Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308312

doi: 10.1111/j.1365-2710.2011.01293.x

Irrational use of antibiotics and role of the pharmacist: an insight from a qualitative study in New Delhi, India
A. Kotwani* PhD, C. Wattal MD, P. C. Joshi PhD, K. Holloway MRCP, PhD
*Department of Pharmacology, V. P. Chest Institute, University of Delhi, Delhi, Department of Clinical Microbiology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, Department of Anthropology, University of Delhi, Delhi and Essential Drugs and Other Medicines, World Health Organization, Regional Ofce for South East Asia, New Delhi, India

Received 22 March 2011, Accepted 04 July 2011

Keywords: antibiotic resistance, antibiotic use, community pharmacists, dispensing practices, India, rational use of antibiotics

SUMMARY What is known and Objective: The overall volume of antibiotic consumption in the community is one of the foremost causes of antimicrobial resistance. In developing countries like India, pharmacists often dispense prescription-only drugs, like antibiotics, to patients who do not have a prescription. Not much data is available regarding detailed information on behaviour of antibiotic use by community pharmacists which is of particular signicance to develop a suitable and sustainable intervention programme to promote rational use of antibiotics. A qualitative study was conducted to understand the dispensing practices and behaviour of community pharmacists to develop policy interventions that would improve the use of antibiotics at the community level. Methods: Focus group discussions (FGDs) were held for ve municipal wards of Delhi with retail pharmacists, public sector pharmacists and the ofce bearers of pharmacists associations. Data on antibiotic use and resistance were collected earlier from these ve wards. FGDs (n = 3 with 40 pharmacists) were analysed through grounded theory. Results and Discussion: Four broad themes identied were as follows: prescribing and dispensing behaviour; commercial interests; advisory role; and intervention strategies for rational use of antibiotics. FGDs with pharmacists working in the public sector revealed that, besides the factors listed above, overstock and near-expiry, and under-supply of antibiotics promoted antibiotic misuse. Suggestions for interventions from pharmacists were the following: (i) education to increase awareness of rational use and resistance to antibiotics; (ii) involving pharmacists as partners for creating awareness among communities for rational use and resistance to antibiotics; (iii) developing an easy return policy for near-expiry antibiotics in public sector facilities; and (iv) motivating and showing appreciation for community pharmacists who participate in intervention programmes. What is new and Conclusions: Inappropriate antibiotic dispensing and use owing to commercial interests and lack of knowledge about the rational use of antibiotics and antibiotic resistance were the main ndings of this in-depth

qualitative study. Community pharmacists were willing to participate in educational programme aimed at improving use of antibiotics. Such programmes should be initiated within a multidisciplinary framework including doctors, pharmacists, social scientists, government agencies and non-prot organizations. WHAT IS KNOWN AND OBJECTIVE Irrational use of antibiotics in the community is a major cause of rising antibiotic resistance.1 In many developing countries, pharmacists who serve as drug retailers not only provide access to pharmaceutical products but also provide advice and prescribe medicines.24 The present study tries to gain an insight into the behaviour of pharmacists, and their knowledge and attitude regarding antibiotic dispensing and usage and antimicrobial resistance. This study was carried out to inform the development of a suitable intervention programme to promote the rational use of antibiotics by community pharmacists. There is evidence for the value and favourable costbenet ratio of such health promotion activities.5 Pharmacists often serve as the rst contact for the patient in the healthcare seeking chain and the last before consumption of the drugs dispensed. They are an important junction from where health promotion materials can be distributed.6,7 Dispensing by pharmacists has not been given much importance in studies of antibiotic usage, compared to other processes such as diagnosis, and drug procurement, inventory control and distribution. It is important to study dispensing behaviour as in many developing countries antibiotics are easily available without a prescription.812 Most of the studies focusing on pharmacists highlight their dispensing practice and their role in facilitating self-medication,3,13 but studies on the perceptions and practices of dispensers are lacking.14 Any community intervention programme must involve consultation with all the stakeholders and be grounded in the local context.15 The present study was carried out as part of a phase II programme on surveillance of antimicrobial use and resistance in the community. Phase I of the study established the methodology for surveillance of antimicrobial drug use and resistance in the community.16,17 The results of the phase I study clearly identied high use of antibiotics and high resistance level in the community, with newer members from each class of antibiotics being used more than the older members of the same class.18

