control were obtained through structured interviews. Staff practices for prevention and management of malaria were assessed through observation of their practice during counseling, selection, and dispensing of anti-malarial. MAIN OUTCOME MEASURES: Professional status of staff in the outlets, the proportion of staff with adequate knowledge on malaria illness and the initiatives for malaria control; skills and practices for the recognition, prevention, and management of malaria. RESULTS: 56% of the staff (n = 269) were non-professionals, whereas 44% (n = 212) were professionals. The hospitals/clinics had more professional staff per outlet than the retail outlets. One hundred and fifty four staff members, including those in-charge of the outlets at the time of data collection (n = 121), and others recommended by the in-charges or outlet owners (n = 33) were assessed. Of these, 83% knew the mode of malaria transmission, 81% could advise clients on practices for malaria prevention, 88% recognized signs/symptoms of uncomplicated malaria, and 64% those of complicated malaria. Less than 40% had adequate knowledge about current initiatives for malarial control, and only 21% could manage malaria cases as recommended by national guidelines. CONCLUSION: Most of the staff, particularly those in the retail outlets were not professionally trained. The staff assessed could recognize malaria illness and counsel clients on practices for disease prevention. The majority, however, lacked knowledge on the current initiatives for malaria control and the skills to manage malaria cases appropriately. In order to achieve public health objectives, interventions to strengthen skills and improve practices for malaria case management are needed. Training on current initiatives for malaria control should also be considered a priority.

Existing capacity to manage pharmaceuticals and related commodities in East Africa: an assessment with specific reference to antiretroviral therapy.

BACKGROUND: East African countries have in the recent past experienced a tremendous increase in the volume of antiretroviral drugs. Capacity to manage these medicines in the region remains limited. Makerere University, with technical assistance from the USAID supported Rational Pharmaceutical Management Plus (RPM Plus) Program of Management Sciences for Health (MSH) established a network of academic institutions to build capacity for pharmaceutical management in the East African region. The initiative includes institutions from Uganda, Tanzania, Kenya and Rwanda and aims to improve access to safe, effective and quality-assured medicines for the treatment of HIV/AIDS, TB and Malaria through spearheading in-country capacity. The initiative conducted a regional assessment to determine the existing capacity for the management of antiretroviral drugs and related commodities. METHODS: Heads and implementing workers of fifty HIV/AIDS programs and institutions accredited to offer antiretroviral services in Uganda, Kenya, Tanzania and Rwanda were key informants in face-to-face interviews guided by structured questionnaires. The assessment explored categories of health workers involved in the management of ARVs, their knowledge and practices in selection, quantification, distribution and use of ARVs, nature of existing training programs, training preferences and resources for capacity building. RESULTS: Inadequate human resource capacity including, inability to select, quantify and distribute ARVs and related commodities, and irrational prescribing and dispensing were some of the problems identified. A competence gap existed in all the four countries with a variety of healthcare professionals involved in the supply and distribution of ARVs. Training opportunities and resources for capacity development were limited particularly for workers in remote facilities. On-the-job training and short courses were the preferred modes of training. CONCLUSION: There is inadequate capacity for managing medicines and related commodities in East Africa. There is an urgent need for training in aspects of pharmaceutical management to different categories of health workers. Skills building activities that do not take healthcare workers from their places of work are preferred.

A strategy to improve skills in pharmaceutical supply management in East Africa: the regional technical resource collaboration for pharmaceutical management.

