Involvement of the Retail Pharmacies in Pakistan Tuberculosis Control:

Assessment of the knowledge of the retail pharmacy staff about

tuberculosis and public tuberculosis Control Programme, and sale
practices of anti-tuberculosis drugs in DI Khan city, Khyber Pukthoon
Khwa Province, Pakistan

1. Introduction

According to the World Health Organization (WHO), the global burden of tuberculosis (TB)
still remains huge. There were an estimated 8.6 million incident cases of TB and 1.3 million
people died from the disease (320,000 among those people who were HIV positive and
940,000 deaths among those people who were HIV negative) in 2012. Among these deaths
there were an estimated 170,000 from multi drug resistant TB, a relatively high total
compared with 450,000 incident cases of multi drug resistant TB.1

The burden of TB disease is very high among women and children, an estimated 410,000
women died from TB in 2012.Among HIV negative children, there were also an estimated
74,000 TB deaths. In 2012, the Western Pacific Regions and south-East Asia collectively
accounted for 58 % of the total world's TB cases.1

Pakistan has the 6th highest burden of TB in the world and in the Eastern Mediterranean
Region, Pakistan contributes approximately 44 percent to the TB burden.2 According to
WHO, the incidence of sputum positive TB cases in Pakistan is 97/100,000 per year and for
all types it is 231/100,000 new cases each year. The prevalence of the disease is to a large
extent higher and is estimated at 373/100,000 population.3

TB is accountable for 5.1 % of the entire countrywide disease burden in Pakistan. 4 A large
percentage of cases take place in women in their child-bearing age and younger age group
ranging from 15 to 49 year age with poverty being the major driving force. Poor domestic
conditions, inequalities and poor nutritional status of individuals and ambient environmental
conditions are the main predisposing features accountable in the spread of TB and incidence
of TB.5
1.1. Country profile

Pakistan came into being on 14th August 1947 as the result of division of British India.
Pakistan is the sixth most crowded country and its present proposed population is around 180
million, spread over an area of 852,392 square kilometres. 6 Life Expectancy at birth is 67
years and the growth rate of population is 2.5%.7

Pakistan is an agricultural country.8 Urdu is the national language, while English is used for
most technical and official purposes. In 2010 the average literacy rate of adult in Pakistan
was 57.7% (45.2% for women and 69.5% for men).9

Administratively, Pakistan has five provinces namely Khyber Pukthoon Khwa (KPK),
Punjab, Baluchistan, Gilgit Baltistan, Sind and three areas including Islamabad Capital of
Pakistan , Federally Administered Tribal Areas , and Azad Jammu Kashmir .
TB and other communicable diseases attribute to 26 % of deaths. 10 It is estimated that about
40% of children whose age is less than 5 year are malnourished. 29 % of people of Pakistan
are poor and 12 % people lead their life by using less than 1 Dollar per day. The majority of
people don't have access to water and sanitation which along with over-crowded cities, low
vaccine coverage and high illiteracy rate lead to very high incidence of infectious diseases.11

1.2. Health system

The Ministry of Health (MOH) is accountable for all matters relating to nationwide planning
and management in the field of health care. The public health sector provides health care
facility to only 30 % of the population, whereas the private sector provides health care facility
to the remaining 70% of the population. Public sector comprises more than 10,000 health care
facilities, ranging from basic health care units (BHUs) to tertiary health care centres. The
BHUs cover around 10,000 people, whereas the larger rural health centres (RHCs) cover
around 30,000 to 450,000 people. Primary health centre units consists of both rural health
centres and basic health care units. The Tehsil Headquarters Hospital provide health care
facilities to the population at Tehsil level, whereas District Headquarters Hospital provide
health care facilities at district level as its name suggests. In addition to private sector and
public sector biomedicine, there are many indigenous forms of treatments. Some man-made
remedies are also available in certain pharmacies. Homeopathy is also taught and practiced in
Pakistan.12

The Drugs Control Organization is a subordinate of the Ministry of Health. It has been
facilitating drug importers and local pharmaceutical units in licensing and registering and
making their involvement possible in different events organized globally. The federal
government is accountable for formulating and planning nationwide health policies while
provincial governments are accountable for implementation under the Pakistani
constitution.12

