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 Table of Contents  
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 175-180

A cross-sectional survey of community pharmacist's knowledge, behavior and attitude toward antibiotic dispensation, Southern Karnataka, India

1 Department of Microbiology, Kasturba Medical College, Mangalore, Karnataka, India
2 Department of Community Medicine, Kasturba Medical College, Mangalore, Karnataka, India

Date of Submission05-Dec-2020
Date of Decision15-Dec-2020
Date of Acceptance25-Jan-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. M Suchitra Shenoy
Department of Microbiology, Kasturba Medical College, Light House Hill Road, Hampankatta, Mangalore - 575 001, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_435_20

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Aim: The study was conducted to determine the knowledge, attitude/perceptions, and behavior of the community pharmacists in the Southern Karnataka district. Settings and Design: The study was a cross-sectional survey conducted with the help of a questionnaire containing open and close-ended questions and Likert-scale-based response items. Materials and Methods: Questionnaires were distributed to pharmacists by simple random sampling. Statistical Analysis: The data were analyzed by Fisher's test and Chi-square test for association between knowledge, attitude, and practices and sociodemographic categories. Results: Majority of the pharmacists considered the use of antibiotics in livestock and agriculture as the reason for antibiotic resistance. All of the pharmacists agreed that refusing to dispense antibiotics without prescription will negatively hit sales. Conclusion: It is imperative to educate pharmacists about rules and regulations regarding antibiotic dispensation. They need to be sensitized about the negative impact of nonprescription antibiotic use on antibiotic resistance and public health.

Keywords: Antibiotic resistance, attitude, behavior, community pharmacists, knowledge, nonprescription, over-the-counter

How to cite this article:
Bhardwaj K, Shenoy M S, Baliga S, Unnikrishnan B. A cross-sectional survey of community pharmacist's knowledge, behavior and attitude toward antibiotic dispensation, Southern Karnataka, India. J Datta Meghe Inst Med Sci Univ 2021;16:175-80

How to cite this URL:
Bhardwaj K, Shenoy M S, Baliga S, Unnikrishnan B. A cross-sectional survey of community pharmacist's knowledge, behavior and attitude toward antibiotic dispensation, Southern Karnataka, India. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 16];16:175-80. Available from: http://www.journaldmims.com/text.asp?2021/16/1/175/322639

  Introduction Top

Antibiotic resistance is a major problem. Many studies have highlighted that antibiotic sales without prescription are a potential factor for antibiotic resistance. On-demand prescription and over-the-counter availability may promote self-medication.[1],[2],[3],[4],[5],[6],[7]

As per the World Health Organization (2014), the majority of the countries did not have a plan for combating antibiotic resistance.[8] The use of antibiotics without a prescription leads to suboptimal drug use and incomplete courses.[9],[10],[11],[12],[13] Pharmacists can prove to be a resourceful healthcare professionals and take part in infection control campaign.[14]

Therefore, the present study was conducted to determine the knowledge, attitude, and practices of the community pharmacists in the Southern Karnataka district.

  Materials and Methods Top

Study design and setting

The study was a descriptive cross-sectional survey conducted among the community pharmacists in Dakshina Kannada, Karnataka, South India, from June 2017 to December 2017. Dakshina Kannada, also known as South Canara, is a district in the South coastal Karnataka with five subdistricts, Mangalore being the district headquarters. All types of community pharmacies - Single, chain, and hospital, were included in the study.

Sample size and sampling technique

Sample size was calculated to be 170 using STATCALC, EPI INFO (Atlanta, USA), version, where expected proportion of knowledge regarding antibiotic use and resistance was 50%, with 95% confidence interval, and 5% absolute precision.

By simple random sampling, study areas were selected from all the subdistricts of Dakshina Kannada. By population proportionate to size sampling method, pharmacies were selected from each study area until the quota was completed.

Data collection

Data were collected with the help of a pretested, validated, Likert-scale based self-administered questionnaire. The questions were both close-ended and open-ended. The questionnaires were distributed to the community pharmacists and pharmacy assistants and were completed either on the spot or collected on a mutually agreed time and day.

Questionnaire development

The questionnaire was based on previous studies related to the topic.[15],[16],[17],[18],[19],[20] It was tested for face validity and content validity by a panel of seven experts. Only those questions that had a content validity ratio (CVR) of 1 (as per the critical values for Lawshe's CVR)[21] were included in the final questionnaire. The questionnaire was available both in English and the local language Kannada.

The questionnaire had three parts. The first part included information on socio-demographics and professional characteristics such as pharmacy setting, type of pharmacy, educational qualification, and years of work experience. The second part consisted of general questions regarding the number of prescriptions dispensed and the number of antibiotic prescriptions dispensed per day.

