Barriers and facilitators to adherence to national drug policies on antibiotic prescribing and dispensing in Bangladesh

Background The National Drug Policy in Bangladesh prohibits the sale and distribution of antibiotics without prescription from a registered physician. Compliance with this policy is poor; prescribing antibiotics by unqualified practitioners is common and over-the-counter dispensing widespread. In Bangladesh, unqualified practitioners such as drug shop operators are a major source of healthcare for the poor and disadvantaged. This paper reports on policy awareness among drug shop operators and their customers and identifies current dispensing practices, barriers and facilitators to policy adherence. Methods We conducted a qualitative study in rural and urban Bangladesh from June 2019 to August 2020. This included co-design workshops (n = 4) and in-depth interviews (n = 24) with drug shop operators and customers/household members, key informant interviews (n = 12) with key personnel involved in aspects of the antibiotic supply chain including pharmaceutical company representatives, and model drug shop operators; and a group discussion with stakeholders representing key actors in informal market systems namely: representatives from the government, private sector, not-for-profit sector and membership organizations. Results Barriers to policy compliance among drug shop operators included limited knowledge of government drug policies, or the government-led Bangladesh Pharmacy Model Initiative (BPMI), a national guideline piloted to regulate drug sales. Drug shop operators had no clear knowledge of different antibiotic generations, how and for what diseases antibiotics work contributing to inappropriate antibiotic dispensing. Nonetheless, drug shop operators wanted the right to prescribe antibiotics based on having completed related training. Drug shop customers cited poor healthcare facilities and inadequate numbers of attending physician as a barrier to obtaining prescriptions and they described difficulties differentiating between qualified and unqualified providers. Conclusion Awareness of the National Drug Policy and the BPMI was limited among urban and rural drug shop operators. Poor antibiotic prescribing practice is additionally hampered by a shortage of qualified physicians; cultural and economic barriers to accessing qualified physicians, and poor implementation of regulations. Increasing qualified physician access and increasing training and certification of drug shop operators could improve the alignment of practices with national policy.

Drug Shop Intervention to Enhance Knowledge, Attitude, and Practices of Patent Medicine Vendors for the Control of COVID-19 In Southeastern Nigeria

Drug shops are the first point of care for most community members in low-resource countries. Because of symptomatic similarities with common illnesses such as malaria, probable coronavirus disease 2019 (COVID-19) cases may seek care at drug shops, where the knowledge and skills required to handle it may be lacking, thereby fostering community spread of the disease. This single-arm study provided an intervention to improve COVID-19-related knowledge, attitude, and practices of patent medicine vendors (PMVs) in 97 participating drug shops selected through cluster sampling in Owerri, southeastern Nigeria. The intervention involved a drug shop sensitization using information, education, and communication material, as well as training on the use of a risk assessment checklist to identify probable COVID-19 cases and to take appropriate action. Data were collected to determine the effect of this intervention using a pre-tested questionnaire and practice observation checklist, first at baseline and then 3 months post-intervention. Data analysis involved exploratory analysis and the t-test to determine pre- and post-intervention mean score differences at the 5% α level. There was post-intervention knowledge improvement on the COVID-19 causative pathogen (98.1% post-intervention versus 61.9% pre-intervention) and disease transmissibility from person to person (95.9% post-intervention versus 81.4% pre-intervention) among other knowledge domains. There was significant post-intervention improvement for positive attitude, with a mean gain score of 2.8 ± 1.7 (t = 4.4, P = 0.005), and preventive practices, with a mean gain score of 6.0 ± 4.7 (t = 4.1, P = 0.007). Engaging patent medicine vendors in the pandemic response plans through targeted interventions such as drug shop intervention could prove vital in the fight against COVID-19.

Motivating antibiotic stewardship in Bangladesh: identifying audiences and target behaviours using the behaviour change wheel

Background South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics. Methods We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings. Results Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course. Conclusions We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Unsafe “crossover-use” of chloramphenicol in Uganda: importance of a One Health approach in antimicrobial resistance policy and regulatory action

Since the introduction of antibiotics into mainstream health care, resistance to these drugs has become a widespread issue that continues to increase worldwide. Policy decisions to mitigate the development of antimicrobial resistance are hampered by the current lack of surveillance data on antibiotic product availability and use in low-income countries. This study collected data on the antibiotics stocked in human (42) and veterinary (21) drug shops in five sub-counties in Luwero district of Uganda. Focus group discussions with drug shop vendors were also employed to explore antibiotic use practices in the community. Focus group participants reported that farmers used human-intended antibiotics for their livestock, and community members obtain animal-intended antibiotics for their own personal human use. Specifically, chloramphenicol products licensed for human use were being administered to Ugandan poultry. Human consumption of chloramphenicol residues through local animal products represents a serious public health concern. By limiting the health sector scope of antimicrobial resistance research to either human or animal antibiotic use, results can falsely inform policy and intervention strategies. Therefore, a One Health approach is required to understand the wider impact of community antibiotic use and improve overall effectiveness of intervention policy and regulatory action.

