AN INVESTIGATION OF NON-PRESCRIPTION
MEDICINE SUPPLY IN COMMUNITY PHARMACIES
IN HANOI, VIETNAM DO XUAN THANG, BPharm, M.Sc.
Thesis submitted to the University of Nottingham for
the degree of Doctor of Philosophy

SEPTEMBER 2013
ii

Abstract

Supplying safe, appropriate and effective non-prescription medicines for customers in

factors that impacted on staff-customer transactions. Being conveniently located, the pharmacy
offering reasonably priced medicines and being a large pharmacy with a good reputation were
also considered important impacting on customer selection of community pharmacy.

The results of this research show that there are limitations in pharmacy service provision and
there is a discrepancy between pharmacy staff perceptions and actual practice in terms of
attitudes. Poor performance, in many situations, did not come from a lack of knowledge; rather
it appeared to result from the negative attitudes of pharmacy staff. Such negative attitudes of
pharmacy staff are likely to be related to their focus on just short-term profit rather than
focusing on a balance between short-term and long-term benefits for both customers and
pharmacies. Positive attitudes, taking greater responsibility, customer loyalty and long-term
benefits were ignored. Poor performance of pharmacy staff, to some extent, was also affected
by their education and training. Some educational organisations have commercialised their
training activities and paid too much attention to the quantity of graduated students rather than
the quality of their education and training.

This study has important implications for the improvement of the responsible supply of non-
prescription medicines in community pharmacies in Vietnam including the identified needs for
attitude interventions and training. New subjects should be added to the pharmacy students’
curricula and training should be developed for pharmacy assistants in areas such as
communication skills, customer psychology, selling skills and patient safety. For pharmacists and
pharmacy assistants, gaining treatment experience from customers’ feedback and keeping up to
date with new information should be a continuous activity. Close co-operation between health
authorities, policy makers and researchers needs to be developed in conducting further research
and implementing appropriate policies, in order to improve the service provision in community
pharmacies in Vietnam.

iv

ACKNOWLEDGEMENTS


FIP Centennial Congress of Pharmacy and Pharmaceutical Sciences, October 2012
(Amsterdam, the Netherlands)
Thang, D.X., Boardman, H., Anderson, C., Pharmacy customers’ opinions about the
counselling for non-prescription medicines in community pharmacies in Vietnam. 2012 FIP
Centennial Congress, Available from: Thang, D.X., Boardman, H., Anderson, C., Pharmacy staff perspectives on the influence of
advertising and the media on customers’ selection of non-prescription medicines in
Vietnam. 2012 FIP Centennial Congress, Available from:

vi

TABLE OF CONTENTS

ABSTRACT…………………………………………………………………………………………………………………… ii
ACKNOWLEDGEMENTS ……………… ……………………………………………………………………………….iv
PUBLICATIONS……………………………………………………………………………………………………………….v
TABLE OF CONTENTS……………………….………………………………………………………………………… vi
LIST OF TABLES……………………………….…………………………………………………………………………….xiii
LIST OF BOXES………………………………………………………………………………………………………………xiv
LIST OF FIGURES……………………………….………………………………………………………………………… xv
LIST OF TERMS AND ABBREVIATIONS………………………………………………………………………… xvii
CHAPTER ONE: INTRODUCTION 1
1.1 Introducing the study 1
1.2 Structure of the thesis 3
CHAPTER TWO: LITERATURE REVIEW 5
2.1 Introduction 5
2.2 The health care system in Vietnam 6

3.2.2.2 Interview methods 64
3.2.2.3 Qualitative data analysis 67
3.2.3 Quantitative methods – questionnaires 69
3.2.4 Validity and reliability 71
3.2.4.1 Validity and reliability: qualitative perspectives 72
3.2.4.2 Validity and reliability: quantitative perspectives 74
3.2.5 Data translation methods 75
3.2.5.1 Types of translation 75
3.2.5.2 Ensuring the quality of translation 78
3.3 Ethical considerations 80
3.4 Developing research tools 82
3.4.1 Observation instrument 84
3.4.2 Interview schedule 85
3.4.3 Survey – structured questionnaire 86
3.5 The pilot study 87
3.6 Recruitment 89
3.6.1 Selection of pharmacies to be observed 89
3.6.2 Recruitment of participants for the interviews 90
3.6.3 Recruitment of participants for the survey 90
3.7 Data collection 91
3.7.1 Observations in community pharmacies 91
viii

3.7.2 Pharmacist and pharmacy assistant interviews 94
3.7.3 Survey with pharmacy customers 94
3.8 Data translation 95
3.9 Data management and analysis 96
3.9.1 Qualitative data analysis process 98
3.9.2 Data management 99
3.9.3 Quantitative Data analysis 100

