International Journal for Quality in Health Care Advance Access originally published online on October 27, 2005
International Journal for Quality in Health Care 2006 18(1):66-72; doi:10.1093/intqhc/mzi086
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Post-training quality of syndromic management of sexually transmitted infections by chemists and druggists in Pokhara, Nepal: is it satisfactory?
1 Department of Public Health, Sapporo Medical University, Sapporo, Hokkaido, Japan, 2 Department of Statistics, Jahangirnagar University, Dhaka, Bangladesh, and 3 Department of Tropical Hygiene and Public Health, Heidelberg University, Heidelberg, Germany
Objective. Using simulated client and provider interview methods, this study assessed chemists and druggists’ post-training management quality of syndromic sexually transmitted infections focusing on the areas of privacy maintaining, encouraging, history taking, counseling, referral practice, partner notification, and drug prescribing and then compared the findings of two methods.
Design. Forty-five pharmacies from a list of 75 in Pokhara, who collected sexually transmitted infections data during 1999, were selected randomly. First simulated client successfully presented either urethral or vaginal discharge syndrome at 37 pharmacies and recorded the events of whole encounter into an observation form within 20 minutes. Later 39 chemists and druggists were interviewed by a pre-tested semi-structured questionnaire.
Main measures. Results were reported mainly by numbers and corresponding percentages. For comparative purpose, P values were also shown.
Results. Overall, interview method revealed satisfactory knowledge of chemists and druggists for management of sexually transmitted infections except drug prescribing but their actual behaviors, revealed by simulated client method, indicated lower quality and differed significantly in the areas of encouraging, history taking, counseling, referral practice, and partner notification. Both methods indicated very poor qualities of drug prescribing.
Conclusion. Retained knowledge of chemists and druggists for syndromic management of sexually transmitted infections were not applied to simulated client in actual practice. They should not prescribe drugs for patients of sexually transmitted infections, except referring to the doctors/hospitals. Continuous monitoring and further motivations for them may improve syndromic management quality of sexually transmitted infections. Moreover, depending on the purpose of study, various methods should be applied simultaneously to reach a better conclusion.
Keywords: interview method, private drug sellers, sexually transmitted infections, simulated client method, syndromic management
Address reprint requests to M. M. H. Khan, Department of Public Health, Sapporo Medical University, Japan. E-mail: khan{at}sapmed.ac.jp
Accepted for publication September 24, 2005.
Sexually transmitted infections—previously known as sexually transmitted diseases—predominantly affect young adults, carry stigma, facilitate transmission and acquisition of the human immunodeficiency virus (HIV) infection, and have a lot of complications [1,2]. Thus, they are considered as a major global public health problem [3,4], especially in developing countries where 75–80% of the 340 million curable sexually transmitted infections occur annually [3]. Control of sexually transmitted infection is one of the highest public health priorities in many of the poor countries. As the etiological approach to control sexually transmitted infections is expensive and delays diagnosis, the World Health Organization has been promoting the syndromic management of sexually transmitted infections by placing increasing emphasis on integrated care at the primary care level [1,2,5–7]. Syndromic sexually transmitted infections’ management is found to be rational and scientifically acceptable [1] in situations where resources for specific diagnosis including laboratory tests are scarce. Briefly, syndrome refers to a group of symptoms and signs which can all be part of the same underlying medical condition [8]. Syndromic management implies an approach in which algorithms are used as decision trees for commonly presenting symptoms and signs, and for treatment [8,9].
Nepal is one of the countries, where sexually transmitted infections and more recently HIV are major health threats, especially because of the cumulated presence of risk factors such as large number of commercial sex workers, unprotected sex, many pockets of injecting drug users, large number of truck drivers, migrant workers, widespread tourism, girls trafficking, poor socioeconomic status, and lack of awareness about sexually transmitted infections/HIV [10–12]. The Nepalese government reacted by forming a national sexually transmitted diseases/AIDS control committee in 1986, which has since initiated various activities in the following areas [13]: (i) involving all health institutions for educating people, (ii) syndromic case finding and early treatment, (iii) preventing sexually transmitted infections/HIV by promoting safe sexual behavior, (iv) training of health care providers, from both public and private sectors, for better management and referral system.
Among the private health care providers in Nepal, chemists and druggists, who are working in medical shops or pharmacies, play an important role in controlling sexually transmitted infections as first line service providers [14,15] including Pokhara [15]. Pokhara is considered an important location for spreading sexually transmitted infections in Nepal [15] mainly due to commercial sex activities, trafficking, huge number of camps for Indian army, migrant laborers, and tourism.
