antibiotic resistance has become one of the most important public health problems worldwide due to morbidity and mortality and healthcare costs .
although the spanish national health system ( snhs ) has a population coverage of almost 100% , 30% of all antibiotic use occurs outside the snhs and is largely due to the dispensing of antibiotics without a medical prescription ( dawmp ) .
although this practice is unlawful , it is common in spain , favoured by the fact that it is not a punishable offence .
this , in turn , means that dispensing depends on the attitude of the individual pharmacist .
this study sought : ( i ) to estimate the percentage of pharmacists who employ dawmp ; and ( ii ) to identify such pharmacists ' personal and professional traits , as well as their knowledge and attitudes , in view of the potential link between these and the practice of dawmp .
although we were undertaking an observational study , the ethics committee for clinical research of galicia was informed and approval was granted ( n 2007/107 ) .
we carried out exhaustive sampling of the study population , which comprised all community pharmacists from a region in north - western spain in september 2012 ( 183 pharmacies and 393 pharmacists ) .
a self - administered questionnaire was used ( available as supplementary data at jac online ) .
the statements were classified into three blocks : ( i ) personal and professional information ; ( ii ) knowledge of and attitudes to antibiotics and antibiotic resistance ; and ( iii ) dawmp in four situations ( urinary , dental and upper respiratory tract infections , and cases where the patient promised to bring the prescription at some later point in time ) . in this last block , respondents were given three options for each of the situations : no / yes / only if the patient is someone known to the pharmacist .
agreement with the statements was measured using an unnumbered , horizontal visual analogue scale 7 cm long , with replies being scored from 0 ( total disagreement ) to 10 ( total agreement ) .
the questionnaire was based on a previous qualitative focus group study conducted by our research group .
( ii ) data were analysed and grouped into categories ( complacency , insufficient knowledge , indifference and external responsibility ) .
( iii ) these categories were transformed into statements , based on expressions used by the participants in the focus groups .
( iv ) the content and face validity was reviewed with the aid of pharmacology , psychology and public health experts .
( v ) the structure of the questionnaire was revised , and both the wording and the content of these items were improved .
( vi ) to assess the reproducibility ( the degree of agreement among answers ) , a pilot test was conducted on 30 pharmacists .
the questionnaire was delivered twice to each pharmacist , with an interval of 4 weeks .
a research team member ( m. z .- c . ) personally delivered and retrieved the questionnaires .
pharmacists who were not at the pharmacy at the time of the visit were not included in the study .
participants who replied  yes or  only if the patient is someone known to the pharmacist in at least one of the four scenarios were classified as dawmp .
the reproducibility of the questionnaire was assessed using the intraclass correlation coefficient ( icc ) , based on the results obtained for the first and second answers from each pharmacist .
to take into account the distribution of the independent variables , we calculated the interquartile odds ratio ( or ) , which is the effect of the exposure change from the 25th to the 75th percentile .
when the or was < 1 , we calculated the inverse interquartile or ( 1/interquartile or ) , which is the effect when the exposure changes from the 75th to the 25th percentile .
although we were undertaking an observational study , the ethics committee for clinical research of galicia was informed and approval was granted ( n 2007/107 ) .
we carried out exhaustive sampling of the study population , which comprised all community pharmacists from a region in north - western spain in september 2012 ( 183 pharmacies and 393 pharmacists ) .
a self - administered questionnaire was used ( available as supplementary data at jac online ) .
the statements were classified into three blocks : ( i ) personal and professional information ; ( ii ) knowledge of and attitudes to antibiotics and antibiotic resistance ; and ( iii ) dawmp in four situations ( urinary , dental and upper respiratory tract infections , and cases where the patient promised to bring the prescription at some later point in time ) . in this last block , respondents were given three options for each of the situations : no / yes / only if the patient is someone known to the pharmacist .
agreement with the statements was measured using an unnumbered , horizontal visual analogue scale 7 cm long , with replies being scored from 0 ( total disagreement ) to 10 ( total agreement ) .
the questionnaire was based on a previous qualitative focus group study conducted by our research group .
( ii ) data were analysed and grouped into categories ( complacency , insufficient knowledge , indifference and external responsibility ) .
