RESEARCH ARTICLE Perspectives of pharmacy staff on dispensing subtherapeutic doses of antibiotics: a theory informed qualitative study Mohamed Ezzat Khamis Amin 1 • Amira Amine 2 • Mohammad Shoukry Newegy 3 Received: 20 March 2017 / Accepted: 10 July 2017 Ó Springer International Publishing AG 2017 Abstract Background Injudicious dispensing of antibi- otics in subtherapeutic doses is common in many devel- oping countries. In Egypt, as in many developing countries, a few pills of common cold products are offered under the name cold group (CG). A cold group may contain one or more pills of antibiotics. A pharmacy client may obtain subtherapeutic doses of antibiotics upon direct request or as part of a CG. Objective To examine factors associated with the unwarranted dispensing of subtherapeutic doses of antibiotics in community pharmacies as part of a CG or upon direct request from patients among community pharmacy staff. Setting Community pharmacy staff in Alexandria, Egypt. Methods Semi-structured interviews were conducted with a purposeful sample of community pharmacy staff. An interview guide was developed based on the theory of planned behavior. Constructs related to attitudes, subjective norm, perceived behavioral control and perceived moral obligation were explored. Directed content analysis was conducted using interview data which were recorded and transcribed verbatim. Main outcome measures Community pharmacy staff’s views on factors associated with the unwarranted dispensing of subthera- peutic doses of antibiotics. Results Nine Pharmacists and six pharmacy assistants were purposively sampled to assure variance in age, gender, time in practice and socioeconomic status of patients served by their corresponding pharmacies. Factors contributing to dispensing antibiotics injudiciously included incorrect beliefs about potential benefit of antibi- otics, profit, client pressure, ease of obtaining antibiotics from other pharmacies, inadequate enforcement of the law, phar- macist absenteeism, and assuming that the ‘nonmalfeasance’ principle is not violated. Reasons for lying to clients about the actual content of CGs included protecting the patient from harm resulting from antibiotic resistance and avoiding a possible argument. Conclusions Examining constructs related to pharmacy staff’s attitude, subjective norm, perceived behavioral control as well as perceived moral obligation provided insight into community pharmacy staff’s behavior related to dispensing subtherapeutic doses of antibiotics. Multi-tiered interventions are urgently needed to tackle dif- ferent factors contributing to this dangerous practice. Keywords Antibiotics Á Antimicrobial resistance Á Drug dispensing Á Egypt Á OTC Á Pharmacy assistant Á Pharmacist Á Theory of planned behavior Impacts on practice • Community pharmacy staff in Egypt are engaged in practices that contribute to the rise of antimicrobial resistance • Multi-tiered interventions should tackle different fac- tors contributing to the injudicious dispensing of antibiotics in subtherapeutic doses • A theory driven approach should be used to evaluate how interventions impact knowledge, attitudes, and behaviors of targeted groups including community pharmacy staff as well as patients & Mohamed Ezzat Khamis Amin mohamedezzat21@gmail.com 1 College of Pharmacy, Natural and Health Sciences, Manchester University, 10627 Diebold Rd., Fort Wayne, IN 46845, USA 2 High Institute of Public Health, Alexandria University, 65 El- Horreya Avenue, Alexandria 21561, Egypt 3 Directorate of Health Affairs, Ministry of Health, 20 Shoukry ElQowatly Street, Matrouh 51511, Egypt 123 Int J Clin Pharm DOI 10.1007/s11096-017-0510-y