University of Heidelberg sexually transmitted disease/HIV project of the National Centre for AIDS and Sexually transmitted disease Control (NCASC) therefore trained the chemists and druggists of Pokhara for syndromic case management sexually transmitted infections [focusing on urethral discharge, vaginal discharge, genital ulcer (both sexes), and lower abdomen pain (female)] and provided a training manual including flow charts of syndromic case management. The training emphasized several issues such as maintaining privacy, history taking, counseling, health education, condom promotion, partner notification, referral, and prescribing drugs [16]. In 1999, the year after training, reporting by chemist and druggist showed that in Pokhara municipality around 70% of all patients of sexually transmitted infections were treated by them [17].
This study assessed the post-training quality of actual practices and retained knowledge of chemists and druggists for syndromic case management of sexually transmitted infection about one-and-a-half years after the intervention by employing simulated client method and provider interview method. Apart from evaluating the intervention, we were interested to compare the results of two methods, thus providing further evidence on how best to assess quality of health care providers. The necessities of using two or more methods including simulated client method and provider interview method to study the same topic of research have been explained elsewhere [18–23].
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Methods |
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This study was conducted on the chemists and druggists who were working at private pharmacies in Pokhara municipality, Nepal. The list of 75 retail pharmacies, provided by the University of Heidelberg sexually transmitted disease/HIV project, was the sampling frame of the study. At least one chemist and druggist from each pharmacy had participated in the project’s training course, and the pharmacies provided monthly report of sexually transmitted infections to the project throughout the year 1999 [16]. From this list, about 50% pharmacies were selected randomly.
A 35-year-old male was trained to act as simulated client. Under simulated client method, a researcher (simulated client) plays the role of actual client seeking health services and records what happened during the encounter with the provider. Most studies employ people who present false personal histories or who claim to be inquiring on behalf of a family member. The health providers are unaware and blinded to client’s research agenda. Therefore, the information gathered by this method is seen as accurately reflecting normal performance by removing the bias introduced by direct observation through a third party. This method provides high quality evaluation of history taking, physical examination, communication, and interpersonal relating [14,24–28].
In this study, the trained simulated client presented in the pharmacies either with a history of urethral discharge (inquiring for himself) or vaginal discharge (inquiring on behalf of his wife) at each pharmacy. For this, a scenario was developed for each syndrome as realistically as possible using Nepalese language. Later, the scripts were translated into English (Table 1). The simulated client was instructed to record the whole encounter in a standardized and pre-tested observation form within 20 minutes of leaving the pharmacy. We used only one simulated client to avoid the bias which may arise from several simulated clients. Because selling medicine by chemists and druggists is common in Pokhara, it is rather difficult to leave the pharmacy without buying some medicines. Therefore, we instructed the simulated client to buy a small quantity of the prescribed medicines. Later, we used these medicines and the prescriptions to classify whether chemists and druggists followed the training guidelines or not.
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Three to four days later, we interviewed chemists and druggists in the same pharmacies using a structured questionnaire. Provider interview method is frequently used in the health sector to measure the retained knowledge and expertise of the providers as well as reported behavior [29]. However, it may overestimate correct performance, as providers may try to impress interviewers, and answers may not reflect actual behavior correctly. The interviewer was trained and spoke both Nepalese and English. The questionnaire was pre-tested in pharmacies not included in the sample and adjustments made before implementing this part of the study.
The training manual of sexually transmitted disease/HIV project was used as the basis for developing the observation form (expected behavior and prescription) as well as the questionnaire (theoretical knowledge and expected behavior).
Analysis
All the analyses were done using Intercooled Stata 5.0. The findings are mainly expressed as total number and percentages. Because one of the objectives was to examine the difference between two methods, P-values of the normal test (for testing equality of two proportions) were also calculated to identify the significance level.
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Results |
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In total, 37 chemists and druggists (22 for urethral discharge and 15 for vaginal discharge) were visited by simulated client successfully. The chemist and druggist attending to client was male in 78.4% of visits, which is slightly less than the chemist and druggist interviewed (85%). Other descriptive factors could only be established for the interviews (N = 39): 82% of the interviewed chemists and druggists had participated in the training. Average age and general education were 31.4 years and 12.5 years, respectively. The average experience as a chemist and druggist was about 10 years, and 92% chemists and druggists reported to work full time in this job. Twenty-three chemists and druggists were identified as being the same individuals, who were observed by simulated client method also. However, analysis of this subgroup did not show differences as compared with the total sample. Therefore results of the total samples (N = 37 for simulated client method and N = 39 for provider interview method) are reported and compared. Average consultancy time and waiting time were 7 minutes and 10 minutes, respectively.
