Simulated Client Research Articles

Can clinical vignettes administered by mobile phone call be used to measure quality of contraceptive care practices in Malawi?

Background Accurate and timely measures of quality of contraceptive care are required for program improvement but can be expensive and time-consuming to implement in low- and middle-income countries (LMICs). Clinical vignettes (CLVs) measure quality knowledge and have been shown to be a valid proxy of provider quality practice in the United States, and may be administered via mobile-phone, making them an attractive cost-savings alternative to field assessments. This cross-sectional study aims to validate mobile-phone CLVs for measuring quality of contraceptive service provision using simulated, “mystery” clients as the gold standard. Methods Researchers trained to simulate clients (SC) seeking contraceptive care visited 112 government-administered clinics in six districts of Malawi. The providers who saw the simulated clients were called via mobile phone approximately three weeks later for CLV administration. We calculated sensitivity, specificity, and area under the ROC receiver operating characteristic curve (AUC) and compared the proportion of quality behaviors measured from both methods. Results Overall, the quality measured by CLVs differed from quality measured with SCs. A higher proportion of providers reported clinical assessments and counseling on more topics during the CLV compared to the SCs, including counseling on what to do if the pill was not taken on time (59% vs. 26%; P<0.01). During the SC, providers asked more questions when taking client history and recommended the preferred method of the case scenario more often (81% vs. 49%; P<0.01). Conclusions The quality of care ascertained through mobile-phone CLV was not similar enough to quality ascertained through SCs to replace them. Mobile phone-based CLV also failed to capture all areas of quality performance. Continued efforts are needed to identify and test innovative methods to accurately and inexpensively measure quality of care to inform improvement of provider performance.

History taking and response to an adult diarrheal case among community drug retail outlets in Gondar town, north-west Ethiopia: a simulated-client survey

BackgroundSelf-care is one of the growing tasks of community pharmacy professionals. They are highly engaged in consultations in response to specific drug request (product-based presentation) or symptoms clients describe (symptom-based presentation).PurposeThis study was aimed at assessing the appropriateness of patient assessment and response to an adult diarrheal case among community drug retail outlets in Gondar town, north-west Ethiopia.MethodsA descriptive cross-sectional study design based on simulated-client method of visit was conducted from 03 August to 21 September, 2020. An adult female diarrheal case scenario was developed and used to guide data collectors to interact with professionals in a standardized and consistent way. All 60 dispensaries in the town during the data collection were included in the study. A pretested data collection tool was used to record the conversation between simulated clients and providers. The data were analyzed using SPSS version 20.ResultsWith regard to patient history, age of the patient, whether diarrhea is watery or bloody and onset and duration of diarrhea were the three most commonly requested questions with 59 (98.3%), 55 (91.7%) and 46 (76.7%), respectively. Past-medical and medication history are enquired in none of the visits. Medication was dispensed in 57 (95%) of the visits and no referral to a health facility was recommended in majority (90%) of cases. The most commonly recommended medications were ciprofloxacin 30 (52.6%) and metronidazole 20 (35.1%). ORS was considered in only 6 (10.5%) dispensaries.ConclusionPatient assessment, final decisions and treatment recommendations for an adult diarrheal case are inadequate, irrational and illegal. Educational interventions coupled with incentive mechanisms for cognitive pharmaceutical service and strict regulatory enforcement are needed to reduce the problem.

A Simulated Client Exploration of Nonprescription Dispensing of Antibiotics at Drugstores for Pediatric Acute Diarrhea and Upper Respiratory Infection in Lahore, Pakistan.