Pakistan is facing many challenges in the delivery of its health care. The private sector and
public sector have no connection with each other in areas of service delivery and also in
financing. Seventy seven percent of the total expenditure for health care comes from out of
pocket in private sector while remaining twenty three percent comes from the public sector.13

1.3. National Tuberculosis Control Programme of Pakistan

National TB Control Program (NTP) is a nationwide body, which is under the Ministry of
Inter-Provincial Coordination, formerly Ministry of Health, Pakistan formed in 1995 in
response to the declaration of global emergency of TB by WHO in 1993. 2 Under this
program, national guidelines were developed and piloted in various regions of Pakistan, but
the program was halted in 1996 when the Federal Directorate for TB Control was dissolved
in 1996.2 TB control activities were resumed in 1998 based on an agreement between the
provincial and federal TB control programs.2 The National TB Program (NTP) was
revitalized in 2001 when TB was declared a national health emergency through the Islamabad
Declaration.14

The NTP of Pakistan is well-respected internationally. The NTP has an emphasis on

countrywide coverage by end-2005 and improvement has been made in a number of areas. It
has reported implementation of the Directly Observed Treatment-Short course (DOTS)
strategy in all the 120 districts of the country, increase in the smear positive case detection
rate from a baseline of 7% in 2001 to 54% in 2005 and a treatment success rate of 79% in the
cohort of 2001.15
Mission of NTP is to attain country wide TB control by DOTS approach and by ensuring
good quality TB care through public sector health services and develop the role and
responsibility of other partners, including Non-Governmental Organizations (NGOs) and
private sector.16

1.4. Directly Observed Treatment-Short-Course (DOTS) STRATEGY FOR CONTROL

OF TUBERCULOSIS

DOTS is a WHO recommended policy for effective TB control in all low income countries,
which has also been adopted by the NTP Pakistan. The key principle of the strategy is to split
the chain of transmission by diagnosing and curing people with contagious TB. The DOTS
strategy has the following five important components, all five components are essential for an
effective TB control programme.17

1) Government commitment.
2) Diagnosis through sputum smear microscopy.
3) Treatment with standardised regimens, which includes direct observation of treatment in
the serious phase for all smear positive and throughout the retreatment course of therapy.
4) Continuous and regular supply of medicines from the nearby health facility.
5) Standardized monitoring and recording and reporting of outcomes of management and
treatment.

1.5. Public Private Partnership in TB Control

It is mostly acknowledged that a large proportion of TB patients take care from private sector,
generally outside the system of NTP . These include para statal health care institutions and
private health care providers for profit and they do not follow the suggested DOTS approach
for management of TB, hence depriving patients to get good quality care, treatment and
management.18

Pakistan is currently undergoing health sector reform and some initiatives include the
engagement of private providers.19 A study conducted in district Thatta demonstrated that by
involving private practitioners in collaboration with the NTP, case detection rate (CDR)
could be significantly increased.20 A 2003 survey of private practitioners in Karachi, a
densely populated urban area of Pakistan, showed a lack of knowledge about key TB
symptoms, a lack of knowledge and confidence in TB diagnosis, over reliance on chest X-
rays for TB diagnosis rather than sputum microscopy and widespread improper treatment
regimens, demonstrating private practitioners un-mindfulness to the public health
implications of a TB patient’s sputum status.21 Inappropriate treatment regimens are the
largest contributing factor to the rise in multidrug resistant (MDR) TB in Pakistan. 22 The
findings of this study indicated the need for improved training of private practitioners and
allowing them the use of free or subsidized sputum examination facilities as part of a public
private mix (PPM) approach to TB control.21
Following the Islamabad Declaration, Pakistan achieved near universal DOTS coverage in
the public sector by 2005. In 2006, a 5 year federal work plan was approved that supported a
number of TB related activities including expansion of the PPM approach to TB control. The
NTP has been dedicated to partnership building and has used the Interagency Coordinating
Committee to facilitate donor support and technical assistance for the programs activities, and
there are annual joint program reviews on TB care with all of the partners involved.
Maintaining this commitment to involving the private sector is especially important given
that private practitioners in Pakistan do not follow NTP guidelines and have poor knowledge
of TB control. By 2010, the NTP engaged 4 non-profit organizations to implement PPM
DOTS pilot projects in 30 districts. The NTP also initiated the “hospital DOTS linkage” as
another PPM strategy. This program, which has been implemented in about 40% of public
and private tertiary care hospitals, enhances laboratory services, introduces standardized
treatment, and develops a referral system between hospitals and DOTS treatment centres. In
2009, data showed there was a 50% increase in case notifications in districts in which the
DOTS linkages had been introduced.14