BACKGROUND: International initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative have significantly increased availability and access to medicines in some parts of the developing world. Despite this, however, skills remain limited on quantifying needs for medications and ordering, receiving and storing medications appropriately; recording medications inventories accurately; distributing medications for use appropriately; and advising patients on how to use medications appropriately. The Regional Technical Resource Collaboration for Pharmaceutical Management (RTRC) has been established to help address the problem of skills shortage in pharmaceutical management in East Africa. METHODS: The initiative brings together academic institutions from four East African countries to participate in skills-building activities in pharmaceutical supply management. The initiative targeted the institutions' ability to conduct assessments of pharmaceutical supply management systems and to develop and implement effective skills-building programmes for pharmaceutical supply chain management. RESULTS: Over a two-year period, the RTRC succeeded in conducting assessments of pharmaceutical supply management systems and practices in Kenya, Rwanda, Tanzania and Uganda. In 2006, the RTRC participated in a materials-development workshop in Kampala, Uganda, and contributed to the development of comprehensive HIV/AIDS pharmaceutical management training materials; these materials are now widely available in all four countries. In Tanzania and Uganda the RTRC has been involved with the training of health care workers in HIV/AIDS pharmaceutical management. In Kenya, Tanzania and Uganda the RTRC has been conducting operations research to find solutions to their countries' skills-shortage problems. Some of the interventions tested include applying and evaluating the effectiveness of a novel skills-building approach for pharmaceutical supply management. CONCLUSION: Nurturing collaboration between regional institutions in resource-limited countries to build in-country skills in pharmaceutical supply management appears to be an effective intervention. Support from local programmes and technical assistance from organizations and institutions with the necessary expertise is critical for success, particularly at inception. The skills acquired by local institutions can be incorporated into both pre-service and in-service teaching curricula. This ensures long-term availability of skills in-country. The ability of trained institutions to mobilize their own resources for skills-building activities is crucial for the success and sustainability of these programmes.

Self-reported use of anti-malarial drugs and health facility management of malaria in Ghana.

OBJECTIVE: To assess the appropriateness of self-reported use of anti-malarial drugs prior to health facility attendance, and the management of malaria in two health facilities in Ghana. METHOD: A structured questionnaire was used to collect data from 500 respondents who were diagnosed clinically and/or parasitologically for malaria at Agogo Presbyterian Hospital and Suntreso Polyclinic, both in the Ashanti Region of Ghana. Collected information included previous use of anti-malarial drugs prior to attending the health facilities, types of drugs used, how the drugs were used, and the sources of the drugs. In addition, the anti-malarial therapy given and outcomes at the two health facilities were assessed. RESULTS: Of the 500 patients interviewed, 17% had severe malaria, 8% had moderate to severe malaria and 75% had uncomplicated malaria. Forty three percent of the respondents had taken anti-malarial drugs within two weeks prior to hospital attendance. The most commonly used anti-malarials were chloroquine (76%), sulphadoxine-pyrimethamine (9%), herbal preparations (9%) and amodiaquine (6%). The sources of these medicines were licensed chemical sellers (50%), pharmacies (21%), neighbouring clinics (9%) or "other" sources (20%) including left-over medicines at home. One hundred and sixty three (77%) of the 213 patients who had used anti-malarial drugs prior to attending the health facilities, used the drugs inappropriately. At the health facilities, the anti-malarials were prescribed and used according to the national standard treatment guidelines with good outcomes. CONCLUSION: Prevalence of inappropriate use of anti-malarials in the community in Ghana is high. There is need for enhanced public health education on home-based management of malaria and training for workers in medicine supply outlets to ensure effective use of anti-malaria drugs in the country.

Medical doctors' perceptions and expectations of the role of hospital pharmacists in Sudan.

AIMS: To investigate medical practitioners' perceptions, expectations and experience with the role of hospital-based pharmacists in Sudan. SETTING: Teaching hospitals in Khartoum State, Sudan. METHODS: A self-administered, pre-tested, structured questionnaire was distributed to 300 randomly chosen medical practitioners of different grades and specialities in four teaching hospitals in Khartoum State. The questionnaire consisted of closed-ended questions. MAIN OUTCOME MEASURES: The level of medical practitioners comfort to, and their expectations and experience of, a range of pharmacist roles and activities. RESULTS: The response rate was 66.7%. One-half (50.0%; 95% CI: 42.9-57.2%) of respondents never or rarely had interaction with pharmacists with regard to patient's medication, 36.9% (CI: 30.2-44.0%) and 13.1% (CI: 8.9-18.8%) had this type of contact once per week or once a day or more, respectively. Respondents were most comfortable with pharmacists: Detecting and preventing prescription errors (49.2%; CI: 42.0-56.5); monitoring outcomes of pharmacotherapeutic regimens and plans (45.9%; CI: 38.8-53.2); designing and monitoring pharmacotherapeutic regimens (43.4%; CI: 36.4-50.8) and suggesting use of prescription medications to physicians (40.3%; CI: 33.3-47.8). Respondents were least comfortable with pharmacists suggesting the use of certain prescription medications to patients (52.8% 'uncomfortable'; CI: 45.6-59.9). Respondents' expectations of pharmacists were positive for most domains. CONCLUSION: Respondents appeared receptive to most statements regarding expectations of pharmacists, suggesting that many elements of patient-centred pharmaceutical care could be introduced with the co-operation of physicians. A key to extending the role of pharmacists in Sudan teaching hospitals should involve making pharmacists more accessible to doctors and patients, ideally, supported by an organised program of continuing professional development.

