Impact of Improved Pharmaceuticals Services on Type 2 Diabetes in Bangladesh

This paper explores the impact of improved pharmaceuticals services on type 2 diabetes in Bangladesh. It includes a brief literature review, rationale, aims, research questions/objectives, study methods, intervention, and data collection methods.

Running Head: IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES
Impact of improved pharmaceuticals services on Bangladesh’ type 2 diabetics patients
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IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 2
Background, Brief Literature, and Rationale
Background
Non-communicable diseases (NCDs) such as type 2 diabetes have been classified as
one of the major global health issues especially in countries such as South Asian.
Globally about 135 million adults are suffering from diabetes according to 1995; however by
2025 the figure is estimated to increase up to about 300 million; that is 120% increase
(Chowghury, Billah, Arifeen & Hoque, 2018). Studies show that about 8.5 million people in
Bangladesh are diabetic with the majority having type 2 thus without effective health
intervention, the number is expected to escalate to about 16 million by 2030 (Caffrey, 2016).
Brief literature Review
Bangladesh is situated in the northeastern of South Asian subcontinent and is
surrounded by India and Myanmar. Bangladesh has a population of about 164.7 million of
people by 2017. The population is projected to increase by another 100 million even be for
the country stabilizes its core services such as health care that is critical to the economy;
development of the country. Diabetes type 2 is recognized as one of the chronic diseases in
Bangladesh however it remains unknown to the public due to a little survey that has been
conducted in the country. It is estimated that more than 80% of bangladesh population are in
the rural setting, however, some few studies indicate that the prevalence of diabetes is higher
in urban settings (Molla & Chi, 2017). Study by Huda, Tahsina, El Arifeen and Dibley (2016)
found out that prevalence was about 2.1% by 1995 while another study of 1997 indicated that
prevalence from both the rural and urban was 3.8% and 7.8% respectively. This is a proof
that there is an increasing development of diabetes in Bangladesh population that needs
proper research and interventions (Biswas & Kabir, 2017) This led to the development of
Systems for Improved Access to Pharmaceuticals and services in (SIAPS) Bangladesh, with a

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 3
goal to assure the availability of quality pharmaceutical services products and services to the
population to achieve the desired health status.
Currently, the retail drugs support majority of the Bangladesh population, about
1,103400 of the licensed retail drugs are involved in the selling of drugs over the counter to
patients of all types of disease (Rahman et al., 2018). According to Armed, Naher, & Hossain
(2017) most of the sales person s on those retail drugs shops do not have the required training
and education in dispensing drugs and offering treatment. However, generally, the
significance of the informal sector of retailing drugs among the Bangladesh population, it is
very imperative that improved regulations are imposed to provide the population with an
opportunity to receive improved services.
Health private sectors play a significant role in Bangladesh populations since more
than 80% of the population seek medical care from the non-private sectors (Adhikary et al.,
2018). This means that retail drug shops are always considered the first stop by the patient
especially the diabetic who does not want to seek medication in the public sector. According
to Schwarz (2012), Bangladesh has approximate of 1, 103,451 licensed drug shops and about
of the same number of unlicensed shops that sell drugs to about 5.5 million diabetics.
However, most of the salesperson in those private drug shops have inadequate training and
dispensing drug information which falls on their daily tasks (Javanbakht et al 2015).
According to the regulation, the drug salesperson should acquire training not minimum to
four months and attain a grade not less than C in pharmacist before they can be awarded any
license on pharmacy or run a drug shop. The training that is conducted by the Bangladesh
Pharmaceutical Society in conjunction with Bangladesh Chemist and Druggist Samity ensure
that the public receives the correct drug, quality and at an affordable price.

