How to Curb Over-The-Counter Sales of Antibiotics? Evidence from a Field Experiment in Ethiopia

Last registered on October 04, 2023
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Pre-Trial

Trial Information

General Information

Title
How to Curb Over-The-Counter Sales of Antibiotics? Evidence from a Field Experiment in Ethiopia
RCT ID
AEARCTR-0012199
Initial registration date
September 28, 2023

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
October 04, 2023, 4:10 PM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

Country
Ethiopia
Region
Addis Ababa

Primary Investigator

Name
Saba yifredew Getnet
Affiliation
Addis Ababa University
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Other Primary Investigator(s)

PI Name
M. Vittoria Levati
PI Affiliation
Department of Economics, University of Verona, Italy
Contact Investigator
PI Name
Ivan Soraperra
PI Affiliation
Max Plank Institute for Human Development, Center for Humans & Machines, Berlin, Germany
Contact Investigator

Additional Trial Information

Status
Completed
Start date
2019-05-09
End date
2019-12-07
Keywords
Behavior, Health
Additional Keywords
Antimicrobial resistance, OTC antibiotics, Community pharmacies, Simulated patients
JEL code(s)
C93, I12, I18, C21
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
Antibiotics revolutionized medicine, but antimicrobial resistance (AMR) now poses a global threat to human health. Over-the-counter (OTC) sales of antibiotics contribute significantly to the proliferation of AMR, especially in developing countries. In this study, we conduct a randomized controlled trial in cooperation with the Addis Ababa Food, Medicine, and Healthcare Administration and Control Authority (AAFMHACA) with the aim of curtailing OTC antibiotic sales in Addis Ababa, the capital city of Ethiopia, where previous research has documented a high prevalence of OTC antibiotic dispensing. We randomly assign 831 community pharmacies and drugstores either to one of three experimental groups or to an untreated control group. Two interventions consist of informational letters targeted at pharmacists and the third intervention is an informational poster on display in the pharmacy premises. To evaluate the primary outcome (namely OTC antibiotic dispensing), we use Simulated Patients (SPs). The SP are blind to the interventions. They are trained to present symptoms of two prevalent health conditions to pharmacists and to ask for the appropriate medicine. The study relies on more than 2,000 unannounced SP's visits to pharmacies, distributed across three distinct waves. The first wave takes place before the interventions and gathers baseline data on the pharmacists' willingness to dispense OTC antibiotics. The second wave occurs three weeks after the delivery of the interventions, allowing us to evaluate their short-run effect. The third wave is conducted five months later, enabling the examination of the persistent effects of the interventions.
External Link(s)

Registration Citation

Citation
Getnet, Saba yifredew, M. Vittoria Levati and Ivan Soraperra . 2023. "How to Curb Over-The-Counter Sales of Antibiotics? Evidence from a Field Experiment in Ethiopia." AEA RCT Registry. October 04. https://doi.org/10.1257/rct.12199-1.0
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Experimental Details

Interventions

Intervention(s)
The study includes three interventions, designed based on the factors that influence the pharmacists' decisions to sell over-the-counter (OTC) antibiotics in developing countries like Ethiopia. Two interventions consist of informational letters targeted at pharmacists and the third intervention entails displaying an informational poster within the pharmacy premises. One of the two letters includes a message reminding pharmacists about the legal consequences of dispensing OTC antibiotics; the other letter draws pharmacists' attention to their key role in promoting the appropriate use of antibiotics. The letters are delivered and the poster is affixed to the pharmacy wall by personnel from AAFMHACA (the main body that regulates the workings of community pharmacies, hospitals, and clinics in Addis Ababa).
Intervention Start Date
2019-06-24
Intervention End Date
2019-07-12

Primary Outcomes

Primary Outcomes (end points)
Changes in the pharmacists' likelihood of dispensing antibiotics over the counter.
Changes in the antibiotic price asked by the pharmacists.
Primary Outcomes (explanation)
The primary outcome is whether or not the antibiotic is sold over the counter by the visited pharmacist at baseline (wave 1), three weeks after the interventions (wave 2), and five months after the interventions (wave 3).
We assess how the likelihood of OTC antibiotic sales changes for the treated pharmacies in comparison to pre-intervention levels, controlling for time trends in sales and characteristics of the pharmacies.
Additionally, we examine the effect of the interventions on the price that the visited pharmacists ask for the antibiotics, in the case of OTC sale.

Secondary Outcomes

Secondary Outcomes (end points)
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
A total of 831 community pharmacies and drugstores in Addis Ababa are randomly assigned either to one of three experimental groups or to an untreated control group.
To collect data on the pharmacists' willingness to sell OTC antibiotics, we use eleven Simulated Patients (SPs) who are kept unaware of the interventions. These SPs are trained to present the symptoms of two common health conditions to the visited pharmacists and to ask for the appropriate medicine. They perform a total of 2286 visits spread over three waves of data collection. The first wave gathers pre-treatment baseline data. In this wave, the SPs visit 710 pharmacies. Afterwards we administer our interventions. Two to three weeks after the interventions, we conduct the second wave during which the SPs make 791 visits. The third wave counts 785 SPs' visits and is implemented five months after the interventions.
Experimental Design Details
Randomization Method
The sampling frame is constructed using the list of pharmacies provided by AAFMHACA. The randomization is done in office by a computer using a random number generator to assign pharmacies to treatments and simulated patients to pharmacies.
Randomization Unit
We randomize on the individual level (pharmacy).
Was the treatment clustered?
No

Experiment Characteristics

Sample size: planned number of clusters
831 community pharmacies and drugstores
Sample size: planned number of observations
The sample is composed by 831 community pharmacies and drugstores. The number of observations, collected over 3 waves, is 2286.
Sample size (or number of clusters) by treatment arms
Approximately 200 pharmacies by treatment
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Supporting Documents and Materials
IRB

Institutional Review Boards (IRBs)

IRB Name
Ethics Committee Economics and Business (EBEC), University of Amsterdam
IRB Approval Date
2019-01-29
IRB Approval Number
EC 20190128010129
Analysis Plan

Post-Trial

Post Trial Information

Study Withdrawal

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Intervention

Is the intervention completed?
Yes
Intervention Completion Date
July 12, 2019, 12:00 +00:00
Data Collection Complete
Yes
Data Collection Completion Date
December 07, 2019, 12:00 +00:00
Final Sample Size: Number of Clusters (Unit of Randomization)
831 community pharmacies and drugstores
Was attrition correlated with treatment status?
No
Final Sample Size: Total Number of Observations
2286
Final Sample Size (or Number of Clusters) by Treatment Arms
228 control group, 203 appeal letter treatment, 200 coercive letter treatment, 200 poster treatment
Data Publication

Data Publication

Is public data available?
No

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Program Files

Program Files
Reports, Papers & Other Materials

Relevant Paper(s)

Reports & Other Materials