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Community drug retail outlet staff’s knowledge, attitudes and practices towards non-prescription antibiotics use and antibiotic resistance in the Amhara region, Ethiopia with a focus on non-urban towns
Antimicrobial Resistance & Infection Control volume 11, Article number: 64 (2022)
Some evidence suggests that knowledge and attitudes towards rational antibiotic use influences dispensing practice in community drug retail outlets. However, there is limited evidence in resource limited countries, including Ethiopia. We aimed to assess the knowledge and attitudes surrounding antibiotic use or supply and antibiotic resistance, and the non-prescribed antibiotic dispensing practices in community drug retail outlets in non-urban Ethiopia.
We conducted a cross-sectional survey of community drug retail outlet staff in the Amhara region, Ethiopia with a focus on non-urban towns. An expert validated self-administered questionnaire was used. Following exploratory factor analysis and best items selection, we summarised our findings and assessed factors associated with non-prescribed antibiotic dispensing. The data were analysed using Stata Statistical Software version 17. P-values < 0.05 were considered significant.
A total of 276 participants from 270 drug outlets completed the questionnaire. The participants median age was 30 (Interquartile range (IQR) = 25–35) years and 79.7% were pharmacy assistants. The majority demonstrated good levels of knowledge about antibiotic use or supply and antibiotic resistance (77.9% and 76% of the participants responded correctly to more than half of the items, respectively). We identified four attitude domains: the role of antibiotics in recovering from diseases regardless of their cause (median score = 2 (IQR = 2–4), beliefs inconsistent with good practice); professional competency to supply non-prescribed antibiotics, and the non-prescribed antibiotics supply (median score for each domain = 4 (IQR = 4–5), attitudes consistent with good practice); and positive attitudes towards actions to prevent antibiotic resistance and promote appropriate antibiotic use (median score = 4 (IQR = 4–5). Fifty eight percent of the participants reported that they had dispensed antibiotics without a prescription. Participants who did not perceive that they were competent to supply non-prescribed antibiotics (adjusted odds ratio = 0.86, 95% confidence interval = 0.78–0.93) were less likely to report non-prescribed antibiotics dispensing.
While most of the participants had appropriate knowledge about and attitudes to antibiotic use and antibiotic resistance, basic knowledge and attitude gaps remain. Despite Ethiopia’s regulatory restrictions, the non-prescribed antibiotic provision continues to be a common practice. Our study highlights the need for multifaceted interventions that may include a strict regulatory system, staff training and public education.
Antibiotics are the most frequently used medicines, with a 46% increase in consumption worldwide after 2000 by the year 2018 . The World Health Organization (WHO) has classified antibiotics into three categories according to their recommended use: access, watch and reserve, with the latter two categories having a higher potential for developing antibiotic resistance (ABR) . Between 2000 and 2015, there has been a marked increase in the consumption of ‘watch’ antibiotics globally, particularly in low- and middle-income countries (LMICs) . The increase in the consumption of antibiotics is driving an increase in ABR [3, 4], and markedly increases with mis or overuse [5,6,7,8,9]. It has been estimated that around 700,000 people lose their lives globally each year due to ABR infections , with the potential to increase to 10 million deaths by 2050 [10, 11].
Self-treatment with antibiotics has been flagged as one of the most common and obvious contributing factors to antibiotic mis- or overuse. This can result not only in individual harm (e.g., worsening of a health situation due to incorrect self-diagnosis and the wrong choice of therapy, avoidable adverse reactions and wastage of resources or increased healthcare cost), but also increases antibiotic consumption overall [12, 13].
Community drug retail outlets (CDROs) (pharmacies, drug stores/shops, rural drug vendors, and Accredited Drug Dispensing Outlets that sell drugs or medicines) are reported as the principal channel to access antibiotics for self-medication, particularly in LMIC settings including Ethiopia [12, 14, 15]. Despite the legal requirement to dispense antibiotics only with prescription, the non-prescription dispensing of antibiotics continues to be a common practice in LMICs . Two systematic reviews and meta-analyses, one of which was conducted around the world  and the other that was conducted in Sub-Saharan Africa  reported that over 60% of CDROs dispensed antibiotics without a prescription. In this regard, several factors including CDRO staff’s knowledge of and attitudes towards antibiotic use or supply and ABR may explain the dispensing of antibiotics without prescription [18,19,20,21,22,23,24,25].