Correspondence: Dr A. Kotwani, Department of Pharmacology, V. P. Chest Institute, University of Delhi, Delhi 110007, India. Tel.: +91 11 27402404; fax: +91 11 27666549; e-mail: anitakotwani@gmail. com

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METHODOLOGY To explore the behaviour of pharmacists on the use of antibiotics and to identify suitable intervention strategies, qualitative focus group discussions (FGDs) were undertaken. This method provides an in-depth knowledge of perceptions and attitudes of the population being studied. In India, medicines prescribed by doctors in the public sector are provided free of charge to patients. At private retail pharmacies, patients pay for medicines. Three focus group discussions (FGDs) were planned, one each for public and private sector pharmacists and one for the leaders of their associations. FGDs were held in February August 2008 with the help of two chief investigators of the study (AK and CW) and a social scientist. One of the chief investigators was an expert on the surveillance of antibiotic use, and the second was a clinical microbiologist and expert on antimicrobial resistance patterns in the study area. The FGDs were facilitated by the former. The study was conducted in New Delhi, India, and covered ve municipal wards (residential areas) from where the antibiotic use and resistance data were collected in 2004 and later in 20082009. Retail pharmacists invited for FGDs were from the same ve municipal wards. Public sector pharmacists were invited from the 10 public health facilities from which data on antibiotic drug use were collected. For public sector meetings, zonal incharges were contacted, and for private sector meetings, ofce bearers of pharmacists associations were contacted for permission and cooperation. One group was comprised exclusively of retail pharmacists14 who ran their own private retail pharmacies, commonly called chemist shops in New Delhi. The second FGD was for public sector pharmacists8 but a few private pharmacists5 who had been unable to attend the rst meeting joined the group. The third FGD was made up of leaders3 and ofce bearers4 of pharmacists organizations and six6 enthusiastic retail pharmacist members from those organizations. For the public sector, 8 of 10 pharmacists invited participated in the FGD. For the private sector, 35 retail pharmacists were contacted and invited, 14 came and 5 joined the FGD with the public sector pharmacists. Forty pharmacists participated with only one female pharmacist from the public sector. The FGDs were conducted with the help of a topic guide, and a theoretical sampling procedure was adopted to enrich the content. The topic guide had ve main key areas that were enriched with each successive FGD. The ve key areas of the topic guide were as follows: antibiotic dispensing behaviour of pharmacists; antibiotic prescribing by pharmacists to patients; knowledge about antimicrobial resistance; understanding about antibiotic misuse; and suggestions for suitable interventions. A brief introduction and results from the completed antibiotic use and resistance study were given in the beginning of focus group discussions. The facilitator focused the discussion on the motivations and behaviours that lead to antibiotic misuse. After the discussion regarding antibiotic dispensing practices as well as prescribing behaviours, pharmacists were asked to suggest suitable interventions to decrease the misuse of antibiotics and antibiotic resistance. All FGDs were videotaped, transcribed and translated where required. There was continuous analysis of FGDs throughout the study from the rst to the last FGD. The data were subjected to grounded theory, which is inductive and iterative. In the rst FGD, discrete themes were identied, which were then used in subsequent FGDs and tested for reality. Transcripts were closely examined to identify themes and categories.

