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What influences antibiotic sales in rural Bangladesh? A drug dispensers' perspective.

ABSTRACT: Background:Antibiotic resistance poses a great threat to global health, especially in low- and middle-income countries with a high infectious disease burden and limited resources. In spite of regulations, antibiotics are sold in many settings as non-prescription medicines, resulting in inappropriate use and resistance. Objective:This study aimed to investigate the current status of access and use of antibiotics in rural Bangladesh, by exploring the perspectives and sales practices of antibiotic drug dispensers. Methods:We used a mixed methods approach (qualitative and quantitative). We mapped and characterized antibiotic purchasing and dispensing sites in the Matlab Health and Demographic Surveillance System catchment area. Furthermore, we investigated the volume of provision of systemic antibiotics in 10 drug outlets. We held 16 in-depth interviews with randomly selected antibiotics dispensers. Interviews explored factors associated with antibiotic selling. Responses were transcribed, coded for themes, and summarized. We used ATLAS.ti 5.2 for conducting a thematic analysis. Results:A total of 301 antibiotic dispensers were identified, of whom 92% (n?=?278) were private and 8% (n?=?23) public. 52% (n?=?155) operated informally (i.e. without legal authorization). In order to promote and survive in their business, dispensers sell antibiotics for a range of conditions without a qualified physician's prescription. Factors that facilitate these inappropriate sales include lack of access to healthcare in the rural community, inadequate doctor: population ratio, limited dispenser knowledge, poor pharmacovigilance concerning safety of self medication, lack of enforcement of policies, financial benefits for both customers and dispensers, and high dependency on pharmaceutical companies' information. Conclusion:Dispensers in rural Bangladesh sell antibiotics inappropriately by ignoring existing national regulations. They operate the antibiotic sales without facing any legal barriers and primarily with a view to sustain their business, resulting in inappropriate sales of antibiotics to the rural community. The influence of the drug industry needs to be replaced with evidence-based, not commercially driven information. Awareness programs for antibiotic providers that promote understanding of antibiotics and antibiotic resistance through tailored interventions may be helpful in changing current antibiotic sales practices.

SUBMITTER: Matin MA

PROVIDER: S-EPMC7268404 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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What influences antibiotic sales in rural Bangladesh? A drug dispensers' perspective.

Matin Mohammad Abdul MA Khan Wasif Ali WA Karim Mohammad Mahbubul MM Ahmed Sabeena S John-Langba Johannes J Sankoh Osman A OA Gyapong Margaret M Kinsman John J Wertheim Heiman H

Journal of pharmaceutical policy and practice 20200603

<h4>Background</h4>Antibiotic resistance poses a great threat to global health, especially in low- and middle-income countries with a high infectious disease burden and limited resources. In spite of regulations, antibiotics are sold in many settings as non-prescription medicines, resulting in inappropriate use and resistance.<h4>Objective</h4>This study aimed to investigate the current status of access and use of antibiotics in rural Bangladesh, by exploring the perspectives and sales practices ...[more]

PMID: 32514362

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Project description:Background: Training improves dispensing behavior of drug dispensers in low- and middle-income countries. Between 2018 and 2020, a total of 5,059 Grade C pharmacists, who completed a 3-month training course for availing a "Grade C pharmacist certificate" were trained on Good Pharmacy Practice (GPP) in 11 districts in Bangladesh by Management Sciences for Health (MSH) under Better Health in Bangladesh (BHB) project. We assessed the impact of GPP among trained Grade C pharmacists under the BHB project compared to those who did not receive GPP training under the BHB project (non-trained), and explored the major challenges towards achieving GPP. Methods: We created a database of trained Grade C pharmacists provided by MSH and randomly selected the trained Grade C pharmacists for recruitment following consent. We created another database of the non-trained Grade C pharmacist who were deployed within a 1-km radius of a trained Grade C pharmacist, and randomly recruited one non-trained against one trained Grade C pharmacist. A semi structured questionnaire was administered to obtain information about knowledge of GPP, including guidelines of dispensing medicines, temperature maintenance, medicine storage, counseling customers and labeling medicines. Dispensing behavior was directly observed following a structured tool. Chi-square test (for categorical variables) and independent sample t-tests (for continuous variables) were applied for comparison between the trained and the non-trained Grade C pharmacists. A logistic regression model was applied to explore an association between knowledge and practice between the two groups. Results: Between February and March 2021, 220 trained and 220 non-trained Grade C pharmacists were recruited. Mean age (SD) of the participants was 41 years (10.5) and 98.4% were male. Compared to the non-trained, the trained Grade C pharmacists had better knowledge about the guidelines of dispensing medicines (97.7% vs 89.5%, p < 0.001), temperature maintenance (91.8% vs 45.5%, p = 0.001), medicine storage (92.3% vs 40.5%, p = 0.001) counseling customers (99.5% vs 92.3%, p < .001) and labeling medicines (91.0% vs 80%, p < 0.001). General dispensing behavior was observed to be better among the trained than the non-trained with labeling of medicines (63.2% vs 53.4%, p = 0.038), counseling customers (39.1% vs 28.6%, p = 0.021) and using a room thermometer for maintaining ambient temperature in the medicine shops (56.8% vs26.8%, p < 0.001). Bad behavior of the customers (39.5%) and lack of GPP knowledge among Grade C pharmacists (28.6%) were recognized to be challenges towards achieving GPP in Bangladesh. Conclusion: Training led to better knowledge and practices about dispensing medicines among Grade C pharmacists in Bangladesh. Periodic training may promote achieving GPP in Bangladesh.

