Antimicrobial stewardship practices and patterns of antibiotic dispensing among retail drug outlets in Ghana

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This study evaluated antimicrobial stewardship practices related to antibiotic dispensing among community retail drug outlets in Ghana to identify current practices and inform targeted interventions to improve rational antibiotic use. Methods A cross-sectional study design was used. Data was collected from 158 dispensers, entered, and analyzed using STATA between April and July 2024. Descriptive statistics (mean, SD, median frequency, and percentages) were used to analyze antimicrobial stewardship practices, antibiotic types dispensed, associated diseases and conditions, and influencing factors of antibiotic dispensation without prescription. Chi-square (χ²), bivariate, and multivariate logistic regression analyses identified significant predictors of antibiotic dispensing without prescription and predictor variables. Results A total of 86 (54.4%) out of 158 respondents dispensed antibiotics without valid prescription, with 80.4% (127) dispensing without a prescription regularly. Ciprofloxacin and amoxicillin (65.8%) were most frequently dispensed, while genitourinary infections (74.7%) were the most common disease conditions for which treatment is given before medications used in treatment. Pharmacists (AOR = 4.63, 95% CI: 1.20-17.83; p = 0.026) were significantly more likely to engage in non-prescription dispensing than other dispensers. Dispensers who requested a history of the client’s history on antibiotic usage (AOR = 0.30, 95% CI: 0.10–0.89; p = 0.03) were less likely to dispense antibiotics without a prescription compared to those who did not request clients’ antibiotic use history. P-values less than 0.05 (p < 0.05) were considered statistically significant associations. Conclusion A high non-prescription sale of antibiotics in retail drug outlets was found in this study, underscoring the urgent need for improved antimicrobial stewardship measures through community-targeted evidence-based interventions. Antibiotics Antimicrobial stewardship practices retail drug outlets Figures Figure 1 Figure 2 Background Microorganisms develop antimicrobial resistance through evolutionary changes that occur in response to medicines previously used to kill them, thereby reducing the effectiveness of those medicines. [ 1 ]. Sustained antimicrobial resistance has resulted in multidrug-resistant pathogens that are associated with prolonged hospital stays, diminished quality of life, increased healthcare infrastructure costs, and excess mortality [ 2 ]. The Centers for Disease Control and Prevention (CDC) posits that there are approximately two million clients who are infected with antimicrobial-resistant pathogens annually in the United States, accounting for more than 23,000 deaths [ 3 ]. Presently, more than 10 million deaths have been associated with antimicrobial resistance, and as such, the World Health Organization (WHO) declared antimicrobial resistance a worldwide emergency [ 4 ]. Despite the concern of antimicrobial resistance in public health, the use of antimicrobials has reduced the occurrence of microbial infections in the last five decades and, consequently, is heavily relied upon for the treatment of common illnesses [ 5 ]. Antimicrobial resistance is accelerated by the misuse and overuse of antimicrobials. Among these are the inappropriate prescription of antibiotics by doctors and pharmacists, misuse, including not completing a treatment course, and the indiscriminate self-medication by patients [ 6 ]. The most important intervention that can be employed to adequately address the misuse of antimicrobials is the strict implementation of antimicrobial stewardship programmes. These programmes emphasize that the use of antimicrobials, including antibiotics, must be controlled and exercised responsibly, ensuring a balance between appropriate use and regulated access to these medicines [ 6 ]. Antimicrobial stewardship programs are implemented through patient-centered care that relies on recommendations and adherence to guidelines for antimicrobial dispensing [ 7 ]. Strategies that regulate the purchase of non-prescribed antimicrobials and improve healthcare providers’ knowledge and perception of antimicrobial use further constitute the scope of antimicrobial stewardship programs [ 8 ]. In the quest to deliver efficient antimicrobial therapy, it is important to preserve the efficacy of antimicrobials within a sustainable healthcare environment. Although antimicrobial stewardship programs may involve an initial cost, they have consistently been shown to reduce unnecessary antibiotic use and are associated with improved patient outcomes and lower healthcare expenditures [ 9 ]. Community drug dispensers are one of the most accessible health professionals within the health system, with the capacity to dispense antibiotics [ 10 ]. However, they are the most essential contributors to the development of antimicrobial resistance among the public through the misguided dispensing of antibiotics [ 11 ]. Purchasing antibiotics with a valid prescription remains a major concern, and despite existing restrictions, antibiotics are still freely sold without a prescription in many developing countries. This practice adds to the already growing burden of antibiotic resistance [ 12 ]. A few studies have examined the behavioural aspects of self-medication and antibiotic use; however, they have not addressed antimicrobial stewardship practices related to antibiotic dispensing patterns, pharmacy personnel knowledge or the factors that influence dispensing behaviours [ 13 ] [ 14 ] [ 15 ] [ 16 ]. To promote appropriate antibiotic dispensing and use, and to help combat the burden of antibiotic resistance, it is important to investigate the practices and factors that influence provider behaviour and to gain insight into these behaviours [ 17 ] [ 18 ]. Although previous studies in Ghana have highlighted the role of community retail drug outlets in contributing to antimicrobial resistance, [ 19 ] [ 16 ], this study evaluated antimicrobial stewardship practices in antibiotic dispensing and its influencing factors. Methods Study Design and Sampling This study employed a cross-sectional design with a multi-stage cluster sampling approach. Due to the finite number of clusters (n = 10), the first stage sampled five clusters (sub-metro) randomly for inclusion in the study. In the second stage sampling, all eligible participants were proportionately sampled to achieve the required sample size. With this method, participants were selected using the lottery method, where unique identifiers were written on identical slips of paper, and participants were asked to select an odd number between one and five for inclusion in the study. All statistical analyses were adjusted to account for the clustered nature of the sampling design. This adjustment addressed the non-independence of observations within clusters. Study Site This study was conducted in the Greater Kumasi Metropolis, the administrative capital of Ghana's Ashanti Region, located between latitudes 6.35° N and 6.40° S and longitudes 1.30° W and 1.35° E. The metropolis covers a land area of approximately 213 km² and has a population exceeding 2,600,000. The Greater Kumasi has seven (7) administrative divisions: Kumasi Metropolitan Assembly (Bantama, Subin, Manhyia North and South, and Nhyiaeso), Asokore Mampong, Asokwa, Suame, Kwadaso, Tafo, and Oforikrom Municipalities [ 20 ]. Study Population The study population comprised all retail community drug outlets within the selected areas of the Greater Kumasi metropolis. All drug outlets in the selected Greater Kumasi metropolitan area that had dispensing professionals available during the data collection period were included in the study. Drug outlets without dispensing professionals available at the time of data collection were excluded from the study. Sample Size Calculation The sample size was determined using Cochran’s formula for a finite population. Cochran’s recommended sample size for large populations is n o =385 [ 21 ]. Since the total number of registered retail drug outlets (pharmacy stores, over-the-counter chemical sellers, and herbal shops) in the selected areas of Greater Kumasi is relatively small (N = 230), the finite population correction was applied using the formula: n = n / (1 + (n − 1) / N) Where n o is Cochran’s recommended sample size. N represents the population size. n is the adjusted sample size. n = 385 / (1 + (385–1) / 230), n = 144.2 To account for potential non-response, a 10% adjustment was applied. = 0.1 * 144.2 = 14.1 ≈ 14 Adding this to the adjusted sample size yielded a final required sample size of: 144 + 14=158 Therefore, a total of 158 retail drug outlets were targeted. Data collection Interviews were conducted among 158 drug dispensers from community retail drug outlets across five randomly selected sub-metropolises between April and July 2024. Drug dispensers were interviewed randomly based on proportionate multi-stage cluster sampling. The survey was translated into the local dialect for dispensers who required clarification of some English terminology. The questionnaire was pretested, and all entries were checked daily by the principal investigator for completeness and accuracy. Dispensing professionals available during data collection were eligible for inclusion. Only Dispensing professionals who provided informed consent participated in the study, while outlets without available dispensers at the time of data collection were excluded from the study. Written and verbal consent was obtained from each dispenser before data collection. Data Analysis Data in Microsoft Excel format was imported into Stata 16 statistical software, where it was cleaned and analyzed. Data cleaning was performed to check for missing values, outliers, and inconsistencies in the data collected. Errors identified were resolved by cross-referencing with the original questionnaire. Descriptive statistical analysis, such as mean, median, frequencies, and percentages were performed on demographic characteristics, antimicrobial stewardship practices, and factors influencing the dispensing of antibiotics. Chi-square tests were performed to determine the association between dispensing antibiotics without prescription and stewardship practices, and factors influencing the dispensing of antibiotics. A bivariate logistic regression was performed to predict determinants of antimicrobial stewardship practices. Multivariate logistic regression was further performed on variables that showed a significant association from the bivariate analysis. All statistical tests were performed at a 0.05 α level and 95% confidence interval. Results Sociodemographic characteristics Most participants, 97 (61.4%), were aged between 26 and 40 years, while those above 40 years constituted the smallest group of 14.6% (23). The mean age was 32.4 years (SD = 10.1). Females, 86 (54.4%), represented slightly more than half of the sample, compared to males, 72 (45.6%). Regarding educational status, tertiary graduates were the most represented, with 112 (70.9%), whereas vocational