MA provision by pharmacy workers: Scale, quality and strategies to improve provision practices Katy Footman, Marie Stopes International

Transcription

1 MA provision by pharmacy workers: Scale, quality and strategies to improve provision practices Katy Footman, 1

2 Background Pharmacies are often a first, preferred source of health care due to convenience, privacy, anonymity, low costs. Very little data available but what we have suggests MA purchased from pharmacies is growing trend. Potential to reduce morbidity and mortality associated with unsafe abortion. But women need adequate information and counselling to be able to use MA drugs effectively. 2

3 Systematic review methods Aims: to describe the scale and practice of pharmacy provision of MA; to assess the effectiveness of interventions aiming to improve the scale and/or quality Timeline: November 2015 Databases: MEDLINE, Web of Science, POPLINE, Embase, Global Health and WHO Reproductive Health Library. Hand-searching websites of six organisations involved in MA research and provision in LMICs. Snowballing on references. Search terms: range of terms related to abortion + range of terms related to pharmacies, drug sellers, or self-medication were used. Inclusion criteria: outcomes met the review objectives; study design used quantitative primary data collection methods; published between 1 st January 1990 and 1 st October 2015; in English, Spanish or French language; LMIC setting; published peer-reviewed journal articles and grey literature. Data extraction: double-extracted using standardised template. Quality assessment: double graded using standardised checklist 3

4 Search results Citations identified in database search (N=2989) Title and abstract screening Full text evaluated (N=61) Studies identified through database search (N=21) Studies identified through handsearching and contacts with experts (N=4) Excluded (N=2932): Duplicates, non LMICs, not related to medical abortion Excluded (N=40) Not related to pharmacy provision of MA (N=18) Sample of women visiting hospital for PAC (N=7) Not primary data (N=3) Not related to MA (other aspects of reproductive health) (N=3) Intervention study with no baseline data to extract (N=2) Language (N=1) Qualitative studies (N=6) Studies included 4 in the review (N=25)

5 Where has research been conducted? 2 or 3 high quality studies 2 medium-high quality studies 2 medium-low quality studies 1 medium-high quality study 1 medium-low quality studies 1 low quality study No studies 5

6 Availability of MA Globally, provision of abortifacients by pharmacies was common without prescription. Considerable variation by setting and over time. Mifepristone less widely available Ineffective abortifacients also commonly provided. Variation also by methodology used. Pharmacies reported demand for MA was common. 6 Kenya, 2009*^ Nigeria, 2010^ Ghana, 2012^ Nigeria, 2013^ Tanzania, 2013* Senegal, 2015* Zambia, 2015^Ɨ Zambia, 2015^ Kenya, 2016^ Latin American city, 2006^ Latin American city, 2006* Argentina, 2007^ Mexico, 2009^ Mexico, 2011^ Dominican Republic, 2012* India, 2005* Vietnam, 2012^ Vietnam, 2012* South East Asian city, 2014* South East Asian city, 2014^ Bangladesh, 2014^ India, 2015* India, 2015^ Bangladesh, 2015* 0% 20% 40% 60% 80% 100% Bars show % pharmacies offering misoprostol-only. *Survey, ^Mystery client

7 Knowledge and counselling Knowledge of, or counselling on, an effective regimen for the drug most commonly sold is rare. Knowledge of the correct regimen did not always translate into accurate advice to mystery clients. Mystery clients rarely advised on what to do in case of complications. Referrals not commonly offered. Ghana, 2012^ Tanzania, 2013* Zambia, 2015^Ɨ Senegal, 2015* Zambia, 2015^ Kenya, 2016* Latin American city, 2006* Latin American city, 2006^ Mexico, 2009^ Mexico, 2011^ India, 2005* South East Asian city, 2014^ Bangladesh, 2014^ Nepal, 2015* Bangladesh, 2015* India, 2015^ India, 2015^ India, 2015* 0% 20% 40% 60% 80% 100% Bars show % pharmacy workers knowing/advising the correct MA regimen for drug most commonly sold. *Survey, ^Mystery client, Ɨ Zambia 2015, 2009 data, Zambia 2015, 2011 data. 7

8 Interventions to improve scale or quality Zambia 2015 Nature of intervention Nature of evaluation One day training Pre-post, no comparison Bangladesh Training, inpharmacy 2015 detailing & call centre Nepal 2015 Two day training + 1 day refresher course 10 months later. 8 Post-intervention survey, comparison with control group Pre-post, comparison group in different region Result: intervention successful? Increase in referrals (47%-68%) Information provision (55%-75%) & selling misoprostol (9% - 32%). Increased odds of knowing correct miso-regimen among miso-sellers if: - used call centre (aor 2.01); - received training (aor 1.89); - received detailing (aor 1.73). Improvement in : - knowledge of regimen (22% to 88% (I) vs 23% to 41% (C)) - identifying complete abortion in intervention group (65% to 77% (I), 51% to 49% (C)). Overall quality grade Low Medium Medium

9 Conclusions Research on MA availability in pharmacies is needed Provision appears to be widespread, but often with poor knowledge and provision of information Providing training and information can improve knowledge and practice More evidence is needed on what works for improving quality of MA provision and safety of selfadministration But how? 9

10 MSI pilot to assess client outcomes after selfmanaged MA Pharmacy workers recruit client into study using standardised script & voucher. Pharmacy workers reimbursed USD 12.70, women reimbursed USD Client instructed to send an SMS with voucher ID to call center Immediate phone back from call center & follow up interview arranged Follow up phone interview after 2 weeks Most pharmacies willing to take part but low continuing commitment. Majority of clients were recruited from a small number of pharmacies Initial enrolment was main barrier to representative sample: Overall response rate = 30% Follow up rate = 87% Final sample: 109 Other challenges: self-reported outcomes 10

11 Next steps: Lessons learned: Pharmacy staff reimbursement important but more monitoring needed Immediate contact by phone facilitated recruitment Inclusion of all pharmacy staff needed Future attempts needed: In settings where misoprostol-only is commonly provided With measures to improve recruitment process more convenient, less potentially threatening Ongoing reimbursement of pharmacy staff rather than one-off payment? Expanding number of pharmacies to increase client numbers Investing in hiring research assistants to be based in pharmacy Alternatives - recruitment of women accessing hotlines/call centres Validation of measures of self-reported complications/outcomes also needed. 11

12 Thank you 12