As part of their strategy to use a PPM approach, the NTP has worked with Green star Social
Marketing Pakistan Ltd. (GS) - an NGO that has worked to engage the private sector in
delivering high-quality TB services to low-income clients and has improved access to TB
diagnostic and treatment services in this population. 22 The NTP has also implemented a
number of innovative programs in Karachi through public-private partnerships as part of the
Stop TB Partnership’s TB REACH initiative. 23 One such program involves bringing chest
screening camps to urban slums as a way to increase case detection, educate the communities
about TB and TB control, and help reduce stigma and raise awareness.23 The program seeks
to involve the private sector in recruiting general practitioners (GPs) to receive training in TB
case management.24 In the first three months of the program’s operation, more than 30,000
TB patients were screened and 350 cases of the most infectious form of TB were found,
representing 50% of normal case finding through routine care in the area. 23 Another public
private partnership implemented in Karachi uses mobile phone technology and conditional
cash transfers to community health workers (CHWs) and GPs to increase case detection and
improve case management.24 In the first 9 months after its implementation, there was a nearly
300% increase in case detection and a 500% increase in paediatric notifications through Indus
Hospital, in which the program was based.24 Through their TB Program Team, Indus Hospital
has also introduced a public-private partnership aimed directly at supporting the
establishment and scaling-up of community-based MDR-TB programs.25

While there is certainly more work to be done in sustaining and expanding DOTS
implementation and adherence to the NTP guidelines in the private sector, PPM has been
shown to make a large contribution to TB control, including accounting for nearly 20% of
total case detection in 2007. One part of the private sector that has been largely left out of
PPM activities are the retail pharmaceutical sellers. Experiences in numerous countries have
shown that with proper training, pharmacists and drug dispensers have the potential to play a
critical role in TB case detection and management.26

1.5.1. Engaging private Pharmacies in TB control:

Private sector retail pharmacies generally have close links to the society, and often the first
point of contact when a person with early un-specific symptoms of TB seeks help from health
care services. Unfortunately, pharmacies often miss the chance to detect and identify a case
of suspected TB and refer the patient to the correct health care facility, which contributes to
health system delays in TB management and diagnosis. Furthermore anti-TB drugs are most
likely dispensed uncontrolled to the people with or without TB. It has been accounted that
private drug sale markets in four countries i.e. India, Indonesia, Pakistan and Philippine had
the biggest relative sales volumes per annum. They sold large amount of first line anti-TB
drugs to supply 65 to 117 percent of the respective countries annual incident cases with a
standard 6-8 months regimen.27
Percentage of anti-TB drugs sold in private market

Drugs sold in the private market

140
120
100
80
60
40
20
0
di
a
es
ia es an in
a nd ss
ia m es
h
ric
a
In n in ik st Ch ia la u na d f
do
p R et la A
In ilip Pa Th Vi
ng ut
h
Ph Ba So

(Source: Global Alliance for TB Drug Development, Annual Report, 2009)