IntroductionThe excessive consumption of antibiotics is a significant contributor to antimicrobial resistance, especially in children. Children are often advised antibiotics for viral infections. In developing countries, drugstores are a prime source of easy access to nonprescription antibiotics. Moreover, in Pakistan, their irrational use is an “everyday routine”. The study, therefore, aimed to evaluate the dispensing of nonprescription antibiotics to children.MethodsUsing pediatric acute diarrhea and acute upper respiratory infection as disease scenarios, a simulated client, cross-sectional study was conducted in Lahore, Pakistan, to explore the antibiotics’ ease of availability at both categories of drugstores (pharmacies and medical stores) from November 1st, 2019 to January 31st, 2020. Chi-square (χ2) test was used to compare the differences in practices of different categorical variables. Multivariable logistic regression was applied to analyze the association of various factors with antibiotics dispensing.ResultsAntibiotics were dispensed without prescription in 456 (59%) of 773 simulated visits out of which 425 (93.2%) were dispensed on the advice of the drugstore staff. A qualified pharmacist was available in only 164 (21.2%) cases. Of the 386 visits for acute diarrhea and 387 for acute upper respiratory infection, nonprescription antibiotic dispensing occurred in 259 (67.1%) and 197 (50.9%) visits, respectively. There were considerable differences (p-value <0.05) in the practices and antibiotics dispensing between each disease scenario presented. Moreover, antibiotics were less commonly dispensed at pharmacist-supervised drugstores compared to unsupervised ones.ConclusionOverall, inappropriate dispensing practices were prevalent to a large extent at the drugstores, and antibiotics were effortlessly obtainable without prescription. The quality of the services provided, especially by the non-pharmacist staff, was also not satisfactory. Therefore, the Drug Regulating Authority of Pakistan must enforce strict implementation of drug laws at the drugstores without delay, especially in major cities to help curb the felonious use of antibiotics.

Decision-Making and Relationship Competence When Reporting Suspected Physical Abuse and Child Neglect: An Objective Structured Clinical Evaluation.

Mandatory reporting of suspected child abuse and neglect highlights the challenges between the ethical and legal obligations of social workers and the need to maintain the therapeutic relationship with the client. The ability to bridge this tension is paramount to ensure continued psychosocial treatment and the well-being of children. This paper discusses a study to determine the decision-making factors of social work students and practitioners when facing a suspicion of child abuse and neglect, how they justify their decision to report or not report to child protection services, and the current and future relationship repair strategies used with simulated clients during an objective structured clinical evaluation (OSCE). Nineteen BSW, MSW, and experienced practitioners (N = 19) underwent an OSCE with one of two child maltreatment vignettes, physical abuse or neglect. Fisher’s exact test was used to examine participants’ historical and current reporting behaviors. Independent samples T-tests, Cohen’s D, and qualitative content analysis was used to examine participants’ decision making and relationship repair strategies when faced with suspected child abuse and neglect. Results showed that six participants discussed the duty to report during the OSCE while 13 participants did not. Participants’ who discussed and did not discuss the duty to report during the OSCE articulated clear reasons for their decision and identified relationship repair strategies in working with the client. A sub-group of participants who identified the child maltreatment but did not discuss the duty to report, provided more tentative and complex reasons for their inaction and next steps in working with the client. All participants demonstrated a degree of competence and critical reflection in the OSCE, with integration for future learning. These findings are discussed and implications for future practice are offered.

Medical abortion kit dispensing practices of community pharmacies in Pokhara Metropolitan, Nepal

BackgroundMedical abortion (MA) refers to the use of medicines to terminate the pregnancy. There is an urgent need to spread safe abortion services in the community. This study assessed the MA kit dispensing practices of community pharmacies in Pokhara Valley, Nepal.MethodsA cross-sectional descriptive study was conducted in Pokhara Valley, Nepal from December 2017 to November 2018. Among the community pharmacies of Pokhara Valley, 115 community pharmacies were selected using a consecutive sampling method. A semi-structured questionnaire was used to collect data. MA kit and related information were requested by simulated male clients visiting the community pharmacies. The information obtained from the pharmacy workers was recorded in the data collection sheet.ResultsNine brands of MA kit from eight manufacturing companies were found in practice in Pokhara Valley, out of those only five (56%) were registered in Nepal. Seven brands were sold at more than the labeled price. The pharmacy workers asked about the gestational age and confirmation of pregnancy in all the cases. Most of them counseled the clients on the frequency, duration, and direction of use. Dispensing practice and level of counseling were found to be significantly correlated (r = 0.40, p value = 0.01).ConclusionDespite the awareness of the pharmacy workers on the MA kit, most of them provided limited information to the clients. Nearly half unregistered MA kits were found in practice at the community pharmacies. Thus, the Department of Drugs Administration and other concerned authorities must provide relevant training and awareness programs to the pharmacy workers of the community pharmacies for preventing the malpractice of MA kit. The Government of Nepal must restrict the illegal entry of unregistered brands and assure the standards of MA kit by regulating drug acts and policies effectively.