Comparative results of behavioral factors
Table 2 gives an overview of how well chemist and druggist remembered the expected correct behavior (measured by provider interview method) and put it to practice (measured by simulated client method) for sexually transmitted infection’s case management in respect to: maintaining privacy during encounter, encouraging the client to talk openly, history taking, counseling the client, referring the client to a doctor/hospital, and notifying partners for better sexually transmitted infection’s management.
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Regarding privacy maintaining, observed and reported behavior were more or less the same except the option requested other customers to come back later, which was significantly higher for provider interview method. All the options of encouraging the client except looked at client in a friendly manner were significantly more frequently mentioned in interview method as compared with observation with simulated client method. For example, talked with patient with a friendly face was observed in 27 (73.0%) chemists and druggists in simulated client method, whereas the figure was 38 (97.4%) (P = 0.002) in provider interview method.
The observation (simulated client method) showed significantly lower implementation of history taking and counseling when compared with reported behavior. For example, 8 (21.6%) chemists and druggists asked simulated client about condom use as part of history taking, although 30 (76.9%) chemists and druggists reported same option when interviewed. Similarly, 13 (35.1%) chemists and druggists suggested the simulated client to use condom, but all (100.0%) chemists and druggists reported that they always counsel the patient with sexually transmitted infection to use condom during sexual intercourse as a safer sex method. Counseling on avoiding sex during treatment was equally low in practice. Because 14 (37.8%) told the simulated client about this, 34 (87.4%) reported to do so.
During interview, 35 (89.7%) chemists and druggists reported that they referred their clients to a doctor, which is the expected behavior according to training guidelines. But their actual practice differed greatly from their reporting. For instance, 12 (32.4%) chemists and druggists referred the simulated client to a doctor (P < 0.001).
All chemists and druggists reported that they notify the partner of the patient, whereas significantly less (16 = 43.2%) explained this to the simulated client. All the options used for partners’ notification such as duplicate prescribing, suggest client to bring the partner for treatment to the same chemist and druggist, and suggest partner for treatment by any provider differed significantly between two methods (see Table 2 for details).
Prescribing patterns by chemists and druggists
Using the training guidelines, the prescribing pattern was divided into 6 categories (Table 3) which are self-explanatory. Simulated client method indicated that 29 (78.4%) chemists and druggists prescribed medicines for the simulated client, although four (10.8%) chemists and druggists followed the recommended guidelines with correct doses. Most of them (43.2%) failed to follow recommended guidelines.
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During the interview, interviewer presented four written scenarios (based on training manual) for urethral discharge, vaginal discharge, genital ulcer, and lower abdominal pain one after another, and then requested chemist and druggist to diagnose these presented scenarios. In response, 35 (89.7%) chemists and druggists correctly identified the described syndromes as urethral discharge, followed by 32 (82.0%) for lower abdominal pain, 28 (71.8%) for both vaginal discharge, and genital ulcer scenarios. The prescribing patterns for the presented scenarios were not satisfactory. For instance, 32 (82.1%) chemists and druggists prescribed medicines for the scenario of urethral discharge, and 13 (33.3%) chemists and druggists prescribed according to the training guidelines. For vaginal discharge, 31 (79.5%) chemists and druggists prescribed medicines but seven (17.9%) chemists and druggists prescribed following the recommended guidelines. The prescribing pattern for genital ulcer and lower abdominal pain was more disappointing as 1 (2.6%) and 0 (0.0%) chemists and druggists prescribed medicines correctly (for details, see Table 3).
The differences of drug prescribing categories (summarized in Table 3) of chemists and druggists by the training intervention (who received the training of syndromic case management of sexually transmitted infections versus who did not receive) were compared and tested. According to findings, all the differences were statistically insignificant (data not shown).
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Discussion |
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Although interview method showed relatively satisfactory knowledge and ‘theoretical’ behavior of chemists and druggists for some areas like maintaining privacy, encouraging client to speak openly, history taking, counseling, referral practice, and partner notification, their implementations in actual practice were poor. Partner notification, which is crucial for effective treatment, may be an example in this regard. Probably, for economic reasons, chemists and druggists do not like to refer the patient to the specialist/doctor. Both simulated client and provider interview methods indicated more or less similar quality of privacy maintaining except the option requested other customers to come back later which was significantly higher in interview method. This may, however, be due to the fact that other customers did not come into the pharmacy during simulated client’s visit, and thus this difference may not be a real difference.
