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Antimicrobial Prescription Habits among Community Pharmacists and Patent and Proprietary Medicine Vendors  in Nigeria: A Rational Use of Drugs Survey

  • Danjuma Kamlen ADDA
  • Obed Tiwah JOHN
  • Prof. Barnabas Toge
  • Dr. Chinwe OCHU
  • Dr. Tochi OKWOR
  • Dr. Abiodun EGWUENU
  • Dr. Ridwan YAHAYA
  • Oscar Facknwie KAHWIR
  • Dr. Fatima SALEH
  • Dr. Fatima SALEH
  • Dr Badaru SIKIRU
  • Rijimra ANDE
  • Mohammed UMARU
  • Joyce C. JOHN
  • Helmina BANTAR
  • 95-112
  • Dec 13, 2023
  • Health

Antimicrobial Prescription Habits among Community Pharmacists and Patent and Proprietary Medicine Vendors  in Nigeria: A Rational Use of Drugs Survey

Danjuma Kamlen ADDA1, Obed Tiwah JOHN1*, Prof. Barnabas Toge1,3, Dr. Chinwe OCHU2 , Dr. Tochi OKWOR2 ,  Dr. Abiodun EGWUENU2, Dr. Ridwan YAHAYA2, Oscar Facknwie KAHWIR1, Dr. Fatima SALEH2, Dr. Fatima SALEH2 ,Dr Badaru SIKIRU2, Rijimra ANDE1, Mohammed UMARU1 ,Joyce C. JOHN1, Helmina BANTAR1

1Centre For Initiative and Development (CFID) Taraba

2Nigeria Centre For Disease Control (NCDC)

3Department of Pharmaceutical Science, University of Calabar, Nigeria

DOI: https://doi.org/10.51584/IJRIAS.2023.81109

Received: 20 November 2023; Accepted: 25 November 2023; Published: 13 December 2023

 ABSTRACT

Introduction

Antimicrobial Resistance (AMR) poses a global health threat, exacerbated by the misuse and overuse of antimicrobials. The need to investigate knowledge, attitudes, and practices among Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) in Nigeria cannot be overemphasized. This study addresses the gaps in understanding antimicrobial dispensing practices among CPs and PPMVs in Nigeria.

Materials/Methods

A Community-based Antimicrobial Stewardship survey was conducted across five Nigerian states. A total of 384 PPMVs and 135 CPs were interviewed using a well-structured questionnaire covering demographic information, knowledge, attitudes, and practices related to antimicrobial use. The survey utilized descriptive statistics, and the data were analyzed to identify strengths, weaknesses, threats, and opportunities in addressing AMR.

Results

The study revealed inadequate knowledge regarding AMR among both PPMVs and CPs. Despite educational backgrounds, a significant proportion believed antibiotics were the best treatment for fever and diarrhea. Dispensing practices included selling antibiotics without prescriptions and, in some cases, dispensing medicines by proxy. The Safety Net Protocol, involving patient education and follow-up, was often neglected by both PPMVs and CPs.

Conclusion

The findings underscore the importance of enhancing knowledge, attitudes, and practices related to antimicrobial prescription among PPMVs and CPs in Nigeria. Regulatory authorities should enforce strict guidelines to curb non-prescription antibiotic sales. Patient education and follow-up initiatives should be prioritized to mitigate AMR risks. In order to develop strategies to improve antimicrobial dispensing practices we recommend the following: AMR education for PPMVs and CPs, Enforce rules to prevent antibiotic sales without prescriptions through regulatory compliance,  public awareness on antibiotic risks and prescription importance, implement Safety Net Protocol for post-purchase education to prevent antibiotic misuse and provision of ongoing professional development for PPMVs and CPs with updated practices that will sustain learning.

Keywords: Antimicrobial, Community pharmacies, PPMVs, Knowledge, Attitude, Practice

INTRODUCTION

Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death (WHO, 2021). The two main drivers of antimicrobial resistance as identified by WHO include the misuse and overuse of antimicrobials. Recent Study conducted in 2019 across the globe estimated that 4.95 million deaths were associated with AMR, of which 1.27 million deaths were attributable to bacterial AMR (Murray et al. 2022). This recent study is higher than the  earlier reported by O’Neill in 2016. Disparities in antimicrobial dispensing habits exist both geographically and among different categories of healthcare workers due to different factors and determinants (Manga et al., 2021). According to the World Health Organization, approximately 93% of access to antimicrobials comes from community pharmacies (WHO, 2020). From this perspective, pharmacists can be considered the last barrier during the dispensing process, capable of preventing inappropriate use of antimicrobials and the possible health problems that could result from such use (Jamshed et al. 2018).

In Nigeria, AMR prevalence rate of 14.4% was estimated in 2017 which is far higher than the global average of 5.5% (Chikezie & Ebuenyi, 2019; United Nation Office on Drugs and Crimes, 2018 ).This could be attributed to indiscriminate and inappropriate dispensing/prescribing with absent/weak regulations/guidelines (Manga et al. 2021). Studies have indicated that interaction between pharmacists and patients enables interventions that optimize the use of antimicrobials in community pharmacies (Auta et al. 2019). Despite this, there is little scientific evidence on the panorama of antimicrobial dispensing practices and interventions provided by community pharmacists.

