Practices of Community Pharmacists Towards COVID-19 Treatment in Vietnam: A Simulated Client Study

doi:10.21203/rs.3.rs-4286626/v1

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Research Article

Practices of Community Pharmacists Towards COVID-19 Treatment in Vietnam: A Simulated Client Study

https://doi.org/10.21203/rs.3.rs-4286626/v1

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Background

Recent reports have raised concerns about drug overuse and misuse in self-medication practices for COVID-19 treatment. This study was aimed to assess the availability and appropriateness of medication dispensing provided by community pharmacists to COVID-19 patients in Ho Chi Minh City, Vietnam.

Methods

The simulated client method was used to examine 102 randomly selected community pharmacies from 13 central districts of Ho Chi Minh City between May 2022 and July 2022. Each pharmacy was visited by 2 simulated clients asking to buy medications for a relative with mild COVID-19 symptoms. Characteristics of pharmacies and pharmacists along with medications dispensed were recorded. Factors associated with appropriate medication transaction were explored using the Bayesian Model Averaging method.

Results

Of 102 enrolled community pharmacies, 63 (61.8%) were independent. Most encountered pharmacists were female (90.2%) and were not pharmacists-in-charge (82%). Of 98 transactions with identified medications, cough medicines (93.88%), antipyretics (88.78%), and dietary supplements (80.61%) were frequently dispensed. Moreover, medications dispensed without a medical prescription such as antibiotics (59.18%), corticosteroids (60.20%) and antivirals (7.14%), were also recorded. Additionally, the type of a pharmacy was significantly associated with the practice of dispensing antibiotics (OR = 0.29, 95% CI = 0.12–0.69)

Conclusions

This study recorded high rates of antibiotics and corticosteroids for COVID-19 mild symptoms dispensed without a prescription. Further research is warranted to improve practices of community pharmacists towards COVID-19 treatment

Community pharmacists

COVID-19

Simulated client

Since the outbreak of the COVID-19 pandemic in 2020, healthcare systems around the world have been under tremendous pressure due to a shortage of medical supplies, a high mortality rate, and significant demands for medical care.(1) Therefore, the preparedness of a country’s healthcare system plays a crucial role in infection control and social stability during the COVID-19 pandemic. Some countries such as the United Kingdom have adapted promptly and efficiently to this crisis situation by enhancing their pharmaceutical services along with providing expanded guidelines and frameworks to ensure both public and healthcare worker safety.(2)

In Vietnam, the healthcare system was overwhelmed with COVID-19 patients during the huge outbreak, especially in Ho Chi Minh City (HCMC) in 2021. To resolve this crisis, the government developed emergency guidance to help reduce the pressure on the frontline medical teams. Patients with mild to moderate COVID-19 were allowed to self-monitor at home and would be distributed medicine packages based on their symptoms.(3, 4) In addition, as pharmacies are the most accessible and the first point of contact in Vietnam,(5) more than 6500 pharmacies in HCMC were called upon to provide consultations and essentials for COVID-19 self-monitored patients at home.(6)

However, there have been many reports on drug abuse and misuse in self-medication practices for COVID-19 prevention and treatment, resulting in unfortunate consequences.(7) This has raised concerns about the preparedness and responses of community pharmacists (CPs) to the COVID-19 pandemic; yet little work has been done to address this problem. This study was aimed to assess the availability and appropriateness of medication dispensing provided by CPs to COVID-19 patients using the simulated client (SC) method.

Design and population

The study was conducted from May to July 2022 in thirteen central districts across HCMC where a total of 1683 pharmacies participated in the COVID-19 healthcare campaign.(8) It was assumed that the proportion of appropriate medication dispensing provided by CPs for COVID-19 self-monitoring patients with mild symptoms was 50% with a confidence interval of 95% and a standard error of 10%. The sample size for the study, which was determined by using the online software Raosoft®, was 91 community pharmacies.

However, to account for attrition, the selected sample size for the study was 104 community pharmacies (8 pharmacies per district). A list of pharmacies, including both independent and chain pharmacies participating in the COVID-19 healthcare campaign, was obtained from the website of HCMC Department of Health.(8) These pharmacies were then coded, filtered by districts, and randomly selected using Microsoft Excel 2016 software to obtain the determined sample size.

