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UNIVERZITA KARLOVA V PRAZE Farmaceutická fakulta v Hradci Králové
Katedra sociální a klinické farmacie
Rigorózní práce
Natalia Duvanova
«Používaní antibiotik farmaceuty»
Vedoucí rigorózní práce (konzultant):
Prof. RNDr. Jiří Vlček, CSc.
V Hradci Králové 2014
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Charles University in Prague
Faculty of Pharmacy in Hradec Králové Department of social and clinical pharmacy
Rigorózní práce
Natalia Duvanova
«Antibiotic use by the pharmacy employees»
Work Supervisior (consultant):
Prof. RNDr. Jiří Vlček, CSc.
Hradec Králové 2014
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Prohlášení
„Prohlašuji, že tato práce je mým původním autorským dílem, které jsem vypracovala samostatně (pod vedením konzultanta). Veškerá literatura a další zdroje, z nichž jsem při zpracování čerpala, jsou uvedeny v seznamu použité literatury a v práci řádně citovány. Práce nebyla využita k získání jiného nebo stejného titulu.“
V Hradci Králové dne...
_______________(Natalia Duvanova) podpis studenta
Poděkování
Dekuji Prof. RNDr. Jiří Vlčku, CSc.za odborné vedení při zpracování této práce, vlídný prístup a za cas, který mi věnoval pri konzultacích.
Děkuji Mgr. Tatianě Belkině za pomoc při vytvoření dotazníku.
Děkuji Mgr. Olgě Ochkur za pomoc a trpělivost při vytvoření překladu do anglického jazýku.
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Anotace
Tato rigorózní práce projednává problematiku nákupu a používaní antibiotik zaměstnanci lékáren v Ruské federaci.
V teoretické části práce jsou uvedené přehled na historii farmacie v Ruske federaci, speciální a vysokoškolské farmaceutické vzdělávání v Rusku, zákony a právní předpisy v platném znění týkající se expedice antibiotik.
V praktické části je popsána metoda výzkumu, jeho průběh, analýza získaných dat.
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Abstrakt
Úvod: Tato práce se zabývá problematikou nákupu a používání antibiotik zamestnanci lékáren v Petrohrade, Ruská federace. Cílem studie bylo zjistit úroven jejich znalostí, postoje a prístupu k problematice užívání antibiotik.
Frekvence konzultací s lékárníky o onemocnení, která casto vyžadují antibiotika, u pacientu v Ruské federaci je pomerne vysoká, a mnozí lékárníci poskytují svá doporucení.
Pruzkumy verejného mínení v držení WCIOM (Ruské centrum pro výzkum verejného mínení) v roce 2011 ukázaly, že 46% respondentu verí, že antibiotika nicí viry. Navíc, od roku 2007 se toto císlo dokonce mírne zvýšilo - tehdy to bylo 45%.
Podle Evropského projektu pro sledování používání antibiotik (ESAC) se celková ambulantní spotreba antibiotik v Ruské federaci v letech 1997-2009, která je vyjádrená v DDD na 1000 obyvatel/den, rovnala 9.8 (2003), 9.3 (2004), 9.1 (2005), 9.6 (2006 ), 10.2 (2007) 10.0 (2008) a 12.2 (2009).
Metodika: Byl proveden pruzkum náhodným výberem z 308 respondentu pomocí dotazníku, který obsahoval otázky týkající se demografických charakteristik, znalostí o užívání antibiotik a vzniku rezistence, postoju a prístupu k užívání antibiotik a zdroju informace.
Výsledky: Pruzkumu se zúcastnilo 316 zamestnancu z 63 lékáren. Nicméne, jen 308 dotazníku bylo použito pro analýzu, tedy 97,47% z celkového poctu. Z toho bylo 99,4% žen a 0,6% mužu.
Ze všech úcastníku 135 dotázaných (43,8%) uvedlo užití antibiotik v posledních 6 mesících, prevážne na infekce horních cest dýchacích (53,3% ze všech prípadu).
Více než tri ctvrtiny farmaceutu (76,2%) si v prípade nemoci sámi naordinují lécbu.
Makrolidy zaujímají nejvetší podíl na trhu (33,18%). Azithromycin je v cele (81,1%) této skupiny. Kombinováná antibiotika jsou druhou nejcasteji používanou skupinou (22,9%).
Samolécba není závislá na stupni vzdelání ci veku respondentu.
Záver: Výsledky této studie potvrzují, že antibiotická samolécba mezi zamestnanci lékáren v Rusku je velmi rozšíreným faktem. Duvodem je zrejme absence príslušné kontroly prodeje antibiotik. Legislativa by mela být pozmenená tak, aby lékárna byla povinná vždy vykázat recept na každé balení prodaného antibiotika.
Klícová slova: antibiotika, samolecba, zamestnanci lékáren, Ruská federace
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Abstract
Introduction: This thesis discusses the issue of the purchase and use of antibiotics pharmacy employees in Saint-Petersburg, Russian Federation. The objectives of the study were to investigate their level of knowledge, attitudes, and behaviors regarding antibiotics.
The frequency of consulting the pharmacists about diseases that often require antibiotics is rather high among patients in the Russian Federation. And many pharmacists provide their
recommendations.
Opinion polls held by WCIOM (Russian Public Opinion Research Center) in 2011 (1) showed that 46% of respondents believe antibiotics kill viruses. Moreover, since 2007 this figure has even increased slightly - then it was 45%.
According to the European Surveillance of Antimicrobial Consumption (ESAC) total outpatient antibiotic use in Russian Federation from 1997 to 2009 expressed in DDD per 1000 inhabitants and per day was 9.8 (2003), 9.3 (2004), 9.1 (2005), 9.6 (2006), 10.2 (2007), 10.0 (2008) and 12.2 (2009) (2).
Methodology: A cross-sectional survey was conducted on a random sample of 308 respondents using a self-administered questionnaire included questions on demographic characteristics, knowledge about antibiotic use and resistance, attitudes and behaviors towards antibiotic use and sources of information.
Results: The questioning involved 316 employees from the 63 pharmacies. However, only 308 questionnaires were used for the analyses, i.e. 97.47 % of received amount, consisting of 99.4%
females and 0.6% males. Among the 308 participants 135 (43.8%) reported the use of antibiotics within the last 6 month and they mostly took antibiotics because of upper respiratory tract infection (53.3% from all cases).
More than three-quarters of pollee pharmacists (76.2%) self-medicate in case of sickness.
Macrolides occupy the largest market share (33.18%). Azithromycin is in the lead (81.1%) in this group. Combination antibiotics are the second most frequently used group (22.9%). Self- medication isn`t effected by education level or age of the respondents.
