Community Interventions for Tackling Antimicrobial Resistance in Ghana (CITAR-Ghana)

This research project aims to test the effect of two interventions targeted to community pharmacies in the Greater Accra region, Ghana, on antibiotics dispensing rates. The general goal is to inform the design of future policies to address the rising threat of antimicrobial resistance.

Study Overview

• Status: Not yet recruiting
• Conditions: Upper Resp Tract Infection
• Intervention / Treatment: Behavioral: Individualized Feedback; Behavioral: Legal Reminder

Detailed Description

Interventions that discourage community pharmacies from providing antibiotics without proper diagnosis and a physician's prescription are critically needed in low- and middle-income countries in order to address the rising threat of antimicrobial resistance. In this study, we will test the effect of two interventions targeted to community pharmacies in the Greater Accra region of Ghana. We will conduct a baseline survey, followed by visits by standardized patients (SPs). We will then implement the interventions (described below) and assess the outcomes again using SPs.

The study has 4 key objectives:

Objective 1. Assess the effect of two behavioral interventions targeted to community pharmacies on antibiotics dispensing rates. We randomly assign 285 pharmacies in Greater Accra 1:1:1 into one of three arms: 1) Control, 2) Individualized Feedback, and 3) Legal Reminder. In the Individualized Feedback arm, we use information from the first visits to provide customized feedback to the pharmacies. In the Legal Reminder arm, we provide a letter from the Ghana authorities emphasizing that providing antibiotics without a physician prescription is against the law.

Objective 2. Assess the extent of know-do gap in antibiotics dispensing behavior among community pharmacies. We compare self-reported data from a baseline survey and the one obtained from SP visits to assess the gap between what the pharmacies know and what they do in practice.

Objective 3. Examine the effect of reduced pressure from patients for antibiotics on pharmacies' dispensing behavior. The two demand variations we will test are the following: 1) Patient asks for a medicine (normal demand pressure), 2) Patient explicitly says that they would prefer not to take antibiotics and mention that they do not have a physician prescription and that their condition appears to be viral (reduced demand pressure).

Objective 4. Assess differential effects of the two interventions and reduced demand pressure across patient's age.

• Study Type: Interventional
• Enrollment (Estimated): 285
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Yubraj Acharya, Ph.D.; Phone Number: 814-865-6898; Email: yua36@psu.edu

Study Locations

• Ghana
  • Legon, Ghana
    • University of Ghana, Regional Institute for Population Studies
    • Contact: Adriana Biney, Ph.D.; Phone Number: 0302 906 800; Email: abiney@ug.edu.gh

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria for community pharmacies:

• Operating within the Greater Accra region of Ghana
• Registered with Ghana Pharmacy Council
• "Stand-alone", i.e., not affiliated or next to a hospital

Exclusion Criteria:

• Operating only outside the Greater Accra region of Ghana
• Not registered with Ghana Pharmacy Council
• Hospital pharmacy

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control; No intervention
Experimental: Individualized Feedback; Pharmacies receive customized feedback on their antibiotics dispensing behavior.	Behavioral: Individualized Feedback; We use information from the baseline visits (e.g., on whether they give antibiotics without a prescription and the time they spend with patients) to provide customized feedback to the pharmacies.
Experimental: Legal Reminder; Pharmacies receive letter from the authorities in Ghana emphasizing that providing antibiotics without a physician prescription is against the law.	Behavioral: Legal Reminder; We provide a letter from the authorities in Ghana emphasizing that providing antibiotics without a physician prescription is against the law.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Non-prescription antibiotics dispensing rate	Whether the pharmacy dispenses antibiotics without prescription in scenarios not requiring them	From baseline (1st SP visit) to the final SP visit (visit 5), lasting approximately 5 months.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Watch or reserve antibiotics	Whether the dispensed antibiotics fall into the Watch or Reserve category in the WHO AWaRE classification.	From baseline (1st SP visit) to the final SP visit (visit 5), lasting approximately 5 months.
Out-of-pocket costs to patients	Amount patients spend out-of-pocket on medications including antibiotics.	From baseline (1st SP visit) to the final SP visit (visit 5), lasting approximately 5 months.
Referral to a physician	Whether the pharmacist recommends the patient to see a doctor before antibiotics can be dispensed.	From baseline (1st SP visit) to the final SP visit (visit 5), lasting approximately 5 months.
History taking	Number of questions asked by the pharmacist based on a pre-specified checklist of appropriate history taking behavior	From baseline (1st SP visit) to the final SP visit (visit 5), lasting approximately 5 months.
Interaction time	Amount of time the pharmacist spends on the patient before giving medicine.	From baseline (1st SP visit) to the final SP visit (visit 5), lasting approximately 5 months.

Collaborators and Investigators

• Sponsor: Penn State University
• Collaborators: University of Ghana

Study record dates

Study Major Dates

• Study Start (Estimated): April 1, 2026
• Primary Completion (Estimated): August 1, 2026
• Study Completion (Estimated): December 1, 2026

Study Registration Dates

• First Submitted: December 3, 2025
• First Submitted That Met QC Criteria: December 3, 2025
• First Posted (Actual): December 16, 2025

Study Record Updates

• Last Update Posted (Actual): December 16, 2025
• Last Update Submitted That Met QC Criteria: December 3, 2025
• Last Verified: December 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Infections; Respiratory Tract Diseases; Respiratory Tract Infections
• Other Study ID Numbers: STUDY00026602; 102725 (Other Grant/Funding Number: Merck and Company, Inc.)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No