The third part assessed the study participants knowledge regarding antibiotics and antibiotic resistance, and behavior, attitude/perceptions toward dispensing antibiotics without prescription. The knowledge section included five questions regarding antibiotic resistance, its causes, and dosing guidelines. The response options were yes/no and multiple-choice. In case of open-ended questions, they were given the option to explain. The behavior section included two questions regarding antibiotic dispensation. The attitude/perception section had four questions regarding antibiotic sales and the role of dispensing antibiotics without a prescription in antibiotic resistance. To measure the behavior, attitude/perception of the participants, the response options were based on a five-point Likert-like scale where 5 = strongly agree, 4 = agree, 3 = disagree, 2 = strongly disagree, and 1 = uncertain.

Statistical analysis

The data were coded and then analyzed with IBM SPSS software of statistics for Windows, version 20.0 (IBM, Armonk, New York, USA). Only those questionnaires that had all the questions answered were considered for analysis. Descriptive analysis was done and the categorical data were reported as median with inter-quartile range. Association of socio-demographic characteristics with participants knowledge was determined by Fisher's exact test. Behavior and attitude/perception questions were scored with each correct answer getting one and each wrong answer getting zero. Categories of behavior and attitude were made based on the scores - Adequate (score >70%), moderate (50%–70%), and poor (<50%). A Chi-square test with Yates correction was done to assess the association between socio-demographic characteristics and behavior and attitude toward dispensing antibiotics. P < 0.05 were considered statistically significant.

Ethical clearance

The study was financially supported by Department of Biotechnology, Ministry of Science and Technology, Government of India in the form of DBT scholarship(DBT/JRF/BET-16/I/2016/ AL08-438) for PhD scholars and Manipal Academy of Higher Education, Manipal, Karnataka, India in the form of contingency fund (MU/REG/CIR-(T), 26/10/2016) for PhD scholars to cover equipment, consumables, and publication costs.

  Results Top

Socio-demographic characteristics of respondents

Two-thirds (77.1%) of the pharmacists were graduates/postgraduates, 22.9% had pharmacy diploma. Sixty-nine percent of the pharmacists worked in an urban setting and 39% worked in a rural setting [Table 1].
Table 1: Baseline sociodemographic characteristics of study participants (n=170)

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Number of prescriptions dispensed

More than half (55%) of the pharmacists reported dispensing between 100 and 800 prescriptions per day, of which 200–300 consisted of antibiotics.

Knowledge of antibiotics and antibiotic resistance

Majority of the pharmacists (98%) reported being aware of the antibiotic dosing guidelines. All the graduates and above (100%) answered positively regarding antibiotic dosing guidelines. Among the diploma holders, 92.3% answered yes to awareness of antibiotic dosing guidelines. There was a statistically significant difference between graduates and above diploma holders regarding knowledge of antibiotic dosing guidelines, P = 0.011. Among those who had >5 years of working experience, 99% were aware of dosing guidelines [Table 2].
Table 2: Knowledge of pharmacists regarding antibiotics and antibiotic resistance across various sociodemographic categories

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When asked about explaining the antibiotic dosing guidelines, 97.4% of the graduates and 87.2% of the diploma holders did not respond. Among the 33 graduate/postgraduate respondents, 27% considered the age of the patient, 18% weight of the patient, 1.7% considered the health condition of the patient, while 0.8% each considered age, weight, and condition of the patient combined as a criterion for antibiotic dosage. Or all the five-diploma holders, age was the only factor for antibiotic dosage.

Among the two experience categories, 69.4% of those with 1–5 years of experience did not respond. Out of the 22 respondents, 20.8% explained age as the guideline for deciding antibiotic dose. Similarly, 83.7% of those with >5 years of experience did not respond to antibiotic dosing guidelines. Of the 16 respondents, 8.2% considered age as the deciding factor.

Only 9.9% of graduates/postgraduates were aware of the initiatives to promote prudent use of antibiotics. None of the diploma holders answered yes regarding the initiatives [Table 2].