Thus, how the dispensing service has been provided to patients and what pharmacist interventions have been carried out during this service remain a huge gap. This study therefore, focuses on antimicrobial dispensing habits among the community pharmacies with particular emphasis on their behaviors, counseling, and AMS interventions provided to patients. It is our belief that understanding these underlying factors will help in developing strategies that will address the gaps in this service and ultimately improve the dispensing process across community pharmacies in Nigeria.

Therefore, CFID conducted RUD survey among PPMVs and CPs in order to identify Strengths, Weaknesses, Threats and Opportunities among community pharmacy/Patent and Proprietary Medicine Vendors (PPMVs) related to their practices in addressing the threats of AMR in their respective communities with the sole goal of strengthening organizational systems/practices, on drugs procurement, dispensing and prescription practices as it relates to AMS in the community settings.

MATERIALS/METHODS

This was a Community based Antimicrobial Stewardship interventional studies conducted across five states in Nigeria (Taraba, Enugu, Rivers, Nasarawa and Benue). A total of 384 PPMVs and 135 community Pharmacies were interviewed. Data was collected based on KAP with help of a well-structured questionnaire scripted into ODK. The questionnaire were divided into sections: Section 1 – Demographic characteristics, Section 2 – Knowledge on CPs/PPMVs care practice, Section 3 – Attitude towards the practice of CPs/PPMVs care, Section 4 – CPs/PPMVs care practice, Section 5 – Barriers to implementation of CPs/PPMVsl care. Descriptive statistics such as simple percentage was used to summaries the data and organize them into groups according to the sections of the questionnaires. It was also designed using point like response format consisting of yes and no and a few open ended questions. Simple percentages were used.

Prior to the commencement of the survey, training was conducted followed by the field work. Survey on Knowledge, Attitudes and Practices of rational use/dispensing of Antimicrobials among PPMVs, Community pharmacists took place between 30th of June, 2022 to 2st of July, 2022 in all the target states.

A total number of 65 participants were trained (the CSOs and their volunteers). The training was virtual which took place on 14thJune 2022; all the volunteers were trained on how to administer the RUD survey tool for PPMVs and Community pharmacists.

RESULTS

Table 1: Summary Analysis of RUD Survey among PPMVs in NIgeria

Taraba Nassarawa Benue Rivers
Sex of respondent Responses Freq % Freq % Freq % Freq %
Male 116 67 75 68 19 49 27 43
Female 56 33 35 32 20 51 36 57
Total 172 100 110 100 39 100 63 100
Education Responses Freq % Freq % Freq % Freq %
Primary 0 0 0 0 0 1 2
Secondary 58 34 50 45 10 26 18 29
Tetiary 109 63 58 53 29 74 40 63
Others 5 2 2 0 0 4 6
Total 172 100 110 100 39 100 63 100
Training Responses Freq % Freq % Freq % Freq %
Apprentice 55 32 58 53 13 33 22 35
CHEW 32 19 16 15 7 18 5 8
JCHEW 20 12 26 24 8 21 0 0
Nursing 21 12 2 2 5 13 22 35
Pharm Tech 24 14 6 5 5 13 7 11
Others 20 12 2 2 1 3 7 11
Total 172 100 110 100 39 28 63 100
Knowledge on antibiotics
1. Have you ever heard of a type of medicine called an antimicrobial medicine? Responses Freq % Freq % Freq % Freq %
Yes 47 27 16 15 7 18 28 44
No 125 73 94 85 32 82 35 56
Total 172 100 110 100 39 100 63 100
2. Have you heard of AMR? Responses Freq % Freq % Freq % Freq %
Yes 54 31 50 45 9 23 28 44
No 118 69 60 55 30 77 35 56
Total 172 100 110 100 39 100 63 100
3. Antibiotics are best used to treat fever. Responses Freq % Freq % Freq % Freq %
Yes 77 45 57 52 26 67 25 40
No 95 55 53 48 13 33 38 60
Total 172 100 110 100 39 100 63 100
4. Antibiotics are best used to treat diarrhea. Responses Freq % Freq % Freq % Freq %
Yes 127 74 34 31 33 85 32 51
No 45 26 76 69 6 15 31 49
Total 172 100 110 100 39 100 63 100
5. Skipping one or more doses does not contribute to development of antibiotics resistance. Responses Freq % Freq % Freq % Freq %
Yes 86 50 17 15 15 38 30 48
No 86 50 93 85 24 62 33 52
Total 172 100 110 100 39 100 63 100
6. Mixing different antibiotics works faster and shortens the duration of treatment and illness. Responses Freq % Freq % Freq % Freq %
Yes 71 41 17 15 15 38 26 41
No 101 59 93 85 24 62 37 59
Total 172 100 110 100 39 100 63 100
7. Due to side effects, antibiotics can be stopped if patient is getting well. Responses Freq % Freq % Freq % Freq %
Yes 115 67 55 50 18 46 32 51
No 57 33 55 50 21 54 31 49
Total 172 100 110 100 39 100 63 100
Antibiotics dispensing practice
1. Do you dispense antibiotics for common cold, catarrh and influenza Responses Freq % Freq % Freq % Freq %
Yes 78 45 63 57 27 69 30 48
No 94 55 47 43 12 31 33 52
Total 172 100 110 100 39 100 63 100
2. Do you dispense antibiotics to treat cough and sore throat? Responses Freq % Freq % Freq % Freq %
Yes 122 71 83 75 32 82 45 71
No 50 29 27 25 7 18 18 29
Total 172 100 110 100 39 100 63 100
3. Do you add antibiotics to malaria treatment to make patient recovery faster? Responses Freq % Freq % Freq % Freq %
Yes 134 78 81 74 27 69 39 62
No 38 22 29 26 12 31 24 38
Total 172 100 110 100 39 100 63 100
4. Do you sell antibiotics to patient without   prescription? Responses Freq % Freq % Freq % Freq %
Yes 122 71 61 55 33 85 33 52
No 50 29 49 45 6 15 30 48
Total 172 100 110 100 39 100 63 100
5. Do you sell part or half card of antibiotics to Patient on their request. Responses Freq % Freq % Freq % Freq %
Yes 79 46 62 56 21 54 42 67
No 93 54 48 44 18 46 21 33
Total 172 100 110 100 39 100 63 100
6. Do you provide education to patients after purchase of medicines Responses Freq % Freq % Freq % Freq %
Yes 40 23 11 10 8 21 26 41
No 132 77 99 90 31 79 37 59
Total 172 100 110 100 39 100 63 100
7. Do you provide safety netting protocol to patients after buying medicines (providing information for patient and follow up after contact with patient) Responses Freq % Freq % Freq % Freq %
Yes 40 23 11 10 8 21 26 41
No 132 77 99 90 31 79 37 59
Total 172 100 110 100 39 100 63 100

