No Prescription, No Problem! A Mixed-Methods Study of Antimicrobial Stewardship Relating to Working Equines in Drug Retail Outlets of Northern India

Abstract

Multidrug resistance (MDR) is already occurring among some equids in India. Donkeys and mules are a mobile species moving between regions and international borders, often populating areas of India where private community pharmacies, or medical stores, are the primary healthcare provider for both humans and animals. This article highlights how the capacities of drug retail outlet workers might affect their antibiotic dispensing practices, particularly in relation to donkeys and mules, in order to consider how this might impact the development of antimicrobial resistance (AMR) on a wider scale. A mixed-methods approach was implemented using patient simulation method (n = 28), semi-structured interviews (SSIs) (n = 23), focus group discussions (FGDs) with veterinary practitioners and non-governmental organisation animal health workers (n = 2 FGDs), and participant observation. Fewer than 48 per cent of drug retail outlet workers admitted to having had any formal training in pharmaceuticals at all, while 78 per cent reported having no formal training in animal-related pharmaceuticals. Moreover, 35 per cent of all participants sold antibiotics without a prescription, unprompted and without specifically being asked for antibiotics. Of the antibiotics dispensed, only 21 per cent were correctly dispensed for the symptoms presented, and all dosages dispensed were incorrect (underdosed). Furthermore, 43 per cent of drug retail outlet workers interviewed believe that some antibiotics can be legally dispensed without a prescription. Equine owners in northern India are frequently being sold antibiotics without a prescription and, in most cases, with incorrect diagnoses, treatment choice, and dosage. A substantial gap in capacities exists amongst Drug Retail Outlet (DRO) workers, with few being sufficiently qualified or trained to dispense antibiotics to animal owners. The study highlights the need for further training of private DRO workers as well as knowledge extension and awareness training for both DRO workers and animal owners regarding antimicrobial resistance and its potential impact upon livelihoods. It also illustrates the need to identify a balance whereby greater enforcement of regulation at all levels is implemented, while at the same time maintaining sufficient access to medicine for rural populations.

‘Don’t Put the Cart before the Mule!’ Challenging Assumptions Regarding Health-Related Treatment Practices of Working Equid Owners in Northern India

“…Thus, home remedies witnessed to be effective can hold higher value than an allopathic treatment deemed to have zero or a negative effect. The latter is further compounded by animal healthcare practitioners operating illegally with little to no formal training, as well as by poor advice delivered by individuals working in veterinary drug retail outlets [ 14 ].…”

“…The methodology also utilised the EARS tool [8] to determine whether any indications existed that suggest that variations in health-treatment choices are associated with different welfare outcomes in working equids. This paper emerged from a larger study which examined the role of veterinary drug retail outlets (locally known as medical stores) on equid welfare [14]. Northern India was selected as a fieldwork site due to the prevalence of working equids in the region, where donkeys and mules are commonly used for work in both brick kilns and on construction sites.…”

“…The primary motive is to promote positive patient outcomes for the animals and, consequently, ensure sustainability of livelihood for owners. Secondly, treatment decisions can have implications for wider global health issues, such as antimicrobial resistance [ 13 , 14 ]. Thirdly, such knowledge can inform future intervention strategies to ensure sustainability of practice.…”

Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review

“…The guidelines propose the appropriate dispensing, labelling and record-keeping of the dispensed antimicrobials and other responsibilities of the pharmacists [ 104 ]. Despite their efforts, there were still cases where antimicrobial medications had been dispensed without valid prescription, which was especially prevalent in low- and middle-income countries, where the prescribing regulations were not adequately enforced [ 102 , 105 ]. In such countries, a pharmacist could have a more prominent role in antimicrobial stewardship.…”

“…Especially useful could be the pharmacists’ role as educators, as farmers are often aware of their overuse of antibiotics, or the existence of antimicrobial resistance, but still continue with their practice as they do not know its consequences on public health or alternative methods to prevent diseases [ 96 , 98 , 103 , 106 ]. Another concerning practice was discovered by a study in India where the veterinary antimicrobial medications for working animals were dispensed intentionally in wrong dosages and in higher quantities for financial gain [ 105 ]. Another obstacle in ensuring the proper use of antimicrobial drugs was the pharmacists’ perceived lack of knowledge about veterinary pharmacology, further potentiated by the lack of developed guidelines about antibiotics use in animals [ 91 , 92 ].…”