In Ethiopia, CDROs include pharmacies; which are medicine shops having the mandate to hold a range of medicines; drug stores are medicine shops with a more limited range of medications, and rural drug vendors, usually found in rural areas with an even more limited range of medications. Unlike Accredited Drug Dispensing Outlets in Tanzania which can be supervised by a person who attended a five-week training course [26, 27], the CDROs of Ethiopia are required to be supervised by a pharmacist or pharmacy assistant.
The CDRO dispensing practice in Ethiopia is regulated by the Ethiopian Food and Drug Authority (EFDA). EFDA released a directive in 2019, which clearly states that any dispenser should not dispense prescription only medication without a prescription . The directive also noted that those who contravene the rules will receive sanctions ranging from verbal or written warnings to suspension or revoking of their license . Although the authority prohibits the dispensing of antibiotics without prescription, the non-prescribed antibiotic dispensing was reported by different studies in Ethiopia showing that the regulations are not strongly enforced [29,30,31]. The non-prescribed antibiotic dispensing is believed to be higher in rural areas of Ethiopia as the regulatory system may be absent or less stringent. A recent nationwide study in China found that non-prescribed antibiotics dispensing was more prevalent in rural areas . This suggests that interventional strategies and further research targeting rural areas should be a priority. However, we have not found any previous multicentre studies conducted in rural areas of Ethiopia that confirmed our hypothesis.
This study aimed to assess CDRO staff’s knowledge of and attitudes towards antibiotics use or supply and ABR, and the non-prescribed antibiotic dispensing practices as well as to explore the relationship between knowledge and attitudes and dispensing practice with a focus on non-urban CDROs in the Amhara region, Ethiopia. We anticipate that the evidence generated by this study will inform the regulatory policies and targeted interventions aimed at improving antibiotic use and dispensing behaviour in rural areas in Ethiopia.
Study setting and design
The survey was conducted in the Amhara Regional State, Ethiopia. The Amhara Regional State, is one of the largest and most geographically diverse regions, and is the second most populous region . The region is divided into eleven zones for administrative purposes. Each zone is composed of several woredas; woredas are the third-level of the administrative division of Ethiopia after zones and regions .
A cross-sectional study using a self-administered questionnaire was conducted among CDRO staff in pharmacies, drug stores and rural drug vendors located in the two large provinces or divisions (Gondar and Gojam) in the Amhara region. Gondar and Gojam, which are composed of several zones and woredas, were purposively selected because they are the largest provinces or divisions in the Amhara region both geographically and in population size and have many and diverse CDROs in addition to their convenience for the study.
In Gondar and Gojam excluding the two main cities (Gondar and Bahir-dar), there are 443 CDROs. All CDROs in Gondar except Gondar city, and all CDROs in Gojam (except the city of Bahir-dar) in woredas or towns near to Gondar were invited to participate. Information about the location and number of CDROs available in each woreda or town was obtained from the district health office. The survey covered 45 woredas or towns in total; 23 of which were in Gondar.
The structured questionnaire was developed from those used in previous studies developed from expert validated research instruments [25, 35,36,37]. The face and content validity of the draft survey was assessed by four experts from Australia and Ethiopia (senior pharmacologist, clinical pharmacist, clinician, pharmacist /behavioural science researcher). Questions were modified, added, or deleted to reduce ambiguity.
The questionnaire was pretested in ten purposively selected CDROs in Gondar city to obtain feedback about the questionnaire clarity, comprehension, and time needed to complete all the items. The survey tool, the participant information sheet and consent form were first developed in English, then translated to the local language (Amharic) and back translated to English.
The final version has four sections (Additional file 1): characteristics of CDROs and their CDRO staff, knowledge about antibiotic use or supply and ABR (33 questions); attitudes towards antibiotic use (29 questions); and non-prescribed antibiotic dispensing practice.
All active CDROs in the study towns were visited by trained data collectors who were either pharmacy postgraduate students or recent pharmacy graduates. The field supervisor closely monitored the data collection process in-person.
The questionnaire was provided to consenting participants in their preferred language (Amharic or English). CDRO staff either completed the questionnaire on the spot or arranged for survey collection at a suitable time and day.
The study was approved by the University of Queensland Human Research Ethics Committee (approval number 2020002195), Australia and University of Gondar Institutional Ethical Review Board, Ethiopia (approval number V/P/RCS/05/412/2020). Written consent was obtained from each participant.
Item response coding
The participants response to each item was coded as 0 = no, 1 = unsure, and 2 = yes. In case of negatively quoted questions (where ‘no’ was the correct answer), reverse scoring was used.
These questions used a 5-point Likert scale and each item was coded as 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree. In case of negatively quoted questions where ‘disagree ‘was the appropriate response, reverse scoring was used.