5.2.5 More power when selling non-prescription medicines 158
5.2.6 Lack of pharmacists working in community pharmacies 159
5.2.7 Reputation of pharmacy and loyalty 161
5.3 Attitude and ethical issues 164
5.3.1 Attitudes and ethical considerations 165
5.3.1.1 Importance of attitudes and ethical issues 165
5.3.1.2 Problems of attitudes and ethical issues 167
5.3.2 Care about customers’ health concerns 168
5.3.3 Responsibilities 170
5.3.3.1 Responsibility for patient safety 172
5.3.3.2 Responsible for rational use of medicines 175
5.3.3.3 Responsibility for customers’ economic status and affordability 179
5.3.3.4 Time spent on staff-customer transactions 182
5.3.4 Selling medicines without giving any questions and advice 184
5.3.5 Selling medicines for profit 185
5.3.6 Attitudes of pharmacy staff 189
5.3.7 Summary 196
5.4 Communication skills 199
5.4.1 Importance of communication skills 200
5.4.2 Questioning skills 202
5.4.2.1 Commonly employed questions 204
5.4.2.2 Asking about a customer’s medical history 208
5.4.2.3 Asking about allergy to medicines 209
5.4.3 Listening skills 213
5.4.4 Giving advice 216
5.4.4.1 Verbal and written instructions 217
5.4.4.2 Lifestyle advice 219
5.4.4.3 Consistency when giving advice 220
5.4.5 Relationship with customers 221
5.4.6 Limitations in communication skills of pharmacy staff 222

6.5 Discussion 270
6.5.1 Respondents report of non-prescription medicines transaction 270
6.5.1.1 Staff questioning of customers 270
6.5.1.2 Advice-giving 272
6.5.2 Associations between customer reports and demographics 274
6.5.3 Respondents’ evaluation of pharmacy staff performance 275
6.5.3.1 Pharmacy staff attitude 275
6.5.3.2 Respondents’ evaluation of pharmacy staff knowledge 276
6.5.3.3 Pharmacy staff communication skills 277
xi

6.5.3.4 Time spending on the transaction 278
6.5.3.5 Factors influencing the supply of non-prescription medicines 278
6.5.4 Respondent opinions of selecting community pharmacy 279
6.5.5 Summary 279
CHAPTER SEVEN: DISCUSSION AND CONCLUSION 280
7.1 Introduction 280
7.2 Factors impacting on the supply of non-prescription medicines 282
7.2.1 The similarities and confirmations 282
7.2.1.1 Pharmacy staff attitudes impact on the supply of non-prescription
medicines 282
7.2.1.2 The influence of communication skills on the supply of NPMs 283
7.2.1.3 The influence of pharmacy staff knowledge on the supply of NPMs 284
7.2.2 Differences and complementary factors 285
7.2.2.1 The influence of pharmacy settings on staff-customer interactions 285
7.2.2.2 The roles of community pharmacies in Vietnam 286
7.2.2.3 Customer factors that impact on staff-customer interactions 288
7.2.3 Associations between customer reports and demographics 289
7.3 Pharmacies’ practical problems 290
7.3.1 The discrepancy between what pharmacy staff say and what they do 290
xiii

LIST OF TABLES

CHAPTER 2: LITERATURE REVIEW
Table 2- 1 Definitions of quality of care 23
Table 2- 2 Dimensions of quality of care 25
Table 2- 3 Dimensions of quality of care according to WHO 26
Table 2- 4 Dimensions in the assessment of quality of care 27

CHAPTER 3: METHODOLOGY AND METHODS
Table 3- 1 Qualitative data collection methods, options, advantages, and limitations 58
Table 3- 2 Common stages in the process of translation 79
Table 3- 3 Qualitative and quantitative data analysis procedures for mixed methods studies
97

CHAPTER 4: PHARMACY OBSERVATIONS
Table 4- 1 Description of participating pharmacies 103
Table 4- 2 Different features between CPs in Vietnam and CPs in the UK 107
Table 4- 3 Characteristics of the pharmacy sites (n=5) and number of interactions observed
108

CHAPTER 5: PHARMACISTS AND PHARMACY STAFF PERSPECTIVES
Table 5- 1 Demographic characteristics of interview participants (n=22) 145
Table 5- 2 Questions which should be asked during customer-staff transactions 211
xv

LIST OF FIGURES

CHAPTER 1: INTRODUCTION
Figure 1- 1 Structure of the thesis 3

CHAPTER 2: LITERATURE REVIEW
Figure 2- 1 Structure of health care system in Vietnam 7
Figure 2- 2 National health expenditure per capita in Vietnam (2008 – 2016) 10
Figure 2- 3 Vietnamese pharmaceutical market value and growth rate (2002-2013) 11
Figure 2- 4 Drug purchases per capita in Vietnam (2000-2010) 12
Figure 2- 5 Health expenditure in Vietnam (2008-16); private, public and as a % of GDP 13
Figure 2- 6 Trends in health financing in Vietnam, 1999-2008 14

CHAPTER 3: METHODOLOGY AND METHODS
Figure 3- 1 Triangulation mixed methods explanation 55
Figure 3- 2 Development of the research project 83

