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- Chalker, John C
(författare)
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Interventions for improved prescribing and dispensing of medicines in Nepal, Thailand and Vietnam
- 2003
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: To find successful interventions to improve drug use, especially antibiotics, is a pressing need in low income countries. The objectives of the research are to explore current practice and knowledge of practitioners in the public and private sectors in resource poor countries, and experiment with different interventions to improve practices in the prescribing and dispensing of medicine. Designs: I: Post intervention, with control. II: Pre post intervention and time series with rolling control. III: Baseline comparison of data from questionnaires and simulated client method (SCM). IV and V: Randomized controlled trial. Settings: Public primary health care facilities (PHC) in 2 hill districts in Nepal (I) and in Hai Phong Province, Vietnam (II). Private pharmacies in Hanoi (III-V) and Bangkok (V). Study Population: I: A 25 % sample of all prescriptions issued in a year by all PHC facilities in the two districts. II: Monthly random collection of 30 prescriptions from all 217 facilities. III: 60 randomly selected private pharmacies as measured by 5 simulated client visits (SCM) and a semi structured questionnaire per pharmacy. IV: Pre post questionnaires to 34 randomly selected matched pairs of pharmacies. V: The intervention and control pharmacies that had all 5 simulated client visits for each condition at each phase in Hanoi and Bangkok. Interventions: I: An assured drug supply scheme with a prescription charge. II: Incentives, controls and the education of providers, patients and communities. IV-V: Multi-faceted interventions with regulatory enforcement, faceto face education and peer influence. Outcome Measures: Attendance (I), items per prescription and % prescriptions containing antibiotics (I & II), % antibiotics prescribed with an adequate dose (II). Correct questions, advice and treatment for managing a case of a sexually transmitted disease (STD) (III, IV), acute respiratory infection (ARI) (IV), and antibiotic and steroid requests (IV and V). Results: In the intervention groups: I: Attendance fell 18% the first year and recovered over 3 years. Items per prescription were 2.5 (1.7 in control and 1.4 calculated needed values). 61 % of prescriptions contained antibiotics (37% in control and 27% calculated needed value). II: The per cent of prescriptions with antibiotics decreased from 68% to 45% and the per cent with an adequate dose, increased from 30% to 93%. III: 74% of drug sellers said they would refer a case of STD to a doctor but only 16% did. None gave correct treatment. Few asked relevant questions and gave relevant advice. IV: After the interventions more drug sellers in the intervention group stated they would ask about the health of the partner (p=0.03) and advise on condom use (p=0.01) and partner notification (p=0.04): For ARI, in the intervention group, more say they would ask questions about fever (p=0.01) and fewer would give antibiotics (p=0.02). Fewer would sell low dose antibiotics without a prescription (p=0.02). V: In Hanoi fewer in the intervention group sold antibiotics (p=0125) and steroids (p <0.0001) and more asked questions and gave advice. In Bangkok there were no changes. Conclusions: The prescribing and dispensing of antibiotics is a major problem in all the locations studied. Studies presented here show that improvements are possible to achieve both in the public and private sectors in most resource poor settings but vary with location. Major problems remain. Comprehensive, tailored, interventions have to be developed for each location including both consumers and their providers. Isolated examples of successful small scale interventions are no longer enough. Indicators as both assessment and managerial tools are central to this endeavour.
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| 2. |
- Gusdal, Annelie K, 1963-, et al.