The level of practice assessed on a 5-point Likert scales as 0 = never, 1 = some of the time, 2 = half of the time, 3 = most of the time, 4 = always. Responses other than never were scored as dispensed. The participants response to the item “I dispense antibiotic/s without prescription” was used to score as dispensed or not.
The data were analysed using STATA (StataCorp. 2021.Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC). The data were analysed using descriptive statistics including frequencies and median (inter-quartile range (IQR). The Chi-square test was used to assess the significance of differences in frequencies of practice between characteristics. Correlation coefficients were estimated between the items measuring knowledge and items that were correlated (correlation coefficient ≥ 0.3) and conceptually related items were grouped. The item with the higher correlation coefficient with the other group items was selected as the ‘best items’ that belong to the group; as rule of thumb, if the coefficient was less than 0.3, the item was dropped from the scale . Of the initial 33 items, 18 items were selected as best items measuring knowledge about antibiotics use or supply and ABR.
Exploratory factor analysis (EFA), was used to reduce the attitude items into meaningful factors explaining most of the total variances for the 29 items evaluating attitudes. Before performing the factor analysis, Kaiser–Meyer–Olkin (KMO) test for sampling adequacy and Bartlett’s test of sphericity were used to measure data suitability for factor analysis. KMO of 0.868 and Bartlett’s test of sphericity significance at P < 0.001, suggested that the dataset was suitable. Factors were extracted using principal axis factoring and retained when the eigenvalue was > 1 . Oblimin rotation was used to assess which variables belongs most strongly to each factor. An item was said to load on a factor when the coefficient was ≥ 0.30, otherwise it was dropped from the scale . The weighted factor-based score was created considering the actual reported value and factor loading value . All 29 attitude items were included in the initial EFA. Five items were dropped from the final factor solution as they had a factor loading of < 0.30 or low commonalities . The EFA retained four factors with eigenvalue greater than 1, explaining 98% of the total variance in the observed variables.
The reliability of each construct was computed using Cronbach’s alpha. The Cronbach’s alpha for items assessing knowledge about antibiotics use or supply domain was 0.801, indicating a good level of internal consistency, and was 0.648 for items assessing knowledge about ABR, indicating an acceptable level of internal consistency. The Cronbach’s alpha for items assessing attitudes towards the role of antibiotics in recovering from health conditions regardless of the cause was 0.944; was 0.856 for attitudes towards non-prescription dispensing of antibiotics; was 0.879 for attitudes towards professional competency to supply non-prescribed antibiotics; and was 0.790 for attitudes regarding the actions to prevent ABR and/or promote appropriate use.
In addition, percentages of participants’ response for each item measuring knowledge, attitudes and practices were calculated and presented. The percentages of response were also calculated for each group of items or domain measuring knowledge and attitudes to better interpret the findings.
Binary logistic regression was used to assess the association between variables and self-reported non-prescribed antibiotics dispensing practice. Multicollinearity and linearity of relationship between the continuous independent variables and the logit transformation of dependent variable was checked using the Box-Tidwell transformation test. The variables with a P-value < 0.20 in the univariable analysis were considered potentially confounding. Reverse stepwise regression was employed, and the covariates in the multivariable model were checked as they were eliminated for potential undue influence on the model stability, and model fit statistics (Akaike’s Information Criterion [AIC] and Schwarz’s Bayesian Information Criteria [BIC]). The results were expressed as odds ratios (OR) and 95% confidence intervals (CIs).
Characteristics of the community drug retail outlets (CDROs) and the participating staff
Of the 318 staff within 312 CDROs who were approached, 276 from 270 CDROs participated in the survey (response rate of 86.8%). Two staff members participated from six CDROs.
The median age of the participants was 30 (IQR = 25–35) years, and almost half were aged 20–29 years (49.6%). Most of the participants were pharmacy assistants (79.7%) (Table 1). Drug stores were the commonest 204/270 (75.6%).
Over half (58%) of participants reported that they have dispensed antibiotics without prescription at least some of the time in the past. A significantly higher proportion of participants working in CDROs greater than 1 km of health facilities 43/59 (72.9%) reported dispensing non-prescribed antibiotics compared to those who work in CDROs within 1 km of health facilities 117/217 (53.9%), (x2 (1, N = 276) = 6.847, P = 0.009) (Table 1).
Type of non-prescribed antibiotics most dispensed in the CDROs
One hundred and fifty-three participants named the type of antibiotics most frequently dispensed without prescription in their CDROs. Nearly all 141/153 (92.2%) reported supplying amoxicillin, 68/153 (44.4%) ciprofloxacin and 64/153 (41.8%) cloxacillin without prescription in their CDROs (Additional file 2).