Data collection

The SC method was used to mitigate the Hawthorne effect as the subjects were not aware of being observed, thereby not altering their behaviors.(9) Four pharmacy students (S.T-T.D, P.B.Q, T.T.D, U.U-T.T) were trained by the researchers (H.Q.N, T-D.N) to act as a SC with a standardized script to ensure the consistency of the representation. The preset scenario was established based on relevant guidance on COVID-19 treatment and prevention issued by Vietnam Ministry of Health and other worldwide organizations.(10–12) The selected pharmacies were each visited by two students simultaneously who acted as family members of a COVID-19 patient with typical symptoms, expected to be provided with medications. According to the preset scenario, the simulated patient was a 32-year-old woman who self-tested positive for COVID-19 the day before, and was experiencing fever, dry cough, loss of smell and aches for 2 to 3 days. One of the two students interacted with the CP, asking to buy medications for the simulated COVID-19 patient, while the other who acted as a companion assisted in recording the conversation by taking notes. Afterwards, the two students documented each pharmacist’s responses using a standardized data collection form immediately after leaving the pharmacy to limit any possible recall bias.

The preset scenario and data collection form were developed by the research team and were evaluated by an expert in the field of clinical pharmacy and an experienced CP. The data collection form comprised four main sections: characteristics of pharmacy and CP, patient information collected by CP, dispensed medications, and other relevant information recorded. Furthermore, another CP with more than 10 years of experience also assisted the research team with the identification of unlabelled medications dispensed which could be encountered in some community pharmacies. The practice of dispensing unlabelled medications at community pharmacies in Vietnam has been reported previously.(13–15)

The preset scenario and data collection form were also piloted with 10 pharmacies which were not included in the study. This helped with validating the scenario as well as assessing the appropriateness and feasibility of both the script and the data collection form.

Data analysis

Data were analyzed using statistical packages of R software version 4.0.5. The study outcomes were appropriate medication transaction (yes/no), antibiotic dispensing (yes/no), and corticosteroid dispensing (yes/no). A medication transaction was deemed appropriate if all medications dispensed were appropriate. Based on the Vietnam Ministry of Health’s guidelines on the management of COVID-19 patients at home,(16) as well as HCMC Department of Health’s guidelines on healthcare packages for COVID-19 patients at home,(17) four groups of medications were considered appropriate to improve symptoms for the simulated COVID-19 patient, comprising cough medicines, antipyretics, dietary and electrolyte supplements. Prescribed medications such as corticosteroids, antibiotics, antiviral drugs, and anticoagulants were deemed inappropriate. The percentage of appropriate medications dispensed in a transaction at each pharmacy was also recorded.

The characteristics of the study sample are presented as numbers (N) and percentages (%) for categorical variables, and medians and interquartile ranges (IQR) for continuous variables. The P-values were calculated with chi-square tests at an alpha level of 5%. We also explored the association between the three study outcomes (i.e. appropriate medication transaction, antibiotic dispensing, and corticosteroid dispensing) and the explanatory variables, comprising type of pharmacy, consultation length, CP’s gender, CP’s age, and CP’s identification.(18, 19) The Bayesian Model Averaging (BMA) analyses were conducted to identify a potential model with the highest posterior probability value for each study outcome.(20, 21) For each selected potential model, the variables with their probability associated the corresponding outcome greater than 50% were then included in the final multivariable logistic regression (P-values < 0.05 were considered significant).(22)

Ethical considerations

This study was approved by the Research Ethical Committee at University of Medicine and Pharmacy at HCMC (No. 508/HDDD-DHYD). Information details about the selected pharmacies and the enrolled CPs was kept confidential in a password-protected laptop and was deleted after the study was completed.

Of 104 randomly selected pharmacies, 102 were visited by the SCs (the other two were found closed and excluded from the study). Most of the enrolled community pharmacies were independent (61.76%) and located on main roads (97.06%) (Table 1). Of 102 encountered pharmacists, 15 (14.71%) were identified as pharmacist-in-charge. The median consultation length was 8 (IQR: 5–9) minutes.