Codes were applied to the broad themes that emerged from the sub-themes already identied. Agreement on themes, sub-themes and coding was sought. The method of constant comparison was central to the process generating various themes and codes.19 Ethical approval Ethical approval for the study was obtained from V. P. Chest Institute, Sir Ganga Ram Hospital, and also from WHO Ethics Review Committee. Informed consent was obtained from all participants involved in the study. RESULTS The focus group discussions (FGDs) with community pharmacists supported our earlier ndings of high antibiotic use in the community.16 Four broad themes were identied: prescribing and dispensing behaviour; commercial interests; advisory role; and intervention strategies for rational use of antibiotics, which were further divided into sub-themes. Prescribing and dispensing behaviour Pharmacists identied contexts in which they either honoured prescriptions or prescribed antibiotics without a prescription: Honouring old prescriptions. Private sector pharmacists frequently honoured old prescriptions. Old prescriptions are referred to those prescriptions that were written in the past by a doctor for certain symptoms. Prescriptions are kept back by the patients in India. Patients bring back the previous prescription and ask for the same antibiotic for similar symptoms may be for self or for a different patient. Although it is not permissible legally, pharmacists generally dispense antibiotics on old prescriptions. This argument was given by a retail pharmacist: Pharmacist- He (pharmacist) does not give (prescribe) from his side in the sense that, doctor had prescribed medicine(antibiotic) earlier, patient either did not take full course and came for rell or after some days or may be after months patient wants the same medicine for similar symptoms. Second time he (patient) did not take doctors advice and came to the pharmacist directly...... Irregularities in supply of antibiotics in public sector. Public sector pharmacists mentioned two contexts where irrational use of antibiotic is seen: when medicines are unavailable or overstocked. In government-run dispensaries (primary health care), the pharmacist is able to dispense only part of the full course prescribed when there is insufcient stock. Poor patients are usually unable to afford buying the rest from private retail pharmacies. Some pharmacists in the government sector stated that surplus stock whose expiry was nearing was usually cleared by over-prescribing, even for antibiotics. The pharmacists and doctors did not return the stock because to do so would have involved lengthy procedures and they were pressured by higher ofcials to exhaust remaining stock. Self-medication. Private retail pharmacists dened self-medication as instances where they did not advise patient about a medicine but the patient asked for the medicines without prescription. Patients came to them with the names of antibiotics that at some point had given relief, with empty strips of used medicine, diaries maintained for different symptoms and drugs to be

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used. None said that they refused selling prescription-only antibiotics. Pharmacists prescribing behaviour. Most of the private retail pharmacists initially denied prescribing themselves, as they were neither qualied nor allowed to do so. Initially, they insisted that they rarely prescribed for patients directly. Most later admitted prescribing antibiotics for diseases or symptoms like diarrhoea, common cold, mild fever, sore throat and cough. For such conditions, they mimicked the prescriptions given by neighbourhood doctors of good standing for patients with similar complaints. The following statement reveals their justication: Pharmacist-Usually we do not prescribe. We usually give six tabletsSeptran (co-trimoxazole). Only when a poor patient comes who cannot afford doctors fees, we treat with simple medicine like SeptranIf he goes to a doctor, he (patient) will have to pay the fees Pharmacists used the context of prescribing to poor patients as doing social work. Most prescribed antibiotics for 23 days. Some private retail pharmacists even mentioned giving just three to six tablets. Antibiotics like cotrimoxazole, erythromycin and clarithromycin were said to be used commonly. For diarrhoea, metrodinazole and noroxacin were used. They prescribed according to the economic status of the patient. They did not think that this practice could lead to an increase in resistance as they were giving antibiotics for only a few days. Some pharmacists said they resorted to such practices for fear of losing patients and lack of awareness about the importance of rational use of antibiotics. Commercial interests Honouring inappropriate prescriptions. Pharmacists said they honoured all kinds of prescriptions for economic reasons even if they thought they were inappropriate. A few of the private retail pharmacists considered themselves as mere traders. Most of the pharmacists felt such dispensing was necessary for their commercial establishment. Push factor of pharmaceutical companies. Pharmaceutical companies run their own drug promotion programmes to maximize prots. Generic drugs are not marketed as they are cheaper and are usually not stocked in chemist shops. Generally, doctors prescribe new antibiotics that are costly and have larger prot margins for pharmacists. Pharmacist-There is pressure from industry to doctors. We will get your clinic renovatedarrange foreign trip for family Company gives them (doctors) such offers. Whatever trend is going on we start stocking antibiotics according to that. They (doctors) are the ones who start prescribing new antibiotics. It is good for us as well since our prot is also more Advisory role of pharmacist Pharmacists from both sectors said they refrained from making remarks on the inappropriateness of prescriptions. They said that if they point it out to a doctor, he will rebuke them for challenging his authority. If an inappropriate prescription is pointed out to a patient, the patient has more faith in the doctor than the pharmacists advice. Although patients may take advice and buy medicines directly from pharmacists, they do not want them to advise or comment on doctors prescription.