Most common symptoms or disease conditions for which antibiotics were dispensed without prescription
Of the participants who dispensed antibiotics without prescription, 114 reported the main symptoms or disease conditions for which they dispensed antibiotics. The most common condition reported was upper respiratory tract infections (URTIs) 81/114 (71.1%) (Fig. 1).
The items were categorised into two domains according to their conceptual correspondence (Table 2): Knowledge about antibiotics use or supply and knowledge about ABR:
Knowledge about antibiotics use or supply. The percentages of participants who correctly responded to knowledge questions regarding antibiotics use or supply ranged from 51.8% for two questions assessing ‘knowledge about antibiotic use for wound infection and urinary tract infection regardless of the causes’ to 93.8% for the ‘knowledge about antibiotic use as an agent to kill or inhibit the growth of bacteria’. However, nearly half of the participants were unsure or agreed that ‘without taking the cause into account antibiotics can be used for urinary tract infections (48.2%), and wound infections (48.2%)’. Most of the participants (77.9%) responded correctly to more than half of the items, and 64.5% answered correctly to at least 10 of the 14 items.
Knowledge about ABR. The percentages of participants who gave the correct answer to questions assessing knowledge about ABR ranged from 74.6% (assessing knowledge about the role of clients’ self-medication with antibiotics in contributing to the development of ABR) to 82.6% (assessing knowledge about the relationship between incomplete antibiotic course and the development of ABR). Seventy six percent of the participants responded correctly to more than half of the items, 54.7% responded correctly to all items and 4.7% did not respond correctly to any items.
The items were categorised in to four domains (Table 3):
Attitudes towards the role of antibiotics in recovering from health conditions regardless of the cause. The overall median score for this domain was two (IQR = 2–4, out of 1–5 increasing Likert scale), indicating inappropriate attitudes by agreeing with the statement that without taking the cause into account, antibiotics may have a role in recovering from health conditions including acute sore throat (56.9%), acute diarrhoea (54%), common cold and cough (47.5%) and wound infection (65.2%).
Attitudes towards non-prescription dispensing of antibiotics. The majority of the participants disagreed or strongly disagreed with the statements that ‘antibiotics should be dispensed without prescription because: clients may easily obtain a prescription from their doctor (82.2%); the pressure from the CDRO owner to increase sales and profits is high (82.3%), and refusal will affect the CDROs’ sales profit (82.9%). Overall, the median score for the items measuring attitudes towards non-prescription dispensing of antibiotics was four (IQR = 4–5, out of the 1–5 increasing Likert scale), indicating better attitudes of participants in relation to discouraging the non-prescription antibiotic supply.
Attitudes towards professional competency to supply non-prescribed antibiotics. The majority of participants disagreed or strongly disagreed with the statements that antibiotics can be dispensed without prescription because: antibiotics are safe medicines (87%); have no or few side effects (84.1%). The median score for the six items measuring attitudes towards professional competency to supply non-prescribed antibiotics was 4 (IQR = 4–5, out of the 1–5 increasing Likert scale), indicating that the participants did not perceive that they were competent to provide antibiotics without prescription.
Attitudes regarding the actions to prevent ABR and/or promote appropriate use. Most of the participants agreed or strongly agreed with the statement that prohibiting clients’ self-medication with antibiotics prevents the occurrence of ABR (71.8%), and that ensuring proper use of antibiotics is a shared responsibility of healthcare professionals, patients, and policy makers (77.5%). The median score for each of the 5 items in this domain was 4 (IQR = 4–5, out of the 1–5 increasing Likert scale), indicating appropriate attitudes towards the actions to prevent ABR and/or promote appropriate use.
Non-prescription antibiotic dispensing practice
Of the 160 participants who reported dispensing antibiotics without prescription at least some of the time, greater than half 92/160 (57.5%) reported that they have dispensed antibiotics without a prescription up on direct request from a client. Most (74%, 118/160) of these participants reported that they had provided antibiotics without prescription for common cold and cough conditions in the last week (Table 4).
Factors associated with the practice of dispensing non-prescribed antibiotics at least some time in the past
Participants who did not agree with their professional competency to supply non-prescribed antibiotics were less likely to report dispensing antibiotics without prescription than those who feel competent (adjusted odds ratio (aOR) = 0.86, 95% confidence interval (CI) = 0.78–0.93). The univariable models showed a significant association between CDROs’ distance from health facilities (crude odds ratio (cOR) = 0.45, 95% CI = 0.24–0.85) and type of CDRO (cOR = 1.88, 95% CI = 1.05–3.35) and non-prescribed antibiotic dispensing. Other covariates considered in the initial model include knowledge score, employment type and status, licensing status, previous training, gender, workplace distance from the centre of the town, and workplace structure (Table 5).