Table 1

Characteristics of visited pharmacies
Characteristics			n (%)
Encountered community pharmacist	Gender	female	92 (90.20)
	Gender	male	10 (9.80)
	Age	\(\le\)40 years old	77 (75.49)
	Age	> 40 years old	25 (24.51)
	Identification	pharmacist-in-charge	15 (14.71)
		non-pharmacist-in-charge	82 (80.39)
		no identification	5 (4.90)
	Consultation length	1–2 minutes	4 (3.92)
		3–5 minutes	30 (29.41)
		6–10 minutes	49 (48.04)
		> 10 minutes	19 (18.63)
Visited pharmacy	Type of pharmacy	independent	63 (61.76)
	Type of pharmacy	chain	39 (38.24)
	Location	main road	99 (97.06)
	Location	alley	3 (2.94)

Medications dispensed by CPs

Of 102 pharmacies visited, one refused dispensing medications due to no confirmation letter (from a local authority or a doctor’s prescription for the simulated COVID-19 patient) provided when being asked. The median number of medications dispensed by CPs among the 101 pharmacies was 5 (IQR: 4–5). Moreover, dispensed medications with no labels were also recorded in 54 transactions (52.94%); the research team only identified unlabelled medications in 51 of 54 transactions.

Among 98 transactions with all medications identified by the research team, the most frequently dispensed medications were cough medicines (93.88%), antipyretics (88.78%), and dietary supplements (80.61%), whereas antihistamines (27.55%), electrolyte supplements (7.14%), and antiviral drugs (7.14%) were less frequently dispensed (Table 2). None of the transactions comprised anticoagulants. Noticeably, antibiotics accounted for 59.18% of the 98 transactions, including penicillins (37.93%), cephalosporins (24.14%), macrolides (17.24%) and quinolones (3.45%). Amoxicillin/clavulanic acid was the most frequently dispensed antibiotic (20.59%). Moreover, corticosteroids accounted for 60.20% of the 98 transactions. Details of the medicines recommended by CPs are displayed in Table S1 (available as Supplementary Data).

Thirthteen (13.27%) of the 98 transactions with identified medications dispensed were deemed appropriate. The median percentage of appropriate medications dispensed at each pharmacy was 60% (IQR: 40.0%-72.9%).

Table 2

Summary of medications recommended by the pharmacists
Medications dispensed		n (%)
Antipyretics (N = 87)	Paracetamol	38 (43.68)
	Paracetamol-containing combinations	35 (40.23)
	Others	14 (16.09)
Dietary supplements (N = 79)	Vitamin and minerals	60 (75.95)
Dietary supplements (N = 79)	Others	19 (24.05)
Cough medicines (N = 92)	Dry cough medicines	53 (57.61)
	Combination products	35 (38.04)
	Others	4 (4.35)
Electrolyte supplements (N = 7)	Oral rehydration salts	7 (100.0)
Corticosteroids (N = 59)	Methylprednisolone	26 (44.07)
	Prednisolone	3 (5.08)
	Others	30 (50.85)
Antibiotics (N = 58)	Penicillins	22 (37.93)
	Cephalosporins	14 (24.14)
	Macrolides	10 (17.24)
	Quinolones	2 (3.45)
	Others	10 (17.24)
Antiviral drugs (N = 7)	Molnupiravir	7 (100.0)
Other medicines (N = 34)	Antihistamines	27 (79.41)
Other medicines (N = 34)	Antacids	7 (20.59)

Responses of CPs

Of the 102 pharmacies visited, relevant information collected by the CPs was recorded, including patient identification (53.92%), patient’s information and medical history (77.45%), and COVID-19-related information (70.59%). Moreover, 45.10% of the CPs inquired about other symptoms besides those described by the SCs. Regarding counseling information, 56 CPs (54.90%) provided general advice on COVID-19 to the SCs. However, only nine CPs (8.82%) provided information on emergency warning signs of COVID-19 during self-monitoring at home. Additionally, seven CPs (6.86%) counselled the SCs on undesirable effects of antivirals (molnupiravir) dispensed; none of the surveyed CPs provided information on usage or cautions of other dispensed medications.

Factors associated with the dispensing practice of CPs

Characteristics of the explanatory variables by the three study outcomes are presented in Table 3.

