RIFT VALLEY UNIVERSITY

FACULTY OF HEALTH SCIENCE

DEPARTMENT OF PHARMACY

NON PRESCRIBING ANTI MICROBIAL USE AND ASSOCIATED FACTORS

AMONG CUSTOMERS IN DRUG RETAIL OUTLET IN ADAMA TOWN,
EAST SHOA ZONE, OROMIA REGIONAL STATE, ETHIOPIA

By:
MESFIN MAMUYE
MOHAMMED JEMAL
BINIAM KEFALEW
BAHILU LEMMA
KASECH LEMMA

A RESEARCH PROPOSAL SUBMITED TO THE DEPARTMENT OF

PHARMACY FACULTY OF HEALTH SCIENCE, RIFT VALLEY
UNIVERSITY IN PARTIAL FULFILLMENT FOR THE REQUIREMENT
FOR BACHELOR DEGREE IN PHARMACY

ADVISOR: TAREKEGN TADESSE

JULY, 2019
ADAMA, ETHIOPIA
 ABSTRACT
Background: Non-prescribed antimicrobial use and their resistance are among the main public
health problems, worldwide. In Ethiopia, particularly in the eastern part, the range of non-
prescribed antimicrobial use and its major determinants is not yet well known. Thus, this study
was done to assess the magnitude of non-prescribed anti-microbial use and associated factors
among customers in drug retail outlet Adama town, east shoa, Oromia, Ethiopia.

Methods: A drug retail outlet based cross-sectional study was conducted among 423 adults aged
18 years and above. A multistage sampling procedure was used to select study participants. Data
was collected using semi structured interviewer administered questionnaire by druggists under
the supervision of pharmacists. Data entry was done by epi info version 7 and analyzed by SPSS
version 20. The analyzed data was presented through table, graph and paragraph forms. Binary
logistic and multi variable logistic regression model were used to identify associated factors.

Results: A total of 423 customers in different drug retail out let were included with response rate
of 100%. Out of study participants around 152(35.9%) came to drug retailer outlets with
systemic disease. The prevalence of non-prescribed antimicrobial use was 52.01 % (95% CI:
47.5-56.7). Among many possible factors being rural residence [AOR]: 1.85(1.84, 4.09),
distance of health facility 5 kilometer away from home [AOR]: 3.96(2.05, 7.64), delayed waiting
time in governmental health facilities [AOR]: 3.310(1.27, 8.63) independently associated factors
with non-prescribed antimicrobial use.

Conclusion and recommendation: The magnitude of non-prescribed antimicrobial use was

high. Being rural residence, delayed waiting time in governmental health care facilities and
distance >5 km from health facility was independently associated with non-prescribed
antimicrobial use. We recommend all customers in drug retail outlet to avoid irrational use of
non- prescribed anti-microbial and government to set law and policy enforcement regarding the
sale of antibiotics without a valid prescription should be in place.

Keywords: Antimicrobial, Magnitude, Non-prescribed, Drug retail outlets

i
 Acknowledgement
Above all, we would like to thank our almighty God for allowing us to accomplish this study
successfully. Secondly, we are very much grateful to our advisor Mr. Tarekegn Tadesse who
has spent his precious time in guiding us while developing this proposal. Special gratitude
should also goes to our friends and families for their support, kindness, encouragement and great
patience all the time in the developing this proposal.

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Table of contents

Table of Contents
ABSTRACT ................................................................................................................................................... i
Acknowledgement ........................................................................................................................................ ii
List of table ................................................................................................................................................... v
List of figure ............................................................................................................................................. vi
Abbreviation ........................................................................................................................................... vii
1. INTRODUCTION .................................................................................................................................... 1
1.1 Background ......................................................................................................................................... 1
1.2 Statement of the Problem .................................................................................................................... 3
1.3 Significance of the study ..................................................................................................................... 4
2. LITERATURE REVIEW. ........................................................................................................................ 5
3. OBJECTIVE ............................................................................................................................................. 7
3.1 General objective ................................................................................................................................ 7
3.2 specific objective ................................................................................................................................ 7
4- METHODS & MATERIALS ................................................................................................................... 8
4.1 study area and period .......................................................................................................................... 8
4.2 study design ........................................................................................................................................ 8
4.3 population ........................................................................................................................................... 8
4.3.1 Source of population .................................................................................................................... 8
4.3.2 Study population .......................................................................................................................... 8
Inclusion criteria ........................................................................................................................................... 8
Exclusion criteria .......................................................................................................................................... 8
4.4 Sample size determination .................................................................................................................. 9
4.5 Sampling techniques ......................................................................................................................... 10
4.6 Variables............................................................................................................................................ 11
4.6.1 Dependent variables ................................................................................................................... 11
4.6.2 Independent variables ................................................................................................................ 11
5. DATA COLLECTION PROCEDURE ................................................................................................... 11
5.1 Data collection instrument ................................................................................................................ 11
5.2 Data quality Assurance ..................................................................................................................... 12