Although there is a growing body of evidence suggesting that knowledge and attitudes of CDRO staff towards rational antibiotic use influences their dispensing practices, a dearth of evidence exists regarding CDRO staff’s views in non-urban CDROs, where the level of compliance to and enforcement of dispensing-related regulatory policies may be different from urban settings. This is the first multicentre study that explored the knowledge, attitudes, and self-reported practices of CDRO staff with a focus on non-urban areas of Ethiopia.
Most of the participants had satisfactory levels of knowledge about antibiotic use or supply, and ABR. This finding is consistent with other studies conducted in low- and middle-income countries [25, 35, 39,40,41]. We found that nearly half of the participants (44.6%) did not know or were unsure that antibiotics are effective only against bacteria by indicating agreement that antibiotics kill or inhibit the growth of fungus, virus, parasites, and bacteria. This knowledge could be partially explained by the fact that our respondents were predominantly pharmacy assistants (79.7%), with limited training on pharmacotherapy and pharmacology.
Nearly half of the participants agreed with the statements that antibiotics can be used to treat some conditions commonly treated by antibiotics without taking the cause into account. While there are clinical indications where antibiotics are initiated as an empirical therapy to target the most probable causative microorganisms (based on local susceptibility data, available scientific evidence, or expert opinion) , a blanket treatment of all minor ailments or conditions with antibiotics without taking possible or probable causes into account to rule out non-bacterial causes, may contribute towards ABR. The regulation requiring antibiotic access only with prescription may not be practicable to implement in many LMICs [43,44,45] such as Ethiopia because of a scarcity of healthcare facilities (the diagnostic capabilities are widely absent or limited to confirm the presence and type of microbe/s), and most of the population lives in rural areas . In these situations, CDROs may serve as a primary healthcare facility and are a main source of medications [14, 15]. We suggest that CDRO staff be equipped with the necessary knowledge and skills for empirical treatment of common conditions with clear symptoms and/or signs (such as urinary tract infections and wound infections) based on the country’s treatment guidelines at least in rural or remote areas to improve appropriate antibiotic access.
Most participants said they were not competent to supply non-prescribed antibiotics and demonstrated an understanding about appropriate use or supply. Studies conducted in Tanzania, Pakistan, Sri Lanka and Zambia also reported that CDRO staff had appropriate attitudes towards antibiotics use or supply [40, 47, 48], and ABR . In contrast, considerable number of participants agreed that regardless of the causes, antibiotics may have a role for recovering from acute sore throat, diarrhoea, wound infection, uncomplicated urinary infection, common cold and cough. Anecdotal evidence in the study area indicates that this might be partly associated to the existing trend of supplying antibiotics in addition to a standard non-antibiotic treatment with the intention to increase the likelihood of recovery from a certain illness.
Even though it is illegal to dispense antibiotics without prescription, a lot of participants reported doing so. Our finding confirms the common practice of supplying antibiotics without prescription in Sub-Saharan Africa as previously reported . The proportion of participants dispensing without a prescription in our study was lower than in reported studies conducted in Thailand and Tanzania which indicated that 99.6% and 74% of the pharmacists agreed that they dispensed antibiotics without prescription, respectively [35, 40]. In Thailand, the higher proportion might be because the licensed pharmacists are legally allowed to dispense most antibiotics without prescription except few reserve antibiotics .
Our study also found that the distance of CDROs from health facilities may be associated with dispensing without a prescription as CDROs closer to health facilities reported less dispensing. This may be because clients who visit CDROs near to health facilities would be more likely to have prescription available. Absence of health facilities in nearby areas have also been reported by previous studies as a factor for increased non-prescription antibiotics supply by CDROs [50,51,52]. Improving access to health facilities could be one potential strategy to contain the non-prescribed antibiotic supply, particularly in rural areas.
Non-prescribed dispensing of ‘watch’ antibiotics (e.g., ciprofloxacin (44.4%), macrolides (5.9%), and cephalosporins (9.8%)) was reported in our study. This increases the risk of ABR and could also be a great challenge to achieving the WHO target of making at least 60% of the national level total antibiotic consumption to be in the access category by 2023 [2, 3]. Furthermore, almost all the antibiotics reported were broad spectrum antibiotics. This might be because of CDRO staff preference to suggest broad-spectrum antibiotics as they will allow a broader range of pathogens to be covered thereby enhancing the possibility of therapeutic success. However, the use of broad-spectrum antibiotics seriously disturbs the normal intestinal flora, enabling bacterial overgrowth with emergent resistant microorganisms [8, 12, 53,54,55].
