title: What motivates antibiotic dispensing in accredited drug dispensing outlets in Tanzania? A qualitative study.
abstract: BACKGROUND
  Tanzania introduced the accredited drug dispensing outlet (ADDO) program more than a decade ago. Previous evaluations have generally shown that ADDOs meet defined standards of practice better than non-accredited outlets. However, ADDOs still face challenges with overuse of antibiotics for acute respiratory infections (ARI) and simple diarrhea, which contributes to the emergence of drug resistance. This study aimed to explore the attitudes of ADDO owners and dispensers toward antibiotic dispensing and to learn how accreditation has influenced their dispensing behavior.
  
  
  METHODS
  The study used a qualitative approach. We conducted in-depth interviews with ADDO owners and dispensers in Ruvuma and Tanga regions where the government implemented the ADDO program under centralized and decentralized approaches, respectively; a secondary aim was to compare differences between the two regions.
  
  
  RESULTS
  Findings indicate that the ADDO program has brought about positive changes in knowledge of dispensing practices. Respondents were able to correctly explain treatment guidelines for ARI and diarrhea. Almost all dispensers and owners indicated that unnecessary use of antibiotics contributed to antimicrobial resistance. Despite this knowledge, translating it to appropriate dispensing practice is still low. Dispensers' behavior is driven by customer demand, habit ("mazoea"), following inappropriate health facility prescriptions, and the need to make a profit. Although the majority of dispensers reported that they had intervened in situations where customers asked for antibiotics unnecessarily, they tended to give in to clients' requests. Small variations were noted between the two study regions; for example, some dispensers in Ruvuma reported sending clients with incorrect prescriptions back to the health facility, a practice that may reflect regional differences in ADDO implementation and in Integrated Management of Childhood Illness training. Dispensers in rural settings reported more challenges in managing ARI and diarrhea than their urban counterparts did.
  
  
  CONCLUSIONS
  To reduce inappropriate antibiotic use, integrated interventions must include communities, health facilities, and ADDOs. Periodic refresher training with an emphasis on communication skills is crucial in helping dispensers deal with customers who demand antibiotics. Responsible authorities should ensure that ADDOs always have the necessary tools and resources available.
authors.affiliation: Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania.
authors.forename: Angel
authors.initials: A
authors.lastname: Dillip
authors.affiliation: Management Sciences for Health, Arlington, VA USA.
authors.forename: Martha
authors.initials: M
authors.lastname: Embrey
authors.affiliation: Pharmacy Council, Dar es Salaam, Tanzania.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Shekalaghe
authors.affiliation: Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA.
authors.forename: Dennis
authors.initials: D
authors.lastname: Ross-Degnan
authors.affiliation: Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Vialle-Valentin
authors.affiliation: Management Sciences for Health, Dar es Salaam, Tanzania.
authors.forename: Suleiman
authors.initials: S
authors.lastname: Kimatta
authors.affiliation: Management Sciences for Health, Dar es Salaam, Tanzania.
authors.forename: Jafary
authors.initials: J
authors.lastname: Liana
authors.affiliation: Management Sciences for Health, Arlington, VA USA.
authors.forename: Edmund
authors.initials: E
authors.lastname: Rutta
authors.affiliation: Management Sciences for Health, Dar es Salaam, Tanzania.
authors.forename: Richard
authors.initials: R
authors.lastname: Valimba
authors.affiliation: Management Sciences for Health, Arlington, VA USA.
authors.forename: John
authors.initials: J
authors.lastname: Chalker
keywords: ADDO; Antibiotics; Antimicrobial resistance