Pharmacy education in Jordan, Saudi Arabia, and Kuwait.

The practice of pharmacy, as well as pharmacy education, varies significantly throughout the world. In Jordan, Kuwait, and Saudi Arabia, the profession of pharmacy appears to be on the ascendance. This is demonstrated by an increase in the number of pharmacy schools and the number of pharmacy graduates from pharmacy programs. One of the reasons pharmacy is on the ascendance in these countries is government commitment to fund and support competitive, well-run pharmacy programs. In this report we describe pharmacy education in 3 Middle East countries: Jordan, Kuwait, and Saudi Arabia. All 3 countries offer bachelor of pharmacy (BPharm) degrees. In addition, 2 universities in Jordan and 1 in Saudi Arabia offer PharmD degree programs. The teaching methods in all 3 countries combine traditional didactic lecturing and problem-based learning. Faculties of pharmacy in all 3 countries are well staffed and offer competitive remuneration. All 3 countries have a policy of providing scholarships to local students for postgraduate training abroad. The majority of students in Jordan and Kuwait are female, while the ratio of male to female students in Saudi Arabia is even. Students' attitudes towards learning are generally positive in all 3 countries. In Saudi Arabia and Kuwait, most pharmacy graduates work in the public sector, while in Jordan, the majority work in the private sector.

Self-medication with antibiotics and antimalarials in the community of Khartoum State, Sudan.

PURPOSE: To estimate the prevalence of self medication with antibiotics and antimalarials in Khartoum State, Sudan and evaluate factors associated with self medication. METHODS: A pre-tested questionnaire was used to collect data from a sample of 600 households, (1750 adult persons), selected from three cities in Khartoum State, Sudan, using a multistage stratified clustered sampling. RESULTS: One thousand two hundred and ninety three (73.9%) of the study population had used antibiotics or antimalarials without a prescription within one month prior to the study. Eight hundred and forty one (48.1%) of the respondents agreed that they have used antibiotics, 43.4% used antimalarials, while 17.5% used both. Self medication with either antibiotics/ antimalarials was found to be significantly associated with age, income, gender and level of education. Overall, self medication with any antibiotics or antimalarials was least common among the > or = 60 years compared to youngest age group (OR: 0.07; 0.04 -0.11) and most common among the female gender (OR: 1.8; 1.4 -2.4), the middle income group (OR: 3.7; 2.6-5.3) and the university graduates. Self medication with antibiotic was found to be significantly higher among females (OR: 1.5; 1.16-1.87), middle aged respondents aged 40-59 (OR: 2.1; 1.5-3.0) compared to younger respondents. Lower income and higher level of education was also found to be significantly associated with the increase risk of self medicating with antibiotic. Increase risk for self medication with antimalarials were, however, found to be significantly associated with male gender and younger age group of < 40 years and middle income earners and less educated respondents. The main reason that was indicated for the self-medication was financial constraints. The main source of medicines was the private pharmacies, which were regarded as a cheaper alternative to other primary healthcare sources. CONCLUSION: The prevalence of self-medication with antibiotics/antimalarials in Khartoum State, Sudan is alarmingly high. Self medication behaviour varies significantly with a number of socio-economic characteristics. Given the growing global resistance for antibiotic and documented health issues related to inappropriate use of such drugs, our findings has major public health policy implications for countries like Sudan.

Self-reported medication use among adolescents in Kuwait.

