Understanding Acceptability and Willingness-to-pay for a C-reactive Protein Point-of-care Testing Service to Improve Antibiotic Dispensing for Respiratory Infections in Vietnamese Pharmacies: A Mixed-methods Study

Abstract

Background: Pharmacies are popular first points of contact for mild infections in the community. Pharmacy services in many countries have expanded to include vaccines and point-of-care tests. In low- and middle-income countries such as Vietnam, poor enforcement of regulations results in substantial volumes of over-the-counter antibiotic sales. Point-of-care tests could provide an economically viable way to reduce antibiotic sales, while still satisfying customer demand for convenient healthcare. C-reactive protein point-of-care testing (CRP-POCT) can reduce antibiotic prescribing for respiratory illness in primary care. Here, we explore the acceptability and feasibility of implementing CRP-POCT in pharmacies in Vietnam.

Methods: We conducted a mixed-methods study between April and June 2021. A customer exit survey with 520 participants seeking acute respiratory infection treatment at 25 pharmacies evaluated acceptability and willingness-to-pay (WTP) for CRP-POCT and post-service satisfaction. Factors driving customers" acceptance and WTP were explored through mixed-effects multivariable regression. Three focus group discussions with customers (20 participants) and 12 in-depth interviews with pharmacists and other stakeholders were conducted and analyzed thematically.

Results: Antibiotics were sold to 81.4% of patients with CRP levels <10 mg/L (antibiotics not recommended). A total of 96.5% of customers who experienced CRP-POCT supported its future introduction at pharmacies. Patients with antibiotic transactions (adjusted odds ratio [aOR], 2.25; 95% confidence interval [CI], 1.13-4.48) and those suffering acute respiratory infection symptoms for more than 3 days (aOR, 2.10; 95% CI, 1.08-4.08) were more likely to accept CRP-POCT, whereas customers visiting for children (aOR, 0.20; 95% CI, .10-.54) and those with preference for antibiotic treatment (aOR, 0.45; 95% CI, 0.23-0.89) were less likely to accept CRP-POCT. A total of 78.3% (95% CI, 74.8-81.7) of customers were willing to pay for CRP-POCT, with a mean cost of US$2.4 (±1.1). Customer's income and cost of total drug treatment were associated with increased WTP. Enablers for implementing CRP-POCT included customers' and pharmacists' perceived benefits of CRP-POCT, and the impact of COVID-19 on perceptions of POCT. Perceived challenges for implementation included the additional burden of service provision, lack of an enabling policy environment, and potential risks for customers.

Conclusions: Implementing CRP-POCT at pharmacies is a feasible and well-accepted strategy to tackle the overuse of antibiotics in the community, with appeal for both supply and demand sides. Creating an enabling policy environment for its implementation, and transparent discussion of values and risks would be key for its successful implementation.

Keywords: antimicrobial resistance; antimicrobial stewardship; community pharmacy; low and middle income countries (LMICs); point-of-care testing.

Figure 1.

(A) Acceptability of CRP POCT service for patients with ARIs at pharmacies and the reasons leading to rejection (our interviewers asked the participants rejecting the service by an open-ended question. The answers were subsequently labeled and categorized in the themes shown). (B) Willingness-to-pay for CRP-POCT service and the relationship between price (x axis) and the proportion of customers willing to pay at least the presented price (y axis) in VND currency.

Figure 2.

Themes and subthemes represented as enablers and challenges for implementation of CRP-POCT at community pharmacies in support of appropriate.