school attendees were the least represented, 8.9%. In terms of professional qualifications for dispensing, a total of 58 (36.7%) respondents held Medical Counter Assistant certificates, 48 (30.4%) had Higher National Diplomas, and 52 (32.9%) held a first degree or higher. For facility type, pharmacy stores were the predominant setting, 126 (79.9%), while herbal shops were the least represented, 5 (3.2%). Most dispensers were medical counter assistants, 65 (41.1%), followed by pharmacy technicians, 35 (22.1%), with uncertified dispensers accounting for 3.8% (6) of the respondents. Most, 100 (63.3%) respondents reported having five years or less of dispensing experience, while 51 (55.1%) had not previously worked in a health facility. Table 1 below summarizes the respondents’ demographic characteristics. Table 1 Sociodemographic characteristics of respondents Characteristic Frequency (N = 158) Percentage (%) Age 40 years 23 14.6 Mean age ± SD 32.4 ± 10.1 Gender Female 86 54.4 Male 72 45.6 Education Basic and high school 32 20.3 Tertiary 112 70.9 Vocational 14 8.8 Credential attained for practice Medicine Counter Assistant Certificates 58 36.7 Higher National Diploma 48 30.4 First-degree or higher 52 32.9 Type of facility Herbal Shop 5 3.2 Over the Counter Chemical Store 27 17.1 Pharmacy Store 126 79.7 Job role Medicine Counter Assistant 65 41.1 Pharmacist 32 20.3 Pharmacy Assistant 20 12.7 Pharmacy technician 35 22.1 Others 6 3.8 Years of dispensing experience ≤ 5 years 100 63.3 > 5 years 58 36.7 Ever worked in a health facility No 87 55.1 Yes 71 44.9 Commonly dispensed antibiotics without a prescription. Respondents were provided with a list of selected antibiotics and asked to indicate which ones they dispense without a prescription, selecting them from most frequently dispensed to least frequently dispensed. As shown in Fig. 1 , ciprofloxacin and amoxicillin were the most dispensed, each reported by 65.8%, followed closely by amoxicillin-clavulanic acid (64.56%) and metronidazole (58.23%). Other frequently dispensed agents included flucloxacillin (56.33%), doxycycline (49.37%), and azithromycin (46.20%). Moderate levels of dispensing were recorded for cefixime (24.68%), ceftriaxone (23.42%), erythromycin (22.15%), ampicillin (22.15%), tetracycline (20.25%), and cotrimoxazole (17.72%). Less commonly dispensed antibiotics included gentamicin (10.13%), ofloxacin (3.80%), cefuroxime (3.16%), clindamycin (1.27%), roxithromycin (1.27%), and several others at or below 0.63%. Disease conditions for antibiotic dispensing without a prescription. Figure 2 below shows the conditions under which antibiotics were most often dispensed without a prescription. Genital and urinary tract conditions dominated antibiotic dispensing, accounting for 74.7% of all reported cases, followed by respiratory infections (17.1%). Antibiotics were rarely dispensed for skin infections (3.8%), gastrointestinal conditions (3.2%), or dental issues (1.3%). Antibiotic stewardship practices among respondents in antibiotic dispensing Among the 158 respondents, 86 (54.4%) reported dispensing antibiotics without a prescription, and 127 (80.4%) indicated that they dispense antibiotics regularly. Most dispensers (86.7%) reported that they would recommend an alternative antibiotic if they believed the requested antibiotic would be ineffective for a client’s use. Similarly, 127 respondents (80.3%) indicated they would substitute a prescribed antibiotic with a cheaper brand if a patient could not afford the original option. Nearly all respondents (98.8%) stated that they provide counselling on the appropriate use of antibiotics. Regarding clients mounting pressure on dispensers to purchase inappropriate antibiotics, 60 respondents (40.0%) reported that they refer such clients to a physician, while 34.8% refuse to dispense under such circumstances. However, 6.3% of respondents admitted to dispensing based on their experience with selling antibiotics. Additionally, 82.3% (n = 130) of participants reported requesting clients’ antibiotic use history before dispensing antibiotics, and 84.8% (n = 134) routinely advise clients to adhere strictly to the dosage instructions provided. Some respondents (29.1%) adhered to facility-established dispensing guidelines as pharmaceutical references used when selling or dispensing antibiotics, while 20.9% consulted clinical guidelines when dispensing antibiotics. Table 2 summarizes the antibiotic stewardship practices and dispensing activities of the respondents. Table 2 Antibiotic stewardship practices in antibiotic dispensation of respondents Variable Frequency (N = 158) Percentage (%) Dispensing antibiotics without prescription No 72 45.6 Yes 86 54.4 Frequency of dispensing without prescription Regularly 127 80.4 Occasionally 31 19.6 Sell if an intended antibiotic will not be effective for client’s condition. No 21 13.3 Yes 137 86.7 Clients’ inability to afford an antibiotic Consult physician 3 1.9 Refer to another drug outlet 28 17.7 Replace with a cheaper alternative 127 80.4 Counseling client on the appropriate use of antibiotics No 5 3.2 Yes 153 98.8 Handling clients insisting on inappropriate antibiotics Ask the client to consult a physician 60 40.0 Dispense anyway 12 7.6 Dispense based on experience 10 6.3 Dispense based on knowledge 21 13.3 Dispense based on use history 55 34.8 Antibiotic use history No 28 17.7 Yes 130 82.3 Advising clients about using antibiotics Complete full course 24 15.2 Adhere to dosage 134 84.8 Pharmaceutical references consulted prior to antibiotic dispensation Clinical guidelines 33 20.9 Consulting other healthcare professionals 43 27.2 Client antibiotic use history 36 22.8 Facility protocols 46 29.1 Factors influencing dispensers to dispense antibiotics without a prescription A total of 71 (44.9%) respondents reported being convinced to dispense antibiotics without a prescription based on a client’s previous antibiotic use, while 32.9% (n = 52) dispensed antibiotics due to the perceived urgency or convenience for the client. Only 3.2% (n = 5) indicated that they were never convinced by clients to dispense without a prescription. Overall, 67.7% (n = 107) of respondents reported that they do not feel pressured by clients to dispense antibiotics. Most 79.1% (n = 126) dispensed antibiotics without a prescription based on the clients’ symptoms, whereas 7.0% (n = 11) did so based on the clients’ ability to pay. Table 3 presents the factors influencing dispensers’ decisions to dispense antibiotics without a prescription. Table 3 Factors influencing dispensers to dispense antibiotics without a prescription Variable Frequency (N = 158) Percentage (%) How clients convince dispensers to dispense antibiotics without a prescription Belief in antibiotic efficacy 30 19.0 Do not rely on clients’ complaints 5 3.2 Previous use 71 44.9 Urgency and convenience 52 32.9 Economic influence to dispense antibiotics without a prescription Fear of negative clients’ feedback 21 13.3 Clients’ ability to pay 11 7.0 Client’s symptoms 126 79.1 Pressure to dispense antibiotics No 107 67.7 Yes 51 32.3 Determinants of antimicrobial stewardship practices in the dispensing of antibiotics In the bivariate analysis, age and gender showed no significant association with dispensing antibiotics without a prescription (p > 0.05). However, job role was significantly associated (χ² = 9.99, p = 0.033) because pharmacists were substantially more likely to dispense antibiotics without a prescription compared to medicine counter assistants (COR = 3.91, 95% CI: 1.49–10.32; p = 0.006), and this association remained significant after adjustment (AOR = 4.63, 95% CI: 1.20 − 17.83; p = 0.026). How respondents handled clients insisting on inappropriate antibiotics was also significantly related to non-prescription dispensing (χ² =12.97, p = 0.011). Those who rely on their knowledge of antibiotics (AOR = 4.53, 95% CI: 1.36–15.11; p = 0.014) or use history (AOR = 3.28, 95% CI: 1.37–7.83; p = 0.008) had significantly higher odds of dispensing without prescription compared to those who referred clients to a physician. Respondents who requested antibiotic use history from clients were protective because they were significantly less likely to dispense without a prescription (AOR = 0.30, 95% CI: 0.10–0.89; p = 0.03) compared to those who did not. Pharmaceutical references consulted before antibiotic administration were also significantly associated with dispensing antibiotics without prescription (χ² =17.49, p < 0.001). Those who relied on pharmacy protocols (COR = 0.23, 95% CI: 0.08–0.60; p = 0.003) or consulted other healthcare professionals or colleagues (COR = 0.38, 95% CI: 0.15–0.98; p = 0.046) were significantly less likely to dispense without a prescription. Other variables, including counseling clients, pressure to dispense, and reasons for being convinced by clients, were not significantly associated. Table 4 shows the predictors of antimicrobial stewardship practices in the dispensing of antibiotics. Table 4 Determinants of antimicrobial stewardship practices in the dispensing of antibiotics Variables Antibiotic dispensing without prescription (n = 158) (%) χ2 (p-value) Crude Odds Ratio, (95% CI), p-value Adjusted Odds Ratio (95% CI), p-value No Yes Age Less than 26 years 20 (52.6) 18 (47.4) 1.0062 (0.605) Ref - 26 to 40 years 42 (43.3) 55 (56.7) 1.46 (0.69–3.10), 0.329 - More than 40 years 10 (43.5) 13 (56.5) 1.44 (0.51–4.10), 0.489 - Gender Female 42 (48.8) 44 (51.2) 0.8124 (0.367) Ref - Male 30 (41.7) 86 (54.3) 1.34 (0.71–2.51), 0.368 - Job role Medicine Counter Assistant 34 (52.3) 31 (47.7) 9.9967 (0.033) * Ref Ref Pharmacist 7 (21.9) 25 (78.1) 3.91(1.49–10.32), 0.006* 4.63 (1.20-17.83), 0.026* Pharmacy Assistant 9 (45.0) 11 (55.0) 1.34 (0.49–3.67), 0.568 1.31 (0.39–4.44), 0.665 Pharmacy technician 18 (51.4) 17 (48.6) 1.03 (0.46–2.36), 0.930 1.55 (0.59–4.06), 0.372 Other pharmacy professionals 4 (66.7) 2 (33.3) 0.55 (0.09–3.2), 0.505 0.56 (0.06–5.26),0.615 Counseling clients on the appropriate use of antibiotics No 4 (80.0) 1 (20.0) 2.4678 (0.116) Ref - Yes 68 (44.4) 85 (55.6) 5.00 (0.55–45.78), 0.154 - Handling clients insisting on inappropriate antibiotics Ask the clients to consult a physician 38 (63.3) 22 (36.7) 12.9730 (0.011) * Ref Ref Dispense anyway 5 (41.7) 7 (58.3) 2.41 (0.68–8.54), 0.170 2.96 (0.73 12.00),0.129 Dispense based on my experience 4 (40.0) 6 (60.0) 2.59(0.66–10.19),0.173 1.42 (0.28–7.11), 0.668 Dispense based on my knowledge 6 (28.6) 15 (71.4) 4.32 (1.46–12.75), 0.008* 4.53 (1.36–15.11), 0.014* Dispense based on use history 19 (34.5) 36 (65.5) 3.27 (1.52–7.03), 0.020* 3.28 (1.37–7.83), 0.008* Convinced by clients to dispense antibiotics without a prescription Belief in antibiotic efficacy 12 (40.0) 18 (60.0) 2.0977 (0.596) Ref - Do not rely on clients’ complaints 1 (20.0) 4 (80.0) 2.67 (0.27–26.86), 0.405 - Previous use 35 (49.3) 36 (50.7) 0.69 (0.29–1.63), 0.393 - Urgency and convenience 24 (46.2) 28 (53.8) 0.78 (0.31–1.93), 0.589 - History of antibiotic usage No 6 (22.2) 21 (77.8) 7.3380 (0.007) * Ref Ref Yes 66 (50.7) 64 (49.3) 0.28(0.10–0.73), 0.010* 0.30 (0.10–0.89), 0.03* Pressure to dispense antibiotics No 51 (47.6) 56 (52.4) 0.5860 (0.444) Ref - Yes 21 (41.2) 30 (58.8) 