Knowledge, Attitude and Practice of Pharmacy Professionals Against Dispensing Antibiotics Without Prescription in Ethiopia

Introduction

Antibiotic resistance is a global public health threat that warrants immediate intervention.¹ Dispensing of antibiotics without prescription (DAWP), is a major contributor to the overuse and misuse of antibiotics.^2–5 It has been reported that antimicrobial-resistant agents are common in communities due to non-prescription use of antimicrobials. Multidrug-resistant organisms have been shown to be caused by the inappropriate use of antibiotics, include methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci species, carbapenemase-producing Enterobacteriaceae, and Gram-negative bacteria that produce extended spectrum beta-lactamases becomes prevalent.^3,6–9 To deal with this issue, 68^th world health assembly passed a resolution on World Health Organization recommendations based on the global action plan for antimicrobial resistance, that directs all member states to establish a national strategic plan for the antimicrobial resistance.^5,10,11

Community pharmacies and drug stores are the main sources of antimicrobials, healthcare professionals especially pharmacy professionals, play a major role in DAWP impacted by myriad factors.^3,6,12–14 Accessibility of community pharmacies, customer pressure, time and financial cost, weak regulatory enforcement mechanisms, and patients’ trust in pharmacy professionals are the commonly quoted determinants of DAWP.^{3,6,13,15–18}

Self-medication and DAWP in drug retail outlets is inappropriate practice that can accelerate the emergence and spread of antibiotic resistance.^19,20 According to the World Health Organization latest estimate, the annual worldwide death toll due to antimicrobial resistance can be as high as 50,000.²¹ Although, DAWP in the developed world is minimal,^19,20 the problem is much higher in Africa and other low-income countries.^17,22–24

Accessibility and availability are commonly involved in public health issues, particularly in circumstances with limited resources. About the usage of primary healthcare and its contribution to universal health coverage, detailed and systematic data are scarce in Ethiopia.^25–27 To the best of authors literature review, the knowledge, attitude and practice of DAWP is not studied in Ethiopia, knowing this could help in identifying potential areas that contribute to DAWP. Hence, the current study aimed to assess the knowledge, attitude and practice of community pharmacists and pharmacy assistants towards DAWP, Addis Ababa, Ethiopia.

Methods

Study Design, Period and Setting

A cross-sectional study was carried out among community pharmacists and pharmacy assistants on December 4. 2021 in Addis Ababa, Ethiopia.

Population

Source population of the study were all pharmacists and pharmacy assistants working in community pharmacies or drug stores in Addis Ababa, Ethiopia. Whereas study population included all pharmacists and pharmacy assistants working in community pharmacies or drug stores in Addis Ababa who attended the 8^th National Pharmacist Day on December 4^th, 2021, in Addis Ababa, Ethiopia.

Sampling and Eligibility Criteria

The data was gathered during the eighth national pharmacist’s day, which was held on December 4^th, 2021, in Addis Ababa, Ethiopia, with the theme “Pharmacists Your Medicine Experts and Health Service Front Liners.” The questioner was distributed to all of the pharmacists and pharmacy assistants who attended the conference, and the study included all pharmacy professionals who were willing to participate in the study. Pharmacy professionals with less than 6 months of experience working in community pharmacy were excluded (they work under supervision of the license holders, they hardly provide pharmaceutical services independently).

Data Collection Instrument, Procedure and Quality Assurance

A thorough search of electronic databases was conducted, and relevant studies were reviewed in order to prepare the questionnaire for the current study.^13,28–32 The questionnaire was prepared in English first, then translated into the local language (Amharic), and then back into English to ensure meaning equivalence between the English and Amharic versions. Experts from a pharmacy school of Ambo University assessed the face and content validity of the questioner. The questionnaire had four sections. The first of which deals with the socio demographic characteristics of respondents. Second, third, and fourth sections addressed the knowledge, attitude, and practice of DAWP. For each question, respondents had three options: “yes”, “no”, and “I don’t know.”

Five pharmacists (B.Pharm) were recruited for the data collection and given a two-day training to ensure consistency in their understanding and interpretation of the study instrument, as well as uniform implementation. Prior to the actual data collection, a pre-test on 25 community pharmacists and pharmacy assistants was performed to evaluate the validity of the instrument, the Cronbach’s alpha score was 0.858.

