Defining the problem in behavioural terms among four groups from formative studies (step 1)
Contextual drivers of antibiotic use among household members, and the inappropriate prescribing and dispensing practices of healthcare professionals and drug shop staff have been published [17, 30]. Among household members, an important contextual driver was that most did not what know an antibiotic was or what antibiotics were for. Household members and healthcare providers reported that antibiotics were stopped when symptoms disappeared. Antibiotics were often purchased by proxies for ill household members/patients. Underage children and adolescents were also able to purchase antibiotics from drug shops. Drug shop staff, regardless of training and qualification, in addition to dispensing antibiotics prescribed by registered physicians, dispensed antibiotics as over-the-counter medications. Counter to common assumptions, households did not report storing or re-using old antibiotics.
A contextual driver of antibiotic dispensing among drug shop staff was that they regularly sold prescription drugs including antibiotics without a government license, in conflict with government policy. Drug shop staff advised and dispensed drugs to patients and their proxies, who were usually family members. Unqualified drug shop staff reported that they followed antibiotic prescribing patterns of registered physicians, referred to as ‘elite’ doctors/‘boro (big)’ doctors.
Patients were more likely to consult registered physicians for more severe diseases, or after an initial treatment had failed. Travel costs and distance to health facilities or clinics were barriers to seeking earlier consultation with qualified professionals [17]. However, doctors were reported to give little time during consultation, prescribe drugs including antibiotics over the telephone and patients perceived that the additional costs of consulting a doctor or undergoing recommended tests were to enhance profits and were often viewed as unnecessary [30].
Pharmaceutical companies were reported to provide incentives to doctors for prescribing their company’s antibiotics. In contrast with registered doctors and drug shop staff, pharmaceutical representatives were fully aware of the BPMI policy and had a thorough understanding of antibiotic resistance.
Selecting and specifying target key behaviours (steps 2 and 3)
Based on data from formative studies on contextual drivers, participants in the intervention design workshop selected and specified behaviours that were amenable to change (Table 1).
Household members: should be encouraged to consult registered physicians and be pro-active in obtaining information about dispensed medications such as whether they are antibiotics. For those receiving antibiotics, the dose, frequency and duration of the course should be explained. Patients/consumers should be encouraged to take a full course of antibiotics obtained from a drug shop that sells quality medicines.
Drug shop staff: should be encouraged to ask the customer for a prescription before dispensing antibiotics; referring them to doctors when they do not provide a prescription. Drug shop staff were considered to have a responsibility to increase awareness among patients, particularly on the importance of taking a full course of antibiotics. Stakeholders thought that there should be incentives for drug shops to recruit qualified staff.
Registered physicians: should be encouraged to base practices on current recommendations to reduce unnecessary prescribing, especially avoiding prescribing multiple and higher generation antibiotics than is necessary. Doctors were considered as important information sources that should reinforce the importance of completing a full course of antibiotics.
Pharmaceutical companies/medical representatives: Stakeholders acknowledged the potential for companies and their representatives to maintain a viable business whilst playing a role in antibiotic stewardship. Suggestions included: modifications to the business strategy of companies; delivering quality training to all representatives and designing antibiotic packaging in a way that would encourage sale of a full course.
Identifying priority audiences
Among 28 participants who voted for first and second priority audiences to target, 19 voted for household members, 12 of which considered this population as their number one priority and 16 voted for drug shop staff, 8 of which voted for this group as their first priority. Doctors were the third priority target audience with 13 votes and pharmaceutical companies/representatives were the lowest priority with 8 votes. During the post-workshop discussions, the research team and creative agency members concluded that using drug shops as a venue for intervention delivery had potential to address both the first and second priority audiences, thereby providing an opportunity to maximise intervention impact.
Capability, opportunity and motivation to improve antibiotic stewardship among priority audiences (com-B model, step 4)
In line with government policy and guidelines [25, 34], to improve antibiotic stewardship, the target behaviors were to sell and purchase fewer antibiotics and to sell and consume antibiotics as full courses only.