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 5.3 Data processing and analysis ............................................................................................................ 12
5.4 Ethical considerations ....................................................................................................................... 12
5.5 Operational Definition ...................................................................................................................... 12
5. RESULT ................................................................................................................................................. 14
5.1 Sociodemographic characteristics of antimicrobial users in drug retailer outlets ........................... 14
5.2 Types of illnesses reported, magnitude of non-prescribed antimicrobial use and its mechanism .. 15
5.3 Factors associated with non-prescribed antimicrobial use .............................................................. 19
6. DISCUSSION............................................................................................................................................. 21
7. CONCLUSION AND RECOMMENDATION ................................................................................................ 23
7.1. CONCLUSION.................................................................................................................................... 23
7.2. RECOMMENDATION ........................................................................................................................ 23
8. REFERENCES ............................................................................................................................................ 24
Appendix I: QUESTIONNAIRE ................................................................................................................ 29

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 List of table
Table 1: Socio-demographic characteristics of antimicrobial users in drug retailer outlets in

Adama Town, Oromia, Ethiopia, 2019 (n=423) ........................................................................... 14

Table 2:Type of illness reported, anti-microbial drug received and health related factors among

customers in drug retailer outlets in Adama town, Oromia, Ethiopia, 2019 (n=423) .................. 15

Table 3:Health care services use and knowledge of antimicrobial among customers in drug

retailer outlets in adama town ,Oromia,2019 (n=423) .................................................................. 17

Table 4:Bivariable and multivariable logistic regression analysis of factors associated with non-

prescribed antimicrobial use among customers in drug retailer outlets in Adama Town, Oromia,

Ethiopia, 2019 (n:423) .................................................................................................................. 20

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 List of figure
Figure 1 Multistage sampling techniques at Adama town ,East shoa, oromia, Ethiopia,2019 ................... 10
Figure 2; magnitude of non-prescribed antimicrobial use ......................................................................... 16
Figure 3:Type of drug which purchase from pharmacy without prescriptions .......................................... 18

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 Abbreviation
AOR: Adjusted odd ratio

CI: Confident interval

COR:crude odd ratio

EU: European Union

LMIC: Low and Middle Income Countries

NGO: Non-governmental organization

OTC: Over the counter

OPD: Outpatient department

P: Prevalence

POM: Prescription only medicine

WHO: World health organization

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 1. INTRODUCTION
1.1 Background
As stated in World Health Organization (WHO, 2016) report Non-prescribed antimicrobial use
refers to the use of medicines to treat self-diagnosed disorders without consulting a medical
practitioner and any medical supervision [1]. These medicines are essential in medical health
care system, especially in the resource scarcity settings where infectious diseases are common
causes of deaths [1,2]. Low coverage in availability and accessibility of the healthcare delivery
systems due to inequitable health care distribution, high costs, lack of health care professionals,
unregulated and un monitoring distribution of medicines, patient attitudes towards physicians are
some of the key drivers of misuse of anti-microbials in the resource scarce settings (2).

Globally, non-prescribed antimicrobial drugs use even for non-bacterial diseases are the most
commonly practiced or oversight by health-care professionals [5, 6]. The immediate
consequences of non-prescribed antimicrobial drugs use include; short duration of treatment,
inadequate dose, sharing of medicines, stopping treatment upon the improvement of disease
symptoms [7]; adverse drug reactions and masking of underlying infectious processes [3, 5, 8].

The potential harms of antibiotic use, especially the emergence of resistant pathogens, are
garnering increasing global attention. A major driver of antimicrobial resistance is the misuse of
antibiotics (3). Community antimicrobial resistance rates are high in communities with frequent
use of nonprescription antibiotics (4). The World Health Organization encourages prescription-
only use of antibiotics in an effort to improve the rational use of antimicrobials (5).
Nonprescription use may be of concern for the development of resistant organisms because it
may involve very short courses, inappropriate drug and dose choices, and unnecessary therapy
(4). Other potential problems associated with nonprescription use include adverse drug reactions,
drug interactions, masking of underlying infectious processes, super infection, and other harms,
including the effect of antibiotics on micro biota.

