Perspectives of pharmacy staff on dispensing subtherapeutic doses of antibiotics: a theory informed qualitative study

Background Injudicious dispensing of antibiotics in subtherapeutic doses is common in many developing countries. In Egypt, as in many developing countries, a few pills of common cold products are offered under the name cold group (CG). A cold group may contain one or more pills of antibiotics. A pharmacy client may obtain subtherapeutic doses of antibiotics upon direct request or as part of a CG. Objective To examine factors associated with the unwarranted dispensing of subtherapeutic doses of antibiotics in community pharmacies as part of a CG or upon direct request from patients among community pharmacy staff. Setting Community pharmacy staff in Alexandria, Egypt. Methods Semi-structured interviews were conducted with a purposeful sample of community pharmacy staff. An interview guide was developed based on the theory of planned behavior. Constructs related to attitudes, subjective norm, perceived behavioral control and perceived moral obligation were explored. Directed content analysis was conducted using interview data which were recorded and transcribed verbatim. Main outcome measures Community pharmacy staff’s views on factors associated with the unwarranted dispensing of subtherapeutic doses of antibiotics. Results Nine Pharmacists and six pharmacy assistants were purposively sampled to assure variance in age, gender, time in practice and socioeconomic status of patients served by their corresponding pharmacies. Factors contributing to dispensing antibiotics injudiciously included incorrect beliefs about potential benefit of antibiotics, profit, client pressure, ease of obtaining antibiotics from other pharmacies, inadequate enforcement of the law, pharmacist absenteeism, and assuming that the ‘nonmalfeasance’ principle is not violated. Reasons for lying to clients about the actual content of CGs included protecting the patient from harm resulting from antibiotic resistance and avoiding a possible argument. Conclusions Examining constructs related to pharmacy staff’s attitude, subjective norm, perceived behavioral control as well as perceived moral obligation provided insight into community pharmacy staff’s behavior related to dispensing subtherapeutic doses of antibiotics. Multi-tiered interventions are urgently needed to tackle different factors contributing to this dangerous practice.