Percentage of anti-TB drugs sold in private market

Pharmacists/retail pharmacy staff has previously been underutilized in TB care and

prevention. An impact assessment study in Pakistan found that giving training to common
people in the society to screen for TB in private sector clinics and then connecting patients to
free treatment and diagnosis from a NTP accepted private health care facility was one of
numerous interventions that amplified case recognition 2 fold over that observed in the
control area.28 Extending these efforts further to connect private retail pharmacies in TB
control, recently the NTP in partnership with DEV-NET and Pakistan Pharmacists
Association (PPA) initiated the project to “Engage Pharmacists in TB Control and care in
Pakistan.29 The NTP can get benefit from engaging private pharmacies for; screening of
individuals with symptoms suggestive of TB and referring them to the TB control programme
(case detection), supervised treatment, education, counselling and awareness. In order to
attain these goals a baseline assessment of the knowledge, attitude and practices of the staff at
the pharmacies is an essential pre-requisite. A survey of the knowledge, attitude and practices
of the retail pharmacy staff has been conducted in four cities; Rawalpindi, Lahore, Peshawar
and Islamabad, (unpublished data). The various regions of Pakistan vary greatly with respect
to the distribution of population, resources, literacy rates and the availability of health
services, warranting the necessity of the baseline surveys in several areas to make sure that
the interventions programmes based on these surveys for engaging pharmacies in the TB
control would be successful.

General objectives:
To engage retail pharmacy staff (private pharmacies) in TB control.

Specific objevtive:

The objectives of the study are:

1. To determine the level of knowledge on TB and MDR TB among providers from private
pharmacies/ chemist shops.
2. To determine practices related to the TB/MDR TB suspects identification, referrals,
availability of education material and training.
3. To determine practices related to the sale of anti-TB drugs.
4. To determine knowledge about NTP, DOTS and TB patient counselling.

General design:

The study is a cross-sectional design which will employ a questionnaire to collect the data
through interviewing the main sellers of pharmacies by the principal investigator (PI) within
DI Khan city. The main sellers could include sales persons, pharmacy assistants, pharmacy
technicians and pharmacists who have the responsibility of dispensing drugs to the
customers.

Study setting:

Dera Ismail Khan (DI Khan) is one of the south most district of Khyber Pukthoon Khwa
province, Pakistan. The area of district is 7,326 km2. District has population of about
1,167,317. There is one DHQ Hospital, 1 THQ Hospital, 4 Rural Health Centres, 29 Basic
Health Units, 26 Civil Dispensaries and 5 Mother and Child Health Care Centres, 4 Civil
hospitals, 3 Reproductive health centres in the whole District.30

DI Khan city has 93 pharmacies in total. Each pharmacy staff would vary in number
depending on the size of the pharmacy. The staff may include sales persons, pharmacy
assistants, pharmacy technicians and pharmacists. Qualified pharmacist may not be available
during all the working hours. The drugs are dispensed by any of the above mentioned persons
and they are supposed to have the information about the availability and sale of drugs. They
are referred to as the main seller in the proposal.
Study population:

Main seller from all of these 93 pharmacies within DI Khan city are intended as the study
population. Homeopathic pharmacies will not be included in the study.

Inclusion & Exclusion criteria:

Main sellers from all the pharmacies within DI Khan city that give consent to participate in
study will be included.

Those who refuse to participate in the study, and those who participate in the pre-testing of
the questionnaire will be excluded

Methods:

Structured questionnaire is prepared according to objectives of the study in English. This will
be translated to national language Urdu and then back to English by two people for
consistency. Pre-test will be conducted in 5 retail pharmacies in the study area to assess the
content and approach of the questionnaire.

Data collection:

All the data collection will be done by the PI during the working hours of the pharmacies by
personal visits to the pharmacies. At each pharmacy permission will be taken from the owner
of the pharmacy and the main seller (if they are different) by administering the information
sheet containing the necessary information about the study, voluntary participation,
confidentiality and anonymity . Further elaboration by the PI will be done if required. After
this elaboration the participants will be asked to sign the consent form. After informed
consent PI will collect data by using the structured questionnaire. All the collected data in
paper form and the signed consent forms will be brought back to the University of Bergen.
Data management and analysis plan:

Data will be entered and analysis will be done by using SPSS.

Ethical consideration:

Ethical approval will be obtained from the Norwegian Ethical Research Committee and
ethical research committee in Pakistan. Informed consent will be obtained from every
participant for voluntary participation in the study. All the study participants will be
anonymous. Names or any personal identifiers will not be recorded.