OBJECTIVE: The objectives of this study were to describe and examine the pattern of medication use, including age and gender differences among adolescents in Kuwait, and to establish the sources of information on medicines in this age group. SUBJECTS AND METHODS: A cross-sectional survey of 1,110 male and female students (14-21 years) from 10 randomly selected public schools in Kuwait was conducted. The prevalence of self-medication was estimated. RESULTS: The prevalence of self-medication among the high school students was 92%. The prevalence increased by age from 87% among 14-year-olds to 95% among 18-year-olds. Sixty-five percent of medicines used were for pain relief, 54% for respiratory conditions, 39% for allergic conditions, and 37% for dermatological conditions. Twenty-two percent of medicines were nutritional supplements and vitamins, 21% gastrointestinal products, 17% antidandruff products, 15% hair products, 13% for migraine while 8% were for athlete's foot. Pain relief, respiratory, dermatologic and hair products were more prevalent in female adolescents than in male while antidandruff and athlete's foot preparations were used more by male adolescents. The most common sources of information on medicines were parents. CONCLUSION: The prevalence of self-medication among adolescents in Kuwait is high. Self-medication tended to increase with age and differed between male and female students. Few students consulted pharmacists for information on drugs. There is need to promote the image of the pharmacist in Kuwait as a provider of medication information.

Unaffordable drug prices: the major cause of non-compliance with hypertension medication in Ghana.

PURPOSE: The prevalence of hypertension is increasing in Ghana. In addition hypertension has been identified as the most common cause of heart failure, stroke, chronic renal disease and spontaneous sudden deaths in Ghana. A major concern arising from this increasing hypertension prevalence is that many patients in this relatively poor country find it difficult to afford the standard hypertension medications. The purpose of this study was to evaluate access to hypertension medication and assess non-compliance with hypertension medication in Ghana. METHODS: Patient interviews were conducted on all new patients attending the hypertension clinic at Komfo Anokye teaching hospital between December 2001 and April 2002. RESULTS: 93% of the interviewed patients did not comply with their medications. 96% of the non-compliant patients cited unaffordable drug prices as the main reason for non-compliance. CONCLUSIONS: Non-compliance with hypertension medication is a major problem in Ghana. Unaffordable drug prices appear the major cause. Effort should be made both locally and internationally to improve access to medications for chronic diseases in developing countries.

Interrupted time series analysis in clinical research.

OBJECTIVE: To demonstrate the usefulness of interrupted time series analysis in clinical trial design. METHODS: A safety data set of electrocardiographic (ECG) information was simulated from actual data that had been collected in a Phase I study. Simulated data on 18 healthy volunteers based on a study performed in a contract research facility were collected based on single doses of an experimental medication that may affect ECG parameters. Serial ECGs were collected before and during treatment with the experimental medication. Data from 7 real subjects receiving placebo were used to simulate the pretreatment phase of time series; data from 18 real subjects receiving active treatment were used to simulate the treatment phase of the time series. Visual inspection of data was performed, followed by tests for trend, seasonality, and autocorrelation by use of SAS. RESULTS: There was no evidence of trend, seasonality, or autocorrelation. In 11 of 18 simulated individuals, statistically significant changes in QTc intervals were observed following treatment with the experimental medication. A significant time of day and treatment interaction was observed in 4 simulated patients. CONCLUSIONS: Interrupted time series analysis techniques offer an additional tool for the study of clinical situations in which patients must act as their own controls and where serial data can be collected at evenly distributed intervals.

Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies.

OBJECTIVES: In an interrupted time series (ITS) design, data are collected at multiple instances over time before and after an intervention to detect whether the intervention has an effect significantly greater than the underlying secular trend. We critically reviewed the methodological quality of ITS designs using studies included in two systematic reviews (a review of mass media interventions and a review of guideline dissemination and implementation strategies). METHODS: Quality criteria were developed, and data were abstracted from each study. If the primary study analyzed the ITS design inappropriately, we reanalyzed the results by using time series regression. RESULTS: Twenty mass media studies and thirty-eight guideline studies were included. A total of 66% of ITS studies did not rule out the threat that another event could have occurred at the point of intervention. Thirty-three studies were reanalyzed, of which eight had significant preintervention trends. All of the studies were considered "effective" in the original report, but approximately half of the reanalyzed studies showed no statistically significant differences. CONCLUSIONS: We demonstrated that ITS designs are often analyzed inappropriately, underpowered, and poorly reported in implementation research. We have illustrated a framework for appraising ITS designs, and more widespread adoption of this framework would strengthen reviews that use ITS designs.