1.3 (0.66–2.55), 0.444 - Pharmaceutical references consulted prior to antibiotic dispensation Clinical guidelines 10 (30.3) 23 (69.7) 17.4882 (0.001) * Ref - Consulting other healthcare professionals 23 (53.5) 20 (46.5) 0.38 (0.15–0.98), 0.046* - Client antibiotic use history 9 (25.0) 27 (75.0) 1.30 (0.45–3.7), 0.623 - Pharmacy protocols 30 (65.2) 16 (34.8) 0.23 (0.08–0.60), 0.003* - * Statistically significant association (α < 0.05) Discussion This study highlights key antimicrobial stewardship challenges and the factors influencing non-prescription antibiotic dispensing in Ghana. The findings show that ciprofloxacin, amoxicillin, amoxicillin-clavulanic acid, and flucloxacillin were the most frequently sold antibiotics without a prescription, while doxycycline and azithromycin were the dispensed antibiotics at moderate levels, and several others, such as levofloxacin, tinidazole, secnidazole, and cefuroxime, were dispensed infrequently. These patterns align with reports from Eastern Congo, where amoxicillin and ciprofloxacin were similarly identified as commonly dispensed antibiotics without prescription [ 23 ]. The practice is concerning as it facilitates inappropriate self-medication and contributes to the development of antimicrobial resistance. Comparable trends have been observed in India, where Dharanindra et al. reported amoxicillin as a frequently dispensed antibiotic and azithromycin as highly dispensed, contrasting with its moderate use in the present study, while ciprofloxacin and amoxicillin-clavulanic acid were among the least dispensed in their setting [ 24 ]. These differences may reflect variations in regulatory enforcement, pharmacy licensing, and the extent to which dispensers assess patient antibiotic-use history before dispensing. Genitourinary infections accounted for the highest use of antibiotics in this study, followed by respiratory infections, which also represented a substantial proportion of conditions for which dispensers supplied antibiotics. In contrast, gastrointestinal and dental conditions were the least common reasons for antibiotic dispensing, suggesting that these illnesses are less frequently treated with antibiotics in the study area. These findings are consistent with Ntizala et al., who also reported that genitourinary tract infections were the most common indications for antibiotic use, particularly cephalosporins [ 23 ]. Similarly, Jamshed et al., found that urinary tract infections were the leading reason for antibiotic dispensing, especially penicillin [ 25 ]. In Nigeria, Olutuase (2022), identified genitourinary infections as among the most frequently treated conditions, with respiratory infections dispensed at moderate levels [ 24 ], correlating with the findings from the current study. The findings from this study show that most dispensers provide antibiotics without a prescription, a practice consistent with reports from the Republic of Congo, Benin, and India [ 1 , 23 , 24 ]. In Benin, Allabi et al. documented that 75% of dispensers supplied antibiotics to clients without a prescription [ 1 ]. Similarly, Dharanindra et al. found widespread non-prescription antibiotic dispensing in Indian community pharmacies, which they partly attributed to limited knowledge of antimicrobial resistance and easy over-the-counter access to antibiotics, conditions that do not differ from the Ghanaian context [ 22 , 24 ]. This finding context is at par with the outcome of Ngyedu et al. (2023), who documented widespread non-prescription antibiotic sales among Ghanaian community pharmacies and retail drug outlets through simulated client visits. In Ghana, Afari-Asiedu et al. reported that clients frequently sought antibiotics without prescriptions because retail drug outlets were easily accessible and provided a quicker alternative to formal healthcare facilities [ 27 ]. This aligns with the present study, where urgency and convenience were major factors influencing clients’ attempts to obtain antibiotics without medical consultation. Afari-Asiedu et al. further highlighted that financial constraints and the cost of travelling to health facilities often drove clients to rely on retail drug outlets instead [ 27 ]. Additional reasons for this behaviour include shorter waiting times, perceived expertise of pharmacists, and the generally more approachable attitude of dispensers compared to hospital staff [ 15 ]. In the present study, most dispensers reported that they would recommend an alternative antibiotic if they believed the one requested by the patient would be ineffective, and many would substitute the intended medication with a cheaper option when cost was a barrier. Similar patterns have been documented elsewhere. In Nepal, for example, a study evaluating antibiotic dispensing practices found that staff frequently substituted antibiotics when the preferred brand was unavailable and often directed clients to other pharmacies when necessary [ 28 ]. Comparable behaviours have been observed in Zambia, where Kalungia et al. noted that pharmacy staff commonly recommended or replaced antibiotics based on perceived effectiveness or product availability [ 29 ]. Their findings suggested that such practices may be partly driven by financial motivations rather than optimal clinical decision-making. Evidence from Saudi Arabia further supports this concern, showing that profit incentives contribute to the dispensing of broad-spectrum antibiotics not specifically requested by clients [ 30 ]. Additionally, in Nepal’s competitive pharmacy market, clients with limited financial resources often received reduced quantities of antibiotics or were offered cheaper substitutes, highlighting the commercial orientation of community pharmacies in Nepal [ 31 ]. This study identified a significant association between dispensing antibiotics without a prescription and the professional role of the dispensers. Pharmacists were found to be three times more likely to dispense antibiotics without a prescription compared to other dispensing staff. This may be attributed to their greater confidence and broader knowledge of antibiotics, which may lead them to make independent dispensing decisions. Similar findings were reported by Abubakar et al. in Nigeria, where pharmacists demonstrated a higher likelihood of dispensing non-prescription antibiotics than other drug outlet personnel [ 32 ]. Likewise, Pongo and Sangeda, in Tanzania, observed that pharmacists were more inclined than other pharmacy professionals to dispense antibiotics without a prescription [ 33 ]. In contrast, Bahta et al. reported no significant difference in antibiotic dispensing practices among pharmacy professionals in their study [ 34 ]. The current study also found a significant association between non-prescription antibiotic dispensing and dispensers’ practice of requesting patient feedback after previous antibiotic use. Dispensers who routinely requested antibiotic use history were less likely to dispense antibiotics without a prescription, possibly because they were unfamiliar with clients’ treatment histories and symptom patterns. Additionally, there was a significant association between non-prescription dispensing and consulting pharmacy protocols before supplying antibiotics, suggesting that the use of reference guidelines may influence dispensing behavior. Conclusion A high non-prescription sale of antibiotics in retail drug outlets was found in this study, underscoring the urgent need for improved antimicrobial stewardship measures through community-targeted evidence-based interventions. Strengthening current antimicrobial stewardship laws, guidelines, and regulatory policies for responsible antibiotic use and sale, alongside regular antimicrobial resistance awareness programs, is essential in promoting more responsible antibiotic use. The study is, however, limited in a way that the relatively small number of clusters used may have reduced the statistical efficiency due to intra-cluster correlation; however, this was mitigated by statistical adjustments and sampling half of the total cluster. In addition, this current study did not explore the motivation for selling antibiotics without a prescription. Exploratory research would ascertain the true views, attitudes, and knowledge about antimicrobial resistance by examining dispensers’ experiences, beliefs, and challenges. Unlike quantitative approaches, researchers would understand the origins of behaviors and practices. This thorough understanding can help identify community initiatives, training, and policy to improve antimicrobial stewardship. Abbreviations CDC Centers for Disease Control and Prevention WHO World Health Organization COR Crude Odds Ratio AOR Adjusted Odds Ratio Declarations Ethical approval and consent to participate: This study was approved by the Committee on Human Research Publication and Ethics (CHRPE) of Kwame Nkrumah University of Science and Technology with approval number CHRPE/AP/649/24. Permission was also sought from the director of the Pharmacy Council, Ashanti Regional Directorate, before conducting this study. All respondents received a participant information sheet that explained the study’s benefits and risks, and provided written informed consent before data collection. Informed consent was obtained from all subjects involved in the study. The study followed the principles of the Declaration of Helsinki. Ethical approval was obtained from the relevant review committee, and all participants provided informed consent before participation. Questionnaire The questionnaire was specifically developed for this study attached as supplementary file 1. Consent for Publication: Not Applicable Clinical trial number Not applicable Competing Interest: The authors declare no conflicts of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution BSD designed the study, collected and cleaned the data, performed the analysis, and wrote the first draft of the manuscript. VEA designed the questionnaire, the data collection tool, and performed further data cleaning, and coding. KB, KB, VEB reviewed, edited, and critically revised the manuscript. All authors contributed to revisions and approved the final manuscript. Acknowledgement Special thanks to the Pharmacy Council of Ghana, Ashanti Regional Directorate, for providing us with the number of retail drug outlets in the metropolis, and Evans Kumotu for his support during data collection. We also thank all participants included in the study for their valuable time and for giving us information. Data Availability Data are available from the corresponding author upon reasonable request. References Allabi AC, Agbo AG, Boya B, Mudenda S. Antimicrobial Stewardship: Knowledge and Attitudes of Pharmacy Staff on Antibiotic Dispensing Patterns, Use and Resistance in Benin. Pharmacol Pharm. 2023;14(06):189–214. https://doi.org/10.4236/pp.2023.146014 . Gajdács M, Paulik E, Szabó A. Knowledge, attitude and practice of community pharmacists regarding antibiotic use and infectious diseases: A cross-sectional survey in Hungary (KAPPhA-HU). Antibiotics. 2020;9(2):1–17. https://doi.org/10.3390/antibiotics9020041 . Rehman I, Asad M, Bukhsh A, Ali Z, Ata H, Dujaili J, Blebil A, Khan T. Knowledge and Practice of Pharmacists toward Antimicrobial Stewardship in Pakistan. Pharmacy. 