Pharmacists’ provision and public’s use of antibiotics for common infections in Sri Lanka

Abstract

Background: Antibiotic resistance (ABR) is a major and complex preventable global problem which transcends international boundaries. It makes infections more difficult to treat or even untreatable as well as contributing to a shrinking range of effective antibiotics available. Transmission of bacteria which are resistant to antibiotics between developed and developing countries is two-way, however it has been rarely explored in developing countries because of inadequate resources. There is evidence suggesting that the emergence and spread of ABR, especially the appearance of multidrug-resistant bacterial strains which are resistant to many antibiotic classes, has raised a major global public health concern, including in Sri Lanka, and has been linked to inappropriate antibiotic supply and use. ABR is also associated with increased morbidity, mortality and treatment costs. It appears that the greatest burden occurs in low and middle-income countries (LMICs) where common infections are higher in rate, particularly diarrhoea, upper respiratory tract infections, and urinary tract infections (UTIs). If no actions are taken, it has been estimated that antimicrobial resistance will lead to 10 million deaths annually by 2050, and a loss of US$100 trillion of the world economic output. Hence, it is important to understand antibiotic supply and use, and factors that contribute to such practices in a country and to develop country specific interventions to promote appropriate practices. Currently, there is a scarcity of research in this area, particularly in LMICs, and none has been conducted in Sri Lanka. Factors which contribute to inappropriate provision and use of antibiotics may be geographically linked and influenced by human behaviour, health literacy, economy, and legislation. Thus, findings in one geographic location may not be generalisable to other areas. Hence, it is imperative to generate local data in order to plan effective country and region-specific interventions. xxi The overall aims of this thesis were to (i) evaluate the supply of antibiotics without a prescription by Sri Lankan community pharmacy staff; their knowledge about, and attitudes towards, antibiotics; and factors that may be associated with the supply for common infections. (ii) investigate how the public in Sri Lanka use antibiotics, including their knowledge about, attitudes to, self-medication with, and requests for, antibiotics from pharmacies; and factors that may be associated with the self-medication and antibiotic request without prescription from pharmacies for common infections. Methods: Antibiotics supply for infections, such as the common cold, acute sore throat, acute diarrhoea and UTIs was measured using three approaches among an estimated sample of 369 community pharmacies in Sri Lanka from Dec. 2016 to Sept. 2017: a self-reported survey, including pharmacy staff’s knowledge and attitudes related to antibiotic supply and two simulated client (SC) visits. SCs visited consenting pharmacies twice, approximately two weeks to six months apart. One SC visit involved directly requesting one of four antibiotics (direct product request or DPR): erythromycin, metronidazole, or ciprofloxacin tablets, or amoxicillin syrup. The other SC visit involved presenting symptoms of one of the four infections (symptoms based request or SBR) and requesting a medicine for the symptoms. The interactions in the pharmacy during the SC visits were covertly audio-recoded with prior permission. The public’s knowledge, attitudes and antibiotic use and self-medication for common infections were assessed using a cross-sectional interviewer-administered household survey among a random sample (n=1100) of the Sri Lankan public. This was conducted in a similar xxii geographical area as where the pharmacies were surveyed. Informed written consent was obtained from each eligible participant prior to the interview. Data were analysed using descriptive statistics including mean and standard deviation (SD), median and interquartile range (IQR), frequencies (%), factor analysis and reliability tests, and inferential statistics including t-test, one-way ANOVA or chi-square test, and binary and multiple logistic regression. Results: Across the four infections – acute sore throat, the common cold and cough, diarrhoea and UTI, the proportion of pharmacy staff who provided an antibiotic without a prescription was found to be 61% (147/242) in the DPR SC study compared to 41% (99/242) in the SBR SC study. These were markedly higher than the findings from the self-reported survey of the identical pharmacy staff 19.4% (47/242). The SBR study revealed that 66% (65/99) of SCs with viral infections were supplied antibiotics inappropriately for reported symptoms of viral infections. Though the availability of a pharmacist reduced the likelihood of unlawful antibiotic supply (OR = 0.53, 95% CI: 0.31–0.89; p = 0.016), it did not impact on appropriate antibiotic supply. The self-reported survey found that the overall knowledge about antibiotics was poor among pharmacy staff. Pharmacists with higher ABR knowledge were less likely to supply antibiotics without a prescription for viral infections in adults (Adj. OR=0.73, 95% CI: 0.55-0.96; P=0.027) and