Conclusions: The results of this study confirm that antibiotic self-medication among the pharmacy employees in Russia is the wide-spread fact. Evidently the reason is in absence of control of antibiotics sales. Orders should be changed in a way, when pharmacy will has to provide prescription on each pack of sold antibiotic.
Keywords: antibiotics, self-medication, pharmacy employees, Russian Federation
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Content
1.INTRODUCTION………. 9
2. THEORETICAL PART………... 12
2.1. History of the pharmacy in Russia……….... 12
2.2. Pharmacy in Russia today………. 13
2.3. Availability of the medicine in Russia……….. 14
2.4. Training of pharmacy staff in Russia……….... 15
2.5. Legal……….. 17
3. EXPERIMENTAL………... 20
3.1. Questionnaire………. 20
3.1.1. Questioning procedure………... 20
3.1.2. Questions. Data analysis……… 20
4. DISCUSSION……….. 30
5. CONCLUSIONS………. 32
REFERENCES……… 45
LIST OF TABLES Table 1. Gender……… 21
Table 2. Age………. 21
Table 3. Education level……….. 21
Table 4. Work experience……… 22
Table 5. Self-medication………. 22
Table 6. Buying antibiotics on prescription………. 22
Table 7. Buying antibiotics without prescription………. 22
Table 8. Taking antibiotics in a past 6 month……….. 23
Table 9. Reason for using antibiotic drug product………... 23
Table 10. Frequency of antibiotics use (sorting by number of use)…………. 24
Table 11. Attitude to the antibiotic therapy………. 26
Table 12. Sources of knowledge about new antibiotics……….. 27
Table 13. Application of antibiotics……… 27
Table 14. Dosage form……… 28
Table 15. Aware of adverse side effects………. 28
Table 16. Side effects……….. 28
Table 17. Aware that AB kill off the normal flora……….. 29
Table 18. Taking probiotics………. 30
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Figure 1. Frequency of antibiotics use. Relative share (%)………. 25
Figure 2. Relative share (%) of antibiotics of macrolide group………... 25
Figure 3. Relative share (%) of antibiotics of fluoroquinolonegroup………. 26
Figure 4. Side effects during antibiotic treatment……… 29
Figure 5. Side-effects during self-medication and doctor`s treatment………. 38
LIST OF ANNEXES Annex 1 Calculation of statistical values………. 33
Annex 2. Interdependence Self-treatment/Age……….... 34
Annex 3. Interdependence Self-treatment/Work experience………... 35
Annex 4. Interdependence Self-treatment/Education……….. 36
Annex 5. Interdependence Self-treatment/Side effects……… 37
Annex 6. Questionnaire (Rus)……….. 39
Annex 7. Questionnaire (Eng)………. 42
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1. INTRODUCTION
Since antibiotics and other antimicrobial drugs first became widely used in the World War II era, they have saved countless lives and blunted serious complications of many feared diseases and infections. The success of antimicrobials against disease-causing microbes is among modern medicine’s great achievements. After more than 50 years of widespread use, however, many antimicrobials are not as effective as they used to be (3).
Russian doctors have admitted that since lately people started visit them more rarely. People self- medicate and consider antibiotics as a panacea for all diseases. Opinion polls held by WCIOM (Russian Public Opinion Research Center) in 2011 (1) showed that 46% of respondents believe antibiotics kill viruses. Moreover, since 2007 this figure has even increased slightly – at that time it was 45%.
According to the World Health Organization (WHO), the self-medication is the "reasonable use of over-the-counter medicines by individuals in order to prevent or treat mild health disorders before receiving professional medical care." The WHO also believes that people can self- medicate only in a limited number of minor illnesses.
Nowadays, self-medication is one of the most significant healthcare problems; and in Russia it is very poorly studied yet. Pharmacists do not only sell drugs, but also offer consultations to the population within the frames of responsible self-medication. However, all advises must be given within the limits of pharmacist’s competence, which means that only OTC drugs can be
recommended.
People in the Russian Federation love to be treated directly at a drugstore but not at a clinic. And there are many reasons for that. To get to the doctor, you have to wait in a long line to make an appointment (as in the Russian Federation you have to do it in person, not by phone or through the web site), and then wait at the doctor's office. It takes a lot of time, the modern pace of living dictates its own rules, and sometimes one just can’t take a sick leave as he/she has to be at work and deal with deadlines, and there is no time to be sick.
In this case the majority would definitely prefer going to the pharmacy and buying a medicine based on the advice of a pharmacist. Self-medication in Russia is often "irresponsible" and it is mainly due to poor public awareness of risks associated with such self-assigned use of
prescription drugs. Let’s take antibiotics for example. People often do not understand what antibiotics are, and what are the risks and consequences of uncontrolled use of this kind of drugs
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(4). And pharmacy employees who have a direct and unlimited access to medicines often do not
“inconvenience” themselves by visiting the doctor.
Antimicrobial agents – is one of the most dynamic group of drugs because of the development of antibiotic resistant (5). Antimicrobial resistance (AMR) is not a recent phenomenon, but it is a critical health issue today. Over several decades, to varying degrees, bacteria causing common infections have developed resistance to each new antibiotic, and AMR has evolved to become a worldwide health threat. With a dearth of new antibiotics coming to market, the need for action to avert a developing global crisis in health care is increasingly urgent (6). Antimicrobial
microorganisms pose a danger not only for the patient from whom they were isolated, but for lots of other people, even those who are separated in both time and space. Bacterial resistance to antibiotics is a major obstacle to the treatment of infectious diseases, which results not only in therapy failures, but in rising of health care expenses. In the U.S. the resistance to antibiotics causes additional annual expenses of more than $ 100 million; however there are other costs in human terms. Infections caused by resistant bacteria usually result in a prolonged course of the disease, more frequent and longer inpatient hospitalizations and higher mortality rate (5).
It is well known that antibacterial drugs, including antibiotics, have the prescription status.
According to the current regulations, eight of ten medications should be of prescription status.
This is comparable with what you see in the European and North American pharmaceutical market. The only distinction is that in Europe and the U.S. the prescription status of medications is strictly observed, while in Russia you can buy almost any drug product (except for narcotic and potent drug products that are accounted in a special way) in the pharmacy without a prescription.
All drugs, except for those included in the list of over-the-counter (OTC) medicinal products, must be dispensed by pharmacies only with a prescription issued according to established procedure in an appropriate form (7). Nevertheless, in Russia the visitor almost always has an opportunity to buy the medication without providing a prescription, in spite of the fact that antibiotics have never been OTC-drugs in Russia.
