Knowledge, Attitudes, and Practices of Community Pharmacy Professionals on Poultry Antibiotic Dispensing, Use, and Bacterial Antimicrobial Resistance in Zambia: Implications on Antibiotic Stewardship and WHO AWaRe Classification of Antibiotics

Round 1

Reviewer 1 Report

The authors have developed and implemented, based on the manuscript, an excellent study, associated with the recognised 'one-health' relationships and between different contextual settings. The background and discussion are excellent, up to date, and all relevant. The scientific of the study design is exceptionally high, for KAP type work, well done.

Always tricky and potentially confusing between the terms of Antimicrobials or antibiotics. Given that most drugs in this context are antibiotics, for bacterial infections, I would prefer the term Antibitiotics, but with a brief note in the introduction that this is just one type of drug for a specific group of microorganisms. The study by Murray 2022 on the global burden, Lancet. used 'bacterial antimicrobial resistance' throughout, which I found helpful. 

Why didn't they stratify by urban/rural? and how was this defined in the reporting of the results? Whilst it was controlled for in the analyses, I think it could have helped with generalisability to have at least a higher proportion of rural, as that is where most small-holdings, in particular, are likely to be based?

How was data on use of abx collected?

Why collect marital status? this seems odd and I can't think of a justification unless it is implicit perhaps that those with a family are more likely to be concerned about this topic

I find the order of presenting the study design, after the results, to be misleading. I suspect this is a journal requirement. However, interpreting results without having assessed a study design is not good science. 

Results, first line, minor typo 'which91(51.1%)'

and again the same typo after Figure one, first sentence

An interesting observation - none employed over the age 50? any comment on this otherwise it possibly might look to a casual reader that you excluded older people too. 

Table 2. First Q. 'I know the withdrawal period of antimicrobial'

- can you clarify, do you mean before resale/slaughter?

Q. Indiscriminate use....Isn't it just the fact that any use, regardless of the reason for their use, that adds to pressures on resistance?

Q. 'Restriction on antimicrobial usage in poultry can be more beneficial than harmfu'l. - this can be true, and it can be false, and really influenced by the farming practice and a host of other factors. I think it is misleading to include or at least make a comment. Q

'Antimicrobial should be sold at a less price when about to expire to prevent wastage. - Ambiguous - if you thought they shouldn't be sold at all, you would select No, but this could then be interpreted in the analyses that you didn't think they should be sold cheaper.

Q 'I ask farmers to increase the dose' - in what circumstances does this apply to?

Para. before heading 4. 'Increasing participants' knowledge through education and training activities on AMU and AMR would, in turn'- to avoid any confusion, change this to 'may be able to have some impact on....'. Also, cross-sectional can't determine if it is the K influencing attitudes/practices, or if it is attitudes influencing their desire to then develop knowledge.

'Nevertheless, this study provides vital information that can lead to developing strategies to restrict the prescribing and dispensing of antibiotics for poultry use'. - I think this is overstated. I would prefer 'that can be used to help develop context-specific strategies more likely to....'.

Conclusion

Further, a need to strengthen the pharmacy training curriculum on poultry diseases and antimicrobial use may improve their practice. - you haven't provided evidence of this - and unclear. Do you mean that given those less than <1 had less positive KAR, it suggests the undergraduate curriculum is weak? or, does it actually suggest that the CPD is strong given that those in service longer are more likely to have been exposed to CPD? 

Finally, I would put a comment that what your study does not include is the reactions/responses from the farmers - maybe they went to another shop to get what they wanted for example. 

I think the paper would benefit from a few sentences about behavior change, as part of the Discussion. Perhaps the model by Mitchie, COM-B, used in a few other Abr studies. 

Well done - interesting to see the next steps

Author Response

Dear reviewer,

Thank you so much for your review comments, they have helped us improve our manuscript. 

Author Response File: Author Response.docx

Reviewer 2 Report

The manuscript aims to give a specific point of view of AMR and AMS in Zambia, surveying pharmacists and pharmacy technologists. 

The manuscript is promising since the abstract. I identified a few typos about double space or missing space between words, but I think that these issues will be highlighted in the proof editing. 

I have a curiosity: why was important for authors to ask to participants if they were married or single? 

Minor revisions:

1) please add an explanation about why veterinarians were not included (I’m waiting to revise the manuscript dealing with the same survey among veterinarians!)

2) Does withdrawal period mandatory or not in Zambia? It is important to explain this and other specific feature about AMR and AMS in Zambia because AMR is different considering geography and also AMS is consequently different. 

3) change $ with "dollar"

Author Response

Dear reviewer,

Thank you very much for your review comments. The comment have helped us to improve our manuscript.

Author Response File: Author Response.docx