Data Analysis

The collected data was checked for completeness, sorted, and categorized accordingly. Then, the data was entered into SPSS version 26 and mean, percentage, standard deviation were computed to describe the data and tables, and figures were used to summarize the descriptive statistics. To predict the determinants of the practice of DAWP, binary logistic regression was used, with a p-value of <0.05 considered statistically significant.

Results

Socio-Demographic Characteristics

A total of 175 community pharmacists and pharmacy assistants were approached, and 158 of them were voluntary and completed back the survey, giving a response rate of 90.28%. The majority of the study participants were males (62.0%). The mean ±SD age of the study participants was 31.76 ±7.88 years, range from 23–60. More than 2/3^rd (67.1%) of the respondents have 2–5 years’ of experience in the community pharmacy. Nearly one-fourth of study participants (24.1%) employed under chain type of community pharmacies (Table 1).

Table 1 Socio-Demographic Characteristics of Study Participants, Addis Ababa, Ethiopia, (N= 158)

Type of Antibiotics and Indications for DAWP

Penicillin (73.4%) and tetracycline (51.3%) were the most commonly dispensed antibiotics without prescription followed by macrolides (44.9%) (Figure 1).

Figure 1 Types of dispensed antibiotics without prescription, Addis Ababa, Ethiopia, (n= 158).

In terms of medication route, study participants revealed that antibiotics were commonly dispensed via the oral route (88.0%), followed by topical medication (70.3%). The most common reason for DAWP was a common cold (76.6%), followed by diarrheal disease (70.9%) (Table 2).

Table 2 Type of Antibiotics and Indications for Dispensing Antibiotics Without Prescription, Addis Ababa, Ethiopia, (N= 158)

Knowledge Towards DAWP

Almost all respondents were aware that DAWP contribute to the development of antibiotics resistance (151, 95.6%), and that antibiotic resistance is becoming a public health issue (149, 94.3%). Majorities of them predicted the problem with DAWP (147, 93.3%). A higher percentage of respondents recognized that DAWP is a major contributor to the development of inappropriate use of antibiotics by the patients (138, 87.3%), that DAWP is not legal practice in Ethiopia (137, 86.7%), and that pharmacist should stop DAWP (146, 92.4%). Nearly two-thirds of the respondents believe that DAWP is common practice among community pharmacies in Ethiopia (99, 62.6%) (Table 3).

Table 3 Pharmacy Professionals Knowledge Towards Dispensing Antibiotics Without Prescription, Addis Ababa, Ethiopia, (N= 158)

Attitude Towards DAWP

The most common reasons given by study participants for DAWP were that most patients do not want to consult prescribers unless the infection appears serious (84, 53.2%), there are patients who cannot afford to consult a prescriber (83, 52.5%), regulatory agencies have poor control mechanisms (82, 51.9%), and increased pressure from owners to maximize profit margins (75, 47.5%) (Table 4).

Table 4 Attitude Towards Dispensing Antibiotics Without Prescription of Study Participants, Addis Ababa, Ethiopia, (N= 158)

Practice Towards DAWP

In this study, the extent of DAWP was found to be 67.7%. Close to one-third (48, 30.4%) of the respondents disclosed that they never ask clients about allergic history prior to DAWP. More than one third (61, 38.6%) of the pharmacy professionals responded they never educate patients or care givers about adherence and the importance of completing the full course of treatment. Almost one-quarter (35, 22.2%) of the respondents admitted they always DAWP (Table 5).

Table 5 Practice of Pharmacy Professionals Towards DAWP Prescription, Addis Ababa, Ethiopia, (N= 158)

Predictive Factors Associated with DAWP

A binary logistic regression was used to determine whether there is a significant relationship between socio-demographic characteristics and community pharmacists’ practice of DAWP. Study participants, with educational background of masters and above were had a 64.6% of lower tendency to DAWP (AOR= 0.354, 95% CI: 0.013–0.744, P= 0.045). Compared to pharmacy professionals employed by independent community pharmacies, those employed by government hospitals had an 86.7% lower risk DAWP (AOR= 0.133, 95% CI: 0.024–0.725, P= 0.020). Pharmacy professionals with two to five years of community pharmacy experience had a 25.5% lower likelihood of DAWP (AOR= 0.745, 95% CI: 0.595–0.933, P= 0.010) (Table 6).