Despite the participants generally had good knowledge and appropriate attitudes towards antibiotic use or supply and ABR, knowledge and attitude gaps remain. Educational training programmes have been reported to improve healthcare professionals’ knowledge and attitudes towards antimicrobial stewardship . However, the reported dispensing of antibiotics without prescription may be more likely to be a consequence of overarching health system issues and the business-centred approaches of CDROs rather than being due to knowledge and attitude gaps. Hence, a multi-faceted integrated approach is required to ensure judicious use of antibiotic including enacting new or a stricter enforcement of laws prohibiting the non-prescribed antibiotics supply [57,58,59,60], CDRO staff training about the importance of antimicrobial stewardship , and public education campaigns about the importance of preserving antibiotics [62,63,64].
The following implementation strategies could be beneficial in addressing our recommendations or the situation: capacity building at the regulatory body level such as increasing human resource, which may increase the frequency of CDRO inspections and improve law enforcement. In addition, controlling CDROs’ potential illegal sources of antibiotics through monitoring, and regularly conducting ‘prescription’ audits at the CDROs may facilitate effective tracking of the antibiotic transactions and enhance enforcement of the regulations. Furthermore, using public gatherings such us holidays, social events, or open markets to educate public about the harms of antibiotic over use may reduce community demand for antibiotics. Moreover, given that high profit motive is a reason for the sale of antibiotics without prescription , government subsidisation of CDROs such as with small scale business loans or reducing the cost of some essential drugs, may partly address their commercial interest, while delivering services in the right way. In addition, drug stores should be targeted with antimicrobial stewardship interventions as they are the most prevalent CDROs in most parts of Ethiopia. The regulatory bodies should also randomly visit the CDROs and verify the qualifications of the dispensers, especially those who are working in remote areas.
Strengths and limitations
This was a multi-centre study conducted in highly populated places with CDROs believed to have multiples sources of medications. Thus, the evidence generated through this study would be a crucial input for stakeholders in targeting interventions. The high response rate was also a strength of this study. Our study has some limitations. Social desirability bias in relation to sharing information regarding antibiotic dispensing practice may underestimate antibiotic dispensing without a prescription. To address this, this study will be followed by a simulated client study to observe their practice in their natural working environment. Potential recall bias may be another limitation of the study. Although the CDRO structure is believed to be similar throughout the Amhara region, generalisability of the result to the entire Amhara region needs caution as our sample was not random. To enable a broader and deeper understanding of the CDRO staff dispensing behaviour, our study highlights the need for qualitative research.
The majority of the CDRO staff surveyed had appropriate knowledge about antibiotics use or supply and ABR. Most of the staff also had appropriate attitudes about discouraging non-prescribed antibiotics provision and towards the actions to prevent ABR and/or promote appropriate use. However, there are basic knowledge and attitude gaps that need improvement. Despite the prohibition of the non-prescribed supply of antibiotics in Ethiopia, 58% of CDRO participants reported dispensing antibiotics without prescription. Our study highlights the need for a multi-faceted integrated intervention including enacting new or stricter enforcement of laws governing antibiotic dispensing, CDRO staff training about the importance of antimicrobial stewardship, public education campaigns, and establishing rigorous practice surveillance system.
Availability of data and materials
All relevant data are included in the paper.
Adjusted odds ratio
Community drug retail outlets
Crude odds ratio
Low- and middle-income countries
Stata Statistical Software
Upper respiratory tract infection
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Chang J, Xu S, Zhu S, Li Z, Yu J, Zhang Y, et al. Assessment of non-prescription antibiotic dispensing at community pharmacies in China with simulated clients: a mixed cross-sectional and longitudinal study. Lancet Infect Dis. 2019;19(12):1345–54.
World population review (2021). Based on projections of the latest United Nations data. https://worldpopulationreview.com/countries/ethiopia-population. Accessed 8 Oct 2021.
Federal Ministry of Health, Health Sector Transformation Plan. HSTP 2015/16-2019/20. August; 2015.
Siltrakool B. Assessment of community pharmacists’ knowledge, attitude and practice regarding non-prescription antimicrobial use and resistance in Thailand. 2018.
