Contribution of Pharmacy Staff in Cotonou Pharmacies to the Management of Sexually Transmitted Infections with Urethral and/or Vaginal Discharge

Socio-Demographic and General Data

A total of 94 pharmacies were included in the study, and 732 people completed the survey questionnaire (Figure 1). The mean age was 27.9 years, with a standard deviation of 5.6. Females were predominant, with a sex ratio of 0.4. Pharmacy assistants were in the majority (81%), and staff with less than 10 years of experience were the most represented (91%). Table 1 presents some of the socio-demographic characteristics of the respondents. Of the 732 people surveyed, 87.4% said they had heard of STIs at least once before their medical studies. Table 2 shows other general data on STIs.

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Knowledge

• The majority of respondents gave a good definition of STIs with urethral discharge (65.3%) and vaginal discharge (62.8%).
• The bacterial origin of STIs with discharge was cited by the majority: 92.2% for urethral discharge and 91.3% for vaginal discharge.
• Almost all (99.2%) of those surveyed cited unprotected sex as the means of transmission of leaking STIs.
• The complication of STIs with urethral and vaginal discharge most frequently mentioned by respondents was sterility (97.1%).

Out of a total score of 18 points, the respondents’ knowledge score varied from 1 to 17, with an average of 11 ± 3.1 points. Overall, the average level of knowledge was higher (35.4%), as shown in Figure 2.

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Attitudes

• Most of the respondents usually saw clients with STIs with urethral and vaginal discharge at the counter, but away from other clients (86.7%), as shown in Figure 3.
• Out of a total score of 5 points, the respondents’ attitude score on STIs with urethral and vaginal discharge varied from 0 to 5, with an average value of 3.1±1.4. Overall, 37.8% of respondents had an average attitude score for STIs with urethral and vaginal discharge. Figure 4 shows the respondents’ overall attitude score towards clients with STIs involving urethral and vaginal discharge.

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Practices

Of the 732 people surveyed, 84.4% had already encountered customers complaining of urethral or vaginal discharge at the counter.

• The majority of customers complaining of urethral or vaginal discharge in pharmacies were seen by an assistant (83.5%).
• When faced with customers complaining of urethral and vaginal discharge, 3 out of 4 respondents mentioned referring the customers for medical consultation. Figure 5 shows the distribution of respondents according to their behaviour when faced with a customer complaining of urethral or vaginal discharge.
• The dermatologist-venereologist is the 2nd most common specialist to whom pharmacy staff refers customers suffering from STIs, after urologists for urethral discharge and gynaecologists for vaginal discharge (Table 3).
• Out of an expected total score of 9 points, the majority of pharmacy staff had an average score of 6.8±1.4 points. Figure 6 shows the distribution of respondents according to their practical score for customers with STIs involving urethral and vaginal discharge.

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KAP (Knowledge, Attitudes and Practices) Overall

The overall KAP level of pharmacy staff was average for 50.7% of respondents, as shown in Figure 7.

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Correlation between Level of Knowledge, Attitudes and Practices

There was a significant association between respondents’ level of knowledge and their attitudes (p<0.001) and practices (p<0.001). An increase in the knowledge score of the respondents was associated with an increase in the attitude score on the one hand, and in the practices score on the other, concerning STIs with urethral and vaginal discharge (Table 4).

Associated Factors

Using the correct KAP level as a reference, we identified the factors associated with the other KAP levels using multinomial logistic regression. Thus, the low KAP level was significantly associated with age, professional qualification, Age group (in years) <30 17.4 [5.5; 55.1] <0.001 12.3 [3.4; 44.4] <0.001 $$ \geq 3 0 \quad 1 \quad < 0. 0 0 1 \quad 1 \quad < 0. 0 0 1 $$ Gender Female 5.4 [2.6; 11.4] <0.001 Male 1 <0.001 Marital status STI training course and the fact of having received cases of STI at the pharmacy counter (Table 5). As for the average KAP level, associated factors were gender (p=0.042) and professional qualification (p<0.001). Women and pharmacy assistants therefore had an average KAP level compared to men and pharmacists and assistants (Table 6).