We assume that this can be explained by the fact that in Russia there is no culture of drug dispensing/purchasing strictly on prescription. Doctors often do not write prescriptions or provide their assignments, including antibacterial drugs on a regular sheet of paper which, in the best case, has a physician’s seal. There is no system that exists, for example, in the Czech Republic, when the insurance company fully or partially covers the cost of medicines. And so they need prescriptions. In Russia in certain cases the patient has the right to purchase the drug with a 50% discount or get it for free if he is in the certain group of people eligible for the state
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social assistance. These prescriptions are served at public pharmacies and the government covers the cost of such medications to the pharmacy.
The frequency of consulting the pharmacists about diseases that often require antibiotics is rather high among patients in the Russian Federation. And many pharmacists provide their recommendations.
This situation and our own experience prompted us to analyze the concept of how the pharmacy employees acquire and use antibiotics for their own personal purposes.
In our work we tried to figure out how pharmacists in general take this group of drugs, what are their principles of choosing antibiotics, and whether they know the rules of antibiotics
application. We also tried to find the relationship between the fact of self-medication and the age, education level and job experience.
Below are the main statistical factors for Russia, such as population, GDP (Gross domestic product), birth rate, etc.
Parameter Russia
Total population (2013) 2 143.300.000
Population under 15 years of age (%) (2012)
5 15.45
Gross National Income (GNI) per capita,
USD (2012) 1 12.700
Life expectancy at birth (2011) 3 69
Under-5 mortality rate per 1000 live births
(2012) 1 10
Maternal mortality rate per 100 000 live
births (2010) 1 34
Total expenditure on health as % of GDP
(Gross domestic product) (2011) 6 6.2 Adult (15+) literacy rate (2011) 4 100 Population with access to improved drinking
water source (%) (2011) 5 97
Population with improved access to sanitation (%) (2011) 5
70
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1 The World Bank
2 Federal State Statistics Service 3 WHO
4 UNESCO (UNDATA) 5 World Health Statistics 6 WHO/Russia
General characteristics: according to the Federal Statistical Office, the population of the Russian Federation is 143.3 million (2013 including 15.45% persons under 15 years old.
Gross National Income as of 2012 amounted to 12,700 USD.
Life expectancy (at birth) is 69 years (2011). Mortality under the age of 5 years in 2012, defined as 10 per 1,000 live births. Maternal deaths per 100,000 live births were 34 cases in 2010.
Health expenditure in 2011 amounted to 6.2% of GDP.
Literacy among the population older than 15 years is 100%.
According to the results obtained in 2011 97 % of the population has access to improved water supply and 70 % of the population has access to improved sanitation, i.e. using improved sanitation and technical facilities.
2. THEORETICAL PART
2.1. History of the pharmacy in Russia
The history of healing in Russia went through a period of primitive era which has resulted in the development of national traditions and extensive experience in folk medicine. In the XVI century first professional pharmacists arrived to Moscow. Pharmacists were first mentioned in 1554.
Pharmacists from the Western Europe came to the Moscow State accompanying doctors who were invited to the tsarist court. The information about those doctors remained since the mid-XV century. Among them was John Frensham, a pharmacist who founded the first European-style pharmacy in Moscow in 1581.
The emergence of pharmacy trade required establishing a management system for a new type of activity. Apothecary Service (Prikaz) was a state administrative agency which was in charge of all medical and pharmaceutical activities in the country. At first, it served only to the tzar family, but in XVII its functions expanded greatly. First of all, they included the drug provision to troops, both in peacetime and during campaigns. It also became responsible for pharmacy training, although until the beginning of the XIX century it was kind of a trade school.
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Apothecary Service paid not only for professional training, but also for teaching foreign languages (Latin and German).
Further development of the pharmacy was held in the era of reforms initiated by Peter the Great.
First of all, Apothecary Service was modified into the Medical Secretariat, and then to the Medical Colleague. As a result, the center of pharmacy education and management was re- located to the new Russian capital Saint Petersburg. The reform of Pharmacy in the beginning of XVIII century has actually strengthened the European style and European standards of pharmacy operations. In the first place, it was not anymore allowed to trade pharmaceutical goods in so- called "herbal shops." In fact, this was recognition of the fact that pharmacies are special sanitary institutions but not just trade shops or wine cellars In 1797 the "Pharmacology" was written, containing descriptions of drugs and their actions (more than 100 recipes), as well as the
"Schedule of the pharmaceutical things" for military regimental and battalion pharmacies.
In the XVIII century the first Russian Pharmacopoeias were prepared. In 1765 the Military Pharmacopoeia has been published; it was written in accordance with the tradition of the Latin language – “Pharmacopoeacastrensis”. The first Russian state civil Pharmacopoeia –
“Pharmacopoea Rossica” appeared in 1778. Russia was among the first states that had its own state Pharmacopoeia. Increasing number of pharmacies was associated with an increase of the pharmacy community. In 1819 the Saint Petersburg Pharmaceutical Society was founded.
Education remained the main factor in the development of the apothecary system. The Moscow University and Saint Petersburg Medical and Surgical Academy (with a branch in Moscow) became the first centers of the domestic pharmaceutical higher education. (8)
2.2. Pharmacy in Russia today
The Russian market of pharmaceutical products is developing dynamically, but mostly by means of the imported goods. The lack of original domestic medicines relevant to the modern world standards is an economic issue in Russia. Today, the Russian pharmaceutical industry produces a rather limited range of drugs, many of which can be regarded as obsolete.
In November 2007, a marketing agency DISCOVERY Research Group completed a study of the Russian pharmaceutical market (9). The volume of Russia's pharmaceutical market by the end of 2006, according to various experts, ranged from $ 10 to 12.3 billion. As well as in previous years, in 2006 the market continued to grow up. Estimates of the rate of the market size growth for 2006 also vary widely - from 17% to 36%. Relative share of imports in total sales volume was 75% in 2006 and continued to increase due to imported and mostly expensive drugs. The
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volume of import of medicines in Russia in 2006 increased by 45-63% and, according to analysts, reached $ 6-6.5 billion. (10)
According to BusnesStat estimates, in a period from 2006 to 2010 the cost market value for antibiotics in Russia has increased by 90% – from 13.2 to 25.1 billion rubles ($ 338.5 to 643.6 mln). The cost volume of sales for antibiotics has grown with rates outrunning those for market growth in size. This lead was due to the fast growth of costs for antibiotic medications: within the period from 2006 to 2010 the average price of 1 package of antibiotics has increased by 66%
(from 55.7 to 92.3 rubles or $ 1.43 to 2.37).
In 2009 the sales of antibiotics have grown by 9% and achieved 271.0 million of packages. In 2011-2015 antibiotics sales will uplift by 43% (from 292.0 to 390.0 million of packages).
In 2009 European Surveillance of Antimicrobial Consumption (ESAC) has issued a paper which presents a detailed quality assessment of outpatient use in Europe in 2009 and an assessment of changes in quality of this use between 2004 and 2009.
