What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India

Abstract

ObjectivesThere are only 0.70 licensed physicians per 1000 people in India. Thus, pharmacies are a primary source of healthcare and patients often seek their services directly, especially in village settings. However, there is wide variability in a pharmacy employee's training, which contributes to inappropriate antibiotic dispensing and misuse. These practices increase the risk of antibiotic resistance and poor patient outcomes. This study seeks to better understand the factors that drive inappropriate antibiotic dispensing among pharmacy employees in India's village communities.DesignWe conducted a mixed-methods study of the antibiotic dispensing practices, including semistructured interviews and a pilot cross-sectional Knowledge, Attitudes and Practice survey. All data were transcribed, translated from Hindi into English, and coded for themes.SettingCommunity pharmacies in villages in Haryana, India.ParticipantsWe recruited 24 community pharmacy employees (all male) by convenience sampling. Participants have a range of characteristics regarding village location, monthly income, baseline antibiotic knowledge, formal education and licensure.Results75% of pharmacy employees in our study were unlicensed practitioners, and the majority had very limited understanding of antibiotic resistance. Furthermore, only half could correctly define the term antibiotics. All reported that at times they dispensed antibiotics without a prescription. This practice was more common when treating patients who had limited access to a licensed physician because of economic or logistic reasons. Many pharmacy workers also felt pressure to provide shortened medication courses to poorer clientele, and often dispensed only 1 or 2 days' worth of antibiotics. Such patients rarely returned to the pharmacy for the complete course.ConclusionsThis study highlights the need for short-term, intensive training programmes on antibiotic prescribing and resistance that can be disseminated to village pharmacies. Programme development should take into account the realities of working with poor clientele, especially in areas of limited healthcare access.

Are pharmacists’ good knowledge and awareness on antibiotics taken for granted? The situation in Albania and future implications across countries

“…This compares favourably with Eslami et al where 86% of pharmacists in Iran gave correct responses when URTIs persist after 10 to 14 days and more than half believed most are viral in origin (6). However, an appreciable improvement when compared with pharmacists in India who had very limited understanding of AMR (14) and favourably with Vietnam where in only 36% of occasions did pharmacists provide advice on the management of ARIs in children in accordance with national guidelines (29), and generally drug sellers' knowledge of antibiotics and AMR was low (10). Similar concerns were also seen in China (3).…”

“…Encouragingly, a high percentage of pharmacists stated they should not dispense an antibiotic without a prescription (Table 3), comparing favourably with other similar countries (3,7,14,16,29) However, there were concerns with a third of respondents admitted selling even just 3 co-amoxiclav tablets.…”

“…These include:  Initiate campaigns to sensitize patients on the optimal use of antibiotics as well as educate them that ARIs are mainly viral in origin, similar to other countries (2,4). This is particularly important for patients with lower and middle education as they are the most likely to try and self purchase antibiotics (12,14,16,26). This year for the first time in Albania (2016/ 2017), a small campaign targeting pharmacists and patients has been undertaken in community pharmacies, including a poster with advice on how to use and dispense antibiotics  Evaluating the impact of the current campaign targeting pharmacists and patients in Albania to guide future initiatives  Appraising the content of current educational programmes among pharmacy students, as well as among community pharmacists in Albania to address information gaps highlighted in our study  Develop treatment protocols with key stakeholder groups surrounding the optimal management of community infections  Greater enforcement of the legislation regarding illegal selling of antibiotics without a prescription (3,9,11).…”

“…Consequently, reducing inappropriate self-purchasing, which is common in many parts of the world (1,3,(5)(6)(7)(8)(9)(10)(11)(12)(13), is essential to reduce AMR rates. There are particular issues in low and middle income countries where access to medical care can be limited, difficult to access and costly, and there can be concerns with physician trust (3,5,7,14). As a result, encouraging patients to self-medicate or seek help from professionals such as pharmacists, thereby reducing physician fees (3,9,10,15).…”

Pharmacist-led Antimicrobial Stewardship

“…Moreover, pharmacists who are regularly the primary purpose of consideration, administer anti-microbials without a doctor solution, offer elective anti-microbials notwithstanding when patients present with a remedy. Inside the clinics absence of observing of anti-infection use is one of the central point driving the spread of opposition [34]. The execution of antimicrobial stewardship programs in essential social insurance is problematic.…”