Budget:

Travelling (from Norway to Pakistan and back)….…………………...…7000 NOK

Travelling cost within DI Khan…………………………….....................5000 NOK
Stationery, printing, Translation, data collection …………………..........6000 NOK
Accommodation/lodging, ..........................................................................7000 NOK

Timeline:

January to April 2014 - proposal development Bergen, Norway

April to June 2014 - Questionnaire development and Ethical clearance.
September to December 2014 - data collection, entry and analysis.
January to April 2015 – Thesis writing Bergen, Norway
References:

1. WHO. Global tuberculosis report 2013, Available from:

http://www.who.int/tb/publications/global_report/en/ [Accessed 8th March 2014].

2. Health Mo. National Tuberculosis Control Programme Pakistan. In: Health P, editor.
Pakistan: Ministry of Health; 2010.

3. WHO. Tuberculosis Profile, Pakistan. 2011 [updated 2011; cited Feb 12, 2011 ]; Available
from: http://www.who.int/tb/data. [Accessed 8th March 2014].

4. National Tuberculosis Control Program (NTP). [cited Feb 12, 2011]; Available from:
http://www.ntp.gov.pk/about.htm.[Accessed 8th March 2014].

5. Nishtar S. The Gateway Paper; Health System in Pakistan – a Way Forward. Islamabad,
Pakistan: Pakistan’s Health Policy Forum and Heartfile; 2006.

6. UNICEF. Pakistan: Statistics. 2009 [updated 2009; cited 2011 May 13]; Available from:
http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html. [Accessed 5th
January 2014].

7. UNICEF. Pakistan Statistics. 2010 [updated 2010; cited 2011 September 14]; Available
from: http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html. [Accessed 5th
January 2014].

8. http://www.iearn.org.au/clp/archive/gilgit2.htm . [Accessed 3rd September 2013].

9. UNESCO. Unesco Institute for Statistics: Education in Pakistan 2008 [updated 2008; cited
2011 May 13]; Available from: http://stats.uis.unesco.org/unesco/TableViewer/
document.aspx?ReportId=121&IF_Language=eng&BR_Country=5860&BR_Region=40535.
[Accessed 16th March 2014].

10. Finance Mo. Facts about Pakistan: Health. [cited 2011 May 13]; Available from:
http://ipdf.gov.pk/home/facts-about-pakistan/social/health. [Accessed 16th March 2014].

11. UNICEF State of worlds children-2000. Oxford University Press.2000. [Accessed 3rd
September 2014].

12. Azhar S, Azmi M, Izham M, Ibrahim M, Ahmad M, Masood I, Akmal A. The role of
pharmacist in developing countries: the current scenario in Pakistan. 2009.

13. Health care financing in Pakistan. Available from:

http://www.thenetwork.org.pk/Resources/Reports/PDF/15-8-2011-3-17-26-931 Health
%20Care%20Financing.pdf. [Accessed 3rd September 2013].

14. Javaid, Arshad. "Tuberculosis Control in Pakistan." Editorial. www.pjcm.net. Pakistan

Journal of Chest Medicine, 2010. Web.

15. World Health Organization. WHO Report 2004 – country profile Pakistan. Geneva,
Switzerland: World Health Organization 2004.

16. NTP. National strategic plan for tuberculosis control in Pakistan; 2004.
17. National TB control programme, Planning workshop on TB-DOTS implementation in
hospitals, first edition, April 2007.

18. Guidelines for Diagnosis and Management of Tuberculosis in Pakistan, April 2012.

19. Report of the Health System Review Mission - Pakistan. Rep. World Health
Organization, Feb. 2007.

20. Ahmed, Jameel, Mubashir Ahmed, Sajid Ali, Zafar Fatmi, and Wasdevl Lohana. "Public
Private Mix Model in Enhancing Tuberculosis Case Detection in District Thatta, Sindh,
Pakistan." Journal of Pakistan Medical Association (2009). Web.
21. Khan, J., A. Malik, H. Hussein, N. K. Ali, F. Akbani, S. J. Hussain, G. N. Kazi, and S. F.
Hussein. "Tuberculosis Diagnosis and Treatment Practices of Private Physicians in Karachi,
Pakistan." Eastern Mediterranean Health Journal 9.4 (2003). World Health Organization.
Web.