Examining Cross-Cultural Child Welfare Practice Through Simulation-Based Education

Simulation-based learning is an emerging pedagogical approach in social work education that is expanding to specialized areas of practice. This research examines the intersection of cross-cultural practice and child maltreatment investigations. Thirty-one (N = 31) BSW and MSW social work students participated in a three-hour voluntary child welfare simulation workshop and engaged with one of three child welfare scenarios: (1) an immigrant Chinese family, (2) an Indigenous family, and (3) a White youth. Drawing upon the concept of cultural agility, a theoretically-informed mixed methods approach was used to analyze the data. Fisher’s exact test and independent samples T-tests were used to examine participants social work education and experience, perceived competencies, acknowledgment of the simulated client’s culture, and evaluation of the simulation experience. Qualitative analysis examined participants’ critical reflection of their cross-cultural exchange with the simulated clients regarding allegations of child maltreatment. Statistical differences were noted among participants who engaged with each of the three child welfare scenarios. All participants expressed positive learning benefits through simulation, however, statistical differences were found between participants who acknowledged the client’s ethno-cultural identity versus those who did not with respect to their overall learning benefits, meta-competencies, and procedural competencies. Participants demonstrated various aspects of the cultural agility framework as they reflected upon their practice. Simulation-based learning offers the opportunity for students to critically examine and reflect upon the ways they operationalize culture and child maltreatment, and how to manage the complexities of working across difference. Future recommendations for research and practice are discussed.

Over-The-Counter Sales of Antibiotics at Community Pharmacies in Belize: A Cross-Sectional Simulated Client Visit study

Aim: In Belize, antibiotics are categorized as prescription-only drugs, and their sales over the counter without a prescription is prohibited. This study assessed the sales and dispensing of antibiotics in community pharmacies without a prescription. Methods: 36 community pharmacies in 4 districts of Belize were assessed for non-prescription sales of antibiotics using a simulated client method (SCM) approach from September to November 2019. Results: The majority (19; 52.8%) of the community pharmacies assessed refused to sell antibiotics without a prescription from a physician. Approximately 17 (47.2%) sold and dispensed antibiotics to simulated clients (SCs) without a prescription. Adequate patient counseling was provided by the pharmacists to the SCs. Conclusion: Some level of lack of compliance with the sales of antibiotics without prescription was observed among community pharmacists in this study. There is a need to reinforce stricter control on the sales and dispensing of antibiotics without prescription in the country of Belize.

Assessing Upstream Determinants of Antibiotic Use in Small-Scale Food Animal Production through a Simulated Client Method.

Small-scale food animal production has been celebrated as a means of economic mobility and improved food security but the use of veterinary antibiotics among these producers may be contributing to the spread of antibiotic resistance in animals and humans. In order to improve antibiotic stewardship in this sector, it is critical to identify the drivers of producers’ antibiotic use. This study assessed the determinants of antibiotic use in small-scale food animal production through simulated client visits to veterinary supply stores and surveys with households that owned food animals (n = 117) in Ecuador. Eighty percent of households with food animals owned chickens and 78% of those with chickens owned fewer than 10 birds. Among the households with small-scale food animals, 21% reported giving antibiotics to their food animals within the last six months. Simulated client visits indicated that veterinary sales agents frequently recommended inappropriate antibiotic use, as 66% of sales agents recommended growth promoting antibiotics, and 48% of sales agents recommended an antibiotic that was an inappropriate class for disease treatment. In contrast, few sales agents (3%) were willing to sell colistin, an antibiotic banned for veterinary use in Ecuador as of January 2020, which supports the effectiveness of government regulation in antibiotic stewardship. The cumulative evidence provided by this study indicates that veterinary sales agents play an active role in promoting indiscriminate and inappropriate use of antibiotics in small-scale food animal production.