children (Adj. OR=0.55, 95% CI: 0.38-0.80; P=0.002). Pharmacy staff who had knowledge about the legal aspects of antibiotic supply were less likely to provide antibiotics (Adj. OR=0.47, 95% CI: 0.30-0.75; P=0.001), and specifically less likely to give an antibiotic for bacterial infections in adults (Adj. OR=0.45, 95% CI: 0.20-0.99; P=0.047). Knowledge xxiii about antibiotic use and misuse reduced the likelihood of dispensing an antibiotic without a prescription for the common cold (Adj. OR=0.75, 95% CI: 0.60-0.94; P=0.011) and acute diarrhoea (Adj. OR=0.76, 95% CI: 0.58-0.99; P=0.048). Pharmacy staff with more positive beliefs about their professional competency to supply and monitor antibiotic use, and their beliefs that antibiotics are effective against different conditions, were more likely to dispense antibiotics without a prescription for common infections. The public survey revealed that half of the public had used an antibiotic in the three months prior to the survey, and nearly all of them (98%, 974/998) reported that they had used an antibiotic in the past. Eighty-seven percent (866/998) of the respondents had obtained their antibiotic (in the past) on a physician’s prescription. About 11% (108/998) had self-medicated with antibiotics in the past, and the main source for self-medication was a community pharmacy (89/108). Overall, 68% (678/998) of the participants requested antibiotics from pharmacies without prescriptions for common infections. The common cold (26%, 258/998), sore throat (14%, 143/998) and wound infections (16%, 163/998) were the most common infections for which the public self-medicated and requested antibiotics from pharmacies without a prescription. The public’s knowledge regarding antibiotics, ABR and use of antibiotics for common infections was poor and most did not know about antibiotic resistance. The public’s knowledge about antibiotic prescription requirements was statistically significantly associated with self-medication with antibiotics (Adj. OR=0.37, 95% CI: 0.19- 0.72; p=0.004). Factor analysis of the attitudinal items resulted in three factors, explaining 56.1% of the variance: ease of access to antibiotics from pharmacies (factor 1), appropriate use of antibiotics (factor 2) and situational use of antibiotics (factors 3). Overall, participants demonstrated positive attitudes (median score was 4/5 for almost every attitude item) towards xxiv appropriate use of antibiotics. Those participants who did not support ease of access to antibiotics from pharmacies (Adj. OR=0.38, 95% CI: 0.27-0.54; p<0.001) and situational use of antibiotics (Adj. OR=0.55, 95% CI: 0.38-0.79; p=0.001); and those who supported appropriate use of antibiotics (Adj. OR=0.64, 95% CI: 0.47-0.86; p=0.003) were less likely to self-medicate with antibiotics. Overall 68% of the public requested antibiotics from pharmacies without prescriptions for the examined common infections (listed in the questionnaire), with the highest request for the common cold and cough where about 26% of the public expected to receive antibiotics from pharmacies without prescriptions for the common cold and cough. Participants who had experienced receiving antibiotics with physicians’ prescriptions, expected antibiotics from pharmacy staff and physicians, and those who self-medicated with antibiotics were more likely to request antibiotics from pharmacies without prescriptions for common infections. Conclusions: These were the first studies which assessed the public’s knowledge about, attitudes to, and use of antibiotics at the same time as community pharmacy staff’s knowledge about, attitudes to, and supply of antibiotics in Sri Lanka for common infections. The findings from this research using four methodological approaches revealed that despite the law prohibiting provision, illegal and inappropriate antibiotic supply is common in Sri Lanka for common infections. Antibiotic supply was primarily associated with a low level of pharmacists’ legal and clinical knowledge about antibiotics. Staff’s beliefs associated with higher level of professional competency and the effectiveness of antibiotics for common infections were predictors of antibiotics supply without a prescription for common infections. xxv Although antibiotic use for common infections is high among the Sri Lankan public, specifically for the common cold and cough, their knowledge about appropriate antibiotic use for common infections was poor. The main source of the public’s antibiotic use for common viral infections was via physicians’ prescriptions; and for self-medication with antibiotics, via pharmacies. The factors such as easy access, appropriate use of antibiotics and situational use of antibiotics were associated with self-medication, the public’s experience strongly predicted antibiotic request from pharmacies. Recommendations: From the findings of this research we recommend development of multifaceted interventions, including for health professionals, policy makers and consumers, which can address the educational gaps and therefore improve antibiotics-related knowledge among the pharmacy staff and the public in Sri Lanka. It is also recommended that the legislation for antibiotic supply is firmly enforced in community pharmacies and national antibiotic prescribing guidelines are implemented for physicians.