Rolf Wahlström

To describe antimicrobial self medication for reproductive tract infections (RTI) including sexually transmitted infections (STI), and to explore the understanding and use of health information among the adult population self medicating with antimicrobials for RTI/STI in two provinces of Laos. This could contribute to quality improvement of RTI/STI management. Cross sectional community based study. Structured interviews (household survey) were conducted among 500 subjects aged 18 or more, who had used antimicrobials as self medication for RTI/STI during the past year. They were recruited among 3056 family members in Vientiane capital and Champasak province, divided equally between the two study sites, and between urban and rural areas. Among the 500 respondents reporting self medication for RTI/STI, 91% had bought the antimicrobials from local private pharmacies without a physician's prescription. 58% of those were advised to buy the drugs from drug sellers. Ampicillin (not recommended as syndromic treatment for RTI/STI) was used in 83% of all cases, in 28% combined with tetracycline. 79% of respondents used antimicrobials for a non-recommended duration of time. Most respondents had access to health messages for RTI/STI, largely from radio/television and drug sellers. However, only 17% of all respondents reported that they had ever used a condom. More than three quarters of respondents, self medicating for RTI/STI with antimicrobials, used inappropriate drugs bought from private pharmacies. There is a need to improve RTI/STI management, including health promotion, through interventions at community level, and to health providers, including private drug sellers.

In most developing countries, including the Lao People’s Democratic Republic (PDR), high prevalence of low quality drugs has been reported. The aim of this study was to explore knowledge and perceptions regarding drug quality among drug sellers and consumers, in Savannakhet province, Lao PDR. Quantitative and qualitative methods were used. Fifty-nine drug sellers and 278 exit customers were interviewed. Eight focus group discussions with drug sellers and community members were conducted. There was inadequate scientific drug knowledge among drug sellers. Only a few customers were aware of the existence of low quality drugs. Only one drug seller knew what constitutes a good quality drug according to the given criteria, and only two drug sellers knew the correct temperature for drug storage. Forty-four per cent had correct knowledge on drug labelling and 73% could read the expiry date. Fifty-eight per cent stated that they bought some drugs from unauthorized sources. Both drug sellers and consumers also elaborated on a local definition of drug quality. They determined drug quality by its perceived efficacy in the sense that a drug is good if it takes the disease away. They also trusted the responsible authorities not to provide them with low quality drugs. A majority of the consumers (73%) did not worry about the quality of the drugs, their greatest problem being financial constraints. People living in urban districts had significantly more knowledge on aspects of drug quality than those living in rural and remote areas. The limitations in scientific knowledge among drug sellers and the low awareness among consumers may contribute to the continued existence of low quality drugs. Government interventions through training of drug sellers and drug information for lay people are suggested.

Physicians' sick-listing practices have been studied to a very limited extent. There is limited scientific evidence that physicians perceive sick-listing duties to be difficult and problematic, regarding both the medical and the insurance-related aspects. There is limited scientific evidence also that quality is often deficient in the sickness certificates issued by physicians. This may affect case management at the local insurance office. There is insufficient scientific evidence to explain the differences in physicians' sick-listing patterns. The effects on patients are also insufficiently studied.

Summary: Background Standard Treatment Guidelines were introduced to all prescribers at provincial hospitals in Lao PDR and treatment indicators were developed within the National Drug Policy programme to monitor compliance.Objectives To evaluate the effects of an educational intervention to improve treatment practices of malaria, diarrhoea and pneumonia.Methods Randomized controlled trial with prescribers at 24 departments at eight provincial hospitals, matched into four pairs. The three departments of internal medicine, paediatrics and out‐patients in each pair were randomized into intervention or control group. The 6‐month intervention was conducted by members of the Drug and Therapeutics Committees, and comprised monthly audit sessions in the form of outcome feedback using indicator scores on recorded treatment of malaria, diarrhoea and pneumonia. We measured treatment indicator scores 6 months after the end of the intervention compared with baseline.Results The aggregated mean scores for all diseases, and for malaria and diarrhoea, improved significantly. For pneumonia, improvement was seen in both the intervention and control groups. Record keeping was improved for all three diseases. For malaria, there were improvements in recording patients’ history, and in frequency of microscope testing; for diarrhoea, regarding weight measurements, palpation of the fontanel for children under 2 years, and reduction of irrational use of anti‐diarrhoeals and antibiotics; for pneumonia, in recording respiratory count, and reducing irrational use of anti‐histamines and anti‐cough medications.Conclusions Audit–feedback systems to improve quality of care are feasible and effective also in hospital settings in low‐income countries.

Objective. The aim of this study was to explore and compare treatment decisions and the influence of specific patient characteristics on asthma management in five European countries, and to relate this to existing guidelines. Methods. Using the technique of clinical judgement analysis, doctors in The Netherlands, Norway, Germany, Sweden and the Slovak Republic (40–100 doctors per country) were presented with sets of written simulated cases on asthma treatment. Patient characteristics were varied to determine their influence on the doctors’ decisions. Decisions indicating over- and under-prescribing in relation to a gold standard derived from guidelines were also determined. Results. Doctors in The Netherlands prescribed more oral steroid courses and fewer antibiotics than doctors in Norway and Sweden, whereas doctors in Germany and the Slovak Republic prescribed the least oral steroids and the most antibiotics. Partially, this variation could be explained by differences in the underlying propensity to prescribe, but differences in the use of patient characteristics also contributed to the variation. Norwegian doctors were most inclined to increase the maintenance treatment of inhaled corticosteroids, which could best be explained by their relatively high focus on the patient’s peak expiratory flow value. Compared with the gold standard, there was 25–56% under-prescribing of oral steroids, and 21–45% over-prescribing of antibiotics. Conclusions. The variation in treatment of asthma patients between doctors in different countries may, in part, be attributed to variations in the underlying propensity to prescribe, and in part to different use of clinical patient characteristics. These findings can be used in tailoring educational programmes to improve treatment practices.

Objective: To describe conceptions of the management of hyperlipidaemia and assess changes in conceptions after an educational intervention. – Setting and subjects: Primary care in Sweden. Twenty...