Table 1: Summary Analysis of RUD Survey among CPs in NIgeria

TARABA Benue Nassarawa Rivers
Gender Response Freq % Freq % Freq % Freq %
Female 18 38 20 51 8 26 8 47
Male 30 63 19 49 23 74 9 53
Total 48 100 39 100 31 100 17 100
6. Education Response Freq % Freq % Freq % Freq %
B. Pharm 28 58 1 20 16 52 10 59
M. Pharm 6 13 2 40 1 3 4 24
Others 14 29 2 40 14 45 3 18
Total 48 100 5 100 31 100 17 100
7. What is your specialization? Response Freq % Freq % Freq % Freq %
Pharmacist with specialty 27 56 4 80 1 3 1 6
Pharmacist without specialty 21 44 1 20 30 97 16 94
Total 48 100 5 13 31 100 17 100
8. Do you think that giving antibiotics for cold is a problem? Response Freq % Freq % Freq % Freq %
Yes 28 58 0 0 18 58 4 24
No 20 42 5 100 13 42 13 76
Total 48 100 5 100 31 100 17 100
9. How much percentage of patients would like to purchase a prescribed antibiotic in your pharmacy compared to total prescription drug traffic? Response Freq % Freq % Freq % Freq %
5% 3 6 0 0 12 39 2 12
10% 8 17 1 20 16 52 3 18
15% 10 21 0 0 2 6 3 18
20% 5 10 1 20 0 0 3 18
25% 3 6 1 20 0 0 2 12
>25% 19 40 2 40 1 3 4 24
Total 48 100 5 100 31 100 17 100
10. How often do you dispense antimicrobials when a patient requires it without medical prescription? Response Freq % Freq % Freq % Freq %
In 1-5% of all antibiotic purchases 11 23 2 40 10 32 7 41
In 5-25% of all antibiotic purchases 20 42 1 20 3 10 1 6
Less than 1% of all antibiotic purchases 5 10 0 0 7 23 3 18
More than 25% of all antibiotic purchases 11 23 2 40 0 0 0
Never 1 2 0 0 11 35 6 35
Total 48 100 5 100 31 100 17 100
11a. My knowledge regarding the pharmacological aspects of antibiotic therapy are appropriate.  Response Freq % Freq % Freq % Freq %
TRUE 47 98 5 100 31 100 16 94
FALSE 1 2 0 0 0 0 1 6
Total 48 100 10 100 31 100 17 100
11b. My knowledge regarding the patomechanism and prevention of infectious diseases are appropriate.  Response Freq % Freq % Freq % Freq %
TRUE 47 98 5 100 31 100 15 88
FALSE 1 2 0 0 0 0 2 12
Total 48 100 5 100 31 100 17 100
11c. My knowledge regarding bacterial resistance is appropriate.  Response Freq % Freq % Freq % Freq %
TRUE 22 46 3 40 12 39 6 35
FALSE 26 54 2 60 19 61 11 65
Total 48 100 5 100 31 100 17 100
11d. I believe that it is problematic that there are pharmacists who dispense antibiotic when the patient require it without prescription.  Response Freq % Freq % Freq % Freq %
TRUE 42 88 4 80 28 90 12 71
FALSE 6 13 1 20 3 10 5 29
Total 48 100 5 100 31 100 17 100
11e. Have you heard of AMR? Response Freq % Freq % Freq % Freq %
Yes 22 46 3 40 12 39 6 35
No 26 54 2 60 19 61 11 65
Total 48 100 5 100 31 100 17 100
11f. Antibiotics  are best used to treat fever.   Response Freq % Freq % Freq % Freq %
TRUE 16 33 2 40 17 55 10 59
FALSE 32 67 3 60 14 45 7 41
Total 48 100 5 100 31 100 17 100
11g. Antibiotics are best used to treat diarrhea.   Response Freq % Freq % Freq % Freq %
TRUE 26 54 2 60 19 61 11 65
FALSE 22 46 3 40 12 39 6 35
Total 48 100 5 100 31 100 17 100
11h. Skipping one or more doses does not contribute to development of antibiotics resistance.   Response Freq % Freq % Freq % Freq %
TRUE 19 40 2 40 7 2 12
FALSE 29 60 3 60 24 15 88
Total 48 100 5 100 31 0 17 100
11i. Mixing different antibiotics works faster and shortens the duration of treatment and illness.   Response Freq % Freq % Freq % Freq %
TRUE 13 27 1 20 2 6 4 24
FALSE 35 73 4 80 29 94 13 76
Total 48 100 5 100 31 100 17 100
11j. Due to side effects, antibiotics can be stopped if patient is getting well.    Response Freq % Freq % Freq % Freq %
TRUE 22 46 3 60 15 48 8 47
FALSE 26 54 2 40 16 52 9 53
Total 48 100 10 200 31 100 17 100
11k. Do you dispense antibiotics for common cold, catarrh and influenza   Response Freq % Freq % Freq % Freq %
Yes 9 19 3 60 16 52 6 35
No 39 81 2 40 15 48 11 65
Total 48 100 5 100 31 100 17 100
11l. Do you dispense antibiotics to treat cough and sore throat?   Response Freq % Freq % Freq % Freq %
Yes 32 67 2 40 18 58 15 88
No 16 33 3 60 14 45 2 12
Total 48 100 5 100 32 103 17 100
