‘When I tried to explain, they shouted back at me!’: exploring how community pharmacists navigate tensions implementing antimicrobial stewardship in Vietnam

ABSTRACT

Antimicrobial resistance is a major global and national health challenge, accelerated by ‘irrational’ antibiotic use. In response, Vietnam has been implementing a public health plan of antimicrobial stewardship since 2013 to reduce antibiotic sales in community pharmacies, although it has had limited effect. Given that private pharmacies are increasingly the entry point to access healthcare, reflective of the inhibited accessibility of primary healthcare, understanding how the positioning of community pharmacists shapes the delivery of antimicrobial stewardship plans warrant further investigation. This qualitative analysis draws on data from 24 in-depth interviews with licensed community pharmacists in Vietnam. Interviewees described being constrained in rationing the sale of antibiotics by tensions within their professional role, in which the delivery of antimicrobial stewardship within their public health commitments rubs up against commercial and social obligations to their livelihoods and communities respectively. The concept of ‘resistance’ provides insight into what obstructs the integration of national antimicrobial stewardship guidance and policy, hindering the transformation of local practices concerning antibiotic sales at the community level. Findings reveal opportunities to recast community pharmacists as ‘productive anchors’ who can facilitate the appropriate use of antibiotics and strengthen links to primary care within the local context. Structural changes are needed, however, so that people do not use antibiotics as a proxy for health care. Improving the accessibility of primary healthcare would also curtail the reliance on community pharmacists’ to dispense antibiotics as a local mechanism of financial protection and social care within community.

KEYWORDS:

• Antimicrobial resistance (ARM)
• antibiotics
• antimicrobial stewardship (AMS)
• Vietnam
• community pharmacists

Acknowledgements

We express our gratitude to study participants for giving us their time and sharing their experiences in this study. Recruitment was assisted by colleagues in the V-RESIST research program and local partners’ staff at district community health centers in Ca Mau and Ha Noi. We thank Susan Luu and Momoe Takeuchi from the World Health Organisation and the National Institute of Hygiene and Epidemiology (NIHE) for their support and assistance with larger research program of which this study was a part.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The participants of this study did not provide written consent for their data to be shared publicly because of the sensitive nature of the research, so supporting data are not available.

Notes

1. We use this term in line with broad definition of rational use of medicines provided by WHO and the World Bank to encapsulate wide range of practices around antibiotics including inappropriate dosages, self-medication, and as treatment for non-bacterial illnesses, and is subject to individual context which will be discussed later (Ofori-Asenso & Agyeman, 2016). The term irrational use’ is also used also to avoid the fairly common misconception in AMR that the misuse of antibiotics is equivalent to their excessive use (McKinn et al., 2021).

Additional information

Funding

This work was supported by a grant from the Australian Department of Foreign Affairs and Trade Indo-Pacific Centre for Health Security [NHMRC APP1153346].