It is estimated that more than 50% of antibiotics worldwide are purchased privately without a
prescription, from pharmacies or street vendors in the informal sector. The situation in
developing countries is of particular concern because the use of antibiotics without medical
guidance is largely facilitated by inadequate regulation of the distribution and sale of prescription

1
drugs.(5,6). Self-medication has also been noted in the United States of America and Europe,
particularly for colds and upper respiratory tract symptoms, which are self-limiting and mostly
caused by viruses. Other sources of nonprescription antibiotic use may include antibiotics “left
over” from previous treatment courses or obtained from relatives or friends. Intended use
(intention to use antibiotics without a prescription or medical guidance) and storage of unused
antibiotics at home are facilitating factors for actual nonprescription use. In a study including 19
European countries, intended self-medication and storage of antibiotics were strong independent
predictors of actual nonprescription use in the past 12 months (10)

We estimated the prevalence’s of nonprescription antibiotic use, intended use, and storage of
antibiotics in a socioeconomically and ethnically diverse sample of adult patients from private
and public primary care clinics. We also examined patient characteristics associated with
nonprescription use, the types of antibiotics used, the sources of nonprescription use, and the
symptoms for which the antibiotics were reportedly used. Community pharmacies that dispense
antibiotics without a medical prescription are important stimulators for self-medication. In
countries where the sale of over-the-counter(OTC) drugs is prohibited but not enforced, like in
many Latin American countries, self-medication with antibiotics is common (5). Moreover, in
the EU where OTC sales of antibiotics is illegal, it occurs frequently in some countries such as
Spain or Greece (12–13). Besides OTC selling, other opportunities to obtain antibiotics without a
prescription are buying antibiotics over the internet or the use of leftovers from family or friends
or from previous courses. Overall, the use of leftovers was most prevalent in Southern, Northern
and Western European countries whereas obtaining antibiotics at the pharmacy without a
prescription was the major source for self-medication in Eastern European countries (11).

As self-medication with antibiotics is an alarming phenomenon which appears in different forms

and can have negative public health effects, it is important to identify determinants that drive
patients to use antibiotics without a medical prescription. When examining these determinants it
is essential to use a broad perspective by focusing on multiple levels. Within the healthcare
context determinants can be found at three levels: the patient level (e.g., the behavior of
individuals), the healthcare professional level (e.g., services provided by healthcare
professionals), and the healthcare system level (e.g., legislation).

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1.2 Statement of the Problem
Among the possible adverse consequences of self-medication are those to individual patients,
which include misdiagnosis and missed diagnoses, misuse of drugs (including unintentional
access by children) and increased risk of adverse reactions and drug interactions, particularly in
children, the elderly, the pregnant and those with pre-existing disease. Antibacterial use is,
however, unique in that it has the potential to harm society in general (as well as individual
patients self-medicating) by decreasing sensitivity to antibacterial. There is also the potential of
lost data on the epidemiology of resistance should antibacterial use extend beyond the existing
prescribing arrangements (14).

This will be because the potential for greater use or misuse is more likely with antibacterial, and
antibacterial resistance is currently of major public and professional concern. The principles we
have set out for the use of antibacterial for self-medication could, however, also apply to other
classes of antimicrobials. The EC has defined the characteristics of a drug which justifies POM
status. This directive indicates broadly that medicines should be available without a prescription
unless there is a good reason why this should not be the case. Many drugs for treating infections
could qualify on safety grounds by these criteria. However, antimicrobial drugs have particular
characteristics. (i) If they are used incorrectly the individual patient may not be harmed, but with
excessive use in the community they may ultimately have reduced usefulness because of drug
resistance. (ii) In the lay mind an ‘antibacterial’ may be viewed as suitable for all infections (and
many patients will in the past have been prescribed the same antibacterial for a variety of
illnesses). Therefore the agent may be inappropriately used, treatment courses fail to be
completed or the drug hoarded and inappropriately used in the future by the purchaser or another
person.

The prevalence of non-prescribed antimicrobial use is widely affected by improvement in

people’s education, general knowledge and socio-economic status. In Low and Middle Income
Countries (LMICs), educational interventions, improving access to quality of public healthcare,
and enforcement of regulations on non-prescribed medicine use could help mitigate the challenge
of antimicrobial use and resistance.

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1.3 Significance of the study
✓ A determinant described in this article can be used in interventions to reduce the use of
non-prescription antibiotics.
✓ The most antimicrobial use occurs outside of hospitals. Interventions to preserve the
effectiveness of antimicrobials have focused on hospitals or providers thereby missing
non-prescription antimicrobial use.
✓ Obtaining baseline data on the use of non-prescribing use of antimicrobials in Adama
town study area.

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 2. LITERATURE REVIEW.
Self-medication can be defined as the use of drugs to treat self-diagnosed disorders or
symptoms, or the intermittent or continued use of a prescribed drug for chronic or
recurrent disease or symptoms.

Self-medication involves obtaining medicines without a prescription, resubmitting old

prescriptions to purchase medicines, sharing medicines with relatives or members of one’s
social circle, or using leftover medicines stored at home.