11m. Do you add antibiotics to malaria treatment to make patient recovery faster?   Response Freq % Freq % Freq % Freq %
Yes 31 65 2 40 15 48 12 71
No 17 35 3 60 16 52 5 29
Total 48 100 5 100 31 100 17 100
11n. Do you sell antibiotics to patient without   prescription? Response Freq % Freq % Freq % Freq %
Yes 39 81 2 40 6 19 9 53
No 9 19 3 60 25 81 8 47
Total 48 100 5 100 31 100 17 100
11o. Do you sell part or half card of antibiotics to Patient on their request.    Response Freq % Freq % Freq % Freq %
Yes 8 17 3 60 8 26 10 59
No 40 83 2 40 23 74 7 41
Total 48 100 5 100 31 100 17 100
12a. Pharmacists should be authorized to perform the  task of selecting the therapy in case of proven uncomplicated infections.  Response Freq % Freq % Freq % Freq %
Agree 47 98 3 60 24 77 11 65
Disagree 1 2 2 40 1 3 2 12
Totally agree 5 16 3 18
Totally disagree 1 3 1 6
Total 48 100 5 100 31 100 17 100
12b. The media devotes enough energy to disseminate information on infectious diseases.  Response Freq % Freq % Freq % Freq %
Agree 34 71 4 80 25 81 7 41
Disagree 14 29 1 20 1 3 8 47
Totally agree 3 10 1 6
Totally disagree 2 6 1 6
Total 48 100 5 100 31 100 17 100
12c. Medicine-related counselling of community  pharmacists is just as important as the physician’s recommendations.  Response Freq % Freq % Freq % Freq %
Agree 41 85 3 60 30 97 7 41
Disagree 7 15 2 40 0 0 4 24
Totally agree 1 3 1 6
Totally disagree 0 0 5 29
Total 48 100 5 100 31 100 17 100
12d. Pharmacists may also perform the task of administering vaccines (after proper training).  Response Freq % Freq % Freq % Freq %
Agree 16 33 5 100 25 81 10 59
Disagree 4 8 0 0 1 3 2 12
Totally Agree 27 56 0 0 4 13 3 18
Totally Disagree 1 2 0 0 1 3 2 12
Total 48 100 5 100 31 100 17 100
12e. I agree with the current funding policy of the National Institute of Health Insurance Fund  Response Freq % Freq % Freq % Freq %
Agree 26 54 3 60 29 94 11 65
Disagree 12 25 1 20 0 0 3 18
Totally Agree 7 15 1 20 2 6 3 18
Totally Disagree 3 6 0 0 0 0 0 0
Total 48 100 5 100 31 100 17 100
12f. Antibiotics are medicines of special importance.  Response Freq % Freq % Freq % Freq %
Agree 19 40 3 60 20 65 8 47
Disagree 0 0 0 0 1 3 6 35
Totally Agree 29 60 2 40 10 32 3 18
Totally Disagree 0 0 0 0 0 0 0 0
Total 48 100 5 100 31 100 17 100
12g. I may be held responsible for the non-prescription  dispensing of antibiotics, as this is a public health risk.  Response Freq % Freq % Freq % Freq %
Agree 27 56 4 80 25 81 9 53
Disagree 15 31 1 20 1 3 5 29
Totally Agree 2 4 0 0 5 16 3 18
Totally Disagree 4 8 0 0 0 0 0 0
Total 48 100 5 100 31 100 17 100
12h. Appropriate patient education would effectively reduce the incidence of AMR.  Response Freq % Freq % Freq % Freq %
Agree 26 54 3 60 29 94 11 65
Disagree 0 0 0 0 0 0 0 0
Totally Agree 22 46 2 40 2 6 5 29
Totally Disagree 0 0 0 0 0 0 1 6
Total 48 100 5 100 31 100 17 100
12i. As I am in direct contact with patients on a daily  basis, I have the opportunity to influence their approach to infectious diseases.  Response Freq % Freq % Freq % Freq %
Agree 33 69 4 80 28 90 12 71
Disagree 1 2 0 0 1 3 0 0
Totally Agree 14 29 1 20 2 6 4 24
Totally Disagree 0 0 0 0 0 0 1 6
Total 48 100 5 100 31 100 17 100
12j. Patients are mostly receptive of my advice during dispensing, they welcome it.  Response Freq % Freq % Freq % Freq %
Agree 25 52 3 60 25 81 13 76
Disagree 1 2 0 0 2 6 0 0
Totally Agree 21 44 2 40 4 13 3 18
Totally Disagree 1 2 0 0 0 0 1 6
Total 48 100 5 100 31 100 17 100
12k. Inappropriate antibiotic therapy does not cause significant surplus health costs on an annual basis.  Response Freq % Freq % Freq % Freq %
Agree 14 29 1 20 16 52 3 18
Disagree 27 56 2 40 10 32 11 65
Totally Agree 2 4 0 0 1 3 0 0
Totally Disagree 5 10 2 40 4 13 3 18
Total 48 100 5 100 31 100 17 100
12l. Education regarding antibiotics and antibiotic  resistance should be more prominent during university training.  Response Freq % Freq % Freq % Freq %
Agree 23 48 3 60 15 48 9 53
Disagree 3 6 0 0 1 3 6 35
Totally Agree 21 44 0 0 15 48 0 0
Totally Disagree 1 2 2 40 0 0 2 12
Total 48 100 5 100 31 100 17 100
