Assessing Antimicrobial Stewardship: A Survey of Distribution Practices in Dispensaries in Ghana

Abstract

Introduction

The extent of antimicrobial stewardship practices remains uncertain in Ghana, a context where health care frequently takes place at the community level, and in private sector entities. Private medicine vendors have previously been identified as disproportionate drivers of antimicrobial misuse fueling the emergence of antimicrobial-resistant pathogen outbreaks. This study sought to assess antimicrobial distribution in dispensaries in Accra, Ghana, to determine patterns in risk for antimicrobial misuse.

Methods

A 72-question survey questionnaire explored the backgrounds, behaviors, and medicine dispensation patterns of dispensaries’ staff (shopkeepers). The survey also assessed economic indicators of the surrounding community, alongside an inventory of sales trends, prices, medications, and neighborhood-level socioeconomic condition. The survey was conducted with 83 pharmacies and chemical shops.

Results

We found that the type of medication most relied upon varied by location. The frequency of antibiotic and antimalarial sales varied widely, with average estimates that antibiotics represented 27% of sales in pharmacies. A majority of respondents asserted that medical decision-making is primarily navigated based on the amount of money on hand for a customer. Shopkeepers exercised a variety of strategies to respond to customers' insufficient funds, the most central of which was a practice of offering progressively lower-cost, generic-brand medicines. Misuse of antimicrobials appears to be relatively limited, but may still occur via over-prescription, unqualified dispensing practices, and the use of subtherapeutic quantities of antibiotics. Over 50% reported occasionally selling incomplete treatment courses to customers unable to pay for an entire course at once.

Discussion

Respondents revealed an overall intention to judiciously guard antibiotics, but a lack of systemic interventions, given competing forces. Key findings suggested that middle-income neighborhoods faced the highest risk of antimicrobial overuse, driven by patient-level expectations, mixed economic access, and weaker stewardship practices by shopkeepers. The findings of this study offer a more recent and detailed outlook on antimicrobial use than prior works in this context.

Conclusion

Shopkeepers' understanding of clients' preferences and disincentives for purchase can inform interventions in the scope of user behaviors. Expanding the diagnostic, health surveillance, and treatment capacity of shopkeepers shows promise for public health interventions seeking to improve stewardship of antimicrobials at the community level.