2018;6(4):1–12. https://doi.org/10.3390/pharmacy6040116 . Gillani SW, Shahwan MKS, Szollosi DE. 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In Journal of Global Antimicrobial Resistance (Vol. 22, pp. 317–324). https://doi.org/10.1016/j.jgar.2020.03.009 Schuts EC, Hulscher MEJL, Mouton JW, Verduin CM, Stuart JWTC, Overdiek HWPM, van der Linden PD, Natsch S, Hertogh CMPM, Wolfs TFW, Schouten JA, Kullberg BJ, Prins JM. Current evidence on hospital antimicrobial stewardship objectives: A systematic review and meta-analysis. Lancet Infect Dis. 2016;16(7):847–56. https://doi.org/10.1016/S1473-3099(16)00065-7 . Aryee A, Price N. Antimicrobial stewardship - Can we afford to do without it? Br J Clin Pharmacol. 2015;79(2):173–81. https://doi.org/10.1111/bcp.12417 . Lim K, Broom A, Olsen A, Seale H. Community pharmacists as antimicrobial guardians and gatekeepers–A qualitative study of the perspectives of pharmacy sector stakeholders. Exploratory Res Clin Social Pharm. 2023;9:100212. Afzal MF. Antibiotic Stewardship: Battle to Defeat Superbugs. Annals King Edw Med Univ. 2017;23(2):97. https://doi.org/10.21649/akemu.v23i2.1557 . Abubakar U, Sulaiman S, S. A., Adesiyun AG. Utilization of surgical antibiotic prophylaxis for obstetrics and gynaecology surgeries in Northern Nigeria. Int J Clin Pharm. 2018;40(5):1037–43. https://doi.org/10.1007/s11096-018-0702-0 . Kpokiri EE, Ladva M, Dodoo CC, Orman E, Aku TA, Mensah A, Jato J, Mfoafo KA, Folitse I, Hutton-Nyameaye A, Okon-Ben I, Mensah-Kane P, Sarkodie E, Awadzi B, Jani YH. Knowledge, awareness and practice with antimicrobial stewardship programmes among healthcare providers in a ghanaian tertiary hospital. Antibiotics. 2022;11(1). https://doi.org/10.3390/antibiotics11010006 . Nyarko E, Akoto FM, Doku-Amponsah K. Perceived antimicrobial dispensing practices in medicine outlets in Ghana: A maximum difference experiment design. PLoS ONE. 2023;18(7 July):1–15. https://doi.org/10.1371/journal.pone.0288519 . Okai GA, Abekah-Nkrumah G, Asuming PO. Perceptions and trends in the use of community pharmacies in Ghana. J Pharm Policy Pract. 2019;12(1):1–9. https://doi.org/10.1186/s40545-019-0186-x . Prah J, Kizzie-Hayford J, Walker E, Ampofo-Asiama A. Antibiotic prescription pattern in a Ghanaian primary health care facility. Pan Afr Med J. 2017;28:1–10. https://doi.org/10.11604/pamj.2017.28.214.13940 . Sono TM, Markovic-Pekovic V, Godman B. Effective programmes to reduce inappropriate dispensing of antibiotics in community pharmacies especially in developing countries. Adv Hum Biology. 2024;14(1):1–4. https://doi.org/10.4103/aihb.aihb_128_23 . Khan H, Maheen S, Alamgeer, Abbas G, Mahmood A, Sarfraz RM, Ashraf Z, Khalil M, Malik MNH. Determinants of increasing trend of self-medication in a Pakistani community. Trop J Pharm Res. 2014;13(3):437–44. https://doi.org/10.4314/tjpr.v13i3.19 . Asante KP, Boamah EA, Abdulai MA, Buabeng KO, Mahama E, Dzabeng F, Gavor E, Annan EA, Owusu-Agyei S, Gyansa-Lutterodt M. Knowledge of antibiotic resistance and antibiotic prescription practices among prescribers in the Brong Ahafo Region of Ghana; A cross-sectional study. BMC Health Serv Res. 2017;17(1):2–9. https://doi.org/10.1186/s12913-017-2365-2 . Ghana Statistical Service. (2021). Ghana 2021 Population and Housing Census. Volume 3. Muyembe Asenahabi B, Anselemo Ikoha P. Scientific research sample size determination. Int J Sci Technoledge. 2023;11(7):8–12. https://doi.org/10.24940/theijst/2023/v11/i7/ST2307-008 . Ngyedu EK, Acolatse J, Akafity G, Incoom R, Rauf A, Seaton RA, Sneddon J, Cameron E, Watson M, Wanat M, Godman B, Kurdi A. Selling antibiotics without prescriptions among community pharmacies and drug outlets: a simulated client study from Ghana. Expert Rev Anti-Infective Therapy. 2023;21(12):1373–82. https://doi.org/10.1080/14787210.2023.2283037 . Ntizala AB, Mulume TY, Runyeruka BL, Kishabongo AS. Antibiotic Dispensing Practices in Community Pharmacies: A Major Health Concern in the Eastern Democratic Republic of Congo. J Pharm Res Int. 2020;33–44. https://doi.org/10.9734/jpri/2020/v32i1430603 . Dharanindra M, Shriram Dhanasekaran K, Rayana S, Noor SM, Bandela P, Viswanadh RPS, Kumar H, K. Antibiotic-Dispensing Patterns and Awareness of Anti-microbial Resistance Among the Community Pharmacists in South-Central India. Cureus. 2023;15(10):1–7. https://doi.org/10.7759/cureus.47043 . Jamshed S, Padzil F, Shamsudin S, Bux S, Jamaluddin A, Bhagavathula A, Azhar S, Hassali M. Antibiotic Stewardship in Community Pharmacies: A Scoping Review. Pharmacy. 2018;6(3):1–11. https://doi.org/10.3390/pharmacy6030092 . Olutuase VO. (2022). Assessment Of Antibiotic Dispensing Practices Of Community Pharmacists In Jos, Plateau State, Nigeria. 1–72. Afari-Asiedu S, Kinsman J, Boamah-Kaali E, Abdulai MA, Gyapong M, Sankoh O, Hulscher M, Asante KP, Wertheim H. To sell or not to sell; The differences between regulatory and community demands regarding access to antibiotics in rural Ghana. J Pharm Policy Pract. 2018;11(1):1–10. https://doi.org/10.1186/s40545-018-0158-6 . Ansari M. Evaluation of community pharmacies regarding dispensing practices of antibiotics in two districts of central Nepal. PLoS ONE. 2017;12(9):1–9. https://doi.org/10.1371/journal.pone.0183907 . Kalungia AC, Burger J, Godman B, de Costa J O., Simuwelu C. Non-prescription sale and dispensing of antibiotics in community pharmacies in Zambia. Expert Rev Anti-Infective Therapy. 2016;14(12):1215–23. https://doi.org/10.1080/14787210.2016.1227702 . Al-Qahtani MA, Amin HS, Al-Qahtani AA, Alshahrani AM, Alghamdi HA, Althwayee MS, Alzahrani AA. Self-medication with antibiotics in a primary care setting in King Khalid University Hospital, Riyadh, Saudi Arabia. J Family Community Med. 2018;25(2):95–101. https://doi.org/10.4103/jfcm.JFCM_124_17 . Ghimire K, Banjara MR, Marasini BP, Gyanwali P, Poudel S, Khatri E, Dhimal M. Antibiotics prescription, dispensing practices and antibiotic resistance pattern in common pathogens in Nepal: a narrative review. Microbiol insights. 2023;16:11786361231167239. https://doi.org/10.1177/11786361231167239 . Abubakar U, Tangiisuran B. Knowledge and practices of community pharmacists towards non-prescription dispensing of antibiotics in Northern Nigeria. Int J Clin Pharm. 2020;42(2):756–64. https://doi.org/10.1007/s11096-020-01019-y . ongo P, B. P., Sangeda RZ. Pharmacists’ Knowledge, Attitude and Practice Regarding the Dispensing of Antibiotics without Prescription in Tanzania: An Explorative Cross-Sectional Study. Pharmacy. 2020;8(4):238. https://doi.org/10.3390/pharmacy8040238 . Bahta M, Tesfamariam S, Weldemariam DG, Yemane H, Tesfamariam EH, Alem T, Russom M. Dispensing of antibiotics without prescription and associated factors in drug outlets of Eritrea: A simulated client method. PLoS ONE. 2020;15(1):e0228013. https://doi.org/10.1371/journal.pone.0228013 . Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 14 Apr, 2026 Reviews received at journal 11 Apr, 2026 Reviews received at journal 25 Mar, 2026 Reviewers agreed at journal 16 Mar, 2026 Reviewers agreed at journal 19 Feb, 2026 Reviewers invited by journal 18 Feb, 2026 Editor invited by journal 10 Feb, 2026 Editor assigned by journal 09 Feb, 2026 Submission checks completed at journal 09 Feb, 2026 First submitted to journal 07 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Donkor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIie3QvQrCMBDA8RPBLgddK6XvcBCoiMV3kUKm+AEOOrq5Ode30MU5EtCl4CZxEwQnB93qpKVuIqFuIvmTLIEfXA7AZvvBqDgSwAUsHioTgFo5Up98TUiWJQ1XLU+DNOoz3V3fMoiChXT2RxNpJnzIEs2bK92LfQTOFhJHZBxMY+jjVVGoBfkAqpMT7hnJLn0Rlgh2z+BRgkiRE62IPBF6CDInzsZIir9gyslLL2ELKWZzhTUjKTaGm4jcqWCHbNwOZtvp2Uje58xvFY0L+5hz/JrYbDbbX/cEMwtK07AClNAAAAAASUVORK5CYII=","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Bismark","middleName":"Senyo","lastName":"Donkor","suffix":""},{"id":594123726,"identity":"49420be2-62c0-4887-8802-4af6fc9f1dd6","order_by":1,"name":"Kingsley Badu","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and 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Technology","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"Edinam","lastName":"Assor","suffix":""}],"badges":[],"createdAt":"2026-02-07 13:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8815736/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8815736/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103503968,"identity":"1e2f271e-038b-42b5-a685-22813edd6900","added_by":"auto","created_at":"2026-02-26 13:06:07","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1337358,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCommonly dispensed antibiotics without a prescription\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8815736/v1/57f05a4eb0f5728239ca8325.jpeg"},{"id":103090890,"identity":"f8e58776-6cd3-47fa-91d3-a2af92c30206","added_by":"auto","created_at":"2026-02-20 16:46:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":22675,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDisease conditions for dispensing antibiotics without a prescription\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8815736/v1/a4195455d74a231393573311.png"},{"id":105751697,"identity":"d3373d8b-fccf-4497-abd6-9311e61bb743","added_by":"auto","created_at":"2026-03-30 15:38:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2847442,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8815736/v1/b8142e61-b46c-4f55-a8d3-6bf60907e341.pdf"},{"id":103090892,"identity":"3bbb8ff0-a58f-42e1-bbd8-c0d93d4cd43c","added_by":"auto","created_at":"2026-02-20 16:46:16","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":659683,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8815736/v1/2750748cb98da89ea699dbc2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Antimicrobial stewardship practices and patterns of antibiotic dispensing among retail drug outlets in Ghana","fulltext":[{"header":"Background","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMicroorganisms develop antimicrobial resistance through evolutionary changes that occur in response to medicines previously used to kill them, thereby reducing the effectiveness of those medicines. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Sustained antimicrobial resistance has resulted in multidrug-resistant pathogens that are associated with prolonged hospital stays, diminished quality of life, increased healthcare infrastructure costs, and excess mortality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The Centers for Disease Control and Prevention (CDC) posits that there are approximately two million clients who are infected with antimicrobial-resistant pathogens annually in the United States, accounting for more than 23,000 deaths [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Presently, more than 10\u0026nbsp;million deaths have been associated with antimicrobial resistance, and as such, the World Health Organization (WHO) declared antimicrobial resistance a worldwide emergency [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite the concern of antimicrobial resistance in public health, the use of antimicrobials has reduced the occurrence of microbial infections in the last five decades and, consequently, is heavily relied upon for the treatment of common illnesses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAntimicrobial resistance is accelerated by the misuse and overuse of antimicrobials. Among these are the inappropriate prescription of antibiotics by doctors and pharmacists, misuse, including not completing a treatment course, and the indiscriminate self-medication by patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The most important intervention that can be employed to adequately address the misuse of antimicrobials is the strict implementation of antimicrobial stewardship programmes. These programmes emphasize that the use of antimicrobials, including antibiotics, must be controlled and exercised responsibly, ensuring a balance between appropriate use and regulated access to these medicines [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Antimicrobial stewardship programs are implemented through patient-centered care that relies on recommendations and adherence to guidelines for antimicrobial dispensing [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Strategies that regulate the purchase of non-prescribed antimicrobials and improve healthcare providers\u0026rsquo; knowledge and perception of antimicrobial use further constitute the scope of antimicrobial stewardship programs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the quest to deliver efficient antimicrobial therapy, it is important to preserve the efficacy of antimicrobials within a sustainable healthcare environment. Although antimicrobial stewardship programs may involve an initial cost, they have consistently been shown to reduce unnecessary antibiotic use and are associated with improved patient outcomes and lower healthcare expenditures [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Community drug dispensers are one of the most accessible health professionals within the health system, with the capacity to dispense antibiotics [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, they are the most essential contributors to the development of antimicrobial resistance among the public through the misguided dispensing of antibiotics [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePurchasing antibiotics with a valid prescription remains a major concern, and despite existing restrictions, antibiotics are still freely sold without a prescription in many developing countries. This practice adds to the already growing burden of antibiotic resistance [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A few studies have examined the behavioural aspects of self-medication and antibiotic use; however, they have not addressed antimicrobial stewardship practices related to antibiotic dispensing patterns, pharmacy personnel knowledge or the factors that influence dispensing behaviours [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. To promote appropriate antibiotic dispensing and use, and to help combat the burden of antibiotic resistance, it is important to investigate the practices and factors that influence provider behaviour and to gain insight into these behaviours [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although previous studies in Ghana have highlighted the role of community retail drug outlets in contributing to antimicrobial resistance, [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], this study evaluated antimicrobial stewardship practices in antibiotic dispensing and its influencing factors.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Sampling\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study employed a cross-sectional design with a multi-stage cluster sampling approach. Due to the finite number of clusters (n\u0026thinsp;=\u0026thinsp;10), the first stage sampled five clusters (sub-metro) randomly for inclusion in the study. In the second stage sampling, all eligible participants were proportionately sampled to achieve the required sample size. With this method, participants were selected using the lottery method, where unique identifiers were written on identical slips of paper, and participants were asked to select an odd number between one and five for inclusion in the study. All statistical analyses were adjusted to account for the clustered nature of the sampling design. This adjustment addressed the non-independence of observations within clusters.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Site\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in the Greater Kumasi Metropolis, the administrative capital of Ghana's Ashanti Region, located between latitudes 6.35\u0026deg; N and 6.40\u0026deg; S and longitudes 1.30\u0026deg; W and 1.35\u0026deg; E. The metropolis covers a land area of approximately 213 km\u0026sup2; and has a population exceeding 2,600,000. The Greater Kumasi has seven (7) administrative divisions: Kumasi Metropolitan Assembly (Bantama, Subin, Manhyia North and South, and Nhyiaeso), Asokore Mampong, Asokwa, Suame, Kwadaso, Tafo, and Oforikrom Municipalities [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study population comprised all retail community drug outlets within the selected areas of the Greater Kumasi metropolis. All drug outlets in the selected Greater Kumasi metropolitan area that had dispensing professionals available during the data collection period were included in the study. Drug outlets without dispensing professionals available at the time of data collection were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eSample Size Calculation\u003c/h3\u003e\n\u003cp\u003eThe sample size was determined using Cochran\u0026rsquo;s formula for a finite population. Cochran\u0026rsquo;s recommended sample size for large populations is \u003cb\u003en\u003c/b\u003e\u003csub\u003e\u003cb\u003eo\u003c/b\u003e\u003c/sub\u003e=385 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Since the total number of registered retail drug outlets (pharmacy stores, over-the-counter chemical sellers, and herbal shops) in the selected areas of Greater Kumasi is relatively small (N\u0026thinsp;=\u0026thinsp;230), the finite population correction was applied using the formula:\u003c/p\u003e\n\u003ch3\u003en = n / (1 + (n − 1) / N)\u003c/h3\u003e\n\u003cp\u003eWhere \u003cb\u003en\u003c/b\u003e\u003csub\u003e\u003cb\u003eo\u003c/b\u003e\u003c/sub\u003e is Cochran\u0026rsquo;s recommended sample size.\u003c/p\u003e \u003cp\u003e \u003cb\u003eN\u003c/b\u003e represents the population size.\u003c/p\u003e \u003cp\u003e \u003cb\u003en\u003c/b\u003e is the adjusted sample size.\u003c/p\u003e \u003cp\u003e \u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;385 / (1 + (385\u0026ndash;1) / 230),\u003c/p\u003e \u003cp\u003e \u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;144.2\u003c/p\u003e \u003cp\u003eTo account for potential non-response, a 10% adjustment was applied.\u003c/p\u003e \u003cp\u003e=\u0026thinsp;\u003cb\u003e0.1 * 144.2\u0026thinsp;=\u0026thinsp;14.1\u003c/b\u003e\u0026thinsp;\u0026asymp;\u0026thinsp;14\u003c/p\u003e \u003cp\u003eAdding this to the adjusted sample size yielded a final required sample size of:\u003c/p\u003e \u003cp\u003e144\u0026thinsp;+\u0026thinsp;14=158\u003c/p\u003e \u003cp\u003eTherefore, a total of \u003cb\u003e158 retail drug outlets\u003c/b\u003e were targeted.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eInterviews were conducted among 158 drug dispensers from community retail drug outlets across five randomly selected sub-metropolises between April and July 2024. Drug dispensers were interviewed randomly based on proportionate multi-stage cluster sampling. The survey was translated into the local dialect for dispensers who required clarification of some English terminology. The questionnaire was pretested, and all entries were checked daily by the principal investigator for completeness and accuracy. Dispensing professionals available during data collection were eligible for inclusion. Only Dispensing professionals who provided informed consent participated in the study, while outlets without available dispensers at the time of data collection were excluded from the study. Written and verbal consent was obtained from each dispenser before data collection.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eData in Microsoft Excel format was imported into Stata 16 statistical software, where it was cleaned and analyzed. Data cleaning was performed to check for missing values, outliers, and inconsistencies in the data collected. Errors identified were resolved by cross-referencing with the original questionnaire. Descriptive statistical analysis, such as mean, median, frequencies, and percentages were performed on demographic characteristics, antimicrobial stewardship practices, and factors influencing the dispensing of antibiotics. Chi-square tests were performed to determine the association between dispensing antibiotics without prescription and stewardship practices, and factors influencing the dispensing of antibiotics. A bivariate logistic regression was performed to predict determinants of antimicrobial stewardship practices. Multivariate logistic regression was further performed on variables that showed a significant association from the bivariate analysis. All statistical tests were performed at a 0.05 α level and 95% confidence interval.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics\u003c/h2\u003e \u003cp\u003eMost participants, 97 (61.4%), were aged between 26 and 40 years, while those above 40 years constituted the smallest group of 14.6% (23). The mean age was 32.4 years (SD\u0026thinsp;=\u0026thinsp;10.1). Females, 86 (54.4%), represented slightly more than half of the sample, compared to males, 72 (45.6%). Regarding educational status, tertiary graduates were the most represented, with 112 (70.9%), whereas vocational school attendees were the least represented, 8.9%. In terms of professional qualifications for dispensing, a total of 58 (36.7%) respondents held Medical Counter Assistant certificates, 48 (30.4%) had Higher National Diplomas, and 52 (32.9%) held a first degree or higher. For facility type, pharmacy stores were the predominant setting, 126 (79.9%), while herbal shops were the least represented, 5 (3.2%). Most dispensers were medical counter assistants, 65 (41.1%), followed by pharmacy technicians, 35 (22.1%), with uncertified dispensers accounting for 3.8% (6) of the respondents. Most, 100 (63.3%) respondents reported having five years or less of dispensing experience, while 51 (55.1%) had not previously worked in a health facility. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below summarizes the respondents\u0026rsquo; demographic characteristics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eSociodemographic characteristics of respondents\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;158)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;26 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26 to 40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e32.