Public sector pharmacist said they did not have enough time to advise or educate patients on the use of antibiotics. Suggestions by pharmacists for intervention strategies for rational use of antibiotics After realizing that antibiotic resistance is indeed a serious problem for which interventions are required especially to change behaviour, many suggestions were put forth. The actions suggested by pharmacists were the following: Increasing awareness among consumers. Many pharmacists believed that if a patient was aware of the importance of taking a full course, this would have signicant effect on use of antibiotics. They gave an example of how an aware foreigner asking for an anti-diarrhoeal would specically mention not wanting any antibiotics. However, some pharmacists mentioned that in their respective areas even educated patients demanded antibiotics to speed up recovery. Therefore, it was suggested that television and newspapers advice about the appropriate usage of antibiotics should be given. Pharmacists of both the sectors readily agreed to take part in the distribution of educational material and help in the campaign to promote the rational use of antibiotics. They also expected recognition and incentives to be given to pharmacists involved in such campaigns. Awareness and education of pharmacists. Many pharmacists were ignorant of the rational use of antibiotics and factors that lead to the development of antibiotic resistance and asked for seminars and educational courses to help them. Changing prescription habits of doctors. Most of the pharmacists were unanimous in their opinion that, rst of all, doctors should change their prescribing habits. Most of the private retail pharmacists modelled their prescriptions on those of a neighbourhood doctors: Pharmacist- If we see different trendslike antibiotics are not prescribed for diarrhoea. whatever trend the doctor is creating that is the norm of that region. Which we chemist also follow. Easy return policy for nearly expired antibiotics. Public sector pharmacists stressed that for near-expiry and over-supplied antibiotics, an easy return policy would help. Changing pharmacists dispensing. Few pharmacists felt that it was their moral responsibility to stop the misuse of antibiotics in the community. However, a majority of them stated that the responsibility rested with patients and doctors. Regulatory authorities should implement and enforce laws against honouring old prescriptions for antibiotics and dispensing smaller quantities of antibiotics than prescribed by the doctor. Redening the role of pharmacists. Many pharmacists felt that they were occupying the second rung in the medical hierarchy. All agreed that intervention should be organized through big and respected organizations. DISCUSSION This is one of the rst comprehensive studies in developing countries of antibiotic dispensing and prescribing practices of community pharmacists. Our study revealed that pharmacists