22. "Communicable Diseases." GreenStar. GreenStar Social Marketing Pakistan. Web.

23. Finding and Treating People with TB in Pakistan. Rep. Geneva: Stop TB Partnership,
2011. Print.

24. The Indus Hospital Initiative. Rep. Geneva: Stop TB Partnership, 2011. Print.

25. Khan, Uzma. “Impact of a private sector funded community-based program for MDR-TB
management on scale-up in Pakistan.” Presentation. 42nd Union World Conference on Lung
Health. Lille, 2011.

26. Richardson, D’Arcy. Engaging the Chemist Sector in TB Control: Country Experiences.
Rep. Lille: USAID, 2011.

27. Source: William. A. Wells, et al; Size and usage pattern of private TB drug market in the
high burden countries (Source: Global Alliance for TB Drug Development, Annual Report,
2009.

28. Harnessing Potential of Pharmacists for TB Prevention and Care in Pakistan:

Stakeholders Meet, 2013. Available from:
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2812%2970116-0/fulltext.
[Accessed 19th March 2014].

29. Rutta E, Ayyaz K et al. Engaging the Retail Pharmacies in Pakistan TB Control: Baseline
Assessment of Knowledge and Practices in Lahore, Islamabad, Rawalpindi and Peshawar,
October 2012.

30. USAID, District health profile, District Dera Ismail Khan, Pakistan initiative for mother
and newborn, Islamabad, Pakistan, 2009.
 Questionnaire for TB

General information & Retail Pharmacy Profile

Date of the interview: ……………....

1a. Are you the:

[ ] Owner
[ ] Pharmacist
[ ] Sales person

1b. Gender:
[ ] Male
[ ] Female

1c. Age (in years):……………………………………..

2. How long has this chemist been in operation?.............years ( Please observe the
license/registration certificate)

3. Is this chemist part of the chain?

[ ] Yes
[ ] No [move to Q6]

4. If yes, what is the name of the chemist’s chain?…………………......

5. How many branches do you have?......................................................

6. What is your professional background?
[ ] Pharmacist
[ ] Pharmacy Assistant
[ ] Pharmacy technician
[ ] Sales person
[ ] Other. Specify.. ……………………………..

7. How long have you worked in this chemist? …..….year(s) or …….Month…........

8. What are the working hours of operation of this chemist?

Open ……………………..am. Close……………………………………..pm

9. How many days in a week are you open?.....................

10. How many sales person work full time/part time in this chemist?
Full time……………
Part time….…………

11. Is there any health facility (private or public or both) around this chemist?
[ ] Yes
[ ] No

12. If yes, how far by walking

[ ] less than 10 minutes
[ ] less than 30mins
[ ] less than 1 hour

13. Where are the majority of your clients coming from? (Tick only one)
[ ] Private clinics/GP clinic
[ ] Patients from both private and public health facilities
[ ] Self-referral/medication/Home
[ ] Informal providers (hakims, homeopathic]
[ ] Others (specify) …………………………………………………………………

14. On average, how many clients/customer do you serve/see per

day?....................................................

15. Do you keep records for your clients? (Please observe those records before ticking)
[ ] Yes
[ ] No

16. If yes (please tick)

[ ] Sales/drug register
[ ] Prescriptions file
[ ] Others (Please specify)…………………………..

Knowledge about tuberculosis and TB DOTS

17. Do you know how TB is transmitted?

[ ] Through breathing in the air containing TB causing microorganisms
[ ] Through sharing of utensil
[ ] Through sex
[ ] Use an already used syringe
[ ] Smoking cigarette
[ ] Using narcotics
[ ] I don’t know
[ ] Others. Specify………………………………………

18. What factors contribute to the spread of TB from patients to other people in the
community? (Please tick all that apply do not read but probe by asking “any other factor”)
[ ] Poor ventilation in the house
[ ] Overcrowding
[ ] Presence of untreated TB patients in the house/community
[ ] Poverty
[ ] I don’t know
[ ] Others (Please specify)…………………………………..

