Knowledge and Practice of Drug Sellers in Tuberculosis Management at the Drug Shops in the Selected Township, Myanmar

Poe Poe Aung,ThaeMaung Maung, Sithu Aung &Saw Saw

Special Issue May 2020

A cross-sectional descriptive study, using mixed methods, was conducted in South Okkalapa Township, Yangon.  It determined availability and use of anti-TB drugs among drug shops; knowledge about TB; dispensing anti-TB drugs and opinion on involving TB control activities of drug sellers. A total of 97 drug sellers participated in semi-structured interview questionnaire. Identification of anti-TB drugs by using check list, validation of dispensing practice of drug sellers by mystery clients and 4 Focus Group Discussions were conducted. Of them, 32(35%) drug shops had anti-TB drugs and 38% sold anti-TB drugs during last month. Child combination (R-cinex kid) was found to be the most selling drug (61.9%). About 59% of drug shops had first line drugs and the rest had second line drugs. About 79.4% had low knowledge on sign and symptoms of TB (mean knowledge score=13.8 for 33 items) and 97.9% had low knowledge on anti-TB treatment (mean knowledge score=3.8 for 21 items). Some 21.6% of drug sellers said they referred TB suspect cases to nearest health center. The amount of anti-TB drugs selling from the drug shops were significantly decreased after these drugs were given free of charge from the health center. Most of the drug sellers obtained knowledge about dispensing drugs by on-job training. They would like to attend short training about TB from health personnels during weekends. The study highlighted to organize the drug sellers to involve in TB control activities by providing necessary information about TB and process of referral to health centers.

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Tuberculosis is one of the major public health problems all over the world. South-East Asia region constitutes approximately 40% of the worldwide burden of tuber-culosis.¹ According to WHO, Multi-Drug Resistance Tuberculosis (MDR-TB) is increasing in many parts of the world.^1,2 In Myanmar, tuberculosis is the third priority disease in National Health Plan. Myanmar is in the 19^th position of 22 TB highest burden countries.¹The number of private sectors and private pharmacies are increasing since 1990s, especially in the urban area.^3-5 And it comprises the important role of health care center in many countries.⁴Moreover, self-medication practice is not uncommon and most of the patients with chest symptoms are seeking treatment in private sectors and private pharmacies at first.^3,4,6 Even though, about 40% of anti-TB drug dispensing occurs in the private sectors, the skill and knowledge about the tuberculosis treatment by the drug sellers from the private pharmacies is little known.^5,7 It promotes misuse of antibiotics and drug resistance, leading difficult to control.^8-10In this case, knowledge of drug sellers on using anti-TB drugs plays the key role in anti-TB drug dispensing. Some TB patients were buying anti-TB drugs from drug shops with or without prescription from medical practitioners.³

In Myanmar, starting from 1997, National Tuberculosis Program (NTP) is presently providing the first-line anti-TB drugs free of charge through the government health system up to the Rural Health Centre (RHC) level according to DOTS strategy.^1,2 Then, NTP prioritizes the prevention and control of MDR-TB in Myanmar and initiates piloting DOTS Plus activities in 2 pilot sites, 5 townships in Yangon and 5 townships in Mandalay Divisions.

There is a weak link between private pharmacies and public sector on tuberculosis control especially drug dispensing practice. This study explored the availability of anti-TB drugs and their types and brands from the drug shops, dispensing practice of anti-TB drugs and knowledge about tuberculosis treatment by drug sellers.



Design and methods

This mixed-methods study was conducted
in the South Okkalapa Township, Yangon Division using both quantitative and qualitative data collection methods. Quantitative data collection was done prior to qualitative method 67.

Quantitative method

A total of 97 drug sellers from 97 drug shops participated in quantitative data collection. Background information of drug shops, knowledge about TB, dispensing practice of anti-TB drugs in tuberculosis treatment and opinion on training about TB by drug sellers were assessed during face-to-face interview by using pre-tested semi-structured interview questionnaire. Types and brands of available anti-TB drugs from drug shops were also identified by observation check lists.

Qualitative method

Four Focus Group Discussion (FGD) sessions (2 groups of drug shops having anti-TB drug and 2 groups without having anti-TB drug) were carried out to explore opinion on involving TB control activities of drug sellers. Two weeks after quantitative data collection and FGD, dispensing practice of anti-TB drugs was validated by mystery clients. 

Mystery client method

This method entailed 5 research assistants acting out the part of a TB patient or a relative going to a medical shop in order to buy medicines without prescriptions. Case scenarios were used for different types of mystery clients. Pre-test and on-job training were carried out in North Dagon Township which is not included in the study. Out of 97 drug shops, 22 shops were involved and each client went to 6 drug shops. Trained research assistant who went to a drug shop during questionnaire survey was not used for that drug shop during mystery client survey.