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A. Kotwani et al. skills.26 Interventions targeted at pharmacists should be embedded in the local health context and take into account their existing perception, beliefs and attitudes.27 To stop the misuse of antibiotics, a multifaceted strategy including education, based on an understanding of existing beliefs, replacement of perverse incentives with those promoting best practices through persuasion, and investment in improved surveillance is required.28 At the pharmacists level, education and motivation are more important. Apart from educational intervention with pharmacists, written information, brochures and posters can be displayed in pharmacies.29 Much work is needed to foster a sense of responsibility among the pharmacists themselves. This is likely to require intervention from the professional bodies the Drug and Chemists Association and the Medical Association. As suggested by pharmacists themselves, a pharmacy week could be used as an intervention programme. Pharmacy week is celebrated throughout India in November by various pharmacists associations to upgrade their members knowledge about new developments through workshops, seminars and continuing medical education. The medical fraternity must take community pharmacists with them in this endeavour. Without this, educational strategies are unlikely to surmount the barriers presented by commercial interests. STRENGTHS AND LIMITATIONS Our study was undertaken in West Delhi and pharmacists from ve municipal wards participated. This may not be representative of general practice as a whole. Although common themes emerged and thematic saturation was satisfactorily achieved, caution is still required in generalizing the ndings. One of the main strengths of this study was the participation of both public and private sector pharmacists. It was encouraging that most of the pharmacists were concerned about antibiotic resistance and were willing to participate in educational programmes. WHAT IS NEW AND CONCLUSIONS Inappropriate antibiotic dispensing and use owing to commercial interests and lack of knowledge about the rational use of antibiotics and antibiotic resistance were the main ndings of this in-depth qualitative study. Community pharmacists were willing to participate in educational programme aimed at improving use of antibiotics. Such programmes should be initiated within a multidisciplinary framework including doctors, pharmacists, social scientists, government agencies and non-prot organizations. ACKNOWLEDGEMENTS We would like to thank Dayanand Yumnam for helping in arrangements and conduct of FGDs. We thank Shashi Katewa for helping in transcribing the videotapes of FGDs and helping in analysis. We thank Alice Easton for reading and checking our draft manuscript. We would also thank all the participants and Zonal incharge, West Zone, Central & New Delhi Zone and Directorate Health Services, Government of NCT, Delhi. FUNDING The study was funded by WHO, Geneva (OD/TS-07-00163).

dispensed antibiotics inappropriately in different contexts. Selfmedication with antibiotics has been reported.3,20 A study conducted in Manila showed that 66% of the purchases were without prescription21 and the most common perceived indications were respiratory tract infections, prophylaxis and gastrointestinal infections. Almost 90% of purchases were for 10 or less capsules or tablets. The median number of units purchased was three. Customers with written prescriptions purchased a mean of eight capsules whereas those who self-prescribed purchased a mean of four units. Pharmacists in our study sold 46 capsules of inexpensive antibiotics for respiratory tract infections, diarrhoea, sore throat and fever. Often patients purchased fewer than the units prescribed by the doctors. Pharmacists also revealed that doctors tended to prescribe newer antibiotics, probably because of pharmaceutical industry pressure and pharmacists themselves followed the prescribing practices of neighbourhood doctors. The inuence of the pharmaceutical industry is well known.22 A New Zealand study23 showed that a majority of nurses recommended treatments to the prescribing doctor and provided advice to patients about over-the-counter medications. In India, pharmacists dispense all antibiotics without a prescription.24 In public sector pharmacies, the antibiotics were prescribed to use up surplus stock and smaller quantities of antibiotics were dispensed when in short supply. Underuse of antibiotics is as dangerous as overuse. Deciencies in the provision of drugs in primary health care are attributable to inadequacies within the drug distribution chain in less afuent settings, a problem recognized by WHO.25 The results observed in our study are troubling from a public health standpoint because of their implications on the emergence of antibiotic resistance. Pharmacists reported prescribing uoroquinolones or metronidazole for diarrhoea because they have seen prescriptions from doctors commonly prescribing these two antimicrobials for diarrhoea. Pharmacists described their own prescribing habits as necessary for economic survival and as a response to patient pressure and pressure from doctors. They also above all attributed their poor prescribing to their own lack of awareness of rational use of antibiotics and antimicrobial resistance. This study adds to the growing body of knowledge about the need to devise effective interventions to improve prescribing of antibiotic by pharmacists in low-income countries. There are no published results of such interventions. Important feedback obtained from pharmacists was their readiness to learn about rational use of antibiotics and to disseminate good practice. Some of the pharmacists and leaders of their associations were optimistic on this issue. Education of patients is important too. Community pharmacists believed those participating in promotion of rational use of antibiotics should be recognized by relevant authorities and organizations. Recognition can be in the form of a certicate and/or award to display in their pharmacies. The pharmacists also stressed that enforced regulatory action from concerned authorities is needed. The minimum qualication required in India for a pharmacist to practice is a Diploma in Pharmacy which is a 2-year course followed by 3 months training at an approved hospital. There is no obligation for continuing education. Our results are similar to those of a study in Karnataka, India, where respondents declared themselves ready to accept pharmacists extended roles if they improved their knowledge base and communication

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