Table 6 Predictive Factors Associated with DAWP

Discussion

The aim of this study was to determine community pharmacists’ and pharmacy assistant’s knowledge, attitudes, and practices regarding DAWP. The study found that DAWP is a common practice in Addis Ababa community pharmacies and drug stores. DAWP is an inappropriate practice that contributes significantly to antibiotic overuse and misuse. This unregulated non-prescription antibiotic access has been identified as a major contributor to the emergence of antimicrobial resistance as well as a variety of negative health outcomes.^31,33

The three most often DAWP were penicillin’s (73.4%), tetracycline’s (51.3%), and macrolides (44.9%). Contrary to this, an Eritrean study using a simulated client visit methodology found that the most frequently DAWP was ciprofloxacin.⁵ Similarly, a Pakistani study found that two of the most frequently DAWP were ciprofloxacin and azithromycin.²⁰ The observed discrepancy may be caused by variations in the sample size, methodological approach and available and reasonably priced of medications for the larger community.

In the current study, the most common reason for DAWP was common cold (76.6%), followed by diarrheal disease (70.9%). A recent systematic review showed that the most common indications stated by study participants for DAWP were upper respiratory disease and diarrheal disease.³⁴ However, most upper respiratory tract infections, including the common cold and non-dysentery type of diarrhea, are caused by viruses, are typically self-limiting, and merely call for symptomatic and/or fluid balance care.

The majority of study participants (86.7%) were aware that DAWP is illegal in Ethiopia. This finding was much higher than in a Saudi Arabian study, where more than two-thirds of community pharmacists were unaware that DAWP was illegal.²⁸ This discrepancy might be brought on by a new Saudi Arabian rule from 2018 that prohibited the retail sale of antibiotics without a prescription in neighborhood pharmacies. Despite the fact that most of study participants were more aware of that giving out antibiotics without a prescription is prohibited in Ethiopia, the practice is common, suggesting that the laws already in place must be strictly followed.

The study found that only 4.4% of respondents believed that DAWP could not contribute to the development of antibiotic resistance. The finding was in line with a qualitative study from Iraq found that community pharmacists lacked knowledge about antibiotic resistance and were unaware of antibiotic stewardship, which led to the DAWP.³⁵ Antibiotic resistance is a public health issue, according to the majority of survey participants 149 (94.3%), however pharmacy professionals’ DAWP while knowing about its effects could be the result of negligence, financial gain, or insufficient regulatory and enforcement action.

The most common reasons given for DAWP were a lack of willingness to consult a physician unless the infection appeared to be too serious, a lack of control mechanisms from regulatory agencies, and the consumers’ economic status; this finding was consistent with other studies.^28,35,36 To effectively address the issue of DAWP in Ethiopia, a multidimensional approach is required, and national regulations governing the sale of antibiotics must be strictly enforced.

The extent of DAWP was found to be 67.7% in this study, which is lower than the majority of previous studies. The magnitude of DAWP in previous studies ranges between 69.0% and 90.5%.^{5,20,24,34,37} This variation could be attributed to the type of study design used, as most of the above studies used a client simulated visit. When asked if they ever inquired about their customers’ allergy histories before DAWP, 30.4% said they never did. According to a Pakistani study, only 4.2% of staff members ask for information about allergic history before dispensing antibiotic.²⁰ Such malpractices have the potential to resulted far-reaching health-care consequences, as well as to erode public trust in the health care system.

Participants in the study with a master’s degree or higher, pharmacy professionals working in government health facilities, and professionals with 2–5 years of work experience had a lower rate of DAWP compared to their counterparts, these findings were supported by Eritrean and Saudi Arabian studies.^28,36

This study is the first of its type to evaluate pharmacy professionals’ knowledge, attitudes, and practices about DAWP in Ethiopia, and the study could be used as an input for future study. There were a few limitations to this study, 1; most of participants were drawn from the country’s capital city, which had a better demographic and socioeconomic profile. As a result, our findings may not be generalizable throughout the country. 2; self-administered questionnaires, such as the one used in this study, are prone to social desirability bias.

Conclusion

Despite the majority of community pharmacy professional are aware that DAWP is illegal and contributes to antibiotic resistance, they commonly DAWP for common cold and diarrheal diseases. Pressure from patients, poor controlling mechanism from regulatory side and unaffordability of clients/patients to visit prescribers are the major reasons for DAWP. This study recommends strict enforcement of existing antibiotic supply policies, as well as ongoing educational support for community pharmacy professionals on the judicious use of antibiotics and the importance of antimicrobial stewardship.