Causes of antibiotic resistance

Explaining the causes of antibiotic resistance, 92.9% chose the use of antibiotics in agriculture and livestock as the reason, followed by noncompliance of prescribed dosage (62.3%), and use of broad-spectrum antibiotics (44.1%) [Figure 1].
Figure 1: The graph depicts causes of antibiotic resistance as selected by pharmacists

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Behavior toward dispensing antibiotics

About 71.2% of the pharmacists agreed to dispensing full dose of antibiotics and encouraging the customers to complete the course as directed by the doctor. About 71.7% of the pharmacists agreed to counseling patients to get a prescription before buying antibiotics [Table 3]. There was a statistically significant association between the type of pharmacy and pharmacy setting and antibiotic dispensing behavior (P = <0.001 and 0.004, respectively) with pharmacists working in single pharmacies and in urban areas showing adequate behavior compared to other pharmacists and in rural setting [Table 4].
Table 3: Behavior of pharmacists regarding antibiotic dispensation

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Table 4: Comparison of behavior of pharmacists regarding antibiotic dispensation across various sociodemographic categories

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Attitude and perception toward dispensing antibiotics without prescription

All the pharmacists (100%) agreed that refusing to dispense antibiotics without a prescription will have negative impact on sales. When asked whether dispensing antibiotics without a prescription can contribute to antibiotic resistance, only 9.3% agreed to the statement. Only 30% of the participants agreed to the statement pharmacists should stop dispensing antibiotics without prescription [Table 5]. No significant statistical association was found between sociodemographic characteristics and attitude toward antibiotic dispensation without prescription [Table 6].
Table 5: Overall attitude of pharmacists regarding antibiotic dispensation

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Table 6: Comparison of attitude of pharmacists regarding antibiotic dispensation across various sociodemographic categories

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  Discussion Top

This is the first study to evaluate community pharmacists' knowledge, attitude/perception, and behaviors toward antibiotic resistance, prescription, and dispensation in Dakshina Kannada. Given the high incidence of antibiotic dispensation without prescription, it is necessary to understand the community pharmacist's knowledge and attitudes to address this public health threat.

Our study demonstrated the insufficient knowledge of pharmacists and their assistants regarding antibiotic resistance, factors contributing to antibiotic resistance, and proper dosing guidelines. They were unable to explain any indications or dosing guidelines. Our study also showed that there was no significant association between pharmacist's education and working experience and their attitude and behavior toward antibiotic dispensation. A study done in Sri Lanka also demonstrated that there was no difference in antibiotic dispensation practices between pharmacists and pharmacy assistants.[22] Studies done in Thailand and rural Haryana, India indicated that pharmacists had poor knowledge about antibiotics and antibiotic resistance.[12],[23] This inadequate knowledge may be a result of lack of professional and clinical training.[24] The causes of antibiotic resistance given by pharmacists were excessive use in agriculture and livestock. They were unaware of the implications nonprescription antibiotic dispensation had on antibiotic resistance. Such results were also seen in a study done in Saudi Arabia.[20]

In our study, it was demonstrated that all the pharmacists agreed on the negative effect of refusal to dispense antibiotics on pharmacy sales. Similar results were also found in studies from Saudi Arabia, Sri Lanka, Egypt, Sudan, and Vietnam.[20],[22],[25],[26],[27] Increasing the sales, making a profit and the fear of losing customers may urge pharmacists to inappropriately dispense antibiotics.

In our study, 71.7% of the pharmacists stated that they counsel patients to get a prescription before buying antibiotics. Studies from other countries such as Jordan, Greece, and Lebanon[28],[29],[30] highlighted that a large proportion (32%–76%) of antibiotics were dispensed without a prescription.

Pharmacists that are properly trained and have adequate knowledge of antibiotic resistance, their use and misuse; and dispensing regulations may help reduce unwanted antibiotic use. In order to control antibiotic resistance, it is important that pharmacists are continuously educated and trained, pharmacy curricula revised and antibiotic dispensing regulations should be strictly implemented.[10]

In our study, participants representative of a large population were randomly selected, but since the study involves self-administered questionnaires, there are some limitations. Only those who could read and write participated in the study. This selection bias excludes many people and may limit the generalization of the study to a large population.

[TAG:2]Conclusion [/TAG:2]

It is important that pharmacists and pharmacy staff's knowledge of antibiotics, antibiotic resistance, dosing guidelines, use, and misuse be improved. It is also important that dispensing regulations are strictly enforced. Pharmacists should be made aware of the initiatives that promote prudent antibiotic use. They should be provided with policies and guidelines that regulate antibiotic dispensation.


We express our sincere gratitude to all the participants for taking part in the survey.

Financial support and sponsorship

The study was financially supported by Department of Biotechnology, Ministry of Science and Technology, Government of India in the form of DBT scholarship (DBT/JRF/BET-16/I/2016/AL08-438) for PhD scholars and Manipal Academy of Higher Education, Manipal, Karnataka, India in the form of contingency fund (MU/REG/CIR-(T), 26/10/2016) for PhD scholars to cover equipment, consumables, and publication costs.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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