19. What are the symptoms of a person who is sick with TB disease (Do not read the list,
please tick all that apply and probe by asking “any other symptoms?”)
[ ] Persistent cough (two weeks or more)
[ ] Fever at night time
[ ] Excessive night sweat
[ ] Loss of weight
[ ] Fatigue, body malaise
[ ] Haemoptysis
[ ] Shortness of breath
[ ] Chest pains
[ ] I don’t know
[ ] Others (please specify)…………………………

20. How did you learn about these symptoms? (Please tick)
[ ] When I was at school/ college/university
[ ] During World TB commemoration day
[ ] During community sensitization meetings
[ ] Reading brochures
[ ] Billboards
[ ] Fellow health care providers
[ ] Radio
[ ] Television
[ ] Newspapers
[ ] At the mosque
[ ] Others (please specify)………………………………

21. How TB can be prevented?

[ ] By covering mouth and nose when you cough
[ ] By curing TB patients
[ ] Any other
22. Do you know which parts of the body that can be affected by
tuberculosis?
[ ] Lungs
[ ] Other organs as well
[ ] Only lungs

23. How is TB Diagnosed?

[ ] Chest x-ray
[ ] Sputum exam
[ ] Physical examination
[ ] History of TB in the family
[ ] Skin test
[ ] I don’t know
[ ] Others, specify….……………….

24. How long does it take to treat TB?

[ ] Less than 6 months
[ ] 6 months
[ ] I don’t know
[ ] Other. Specify………………………………………………

25. What happens to a patient who does not complete TB treatment?

[ ] Dies
[ ] Disease gets worse/deteriorates
[ ] Disease comes back/Recurrence
[ ] Disease spread to others
[ ] TB becomes resistant
[ ] I don’t know

26. Have you heard of TB DOTS (Directly Observed Treatment Short Course?)
[ ] Yes
[ ] No [skip to Q28]

27. If yes, where did you hear it from?

[ ] When I was at college/university
[ ] During World TB commemoration day
[ ] During community sensitization meetings
[ ] Reading brochures and newspapers
[ ] Billboards
[ ] Fellow health care providers
[ ] Others (please specify)……………….

28. Are you aware of multidrug resistant (MDR) TB?

[ ] Yes
[ ] No

29. What factors contribute to the spread of MDR TB? (Tick all that apply)
[ ] Improper treatment regimens
[ ] Failure to complete treatment
[ ] Presence of patients with MDR-TB in household/community
[ ] I don’t know
[ ] Other …..........

30. How anti-TB drugs should be taken?

[ ] Empty stomach
[ ] Full stomach
[ ] I don't know

31.Which first line anti-TB medicine causes discolouration of urine?

[ ] Isoniazid
[ ] Rifampicin
[ ] Ethambutol
[ ] pyrazinamide
[ ] Streptomycin
[ ] I don't know

Action and practices in TB case detection

32. Based on your experiences, do you see clients come to this chemist with TB symptoms?
[ ] Yes
[ ] No

33. How many suspected TB patients do you see on average per week? …........

34. What do you do when you suspected a TB patient? (Please tick more than one)
[ ] Refer to a nearby laboratory
[ ] Refer to a nearby GP
[ ] Refer to a nearby specialized chest physician
[ ] Dispense broad spectrum antibiotics [e.g. Flouroquinolones]
[ ] Dispense cough syrup
[ ] Dispenses Anti- TB drugs
[ ] Others (please specify)………………………………

35. Do you see TB patients who come with a doctor’s prescription of anti TB medicines?
[ ] Yes
[ ] No

36. If yes, on average how many patients do you dispense TB medicines per
week?..........................

37. On average, what is the duration of anti-TB drugs in prescription?

[ ] 1 month
[ ] 2 month
[ ] 3 month
[ ] 4 month
[ ] 5 month
[ ] 6 month
[ ] Other (please specify)………………………………

38. On average, for how much long time patient buy anti-TB medicines?

[ ] less than 1 month

[ ] 1 month
[ ] 2 months
[ ] 3 months
[ ] 4 months
[ ] 5 months
[ ] 6 months
[ ] Other (please specify)………………………