Project description:BackgroundThe irrational overuse of antibiotics should be minimized as it drives the development of antibiotic resistance, but changing these practices is challenging. A better understanding is needed of practices and economic incentives for antibiotic dispensing in order to design effective interventions to reduce inappropriate antibiotic use. Here we report on both quantitative and qualitative aspects of antibiotic sales in private pharmacies in northern Vietnam.MethodA cross-sectional study was conducted in which all drug sales were observed and recorded for three consecutive days at thirty private pharmacies, 15 urban and 15 rural, in the Hanoi region in 2010. The proportion of antibiotics to total drug sales was assessed and the revenue was calculated for rural and urban settings. Pharmacists and drug sellers were interviewed by a semi-structured questionnaire and in-depth interviews to understand the incentive structure of antibiotic dispensing.ResultsIn total 2953 drug sale transactions (2083 urban and 870 rural) were observed. Antibiotics contributed 24% and 18% to the total revenue of pharmacies in urban and rural, respectively. Most antibiotics were sold without a prescription: 88% in urban and 91% in rural pharmacies. The most frequent reported reason for buying antibiotics was cough in the urban setting (32%) and fever in the rural area (22%). Consumers commonly requested antibiotics without having a prescription: 50% in urban and 28% in rural area. The qualitative data revealed that drug sellers and customer's knowledge of antibiotics and antibiotic resistance were low, particularly in rural area.ConclusionOver the counter sales of antibiotic without a prescription remains a major problem in Vietnam. Suggested areas of improvement are enforcement of regulations and pricing policies and educational programs to increase the knowledge of drug sellers as well as to increase community awareness to reduce demand-side pressure for drug sellers to dispense antibiotics inappropriately.

Project description:IntroductionFew studies have reported antibiotic purchases from retail drug shops in relation to gender in low and middle-income countries (LMICs). Using a One Health approach, we aimed to examine gender dimensions of antibiotic purchases for humans and animals and use of prescriptions in retail drug shops in Bangladesh.MethodsWe conducted customer observations in 20 drug shops in one rural and one urban area. Customer gender, antibiotic purchases, and prescription use were recorded during a four-hour observation (2 sessions of 2 hours) in each shop. We included drug shops selling human medicine (n = 15); animal medicine (n = 3), and shops selling both human and animal medicine (n = 2).ResultsOf 582 observations, 31.6% of drug shop customers were women. Women comprised almost half of customers (47.1%) in urban drug shops but only 17.2% of customers in rural drug shops (p < 0.001). Antibiotic purchases were more common in urban than rural shops (21.6% versus 12.2% of all transactions, p = 0.003). Only a quarter (26.0%) of customers who purchased antibiotics used a prescription. Prescription use for antibiotics was more likely among women than men (odds ratio (OR) = 4.04, 95% CI 1.55, 10.55) and more likely among urban compared to rural customers (OR = 4.31 95% CI 1.34, 13.84). After adjusting for urban-rural locality, women remained more likely to use a prescription than men (adjusted OR = 3.38, 95% CI 1.26, 9.09) but this was in part due to antibiotics bought by men for animals without prescription. Customers in drug shops selling animal medicine had the lowest use of prescriptions for antibiotics (4.8% of antibiotic purchases).ConclusionThis study found that nearly three-quarters of all antibiotics sold were without prescription, including antibiotics on the list of critically important antimicrobials for human medicine. Men attending drug shops were more likely to purchase antibiotics without a prescription compared to women, while women customers were underrepresented in rural drug shops. Antibiotic stewardship initiatives in the community need to consider gender and urban-rural dimensions of drug shop uptake and prescription use for antibiotics in both human and animal medicine. Such initiatives could strengthen National Action Plans.