Non-prescription sale of antibiotics and service quality in community pharmacies in Guangzhou, China: A simulated client method.

ObjectiveTo measure the situation of the non-prescription sale of antibiotics and the service quality of community pharmacies in Guangzhou, China.MethodsA simulated client method was conducted to estimate the non-prescription sale of antibiotics and service quality based on scenarios about adult acute upper respiratory tract infection in 2019. A total of 595 community pharmacies from 11 districts were investigated in Guangzhou, China. We used binary logistic regression to evaluate the factors associated with the non-prescription sale of antibiotics.ResultsThe proportion of non-prescription dispensing of antibiotics was 63.1% in Guangzhou, China, with a higher incidence of antibiotic dispensing without prescription in outer districts (69.3%). Cephalosporin (44.1%) and Amoxicillin (39.0%) were sold more often than other antibiotics. Chain pharmacies had better performance on the prescription sale of antibiotics and service quality. Traditional Chinese medicine was commonly recommended by pharmacy staff.ConclusionSince the non-prescription sale of antibiotics is prevalent in Guangzhou, effective solutions should be determined. Strengthened public awareness and regulatory system innovation are needed.

Assessment of community pharmacy management towards self-medication requests of tetracyclines for pregnant women: a simulated client study in Upper Egypt.

Background Self-medication is a worldwide phenomenon of using medications without medical supervision. It is even more prevalent in low-income countries, where individuals seek community pharmacies because of accessibility and affordability. Although self-medication is associated with an increased risk of medication errors, few studies have been conducted to examine the quality of community pharmacy management towards self-medicating individuals of at-risk populations such as pregnant women. Objective We sought to investigate the quality of community pharmacies management of self-medication requests of tetracyclines for pregnant women. Setting The study was conducted in community pharmacies in Minya, Egypt. Methods A random sample of 150 community pharmacies was chosen from the urban areas of five districts of Minya, Egypt. To evaluate the actual practice, a simulated client was trained to visit pharmacies and purchase doxycycline for a pregnant woman. In a random subset of the sampled pharmacies (n = 100), interviews were conducted to evaluate pharmacy staff knowledge and attitudes regarding information gathering and dispensing practice. Main outcome measure Dispensing rate of doxycycline for pregnant women. Results From simulated client visits, almost all pharmacy staff (99.1%) dispensed doxycycline without requesting a prescription or collecting any information. About 25% of staff members did not abstain from dispensing even after knowing about pregnancy. On the other hand, most interviewed pharmacy staff (91.5%) reported that they ask about pregnancy before dispensing. Conclusion Our findings show that the current community pharmacy practice puts pregnant women at high risk of experiencing harmful self-medication outcomes. Therefore, strict legislative measures and pharmacy education programs should be considered in Egypt to lessen inappropriate dispensing rates in community pharmacies.

Using interpretive phenomenological analysis (IPA) to understand the development of legal ethical competence through reflection in a clinical learning environment

ABSTRACT This study proposes to investigate the contribution clinical legal education (CLE) can make to student learning in legal ethics. CLE (in the form of student law clinics and CLE modules) is a learning environment in which students learn from experience by providing legal advice to live or simulated clients with the support of their tutors or supervisors. Reflection has been identified as a key feature of CLE in terms of teaching legal ethics. The main impetus for this study is that reflection as a facilitator of professional learning is, however, not well understood and insufficiently explored. This study will therefore aim to fill this gap in existing research by investigating how reflection, as one of the key features of CLE, develops ethical competence in law students, using an interpretive phenomenological analysis (IPA) approach. The findings of this study therefore have the potential to be an original contribution in this field, as well as having practical implications for the design of CLE modules and student law clinics in future.