12m. For patients requesting antibiotics without  prescription and are probably not in need of antibiotic therapy, I feel obligated to inform and educate them.  Response Freq % Freq % Freq % Freq %
Agree 24 50 2 40 26 84 10 59
Disagree 2 4.16667 1 20 0 0 0 0
Totally Agree 21 43.75 2 40 5 16 4 24
Totally Disagree 1 2 0 0 0 0 3 18
Total 48 100 5 100 31 100 17 100
12n. There are several occasions when many times more  time is needed to educate patients because doctors have not done this properly.  Response Freq % Freq % Freq % Freq %
Agree 27 56 3 60 23 74 11 65
Disagree 1 2 0 0 0 0 2 12
Totally Agree 19 40 2 40 8 26 3 18
Totally Disagree 1 2 0 0 0 0 1 6
Total 48 100 5 100 31 100 17 100
12o. promoters is just as important (or more important) in the development of bacterial resistance as their inappropriate prescription/consumption in health care Response Freq % Freq % Freq % Freq %
Agree 35 73 3 60 29 94 12 71
Disagree 5 10 1 20 0 0 3 18
Totally Agree 7 15 1 20 2 6 2 12
Totally Disagree 1 2 0 0 0 0 0
Total 48 100 5 100 31 100 17 100
12p. The personality and behavior of patients significantly influences my dispensing practices.  Response Freq % Freq % Freq % Freq %
Agree 37 77 1 20 27 87 6 35
Disagree 5 10 3 60 3 10 7 41
Totally Agree 4 8 0 0 1 3 2 12
Totally Disagree 2 4 1 20 0 0 2 12
Total 48 100 5 100 31 100 17 100
12q. Proper use of antibiotics would be greater if  pharmacists had time to perform their pharmacological care duties.  Response Freq % Freq % Freq % Freq %
Agree 24 50 3 60 20 65 10 59
Disagree 0 0 0 0 0 0 4 24
Totally Agree 24 50 2 40 11 35 0 0
Totally Disagree 0 0 0 0 0 0 3 18
Total 48 100 5 100 31 100 17 100
12r. During my work as a pharmacist, I not only have to  make therapeutic decisions about acute infection, but I also have to provide lifestyle advise to the patient Response Freq % Freq % Freq % Freq %
Agree 30 63 3 60 27 87 10 59
Disagree 3 6 1 20 0 0 1 6
Totally Agree 14 29 1 20 4 13 4 24
Totally Disagree 1 2 0 0 0 0 2 12
Total 48 100 5 100 31 100 17 100
12t. I offer probiotics for the patients purchasing a prescribed antibiotic.  Response Freq % Freq % Freq % Freq %
Agree 36 75 4 80 28 90 12 71
Disagree 4 8 1 20 1 3 5 29
Totally Agree 7 15 0 0 2 6 0 0
Totally Disagree 1 2 0 0 0 0 0 0
Total 48 100 5 100 31 100 17 100
12u. I detail the proper use of antibiotics when counselling the patient.  Response Freq % Freq % Freq % Freq %
Agree 32 67 3 60 24 77 12 71
Disagree 1 2 0 0 0 0 1 6
Totally Agree 15 31 2 40 7 23 4 24
Totally Disagree 0 0 0 0 0 0 0 0
Total 48 100 5 100 31 100 17 100
12v. I consider it important to become acquainted with the  antibiotics of the current drug pool and those newly licensed on the market.  Response Freq % Freq % Freq % Freq %
Agree 37 77 3 60 30 97 8 47
Disagree 2 4 0 0 0 0 0 0
Totally Agree 9 19 2 40 1 3 5 29
Totally Disagree 0 0 0 0 0 0 4 24
Total 48 100 5 100 31 100 17 100
12w. I dispense drugs by proxy  Response Freq % Freq % Freq % Freq %
Agree 22 46 0 0 24 77 9 53
Disagree 22 46 3 60 6 19 5 29
Totally Agree 2 4 0 0 1 3 1 6
Totally Disagree 2 4 2 40 0 0 2 12
Total 48 100 5 100 31 100 17 100
12x. Do you provide education to patients after purchase of medicines Response Freq % Freq % Freq % Freq %
Agree 2 4 1 20 0 0 2 12
Disagree 26 54 3 60 15 48 3 18
Totally Agree 20 42 2 40 16 52 13 76
Totally Disagree 0 0 0 0 0 0 1 6
Total 48 100 6 120 31 100 19 112
12y. Do you provide safety netting protocol to patients after dispensing medicines (providing information for patient and follow up after contact with patient) Response Freq % Freq % Freq % Freq %
Agree 1 2 0 0 0 0 0 0
Disagree 25 52 2 40 18 58 13 76
Totally Agree 22 46 0 0 13 42 2 12
Totally Disagree 0 0 4 80 0 0 0 0
Total 48 100 6 120 31 100 15 88
12z. Do you dispense medicines by phone calls? Response Freq % Freq % Freq % Freq %
Yes 41 85 0 0 11 35 7 41
No 7 15 5 100 20 65 10 59
Total 48 100 5 100 31 100 17 100
If Yes to what extend   Response Freq % Freq % Freq % Freq %
Always 15 37 0 0 1 9 2 29
Often 26 63 0 0 10 91 5 71
Total 41 100 0 0 11 100 7 100

