EXPLORING FACTORS THAT INFLUENCE THE SUPPLY AND USE OF ANTIBIOTICS FROM COMMUNITY PHARMACIES IN THAILAND Sisira Donsamak A thesis submitted in accordance with the conditions governing candidates for the degree of Philosophæ Doctor in Cardiff University DECEMBER 2020 Cardiff School of Pharmacy and Pharmaceutical Sciences CARDIFF UNIVERSITY Acknowledgements Firstly, I would like to thank the Thai Royal Government for the funds granted to undertake my PhD study. Thanks to the scholarship team who supported me throughout my stay in Wales; my affiliation, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University who provided the huge opportunity for me to pursue this study. I am eternally grateful for this opportunity. Secondly, I would like to thank my supervisors Professor Dai John and Professor Marjorie Weiss for their guidance, advice, and support. Professor Dai provided guidance that opened up a whole new world of research possibilities for me, without your kindness and endless support, I would not been able to come this far. I really appreciate. Professor Marjorie provided enormous amount of help. Your comments and guidance were more than valuable. To both of you I wish to express my deepest gratitude. I have learnt so much from you. I would also like to thank all of my friends at Redwood; sharing the journey with you has made it all the more enjoyable. Thanks to all my friends in Thailand for your help and support all the way of my data collection. I would like to thank you the individuals who agreed to take part in this research, without their participation the study would not have been possible. Last but not least, thanks to my family for your love and care. Thanks to my lovely daughters, Tonnam and Lamthan, for understanding and putting up with me while mammy need to work in peace. Thank you for your love. I love you. i Summary In Thailand, antibiotics are available lawfully from community pharmacies without a prescription. Inappropriate supply of antibiotics from Thai community pharmacies to the public for common, self-limiting diseases has been reported, and is associated with increased antimicrobial resistance. This study aims to explore factors influencing the use and supply of antibiotics from community pharmacies in Thailand. Semi-structured interviews with Thai community pharmacists (n=23) and citizens (n=21) were conducted to explore the practice and reasons for antibiotic supply from pharmacies. Findings from the interviews and a literature review were used to develop a questionnaire for a stratified sample of community pharmacists, including nine vignettes for pharmacists to identify how they would respond in practice. Approval was obtained from Thailand and Wales ethics committees. Three-hundred-and-twenty community pharmacists in all four Thai regions responded. In response to vignettes, 46% (147/320) of pharmacists would supply antibiotics without an appropriate indication for a URI, 50% (321/638) of pharmacists would suggest inappropriate antibiotics and/or regimens for patients with possible/probable group A streptococcal pharyngitis. In addition, 13% (74/640) and 11% (71/638) of pharmacists would supply antibiotics for acute diarrhea and simple wounds, respectively, where antibiotics were not recommended. Inappropriate antibiotic choices and/or incorrect dosage regimens were also reported. A higher proportion of younger pharmacists and/or those with less experience, Pharm D. graduated pharmacists, employee pharmacists and those pharmacists who worked in a chain pharmacy were more likely to indicate appropriate antibiotic supply in response to the vignettes (p<0.05). Additionally, pharmacists who perceived an advantage of antibiotics is being cured quickly, were more likely to indicate less appropriate supply of antibiotics (p<0.05). The findings suggest that improved public education, more pharmacist education on antibiotic use and AMR, better enforcement of existing regulations and stricter regulation on the supply of some antibiotics may lead to improved rational antibiotic use in Thailand. ii List of Abbreviations AMR Antimicrobial resistance ASU Antibiotics Smart Use CSMBS Civil Servants Medical Benefits Scheme GAS Group A streptococcal GPP Good pharmacy practice HCs Health centres MoPH Ministry of Public Health NCDs Noncommunicable diseases NHSO National Health Security Office PCT Pharmacy Council of Thailand PharmD Doctor of Pharmacy PHCs Public health centres RADT Rapid Antigen Detection Testing PPHO Provincial Public Health Offices SCM Simulated client method SSS Social Health Insurance Scheme Thai-FDA Thai Food and Drug Administration THPHs Tambon health-promoting hospitals UCS Universal Coverage Scheme URIs Upper respiratory infections UTIs Urinary tract infections VHVs Village health volunteers WHO World Health Organization iii Table of Contents Acknowledgements ............................................................................................................................. i Summary ................................................................................................................................................. ii List of Abbreviations ........................................................................................................................ iii Table of Contents ............................................................................................................................... iv List of tables ......................................................................................................................................... x List of figures .................................................................................................................................... xii Chapter One ........................................................................................................................................... 1 1 Introduction ................................................................................................................................. 2 1.1 Thailand country profile ................................................................................................. 2 1.1.1 Thailand health system .......................................................................................... 3 1.1.2 Community pharmacy in Thailand ................................................................... 6 1.1.3 Regulation relating to pharmaceutical products in Thailand ............... 6 1.1.4 Professional and regulatory pharmacy organizations ............................. 8 1.1.5 Pharmacy education in Thailand ....................................................................... 9 1.1.6 Community pharmacy practice in Thailand ............................................... 10 1.2 The problem of antimicrobial resistance ............................................................. 12 1.2.1 The burden of antimicrobial resistance ....................................................... 12 1.2.2 Action plan to combat AMR ............................................................................... 14 1.2.3 Roles/Potential roles of community pharmacists in combating AMR ....................................................................................................................................... 18 1.2.4 Programmes to tackle antimicrobial resistance in Thailand .............. 19 1.3 Structure of thesis .......................................................................................................... 22 Chapter Two ....................................................................................................................................... 24 2 Literature Review ................................................................................................................... 25 2.1 Refining the search ........................................................................................................ 25 2.2 The supply of antibiotics from community pharmacy ................................... 28 2.2.1 The supply of antibiotics without a prescription .................................... 28 iv 2.2.2 Supplying antibiotics by non-qualified pharmacists ..............................31 2.2.3 Factors influencing the inappropriate supplying of antibiotics ........32 2.3 Use of antibiotics in community ...............................................................................43 2.3.1 Self-medication with antibiotics ......................................................................43 2.3.2 Sources of information on antibiotics and where antibiotics are obtained ......................................................................................................................................49 2.3.3 Adherence to antibiotic regimens ...................................................................51 2.3.4 Knowledge and views of the public towards antibiotic resistance ..52 2.4 The need for research ...................................................................................................54 2.5 Aims of the studies in this thesis ..............................................................................58 Chapter Three .....................................................................................................................................59 3 Methodology .............................................................................................................................60 3.1 Philosophical worldviews and epistemological consideration ...................60