The inappropriate use of antibiotics through self-medication may cause significant adverse

effects, such as antibiotic resistance, treatment failure, and drug toxicity(13).

Nationwide non-prescription sales of antibiotics increased three-fold and reached nearly 2%

prevalence in 2004. Substantial interregional differences were detected in both the level and the
share of non-prescription antibiotics sales (14).

surveys conducted in three African countries shows that; two were surveys of the general
population in Nigeria and Sudan and one was a survey of sex workers or soldiers who had sex
with them in Nigeria. Both general community surveys focused on nonprescription use of anti-
microbials and reported frequency of antimicrobial use from 48% over 1 month to 100% lifetime
use. Of the antimicrobials used, weighted nonprescription use was 100% (2250 of 2250). Of the
nonprescription antimicrobials, 76% were purchased at a pharmacy and 24% were from friends,
family, or home (one study enrolled participants at a pharmacy, potentially increasing the
proportion of non-prescription antimicrobials purchased at a pharmacy (15-17).

study done in Tigray central zone on Non prescribing antimicrobial drug use reveals that the
magnitude of non-prescribed antimicrobial use was 47.1% (95% CI: 43.8, 50.5). The factors
which were independently associated with non-prescribed antimicrobial use were male sex
[AOR = 1.72, 95% CI = 1.21, 2.44], seeking modern health care in private/Non-Governmental
Organization (NGO) [AOR =0.47, 95% CI; 0.23, 0.98], moderate waiting time in health care
facilities [AOR = 1.92, 95%CI; 1.20, 3.09], delayed waiting time in health care facilities [AOR =
1.56, 95% CI; 1.03, 2.38], ever received antimicrobial [AOR = 3.51, 95% CI; 2.45, 5.02], and
frequency of purchasing non-prescribed antimicrobial (1–3 times and 4 times, [AOR = 2.04, 95%

5
CI; 1.36, 3.06] and [AOR = 2.66, 95% CI; 1.24, 5.68] respectively)(18). The number of
participants using antibiotics irrationally was assessed to be 135 (88.8%). The majority, 116
(76.3%), of purchases were without a prescription and 35 (23%) participants bought an
incomplete dosage of less than 5 days.(19).

Study conducted in Gondar show that the overall prevalence of self-medication practices among
households at Gondar town were 50.2%. The odds of self-medication practices among unmarried
participants (AOR = 3.12; 95% CI 2.35, 5.34), influenced by peer (AOR = 3.58; 95% CI 2.89,
7.28), poor perceived quality of health care services (AOR = 4.67; 95% CI 2.56, 7.96) and access
to pharmacy (AOR = 2.32; 95% CI 1.65, 6.76) were higher compared with their
counterparts(20). A study in developing countries has evidenced that the magnitude of non-
prescribed antimicrobial use is high (38.8%) [21]. Other similar studies from various countries
support this irrational use of medicine, in India (50%–66.7%) [22, 23], Saudi Arabia (48%–
77.6%) [24,25], Uganda (75.7%) [26], Zambia (97%) [27] and in Ethiopia ranges from (14.5% -
43.24%) [28–30].Several studies evidenced that a number of risk factors for non-prescribed
antimicrobial have been documented across the globe. Socio-demographic characteristics
including; sex in Northern Uganda [26], Sudan [31], India [32] and Spain [33], age [31, 34–37],
marital status [34, 35, 38], occupation [34, 39], income [31, 34], religion [34], residence [35],
and educational status [31, 37, 40] have been documented as determinants of non-prescribed
anti-microbial drugs use

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 3. OBJECTIVE
3.1 General objective
Non prescribing anti-microbial drug use and associated factors among customers drug outlet in
Adama town, East Shoa, Oromia, Ethiopia, from July 2019 to September 2019.

3.2 specific objective

• To determine magnitude of anti-microbial drug use nonprescription among customers
drug outlet in Adama town, East Shoa, Oromia, Ethiopia, from July 2019 to September
2019.
• To assess the associate risk factors for anti-microbial drug use without prescription among
customers drug outlet in Adama town, East Shoa, Oromia, Ethiopia, from July 2019 to
September 2019.

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 4- METHODS & MATERIALS
4.1 study area and period

Adama is located at 99 km away from the capital city of Ethiopia, Addis Ababa, to the east.
According to the Central Statistical Agency report in 2007, the town has a total population of
341,796 (male 170,838 and female 170,953).
The information from Adama town health Bureau shows that currently the town has 1
governmental Medical college hospital, 7 government health centers, 4 private hospitals, 94
private clinics with different level of which 17 special privet clinics, 4 Non-Governmental clinics
and 108 drug store and Pharmacies. The college hospital, AHMC, has catchment population of
about 5.2 million serving as referral hospital for all nearby district hospitals and the adjacent
regions.
4.2 study design
A cross- sectional study was carried out by using open ended and closed ended questioner
through face to face interview.