Antibiotics sales are increasing because of the high demand that is largely determined by the fact that microorganisms quickly became resistant to new products, thus there is a need in continuous assortment expanding. Another reason is that bacteria are more aggressive now: some infections that formerly were treated with a single injection now require a long-term course of treatment (for example, Chlamydia infection, Lyme disease, pneumonia etc.). Diseases such as
tuberculosis, gonorrhea, malaria, and childhood ear infections are now more difficult to treat than they were just a few decades ago (3).
In 2010 production of antibiotics was 197 million packs. In 2011-2015 the decline in antibiotics production to 173.7 million packs is expected in the Russian Federation. The main reasons for such drop are as follows: consumption of fixed assets, out-of-date nomenclature of substances in context of the need for development of new and more efficient medications, and strong foreign competition (11).
2.3. Availability of the medicine in Russia
According to the results obtained in the study of drug product availability conducted by the Federal Antimonopoly Service of the Russian Federation (FAS) in 2013-2014, the following conclusions were made:
1. More than 50% (15 of 26) of expensive monopoly VED (Vital and essential drugs) analyzed by FAS are imported at prices higher than those in other CIS countries.
2. In some territories of the Russian Federation, despite the fact that they have the lowest total wholesale and retail mark-ups to the marginal cost, the total cost of a set of prescription VED
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may be higher than that for the same set sold in those territorial entities of the Russian Federation which have higher mark-ups.
3. For a set of best-selling prescription VED: the average countrywide retail price of and the price in separate territorial entities of the Russian Federation differs by 2.6 times.
4. For a set of best-selling prescription drugs not included in the list of vital drugs: the average countrywide retail price and the price in separate territorial entities of the Russian Federation differs by 2.1 times.
5. The best selling drugs in Russian pharmacies (retail) in general are more expensive than in other countries (even more expensive are those drugs that have analogues and, therefore, their prices should be set under the influence of price competition).
6. In the EU, the average drug expenses from the state and public sources are more than 60% of total drug expenditure, while in Russia they do not exceed 45%.
7. A common feature of drug supply management systems in economically developed countries is that patients receive a partial refund of the cost of drugs prescribed by doctor. The drug
reimbursement system (drug insurance) has a significant impact on the price of drug products, as well as on the price-related and physical availability of medicines to the public.
In Russia, only specified categories of the population receive free medication within the ONLS (Population Drug Coverage) and DLO (Extensive Drug Coverage) programs. However, it is rather difficult for patients to get preferential prescriptions, as the procedure for prescription preparation is time-consuming, and pharmacies do not have enough amounts of drug products (deficit, supply disruptions).
The problems of drug availability in Russia are associated with both the prices of medicines and their physical availability. As a result of insufficient coverage of drug programs and existing problems with medical care availability, most people instead of going to the doctor prefer self- medication and self-diagnosing, and chose drug products for themselves.
8. Drug products of low-price category continue to disappear from pharmacies. As a result, although the state price regulation for specific drugs keeps prices down, the overall population expenditures on medicines are increasing. (11)
2.4. Training of pharmacy staff in Russia
In Russia at the pharmacy you can meet the experts who are named «Provizor» and
«Pharmacist».
Pharmacists received vocational secondary education and graduated from professional
pharmaceutical schools. In St. Petersburg there is a pharmaceutical college. The program based
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on the State Standard is designed for 3 years of study for a basic level and additional 10 months for advanced level. Each semester ends with an exam. Each level ends with state comprehensive exam. Upon completion of each level, diplomas are issued. Students can undertake their
internship in the best pharmacies, health care facilities and wholesale companies. Specialists with a diploma in Pharmacy can work in pharmacies where drugs are compounded, in pharmacy stores etc. Specialists with a diploma in Pharmacy with additional business training can work at the same field and hold managerial positions in pharmaceutical companies. Specialists who are qualified in "Commerce in Pharmacy" field can work as sales managers for medicines and pharmaceutical products, may hold the position of Pharmacy Assistant Director for Business
.
Provizors (lat. provisor - PREPARING) is the highest professional qualification which entitles the person to work independently with pharmaceuticals and pharmacy management.
According to Head Hunter, the leading Russian recruitment company, despite the overall decline in the labor market during the crisis, the need for specialists in pharmaceutical field remains unchanged and is almost by 50% higher than the demand for specialists in other professions.
During the period from 2008 to the end of 2010, the growth of jobs in the pharmaceutical industry amounted to about 150%.
In particular, after graduating the Saint Petersburg Chemical Pharmaceutical Academy, alumnus work in pharmacies, pharmaceutical companies, pharmaceutical warehouses, quality control and analytical laboratories and pharmaceutical plants, are the heads of military pharmacies units and pharmacies at medical facilities of the power ministries and departments of the Russian
Federation, work in the forensic bureaus, institutions for implementation of medical equipment, in the Committee on Drug Control, as experts at the customs control, etc. (12)
In Europe the system is different. Here we have the «Master of Pharmacy», «Bachelor of Pharmacy» and «Doctor of Pharmacy». In the Czech Republic pharmacists are medical
professionals along with doctors and dentists. Conditions for eligibility to work in the profession are determined by the Law No. 95/2004 Sb.; the principal operation rules for pharmacists are specified in the Decree No. 84/2008 Sb and in the Law No. 378/2007Sb.
Despite the fact that by 2011, Russia's new two-tie system of education - Bachelor (4 years ,on the basis of secondary (complete) general education and on the basis of secondary vocational education) and Master (6 years ,based on the Bachelor), for medical, technical and military institutions of higher education, this system does not apply. There is still a specialization that allows you to get the qualification «specialist». The studies last 5-5 1/2 years (on the basis of
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general secondary education and on the basis of secondary vocational education) for pharmacists and pharmacist for three years.
For your pharmacist activities, in addition to higher pharmaceutical education, must have a certificate in one of three disciplines issued by institutions of higher education, state accredited for a period to 5 years. Under current law №210n of April 23, 2009 «The list of specialists with higher and postgraduate medical and pharmaceutical education in the field of health of Russian federation», a pharmacist can have one of three specialties: management and economics of pharmacy, pharmaceutical technology and pharmaceutical chemistry and pharmacognosy.
Pharmacists receive a certificate in the specialty «Pharmacy». It is also valid for the fifth years (14).
In pharmacies in Russia a big difference between the pharmacist, who has a higher education, and the pharmacist with the secondary one is not. As a rule, they have the same duties and obligations, i.e. the employees of the «first table» and communicate directly with customers, suggesting treatment, sell goods and drugs, including prescription as well.
Differences arise when there is a question for the post of Deputy Head or Head of the pharmacy.
