Variation in service-providers’ prescribing behaviour and policy implications for women with genitourinary tract infections in Ramallah, occupied Palestinian territory (oPt) Rula Ghandour BPharm MPH Rana Khatib Bpharm, MSc, PhD Institute of Community and Public Health Birzeit University -oPt

Background(1) Globally: Genitourinary tract infections including both reproductive (RTI) and urinary (UTI) tract infections are among the most common reasons for women seeking health care worldwide. Both Infections are associated with adverse pregnancy outcomes and negatively affect women’s quality of life. Emerging resistance to agents active against uropathogenes is noted worldwide 2

In the oPt Limited data available on RTIs and UTIs. Limited data available on microbial resistance patterns to such infections. Although some guidelines were available, yet, with inadequate awareness and minimal adherence at the clinic level. 3 Background(2)

Objectives of the study  To assess prescribing patterns related to RTIs and UTIs in selected women's health clinics in the Ramallah district in the occupied Palestinian territory;  To provide the evidence required to set policy and improve prescribing patterns. 4

Methodology (1) Type of study: Observational (Descriptive analytical) Target population: all women attending women’s health clinics in the Ramallah district of Palestine Sample: Convenient sample (12 clinics, cases per clinic). Time frame: 4 months (February – May 2010) Tools used: Women’s questionnaire Physicians’ questionnaire Consent: Verbal 5

Methodology (2) Appropriateness of treatment was based on: Evidence based medicine and available guidelines under the assumption of correct diagnosis. An appropriate treatment included: Indication Dosage regimen (strength, frequency) Duration of treatment 6

Results and Discussion(1) Sample: Sample size: 1052 women Response rate: 98% 15% (162) of the total sample were diagnosed as having an RTI, UTI or both infections by their women’s health physicians. 7

Socio-demographic characteristics for women with genitourinary tract infections (162): Young : 69.1% < 35 years old Mostly married : 96.3% ever married Low level of education: 61% below secondary Living within nuclear families : 65.8% nuclear families Living within the low or middle socio-economic status: 43.2% and 48.4% respectively 8 Results and Discussion(2)

Results and Discussion(3) 9 Diagnosis

Appropriateness of Treatment per diagnosis 10 The medications prescribed to 132 (81%) of 162 women at the time of diagnosis were not in accord with treatment guidelines or the evidence based medicine Results and Discussion(4)

Appropriateness of treatment (inappropriate practice) % (132) of the total women with infection were treated inappropriately Results and Discussion(5)

Conclusion Results of this study showed: High rate of variation in prescribing practices and managing women with such infections Indication and duration of treatment were the major contributors to this variation. Inadequate awareness and implementation to treatment guidelines and protocols leading to inappropriate treatment 12

Policy Recommendations Management guidelines (diagnosis and treatment) should be implemented and supervised at the clinic level Continuing professional development for women’s health physicians supported by proper supervision and follow-up is needed Microbial resistance patterns should be identified in the local context to guide appropriate prescribing patterns. 13