Motivating antibiotic stewardship in Bangladesh: Identifying audiences and target behaviours using the Behaviour Change Wheel

Background: South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals, a lack of compliance with policy among healthcare providers, high population density and high infectious disease burden. This paper describes development of social and behavioural change communication (SBCC) to increase appropriate use of antibiotics. Methods: We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) qualified physicians and 4) pharmaceutical companies/medical representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, to prioritize audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings. Results: Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritized as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change; suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek qualified physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, several antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions; referring them to qualified physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course. Conclusions: We prioritized drug shops for intervention delivery to drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and should address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Regulatory inspection of registered private drug shops in East-Central Uganda—what it is versus what it should be: a qualitative study

Background Regulatory inspection of private drug shops in Uganda is a mandate of the Ministry of Health carried out by the National Drug Authority. This study evaluated how this mandate is being carried out at national, district, and drug shop levels. Specifically, perspectives on how the inspection is done, who does it, and challenges faced were sought from inspectors and drug sellers. Methods Six key informant interviews (KIIs) were held with inspectors at the national and district level, while eight focus group discussions (FGDs) were conducted among nursing assistants, and two FGDs were held with nurses. The study appraised current methods of inspecting drug sellers against national professional guidelines for licensing and renewal of class C drug shops in Uganda. Transcripts were managed using Atlas ti version 7 (ATLAS.ti GmbH, Berlin) data management software where the thematic content analysis was done. Results Five themes emerged from the study: authoritarian inspection, delegated inspection, licensing, training, and bribes. Under authoritarian inspection, drug sellers decried the high handedness used by inspectors when found with expired or no license at all. For delegated inspection, drug sellers said that sometimes, inspectors send health assistants and sub-county chiefs for inspection visits. This cadre of people is not recognized by law as inspectors. Inspectors trained drug sellers on how to organize their drug shops better and how to use new technologies such as rapid diagnostic tests (RDTs) in diagnosing malaria. Bribes were talked about mostly by nursing assistants who purported that inspectors were not interested in inspection per se but collecting illicit payments from them. Inspectors said that the facilitation they received from the central government were inadequate for a routine inspection. Conclusion The current method of inspecting drug sellers is harsh and instills fear among drug sellers. There is a need to establish a well-recognized structure of inspection as well as establish channels of dialogue between inspectors and drug sellers if meaningful compliance is to be achieved. The government also needs to enhance both human and financial resources if meaningful inspection of drug sellers is to take place.

Peer supervision experiences of drug sellers in a rural district in East-Central Uganda: a qualitative study

Background Support supervision improves performance outcomes among health workers. However, the national professional guidelines for new licenses and renewal for class C drug shops in Uganda prescribe self-supervision of licensed private drug sellers. As such, inappropriate treatment of malaria, pneumonia and diarrhoea among children under five years of age continues unabated. This study assessed experiences of drug sellers and peer supervisors at the end of a peer supervision intervention in Luuka district in East Central Uganda. Methods Eight in-depth interviews (IDIs) were held with peer supervisors while five focus group discussions (FGDs) were conducted among registered drug sellers at the end of the peer supervision intervention. The study assessed experiences and challenges of peer supervisors and drug sellers regarding peer supervision. Transcripts were imported into Atlas ti 7 qualitative data management software (ATLAS.ti GmbH, Berlin) where they were analysed using qualitative thematic content analysis. Results Initially, peer supervisors were disliked and regarded as another extension of drug inspectors by drug sellers. However, with time a good relationship was established between drug sellers and peer supervisors leading to regular, predictable and supportive peer supervision. This increased confidence of drug sellers in using respiratory timers and rapid diagnostic tests in diagnosing pneumonia symptoms and uncomplicated malaria respectively among children under five years. There was also an improvement in completing the sick child register which was used for self-assessment by drug sellers. The drug shop association was mentioned as a place where peer supervision should be anchored since it was a one-stop center for sharing experiences and continuous professional development. Drug sellers proposed including community health workers in monthly drug shop association meetings so that they may also gain from the associated benefits. Untimely completion of the sick child registers by drug sellers and lack of adequate resources were the main peer supervision challenges mentioned. Conclusion Drug sellers benefitted from peer supervision by developing a good relationship with peer supervisors. This relationship guaranteed reliable and predictable supervision ultimately leading to improved treatment practices. There is need to explore the bare minimum resources needed for peer supervision.