Table 3

Characteristics of the explanatory variables by the three study outcomes
Explanatory variables^a		Appropriate medication transaction			Transaction with corticosteroids dispensed			Transaction with antibiotic dispensed
Explanatory variables^a		Yes N (%)	No N (%)	P value^b	Yes N (%)	No N (%)	P value^b	Yes N (%)	No N (%)	P value^b
Type of pharmacy (N = 98)	independent	5 (38.5)	54 (63.5)	0.1569	39 (66.1)	20 (51.3)	0.2090	41 (70.7)	18 (45.0)	0.0191
Type of pharmacy (N = 98)	chain	8 (61.5)	31 (36.5)	0.1569	20 (33.9)	19 (48.7)	0.2090	17 (29.3)	22 (55.0)	0.0191
Gender of pharmacist (N = 98)	female	13 (100.0)	75 (88.2)	0.3498	51 (86.4)	37 (94.9)	0.3070	51 (87.9)	37 (92.5)	0.5206
Gender of pharmacist (N = 98)	male	0	10 (11.8)	0.3498	8 (13.6)	2 (5.1)	0.3070	7 (12.1)	3 (7.5)	0.5206
Age of pharmacist (N = 98)	\(\le\)40 years	10 (76.9)	65 (76.5)	1.000	46 (78.0)	29 (74.4)	0.8658	44 (75.9)	31 (77.5)	1.000
Age of pharmacist (N = 98)	> 40 year	3 (23.1)	20 (23.5)	1.000	13 (22.0)	10 (25.6)	0.8658	14 (24.1)	9 (22.5)	1.000
Identification of pharmacist (N = 94)	pharmacist-in-charge	3 (23.1)	11 (13.6)	0.4035	6 (10.7)	8 (21.1)	0.2773	7 (12.5)	7 (18.4)	0.6198
Identification of pharmacist (N = 94)	non-pharmacist-in-charge	10 (76.9)	70 (86.4)	0.4035	50 (89.3)	30 (78.9)	0.2773	49 (87.5)	31 (81.6)	0.6198
Consultation length^c (N = 98)		8 (5–9)	8 (5–9)	0.6312	8 (5–9)	9 (5–10)	0.6346	8.5 (5–10)	9 (5–10)	0.1175

^aChi square test was employed to test the association between two independent variables, except consultation length which was examined using Wilcoxon test.

^bP value < 0.05 was considered significant.

There were 94 transactions with all the explanatory variables fully recorded. These transactions were eligible to be included in models based on the BMA approach. The BMA approach identified potential models for the study outcomes ‘appropriate medication transaction’, ‘antibiotic dispensing’, and ‘corticosteroid dispensing’ with the posterior probability values of 33.2%, 37.7%, and 36.6%, respectively (Table S2, available as Supplementary Data). However, the probability values of all explanatory variables in the models for the outcomes ‘appropriate medication transaction’ and ‘corticosteroid dispensing’ were less than 50%. In the model for the outcome ‘antibiotic dispensing’, only the probability value of the explanatory variable ‘type of pharmacy’ was greater than 50%; therefore, the logistic regression was developed to explore the association between type of pharmacy and antibiotic dispensing (Table 4). CPs at chain pharmacies were less likely to dispense antibiotics compared to those at independent pharmacies, with OR of 0.29 (95% CI, 0.12–0.69).

Table 4

Factor associated with dispensing antibiotics
Type of pharmacy	Dispensing antibiotics
	Yes (N = 56)	No (N = 38)	OR^a	95% Cl	P value^b
Chain	16 (28.57)	22 (57.89)	0.29	0.12–0.69	0.0052
Independent	40 (71.43)	16 (42.11)
^aOR: adjusted odds ratio

^bLogistic regression model was used to examine the relation between the variables and the dispensing of antibiotics.

Our study found only 13.27% of medication transactions provided by CPs for a simulated COVID-19 patient with mild symptoms were deemed appropriate. Antibiotics and corticosteroids accounted for 59.18% and 60.20% of the transactions, respectively. Although the government has issued guidelines on COVID-19 treatment for self-monitoring at home,(23) these findings may suggest the current issue with medication misuse in COVID-19 treatment among community pharmacies in Vietnam.

Over half (59.18%) of the recorded transactions dispensed by CPs comprised at least one antibiotic. It should be noted that the practice of dispensing antibiotics without a prescription in community pharmacies is prohibited under the laws of Vietnam.(24, 25) However, this practice in Vietnam has been reported in previous studies before the COVID-19 pandemic(26–28); for instance, a study in 2019 recorded that 92% transactions for common viral infection included antibiotics.(29) Antibiotics may be appropriate if bacterial infections overlaps COVID-19. However, other studies indicate that bacterial co-infection in COVID-19 patients is relatively rare (3.5%-7.6%); yet most of the patients were prescribed antibiotics (56.6%-71.9%).(30, 31) Antibiotic overuse in COVID-19 treatment may result in adverse effects as well as antimicrobial resistance.(32, 33) For this reason, this malpractice needs rapid interventions to avoid long-term consequences, considering Vietnam is one of the countries that suffers from high rates of antimicrobial resistant infections.(34)

Another issue of concern was the irrational dispensing of corticosteroids for COVID-19 patients with mild symptoms. According to current guidelines on COVID-19 treatment, corticosteroids can be used only if the patients develop severe or critical symptoms.(23, 35–37) In addition, a recent study has shown that using corticosteroids at an early stage in mild to moderate COVID-19 patients can potentially worsen patient’s clinical conditions.(38) Nonetheless, 60.2% of the surveyed CPs dispensed corticosteroids for the simulated COVID-19 patient in our study without any further instructions. This practice may imply a potential harm for COVID-19 patients with mild symptoms as well as a possible lack of knowledge on COVID-19 healthcare among CPs.