4.3 population
4.3.1 Source of population
All clients use of non-prescribing antimicrobials drug in drug retial outlet in Adama Town

4.3.2 Study population

All, clients use of non prescribing antimicrobial drug in drug retial outlet in Adama Town

during the study period.

Inclusion criteria
✓ All clients use of self-medication
✓ Both male and female
✓ Age greater than 18 years old

Exclusion criteria
✓ Age less than 18 years old
✓ Pregnant women

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4.4 Sample size determination
Sampling size calculation and sampling technique will be done for sample size determination of
this study.

The sample is calculated using single population proportion formula:

n=Z2 Pq
d2
n= 1.96× 0.502(1-0.502) /(0.05)
n=384

Were;

N= the required sample size

Z= 1.96, standard score corresponding to 95% CI

P= The overall prevalence of self-medication practices among households at Gondar town were

50.2%

q= 1-p=0.498

d= the margin of error tolerable i.e 5%

Adding 10% non- respondent the final sample size of the study is 384+ 39 =423

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 4.5 Sampling techniques
The study will be used probability sampling method to get the sample size of patients.
Proportionate random sampling technique will be used to get the patients to be interviewed.

Systematic random sampling is used to get the sample interval for each stratum.

ADAMA TOWN

Sub-city

Bole Boku
Aba gada Dabe Luko Danbela
15 14
50 9 7 12

sky time wendem gada cafe sewlasew sifen

303 120

423

Figure 1 Multistage sampling techniques at Adama town ,East shoa, oromia, Ethiopia,2019

10
 ➢ Numbers indicate the availability of pharmacy in the Adama town
➢ From the total subcity ,aba gada and danbela subcities are rondamily selected.

4.6 Variables
4.6.1 Dependent variables
Nonprescription antimicrobial drugs

4.6.2 Independent variables

Socio-demography variables

✓ Age
✓ Gender
✓ Marital status
✓ Educational level
✓ Occupation
✓ Place of residence
✓ Income status

Other explanatory variables

✓ Medication Cost
✓ Type of medicine per a day
✓ Health care provider & health system factors

5. DATA COLLECTION PROCEDURE

5.1 Data collection instrument
The data from patient questionaries’ was collected through questioner list that was developed
from related studies after making all the necessary modifications to fit the local condition and the
questionaries’ converted to local language from English to Afan Oromo.

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5.2 Data quality Assurance
✓ To maximize quality of the data, one of us will act like supervisor to control the overall
process during the data collection. Besides, the investigators will take adequate care to
extract the necessary data.
✓ Pretest was conducted in one of the selected drug store and pharmacy before actual data
collections.

5.3 Data processing and analysis

The collected data was analyzed manually; frequency and percentage will be used. The analyzed
data was presented through table, graph and narrative paragraph forms.

5.4 Ethical considerations

Ethical approval for the protocol was obtained from Rift Valley University, health research
coordinating office, department of pharmacy.

5.5 Operational Definition

Antimicrobial

The drugs are provided for the treatment of bacteria, parasites, viruses and fungi.

Non-prescribed antimicrobial use

Use of antimicrobial drug without prescription.

Care giver medication practice

Non-prescription antimicrobial offers for other sick person to treat health problems of minors or
other care seeking with perceived similar health problem.

Customers

Clients aged 18 years and above who received antimicrobial from private drug retail outlets.

Knowledgeable

When customers’ knowledge was above the computed mean of the ten dichotomized (yes/no)
questions, otherwise not knowledgeable.

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Drug retail outlet

A place used for the conduct of the drug sale, administering or dispensing and licensed by the
responsible body as a place wherein the practice of pharmacy may lawfully occur.

Systemic infection

Pharmacy personnel diagnose clinically the respondents’ self-reporting of symptoms of the

whole body or disease for which antimicrobial medicines are used.

Systemic antibiotics

Are antimicrobials whose effects are manifested to the whole body.