39. Majority of TB patients belongs to which socio-economic class?

[ ] High class
[ ] Middle class
[ ] Low class

40. On average, how many anti-TB drugs are present in prescription?

[]1
[]2
[]3
[]4
[]5
[]6
[ ] Other (please specify)………………………

41. Vitamin B6 supplement is present in TB patient prescription?

[ ] Yes

[ ] No
42. Are there any Informational Education and Communication materials on TB available in
the chemist shop?
Please observe
[ ] Yes
[ ] No

43. If yes, what are they?

[ ] Brochure/pamphlet
[ ] Posters
[ ] Pharma companies TB medicines sales advertisement
[ ] Others specify…….

44. Have you received any training on TB in last two years?

[ ] Yes
[ ] No [skip to Q47]

45. Which organization/institution conducted the training?.........................

46. What did the TB training cover?

[ ] TB General
[ ] MDR TB
[ ] Direct Observed Therapy (DOTs)
[ ] I don’t remember
[ ] Others. Specify………………………………………
47. Which are most frequently sold TB medicines? (Please tick the top 3 frequently sold)
[ ] 4-FDC-RHZE (Rifampicin/Isoniazid/Pyrazinamide/Ethambutol) combination
[ ] 3-FDC- RHE combination
[ ] 2-FDC-RH combination
[ [Pyrazinamide
[ ] Ethambutol
[ ] Kanamycin
[ ] Streptomycin
[ ] Isoniazid
[ ] Others. Specify………………………………………………

48. Do you know about the National TB Program (NTP)?

[ ] Yes
[ ] No

49. If no, would you like to know more about the National TB Program (NTP)?
[ ] Yes
[ ] No

50. Would you like to be involved in the TB control efforts by getting training and thereby
referring patients to the DOTS delivery facilities?
[ ] Yes
[ ] No
 CONSENT TO PARTICIPATE IN RESEARCH

Assessment of the knowledge of the retail pharmacy staff about tuberculosis and public
tuberculosis Control Programme, and sale practices of anti-tuberculosis drugs in DI
Khan city, Khyber Pukthoon Khwa Province, Pakistan

I have been given all the relevant information regarding this research project and have
understood an explanation of this research project. I have had chance to enquire questions
and have them answered to my fulfilment. I have the knowledge that I may pull out myself
from this research project at any time depending on my wish without giving any reasons.

I understand that any information I give will be kept anonymous and confidential. I
understand that no opinion will be connected to me in any means that will recognize me and
the published results will not use my pharmacy name or my name. I understand that the data I
provide will not be used for any other purpose or released to others without my written
consent. I voluntarily choose to take part in this research project.

Name of principal investigator:

Signature of principal investigator:

Name of participant:

Signature of Participant:

Date:
 INFORMATION SHEET

Information Sheet for a Research project

Researcher: Yasir Shahzad, Centre for International Health , University of Bergen

I am a Pharmacist from University of Peshawar and currently undertaking Master in

International Health at the University of Bergen, Norway. As part of international health
degree I am doing a research project leading to a thesis. The project is on the assessment of
the knowledge of the retail pharmacy staff about tuberculosis and public tuberculosis Control
Programme and sale practices of anti-tuberculosis drugs. This research project has received
approval from Ethical Committees of Pakistan and Norway.

I would collect information by taking interview from the main sellers of pharmacy by using a
short questionnaire. The questionnaire will take about half an hour to complete. If any
participant wants to pull out from the project, he may do so without giving any reason at any
time.

Responses will make the foundation of my research project and will be put into a written
report on an anonymous and confidential basis. All data collected will be reserved
anonymous and confidential. No other person except me and my supervisor will see the
questionnaires. The copy of thesis will be submitted to university of Bergen and will be
deposited in the University Library. It is planned that the data will also be used to write
research article for publication in public health journal. Questionnaires will be destroyed
three years after the end of this research project.

If you have any additional questions or would like to receive further detail information about
the research project, please feel free to contact me on my email address
yasirshahzad203@yahoo.com.