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic and high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCredential attained for practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicine Counter Assistant Certificates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher National Diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst-degree or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHerbal Shop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOver the Counter Chemical Store\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy Store\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJob role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicine Counter Assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy Assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of dispensing experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver worked in a health facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cb\u003eCommonly dispensed antibiotics without a prescription.\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eRespondents were provided with a list of selected antibiotics and asked to indicate which ones they dispense without a prescription, selecting them from most frequently dispensed to least frequently dispensed. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, ciprofloxacin and amoxicillin were the most dispensed, each reported by 65.8%, followed closely by amoxicillin-clavulanic acid (64.56%) and metronidazole (58.23%). Other frequently dispensed agents included flucloxacillin (56.33%), doxycycline (49.37%), and azithromycin (46.20%). Moderate levels of dispensing were recorded for cefixime (24.68%), ceftriaxone (23.42%), erythromycin (22.15%), ampicillin (22.15%), tetracycline (20.25%), and cotrimoxazole (17.72%). Less commonly dispensed antibiotics included gentamicin (10.13%), ofloxacin (3.80%), cefuroxime (3.16%), clindamycin (1.27%), roxithromycin (1.27%), and several others at or below 0.63%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDisease conditions for antibiotic dispensing without a prescription.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below shows the conditions under which antibiotics were most often dispensed without a prescription. Genital and urinary tract conditions dominated antibiotic dispensing, accounting for 74.7% of all reported cases, followed by respiratory infections (17.1%). Antibiotics were rarely dispensed for skin infections (3.8%), gastrointestinal conditions (3.2%), or dental issues (1.3%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAntibiotic stewardship practices among respondents in antibiotic dispensing\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAmong the 158 respondents, 86 (54.4%) reported dispensing antibiotics without a prescription, and 127 (80.4%) indicated that they dispense antibiotics regularly. Most dispensers (86.7%) reported that they would recommend an alternative antibiotic if they believed the requested antibiotic would be ineffective for a client\u0026rsquo;s use. Similarly, 127 respondents (80.3%) indicated they would substitute a prescribed antibiotic with a cheaper brand if a patient could not afford the original option. Nearly all respondents (98.8%) stated that they provide counselling on the appropriate use of antibiotics. Regarding clients mounting pressure on dispensers to purchase inappropriate antibiotics, 60 respondents (40.0%) reported that they refer such clients to a physician, while 34.8% refuse to dispense under such circumstances. However, 6.3% of respondents admitted to dispensing based on their experience with selling antibiotics. Additionally, 82.3% (n\u0026thinsp;=\u0026thinsp;130) of participants reported requesting clients\u0026rsquo; antibiotic use history before dispensing antibiotics, and 84.8% (n\u0026thinsp;=\u0026thinsp;134) routinely advise clients to adhere strictly to the dosage instructions provided. Some respondents (29.1%) adhered to facility-established dispensing guidelines as pharmaceutical references used when selling or dispensing antibiotics, while 20.9% consulted clinical guidelines when dispensing antibiotics. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the antibiotic stewardship practices and dispensing activities of the respondents.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eAntibiotic stewardship practices in antibiotic dispensation of respondents\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;158)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispensing antibiotics without prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of dispensing without prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegularly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccasionally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSell if an intended antibiotic will not be effective for client\u0026rsquo;s condition.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClients\u0026rsquo; inability to afford an antibiotic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsult physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRefer to another drug outlet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReplace with a cheaper alternative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCounseling client on the appropriate use of antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandling clients insisting on inappropriate antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsk the client to consult a physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispense anyway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispense based on experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispense based on knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispense based on use history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotic use history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvising clients about using antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete full course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdhere to dosage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmaceutical references consulted prior to antibiotic dispensation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsulting other healthcare professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClient antibiotic use history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacility protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFactors influencing dispensers to dispense antibiotics without a prescription\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA total of 71 (44.9%) respondents reported being convinced to dispense antibiotics without a prescription based on a client\u0026rsquo;s previous antibiotic use, while 32.9% (n\u0026thinsp;=\u0026thinsp;52) dispensed antibiotics due to the perceived urgency or convenience for the client. Only 3.2% (n\u0026thinsp;=\u0026thinsp;5) indicated that they were never convinced by clients to dispense without a prescription. Overall, 67.7% (n\u0026thinsp;=\u0026thinsp;107) of respondents reported that they do not feel pressured by clients to dispense antibiotics. Most 79.1% (n\u0026thinsp;=\u0026thinsp;126) dispensed antibiotics without a prescription based on the clients\u0026rsquo; symptoms, whereas 7.0% (n\u0026thinsp;=\u0026thinsp;11) did so based on the clients\u0026rsquo; ability to pay. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the factors influencing dispensers\u0026rsquo; decisions to dispense antibiotics without a prescription.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors influencing dispensers to dispense antibiotics without a prescription\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;158)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow clients convince dispensers to dispense antibiotics without a prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief in antibiotic efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not rely on clients\u0026rsquo; complaints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrgency and convenience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEconomic influence to dispense antibiotics without a prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of negative clients\u0026rsquo; feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClients\u0026rsquo; ability to pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClient\u0026rsquo;s symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePressure to dispense antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of antimicrobial stewardship practices in the dispensing of antibiotics\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIn the bivariate analysis, age and gender showed no significant association with dispensing antibiotics without a prescription (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, job role was significantly associated (χ\u0026sup2; = 9.99, p\u0026thinsp;=\u0026thinsp;0.033) because pharmacists were substantially more likely to dispense antibiotics without a prescription compared to medicine counter assistants (COR\u0026thinsp;=\u0026thinsp;3.91, 95% CI: 1.49\u0026ndash;10.32; p\u0026thinsp;=\u0026thinsp;0.006), and this association remained significant after adjustment (AOR\u0026thinsp;=\u0026thinsp;4.63, 95% CI: 1.20 \u0026minus;\u0026thinsp;17.83; p\u0026thinsp;=\u0026thinsp;0.026). How respondents handled clients insisting on inappropriate antibiotics was also significantly related to non-prescription dispensing (χ\u0026sup2; =12.97, p\u0026thinsp;=\u0026thinsp;0.011). Those who rely on their knowledge of antibiotics (AOR\u0026thinsp;=\u0026thinsp;4.53, 95% CI: 1.36\u0026ndash;15.11; p\u0026thinsp;=\u0026thinsp;0.014) or use history (AOR\u0026thinsp;=\u0026thinsp;3.28, 95% CI: 1.37\u0026ndash;7.83; p\u0026thinsp;=\u0026thinsp;0.008) had significantly higher odds of dispensing without prescription compared to those who referred clients to a physician. Respondents who requested antibiotic use history from clients were protective because they were significantly less likely to dispense without a prescription (AOR\u0026thinsp;=\u0026thinsp;0.30, 95% CI: 0.10\u0026ndash;0.89; p\u0026thinsp;=\u0026thinsp;0.03) compared to those who did not. Pharmaceutical references consulted before antibiotic administration were also significantly associated with dispensing antibiotics without prescription (χ\u0026sup2; =17.49, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Those who relied on pharmacy protocols (COR\u0026thinsp;=\u0026thinsp;0.23, 95% CI: 0.08\u0026ndash;0.60; p\u0026thinsp;=\u0026thinsp;0.003) or consulted other healthcare professionals or colleagues (COR\u0026thinsp;=\u0026thinsp;0.38, 95% CI: 0.15\u0026ndash;0.98; p\u0026thinsp;=\u0026thinsp;0.046) were significantly less likely to dispense without a prescription. Other variables, including counseling clients, pressure to dispense, and reasons for being convinced by clients, were not significantly associated. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the predictors of antimicrobial stewardship practices in the dispensing of antibiotics.