What motivates antibiotic dispensing in accredited drug dispensing outlets in Tanzania? A qualitative study

Our study sample included 84 respondents, 51 (61 %) of whom were women and 33 (39 %)
men. As planned, we conducted seven interviews in each study group and in each study
district, except in Mbinga, where we interviewed six ADDO owner-dispensers and eight
ADDO dispenser-not owners because of challenges in tracking down ADDO owners who are
also dispensers.

Results are presented in the following five categories: 1) knowledge about treatment
guidelines, 2) motivation behind antibiotic dispensing, 3) medicine use and antimicrobial
resistance, 4) referrals for pneumonia cases, and 5) for the ADDO owners, perceptions
about AMR and their role in the community.

Knowledge about treatment guidelines

We assessed knowledge of disease management in ADDOs as per the IMCI and adult training
manual for ADDO dispensers 24]. Dispensers were asked to explain treatment guidelines for ARI and diarrheal diseases.

Severe pneumonia

For treatment of severe pneumonia, the standard treatment protocol for ADDO dispensers
recommends providing an antibiotic and then immediately referring the case to a health
facility.

Nearly all ADDO dispensers (55/56) in all study regions were able to correctly explain
the management of severe pneumonia, “I don’t handle severe pneumonia here. Health facility is very close, when I receive
such cases, I immediately refer a patient to health facility, although I currently
don’t have referral forms” (dispenser and owner, Tanga). Another respondent said, “I will give her antibiotics and insist that she finishes the dose. I will also advise
her to go to health facility if no improvements” (dispenser and owner, Mbinga district).

We observed several differences in knowledge between rural and urban settings. More
owner-dispensers in the urban areas of Tanga and Songea (10/14) correctly explained
the management of severe pneumonia than those in the rural Mbinga and Muheza districts
(7/13).

Pneumonia

Standard treatment protocols for pneumonia at the ADDO require provision of antibiotics
and referral to a health facility in the case of danger signs, such as fast or difficult
breathing. As with severe pneumonia, a higher proportion of dispensers (27/28) in
the urban areas of Tanga and Songea knew how to manage pneumonia compared to those
working in the rural areas of Mbinga and Muheza (21/27). “If it is a child, I will give her antibiotic syrup, and if it is an adult, I will
provide her with antibiotics in the form of tablets” (dispenser and owner, Songea urban).

Non-pneumonia cold/cough

The standard treatment for non-pneumonia cough at the ADDO is paracetamol for fever
and headache and an appropriate remedy to soothe the cough. We observed discrepancies
between districts. While the majority of ADDO dispensers appropriately explained treatment
of non-pneumonia cold/coughs (21/28), four of seven dispensers in Muheza district
reported that they would dispense antibiotics to clients with non-pneumonia coughs.
“I will give her Septrin or amoxicillin or Pen-V” (dispenser, Muheza district).

Non-bloody diarrhea

The standard treatment for non-bloody diarrhea at ADDO is ORS and zinc—not antibiotics.
Interestingly, all dispensers in the Tanga urban and Mbinga rural districts understood
how to correctly manage non-bloody diarrhea, while fewer in Songea urban (4/7) and
Muheza rural (4/7) knew the recommended practice. “Because with diarrhea, one loses a lot of water, so I will provide him with ORS; you
cannot provide antibiotics, it will not treat the patient” (dispenser, Mbinga district). All owner-dispensers in all study districts knew the
correct management practices with the exception of Muheza (4/7).

Bloody diarrhea

Blood in the stool likely indicates dysentery for which standard treatment protocols
recommend antibiotics. Knowledge of the recommended treatment was also quite high;
almost all respondents (54/56) correctly explained how ADDO dispensers should manage
bloody diarrhea. “For someone who is having bloody diarrhea, he definitely has bacteria that goes and
destroy intestines; I would dispense an antibiotic like erythromycin that will treat
the patient” (dispenser, Muheza).

Motivation behind unnecessary antibiotic dispensing

Given the generally widespread knowledge about correct practices for these illnesses,
we sought to learn from dispensers why they often dispense antibiotics for non-pneumonia
coughs and simple diarrhea. While acknowledging continued overuse, almost all respondents
felt that unnecessary antibiotic dispensing had significantly declined compared to
the time before drug shops were accredited. We noted small variations in responses
across regions, particularly regarding the specific reasons for unnecessary antibiotic
dispensing.

Customer preference

86 % of dispensers interviewed (48/56) reported that customers prefer to purchase
antibiotics for non-pneumonia coughs and for non-bloody diarrhea (41/56, 73 %). “You know the clients communicate among themselves; they tell each other that antibiotics
treat cough, so when they come here, they specifically ask for antibiotics” (dispenser, Tanga urban). Half of ADDO dispensers claimed to intervene by educating clients on the correct
treatment for non-pneumonia coughs/colds and simple diarrhea and on the fact that
antibiotics do not treat such health problems. However, respondents also admitted
that when clients demand what they want that dispensers frequently end up adhering
to their wishes.

Dispense according to health facility prescription

Another frequently mentioned reason for dispensing antibiotics for non-pneumonia coughs
was following the prescriptions they get from health facilities. This was recounted
by 23 of 29 (79 %) dispensers and 12 of 27 (44 %) owner- dispensers for non-pneumonia
cough and 18 of 29 (62 %) dispensers and 7 of 27 (26 %) owner- dispensers for non-bloody
diarrhea.

