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.

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.

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