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 4
Rationale
Since most of the private drug sellers have inadequate exposure and training, they
tend to misguide a large number of patients since their drug sales information and
recommendations do not meet the requirement; thus resulting into new disease, long-term
treatment and even financial constrict among the patients especially the diabetic who use
drugs for quite a long tie of period (Flood et al., 2016). Studies indicate the irrational use of
drugs such as over-prescribing, use of unnecessary drugs, multi-prescribing, drug dispensing
without prescription, improper injections and overuse of antibiotics are common among these
private drug retailers and always results into severe medical complications.
Several studies that have analyzed the adherence of diabetic medication found out
than non-adherence had a high frequency of hospitalization. Professional says that diabetes is
chronic and a progressive in nature, meaning that early medical intervention is significant to
its management (Ong et al., 2018). In Bangladesh, the newly diagnosed type 2 diabetes
patients always fail to adhere with the prescribed standards either through dropping out of
medications or seeking other types of medicines from these private sectors that increase the
rate of hospitalization by about 24%. The association between poor drug dispensing practices
and prevalence of diabetes among the Bangladesh population has not been fully studied, thus
this project aims at fulfilling the gap in the studies.
Aims
Due to the high rising rate of HIV, and other prevalence in Bangladesh, the
government built a health care system in 1970 to reduce the spread and growth of the
communicable among the population and forgot of these non-communicable diseases such as
diabetic that has attacked a large number of people. To fully address these communicable
diseases, the stakeholders need to understand the underlying factors that facilitate the
infections and how these diseases can be controlled. The aim of this study thus is to generate

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 5
an understanding of how improving the Bangladesh pharmaceutical services would impact
the prevalence of type 2 diabetic among the Bangladesh population.
Research questions/ Objectives
The following principle research questions will assist the researcher in collecting
relevant information about the topic under study:
RQ1: Do the drug sellers in Bangladesh meet the minimum legal requirement such as posing
valid business license?
RQ2: What are the accredited opportunities for drug sellers to improve the quality of services
in Bangladesh?
RQ3: How affordable, available and level of quality of the drugs in the private drugstores in
Bangladesh?
RQ3: How does the services offer generally affect the treatment of diabetes in Bangladesh?
Objective
The objective of this project is to improve the diabetic prevention and treatment
among the Bangladesh population by improving the pharmaceutical services and designing a
better way of the drug dispensing process among the salespersons. Through the use of the
findings of this project, both the community and drug salesperson will not only be enhanced
on the knowledge about common illness but will be equipped with better ways, of eliminating
the possibility of contracting the non-communicable disease.
Study Methods
This paper is a facility-based and cross-sectional study, aim at exploring the nature of
the regulations and operations of the retail drugs shops and drug dispensing services practices
in Bangladesh. The paper also finds how the service is impacting the general health of the
population especially those that are suffering from type 2 diabetic.

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 6
The respondents of this study will be
 salespersons from the selected drug dispenser shops,
 a sample of the Bangladesh patients/community who were at the areas of the surveys,
 structured observing dispensing practices of the drug salesperson the dispensing
practices of the drug salespersons.
Sampling methods
This study entails all the drug shops from both the rural and the urban setting that are
spread across all the seven divisions of Bangladesh. The rural samples will be retrieved from
the drug shops that are in the neighborhood of the Upazilas health complex, business centers,
and markets, and because of the time constraint, the number of samples limited. From the
Upazilas center, there will be 30, and the choice will be based on geographical distance; it is
situated on the remote area of the district; those that are at the periphery of the district and
those that are situated at the center of the district.
All the drug shops will have to fulfill the following criteria:
a. Drug shops must have the highest customer traffic.
b. Drug shops must be in the neighborhood of the UHC and drug shops selected
must be strategically placed( one must be near to UHC, another further from
UHC and the last must be centrally placed).
The urban samples also will be regulated by the time and resources available, thus out of
the 11 city corporations, 7 cities will be selected and from each of this, 3 drugs shops will be
identified to bring a total of 21 drug shops in the urban setting (Urach et al.,2016). The drugs
shops selected from the urban setting thus will have to meet the following criteria:
a) Drugs shop selected should be near to subdistrict