Description of Results among PPMVs

A total of 384 respondents (PPMVs) were interviewed, out of which 172 were drawn from Taraba, 39 from Benue State, Enugu State, 110 from Nasarawa State, and 63 from Rivers States, respectively.

Most of the sampled population (PPMVs) had Secondary or tertiary levels of education, and the majority of them received their training through apprenticeship, JCHEW, CHEW, Pharmacy technicians, nursing, and others.

Results also show that most PPMVs have not heard about antimicrobials or AMR; for example, 73% in Taraba, 85% in Nasarawa, 82% in Benue, and 56% in Rivers.

The result shows that most PPMVs were of the opinion that antibiotics are always the best treatment options for fever and diarrhea, for example, in Taraba (77%, 74%), Nasarawa (52%, 315), Benue (67%, 85%), and Rivers (40%, 51%), respectively. Respondents (PPMVs) also responded that skipping one or more doses does not in any way contribute to AMR.

PPMVs responded that mixing different antibiotics works faster and shortens the duration of treatment and illness; this was mostly reported in Taraba and Rivers states (71% and 41%, respectively).

Most PPMVs were also said to dispense antibiotics for the common cold, catarrh, and influenza, as well as cough and sore throat, for example, in Taraba (45%, 71%), Nasarawa (57%, 75%), Benue (69%, 82%), and Rivers (48%, 71%).

PPMVs were also of the opinion that when antibiotics are added to malaria treatment, it makes patients recover faster, and these were cut across all states, for example, 78% in Taraba, 74% in Nasarawa, 69% in Benue, and 62% in Rivers states, respectively.

The result shows that most PPMVs sell antibiotics without prescription, and they always sell part or half a card of antibiotics based on clients or patients requests, for example, in Taraba (55%, 46%), Nasarawa (55%, 56%), Benue (85%, 54%), and Rivers (52%, 67%).

The result also shows that most PPMV owners do not provide education to patients after the purchase of medicines or provide them with information and follow up after contact with them (Safety net protocol), for example in Taraba (77%), Nasarawa (90%), Benue (79%), and Rivers (59%).