Sosyal Hizmet Eğitiminde Teori ve Pratiği Bütünleştirmede Bir Yöntem Olarak Simule Müracaatçılar

Field practice is an indispensable part of social work education. The students of the social work department, who receive different information on the basis of knowledge, skill and value for working with individuals, groups and society during their education, are expected to put this education into practice. Studies show that students have problems transferring theoretical education to practice. It is very important for students to see how they can achieve this transfer without encountering real clients. For this, '’more realistic'’ simulated clients are used instead of the role playing technique frequently used in social education Simulated clients, which are widely used in many disciplines in the field of healthcare, especially in medicine and nursing, are also a method that has been revealed by researches, in order to transfer students' theoretical education to practice. In this context, firstly, information about the definition and scope of the simulation method and its use in social work education is given. Then, it is recommended to train simulated clients based on the idea that the quality of education will increase through the use of simulated clients in education and will contribute to the scientific base and social recognition of the profession.

Students’ conceptualization of culture and diversity with a simulated client

ABSTRACT Teaching students about culture and diversity in social work practice is a complex and important task for social work educators. In this study, we assessed students’ conceptualization of culture and diversity factors following a simulated interview. Participants (N = 57 MSW students) completed a reflection questionnaire post-simulation and we conducted thematic analysis of the data. Three themes emerged: 1) culture and diversity impacted the interview, 2) culture and diversity didn’t really impact the interview, but …, and 3) culture and diversity didn’t really impact the interview. The results indicate it is important to enhance teaching methods related to culture and diversity, and simulation is a promising innovation to prepare students for practice.

Observational learning in simulation-based social work education: comparison of interviewers and observers

ABSTRACT Simulation-based learning is gaining attention in social work education. While research suggests clear pedagogical benefits for those who engage simulated clients as interviewers, little is known about the learning processes among observers of simulation teaching. Using social learning and social cognitive theories as a theoretical framework, we examined observational learning in simulation by comparing the experiences of students who participated as an interviewer versus students who participated as an observer. An online survey was administered to Bachelor and Master of Social Work students (N = 66) to collect quantitative and qualitative responses (N = 107) about their learning experience from the perspective of either an interviewer or an observer. Quantitative analyses revealed that interviewers perceived simulation with SCs to be more beneficial to their clinical learning compared to observers. No other differences were found between the two groups. A thematic analysis of qualitative data showed the following three unique learning processes among observers: (1) emotional distance from practice, (2) observation of the relationship between theory and practice, and (3) vicarious learning from peers. Results suggest that educators leverage student learning opportunities in observing roles and actively engage them during simulation debriefing sessions. Implications for simulation-based education and further research are discussed.

Community pharmacy services and preparedness during COVID-19 outbreak in Madinah, Saudi Arabia

BackgroundWearing facial masks, hand hygiene, and social distancing are highly recommended preventive measures against COVID-19. Masks and disinfectants are usually sold in community pharmacies that are supposed to undertake extreme precautions to avoid cross infection among clients. It is also their responsibility to play a prominent role in educating the community regarding this outbreak. ObjectivesTo investigate the preparedness of private community pharmacies in Madinah, Saudi Arabia, for the COVID-19 outbreak with regard to safety measures, customer education, and quality of preventive aids sold by them. MethodsOne hundred pharmacies were visited by simulated clients. The availability of free hand disinfectants, masks, gloves, and customer educational aids as well as the measures employed to ensure maintenance of safe distances between customers were documented. The adherence of pharmacists and customers to safety precautions and the behavior of pharmacists against violators of regulations were also observed. Finally, the availability and quality of facial masks and hand disinfectants sold by these pharmacies was documented. ResultsFifty-five pharmacies offered free hand disinfectants but only in three of them all customers used them. Only two pharmacies offered free disposable masks and temperature screening was available in only one pharmacy. Educational aids were found in 31 pharmacies and only 53 pharmacies used visual indicators for social distancing. Violation of wearing masks by pharmacy personnel and customers was seen in 34 and 87 pharmacies, respectively. Social distancing was violated in 64 pharmacies and intervention by staff was seen in only three of them. Finally, facial masks were available for sale in only 35 pharmacies, and in 23 of these, the quality was questionable; hand disinfectants were available in 84 pharmacies, and in 14 of these, the quality was unknown. ConclusionsCommunity pharmacies in Madinah were short of registered, high-quality facial masks during the survey. Means to control the transmission of infection inside pharmacies were unsatisfactory. Society has shown poor compliance to preventive measures against COVID-19 infection and the role of community pharmacists in promoting compliance was found to be poor. The study reveals an unsatisfactory level of preparedness of Madinah community pharmacies for the pandemic.