In this case, the education level plays a significant role. According to the current law, namely RF Government Resolution No. 1081 of December 22, 2011 "On Licensing of Pharmaceutical Activity", the applicant for the license for pharmaceutical activities must satisfy the following licensing requirements (among others) :
the Head of the organization (except for healthcare organizations) whose activities are directly related to the wholesale trade of medicinal products, storage, transportation and (or) retail of medicinal products, dispensing, storage, transportation and manufacturing should have the following:
To carry out pharmaceutical activities in the field of circulation of medicines – higher
pharmaceutical education and professional experience of no less than 3 years, or the vocational pharmaceutical education and professional experience of no less than 5 years; professional certificate (15).
2.5. LEGAL
Pharmacy activity is regulated by many laws, orders and decrees approved by the Government and also by The Ministry of Health of Russian Federation.
Regarding the sale of prescription drugs the main legislative documents are:
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«On the Circulation of Medicines»
This Federal Law regulates relationships arising in connection with the circulation of medicines in development, preclinical studies, clinical studies, expert evaluation, state registration,
standardization and quality control, manufacture, storage, transportation, import to the territory of the Russian Federation, export from the territory of the Russian Federation, advertising, shipping, sale, transfer, use, and disposal of medicinal products.
2. Order No. 1175n of December 20, 2012 of the Ministry of Healthcare of the Russian Federation
«On Approval of the Procedure for Prescribing Pharmaceuticals as well as the Prescription Forms for Pharmaceuticals and the Procedure for Preparing, Registering, and Keeping such Forms»
This Order states the procedure for appointing and prescribing medications; prescription forms, as well as policies of prescription forms, their registering and storage.
3. Order No. 785 of December 14, 2005 of the Ministry of Healthcare of the Russian Federation
« On Dispensing of Pharmaceuticals»
Abstract from the Order:
II. General requirements for dispensing the medicines
2.1. All pharmaceuticals except for those included in the List of Prescription-free medicines must be dispensed by pharmacies by prescription only. Prescriptions must be filled out on appropriate prescription forms in accordance with established procedure.
2.6. Upon dispensing prescription medicines, the pharmacist must note a prescription putting information on product dispensing (name or number of the pharmacy, name and dosage form of the medicinal product, amount dispensed, signature of responsible person and the issue date).
2.14. Prescriptions for controlled substances (subjects to strict record keeping), medicinal products included to the List of prescription products, and other medicinal products dispensed free of charge or with discounts, and anabolic steroids should remain in the pharmacy for further separated storage and destruction upon keeping period expiration.
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4. Decree No. 1081 of December 22, 2011 (as amended on April 15, 2013) of the Government of the Russian Federation
«On Licensing of Pharmaceutical Activity»
This Decree regulates the licensing procedure for pharmaceutical activities carried out by legal entities, (including the organization of wholesale distribution of medicines), pharmacy
organizations, veterinary pharmacy organizations, as well as by medical organizations and their subdivisions (centers/offices of general/family practice, outpatient clinics, paramedical stations, medical and obstetrics stations located in rural areas which have no pharmacies), and by
individual entrepreneurs.
Pharmaceutical activities include the following services and activities:
In the circulation of drug products for medical use:
1. Wholesale distribution of medical drug products;
2. Storage of pharmaceutical substances and medicinal products;
3. Transportation of pharmaceutical substances and medicinal products;
4. Retail sales and dispensing of medical drug products;
5. Production of medical drug products.
Requirements to the licensee include as follows:
1. To work in the field of the circulation of medicines, the Head of Organization, whose work is directly related to the wholesale distribution of drugs, their storage, transportation and/or retail distribution, dispensing, storage, transportation and manufacturing (except for medical
institutions), must have B.S. or M.S. in Pharmacy and professional experience of no less than 3 years, or a diploma for vocational pharmaceutical education and professional experience of no less than 5 years. He/she also must have a valid professional certificate.
To work in the field of the circulation of medical products for veterinary use, the Head of Organization must complete higher or secondary pharmaceutical or veterinary education, professional experience of no less than 3 years, and a valid professional certificate.
2. Specialists with a diploma in pharmacy or veterinary medicine should take advanced courses at least once in 5 years.
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3. EXPERIMENTAL 3.1. Questionnaire
3.1.1. Questioning procedure
The questioning was held in August – September, 2013 in Saint Petersburg, Russia.
The questioning involved 316 employees from the 63 pharmacies. In each of the pharmacies questionnaires were answered only by a part of the staff. This was due to the fact that employees in these pharmacies work on a shift basis. As we visited every pharmacy only once, so we could interview only those employees who were at work on that particular day.
The questioning was held in one of the largest pharmacy networks in St. Petersburg and Leningrad Region. By the time of questioning this network included 410 employees working in pharmacies. As noted above, we received 316 filled questionnaires, which correspond to 77.07 % of all network staff. However, only 308 questionnaires were used for the analyses, i.e. 97.47 % of received amount. This was due to the fact that 8 people, who work at pharmacies and filled out our questionnaire, have higher medical (non-pharmaceutical) education. I.e. their responses cannot be used from the integrity of test perspective.
The questionnaire was adapted from previous study and modified to suit our group of respondents (16).
The questions in the questionnaire were grouped into the following categories: (a) socio-
demographic characteristics of the participants (gender, age, educational level, work experience);
(b) reasons for using antibiotics in past 6 month; (c) principles of the antibiotic therapy; (d) self- reported practices related to antibiotics use; (e) risks associated with the antibiotic use.
The questionnaire consisted of closed and one open-ended questions, regarding demographic characteristics, knowledge about antibiotics use and resistance, attitudes and behaviors towards antibiotics use, and sources of information.
3.2.2. Questions
.Data analysis
The query contained 16 questions.
We grouped the questions according to such criteria as demographic characteristics, attitudes toward antibiotics, treatment principles, etc.
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Demographic profile of participants
Table 1. Gender
Gender Rate of respondents Male 0.6%
Female 99.4%
This group of questions helped us identifying the demographic profile of study participants. We found that 99.4% of respondents were female, which is rather typical for Russian pharmacies.
You rarely can meet men working as pharmacists, and most of them are students from Pharmacy schools doing their compulsory internships. After graduation, men mostly look for jobs related to production or distribution of medicines, nutritional supplements or parapharmaceutical products.
Higher Education Statistics Agency (HESA, UK) data shows that when the cohort entered pharmacy school only 62.6% of the cohort was female, suggesting females were over-
represented. However, what remains clear is that the feminization of the profession will continue (17).
Table 2. Age
Age Rate of respondents
<20 0.3%
20-30 32%
31-40 21%
41-60 45%
>60 2%
The average age of respondents is 39.3 years (see Annex 1). Overall, nearly half of respondents, 45% - are employees aged 41 to 60 years.
