|Sexually Transmitted Diseases (STD) Prevention: New Challenges, New Approaches (AIDSCAP/FHI - USAID, 1996, 47 p.)|
by Aurorita M. Mendoza and Waranuch Chinvarasopak
A customer in a Thai pharmacy learns how to take her prescription.
In Thailand, pharmacies are believed to be the first recourse for two out of the three people with symptoms of STD.
· Suvit, a 20-year-old truck driver, notices swelling in his groin. He goes to a drugstore and tells the clerk his problem. Without a moment's hesitation, the clerk hands him a packet of medicine, advising him to take it for two weeks.
· Prontip, a 22-year-old housewife, has been experiencing painful urination and malodorous discharge for three days. The last time she had this problem, the local pharmacist sold her some tetracycline. Remembering how quickly the medicine relieved her symptoms, she goes to the pharmacy and buys more tetracycline.
· Sunee, an 18-year-old waitress, asks a drugstore clerk what she should take for inflammation in her genital area. The clerk recommends taking an antibiotic and using a cream for at least one week, but Sunee has only enough money to buy a three-day supply. After three days she feels better, so she does not return to buy the rest of the dosage.
These are familiar scenarios in Thailand, where pharmacies are believed to be the first recourse for two out of three people with symptoms of sexually transmitted disease (STD). Because of the social stigma associated with STDs, many people prefer to treat themselves rather than go to a clinic or physician's office. But unless the pharmacists and drugstore staff who supply drugs for self-treatment are well-informed, the results can be persistent infections, serious health complications and increases in resistance to drugs.
Recognizing drugstore personnel's potential as partners in STD control, as well as the potential for harm if their role in STD treatment were ignored, the AIDS Control and Prevention (AIDSCAP) Project and the Program for Appropriate Technology in Health (PATH) developed a pilot project with drugstore personnel. By educating pharmacists and drugstore staff and their clients, the project aimed to improve STD management practices in Chiang Mai, a province in northern Thailand with high rates of HIV prevalence, and create a model that could be replicated in other parts of Thailand.
The pilot project began with a baseline study of drugstore services and drug-buying behavior. The study found that 256 drugstores in Chiang Mai Province sold modern medicine. Of these, 149 were licensed to sell prescription medicines because they were owned or managed by a registered pharmacist. The remaining 107 stores sold only over-the-counter medication. These stores are usually managed by a nurse or someone who has received training from the Thai Ministry of Public Health.
As part of the baseline study, mystery shoppers were sent to drugstores to pretend they had STD symptoms and buy drugs to treat themselves. They found that pharmacists and sales personnel seldom asked them about their symptoms, gave them minimal instructions about how to take the drugs they bought, and rarely referred them to health facilities for diagnosis and treatment.
Results of the mystery shopper survey presented a bleak picture of STD treatment practices at the pharmacies and other drugstores. Less than half of the pharmacy personnel correctly dispensed medications for most STDs-notably syphilis, gonorrhea and chancroid. Medication for syphilis was correctly dispensed at only two out of 30 drugstores.
Small group discussions were held with drugstore staff to gain a better understanding of the problems they faced. Drugstore personnel said they often had difficulty determining the cause of a client's symptoms. They do not always have the most current information about the appropriate treatments for certain diseases or about drug resistance in their region.
During the small group discussions, facilitators solicited participants' suggestions for solutions to these problems. Proposed solutions included training drugstore personnel in STD management, disseminating educational materials to drugstore staff and customers, and holding meetings to enable pharmacists and non-pharmacist drugstore staff to exchange information, ideas and experiences.
AIDSCAP and PATH worked with the province's two drugstore associations, the Pharmacist Club and the Drugstore Club, to improve drugstore personnel's knowledge of STDs. A series of workshops were organized to train pharmacists and drugstore owners and managers to recognize STD syndromes and dispense appropriate medications.
Workshops were held Sundays - the trainees' day off-for 35 to 45 trainees. Two hundred pharmacists and drugstore owners and managers attended the workshops; 100 more received information from project staff who visited their drugstores.
The business practice of 'give the customer what he wants' was a prevailing notion, so educating the clientele also was important, said Dr. Busabon Jamroendararasame, then project manager of the Chiang Mai Pharmacist Club.
An information campaign to encourage people to seek appropriate treatment for STDs targeted three groups of consumers: military personnel, youth (including pharmacy students) and the general public. These groups were reached through training workshops, small group discussions and a public exhibition. In addition, Chiang Mai University and the Institute for Management Education of Thailand held two seminars for leading businesswomen to encourage them to educate their employees about HIV/AIDS and other STDs.
A variety of print materials, including a pictorial pamphlet about STD treatment, a flip-calendar describing appropriate treatments for common STDs, and a handbook on STD treatment, were produced and distributed to drug sellers for their own reference and to use in educating clients. Every month the Chiang Mai Pharmacist Club distributed 500 copies of its newsletter with the latest information on STD drugs to its members and to members of the Chiang Mai Drugstore Club and other medical organizations. A periodical produced jointly by the two associations, which included information about their participation in improving STD management skills, was distributed every four months to 1,000 people.
The results of the pilot project show that given proper education, drugstore personnel can play an important role in STD control. During the 18-month project, great progress was made in improving the knowledge of staff and their clients and helping them use that knowledge to improve STD case management.
After participating in the training workshops, pharmacists and clerks were more likely to explain why certain drugs were being dispensed and how they should be used.
A project evaluation that included another mystery shopper survey revealed marked improvements in the sale of appropriate drugs for some STDs. The mystery shoppers also found that drugstore personnel had become more open to questions from clients. Pharmacists and clerks were more likely to explain why certain drugs were being dispensed and how they should be used.
One of the project's strengths was its participatory approach. Pharmacists and drugstores were involved in every phase of the project, from needs assessment to activity planning and problem solving. Pharmacists and drugstore owners and managers who attended the training workshops helped organize meetings, produce periodicals, develop curricula and prepare technical papers. This participatory process and the opportunities for professional development that it provided were key factors in enhancing participants' commitment to improving STD management practices and promoting sustainability.
An indicator of the prospects for sustaining and building on the benefits of the pilot project was the willingness of drugstore owners to provide financial support to the Pharmacist Club so it could continue funding and producing educational materials for dissemination to drugstores. The involvement of the two organizations in this project helped them realize that they had the capacity as well as the resources to play a more positive role in the health system.
The project's collaboration with the drugstore associations laid a good foundation for further work with drugstores and pharmacies. Encouraged by the success of the pilot, the European Community is supporting a similar training program for drugstore personnel in Bangkok that will also establish referral networks between drugstores and health facilities. Most recently, an effort has begun to train drugstore personnel throughout Thailand so that they can play a greater and more constructive role in the national AIDS prevention and control program.
Aurorita M. Mendoza is regional representative and Waranuch Chinvarasopak is associate program officer for the Program for Appropriate Technology in Health (Bangkok), a subcontractor to the AIDSCAP Project.