CHAPTER 4: PHARMACY OBSERVATIONS
Figure 4-1 Pharmacy P 1 – floor layout ……………………………………………………………………………104
Figure 4-2 Pharmacy P 2 – floor layout ……………………………………………………………………………105
Figure 4-3 Pharmacy P 3 – floor layout ……………………………………………………………………………105
Figure 4-4 Pharmacy P 4 – floor layout ……………………………………………………………………………106
Figure 4-5 Pharmacy P 5 – floor layout …………………………………………………………………………. 106
Figure 4-6 Themes from observation of customer-staff interactions about NPMs ………….108
Figure 4-7 Community pharmacy 1 (large pharmacy) customer-staff interactions,
computers, facilities and the layout of pharmacy ………………………………………………………… 109


xvii

List of Terms and Abbreviations

ADRs
Adverse Drug Reactions
CPs
Community Pharmacies
GDP
Gross Domestic Product
GP
General Practitioner
NHS
National Health Service in England
NICE
National Institute for Health and Care Excellence
NPMs
Non-prescription Medicines
OTC
Over The Counter
PSA
Pharmaceutical Society of Australia
QCPP
Quality Care Pharmacy Program
QCPSC
Quality Care Pharmacy Support Centre
RPSGB
Royal Pharmaceutical Society of Great Britain
UK

Kingdom [8-12], Australia [13-19], Germany [20, 21] and Spain [22]. In contrast, there is
limited research about the supply of non-prescription medicines in community pharmacies
in Vietnam. So, conducting research to investigate non-prescription medicines supply in
community pharmacies in Vietnam is needed.

This chapter of my thesis provides an introduction to my research study, including the
origins and development of my PhD as well as the structure of this thesis. Chapter 1 Introduction
2

I have been involved in the area of community pharmacy for the last ten years as part of my
role as a researcher and university lecturer in social pharmacy and pharmacy practice at
Hanoi University of Pharmacy. Over this period of time, I have observed the changes within
the pharmacy environment, and experienced some of the issues in pharmacy practice in
community pharmacies in Vietnam. I am interested in the improvement of pharmacy
practice and this raised a question in my mind as to what factors affect pharmacy service
delivery and how we can improve the quality of pharmacy services in order to provide
better care for customers. This ambition encouraged me to pursue my PhD degree in the
United Kingdom and conduct a research project in the area of pharmacy practice in
community pharmacies in Vietnam.
Figure 1- 1 Structure of the thesis

INTRODUCTION

METHODOLOGY
AND METHODS

RESULTS

DISCUSSION AND
CONCLUSION
Chapter 1
Introduction
to the thesis
Chapter 2
Literature
review
Chapter 3
Methodology
and methods
Chapter 4
Pharmacy
Observation
s
Chapter 5
Pharmacy staff
perspectives
Chapter 6
Survey of
pharmacy


Chapter 2 Literature review
5

2 CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction
The purpose of this chapter is to review the literature relevant to the supply of non-
prescription medicines in community pharmacies and provide the background for
conducting a study to investigate the non-prescription medicine supply in community
pharmacies in Vietnam.

This research project was conducted in community pharmacies in Hanoi, Vietnam and in
the context of Vietnamese health care and pharmaceutical systems. A review of the
literature about the health care system in Vietnam is presented and discussed in order to
provide underpinning context for further understanding about the activities in community
pharmacies and customers’ reactions. The structure of the health care system in Vietnam is
presented; the expenditure for health care and the health care financing as well as the
insurance system are discussed. Furthermore, the historical development and the role of
community pharmacies in Vietnam are presented in order to support the research.

In addition, this research project focuses on the supply of non-prescription medicines. So
the fundamental information about non-prescription medicines such as definitions of non-
prescription or over-the-counter (OTC) medicines, criteria to classify medicines as OTC and
standards for the supply of non-prescription medicines are also presented. Finally, quality
of care is discussed in the context of health care in community pharmacies.

Chapter 2 Literature review
6


public hospitals with more than 128,000 beds, and 135 private hospitals [23]. Ninety-five
percent of communes have health stations, with more than 95% having skilled birth
attendance. Human resources for health is limited and imbalanced;

there are 34.7 health
workers per 10,000 people, among whom 6.5 are medical doctors, 1.2 are pharmacists, and
8 are nurses [29].

Figure 2- 1 Structure of health care system in Vietnam [23] Chapter 2 Literature review
8

The health system in Vietnam is a mixed public-private provider system as a result of the
economic reform in the late 1980s, in which the public system still plays a key role in health
care, especially in prevention, research and training [30]. The Vietnamese healthcare
system is dominated by public hospitals as they are heavily subsidised. Public hospitals in
Vietnam receive their income from three main sources: the government, fee income
received from patients and the health insurance agency. Financial resources from the state
budget allocation and health insurance usually form 60-70% of public hospital revenue. In
addition, public hospitals have long history and enjoy a good reputation with the public as
having the best trained, experienced doctors in the country. In contrast, private hospitals in
Vietnam have a short history. The oldest ones were established in 1997. Public perceptions
about private hospitals are that they provide better caring services but do not have such
good doctors as their public counterparts. There were 135 private hospitals from a total of
1184 hospitals in Vietnam in 2011. Private hospitals provided 4.2% and 5.1% of total
hospital system’s inpatients and outpatients in 2011, respectively [27]. Overall, there are
around 200,000 health staff of all categories in Vietnam, including doctors, pharmacists,
nurses, nurse aids, midwives and technicians [31]. The system delivered 205 million