Among households, there were two main behaviours that needed to change: suboptimal health seeking and early cessation of antibiotic treatment. When assessing capabilities, a recurring theme was knowledge. Most household members could not distinguish a qualified from an unqualified provider and made decisions on who to visit primarily on disease severity considerations. They also had limited knowledge about antibiotics and their mode of action. Thus, opportunities exist for developing an SBCC that strengthens knowledge that can empower household members with potential to impact responsible antibiotic consumption. These include encouraging household members to ask about the medicines that they receive, and ask about timing, dosage, and course duration. Motivation for this group can be encouraging them to seek appropriate healthcare advice and medicines by appealing to potential financial burden and accessibility to registered physicians.
When identifying drug shop staff behaviours that needed to change, there were similar capability issues evident as limited knowledge of the government policy including the BPMI on licensing, staff qualification and adequate provision of information on antibiotics to customers. They lacked knowledge about antibiotic resistance. Some of these knowledge gaps can be filled using an educational SBCC. Drug shop staff are likely to remain the first line of access to health care in many communities, presenting an opportunity to have them serve as an information source on antibiotic use/dose/timing for customers. For an educational campaign that is located at drug shops, it must motivate drug shop staff by addressing financial concerns of potential lost business by encouraging household members to seek care from registered physicians and by acknowledging their status in the community. While the BPMI is clear about staff qualifications, there does not appear to be evidence of enforcement, which could act as a motivator (Table 2).
Intervention resource development and pilots for household members and drug shop staff
The National Drug Policy, 2016 states ‘To prohibit sales and distribution of drugs without prescription from registered physician to ensure rational use of drugs”. During the pilot phase of intervention resource development, there was considerable discussion on how to convey ‘registered physician’. Household members often referred to their local drug shop staff as a doctor or ‘small doctor’ [17]. Village doctor is also a common term used for a rural health practitioner, a post that is not considered a registered physician. To overcome existing ambiguity, we decided to pilot ‘(Bachelor of Medicine, Bachelor of Surgery) MBBS doctor’ for the intervention resources and measure understanding of this term among drug shop staff and customers.
Among the messages suggested during the intervention design workshop, the research team and VISCOM team prioritised those that we thought would resonate with the two selected audiences. For drug shop staff, these were related to asking for prescriptions, referral to registered physicians, increase in client/customer awareness when they were receiving an antibiotic, and the need for a full course.
Pilot feedback
Pilot drug shop staff respondents were all male, between 20 and 62 years of age and education status ranged from Secondary School Certificate (approximately grade 10) to master’s degree, with most having a Higher School Certificate (approximately grade 12) qualification. All 50 respondents received and displayed the intervention materials and found them simple, clear and easy to read. Among the recommendations on antibiotics, 5 thought they would be difficult, 5 thought they would need time to integrate recommendations and the remainder thought the recommended behaviours were reasonable. There were suggestions on format (color, number of messages and font size).
Among the customers, 40 were male, 10 were female, ranging in age from 20 to 65 years. Some had no education, and most had attended between grade 5 and Higher School Certificate with one completing a master’s degree. The vast majority (45) found that the messages were simple and easy to understand and were able to repeat the key messages. However, they found recommendations were different from their usual practices reporting that they buy antibiotics directly as it is easier and saves money and they didn’t see a justification for visiting a registered physician for simple diseases. The majority (40) reported that medicines were recommended to them by the drug shop staff. Similar to drug shop staff materials, customers recommended some format revisions such as using more color, including fewer messages and using a larger font.
Revised intervention resources included the following messages (example in Fig. 2), for drug shop staff: tell the customer when you sell them antibiotics, remind them of timing and completing the full course, always sell antibiotics prescribed by a doctor (MBBS), refer patients to doctors for the appropriate treatment, tell customers to report side effects to doctors. For customers messages included: antibiotics cure illness by killing germs, take a full course and follow dose and timing to be cured, not taking a full course may cause your disease to return and cost more money, antibiotics are not needed for all diseases, only a MBBS doctor can prescribe antibiotics.