Results among Community Pharmacists  Description

A total of 135 respondents (community pharmacy shop owners) were interviewed, out of whom 48 were drawn from Taraba, 39 from Benue State, 31 from Nasarawa State, and 17 from Rivers States, respectively.

Most of the sampled population (Community pharmacists (CPs)) had a bachelor’s degree in pharmacy, among others. Only a few (6%) had a master’s in Pharmacy across all the target states. A small number of the sampled pharmacists had a specialty, while others did not.

The community pharmacists were of the view that between 5-25% of patients would like to purchase a prescribed antibiotic in a pharmacy compared to total prescription drug traffic.

Results also show that most CPs had inadequate knowledge regarding bacteria resistance, for example, 98% in Taraba, 100% in Nasarawa, 100% in Benue, and 88% in Rivers.

Most of the CPs believed that it was problematic that there were pharmacists who dispensed antibiotics when patients required them without a prescription. The results also show that most CPs have not heard about AMR, for example, 54% in Taraba, 61% in Nasarawa, 60% in Benue, and 65% in Rivers.

Despite the levels of education acquired by CPs, the result shows that most CPs are still of the opinion that antibiotics are always the best treatment options for fever and diarrhea, for example, in Taraba (33%, 54%), Nasarawa (55%, 61%), Benue (40%, 60%), and Rivers (59%, 65%), respectively. Participants (CPs) responded that skipping one or more can contribute to AMR.

Although some CPs responded that mixing different antibiotics does not work faster or shorten the duration of treatment or illness, others agreed that mixing works faster.

Most CPs were also said to dispense antibiotics for the common cold, catarrh, and influenza, as well as cough and sore throat, for example, in Taraba (19%, 67%), Nasarawa (52%, 58%), Benue (60%, 40%), and Rivers (35%, 88%).

Some CPs were also of the opinion that when antibiotics are added to malaria treatment, it makes patients recover faster, and this differs from one state to another, for example, 65% in Taraba, 48% in Nasarawa, 40% in Benue, and 71% in Rivers states, respectively.

The result shows that some CPs sell antibiotics without prescription; however, most do not sell part or half cards of antibiotics based on clients or patients requests, for example, in Taraba (81%, 17%), Nasarawa (19%, 26%), Benue (85%, 54%), and Rivers (53%, 59%).

Most CPs are of the opinion that Pharmacists should be authorized to perform the task of selecting the therapy in cases of proven uncomplicated infections. The CPs also responded that Medicine-related counseling for CPs is just as important as the physician’s recommendations. The CPs also agreed that appropriate patient education would effectively reduce the incidence of AMR. However, a significant number of CPs dispense medicines by proxy.

The result also shows that most CPs do not provide education to patients after purchase of medicines or provide them with information and follow up after contact with them (Safety netting protocol), for example in Taraba (54%, 52%), Nasarawa (52%, 58%), Benue (60%, 40%), and Rivers (76%, 76%), respectively.

Results also show that most CPs dispense medicines through phone calls, and this, according to the results, is done most often.

DISCUSSION OF OVERALL RESULTS

The results describe a survey conducted among patent and proprietary medicine vendors (PPMVs) and community pharmacy shop owners in different states and communities of interest in Nigeria. The survey aimed to assess their knowledge, attitudes, and practices regarding antimicrobial resistance (AMR) and the use of antibiotics.

Demographics

A total of 384 respondents (PPMVs) were interviewed out of which 172 were drawn from Taraba, 39 from Benue state, Enugu State, 110 from Nasarawa State and 63 from Rivers States respectively. Most of the sampled population (PPMVs) had Secondary or tertiary levels of education and majority of them received their training through apprenticeship, JCHEW, CHEW, Pharmacy Technicians or Nursing and others. A total of 135 community pharmacy shop owners were interviewed, with 48 from Taraba, 39 from Benue state, 31 from Nasarawa State and 17 from Rivers States respectively. Most of the sampled population (Community pharmacists (CPs)) had Bachelor of Pharmacy and others, and only few had Masters in Pharmacy.

Knowledge and Attitude on Antimicrobial Resistance and Antimicrobial Use

The results indicate that most PPMVs and CPs had inadequate knowledge regarding bacteria resistance and that many respondents in both groups have not heard about AMR. However, most of them believed that it is problematic for pharmacists to dispense antibiotics without prescription.

Most PPMVs and CPs were still with the opinion that antibiotics are always the best treatment options for fever and diarrhea. Both groups responded that skipping one or more doses does not contribute to AMR. However, some respondents agreed that mixing different antibiotics works faster and shortens the duration of treatment and illness. Most PPMVs and CPs were also found to dispense antibiotics for common cold, catarrh, influenza, cough, and sore throat. Some respondents were also of the opinion that adding antibiotics to malaria treatment helps patients recover faster.