(författare)
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Peer counselors' role in supporting patients' adherence to ART in Ethiopia and Uganda
- 2011
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Ingår i: AIDS Care. - : Informa UK Limited. - 0954-0121 .- 1360-0451. ; 23:6, s. 657-662
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Tidskriftsartikel (refereegranskat)abstract
- Our aim was to explore peer counselors' work and their role in supporting patients' adherence to antiretroviral treatment (ART) in resource-limited settings in Ethiopia and Uganda. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Two main categories with related subcategories emerged from the analysis. The first main category, peer counselors as facilitators of adherence, describes how peer counselors played an important role by acting as role models, raising awareness, and being visible in the community. They were also recognized for being close to the patients while acting as a bridge to the health system. They provided patients with an opportunity to individually talk to someone who was also living with HIV, who had a positive and life-affirming attitude about their situation, and were willing to share personal stories of hope when educating and counseling their patients. The second main category, benefits and challenges of peer counseling, deals with how peer counselors found reward in helping others while at the same time acknowledging their limitations and need of support and remuneration. Their role and function were not clearly defined within the health system and they received negligible financial and organizational support. While peer counseling is acknowledged as an essential vehicle for treatment success in ART support in sub-Saharan Africa, a formal recognition and regulation of their role should be defined. The issue of strategies for disclosure to support adherence, while avoiding or reducing stigma, also requires specific attention. We argue that the development and implementation of support to peer counselors are crucial in existing and future ART programs, but more research is needed to further explore factors that are important to sustain and strengthen the work of peer counselors.
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| 3. |
- Gusdal, Annelie K, 1963-, et al.
(författare)
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Voices on adherence to ART in Ethiopia and Uganda : a matter of choice or simply not an option?
- 2009
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Ingår i: AIDS Care. - : Informa UK Limited. - 0954-0121 .- 1360-0451. ; 21:11, s. 1381-1387
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Tidskriftsartikel (refereegranskat)abstract
- This paper explores HIV patients' adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Interviewees voiced their experiences of, and views on ART adherence both from an individual and a system level perspective. Two main themes emerged from the content analysis: "Patients' competing costs and systems' resource constraints'' and "Patients' trust in ART and quality of the patient-provider encounters.'' The first theme refers to how patients' adherence was challenged by difficulties in supporting themselves and their families, paying for transportation, for drug refill and follow-up as well as paying for registration fees, opportunistic infection treatment, and expensive referrals to other hospitals. The second theme describes factors that influenced patients' capacity to adhere: personal responsibility in treatment, trust in the effects of antiretroviral drugs, and trust in the quality of counseling. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling.
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| 4. |
- Obua, Celestino, et al.
(författare)
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Multiple ART Programs Create a Dilemma for Providers to Monitor ARV Adherence in Uganda
- 2011
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Ingår i: Open AIDS Journal. - : Bentham Science Publishers Ltd.. - 1874-6136. ; 5, s. 17-24
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Tidskriftsartikel (refereegranskat)abstract
- Background: Increased availability and accessibility of antiretroviral therapy (ART) has improved the length and quality of life amongst people living with HIV/AIDS. This has changed the landscape for care from episodic to longterm care that requires more monitoring of adherence. This has led to increased demand on human resources, a major problem for most ART programs. This paper presents experiences and perspectives of providersin ART facilities, exploring the organizational factors affecting their capacity to monitor adherence to ARVs. Methods: From an earlier survey to test adherence indicators and rank facilities as good, medium or poor adherence performances, six facilities were randomly selected, two from each rank. Observations on facility set-up, provider-patient interactions and key informant interviews were carried out. The strengths, weaknesses, opportunities and threats identified by health workers as facilitators or barriers to their capacity to monitor adherence to ARVs were explored during group discussions. Results: Findings show that the performance levels of the facilities were characterized by four different organizational ARTprograms operating in Uganda, with apparent lack of integration and coordination at the facilities. Of the six facilities studied, the two highadherence performing facilities were Non-Governmental Organization (NGO) programs, while facilities with dual organizational programs(Governmental/NGO) performed poorly. Working conditions, record keeping and the duality of programs underscored the providers' capacity tomonitor adherence. Overall 70% of the observed provider-patient interactions were conducted in environments that ensured privacy of the patient. The mean performance for record keeping was 79% and 50% in the high and low performing facilities respectively. Providers often found it difficult to monitor adherence due to the conflicting demands from the different organizational ART programs. Conclusion: Organizational duality at facilities is a major factor in poor adherence monitoring. The different ART programs in Uganda need to be coordinated and integrated into a single well resourced program to improve ART services and adherence monitoring. The focus on long-term care of patients on ART requires that the limitations to providers' capacity for monitoring adherence become central during the planning and implementation of ART programs.
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