Evaluation of Veterinary Students' Communication Skills with a Service Dog Handler in a Simulated Client Scenario.

Effective communication skills serve as a key component of excellent veterinary care and provide a foundation for building trusting relationships with clients. While many veterinary clients value their pets for companionship, the focus of other relationships may be based on a partnership between the human and animal, as is the case with the handlers of service dogs. As the use of service dogs in the US continues to grow, it is important that veterinary professionals are educated on how best to meet the unique needs of service dogs and their handlers. This article evaluates the interactions of veterinary students with a service dog handler in a simulated client scenario. Ten videotaped interactions were coded to assess third-year students' communication skills (nonverbal communication, open-ended questions, reflective listening, and empathy), and their ability to discuss the diagnostic and therapeutic options for a dog with suspected intervertebral disk disease. Results showed that the majority of students demonstrated competence in the use of nonverbal communication skills and in discussing the biomedical aspects of the disease. Students require development in the use of open-ended questions, reflective listening statements, and expression of empathy, as well as building client rapport and discussing the psychosocial aspect of the disease on the client and patient. These findings suggest that veterinary students may benefit from targeted instruction on "best practices" in caring for service dogs and their handlers, including greater attention to the psychosocial aspects of a disease, and from additional communication practice using standardized clients with service dogs.

Sale of WHO AWaRe groups antibiotics without a prescription in Pakistan: a simulated client study

IntroductionResistant strains of bacteria are rapidly emerging with increasing inappropriate use of antibiotics rendering them less efficacious. Self-purchasing of antibiotics particularly for viral infections is a key driver of inappropriate use, especially in lower- and middle-income countries. There is a particular issue in countries such as Pakistan. Consequently, there is a need to assess current rates of self-purchasing especially for reserve antibiotics to guide future policies.AimsAssess the extent of current antibiotic sales without a prescription in urban areas of Pakistan.MethodologyA multicenter cross-sectional study was conducted in different areas of Punjab, Pakistan using Simulated Client technique. The investigators demanded different predefined antibiotics from WHO AWaRe groups without prescription. Three levels of demand were used to convince the pharmacy staff in order to dispense the antibiotic without a prescription. A data collection form was completed by simulated clients within 15 min of each visit.ResultsOverall 353 pharmacies and medical stores were visited out of which 96.9% pharmacies and medical stores dispensed antibiotics without demanding a prescription (82.7% at demand level 1 and 14.2% at demand level 2), with only 3.1% of pharmacies refusing to dispense antibiotics. The most frequently dispensed antibiotic was ciprofloxacin (22.1%). Surprisingly, even the reserve group antibiotics were also dispensed without a prescription. In only 25.2% visits, pharmacy staff guided patients about the use of antibiotics, and in only 11.0% pharmacists enquired about other medication history.ConclusionCurrently, antibiotics are easily acquired without a legitimate prescription in Pakistan. There is a need for strict adherence to regulations combined with a multi-dimensional approach to enhance appropriate dispensing of antibiotics and limit any dispensing of WHO restricted antibiotics without a prescription.

Development and Validation of a Novel Measure for the Direct Assessment of Empathy in Veterinary Students.