Table 3. Education level
Education level Rate of respondents Higher pharmaceutical degree 36%
Higher degree in non-pharm fields 2%
Vocational pharmaceutical degree 56%
Vocational degree in non-pharm fields 6%
The majority of pharmacists have a baccalaureate degree (56%) as their current level of education.
- 22 - Table 4. Work experience
Work experience Rate of respondents
<1 year 4.2%
1-5 years 26.9%
6-10 years 26%
>10 years 42.9%
Almost a half (42.9%) of pharmacists has been working in the pharmacy more than 10 years.
Treatment with antibiotics
Table 5. Self-medication
If you feel you`re getting sick Rate of respondents You go to the doctor 23.8%
You self-medicate 76.2%
Total number of questionnaires is 308.
In 14 questionnaires both options were marked simultaneously.
Total are 294 questionnaires to process.
More than three-quarters of pollee pharmacists (76.2%) self-medicate in case of sickness.
Table 6. Buying antibiotics on prescriptoin
I buy antibiotics according to the doctor's prescription
Rate of respondents
Always 33%
Never 6%
Sometimes 61%
Total number of questionnaires is 308.
In 10 questionnaires no answer was provided.
In 1 questionnaire two options were chosen simultaneously.
Total are 297 questionnaires to process.
Only 33% say they buy antibiotics on doctor`s prescription. More than a half (61%) goes to the doctor on examination and gets a prescription from time to time.
6% of staff pharmacists say they have never bought antibiotics on prescription.
Table 7. Buying antibiotics without prescription
I buy antibiotics without prescription Rate of answers * According to your knowledge 81.5%
According to your experience of previous treatment 49%
According to the analysis of prescriptions brought by pharmacy customers
17%
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According to your friend’s advice 5%
According to the cost of medicine 8%
*every answer = 100%
Those 67% of respondents who don`t go to the doctor for prescription (6%) or go rarely (61%) (see table 6), buy antibiotics drugs relying on their knowledge (81.5%), analyzing an experience of previous treatment (49%) and according to the analysis of prescriptions brought by pharmacy customers (17%). Cost of medicine is key factor for 8% of respondents and 5% rely on a friend advice.
Reasons for using antibiotics in the past 6 months
Table 8. Taking antibiotics in a past 6 month
Have you or your family members
taken any antibiotic drug product in the past 6 months
Rate of respondents
Yes 44%
No 56%
If yes, what was the reason for using antibiotic drug product (rate of respondents is 135. That’s the rate of the respondents, who said they have taken antibiotics in a past 6 month).
Table 9. Reason for using antibiotic drug product
Reason for using antibiotic drug product Rate of cases Upper respiratory tract infection 53.3%
Low respiratory tract infection 19.3%
Dental infection 14.1%
Respiratory inflammations 13.3%
Post surgery 5.9%
Gastrointestinal infections 12.6%
Gynecological inflammations 8.1%
Bones and joint infections 0.7%
Skin and soft tissue infections 5.9%
Urinogenital infections 13.3%
Chronic infectious disease 3.7%
Our respondents say they mostly took antibiotics because of upper respiratory tract infection (53.3% from all cases).
In the public primary care setting, it was found that half of all the antibiotics prescribed were for upper respiratory tract infections (URTIs). Overuse of antibiotics for URTIs has been reported
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even though the majority of these infections are caused by viruses, against which antibiotics have little or no clinical benefit (18).
On the second place are low respiratory tract infections (19.3%). Also there were cases of dental infection (14.1%), urinogenital infections and respiratory inflammations (both 13.3%) and gastrointestinal infections (12.6%). Skin and soft tissue infections and post surgery state required using antibiotics in 5.9% of all cases.
In our research we also asked respondents to name antibiotics they had used in past 6 month.
Table 10: Frequency of antibiotics use (sorting by number of use) ATC
CLASSIFICATION
NUMBER
OF USE SECTION
J01FA 74 Macrolides
J01CR 52
Combination of penicillins incl. beta-lactamase
inhibitors
J01MA 34 Fluoroquinolones
J01CA 30
Semi/synth PCN (penicillins with extended
spectrum)
J01AA 13 Tetracycline
J01DD 9 Cephalosporins III
J01FF 3 Lincosamides
J01DC 3 Cephalosporins II
J01EE 1
Combination of sulfonilamides and trimethoprim incl. derivates
J01GB 1 Other aminoglycosides
G01AX 1 Other anti-infectives and
antiseptics
J01XD 1 Imidazole derivatives
G01BA 1 Antibiotics and
corticosteroids
- 25 -
Figure 1: Frequency of antibiotics use. Relative share (%)
Macrolides occupy the largest market share (33.18%). Azithromycin, an azalide used for the treatment of a number of bacterial infections, is in the lead (81.1%) in this group. It is on the World Health Organization's List of Essential Medicines, a list of the most important medications that satisfy the priority health care needs of the population (19).
The next one is Clarithromycin (10.8%) – a semisynthetic macrolide antibiotic with a wide spectrum. Also the group of popular macrolide antibiotics includes Midecamycin (5.4%) and Josamycin (2.7%).
Figure 2: Relative share (%) of antibiotics of macrolide group 0
10 20 30 40 50 60 70 80
0 10 20 30 40 50 60 70 80 90
Azithromycin Clarithromycin Josamycin Midecamycin
- 26 -
Combination antibiotics are the second most frequently used group (22.9%). Usually they contain Amoxicillin (a semisynthetic β-lactam antibiotic) and potassium clavulanate (a β-
lactamase inhibitor). This combination creates a medication with wider spectrum of action which remains its efficacy against amoxicillin-resistant bacteria producing β-lactamase. In this group two drugs were mentionedby our respondents– Amoxiclav (92.2%) and Augmentin (7.8%).
Both are a combination of Amoxicillin and Clavulanic acid. We should note that Augmentin is the original drug product, while Amoxiclav is a generic.
Fluoroquinolone antibiotics are completing the top three with the share of 15.2%. Ciprofloxacin is the most popular product in this group (55.9 %), followed by Norfloxacin (29.4%),
Levofloxacin (8.8%) and Ofloxacin (5.9%).
Figure 3: Relative share (%) of antibiotics of fluoroquinolonegroup
Other groups of antibiotics in descending order of preference are as follows: semisynthetic penicillins (Amoxicillin) with 13.5% share, Tetracycline (5.8%), third-generation cephalosporins (4%), lincosamides (1.4%), second generation cephalosporins (1.4 %), and aminoglycosides (0.89 %). The last in the list are 5 - nitroimidazoles (metronidazole), nitrofurans, penicillins and sulfonamides with a specific share of 0.45% each.