Waiting time

The length of time from when the patient entered the outpatient clinic/department to the time the
patient actually leaves the OPD (Fast= less than 1 h,Moderate=1–2h,andDelayed= more than 2 h)

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 5. RESULT
5.1 Sociodemographic characteristics of antimicrobial users in drug retailer outlets
A total of 423 study participants were included in this study with response rate of 100%. Among
the total respondents, 223 (52.7%) were male while the remaining were female. Nearly half
227(53.7%) of study participants were married. Regarding their educational status most of them
236(55.8%) were post graduate. Among total respondents 405(95.7%) were reside in urban
(Table 1).
Table 1: Socio-demographic characteristics of antimicrobial users in drug retailer outlets in
Adama Town, Oromia, Ethiopia, 2019 (n=423)

VARIABLES FREQUENCY

Number (n) Percent (%)

Sex Female 200 47.3

Male 223 52.7

Age Group 19-24 39 9.2

25-29 173 40.9

30-34 144 34.0

35-40 46 10.9

Above 40 21 5.0

Marital Status Single 166 39.2

Divorced/ Widowed 30 7.1

Married 227 53.7

Level Of Education Never Wants To School 2 .5

Primary Education 52 12.3

Secondary School 133 31.4

Post Graduate 236 55.8

Average Monthly Income Less Than 3000 117 27.7

3000-6000 166 39.2

Greater Than 6000 140 33.1

Residence urban 405 95.7

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 rural 18 4.3

5.2 Types of illnesses reported, magnitude of non-prescribed antimicrobial use and its
mechanism
Out of study participants around 152(35.9%) came to drug retailer outlets with systemic disease.
From total 322(76.1%) of them had history of illness less than one month. Regarding type of
illness 115(27.2%) came to drug retailer out lets because of GIT (Table 2)

Table 2:Type of illness reported, anti-microbial drug received and health related factors among customers in drug
retailer outlets in Adama town, Oromia, Ethiopia, 2019 (n=423)

VARIABLES FREQUENCY

Number(N) Percent (%)

Types of Illness Respiratory 94 22.2

GIT 115 27.2

Skin 62 14.7

Others 152 35.9

Group of Illness Systemic 152 35.9

Topical 80 18.9

Ear/Eye Infection 42 9.9

Others 149 35.2

Period Of Illness Less Than 1 Months 322 76.1

Greater Than 1 Month 101 23.9

Mechanism Of provision of prescription 157 37.1

Antimicrobials telling of name/shape/container 112 26.5

Received from pharmacy telling of sign and symptoms 94 22.2

provision of written pies of paper 60 14.2

Ever used modern health no 25 5.9

care
yes 396 93.6

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 5.2 Magnitude of non-prescribed anti-microbial use

The magnitude of non-prescribed antimicrobial use in this study was 52.01 % (95% CI: 47.5-56.7).

Figure 2; magnitude of non-prescribed antimicrobial use

Health care services use and knowledge of antimicrobial among customers in drug retailer
outlets in adama town

Of the total respondents included in this study, 226 (53.4%) respondents knew that
antimicrobial cannot be taken with alcohol. Similarly, 235(55.6 %) of respondents reported that
drug resistance can occur when antimicrobial users do not complete the full course of treatment
in the prescribed dose. Among total, 274 (64.8%) of them knew that antimicrobial prescribed for
adults should not be given to children, 287 (67.8%) of respondents knew that the expiry date of
the antimicrobial should be checked before using it Table 3.

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Table 3:Health care services use and knowledge of antimicrobial among customers in drug retailer outlets in adama
town ,Oromia,2019 (n=423)

VARIABLES FREQUENCY
Number(N) Percent(%)

Ever used modern health care No 27 6.4

services Yes 396 93.6
Place of receiving modern health Public health facilities 238 56.3
care services Private pharmacy/drug store 134 31.7
private clinic/NGO 51 12.1
Distance of health facility from Within 5 km length 392 92.7
home Far from 5 km 31 7.3
Self-perceived of waiting time in fast 27 6.4
health care facilities Moderate 225 53.2
delay 159 37.6
others 12 2.8
Anti-microbial with some other No 106 24.8
drugs
Yes 318 75.2
Antimicrobial with alcohol
No 226 53.4
Yes 197 46.6
Ant-microbial with some foods No 142 33.6
Yes 281 66.4
Benefit from placing of anti- No 175 41.4
microbial at unreachable area to
children Yes 248 58.6
Anti-microbial resistance when No 188 44.4
incomplete the prescribed dose
Yes 235 55.6
Anti-microbial prescribed for No 274 64.8
adult sharing to children
Yes 149 35.2
All types of anti-microbial give to No 288 68.1
pregnant and lactating mothers
Yes 135 31.9
All types of anti-microbial given No 258 61.0
to patients with chronic diseases
Yes 165 39.0
Checking expiry date of the No 136 32.2
antimicrobial
Yes 287 67.8
Overall knowledge status Not knowledgeable 152 35.9
Knowledgeable 271 64.1

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Figure 3:Type of drug which purchase from pharmacy without prescriptions

The consumption of antibiotics from the above chart cephalosporin 22(5.29%),flouroqoinolone

89(21.04%), penicillin 75(17.73%), tetracyclines 89(21.04%), macrolide 148(34,98%).