Our findings also provided insight into how CPs in HCMC responded to the COVID-19 pandemic. Most CPs were aware of the typical symptoms of COVID-19; however, 54.90% of them provided general advice on COVID-19 to the SCs. Furthermore, less than 10% of the surveyed CPs provided guidance on COVID-19 emergency warning signs concerning the appropriate timing of taking corticosteroids. Noticeably, around 7% of the CPs provided information on medications dispensed, all of which focused on possible adverse effects of molnupiravir. It should be mentioned that all pharmacies included in the studies participated in the COVID-19 healthcare campaign in HCMC.(8) The disparities between information provided and medications dispensed by the CPs may warrant interventions to improve knowledge, skills and attitude towards healthcare for COVID-19 patients for CPs.(39)

One notable finding of this study was the association between the type of a pharmacy and the antibiotic dispensing practice in CPs. It was noted that the rate of antibiotics dispensed in chain pharmacies was lower than that in independent ones. This finding is consistent with previous research conducted in India (2017) and Pakistan (2022) which indicated that independent pharmacies were more likely to dispense medications without a prescription compared with chain ones.(40, 41) This may be because most chain pharmacies focus on establishing strong and trustworthy brand image by improving customer experience as well as working with experts to enhance capabilities of their pharmacists whereas independent pharmacies tend to prioritize medicine sales.

Strengths and limitations

While other studies examining pharmaceutical care provision during the COVID-19 pandemic through interviews and surveys,(42, 43) this study used the SC method, a robust alternative to prevent biases related to actual behaviors of the pharmacists. In addition, each pharmacy was visited by 2 simulated clients to avoid recall bias. Although this might affect the consistency of implementing the scenarios, the use of standardized script could mitigate this issue. However, some information about community pharmacists might be challenging to gather using the SC method. For example, less than 10% of surveyed pharmacists’ educational attainments were collected as most pharmacists were not willing to disclose their personal details. Moreover, the constraints related to COVID-19 pandemic, time and research costs limited the scale of this study. For this reason, further and follow-up studies in HCMC and other provinces across Vietnam are recommended.

This study revealed a noticeable inadequacy in the quality of COVID-19 treatment provided by community pharmacists for COVID-19 patients with mild to moderate symptoms in HCMC. The findings indicated a need to enhance the management of COVID-19 medications provided by community pharmacists in Vietnam. Moreover, healthcare authorities should build up professional training programs to improve community pharmacist’s capabilities to deal with COVID-19.

CPs

Community pharmacists

HCMC

Ho Chi Minh City

Simulated client

WHO

World Health Organization

IQR

Interquartile Range

Ethics approval and consent to participate

This study was approved by the Research Ethical Committee at University of Medicine and Pharmacy at HCMC (No. 508/HDDD-DHYD). Consent was obtained from all pharmacy participants taking part one or two months before data collection.

Consent for publication

Not applicable

Availability of data and materials

The data collected and analysed during the current study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

Not applicable

Authors' contributions

T-D.N., H.Q.N., S.T-T.D.: Conceptualization, design of methodology, data collection, analysis, editing manuscript and project administration. P.B.Q., U.U-T.T., T.T.D.: Data collection, analysis, writing and editing manuscript. B.D.G.N., N.TQ.N.: Design of methodology, analysis and editing manuscript. All authors read and approved the final manuscript.

Acknowledgements

We extend our gratitude to all participants for providing their responses.

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No competing interests reported.

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Practices of Community Pharmacists Towards COVID-19 Treatment in Vietnam: A Simulated Client Study

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Abstract

Background

Methods

Results

Conclusions

Background

Method

Design and population

Data collection

Data analysis

Ethical considerations

Results

Medications dispensed by CPs

Responses of CPs

Factors associated with the dispensing practice of CPs

Discussion

Strengths and limitations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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