Lao People's Democratic Republic, with a population of about 5.5 million,7 is one of the world's least developed countries, low on health indicators.8 Fifty eight per cent of health spending in the country comes from households, of which two thirds are spent on private services, mostly at private pharmacies,9 of which less than 10% are run by a qualified pharmacist or an assistant pharmacist.10 Self medication with antimicrobials is commonly found in developing countries, and misuse of antibiotics has been reported.11 A high percentage of irrational antibiotic use may worsen the increasing antibiotic resistance, resulting in treatment failure and increasing mortality and morbidity.11 Private pharmacies are usually the first point of contact with health delivery services.12,13 In one study in Laos, 60% of drugs were obtained without a prescription, drug sellers were untrained and dispensed drugs irrationally, and little or no information was given to patients.14

Few data on RTI/STI are available from Laos. In 2000, HIV prevalence in Laos was estimated to be 0.05% of the 15–49 year old population.15 However, a sentinel surveillance in 2001 showed that the HIV prevalence rate was 0.9% among high risk groups (such as service women—any woman who worked in a small drink shop, nightclub, or guesthouse and had direct contact with customers16—and long distance truck drivers), and that infection rates of certain STI among service women were high, 32% for chlamydia and 14% for gonorrhoea.16 Community based surveys showed that 38% of those reporting more than three sexual partners had never used condoms.17 The possible introduction of HIV in such an environment could lead to a fast evolving epidemic, emphasising prevention and treatment of RTI/STI as a priority component of HIV/AIDS control.18 As yet, no study on self medication with antimicrobials for RTI/STI has been done in Laos, but is highly relevant to the nation, as it is a response to the continuing increase in antimicrobial resistance, and to the high levels of STI/HIV in neighbouring countries.19,20

More than three quarters of the respondents reported using antibiotics for an inappropriate duration of time, and few of them knew the dosage of drugs used. Ampicillin was the most common drug taken, probably because of low costs, easy access at every drugstore without a prescription, and familiarity with “ampi.” However, following the WHO's recommendations,23 ampicillin should not be used according to the national guidelines for syndromic STI case management,18 as a high level of resistance has been detected in some Asian countries,23 including Laos. As antimicrobial resistance compromises effective treatment of RTI/STI, it is important to educate people about the benefits of appropriate treatment with effective drugs in order to prevent treatment failure that may cause complications, relapse, and further transmission of infection.

Almost all respondents had bought the antimicrobials from private pharmacies and more than half had the advice to buy the drugs from the drug sellers themselves. In Laos, all kinds of drugs, including antibiotics, are easy to access everywhere without a physician's prescription and a correct diagnosis. In addition, stigma and shame associated with RTI/STI might be important barriers to appropriate diagnosis and treatment services,24 as many women respondents reporting RTI/STI symptoms said that they were shy of the genital examination and opted for self medication. Similarly, studies in private pharmacies in Vietnam and Brazil found that none provided correct treatment for STI.25,26

As private pharmacies in Laos are a common place for people to obtain advice for RTI/STI treatment, the critical question is how the quality of care can be improved. Evidence suggests that STI services provided by pharmacy staff, especially pharmacists, can be significantly improved through short term training, although the improvements have been shown to be time limited, indicating the need for continued training and supervision.27,28,29 Recognising the importance of prompt and correct treatment with effective drugs for RTI/STI in combination with health education to the public, continuous training of drug sellers on syndromic STI case management should be initiated to improve their awareness and competence. In addition, strict control should be put on the prescription and sale of these antimicrobials. However, this can be done only if there is enough access to trained doctors or other personnel, as well as diagnostic equipment being available throughout the country.

The most common reasons for self medication with antimicrobials for RTI/STI were habit or following previous self treatment of similar symptoms. Such behaviour in association with inappropriate antimicrobial use may contribute to the development of antimicrobial resistance.30 In order to encourage appropriate and prompt care seeking behaviour for RTI/STI, there is a need to improve health education messages, focusing on behaviour change communication for RTI/STI, such as a change in knowledge about RTI/STI, causation, transmission, prevention, or treatment. However, it has been well substantiated that real, long lasting behavioural change is not the result of simply telling people what to do.31 To address a sensitive issue like RTI/STI and to promote changes in health seeking behaviour requires an understanding of people's needs, concerns, and perceptions. As an example, the low rate of self reported use of condoms raises concerns that promotion of condoms should be one priority in the health education activities for protection against HIV and RTI/STI.32

The limitations of this study include: (1) its reliance on self reported information on symptoms of RTI/STI, and the fact that it was not possible to validate symptoms by laboratory tests for practical reasons; (2) an interval of up to 12 months between antimicrobial self treatment of RTI symptoms and interview may affect accurate recall, resulting in under‐reporting as well as over‐reporting; and (3) the possibility of response bias because of the sensitive character of RTI/STI could not be excluded.