Hadi MA, Karami NA, Al-Muwalid AS, Al-Otabi A, Al-Subahi E, Bamomen A, et al. Community pharmacists’ knowledge, attitude, and practices towards dispensing antibiotics without prescription (DAwP): a cross-sectional survey in Makkah Province, Saudi Arabia. Int J Infect Dis. 2016;47:95–100.
Zawahir MS. Pharmacists’ provision and public’s use of antibiotics for common infections in Sri Lanka (Doctoral dissertation); 2019.
De Vaus DA. Surveys in Social Research. 6th ed. Abingdon: Routledge; 2014.
Mudenda S, Hankombo M, Saleem Z, Sadiq MJ, Banda M, Munkombwe D et al. Knowledge, Attitude, and Practices of Community Pharmacists on Antibiotic Resistance and Antimicrobial Stewardship in Lusaka, Zambia. medRxiv. 2020.
Poyongo BP, Sangeda RZ. Pharmacists’ knowledge, attitude and practice regarding the dispensing of antibiotics without prescription in Tanzania: an explorative cross-sectional study. Pharmacy. 2020;8(4):238.
Zakaa El-Din M, Samy F, Mohamed A, Hamdy F, Yasser S, Ehab M. Egyptian community pharmacists’ attitudes and practices towards antibiotic dispensing and antibiotic resistance; a cross-sectional survey in Greater Cairo. Curr Med Res Opin. 2019;35(6):939–46.
Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries. A practical toolkit. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.
Afari-Asiedu S, Kinsman J, Boamah-Kaali E, Abdulai MA, Gyapong M, Sankoh O, et al. To sell or not to sell; the differences between regulatory and community demands regarding access to antibiotics in rural Ghana. J Pharm Policy Pract. 2018;11:30.
Afari-Asiedu S, Oppong FB, Tostmann A, Ali Abdulai M, Boamah-Kaali E, Gyaase S, et al. Determinants of inappropriate antibiotics use in rural central ghana using a mixed methods approach. Front Public Health. 2020;8:90.
Nguyen HH, Ho DP, Vu TLH, Tran KT, Tran TD, Nguyen TKC, et al. “I can make more from selling medicine when breaking the rules”—understanding the antibiotic supply network in a rural community in Viet Nam. BMC Public Health. 2019;19(1):1560.
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Khan FU, Khan FU, Hayat K, Ahmad T, Khan A, Chang J, et al. Knowledge, attitude, and practice on antibiotics and its resistance: a two-phase mixed-methods online study among pakistani community pharmacists to promote rational antibiotic use. Int J Environ Res Public Health. 2021;18(3):1320.
Zawahir S, Lekamwasam S, Aslani P. Factors related to antibiotic supply without a prescription for common infections: a cross-sectional national survey in Sri Lanka. Antibiotics (Basel). 2021;10(6):647.
Sommanustweechai A, Chanvatik S, Sermsinsiri V, Sivilaikul S, Patcharanarumol W, Yeung S, et al. Antibiotic distribution channels in Thailand: results of key-informant interviews, reviews of drug regulations and database searches. Bull World Health Organ. 2018;96(2):101–9.
Asghar S, Atif M, Mushtaq I, Malik I, Hayat K, Babar ZU. Factors associated with inappropriate dispensing of antibiotics among non-pharmacist pharmacy workers. Res Social Adm Pharm. 2020;16(6):805–11.
Barker AK, Brown K, Ahsan M, Sengupta S, Safdar N. What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India. BMJ Open. 2017;7(3): e013190.
Salim AM, Elgizoli B. Exploring the reasons why pharmacists dispense antibiotics without prescriptions in Khartoum state. Sudan Int J Pharm Pract. 2017;25(1):59–65.
Ampaire L, Muhindo A, Orikiriza P, Mwanga-Amumpaire J, Bebell L, Boum Y. A review of antimicrobial resistance in East Africa. Afr J Lab Med. 2016;5(1): a432.
Mekuria B, Gebretekle GB, Bekele T, Negussie M, Kifle M, Fenta TG. Bacterial resistance to fluoroquinolones and contributing factors in Addis Ababa, Ethiopia: a mixed methods study. Ethiopian Pharmaceut J. 2018;34(1):61–72.
Workneh M, Katz MJ, Lamorde M, Cosgrove SE, Manabe YC. Antimicrobial resistance of sterile site infections in Sub-Saharan Africa: a systematic review. Open Forum Infect Dis. 2017;4(4):209.