It is worth noting that the last group of sulfonamides de facto doesn`t belong to antibiotics.
Principles of antibiotic therapy
Table 11. Attitude to the antibiotic therapy
Your attitude to the antibiotic therapy Rate of respondents I consider antibiotics as the first-choice medicine 3.9%
I take antibiotics only in emergency cases 93.1%
0 10 20 30 40 50 60
Ciprofloxacin Levofloxacin Norfloxacin Ofloxacin
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I am totally against antibiotics 3%
Total number of questionnaires is 308.
In three questionnaires were marked at the same time 2 or more options.
Total are 305 questionnaires to process.
3% of respondents are totally against antibiotics, while 3.9% consider antibiotics as the first-choice medicine. The majority of pharmacists (93.1%) say they take antibiotics only in emergency cases.
Table 12. Sources of knowledge about new antibiotics
What are your sources of knowledge about new antibiotics
Rate of answers Study, training by medical representatives 72.4%
Special literature 44.8%
Patient information leaflet (PIL) 49.4%
Getting information from the medical representatives is the most popular way to get new knowledges about medicine with antibiotics among others. Other sources in order are PIL (49.4%) and special literature (44.8%).
Table 13. Application of antibiotics
Application of antibiotics Rate of respondents I stop taking antibiotics when I feel
better
2.3%
I take antibiotics as prescribed by my physician
24.7%
I take antibiotics according to prescribing information
73%
Total number of questionnaires is 308.
In 1 questionnaire was not given an answer.
In 48 questionnaires were marked at the same time 2 or more options.
Total are 259 questionnaires to process.
2.3% of respondents stop taking antibiotics when feel better.
Nearly one-quarter of respondents (24.7%) take antibiotics as prescribed by their physician, and about three-quarters (73%) take antibiotics according to prescribing information.
- 28 - Table 14. Dosage form
You prefer to use antibiotics
Rate of respondents In oral dosage form 93.1%
In injection dosage form 6.9%
Most pharmacists (93.1%) prefer oral dosage form of antibiotics.
Risks associated with the use of antibiotics
Table 15. Aware of adverse side effects
Are you aware of adverse side effects that
can be caused by antibiotic treatment Rate of respondents
Yes 100%
No 0
Total number of questionnaires is 308.
In 2 questionnaires was not given an answer.
Total are 306 questionnaires to process.
Table 16. Side effects
What side effects did you have
during your antibiotic treatment Number of cases
Diarrhea 124
Constipation 23
Vomiting 11
Nausea 78
Dyspepsia 71
Skin manifestations 42
Myxedema 5
Mucitis 13
Asthenia 46
Hyperhidrosis 12
Tachycardia/Bradycardia 8
Blood pressure changes 2
Other 18
I didn`t experience any side effects 96
- 29 -
Figure 4: Side effects during antibiotic treatment
Among the side effects, which respondents suffer from the most frequent was diarrhea. The World Health Organisation defines antibiotic-associated diarrhoea (AAD) as three or more abnormally loose bowel movements per 24 hours while on antibiotics. Antibiotics that act on anaerobes, such as aminopenicillins, cephalosporins and clindamycins, are most associated with diarrhea. Twenty percent of people who take a course of antibiotics suffer from diarrhea (20).
On the second place of frequency is nausea and on the third – dyspepsia. Occasional were notified myxedema and blood pressure changes.
96 respondents say they didn`t have any side effects.
Table 17. Aware that AB kill off the normal flora
Are you aware of the fact that
antibiotics kill off the normal flora Rate of respondents
Yes 99.7%
No 0.3%
Almost everyone (99.7%) is awared of the fact that antibiotics kill off normal flora.
0 20 40 60 80 100 120 140
Number of cases
Side effects
- 30 - Table 18. Taking probiotics
Do you take any probiotics
during/after antibiotic treatment
Rate of respondents
Yes 90.5%
No 9.5%
Total number of questionnaires is 308.
In 3 questionnaires no answer was provided.
In one questionnaire both options were chosen simultaneously.
Total are 304 questionnaires to process.
Almost every pharmacist who took part in our study knows that antibiotic drugs kill off normal microflora, but only 90.5% of respondents say they take probiotics during or after antibiotic treatment.
It is now well recognized that antibiotics (particularly broad spectrum antibiotics) can adversely affect the balance of the resident gut micro flora resulting in a dysbiosis, or micro flora
imbalance, of the gastrointestinal (GI) tract and can therefore act as an immune suppressor. The use of probiotics in conjunction with antibiotics, will act to reduce the effects of the dysbiosis caused by the antibiotics, and maximize the benefits of the probiotic directly in the gut on competitive exclusion and immune stimulation. It is advisable however to stagger the
administration of the antibiotic and probiotic such that the probiotic is administered at least three hours after the antibiotic dose, where possible, otherwise the antibiotic may reduce the efficacy of the probiotic microorganisms. It is important to note that the reverse is not true: probiotics will not cause a reduction in efficacy or effectiveness of the antibiotic. The administration of the probiotic for at least one week following the completion of the antibiotic course. Whilst the spectrum of many antibiotics means they are compatible with Protexin ® probiotics, staggering the administration of the probiotic so that it is administered at least 3 hours after the antibiotic dose is recommended (20).
4. DISCUSSION
This study discusses the issue of the purchase and use of antibiotics pharmacy employees in the Russian Federation. The objectives of the study were to investigate their level of knowledge, attitudes, and behaviors regarding antibiotics.
More than three-quarters of pollee pharmacists (76.2%) self-medicate in case of sickness.
Antibiotics were used by 44% of the study pharmacy employees. And only 33% say they buy antibiotics on doctor`s prescription. More than a half (66%) goes to the doctor on examination
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and gets a prescription from time to time. 6% of staff pharmacists say they have never bought antibiotics on prescription.
We suggest that the main contributing factor is the ease with which antibiotics can be acquired from the pharmacy by its employees. According to the current laws pharmacy must not show the prescription on the antibiotic, which was already sold, in case of inspection.
Finding interdependence between age and self-medication (see Annex 2) we found out that in 3 of 5 age groups dominates self-medication. Still this domination is not large. In the age group 20-30 years 31.4% prefer going to the doctor in case of illness and 32.1% say they self-medicate.
In the age group of 41-60 years rates are 42.8% and 45.09% respectively and in the age group 60+ rates are 1.4% and 2.2% respectively.
Young and middle aged respondents (31-40 years) are more responsible. 22.8% of them go to the doctor and 20.5% self-medicate.
Most pharmacists take antibiotics only in emergency cases (93%). Almost 4% consider antibiotics as the first-choice medicine, while 3% are totally against antibiotics.