From the above information the highest purchase drug from pharmacy macrolides

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5.3 Factors associated with non-prescribed antimicrobial use
In the bivariate logistic regression analysis sex, residence, average monthly income, ever used
modern health care, distance of health facility from home, self-perceived of waiting time in
health care facilities had significant association (p<0.05) with non-prescribed antimicrobial use.
The remaining variables had not shown significant association (P>0.05) with non-prescribed
antimicrobial use. In multivariable analysis being rural residence [AOR]: 1.85(1.84, 4.09),
distance of health facility 5 kilometer away from home [AOR]: 3.96(2.05, 7.64), delayed waiting
time [AOR]: 3.310(1.27, 8.63) independently associated factors with non-prescribed
antimicrobial use.

In this study we found that customers from rural residence 2 times more likely to use non-
prescribed antimicrobial compared those customers from urban residence. Similarly those
customers with distance 5KM away from health facility 4 times more likely to use none
prescribed antimicrobial as compared those customers with close proximity to health facility.
Lastly those customers that perceived delayed waiting time in health care facilities 3 times more
likely to use non-prescribed antimicrobial compared those fast waiting time in health facilities.

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 Table 4:Bivariable and multivariable logistic regression analysis of factors associated with non-prescribed antimicrobial
use among customers in drug retailer outlets in Adama Town, Oromia, Ethiopia, 2019 (n:423)

VARIABLES Use of Antimicrobial drug(s) Crude OR (95% CI) Adjusted OR (95% p.valu
CI) e
Prescribe Non-prescribed

Age 19-24 17 22 1.00

25-29 87 86 1.73(.59, 5.04)

30-34 69 75 1.32(.53,3.29)

35-40 18 28 1.45(.58,3.65)

Above 40 12 9 2.07(.73,5.91)

sex female 100 81 1.00

male 103 139 1.68(1.13,2.46)**

Marital status single 87 79 2.570(.94,7.01)

divorced 6 14 .275(.06-1.34)

widowed 8 2 1.350(.90-2.02)

married 102 125 1.00

Residence Urban 190 179 1.00

rural 13 41 3.35(1.74,6.45)*** 1.85(1.84, 4.09) 0.035

Average monthly <3000 45 56 6.22(1.3,29.90)**

income
3000-6000 79 87 5.51(1.17,25.90)**

>6000 69 73 1.00

Ever used modern health yes 191 162 1.00

care service
No 12 58 5.502(2.85, 10.62)**

Distance of health facility Within 5 km 186 162 1.00 1.00

from home
Far from 5 km 17 58 3.92(2.20-7.00)*** 3.96(2.05, 7.64) 0.000

Self-perceived of fast 19 8 1.00 1.00

waiting time in health
care facilities moderate 114 94 .250(.10-.60)** -

delayed 70 118 .489(.33-.73)** 3.310(1.27, 8.63) 0.014

20
 6. DISCUSSION

Our study finding indicates the overall prevalence of non-prescribed antimicrobial use were
52.01 % (95% CI: 47.5-56.7). This finding is lower compared to studies done in different
countries India 71.7 %(46), Northern Tanzania 76.3%(45), Zambia (97%) [27], Uganda (75.7%)
[26], Harar City eastern Ethiopia 65.3%(47), Addis Ababa 72.8%(48).however, this finding is
higher than studies done USA (5%)(42), Mongolia 42.3%(43) , Lithuania 31.0%(44) , Saudi
Arabia 34%(49), Tigray northern Ethiopia 47.1%(18).but consistent with studies done in Gondar
town 50.2%(20).The existence of such variations may be explained by the differences due to
study period, sample size, study design and social determinants of health, beliefs, culture of the
population, and variation on recall periods used in each study.

Among many possible factors in current study we found that being rural residence, distance of
health facility 5 kilometer away from home, delayed waiting time in health facility independently
associated factors with non-prescribed antimicrobial use .in present study we found those
customers with distance 5KM away from health facility 4 times more likely to use none
prescribed antimicrobial as compared those customers with close proximity to health facility.
Similar finding was reported in Tanzania and Sudan that reasons for non-prescribed medication
were shortages of drugs, long distance at/to health facilities, inability to pay for health care
charges and the freedom to choose the preferred drugs [31, 45]

In current study those customers that perceived delayed waiting time in health care facilities 3
times more likely to use non-prescribed antimicrobial compared those fast waiting time in health
facilities. This finding is in line with study done in Saudi Arabia and Gonder that reports the
long waiting time to visit a physician, and the lack of time and health insurance significantly
linked with non-prescribed anti-microbial use [20, 49].

