Socio-demographic characteristics
A total of 1,100 licensed pharmacists were contacted and requested to fill the questionnaire through an online invitation link. A total of 226 (20.5%) responses were recorded, of which 213 responses were complete and used for analysis. Out of 213 respondents, 148 (69.5%) were males and 65 (30.5%) were females.
The highest education level for most of the respondents was a bachelor degree in pharmacy 164 (77.0%), 46 (21.6%) had masters and only 3 (1.4%) respondents were PhD holders. Out of 211 pharmacists, 195 (92.4%) pharmacists completed their bachelor studies in Tanzania, 9 (4.3%) in India and the rest 7 (3.3%) from other countries.
Out of 211 respondents, 134 (63.5%) work in community pharmacies where 14 (10.4%) were owners, 89 (66.4%) were dispensing pharmacist and 31 (23.2%) were both owner and dispensing pharmacists. The majority, 68 (51.9%) of the respondents work in community pharmacies that are located in Dar es Salaam region, 12 (9.2%) in Mwanza while Arusha region, Mara region, Mbeya region and Tanga region each contributed 5 (3.8%) of responses from community pharmacies in respective regions. The summary of social demographic data of the respondents is in Table 1.
Pharmacists’ knowledge
Ten questions covering legal requirements for dispensing antibiotics and knowledge of AMR were asked and scored. The items assessed if a pharmacist was aware of different rules, regulations and laws that govern the dispensing of antibiotics. The questions also were designed to evaluate if pharmacists know about AMR as one of the consequences of dispensing antibiotics without prescription. Each correct answer was given a score of 10 points, after which an overall score was calculated per respondent. The maximum score was 100 points, while the minimum score was 20 points. A Likert scale was used to categorize knowledge whereby those who scored 80-100 points were labelled as excellent knowledge, 60-70 points were labelled very good knowledge, 40-50 points were labelled good knowledge while those who scored 20-30 points were regarded to have poor knowledge and 0-10 points were labelled very poor knowledge (Figure 1).
The responses of pharmacists to questions assessing knowledge were as follows: 79.7% of respondents were aware that the dispensing of antibiotics without prescription is illegal in Tanzania and 20.3% did not know that the practice is illegal. 114 (53.8%) pharmacists were not sure if there is a penalty to a person who dispenses without prescription. More than 90.0% of pharmacists agreed that dispensing without prescription contributes to the irrational use of antibiotics and the development of AMR. 75.1% of pharmacists had overall excellent knowledge, 17.4% very good knowledge and 3.3% poor knowledge (Figure 1).
Pharmacists’ attitude towards dispensing of antibiotics without prescription
Five questions were asked to assess pharmacists' attitudes on dispensing antibiotics without prescription. Each response was scored 10 for the positive attitude and 0 scores for a negative attitude. The overall score was recorded and those who scored 30-50 out of 50 were labelled to have positive attitude while those who scored less than 30 out of 50 were considered to have a negative attitude on dispensing antibiotics without prescription.
Concerning pharmacists' attitude, 38.8% (82) had a negative attitude while 61.2% (129) pharmacists had a positive attitude on dispensing antibiotics without prescription. A positive attitude was for the ones who thought dispensing without prescription should be stopped as it has negative consequences to the patient and society in general, and other related questions, as shown in table 2.
Pharmacists practice
Out of 212 pharmacists, 156 (74%) agreed that they do dispense antibiotics to a patient without a prescription in their practice and 56 (26%) denied to dispensed antibiotics without prescription. A large proportion of pharmacists who work in community pharmacies dispense without prescription more than those who do not work in community pharmacies (p<0.001). Education level was observed to influence the practice as 85.7% (42/49) pharmacists with high education (masters and PhD holder) admitted to dispensing without prescription compared to 69.9% (114/163) bachelor holder who dispenses without prescription (chi-square p-value of 0.028). This suggests that with the increase in the education level, the more a pharmacist feels confident to dispense without prescription. There was a strong association between pharmacists' attitudes and dispensing without prescription (p<0.001). Age (p=0.651), experience (p=0.707) and country of graduation (p=0.394) had no statistical association with the dispensing of antibiotics without prescription. More than 60.0% of pharmacists claimed to counsel their customers about drug-drug/food interaction and insist patients adhere to the dispensed course of medication.
Out of the 156 pharmacists who admitted to dispensing antibiotics without prescription, 95 (60.9%) promised to stop this practice in the future. They felt this was a bad practice that contributes to the irrational use of antibiotics and has the potential to influence the development and spread of AMR. 57 (36.5%) pharmacists denied to stop the practice even in the future as they regarded the practice to be helpful to the patient and pharmacists being knowledgeable can help a patient to get the right antibiotics even without laboratory tests and a prescription. Some of the reasons which were given out by pharmacists for stopping and not stopping dispensing antibiotics without prescription in the future are summarized in table 3.
Reasons for dispensing without prescription were also revealed. Some of the reasons were attributed to pharmacists to dispense without prescription, included pharmacists thinking that they are knowledgeable enough to dispense without prescription 150 (71.1%), pharmacists being in close relationship with a customer who needs antibiotics 106 (50.5%) and business nature of pharmacy that focuses on making more profit. Out of 210 pharmacists, 140 (67%) think that pharmacists will stop dispensing antibiotics without prescription if there could be a regular inspection by regulatory authorities like the Pharmacy Council and the TMDA.
Patients based reasons included that push patients to visit pharmacies without a prescription asking for antibiotics when they are sick were noted. The leading causes were the fear of spending many hours during the patients' visit to the health facilities and wait for a consultation to complete (79.0%). The next leading cause was the inability of patients to afford consultation fee and cost for a laboratory test. in Tanzania. The light-blue colour portion agreed to dispense antibiotics without prescription, while the red part denied.
Classes of antibiotics that are mostly dispensed without a prescription
Pharmacists responded to the question that asked what antibiotics would they readily and easily dispense to a patient without a prescription suffering from suspected bacterial infection by selecting from the list. A respondent was allowed to choose more than one class of antibiotics that he/she will feel comfortable to dispense to a patient who has no prescription.
Regarding the type of antibiotics, the pharmacist would readily dispense to a patient suffering from suspected bacterial infection without a prescription. Penicillins 169 (79.3%) was the most selected class of antibiotics, followed by macrolides 86 (40.3) and fluoroquinolones 69 (32.4%) (Figure 3).
Medical conditions to which antibiotics are commonly administered without a prescription
Pharmacists mentioned some diseases to which antibiotics are usually dispensed without a prescription. The leading conditions were urinary tract infection 149 (70.0%), cough 115 (54.0%) and sexually transmitted diseases 87 (40.8%) (Figure 4).