Bivariate binary logistic regression (Bad vs. Good) Multivariate binary logistic regression (Bad vs. Good) OR [95% CI OR] p OR [95% CI OR] p Single/Divorced/Widowed 6.5 [2.7; 15.5] <0.001 Married 1 <0.001 Professional qualifications Assistant 0.3 [0.0; 5.1] <0.001 0.1 [0.0 :2.9] <0.001 Pharmacy Assistant 95 [10.8; 837.2] 0.398 37.6 [3.1; 452.0] 0.193 Pharmacist 1 <0.001 1 0.004 Years of experience

1-3 2.2 [1.1; 4.4] 0.032 ≥4 1 0.032

Country of diploma or training certificate acquisition Benin 8.4 [2.6; 27.5] <0.001

Bivariate binary logistic regression (Average

vs. Good)

Multivariate binary logistic regression

(Average vs. Good)

OR [95% CI OR]

p

OR [95% CI OR]

p

Age group (in years)

<30

1.7 [0.9; 3.1]

$$
\begin{array}{l l l} < 3 0 &

$$ \begin{array}{l l l} < 3 0 & 1. 7 [ 0. 9; 3. 1 ] & 0. 0 9 8 \\ \geq 3 0 & 1 & 0. 0 9 8 \\ \hline \hline \text {Gender} \\ \text {Female} & 3. 9 [ 2. 1; 7. 2 ] & < 0. 0 0 1 \\ \hline \end{array} $$

3.9 [2.1; 7.2]

<0.001 2.0[1.1; 3.9] 0.042 Male 1 <0.001 1 Marital status Single/Divorced/Widowed

1.3 [0.7; 2.3]

0.466 Married 1 0.466 Professional qualifications Assistant

0.8 [0.3; 1.9]

<0.001 0.7[0.3 :1.7] <0.001 Pharmacy Assistant

95 [10.8; 837.2]

0.596 Yes 1 0.596 Table 6: Factors associated with the average KAP level of pharmacy staff in Cotonou pharmacies for STIs with urethral and vaginal discharge in 2023 (bivariate and multivariate analysis).

General Information

Of the 110 pharmacies in Cotonou, we conducted our survey in 94 pharmacies, with a rate of 84.45%. This participation rate of pharmacies in a scientific study is comparable to that of Badoum G, et al. [6] on the attitude of community pharmacists in dispensing asthma medications in Burkina Faso, where the participation rate was 82.4%. Most of the people surveyed were young, with the 20-29 age groups the most represented (73.9%). This youthfulness of pharmacy staff was also revealed by Traore D [7] in his study of the problem of selling medicines in Mali, the case of the peripheral municipality of Kalaban-Coro in 2010, where more than half of those surveyed were aged between 21 and 30.

We noted a predominance of women (72.4%) with a sex ratio (male/female) of 0.4. Ganfon H, et al. [8] in their study on the knowledge and practices of malaria management by private pharmacy staff in five large cities in Benin, Burkina Faso and Mali in 2014, found a sex ratio in Benin of 0.53. This result is close to ours. This can be explained by the fact that women are more welcoming and are not very demanding when it comes to salary. They are content with little to meet their needs, and are therefore relatively more recruited in pharmacies. Pharmacy assistants were in the majority in our study (81%). Bouraima F, et al. [9] found a similar result (86.05%). The same finding was made by Mbow F, et al. [10] in their study on “private pharmacies in the provision of family planning services in Senegal”, with a participation rate of 66.7% of auxiliaries. This can be explained by the fact that pharmacies recruit more auxiliaries than assistants, because auxiliaries are paid less than assistants.

People with less than 10 years of seniority were the most represented (91.1%). Mbow F, et al. [10] found that 55.1% of respondents had less than 10 years’ experience. This result is also close to that of Barry M [11] in his study on “Management of sexually transmitted infections, contribution of private pharmacies in Ouagadougou”, where he found that 58.82% of respondents had less than 5 years of experience.

Of those surveyed, 91.4% said they had received cases of STIs at the counter. Barry M [11] found a similar result, with 91.25% of pharmacists and 99.5% of auxiliaries in the city of Ouagadougou stating that they had received STI patients in their pharmacies. This result proves that patients with STIs visit pharmacies before going for a medical consultation.