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDeterminants of antimicrobial stewardship practices in the dispensing of antibiotics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAntibiotic dispensing without prescription\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;158) (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ2\u003c/p\u003e \u003cp\u003e(p-value)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCrude Odds Ratio, (95% CI), p-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted Odds Ratio (95% CI), p-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 26 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0062 (0.605)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26 to 40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (56.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.46 (0.69\u0026ndash;3.10), 0.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (43.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (56.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.44 (0.51\u0026ndash;4.10), 0.489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (51.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.8124 (0.367)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (54.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.34 (0.71\u0026ndash;2.51), 0.368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJob role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicine Counter Assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.9967 \u003cb\u003e(0.033) *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.91(1.49\u0026ndash;10.32), \u003cb\u003e0.006*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.63 (1.20-17.83), \u003cb\u003e0.026*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy Assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (45.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.34 (0.49\u0026ndash;3.67), 0.568\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.31 (0.39\u0026ndash;4.44), 0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.03 (0.46\u0026ndash;2.36), 0.930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.55 (0.59\u0026ndash;4.06), 0.372\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther pharmacy professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.55 (0.09\u0026ndash;3.2), 0.505\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.56 (0.06\u0026ndash;5.26),0.615\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCounseling clients on the appropriate use of antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.4678 (0.116)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.00 (0.55\u0026ndash;45.78), 0.154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandling clients insisting on inappropriate antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsk the clients to consult a physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (63.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.9730 \u003cb\u003e(0.011) *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispense anyway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.41 (0.68\u0026ndash;8.54), 0.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.96 (0.73 12.00),0.129\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispense based on my experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.59(0.66\u0026ndash;10.19),0.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.42 (0.28\u0026ndash;7.11), 0.668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispense based on my knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.32 (1.46\u0026ndash;12.75), \u003cb\u003e0.008*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.53 (1.36\u0026ndash;15.11), \u003cb\u003e0.014*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispense based on use history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (65.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.27 (1.52\u0026ndash;7.03), 0.020*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.28 (1.37\u0026ndash;7.83), \u003cb\u003e0.008*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConvinced by clients to dispense antibiotics without a prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief in antibiotic efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0977 (0.596)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not rely on clients\u0026rsquo; complaints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.67 (0.27\u0026ndash;26.86), 0.405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (49.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.69 (0.29\u0026ndash;1.63), 0.393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrgency and convenience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.78 (0.31\u0026ndash;1.93), 0.589\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of antibiotic usage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.3380 \u003cb\u003e(0.007) *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (49.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28(0.10\u0026ndash;0.73), \u003cb\u003e0.010*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.30 (0.10\u0026ndash;0.89), \u003cb\u003e0.03*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePressure to dispense antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.5860 (0.444)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.3 (0.66\u0026ndash;2.55), 0.444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmaceutical references consulted prior to antibiotic dispensation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (69.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4882 \u003cb\u003e(0.001) *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsulting other healthcare professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.38 (0.15\u0026ndash;0.98), \u003cb\u003e0.046*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClient antibiotic use history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.30 (0.45\u0026ndash;3.7), 0.623\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.23 (0.08\u0026ndash;0.60), \u003cb\u003e0.003*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e* Statistically significant association (α\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/h2\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study highlights key antimicrobial stewardship challenges and the factors influencing non-prescription antibiotic dispensing in Ghana. The findings show that ciprofloxacin, amoxicillin, amoxicillin-clavulanic acid, and flucloxacillin were the most frequently sold antibiotics without a prescription, while doxycycline and azithromycin were the dispensed antibiotics at moderate levels, and several others, such as levofloxacin, tinidazole, secnidazole, and cefuroxime, were dispensed infrequently. These patterns align with reports from Eastern Congo, where amoxicillin and ciprofloxacin were similarly identified as commonly dispensed antibiotics without prescription [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. The practice is concerning as it facilitates inappropriate self-medication and contributes to the development of antimicrobial resistance.\u003c/p\u003e\u003cp\u003eComparable trends have been observed in India, where Dharanindra et al. reported amoxicillin as a frequently dispensed antibiotic and azithromycin as highly dispensed, contrasting with its moderate use in the present study, while ciprofloxacin and amoxicillin-clavulanic acid were among the least dispensed in their setting [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. These differences may reflect variations in regulatory enforcement, pharmacy licensing, and the extent to which dispensers assess patient antibiotic-use history before dispensing.\u003c/p\u003e\u003cp\u003eGenitourinary infections accounted for the highest use of antibiotics in this study, followed by respiratory infections, which also represented a substantial proportion of conditions for which dispensers supplied antibiotics. In contrast, gastrointestinal and dental conditions were the least common reasons for antibiotic dispensing, suggesting that these illnesses are less frequently treated with antibiotics in the study area. These findings are consistent with Ntizala et al., who also reported that genitourinary tract infections were the most common indications for antibiotic use, particularly cephalosporins [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. Similarly, Jamshed et al., found that urinary tract infections were the leading reason for antibiotic dispensing, especially penicillin [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. In Nigeria, Olutuase (2022), identified genitourinary infections as among the most frequently treated conditions, with respiratory infections dispensed at moderate levels [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], correlating with the findings from the current study.\u003c/p\u003e\u003cp\u003eThe findings from this study show that most dispensers provide antibiotics without a prescription, a practice consistent with reports from the Republic of Congo, Benin, and India [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. In Benin, Allabi et al. documented that 75% of dispensers supplied antibiotics to clients without a prescription [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. Similarly, Dharanindra et al. found widespread non-prescription antibiotic dispensing in Indian community pharmacies, which they partly attributed to limited knowledge of antimicrobial resistance and easy over-the-counter access to antibiotics, conditions that do not differ from the Ghanaian context [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. This finding context is at par with the outcome of Ngyedu et al. (2023), who documented widespread non-prescription antibiotic sales among Ghanaian community pharmacies and retail drug outlets through simulated client visits.