In spite of rather high level of correct diagnosis (more than 70%) of the four specific scenarios, the quality of diagnosing sexually transmitted infections and prescribing medications for all of them was really unsatisfactory, particularly for genital ulcer and lower abdominal pain. This confirms that poor treatment quality by chemist and druggist—as also reported e.g. from Vietnam by Chalker et al. [18] and from South Africa by Ward et al. [30]—is a problem which needs urgent attention, especially as chemists and druggists in Pokhara are an important first contact point for clients with suspected sexually transmitted infections [15,17]. According to the study of Chalker et al. [18], which also applied both simulated client and interview methods to the pharmacies in Hanoi, Vietnam for studying the syndromic management quality of sexually transmitted infections (urethral discharge), educational interventions are urgently needed among the private pharmacies for better management of sexually transmitted infections.
Our study was done as a post-intervention assessment, and the results clearly showed that the training received by chemists and druggists was not sufficient to improve their practice to acceptable quality. This seems in part not to be a problem of knowledge as shown by the provider interviews and therefore may need further investigation of the underlying factors (e.g. economic necessity to sell medicines versus the request to refer clients to a doctor). Further monitoring, motivation, and training to encourage the chemists and druggists to apply their retained knowledge to the clients with sexually transmitted infections for better management including referral system may play an important role to improve the situation.
Our study also reconfirmed large differences between simulated client method and interview method, as has been reported by various authors [20,22,27]. Franco et al. [20] mentioned that provider interviews do not yield valid data about what these same providers were observed to be doing, although provider interview method is considered to be a very reliable method to study the retained knowledge and expertise of the providers alone [29]. In our study, the actual practice assessed by simulated client method was consistently less satisfactory than the reported practice (revealed by provider interview method) of the chemists and druggists in many areas of sexually transmitted infections’ case management. Our findings thus support the experience of others that provider interview method strongly overestimates correct performance and is not a suitable method for studying the actual performances of health service providers. One aspect which needs careful consideration when applying simulated client method is the issue of ethics, as no informed consent can be obtained directly. This limitation including the ways to overcome it has been discussed in detail by Madden et al. [26]. We have sought general permission by the Association of Chemists and Druggists in Pokhara, which is an acceptable substitute for individual consent as long as individuals are not identifiable in the report later.
We hope that this study, in spite of its only moderately encouraging results, will make a small contribution to better addressing the issue of quality sexually transmitted infections’ services in Pokhara and Nepal as such with the aim to ultimately reducing the burden of sexually transmitted infections/HIV in Nepal.
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Authors are thankful to Mr. K. P. Bista, P. Chaudhury, and other staff of the University of Heidelberg sexually transmitted disease/HIV Project of the NCASC, Teku, Nepal for their assistance during data collection in Nepal. The authors also express their thanks to German Academic Exchange Service (DAAD) for supporting the cost of the study. Moreover, the authors are grateful to the staff of the department of Tropical Hygiene and Public Health, Heidelberg University, Germany especially Dr M. Rabbow for providing all facilities during the research.
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References |
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|---|
- Bosu WK. Syndromic management of sexually transmitted diseases: is it rational or scientific? Trop Med Int Health 1999; 4: 114–119.[CrossRef][Web of Science][Medline]
- Mayaud P, Ka-Gina G, Grosskurth H. Effectiveness, impact and cost of syndromic management of sexually transmitted diseases in Tanzania. Int J STD AIDS 1998; 9 (suppl. 1): 11–14.
- Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges. Sex Transm Infect 2004; 80: 174–182.
[Abstract/Free Full Text] - World Health Organization. Guidelines for Sexually Transmitted Infections Surveillance. Geneva: WHO, 1999.
- Hudson CP. Syndromic management for sexually transmitted diseases: back to the drawing board. Int J STD AIDS 1999; 10: 423–434.
[Free Full Text] - Matteelli A, Kassa A, Gerbase A et al. Passive sentinel surveillance system for sexually transmitted diseases in primary health care sites in Ethiopia, 1991–3. Sex Transm Infect 2000; 76: 131–133.
[Abstract/Free Full Text] - Ramos MC, da Silva RDC, Gobbato RO et al. Pharmacy clerks’ prescribing practices for STD patients in Porto Alegre, Brazil: missed opportunities for improving STD control. Int J STD AIDS 2004; 15: 333–336.[CrossRef][Web of Science][Medline]
- Women Commission for Refugee Women and Children (WCRWC). Guidelines for the Care of Sexually Transmitted Infections in Conflict-Affected Settings. The Reproductive Health Response in Conflict (RHRC) Consortium. New York: WCRWC, 2004.