( iii ) these categories were transformed into statements , based on expressions used by the participants in the focus groups .
( iv ) the content and face validity was reviewed with the aid of pharmacology , psychology and public health experts .
( v ) the structure of the questionnaire was revised , and both the wording and the content of these items were improved .
( vi ) to assess the reproducibility ( the degree of agreement among answers ) , a pilot test was conducted on 30 pharmacists .
the questionnaire was delivered twice to each pharmacist , with an interval of 4 weeks .
a research team member ( m. z .- c . ) personally delivered and retrieved the questionnaires .
pharmacists who were not at the pharmacy at the time of the visit were not included in the study .
participants who replied  yes or  only if the patient is someone known to the pharmacist in at least one of the four scenarios were classified as dawmp .
the reproducibility of the questionnaire was assessed using the intraclass correlation coefficient ( icc ) , based on the results obtained for the first and second answers from each pharmacist .
associations between the independent variables and dawmp were modelled by multiple logistic regression . to take into account the distribution of the independent variables , we calculated the interquartile odds ratio ( or ) , which is the effect of the exposure change from the 25th to the 75th percentile .
when the or was < 1 , we calculated the inverse interquartile or ( 1/interquartile or ) , which is the effect when the exposure changes from the 75th to the 25th percentile .
in the pilot study , all scale items had an icc > 0.4 . of the pharmacies visited , 22 ( 12.0% ) refused to participate in the study .
of the 286 pharmacists ( 72.8% ) who completed the questionnaire , 185 stated that they carried out dawmp ( 64.7% ) .
none of their personal and professional traits showed any relationship with dawmp ( table  1 ) .
table  2 shows the degree of agreement with the attitudes and their influence on dawmp .
the changes in exposure from the 25th to the 75th percentile increased the probability of dawmp by 14% ( 95% ci 1%30% ) for insufficient knowledge , 119% ( 95% ci 42%236% ) for external responsibility ( health system ) , 46% ( 95% ci 11%92% ) for indifference and 484% ( 95% ci 235%915% ) for complacency . in the case of external responsibility ( investigation ) , a change from the 75th to the 25th percentile in the assessment of this opinion would mean an 80% increase ( 95% ci 19%170% ) in the probability of dawmp . 

table  1.influence of personal and professional traits on dawmptraitsdawmp , n ( % ) analysisnoyesor ( 95% ci)pgender  female79 ( 78.2)145 ( 78.4)1.00  male20 ( 19.8)35 ( 18.9)1.01 ( 0.482.14)0.974  md2 ( 2.0)5 ( 2.7)age ( years )  < 3927 ( 26.7)58 ( 31.4)1.00  394834 ( 33.7)55 ( 29.7)0.70 ( 0.222.25)0.546  > 4827 ( 26.7)60 ( 32.4)0.81 ( 0.312.16)0.680  md13 ( 12.9)12 ( 6.5)work status  owner56 ( 55.4)86 ( 46.5)1.00  staff43 ( 42.6)98 ( 53.0)0.85 ( 0.421.71)0.639  md2 ( 2.0)1 ( 0.5)population  rural47 ( 46.5)89 ( 48.1)1.00  semi - rural20 ( 19.8)29 ( 15.7)0.67 ( 0.311.43)0.298  urban32 ( 31.7)65 ( 35.1)0.69 ( 0.271.78)0.444  md2 ( 2.0)2 ( 1.1)years of experience as community pharmacist  < 1128 ( 27.7)58 ( 31.4)1.00  112038 ( 37.6)67 ( 36.2)0.99 ( 0.293.42)0.989  > 2026 ( 25.7)49 ( 26.5)0.83 ( 0.312.21)0.705  md9 ( 8.9)11 ( 5.9)medication dispensed per day  < 8021 ( 20.8)56 ( 30.3)1.00  8015039 ( 38.6)74 ( 40.0)1.11 ( 0.413.06)0.837  > 15015 ( 14.9)33 ( 17.8)0.82 ( 0.351.94)0.658  md26 ( 25.7)22 ( 11.9)antibiotics dispensed per day  < 524 ( 23.8)54 ( 29.2)1.00  51035 ( 34.7)88 ( 47.6)1.40 ( 0.464.28)0.554  > 1014 ( 13.9)23 ( 12.4)1.74 ( 0.724.20)0.220  md28 ( 27.7)20 ( 10.8)md , missing data.adjusted for the effects of the other variables included in the table.categorized by tertiles of the total sample . 