Project description:BackgroundAlcohol outlets have been associated with various forms of injury and may contribute to neighborhood disparities in drug overdose. Few studies have examined the associations between alcohol outlets and drug overdose. This study investigated whether alcohol outlets were associated with the neighborhood drug overdose rate and whether the sale of drug paraphernalia contributes to this association.MethodsA cross-sectional ecological spatial analysis was conducted within census block groups in Baltimore City (n = 653). Outcomes were counts of EMS calls for any drug overdose in 2015 (n = 3,856). Exposures of interest were counts of alcohol outlets licensed for off-premise and on-premise consumption and the proportion of off-premise outlets selling drug paraphernalia (e.g., blunt wrappers, baggies, pipes). Negative binomial regression was used to assess the relationship between outlet count and overdose rate, and if paraphernalia sales altered this relationship, controlling for other neighborhood factors. Spatial autocorrelation was assessed and regression inference adjusted accordingly.ResultsEach additional off-premise alcohol outlet was associated with a 16.6% increase in the neighborhood overdose rate (IRR=1.17, 95%CI=(1.11, 1.23)), adjusted for other neighborhood variables. On-premise alcohol outlets were not significantly associated with overdose rate when adjusting for off-premise alcohol outlets (IRR=1.01, 95% CI=(0.97, 1.06)). The proportion of off-premise outlets that sold drug paraphernalia was negatively associated with overdose rate (IRR=0.55, 95% CI=(0.41, 0.74)) and did not alter the relationship between off-premise outlets and overdose.ConclusionThis study provides preliminary public health evidence for informing policy decisions about alcohol outlet licensing and zoning. Alcohol outlets could be potential community partners for harm reduction strategies such as health communication in identifying overdose symptoms or Good Samaritan Laws.

Project description:BackgroundAlthough prompt, effective treatment is a cornerstone of malaria control, information on provider adherence to malaria in pregnancy (MIP) treatment guidelines is limited. Incorrect or sub-optimal treatment can adversely affect the mother and fetus. This study assessed provider knowledge of and adherence to national case management guidelines for uncomplicated MIP.MethodsWe conducted a cross-sectional study from September to November 2013, in 51 health facilities (HF) and a randomly-selected sample of 39 drug outlets (DO) in the KEMRI/CDC Health and Demographic Surveillance System area in western Kenya. Provider knowledge of national treatment guidelines was assessed with standardized questionnaires. Correct practice required adequate diagnosis, pregnancy assessment, and treatment with correct drug and dosage. In HF, we conducted exit interviews in all women of childbearing age assessed for fever. In DO, simulated clients posing as first trimester pregnant women or as relatives of third trimester pregnant women collected standardized information.ResultsCorrect MIP case management knowledge and practice were observed in 45% and 31% of HF and 0% and 3% of DO encounters, respectively. The correct drug and dosage for pregnancy trimester was prescribed in 62% of HF and 42% of DO encounters; correct prescription occurred less often in first than in second/ third trimesters (HF: 24% vs. 65%, p<0.01; DO: 0% vs. 40%, p<0.01). Sulfadoxine-pyrimethamine, which is not recommended for malaria treatment, was prescribed in 3% of HF and 18% of DO encounters. Exposure to artemether-lumefantrine in first trimester, which is contraindicated, occurred in 29% and 49% of HF and DO encounters, respectively.ConclusionThis study highlights knowledge inadequacies and incorrect prescribing practices in the treatment of MIP. Particularly concerning is the prescription of contraindicated medications in the first trimester. These issues should be addressed through comprehensive trainings and increased supportive supervision. Additional innovative means to improve care should be explored.

Project description:The purpose of this paper is to analyse the global Sales and Operations Planning (S&OP) process and investigate the steps to support consolidated business planning in worldwide operations and large-scale supply chains. The paper conducts a case study at a multinational manufacturing company applying an abductive approach. It combines the deductive logic from theory and the inductive logic from field observation in an attempt to elaborate further on theory on global S&OP. The analysis is structured and guided by a novel framework for global S&OP, which is developed based on the theoretical background and the case study findings. The research findings characterise the S&OP process for global operations and identify challenges related to the need to synchronise the subsidiaries' S&OP efforts worldwide to deal with different contingencies of these subsidiaries, and to manage and analyse a large amount of information gathered. The research reveals how the subsidiaries' performance is analysed by top executives along the global S&OP process, feeding strategic initiatives in the organisation and identifying business opportunities like benchmarking among subsidiaries, synergies with other management practices, and global gains. This paper offers a novel investigation of the global steps on S&OP in a real-life setting, offering a well-documented characterisation of the process that goes beyond the traditional local approach. Moreover, it is the first study to reveal challenges and expected outcomes of such a global perspective for S&OP. The theoretical advancements of S&OP research offered herein aid scholars, opening avenues for middle-range theorising, highlighting the cross-disciplinary nature of the domain, and discussing the use of concepts from related disciplines like Economics, Psychology, and Information Systems. The research findings can also assist executives, especially from multinational manufacturers, in their efforts to consolidate global planning.

Dataset Information

What influences antibiotic sales in rural Bangladesh? A drug dispensers' perspective.

Publications

What influences antibiotic sales in rural Bangladesh? A drug dispensers' perspective.

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