Dangerous Drugs

In the 17th century, the Dutch Republic was the centre of the world trade in exotic drugs and spices. They were sought after both as medicines, and as luxury objects for the bourgeois class, giving rise to a medical and moral anxiety in the Republic. This ambivalent view on exotic drugs is the theme of the poetry of Joannes Six van Chandelier (1620-1695). Six, who himself ran the drug shop ‘The Gilded Unicorn’ in Amsterdam, addresses a number of exotic medicines in his poems, such as musk, incense, the miracle drug theriac, Egyptian mumia, and even the blood of Charles I of England. In Dangerous Drugs, these texts are studied for the first time. The study shows how Six, through a process of self-presentation as a sober and restrained merchant, but also as a penitent sinner, thirsting for God’s grace, links early modern drug abuse to different desires, such as lust, avarice, pride and curiosity. The book shows also how an early modern debate on exotic drugs contributed to an important shift in early modern natural science, from a drug lore based on mythical and fabulous concepts, to a botany based on observation and systematic examination.

Dangerous Drugs

In the 17th century, the Dutch Republic was the centre of the world trade in exotic drugs and spices. They were sought after both as medicines, and as luxury objects for the bourgeois class, giving rise to a medical and moral anxiety in the Republic. This ambivalent view on exotic drugs is the theme of the poetry of Joannes Six van Chandelier (1620-1695). Six, who himself ran the drug shop ‘The Gilded Unicorn’ in Amsterdam, addresses a number of exotic medicines in his poems, such as musk, incense, the miracle drug theriac, Egyptian mumia, and even the blood of Charles I of England. In Dangerous Drugs, these texts are studied for the first time. The study shows how Six, through a process of self-presentation as a sober and restrained merchant, but also as a penitent sinner, thirsting for God’s grace, links early modern drug abuse to different desires, such as lust, avarice, pride and curiosity. The book shows also how an early modern debate on exotic drugs contributed to an important shift in early modern natural science, from a drug lore based on mythical and fabulous concepts, to a botany based on observation and systematic examination.

Peer supervision experiences of drug sellers in a rural district in East-Central Uganda: a qualitative study

BackgroundSupport supervision improves performance outcomes among health workers. However, the national professional guidelines for new licenses and renewal for class C drug shops in Uganda prescribe self-supervision of licensed private drug sellers.As such, inappropriate treatment of malaria, pneumonia and diarrhoea among children under five years of age continues unabated. This study assessed experiences of drug sellers and peer supervisors at the end of a peer supervision intervention in Luuka district in East Central Uganda.MethodsEightin-depth interviews (IDIs) were held with peer supervisors while five focus group discussions (FGDs) were conducted among registered drug sellersat the end of the peer supervision intervention. The study assessed experiences and challenges of peer supervisors and drug sellers regarding peer supervision.Transcripts were imported into Atlas ti 7 qualitative data management software (ATLAS.ti GmbH, Berlin) where they were analysedusing thematic content analysis.ResultsInitially, peer supervisors were disliked and regarded as another extension of drug inspectors by drug sellers. However, with time a good relationship was established between drug sellers and peer supervisors leading to regular, predictable and supportive peer supervision. This increased confidence of drug sellers in using respiratory timers and rapid diagnostic tests in diagnosing pneumonia symptoms and uncomplicated malaria respectively among children under five years. There was also an improvement in completing the sick child register which was used for self-assessment by drug sellers. The drug shop association was mentioned as a place where peer supervision should be anchored since it was a one-stop center for sharing experiences and continuous professional development. Drug sellers proposed including community health workers in monthly drug shop association meetings so that they mayalso gain from the associated benefits. Untimely completion of the sick child registers by drug sellers and inadequate financial resources were the main peer supervision challenges mentioned.ConclusionDrug sellers benefitted from peer supervision by developing a good relationship with peer supervisors.This relationship guaranteed reliable and predictable supervision ultimately leading to improved treatment practices.There is need to explore the minimum resources needed for peer supervision of drug sellers to further inform practice and policy.