\u003c/p\u003e\u003cp\u003eIn Ghana, Afari-Asiedu et al. reported that clients frequently sought antibiotics without prescriptions because retail drug outlets were easily accessible and provided a quicker alternative to formal healthcare facilities [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. This aligns with the present study, where urgency and convenience were major factors influencing clients’ attempts to obtain antibiotics without medical consultation. Afari-Asiedu et al. further highlighted that financial constraints and the cost of travelling to health facilities often drove clients to rely on retail drug outlets instead [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. Additional reasons for this behaviour include shorter waiting times, perceived expertise of pharmacists, and the generally more approachable attitude of dispensers compared to hospital staff [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present study, most dispensers reported that they would recommend an alternative antibiotic if they believed the one requested by the patient would be ineffective, and many would substitute the intended medication with a cheaper option when cost was a barrier. Similar patterns have been documented elsewhere. In Nepal, for example, a study evaluating antibiotic dispensing practices found that staff frequently substituted antibiotics when the preferred brand was unavailable and often directed clients to other pharmacies when necessary [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eComparable behaviours have been observed in Zambia, where Kalungia et al. noted that pharmacy staff commonly recommended or replaced antibiotics based on perceived effectiveness or product availability [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Their findings suggested that such practices may be partly driven by financial motivations rather than optimal clinical decision-making. Evidence from Saudi Arabia further supports this concern, showing that profit incentives contribute to the dispensing of broad-spectrum antibiotics not specifically requested by clients [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Additionally, in Nepal’s competitive pharmacy market, clients with limited financial resources often received reduced quantities of antibiotics or were offered cheaper substitutes, highlighting the commercial orientation of community pharmacies in Nepal [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study identified a significant association between dispensing antibiotics without a prescription and the professional role of the dispensers. Pharmacists were found to be three times more likely to dispense antibiotics without a prescription compared to other dispensing staff. This may be attributed to their greater confidence and broader knowledge of antibiotics, which may lead them to make independent dispensing decisions. Similar findings were reported by Abubakar et al. in Nigeria, where pharmacists demonstrated a higher likelihood of dispensing non-prescription antibiotics than other drug outlet personnel [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. Likewise, Pongo and Sangeda, in Tanzania, observed that pharmacists were more inclined than other pharmacy professionals to dispense antibiotics without a prescription [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. In contrast, Bahta et al. reported no significant difference in antibiotic dispensing practices among pharmacy professionals in their study [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe current study also found a significant association between non-prescription antibiotic dispensing and dispensers’ practice of requesting patient feedback after previous antibiotic use. Dispensers who routinely requested antibiotic use history were less likely to dispense antibiotics without a prescription, possibly because they were unfamiliar with clients’ treatment histories and symptom patterns. Additionally, there was a significant association between non-prescription dispensing and consulting pharmacy protocols before supplying antibiotics, suggesting that the use of reference guidelines may influence dispensing behavior.\u003c/p\u003e\u003c/div\u003e "},{"header":"Conclusion","content":"\u003cp\u003eA high non-prescription sale of antibiotics in retail drug outlets was found in this study, underscoring the urgent need for improved antimicrobial stewardship measures through community-targeted evidence-based interventions. Strengthening current antimicrobial stewardship laws, guidelines, and regulatory policies for responsible antibiotic use and sale, alongside regular antimicrobial resistance awareness programs, is essential in promoting more responsible antibiotic use.\u003c/p\u003e\u003cp\u003eThe study is, however, limited in a way that the relatively small number of clusters used may have reduced the statistical efficiency due to intra-cluster correlation; however, this was mitigated by statistical adjustments and sampling half of the total cluster. In addition, this current study did not explore the motivation for selling antibiotics without a prescription. Exploratory research would ascertain the true views, attitudes, and knowledge about antimicrobial resistance by examining dispensers’ experiences, beliefs, and challenges. Unlike quantitative approaches, researchers would understand the origins of behaviors and practices. This thorough understanding can help identify community initiatives, training, and policy to improve antimicrobial stewardship.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eCDC Centers for Disease Control and Prevention\u003c/p\u003e \u003cp\u003eWHO World Health Organization\u003c/p\u003e \u003cp\u003eCOR Crude Odds Ratio\u003c/p\u003e \u003cp\u003eAOR Adjusted Odds Ratio\u003c/p\u003e "},{"header":"Declarations","content":" \u003ch2\u003eEthical approval and consent to participate:\u003c/h2\u003e \u003cp\u003e This study was approved by the Committee on Human Research Publication and Ethics (CHRPE) of Kwame Nkrumah University of Science and Technology with approval number CHRPE/AP/649/24. Permission was also sought from the director of the Pharmacy Council, Ashanti Regional Directorate, before conducting this study. All respondents received a participant information sheet that explained the study\u0026rsquo;s benefits and risks, and provided written informed consent before data collection. Informed consent was obtained from all subjects involved in the study. The study followed the principles of the Declaration of Helsinki. Ethical approval was obtained from the relevant review committee, and all participants provided informed consent before participation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eQuestionnaire\u003c/strong\u003e \u003cp\u003eThe questionnaire was specifically developed for this study attached as supplementary file 1.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication:\u003c/strong\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical trial number\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interest:\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFunding\u003c/strong\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e \u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBSD designed the study, collected and cleaned the data, performed the analysis, and wrote the first draft of the manuscript. VEA designed the questionnaire, the data collection tool, and performed further data cleaning, and coding. KB, KB, VEB reviewed, edited, and critically revised the manuscript. All authors contributed to revisions and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eSpecial thanks to the Pharmacy Council of Ghana, Ashanti Regional Directorate, for providing us with the number of retail drug outlets in the metropolis, and Evans Kumotu for his support during data collection. We also thank all participants included in the study for their valuable time and for giving us information.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAllabi AC, Agbo AG, Boya B, Mudenda S. 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Pharmacy. 2020;8(4):238. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/pharmacy8040238\u003c/span\u003e\u003cspan address=\"10.3390/pharmacy8040238\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahta M, Tesfamariam S, Weldemariam DG, Yemane H, Tesfamariam EH, Alem T, Russom M. Dispensing of antibiotics without prescription and associated factors in drug outlets of Eritrea: A simulated client method. PLoS ONE. 2020;15(1):e0228013. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0228013\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0228013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antibiotics, Antimicrobial stewardship practices, retail drug outlets","lastPublishedDoi":"10.21203/rs.3.rs-8815736/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8815736/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSelf-medication with antibiotics purchased from community retail drug outlets without valid prescriptions has emerged as a major contributor to antimicrobial resistance. This study evaluated antimicrobial stewardship practices related to antibiotic dispensing among community retail drug outlets in Ghana to identify current practices and inform targeted interventions to improve rational antibiotic use.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study design was used. Data was collected from 158 dispensers, entered, and analyzed using STATA between April and July 2024. Descriptive statistics (mean, SD, median frequency, and percentages) were used to analyze antimicrobial stewardship practices, antibiotic types dispensed, associated diseases and conditions, and influencing factors of antibiotic dispensation without prescription. Chi-square (χ\u0026sup2;), bivariate, and multivariate logistic regression analyses identified significant predictors of antibiotic dispensing without prescription and predictor variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 86 (54.4%) out of 158 respondents dispensed antibiotics without valid prescription, with 80.4% (127) dispensing without a prescription regularly. Ciprofloxacin and amoxicillin (65.8%) were most frequently dispensed, while genitourinary infections (74.7%) were the most common disease conditions for which treatment is given before medications used in treatment. Pharmacists (AOR\u0026thinsp;=\u0026thinsp;4.63, 95% CI: 1.20-17.83; p\u0026thinsp;=\u0026thinsp;0.026) were significantly more likely to engage in non-prescription dispensing than other dispensers. Dispensers who requested a history of the client\u0026rsquo;s history on antibiotic usage (AOR\u0026thinsp;=\u0026thinsp;0.30, 95% CI: 0.10\u0026ndash;0.89; p\u0026thinsp;=\u0026thinsp;0.03) were less likely to dispense antibiotics without a prescription compared to those who did not request clients\u0026rsquo; antibiotic use history. P-values less than 0.05 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were considered statistically significant associations.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eA high non-prescription sale of antibiotics in retail drug outlets was found in this study, underscoring the urgent need for improved antimicrobial stewardship measures through community-targeted evidence-based interventions.\u003c/p\u003e","manuscriptTitle":"Antimicrobial stewardship practices and patterns of antibiotic dispensing among retail drug outlets in Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-20 16:46:06","doi":"10.21203/rs.3.rs-8815736/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-14T04:13:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-11T06:50:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T02:57:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47363726067473577018763302775329510600","date":"2026-03-16T18:21:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164369698847384189457089218893734685995","date":"2026-02-20T03:56:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-18T14:54:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-11T04:59:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-10T00:34:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-10T00:32:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-07T13:11:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6011f96-94cf-4c2f-8222-39d89430f7c5","owner":[],"postedDate":"February 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T15:53:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-20 16:46:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8815736","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8815736","identity":"rs-8815736","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}