Introduction
Methods
Data sources and search strategy
Eligibility screening
Inclusion criteria | Exclusion criteria |
---|---|
Simulated client studies, onsite observation surveys or mixed methods studies, conducted in a CDRO setting, reporting the proportion of dispensing of antibiotics without a prescription Studies conducted in a CDRO setting involving interviewing pharmacy staffs and generating a report about a recent transaction made Studies involving exit interviews conducted with clients as they left retail outlets and reporting data on the OTC sale of antibiotics | Articles conducted in hospital or veterinary pharmacy settings Studies that were published in languages other than English Studies that explored knowledge and attitudes of pharmacists (or the public) about antibiotics but lacked data on the magnitude of non-prescribed sale of antibiotics Abstracts without the full text available for retrieval, and reviews, conference proceedings, letter to editor and meeting notes Pharmacy staffs (or public) opinion surveys on the supply and/or sources of non-prescribed antibiotics Studies not undertaken in SSA |
Quality assessment of the included studies
Data extraction
Statistical analysis
Results
Characteristics of the included studies
Articles | Study locations | Data collection method | Case scenarios that resulted in antibiotics supply | Number of drug retail outlets visited | Number of visits/encounters/transactions | Encounters in which antibiotics were sold without prescriptions (%) | Main classes of antibiotics dispensed |
---|---|---|---|---|---|---|---|
Simulated client, acute childhood diarrhoea | |||||||
Abegaz et al. [28] | Ethiopia | Simulated client | Acute childhood diarrhoea | 113 | 113 | 51 | Sulphonamide, Nitro-imidazole |
Berih et al. [27] | Sudan | Simulated client | Acute childhood diarrhoea | 63 | 63 | 67 | Sulphonamide, Nitro-imidazole |
Mengistu et al. [37] | Ethiopia | Simulated client | Acute childhood diarrhoea | 105 | 105 | 87 | Sulphonamide |
Simulated client, acute childhood diarrhoea plus adult upper respiratory infections (URTIs) | |||||||
Ayele et al. [29] | Ethiopia | Simulated client | Acute childhood diarrhoea and URTIs in adult | 22 | 44 | 64 | Sulphonamide, Nitro-imidazole, Penicillin, Macrolide Fluoroquinolone, |
Erku DA et al. [33] | Ethiopia | Simulated client | Acute childhood diarrhoea and URTIs in adult | 50 | 100 | 86 | Sulphonamide, Nitro-imidazole, Penicillin, Macrolide, Fluoroquinolone Cephalosporin |
Simulated client, acute childhood diarrhoea plus other conditions in all ages | |||||||
Nyazema et al. [39] | Zimbabwe | Simulated client | Acute childhood diarrhoea, vaginal discharge and itching, urethral discharge | 87 | 184 | 8 | Penicillin, Sulphonamide, Tetracycline, Fluoroquinolone |
Koji et al. [36] | Ethiopia | Simulated client | Common cold, acute childhood diarrhoea, childhood pneumonia, meningitis, critically sick, then each case was followed by different antibiotics request | 262 | 262 | 63 | Penicillin, Macrolide, Sulphonamide, Nitro-imidazole, Cephalosporin, Aminoglycoside, |
Minzi et al. [38] | Tanzania | Simulated client | Cough, headache and childhood diarrhoea, left hip injury, fever and childhood diarrhoea, vomiting and diarrhoea, persistent cough, yellowish urethral discharge with a bad smell, then each case was followed by different antibiotics request | 145 | 145 | 69 | Penicillin, Fluoroquinolone, |
Simulated client, adult acute diarrhoea plus other conditions | |||||||
Bahta et al. [20] | Eritrea | Simulated Client | Acute watery diarrhoea and urinary tract infection(UTI) | 84 | 153 | 88 | Fluoroquinolone Sulphonamide, Penicillin, Tetracycline, Nitro-imidazole |
Horumpende et al. [35] | Tanzania | Simulated client | Unspecified fever, cough, acute diarrhoea, pain during urination | 39 | 39 | 92 | Penicillin, Macrolide, Cephalosporin, Sulphonamide, Nitro-imidazole,, Fluoroquinolone |
Damisie et al. [32] | Ethiopia | Simulated client | Acute diarrhoea, sore throat, UTI | 18 | 54 | 87 | Fluoroquinolone Sulphonamide, Penicillins Nitro-imidazole,, Macrolide |
Simulated client, URTIs plus antibiotics product request in all ages | |||||||
Erku et al. [34] | Ethiopia | Simulated client | URTIs and amox-clav request | 58 | 116 | 82 | Penicillin Macrolides, Cephalosporin, Fluoroquinolone |
Wafula et al. [41] | Kenya | Simulated client | Acute respiratory infection followed by amoxicillin request | 200 | 200 | 87 | Penicillin |