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 7
b) The second drug shop should be 1 kilometer from the first selection.
c) The third shop should be at the periphery of the subdistrict.
Sample size and power
An approximate of 500 individuals both male and female above 20 years will be
identified through census before the commencement of the survey from all the division s and
the drug shops. The sample size will be calculated through N=Z 2PQ/d2
Intervention
There is a high risk of death for patients with type 2 diabetes and is increasing due to
poor medication among the patients. The glycaemic control among the patients helps in
reducing the risk of death. When insulin is provided in approximately, then the patient might
develop a severe condition that might also lead to death (Biswas & Kabir 2017). Therefore, it
is imperative for the pharmacist to be familiar with particular educational pints to ensure
maximum therapeutic results among the diabetic patients in Bangladesh. Thus it is apparent
to the medical providers to help the patients achieve an optimum blood glucose level,
adherence to drugs and acquirement of self-management. The global statistics indicate
variance of between 36% and 93% adherence to drugs (Animaw & Seyoum, 2017). The most
commonly used drug is insulin and the injection should always be adjusted systematically to
help the patients adapt to it and maintain a particular glucose level. The educational points
include insulin storage and handling conditions, compatibility of insulin with other mixtures
and insulin administration.
Insulin is protein in nature, thus loses potency in presence of high temperatures.
Unopened bottles should be kept in cool places until the need of the use arises and should be
discarded on the passage of the expiration date (Animaw & Seyoum, 2017). Without
adherence to these conditions, such affected insulin always causes discomfort among the

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 8
patients. Insulin is not compatible with glargine and short-acting insulin are compatible in the
same syringe with NPH, while regular insulin is compatible with Lente and Ultrallente.
Lispro is compatible with Ultralente, thus any combination results into side effects, however,
Lente and Ultralenet can be combined without side effects. On the administration, patients
should always be aware that the primary injection sites entail abdomen, thigh, buttock and
upper arms. The injections are always made at the pinched area of the subcutaneous lately at
90-degree to ensure that insulin directly gets into the bloodstream. Injection into different
places other than the prescribed ones will slow the rate of absorption, hence might not help
the patient (O’Reilly et al., 2018). These are information that these pharmaceuticals should
know at the tip of their fingers, unfortunately, due to inadequate information, they commit
clinical errors on the patients that seek assistance from them.
The wrong dosage of insulin always results in hypoglycemia; a situation where blood glucose
level is higher than 70mg/dL. Pharmacist thus is required to know symptoms of
hypoglycemia: tremor, perspiration, confusion and tachycardia and pharmacists should know
how to treat in case of hypoglycemia, without over treating it through the provision of right
glucose tablets and always repeated systematically until the blood glucose returns to the
normal level.
Data collection method
The data collection method of this study will extensively entail the use of survey
questionnaire and the FGD guidelines that will be made from the tools adapted to form the
Management Science for Health (MSH) of same studies in other countries such as Pakistan.
A list of the essential drugs on common illnesses, especially on the diabetic, will be retrieved
from the Government update list of Essential Drugs to help in counterchecking the essential
drugs dispensed in this selected drug retails.

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 9
The retrieved reference list will be useful in confirming whether the essential drugs for the
illness such as diabetic are readily available in these drug dispense shops with the required
prices, quality, packaging, storage and are within the shelf-life.
A research Assistant with enough knowledge on the health and sciences will be
employed to assist in this study and will be subjected to a one-week day training to enhance
the reach requirements. The training will entail all the lecture notes on the research
methodology, and simulation of the perceived study areas as the daily training activities will
be overseen by the lead trainers from renowned institutions (Lai, Chen & Wu, 2017). The
trainees will be provided with guidelines by the PIs and Co-PIs and the whole research data
collection process will be supervised and managed by the researcher and is expected to be
completed within four days. Data will be collected through the use of different methods that
are document review to ascertain the regulatory and policy environment.
a. Quantitative survey to help in grouping the drug shops and determine the
training end experiences level of the salespersons.
b. Qualitative exploration among the community and other stakeholders to elicit
their perceptions of the products and services of the drug shops
c. Structured observation of the sampled drug shops to document the nature of
the dispensing practices. Therefore, a total of 111 drug shops (21 from the
urban and 90 from the rural setting) all from the seven divisions in Bangladesh
will be included in the study.
Ethical statement
The researcher will obtain consent from all the participants before the commencement of
the study, by making them understand the importance of the study to the general public and