Empathy is a requisite clinical skill for health professionals and empathy scores have been positively associated with professionalism, clinical competency, confidence, well-being, and emotional intelligence. In order to improve empathy in the veterinary field, it is critical to measure the construct of empathy accurately. Most research has relied on self-reporting measures to assess empathy, while some studies have recently implemented the use of simulated client encounters in veterinary education. Building on this research, the aim of the current study was to develop and validate a novel quantitative assessment tool-the Empathy Clinical Evaluation Exercise (ECEX)-designed to measure empathy based on directly observable behaviors, using simulated clients. To evaluate empathy, evaluators used the ECEX to assess the performance of student clinicians in a simulated client encounter, which contained a pre-determined number of opportunities designed to elicit empathic responses from student clinicians. Statistical analysis suggests the test has a high degree of inter-rater reliability. In addition, there was moderate correlation between average empathy scores using ECEX and previously validated measures of empathy, compassion satisfaction, and burnout. Using these methods, we found the majority of students we studied had increased empathy scores at the completion of their primary care rotations. These results provide preliminary support for the use of the ECEX as a direct and quantitative tool for the assessment of empathy. Health professionals could use this novel empathy assessment tool to teach students, evaluate teaching strategies, and improve communication competencies in a wide variety of clinical settings. Our broad aim was to examine the utility of a direct and quantitative assessment tool for measuring empathy-the ECEX-in order to answer the following questions: (1) Does the tool have good inter-rater reliability? (2) Does the tool correlate with previously validated empathy measures? and (3) Does the tool correlate with similar constructs of compassion fatigue and burnout? Our secondary aim was to evaluate the change in empathy scores over the course of a 4-month (16-week) primary care rotation (pre- to -post).

Determinants of non-prescription antibiotic dispensing in Chinese community pharmacies from socio-ecological and health system perspectives.

Although non-prescription antibiotic dispensing (NPAD) has been officially forbidden by the Chinese government since 2004, it is still a common practice throughout the country. In this study, we use China as an example to explore the determinants of NPAD within the framework of its health system from a socio-ecological perspective. A mixed-method combining the simulated client method (SCM) and key informant interviews conducted in Zhejiang, Hubei, and Sichuan provinces was adopted. 73.3% of the SCM interactions engendered NPAD (91.7% through antibiotic requests vs. 55% through consultation) in Chinese community pharmacies; a much higher rate than the global average. At the intrapersonal level, NPAD was found to be driven by profits from selling non-prescription antibiotics and traditional Chinese medicine. At the interpersonal level, NPAD was driven by fierce competition in the community pharmacy market and by customers' unreasonable expectations. At the institutional level, it is easy for community pharmacies to evade the Food and Drug Administration's (FDA) supervision by obtaining unsupervised and fake prescriptions, refusing to give customers sale receipts, and hiding their antibiotic supplies and sale records. At the policy level, the low cost of violating the prescription-only antibiotic sale regulation and poor FDA supervision facilitated NPAD. The Chinese health system has thus failed to establish and regulate a diverse network of pharmacies for patients to fill their prescriptions; few antibiotic prescriptions are transferred from hospitals to community pharmacies. Education campaigns to increase awareness about the risks of self-medication with antibiotics among the general public, recognizable standardize prescriptions for customers to fill their prescriptions in community pharmacies, regulations on Internet and private clinic doctors' antibiotic prescribing behaviors, electronic tracking and tracing system to purchases and sales data of antibiotics and other prescription drugs, increasing cost of violating the prescription-only regulations for antibiotics sales are expected interventions to reduce NPAD.

The Effects of Remote Behavioral Skills Training on Conducting Functional Analyses

In the present study, we sought to extend the current literature on utilizing behavioral skills training (BST) to teach practitioners how to implement functional analyses (FA). We used a non-concurrent multiple baseline design across ten participants to measure the effects of a remote BST package on accuracy of implementing FA procedures. The entire remote BST package was delivered via secure remote technology. Each participant experienced four phases which included baseline (only instructions with a simulated client), BST (instructions, modeling, rehearsal, and feedback with a simulated client), post-training probes (probes with a simulated client), and in situ probes (probes with actual clients). All participants increased their accuracy in implementing FAs during the remote BST phase. During post-training probes with a simulated client and in situ probes with actual clients, eight of the ten participants maintained their performance at or above mastery criterion. Two of the ten participants needed additional coaching and training. These results suggest that the use of remote technology for training purposes could be a cost-effective and feasible solution to increase the quality of services and number of trained professionals in underserved areas.