Chikowe et al. [31] | Malawi | Simulated client | Direct product request(amoxicillin) (if asked, clarified as flu or cold) | 45 | 45 | 93 | Penicillin |
Chalker et al. [30] | Tanzania | Simulated client | Cough and breathing difficulty and fast breathing with harsh noise; cough and runny nose, cough and runny nose then “co-trimoxazole (septrin) request | 306 | 306 | 58 | Sulphonamide |
Simulated client, adult sexually transmitted infections | |||||||
Viberg et al. [40] | Tanzania | Simulated client | Vaginal discharge and itching, urethral discharge | 94 | 251 | 53 | Tetracycline, Penicillin, Sulphonamide, Macrolides, Fluoroquinolone, Nitro-imidazole, |
Questionnaire based surveys, observation while pharmacy staffs are dispensing | |||||||
Ahiabu et al. [47] | Ghana | Observation at the pharmacies | N/A | 6 | 307 | 91 | Penicillin, Nitro-imidazole, fluoroquinolone, Sulphonamide, Tetracycline, Cephalosporin, Macrolide |
Abula [42] | Ethiopia | Observation at the pharmacies | N/A | 12 | 58 | 31 | Penicillin, Sulphonamide |
Questionnaire based surveys, onsite customers interview about their antibiotic purchase | |||||||
Elong Ekambi et al. [48] | Cameron | Interviewing clients at Pharmacies | N/A | 7 | 402 | 47 | N/A |
Gebrekirstos et al. [43] | Ethiopia | Interview of clients at the pharmacies | N/A | 14 | 780 | 38 | NA |
Questionnaire based surveys, dispensers asked about their antibiotic transaction (supplied for URTIs plus other conditions) | |||||||
Mbonye et al. [46] | Uganda | Interviewing the pharmacy staff on duty about recent sale | Childhood illness (URTIs, diarrhoea) | 170 | 170 | 94 | Penicillin, Sulphonamide, tetracycline, aminoglycoside |
Kalungia et al. [45] | Zambia | A structured Interviewer administered questionnaire using simulated case scenario | Childhood respiratory tract infection and UTI | 73 | 146 | 71 | Penicillins, Sulphonamide, Nitro-imidazole |
Questionnaire based surveys, customers’ requested about their antibiotic purchase when they left the CDROs | |||||||
Mboya et al. [44] | Tanzania | Interviewing clients at exit of the pharmacies | URTIs, UTI, diarrhoea/diarrhoea and vomiting, wound/abscess, urinary tract infection, abdominal pain, tonsillitis, asthma, fever, gastric ulcer,post-surgery, allergy, pneumonia, weeping eye, typhoid | 12 | 152 | 76 | Penicillin, Nitro-imidazole, Fluoroquinolone, Macrolide, Cephalosporin, Sulphonamide |
Quality assessment of the included studies
Meta-analysis of the dispensing of antibiotics without a prescription
Pooled estimates of non-prescribed sale of antibiotics by country
Subgroup meta-analysis of the proportion of non-prescription dispensing of antibiotics
Subgroups | Non-prescription dispensing of antibiotics(95% CI) | Difference in estimate between categories (P value) | Number of studies | Heterogeneity |
---|---|---|---|---|
Study publication year a | ||||
2016–2020 | 0.76 (0.65–0.87) | P = 0.066 | 16 | I2 = 98.3%, P < 0.001 |
2000–2015 | 0.51 (0.23–0.79) | 6 | I2 = 99.3%, P < 0.001 | |
< 2000 | 0.67 (0.54–0.77) | 1 | NA | |
Region | ||||
East Africa | 0.69 (0.57–0.81) | P = 0.66 | 21 | I2 = 98.8%, P < 0.001 |
Central Africa | 0.47 (0.42–0.52) | 1 | NA | |
West Africa | 0.91 (0.87–0.94) | 1 | NA | |
Case scenarios | ||||
Multiple** | 0.71 (0.53–0.88) | P = 0.235 | 13 | I2 = 99.0%, P < 0.001 |
Single* | 0.76 (0.64–0.89) | 6 | I2 = 95.9%, P < 0.001 | |
Not specified | 0.52 (0.22–0.82) | 4 | I2 = 99.5%, P < 0.001 | |
Number of visits*** | ||||
≤ 146 | 0.74 (0.65–0.83) | P = 0.320 | 12 | I2 = 92.9%, P < 0.001 |
> 146 | 0.64 (0.46–0.82) | 11 | I2 = 99.4%, P < 0.001 | |
Number of outlets*** | ||||
≤ 63 | 0.71 (0.57–0.86) | P = 0.603 | 12 | I2 = 98.5%, P < 0.001 |
> 63 | 0.66 (0.48–0.85) | 11 | I2 = 99.2%, P < 0.001 |
Proportion of non-prescribed antibiotics dispensed by symptom group
Types of symptom | Pooled estimate %(95% CI) | Heterogeneity | Number of studies |
---|---|---|---|
Acute diarrhoea | 60 (33–86) | I2 = 98.0%, P < 0.001 | |
Upper respiratory tract infections with or without a direct antibiotics request | 84 (74–94) | I2 = 92.1%, P < 0.001 | |
Sexually transmitted infections (STIs) | 25 (21–28) | I2 = 0.0% | |
Acute diarrhoea and Urinary tract infection | 88 (81–92) | NA | 1 [20] |
Urinary tract infection (UTI) | 94 (74–99) | NA | 1 [32] |
Sore throat | 78 (55–91) | NA | 1 [32] |
Case not reported or reported but the magnitude for each symptom not identified | 67 (52–83) | I2 = 98.9%, P < 0.001 |