As it was marked by the participants of our study, they mostly took antibiotics because of upper respiratory tract infection. 13.3% had taken antibiotics on respiratory inflammation. This fact also indicates the belief that antibiotics can treat and eradicate any infections irrespective of their origin (21), and that even some of the pharmacists do not know that antibiotics do not work on most coughs and colds (22).
The most popular group of antibiotics used by our respondents is macrolides. Azithromycin is in the lead (81.1%) in this group. Combination antibiotics are the second most frequently used group (22.9%). Fluoroquinolone antibiotics are completing the top three with the share of 15.2%.
By comparison in 2004 in Russia was held the research to evaluate the outpatient use of systemic antimicrobials in 24 different regions of Russia. Outpatient use of systemic antimicrobials in 24 regions of Russia (including saint-Petersburg) during year 2004 ranged from 4.9 to 32.1 DID with mean of 11.5 DID. In 23 regions the penicillins were the most frequently used antimicrobials (from 17.2% in Voronezh region to 41.1% in Perm region). In Kursk region tetracyclines were the prevalent class of antimicrobials (25.3%). In all regions, except Perm, among penicillins the broad spectrum penicillins were prevalent (ampicillin, amoxicillin, carbenicillin). On the second positions in the structure of antimicrobial’s use in 11 regions were tetracyclines (with more than 75% of doxycycline in this group), in 7 regions – quinolones (mostly due to ciprofloxacin), in 6 regions – sulfonamides (mainly co-trimoxazole). The role of macrolides and lincosamides varied from 7.8% in Saratov region to 16.7% in Khabarovsk;
cephalosporins – from 1.1% in Krasnoyarsk and Nizhniy Novgorod regions to 5.7% in Omsk
- 32 -
region, chloramphenicol – from 1.3% in Perm to 10.8% in Belgorod region, aminoglycosides – from 1.0% in Saint Petersburg to 6.1% in Kursk. So, it can be assumed, that there is a significant difference in the outpatient consumption of systemic antimicrobials in different regions of Russia. Thus, in some regions the older agents with unfavorable safety profiles are widely administered. In opposite, in other regions newer agents are used more frequently (23).
It is known that it is very important to take the antibiotics exactly as prescribed. The common rules say patient should complete all the antibiotic prescribed, even if he feel better, so all
residual bacteria are killed, thus avoiding a rebound infection. Also should always take antibiotic at the same time of day. Consistency matters.
Unfortunately 2.3% of respondents don`t follow these rules. They stop taking antibiotics when feel better. About three-quarters (73%) take antibiotics according to prescribing information.
This study is limitated with the fact that the participants were self-reporting via the
questionnaire, so there is a possibility that they may over-report socially desirable behaviors or under-report socially undesirable behaviors. There were no mechanisms to objectively
assess the honesty of the participants’ answers to the survey questions. The absence of identifying data on the questionnaire sheets and confidentiality would tend to minimize such bias.
5.CONCLUSION
The results of this study confirm that antibiotic self-medication is a frequent problem in Russia with the pharmacy staff involved. Pharmacy employees have to know rules, orders etc. on how to sell antibiotics. But most of them do not follow them. It is suggested that a well-planned, organized and structured educational program should be taken within doctors and pharmacists to improve the appropriate use of antibiotics.
- 33 - Annex 1
Calculation of statistical values
Age Mid-
range V
Number of respondents
n
Weighted arithmetic average
Vn
Deviation from the arithmetic mean d
Squared deviations
d2 d2n
<20 9,5 1 9,5 -29,79707792 887,8658527 887,8658527
20-30 25 99 2475 -14,29707792 204,4064371 20236,23727
31-40 35,5 63 2236,5 -3,797077922 14,41780075 511,8319265
41-60 50,5 139 7019,5 11,20292208 125,5054631 17445,25937
>60 60,5 6 363 21,20292208 449,5639046 2697,383428
Total 308 12103,5 41778,57785
Arithmetic mean 39,297078
An average error of the arithmetic mean 0,6636302
Standart deviation + - 11,646662
Coefficient of variation Cv 29,637476
Findings: mean age is 39,3 years + - 11,6 and it is quite representative (typical).
- 34 - Annex 2
Interdependence Self-treatment/Age
Characteristics Age, years Number
<20 20-30 31-40 41-60 >60 %
When you feel you`re falling sick
You go to the doctor 1 22 16 30 1 70
1,428571429 31,4285714 22,8571429 42,85714 1,428571 100
You`re doing self-treatment 0 72 46 101 5 224
0 32,1428571 20,5357143 45,08929 2,232143 100
Total number of questionnaires
294 1 94 62 131 6 294
% 0,340136054 31,9727891 21,0884354 44,55782 2,040816 100
0 5 10 15 20 25 30 35 40 45 50
<20 years 20-30 years 31-40 years 41-60 years >60 years
Number of respondents
Age of respondents
Go to the doctor, % Doing self-treatment, %
- 35 - Annex 3
Interdependence Self-treatment/Work experience
Characteristics
Work experience Number
<1 year 1-5years 6-10 years
>10
years %
When you feel you`re falling sick
You go to the doctor 2 15 23 31 71
2,816901408 21,126761 32,3943662 43,66197 100 You`re doing self-
treatment
12 66 55 97 230
5,217391304 28,695652 23,9130435 42,17391 100
Total number of
questionnaires (without lost data)
301 14 81 78 128 301
% 4,651162791 26,910299 25,9136213 42,52492 100
0 5 10 15 20 25 30 35 40 45 50
<1 year 1-5 years 6-10 years >10 years
Go to the doctor, % Doing self-treatment, %
- 36 - Annex 4
Interdependence Self-treatment/Education
Education Go to the doctor, % Doing self-
treatment, %
Higher farmaceutical
28,57142857 35,93073593Other higher
7,142857143 6,060606061Vocational farmaceutical degree
58,57142857 53,67965368Other vocational degree
5,714285714 4,32900432912,85714 10,38961
0 10 20 30 40 50 60 70
Go to the doctor, %
Doing self- treatment,
%
Higher farmaceutical
Other higher
Vocational
farmaceutical degree Other vocational degree
- 37 - Annex 5
Interdependence Self-treatment/Side effects
When you feel you`re falling sick, you go to the doctor 70 %
Did you have side effects Yes 55 78,57143
No 15 21,42857
When you feel you`re falling sick, you`re doing self-treatment 231
%
Did you have side effects Yes 152 65,80087
No 79 34,19913
0 10 20 30 40 50 60 70 80 90
AB by doctor,
%
AB by self- treatment, %
Yes No
- 38 - Figure 5: Side-effects during self-medication and doctor`s treatment
0 10 20 30 40 50 60 70
AB prescribed by doctor, % AB by self-treatment, %