As relates to the present study, several studies report (Akinyandenu and Adeyini, 2014;  Akinyandenu et al., 2014; Adamu et al., 2020; Abubakar et al., 2023) high rates of irrational use and dispensing of antibiotics despite the prescription-only medicines (POMs) law activated in Nigeria. Inadequate education and awareness on rational use are important factors contributing to the irrational use of antibiotics among CPs and PPMVs, which accounts for their attitude. One of the main causes of antibiotic overuse and rising AMR levels is the non-prescription drug distribution of antibiotics. For many people in communities all around Nigeria, PPMVs are their main source of healthcare, offering treatment for a wide range of illnesses in both adults and children. Given the high demand for their services, they engage in the sales of antibiotics which by law they are not supposed to. Antibiotic stocking and sales at PPMV are accompanied by a surge in non-prescription purchases, which in turn fuels additional antibiotic stocking and sales, thus is a vicious cycle. This attitude gives rise to dispensing the wrong antimicrobial agent for the wrong microbe (e.g. giving antibiotics to a patient with a non-bacterial infection). Furthermore, the quest to make quick gain, fearing loss of customer and patient pressure on cutting antimicrobial agents is a huge contributing factor to the irrational attitude of dispensing among CPs and PPMVs which in the end promotes the emergence of AMR.

Practice of Antimicrobial Dispensing

In this study, result shows that most PPMVs and CPs sell antibiotics without prescription, and ome dispense medicines by proxy. This agrees with a study by Abdu et al.  (2022) who found that two-third (66.70%) of the PPMVs reported that they have sold non-prescribed antibiotics however, a significance variation was noticed between CPs and PPMVs. This could be attributed to poor regulatory enforcement regarding the sale of antibiotics and financial considerations for the PPMVs and CPs to sell antibiotics without prescription. Results also shows that most CPs/PPMV owners do not provide education to patients after purchasing the medicine or provide them with information and follow up after contact with them (safety netting protocol). This study disagrees with that of Ugwu et al. (2023) in Nigeria among Community Pharmacists in Abuja whose findings recorded a positive indication that Community Pharmacists know their roles in AMS programs as 62.2% of the community pharmacists agreed to educate patients/clients on the on antibiotics use and its consequent misuse as it relates to resistance. The possible reason for the disagreement could be attributed to differences in the sampling methodology or variations in the scope of practice and roles assigned to PPMVs and CPs.

In Summary, the survey results on the knowledge, attitudes, and practices of PPMVs and CPs regarding antimicrobial resistance and the use of antibiotics in Nigeria are consistent with previous studies on the topic. A systematic review of the role of proprietary and patent medicine vendors in Nigeria found that PPMVs are a main source of medicines for acute conditions and that many of them lack adequate knowledge and training in drug dispensing . Similarly Beyeler & Sieverding (2015), a study on the quality of information offered to women by drug sellers in Nigeria found that many PPMVs dispense misoprostol-containing medication for abortion without providing adequate information or follow-up care.

The results also highlight the need for better education and training of PPMVs and CPs on antimicrobial resistance and appropriate use of antibiotics. This is consistent with the finding of a study on the potential role of patent and proprietary medicine vendors in Nigeria (Treleaven et al., 2015, Beyeler & Sieverding, 2015), which recommended that PPMVs should be included in efforts to improve antimicrobial use and surveillance. Additionally, the finding that many PPMVs and CPs sell antibiotics without prescription underscores the need for stronger regulation and enforcement of drug dispensing practices in Nigeria. This is consistent with the promising high-impact practice in family planning that focuses on expanding contraceptive choice and access in the private sector (HIPs, 2021), including pharmacies and drug shops, through standards and accreditation programs.

CONCLUSION

The study demonstrates a deficit of knowledge and practice in pharmaceutical care among community pharmacists and Patent and Proprietary Medicine Vendors (PPMVs), as well as a lack of competence. The role of pharmacists in enhancing patient care necessitates regulatory authorities implementing rules and standards that allow them to provide pharmacological treatment in community settings.

RECOMMENDATIONS

The results show clear need to improve knowledge and practices regarding the use of antibiotics and prevention of AMR. For example, there should be more education and training on appropriate use of antibiotics and the dangers of AMR, and regulations should be put in place to prevent the dispensing of antibiotics without prescription. Providing patient education and follow-up after medication use may prevent misuse of antibiotics and contribute to the fight against AMR.

CONFLICTS OF INTEREST

All authors – none to declare.

FUNDING 

Financial support for this study was provided by Pfizer Independent Quality Improvement grant to Centre For Initiative and Development (CFID) NGO in Nigeria. Pfizer had no role in the study design or data collection, analysis, or interpretation. The authors have access to all study data and have final responsibility for the writing and decision to submit for publication.

ACKNOWLEDGMENT

The authors acknowledge all recruited CSOs, Communities and states of interest who actively participated in CAMS project activities.

Ethics approval and consent to participate

Ethics approval was received from the National Health Research Ethics Committee with NHREC Protocol Number: NHREC/01/01/2007-01/11/2021. Informed consent was obtained from each participants prior to the observation of any consultations. Consent was also obtained from Ministries of Health and Education in all the six target states, .

REFERENCES

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