In this study we found that customers from rural residence 2 times more likely to use non-
prescribed antimicrobial compared those customers from urban residence. The finding from
Lithuania also reveals respondents with lower educational qualifications and those from rural
places of residence were less knowledgeable about rational use antibiotics [44].

21
In current study age of study participant, sex, marital status, average monthly income,
educational status, occupation and ever used modern health care service doesn’t have strong
association with non-prescribed antimicrobials use. Unlike current study Socio-demographic
characteristics including; sex in Northern Uganda [26], Sudan [31], India [32] and Spain [33],
age [31, 34–37], marital status [34, 35, 38], occupation [34, 39], income [31, 34], religion [34],
and educational status [31, 37, 40] have been documented as determinants of non-prescribed
anti-microbial drugs use.

STRENGTH AND LIMITATION OF STUDY

STRENGTH
➢ Considering multiple determinants of non –prescribed use of antimicrobials
➢ Response rate 100%
➢ Randomization

LIMITATION OF STUDY

➢ This study was conducted in urban setting lacks generalizability to rural area/settings.
➢ The study assess only about modern medicines which did not include practices of
traditional Medications that might be under estimate our findings in the study area
➢ There might be potential recall bias among respondents answering questions relating to
events happening in the past

22
7. CONCLUSION AND RECOMMENDATION
7.1. CONCLUSION
The magnitude of non-prescribed antimicrobial use was high (52.01 %). Being rural residence,
delayed waiting time in governmental health care facilities and distance >5 km from health
facility was independently associated with non-prescribed antimicrobial use.

7.2. RECOMMENDATION

We recommend all customers in drug retail outlet to avoid irrational use of non- prescribed anti-
microbial as it fuels current antimicrobial resistance than ever.

We recommend health care provider in particular pharmacist and druggist to create health
awareness campaigns to prevent antibiotic misuse to halt the global and local growth resistance
of utilized antibiotics. We recommend adama town health facilities and government to expand
community pharmacy in close proximity to the community and to improve delay in waiting time
in each health facility.

We recommend government to set law and policy enforcement regarding the sale of antibiotics
without a valid prescription should be in place. This will ultimately help to shift the current
pharmacy practices from commercial and business-based interests/practices to the provision of
primary healthcare services to the community. We also recommend the Health sector and policy
maker to strengthened community health education to enhance rational use of antimicrobial more
than usual.

23
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 Appendix I: QUESTIONNAIRE
Instructions

Participation in this exercise is voluntary. Kindly answer these questions honestly and accurately.
Do not write your name anywhere in this questionnaire. Please tick or fill appropriately (√)

Section 1: SOCIO DEMOGRAPHIC CHARACTERISTICS

1. Age

a.15 – 19 years ------------

b.20 – 24 years -------------

c.25 – 29 years -------------

d.30 - 34 years ---------------

e.35 – 48 years---------------

f. above 49 years -----------

2. Gender

1. Male--------- 2. Female-----------

3. Marital Status

Single (never married) ----------- Married--------------

Divorced-------- Widowed------------

4. What is the highest level of education you have completed?

1. Never went to school --------

2. Basic education--------------

3. Primary School--------------

4. Secondary school--------------

29
 5. Post-secondary school (graduate level) ----------

5. What is your occupation?

1. Government -----------

2. Farmer ----------------

3. Merchant --------------

4. House wife -------------

5. Others-------------------

6.What is your monthly income?

7. Where you live? 1. Urban------------- 2. Rural--------

Section 2 . Health Care Services Use Antimicrobial use

1. How to purchase the drug from pharmacy

a. using of Prescription paper

b. orally

c.both

2.Ever used modern health care services

a. No

b. Yes

3.Place of receiving modern health care services

a.Public health facilities

b.Private pharmacy/drug store

c.Others

30
4.Distance of health facility from home

a.Within 5 km length

b.Far from 5 km

5.Self perceived of waiting time in health care facilities

a. Fast

b. Moderate

c. Delay

d. Others

section 3. Knowledge of antimicrobial among customers in drug

retailer outlets in adama town

1. Anti-microbial with some other drugs

a.No b.Yes

2. Anti-microbial with alcohol

a.No

b.Yes

3. Ant-microbial with some foods

a. No

b. Yes

4. Benefit from placing of anti-microbial at unreachable area to children

A .No

b. Yes

31
5. Anti-microbial resistance when incomplete the prescribed dose

a. No

b. Yes

6.Anti-microbial prescribed for adult sharing to children

a. No

b. Yes

7.All types of anti-microbial give to pregnant and lactating mothers

a. No

b. Yes

8. All types of anti-microbial give to patients with chronic diseases

a. No

b. Yes

9. Prescribed anti-microbial rightly use according the dispenser information

a. No b. Yes

10. Checking expiry date of the anti-microbial

a. No b. Yes

32