We wanted to learn if dispensers ever intervene when they receive an incorrect health
facility prescription. Less than half of dispensers reported sending the clients back
to the facility for a new prescription or asking them to buy the prescribed medicines
from other ADDOs. More dispensers in Ruvuma region than Tanga region said they challenged
wrong prescriptions from health facilities, but not always with positive results.
“Yes, we send them back to health facility, but again they insult us that we are just
dispensers, we don’t have any medical knowledge and that what the doctor has decided
we should follow; it is not easy” (dispenser and owner, Songea urban). “It is difficult to challenge what the doctor has prescribed; people respect doctors
a lot. A day before yesterday, a child aged three months was brought with antibiotic
prescribed for cough problem. I refused to provide an antibiotic. I sent the parent
back to the health facility. I am not sure if she went back or not” (dispenser and owner, Songea urban). Sixty-eight percent of respondents (38/56) reported
that they always adhere to doctors’ prescriptions. “You cannot go against the doctor’s prescription. He has the last say, even when we
see the prescription is wrong; you just give the client what is written” (dispenser, Muheza district).

Business reasons

Respondents also reported that they sometimes dispense antibiotics inappropriately
to finish the shop’s medicine stock or to make more profit on expensive medicines
(i.e., antibiotics). Seventy-seven percent of dispensers (43/56) reported these reasons
for dispensing antibiotics for non-pneumonia coughs and 71 % (40/56) for non-bloody
diarrhea. Of note, many dispensers accused ADDO owner-dispensers of these practices
to increase income. Some dispenser-not owners (5/29) admitted to receiving pressure
from their owners to sell more antibiotics—although only 9 of 27 owner-dispensers
reported ever having had heard of the practice.

Common practice

Over three-quarters of dispenser-not owners (23/29) admitted that it is just common
practice (“mazoeza”) for them to dispense antibiotics for non-pneumonia coughs. A smaller proportion
of owner-dispensers admitted this reason (11/27).

Medicine use and antimicrobial resistance

More than 90 % of study respondents reported that they saw AMR as a consequence of
unnecessary use of antibiotics. Some expressed the view that when antibiotics are
administered unnecessarily, the medicine can lose its strength and fail to treat.
“It causes drug resistance and kills white blood cells” (dispenser and owner, Mbinga district). “You can be surprised, someone will use and use and use, but he will not get treated,
because the medicine is already resistant” (dispenser, Tanga urban).

Failure to refer pneumonia cases

We questioned dispensers about their reasons for not providing referrals for pneumonia
cases, as recommended in their training. We noted variations in responses between
the two regions. More Ruvuma dispensers (23/28) than their Tanga counterparts (12/27)
disclosed that business is the main factor driving their referral decisions, because
referral means no income. “They want to make money, raise income….that is the reason referrals are not provided” (dispenser, Songea urban). Other reasons reported included laziness and community
affordability, as the following comments illustrate: “There are times when dispensers feel lazy to fill referral forms so they just dispense
medicines” (dispenser and owner, Songea urban). “Other customers may come and want to take medicine on loan basis, so if you tell
them to go to health facility, they will not go because they do not have money, so
you just give them medicine” (dispenser and owner, Songea urban).

In Tanga region, respondents mentioned that there are no referral forms at the outlets,
while others felt that they did not need to refer pneumonia patients because they
have satisfactory knowledge about how to treat the condition. Fear of losing trust
from the community was another factor reported in rural Muheza and Mbinga. “People trust us as professionals, so when you give referral, they question your ability,
and your status might go down…besides we have all medicines to treat severe pneumonia” (owner and dispenser, Muheza).

ADDO owners’ perceived roles

We were specifically interested to learn from ADDO owner-not dispensers about their
perceived roles in the community and their perceptions about antibiotic dispensing
and AMR.

Of 28 owners interviewed, 26 (93 %) perceived their outlets as a place where community
members can access medical services and advice. They felt that their main responsibilities
as owners were to ensure that essential medicines are available in their outlets,
that medicines are of good quality, that expired medicines are not on the shelves,
and that their business increases.

When asked what kinds of medicines they sold most in their outlets, antibiotics were
mentioned by more than half of owners, followed by antimalarials and painkillers.
Sixty-one percent of owners (17/28) attributed the practice of dispensing antibiotics
without doctor’s advice to customer preference. “You know, we have problems with customers. When they come, they always demand antibiotics” (owner, Tanga urban).

Almost all owners mentioned antimicrobial resistance as one effect of the unnecessary
use of antibiotics. Moreover, 95 % of owners (26/28) reported that their dispensers
manage various health problems by following treatment guidelines.

Regarding changes in antibiotic sales after the ADDO program was implemented, respondents
reported mixed views. Overall, 17 of 28 (61 %) perceived that antibiotic sales increased
after the ADDO program began because antibiotics were previously not allowed to be
sold in the shops. “It is true after ADDO program, we now have more antibiotics which we are allowed to
sell compared to the period during Part II drug shops; it is not that they are sold
unnecessarily, but because they are there, people can have easy access” (owner, Songea urban).

The remaining owners (11/28, 39 %) thought that antibiotic sales are lower now because
they need to be dispensed with doctor’s prescriptions. “You know before the ADDO program, dispensers were selling antibiotics illegally, but
now, it is hard to be sold an antibiotic without prescription” (owner, Mbinga).