 table  2.influence of attitudes to and opinions about dawmpattitudespercentilesor ( 95% ci)interquartile or ( 95% ci)inverse interquartile or ( 95% ci)p255075(1 ) antibiotic resistance is an important public health issue.9.010.010.01.14 ( 1.011.30)1.14 ( 1.011.30)0.041(2 ) the fact that an antibiotic is prescribed to a patient will not influence the appearance of resistance.1.03.87.50.96 ( 0.891.02)1.35 ( 0.862.13)0.193(3 ) the prescription of antibiotics is less strict under private insurance than under the galician health service ( servizo galego de sade  sergas).0.52.05.51.17 ( 1.071.27)2.19 ( 1.423.36)<0.001(4 ) when dispensing antibiotics , i warn the patient about the importance of correct therapeutic compliance.10.010.010.00.94 ( 0.711.27)1.00 ( 1.001.00)0.711(5 ) when dispensing , possible interactions between the antibiotic and other drugs that the patient is taking should be evaluated.9.510.010.01.00 ( 0.831.21)0.988(6 ) antibiotics are sometimes dispensed without medical prescription because the patient is known to have difficulty in gaining access to a doctor.0.94.57.01.33 ( 1.221.46)5.84 ( 3.3510.15)<0.001(7 ) the main cause of the appearance of antibiotic resistance is inappropriate use by patients.8.09.510.00.98 ( 0.891.08)1.04 ( 0.851.27)0.693(8 ) the wrong antibiotic is sometimes knowingly dispensed by pharmacists because there is no time to explain why it is not the correct one.0.51.03.31.15 ( 1.041.27)1.46 ( 1.111.92)0.007(9 ) i am convinced that new antibiotics will be developed to solve the resistance issue.4.95.59.50.88 ( 0.810.96)1.80 ( 1.192.70)0.005(10 ) the use of antibiotics on animals is an important cause of the appearance of new resistance.5.07.510.01.04 ( 0.951.13)1.20 ( 0.791.83)0.381(11 ) if patients feel that they need an antibiotic and it is not dispensed , they will try to obtain it at another pharmacy.2.55.59.51.17 ( 1.091.26)3.04 ( 1.825.10)<0.001(12 ) the phenomenon of resistance to antibiotics is mainly a problem in hospital settings.1.02.55.81.06 ( 0.981.15)1.32 ( 0.921.92)0.132insufficient knowledge.external responsibility.complacency.indifference .
influence of personal and professional traits on dawmp adjusted for the effects of the other variables included in the table
the results of this study indicate that pharmacists ' knowledge and attitudes are strongly associated with dawmp .
indifference , complacency , external responsibility and insufficient knowledge have all been identified as attitudes that increase the risk of dawmp .
since attitudes are potentially modifiable , these results would indicate that educational strategies specifically aimed at changing certain attitudes could substantially improve antibiotic dispensing .
our data confirm that the sale by pharmacies of antibiotics without a medical prescription continues to be widespread in spain , since over 60% of the pharmacists in our study acknowledged the practice .
one possibility is that pharmacists feel competent to undertake dawmp , particularly in the case of minor infections .
our results indicate a much greater propensity to dispense in the case of urinary and dental infections than in the case of respiratory infections .
some authors have shown their agreement with the dispensing of antibiotics over the counter in cases such as minor urinary infections , although this is controversial .
when we performed a second analysis excluding dispensing for minor urinary infections , the influence of attitudes on dispensing habits was unchanged ( data not shown ) .
when the pharmacist knew the patient ( complacency ) , this increased the probability of dawmp , which is consistent with another study conducted in the same setting .
some pharmacists explain this practice by saying that they have regular customers and are familiar with their clinical history .
since income depends on sales , this behaviour could nevertheless be motivated by the fear of losing a regular customer .
moreover , pharmacists who believe that patient would find the antibiotic at some other pharmacy increase the probability of dawmp , probably to foster customer loyalty or for fear of losing the sale . another factor that might influence dawmp is the pressure exerted by patients to obtain an antibiotic .
medical prescribing is influenced by patients ' expectations , and a similar pattern of behaviour could well arise in the dispensing process , particularly in countries like spain where patients are more prone to use antibiotics even for treating minor complaints and/or viral illnesses .
this paradoxical effect can be explained because they give more importance to immediate efficacy or patient satisfaction ( an individual point of view ) over potential long - term antibiotic resistance in the population ( a collective point of view ) . 