Knowledge

Our study revealed that most pharmacy staff does not have a good level of knowledge about STIs involving urethral and vaginal discharge. The means of transmission of leaking STIs cited by almost all respondents was sexual intercourse. Similarly, the use of condoms during sexual intercourse was mentioned as a means of preventing these STIs. In Barry’s study [11], sexual intercourse was also cited by the majority of respondents (91.85%). Most of them (69.70%) also said that condoms were a means of preventing STIs. In principle, pharmacy staff with a good knowledge of the means of transmission and prevention of STIs should play an important role in preventing STIs in pharmacies by raising awareness.

Attitude

Overall, 37.8% of respondents had an average attitude to STIs with urethral and vaginal discharge. The majority of respondents usually received customers with urethral and vaginal discharge at the counter, but away from other customers. A customer who comes to the pharmacy for advice on an STI should preferably be welcomed in a confidential area; this area should be large, with space for communication. The questioning carried out in the event of a spontaneous request must be as discreet as possible [12]. However, at the time of the survey we noted that some pharmacies did not have a sufficiently large space. Customers suffering from urethral discharge should be given preferential treatment in an office. However, 12.7% of respondents said that they received customers suffering from urethral and vaginal discharge in an office. Barry M [11] found a slightly lower result; 65% of staff said they received clients with STIs at the counter and 25% of staff said they received clients with STIs in a consulting room. This may be explained by the fact that pharmacies in Ouagadougou have a consultation room reserved for patient counselling. Tran B, et al. [13] in their study on the “management of sexually transmitted infections in private pharmacies in Hanoi in 2014”, had reported that the simulated patient (false patient) was welcomed at the counter in front of the other customers without any space for confidentiality.

Practice

Respondents’ experience of STIs with discharge was generally average in 46.5% of cases and good in 35.7%. Customers complaining of urethral or vaginal discharge were generally seen in pharmacies by assistants (83.5%) or full pharmacists (79%).

The majority of respondents said they would prefer to refer a customer complaining of urethral or vaginal discharge to a medical centre (91.4%). This proves that pharmacy staff has a good knowledge of their limits and of the best way to deal with customers suffering from STIs. Dermatologists and venereologists are the second most common specialists to whom pharmacy staff refers customers suffering from STIs with urethral or vaginal discharge. This shows that most people are unaware of the role of dermatologists in the treatment of STIs. In fact, a dermatologist is also a venereologist, and is therefore trained to treat all STIs. Information campaigns aimed at pharmacy staff needs to be launched.

However, a large number of respondents preferred to offer antibiotics or antifungals to customers complaining of urethral and vaginal discharge. Tran B, et al. [13] found that in 86% of cases of genital discharge, treatment was offered by pharmacy staff. This result shows that pharmacy staff is giving the usual and inappropriate drug advice in pharmacies, even though they are not qualified to prescribe antibiotics. This means that in 2023, pharmacies in Cotonou will continue to dispense antibiotics to the public without a prescription, despite the measures taken by Benin’s health authorities to ensure that antibiotics are dispensed only on prescription.

Correlation and Associated Factors

An increase in the knowledge score of the respondents was associated with an increase in the attitude score on the one hand and in the practice score on the other for STIs with discharge Low KAP level was significantly associated with age, professional qualification, STI training course and having received STI cases at the pharmacy counter. Respondents aged fewer than 30 were 12.3 times more likely to have a poor KAP level than those aged 30 or over. This result can be explained by the fact that older respondents have more experience, which enables them to have good attitudes and practices when dealing with customers, particularly customers with STIs. Pharmacy assistants were 37.6 times more likely to have a poor KAP than pharmacists and assistants. This result can be explained by the fact that pharmacists and assistants have received good training during their schooling, which also enables them to adopt good attitudes and practices. Respondents who had not attended an STI training course were 11 times more likely to have a low KAP score than those who had. Also, respondents who did not have the opportunity to see customers suffering from STIs at the pharmacy counter were more likely to have a poor KAP score compared to others. We can therefore deduce the need to provide ongoing training to pharmacy staff so that they can contribute effectively to the management and prevention of STIs in our underdeveloped countries.