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 10
the business. All the participants will also not influenced or coerced to provide information
that might alter the results as intended by the researcher and will be allowed to exit wherever
they feel like. The secondary source of information will also be used only after the consent of
the authors by writing and privacy will be acknowledged. The study process will be reviewed
by the cause supervisor before the commencing and relevant adjustments will be made as
communicated by the lecturer.
Data Analyses
The secondary collected data, such as those that will be retrieved from the Health
Sector and government database will be coded and entered into survey data for easy analysis.
The primary collected from the questionnaire will be fed into the MS Access database and the
data management will be accomplished by an identified professional data entry operator,
assisted by the data management team to ensure minimum error in the data analysis who will
enter five per cent of the total data into control quality (Aldhdouh, 2018). During the data
entry session, both the PIs and Co-Pis and the researcher will have the total control over the
data entry team to ensure that the correct data are entered into the system. The data entry
method will be facilitated by the codebook that will have been constituted by the researcher
and will be strictly followed to ensure validity.
After the completion of the data entry, the data will be analyzed through the use of SPSS,
whereby the biostatistician will ensure that the data we cleaned at least two times to remove
any ambiguity (Pulverer & Rmbruster (2017). The data will then be analyzed on the basis of
demographics; rural versus urban and by the division. The results will be presented in the
forms of means, frequency, and standard deviations to bring the relationships between the
drug shop services and the prevalence of diabetic among the population.
Anticipated outcomes and significance
Anticipated outcomes

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 11
After the completion of this research, the researcher is anticipating to find a relation
between the services offered by private drug sellers and the level of diabetes among the
population. Based on the underlying literature, most of the private drug sellers have
inadequate medical information and training especially on diabetes; this will have little effect
in reducing or helping the patients in controlling and managing the condition. The situation is
more worse since most of the Bangladesh patents visits these private drug points wherever
they feel uncomfortable, this means that a large number of the patient of type 2 diabetes are
more likely to suffer hyperglycemia as a result of poor insulin storage, handling, and
ministration by the pharmacists.
Significance
The information received from this study will be helpful to the general public,
government agencies, and the private sectors. The general public will have adequate
information on the type of private clinics they should go to acquire assistance, especially on
the chronic medical conditions since most of the private sectors do not have the required legal
and professional standards. Attending such clinical points will only elevate the medical
condition that might result into loss of life. The government agencies will also benefit in that
they will be able to identify the substandard private medical point that risk the life of the
public by breaking the rules, hence shut them down in a move to reduce the infection of
chronic diseases, controlling of the non-communicable diseases and eliminate exploitation of
the public. Consequently, the private sectors will also benefit from the study by getting to
know the minimum requirement and the consequence of not adhering to the rules and
regulations.

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 12
Proposed Timeline
Budget and justification of budget
Budget, project activities and Gantt chart
The budget for the study has been allocated as result of the following reasons:

IMPROVED PHARMACEUTICALS SERVICES ON TYPE 2 DIABETES 13
 The literature Review will require the use of the journals, textbooks, websites that are
charged to have accessibility and that will cost about $3000
 The data collection materials such as printing of interview questionnaire will cost
about $ 4,500
 Data analysis will cost about $3,000
Summary of the budget
Purpose Estimated Amount($)
Literature Review 3,000
Data Collection 4,500
Data Analysis 3,000
Total Estimated Budget 10,500

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