Study area

This study was conducted in South Okkalapa Township purposively after discussion with NTP and MMA because Myanmar Medical Association (MMA) aims to undergo a short training programme for drug sellers about knowledge on tuberculosis and referral scheme.

Study population

All registered drug shops and drug sellers from South Okkalapa Township were included in the study. If there are more than one drug seller in a drug shop, the most experienced person was selected for interview.

Data management and analysis

After data collection interviews, coding, manual cleaning, checking for consistency and errors was carried out for questionnaire and check-list. Double data entry was carried out by Epidata software version 3.1 and analysis was done by SPSS version 16. Descriptive analysis was performed for socio-demographic characteristic and availability of anti-TB drugs among drug shops, showing number and percentage. Knowledge score was calculated and categorized into low and high knowledge score based on the cut-off value of mean knowledge score. Bivariate analysis using Chi-squared test was performed on level of knowledge and socio-demographic characterristics. Statistical significant was set at p<0.05.

During FGD sessions, the conversations were recorded by cassette tapes with the permission of the participants and transcribed into master data file. Data from mystery clients were written immediately into structured data form before going to another drug shop and supervised by a senior researcher. ATLAS.ti software version 6 was used for analysis according to different themes and sub-themes.

Ethical consideration

The ethical clearance was obtained from Ethics Review Committee (DMR).  Informed consent was taken from drug sellers participated in the study. Visit of mystery clients to drug shops was not informed in advance for the following reasons. It was ensured that using mystery client would not be harmful to the participants. If drug sellers were informed about mystery client, they would have more caution in dispensing practice. Thus, this will affect validity of data collected by mystery client method.

Of 97 drug shops, most drug shops were established for many years and few were new shops, showing the community self-medication practice was also established in the study township. It was a good finding that all drug sellers knew where THC is situated. Majority of drug sellers were graduated and had some kind of private pharmaceutical training but their knowledge about tuberculosis and treatment were quite low. This study highlighted that it is very common practice for clients to go directly to pharmacies and obtain medicines for their self-limiting symptoms. Self-medication is often a necessary part of health care in India, especially in suburban.¹⁰ This perhaps shows the need to improve “Good Pharmacy Practice”.¹⁰

Findings from mystery clients indicated that different types of antibiotics including third generation antibiotics, analgesics and cough suppressants were freely available across all the drug shops with or without a prescription. The use of inappropriate antibiotics could lead to antimicrobial resistance which could have major implications for public health especially for multi-drug resistant TB (MDR-TB).¹⁰ These findings reflect the problems in drug regulation, such as availability of anti-TB drugs over the counter without any prescriptions from medical doctors findings reflect the problems in drug regulation, such as and lack of knowledge and training of drug sellers. Educational and regulatory interventions are needed which include improving knowledge and professional behavior of drug sellers.^{10, 11}

Regarding DOTS, it is still needed to improve the understanding of and accessibility to DOTS by drug sellers. At the time of dispensing, drug sellers were willing to talk health education to TB suspected cases and referred to nearby health center or clinics. This shows that drug sellers play major role as a bridge between patients and health centers. It is also found that the quality of health care service by public health sectors is still needed to improve for the patient satisfaction.

Moreover, drug sellers agreed and wanted to attend short training course about TB and referral scheme during their appropriate time. Therefore, it is highly recommended to provide short training to drug sellers to improve the knowledge about TB and to involve in the TB control activities by referral scheme.

In Myanmar, private sectors play an important role in drug regulation and dispensing to the community. The purpose of drug regulation is to promote public health, protect the public from harmful condition of the dispensing practice of drugs and prevent the anti-microbial resistance. Therefore, legal structures should form the foundation of drug regulation and regulatory gaps should be addressed by modifying or extending existing rules and regulations to prevent drug dispensing practice of anti-TB drugs over the counter without precriptions.¹¹

We would like to express our sincere gratitude to Director-Generals of Department of Health and Department of Medical Research for their kind permission and inter-departmental coordination for project activities. Data collection activities got much support from Township Medical Officer Dr. Aye Thwin, Township Coordinator Dr. Khin Than Nwe from Myanmar Medical Association and local health presonnels by their interest and cooperation; helping the team with arrangement for timely local field visits. We would also like to acknowledge with our deepest gratitude to all drug sellers participated in the study for giving us their time, sharing their knowledge and experiences in this study. The last but not the least; we would like to acknowledge USAID for granting financial assistance.

The authors declare that they have no competing interests.

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