- Boonstra E, Lindbaek M, Klouman E, Ngome E, Romoren M, Sundby J. Syndromic management of sexually transmitted diseases in Botswana’s primary health care: quality of care aspects. Trop Med Int Health 2003; 8: 604–614.[CrossRef][Web of Science][Medline]
- Agarwal S, Garg VK, Agarwalla A, Deb M. Clinical profile and sexual behaviors in patients of sexually transmitted diseases in a teaching hospital of eastern Nepal. J Nepal Med Assoc 2001; 40: 172–176.
- Furber AS, Newell JN, Lubben MM. A systematic review of current knowledge of HIV epidemiology and of sexual behavior in Nepal. Trop Med Int Health 2002; 7: 140–148.[CrossRef][Web of Science][Medline]
- Pokharel BR, Ayyal S, Bhattarai A, Pyakuryal A, Suvedi BK. Situation Analysis of HIV/AIDS in Nepal. Teku, Kathmandu: National Centre for AIDS and STD Control, 2000.
- Department of Health Services Annual Report. His Majesty’s Government of Nepal. Kathmandu: Ministry of Health, Department of Health Services (2054/55), 1997/98.
- Tuladhar SM, Mills S, Acharya S, Pradhan M, Pollock J, Dallabetta G. The role of pharmacists in HIV/STD prevention: evaluation of an STD syndromic management intervention in Nepal. AIDS 1998; 12 (suppl. 2): S81–S87.
- Zeeb DH Provision of Care for Patients with Sexually Transmitted Diseases in Pokhara, Nepal (A Research report for the degree of Post Graduate Master of Science in Community Health and Health Management in Developing Countries). Heidelberg, Germany: University of Heidelberg, 1996.
- National Center for AIDS and STD Control (NCASC). National STD Case Management Guidelines. Kathmandu, Nepal: Teku, 1997.
- Bista KP, Chaudhary P, Slanger TE, Khan MH. The practice of STI treatment among chemists and druggists in Pokhara, Nepal. Sex Transm Infect 2002; 78: 223.
[Free Full Text] - Chalker J, Chuc NTK, Falkenberg T, Do NT, Tomson G. STD management by private pharmacies in Hanoi: practice and knowledge of drug sellers. Sex Transm Infect 2000; 76: 299–302.
[Abstract/Free Full Text] - Barbour RS. The case for combining qualitative and quantitative approaches in health services research. J Health Serv Res Policy 1999; 4: 39–43.[Medline]
- Franco LM, Franco C, Kumwenda N, Nkhoma W. Methods for assessing quality of provider performance in developing countries. Int J Qual Health Care 2002; 14 (suppl. 1): 17–24.
- Hermida J, Nicholas DD, Blumenfeld SN. Comparative validity of three methods for assessment of the quality of primary health care. Int J Qual Health Care 1999; 11: 429–433.
[Abstract/Free Full Text] - Miller GE. Conference summary. AAMC consensus conference on the use of standardized patients in the teaching and evaluation of clinical trials. Acad Med 1993; 68: 471–476.[Web of Science]
- Rethans JJ, Westin S, Hays R. Methods for quality assessment in general practice. Fam Pract 1996; 13: 468–476.
[Abstract/Free Full Text] - Beullens J, Rethans JJ, Goedhuys J, Buntinx F. The use of standardized patients in research in general practice. Fam Pract 1997; 14: 58–62.
[Abstract/Free Full Text] - Huntington D, Schuler RS. The simulated client method: evaluating client–provider interactions in family planning clinics. Stud Fam Plann 1993; 24: 187–193.[CrossRef][Web of Science][Medline]
- Madden JM, Quick JD, Ross-Degnan D, Kafle KK. Undercover care seekers: simulated clients in the study of health provider behavior in developing countries. Soc Sci Med 1997; 45: 1465–1482.[CrossRef][Web of Science][Medline]
- Rahman S, Ahmed MU, Khuda B. Can medicine-sellers in pharmacies of urban Bangladesh meet the needs of clients with STD? J Health Popul Dev Countries 2000; 3 (2/winter): online.
- Wallace J, Rao R, Haslam R. Simulated patients and objective structured clinical examinations: review of their use in medical education. Adv Psychiatry Treat 2002; 8: 342–350.
- Franco LM, Daly CC, Chilongozi D, Dallabetta G. Quality of case management of sexually transmitted diseases: comparison of the methods for assessing the performance of providers. Bull World Health Organ 1997; 75: 523–532.[Web of Science][Medline]
- Ward K, Butler N, Mugabo P et al. Provision of syndromic treatment of sexually transmitted infections by community pharmacists: a potentially underutilized HIV prevention strategy. Sex Transm Dis 2003; 30: 609–613.[Web of Science][Medline]
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