responsibility to other professionals ( other pharmacists / medical staff , patients , the healthcare system or the use of antibiotics in animals ) is another attitude associated with dawmp and is common among health professionals .
a possible limitation of this study is bias caused by those who did not respond .
however , the level of participation was very high , to the extent of being one of the highest for this type of study ( 72.8% ) .
another possible limitation is that the percentage of pharmacists who acknowledged dawmp might be underestimated .
such an acknowledgement could indicate that professionals placed trust in the anonymity of the questionnaire , presumably because it had been issued by an academic institution .
another possible study limitation was the difficulty of assessing the validity criterion , since there is no reference method for measuring attitudes .
however , the fact that knowledge and attitudes can discriminate between dispensing antibiotics with and without a prescription , supports the construct validity of these statements
. the results of this study may not be applicable in environments where the legislative framework regarding dawmp is stricter , as in the case of northern europe and north america .
the results of this study could be used to design interventions to improve antibiotic dispensing .
these interventions could emphasize : ( i ) the high level of dawmp ( responsibility ) ; ( ii ) the importance of resistance and its association with antibiotic use in outpatients ( insufficient knowledge and indifference ) ; and ( iii ) pharmacist - patient communication through health education ( complacency ) .
the results of this study could be used to design interventions to improve antibiotic dispensing .
these interventions could emphasize : ( i ) the high level of dawmp ( responsibility ) ; ( ii ) the importance of resistance and its association with antibiotic use in outpatients ( insufficient knowledge and indifference ) ; and ( iii ) pharmacist - patient communication through health education ( complacency ) .
this work was supported by health research fund ( fondo de investigacin sanitaria ) grants ( pi 081239 , pi09/90609 ) from the spanish ministry of health .
a. f. and p. l .- v . designed the study , and a. f. , p. l .- v .
data collection was carried out by m. z .- c . , who also undertook database management and statistical analysis .
the text was drafted by m. z .- c . and a. f. , and discussed in depth by m. z .- c . , a. f. , c. g .-
a. f. and p. l .- v . designed the study , and a. f. , p. l .- v .
data collection was carried out by m. z .- c . , who also undertook database management and statistical analysis .
the text was drafted by m. z .- c . and a. f. , and discussed in depth by m. z .- c . , a. f. , c. g .-
 objectivesantibiotic resistance is a major public health concern and is greatly exacerbated by inappropriate antibiotic use at a community level . 
 the aim of this study was to ascertain which attitudes of community pharmacists were related to inappropriate antibiotic dispensing.methodswe conducted a cross - sectional study of community pharmacists in a region situated in northern spain ( n  =  393 ) . 
 personal interviews were conducted using a self - administered questionnaire . 
 the degree of agreement with each item of knowledge and attitude was measured using an unnumbered , horizontal visual analogue scale , with replies being scored from 0 ( total disagreement ) to 10 ( total agreement ) . 
 the data were analysed using logistic regression.resultsof the total of 286 pharmacists ( 72.8% ) who completed the questionnaire , 185 ( 64.7% ) acknowledged having undertaken dispensing of antibiotics without a medical prescription ( dawmp ) . 
 attitudes such as patient complacency , external responsibility , indifference and insufficient knowledge were shown to be related to dawmp . 
 in contrast , no association was found with any of the pharmacists ' personal or professional traits.conclusionsthis study confirms that , albeit unlawful , dawmp is a common practice in spanish pharmacies . 
 dawmp was seen to be usually associated with some of the attitudes evaluated . 
Introduction
Methods
Ethics statement
Study setting and population
Measures
Questionnaire design, validity and reliability
Procedure
Definition of variables
Statistical analysis
Results
Discussion
Conclusions
Funding
Transparency declarations
Author contributions
Supplementary data