Tahoon MA, Khalil MM, Hammad E, Morad WS, Ezzat S. The effect of educational intervention on healthcare providers’ knowledge, attitude, & practice towards antimicrobial stewardship program at, National Liver Institute, Egypt. Egyptian Liver J. 2020;10(1):1–7.
Apisarnthanarak A, Tunpornchai J, Tanawitt K, Mundy LM. Nonjudicious dispensing of antibiotics by drug stores in Pratumthani, Thailand. Infect Control Hosp Epidemiol. 2008;29(6):572–5.
Park S, Soumerai SB, Adams AS, Finkelstein JA, Jang S, Ross-Degnan D. Antibiotic use following a Korean national policy to prohibit medication dispensing by physicians. Health Policy Plan. 2005;20(5):302–9.
Santa-Ana-Tellez Y, Mantel-Teeuwisse AK, Dreser A, Leufkens HG, Wirtz VJ. Impact of over-the-counter restrictions on antibiotic consumption in Brazil and Mexico. PLoS ONE. 2013;8(10): e75550.
Wirtz VJ, Herrera-Patino JJ, Santa-Ana-Tellez Y, Dreser A, Elseviers M, Vander Stichele RH. Analysing policy interventions to prohibit over-the-counter antibiotic sales in four Latin American countries. Trop Med Int Health. 2013;18(6):665–73.
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Filippini M, Ortiz LG, Masiero G. Assessing the impact of national antibiotic campaigns in Europe. Eur J Health Econ. 2013;14(4):587–99.
Kandeel A, Palms DL, Afifi S, Kandeel Y, Etman A, Hicks LA, et al. An educational intervention to promote appropriate antibiotic use for acute respiratory infections in a district in Egypt- pilot study. BMC Public Health. 2019;19(Suppl 3):498.
Sulis G, Gandra S. Access to antibiotics: not a problem in some LMICs. Lancet Glob Health. 2021;9(5):e561–2.
The authors acknowledge the University of Queensland for supporting SAB through the University of Queensland Research and Training Scholarship scheme. We would like to thank the data collectors for collecting the data and the field supervisor for closely monitoring the data collection process. Also, we are grateful to the CDRO staff for participating in the study.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. SAB was supported by The University of Queensland Research and Training Scholarship.
Ethics approval and consent to participate
The study was approved by the University of Queensland Human Research Ethics Committee (approval number 2020002195), Australia and University of Gondar Institutional Ethical Review Board, Ethiopia (approval number V/P/RCS/05/412/2020).
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Belachew, S.A., Hall, L. & Selvey, L.A. Community drug retail outlet staff’s knowledge, attitudes and practices towards non-prescription antibiotics use and antibiotic resistance in the Amhara region, Ethiopia with a focus on non-urban towns. Antimicrob Resist Infect Control 11, 64 (2022). https://doi.org/10.1186/s13756-022-01102-1
- Antibiotic dispensing
- Community pharmacy


Reports out of China say that Apple completed the third test phase for the new iPhone 7.
New reports out of China repeat earlier rumors that said that the new iPhone 7 is waterproof and dustproof. Apple has according to the reports just completed the third test phase of the new iPhone 7.
Don't Miss: Sam's Club Black Friday 2016 Details
Another feature mentioned in the report is about a redesigned home button. The iPhone 7 would feature a touch sensitive button and not a physical button as found in the current iPhone. This would enable Apple to make the front surface of the iPhone 7 completely flush.
Other rumors said that the backside will also get rid of the protruding camera lens. If these rumors ar true than the iPhone 7 story could be about keeping the overall iPhone 6S look, but feature important changes that make the iPhone more solid and appear as one piece.
A waterproof iPhone is long overdue. Other smartphone makers including Samsung and Sony are already offering waterproof smartphones. If Apple got rid of all surface disturbances on the iPhone, it would make it appear much more sophisticated.
KGI's Apple analyst Ming-Chi Kuo just released a research note that says that the iPhone 7 will not have many attractive selling points. He believes according to AppleInsider that Apple will be the only smartphone vendor from the top 5 to see shipments decline this year.
It feels a bit that Ming-Chi Kuo is on a mission to diminish the iPhone 7. The information about the iPhone 2017 redesign comes mostly from him. Now he calls a sales decline on his predictions of upcoming iPhones.
A completely flush iPhone 7 that is waterproof and dustproof certainly would catch my interest. I am not yet discounting the iPhone 7, despite the rumors about the 2017 iPhone. In 2017 Apple is supposed to adopt OLED screens for the iPhone the first time. The iPhone in 2017 (iPhone 7S or iPhone 8?) will supposedly also feature a new design with front and back made from glass like the iPhone 4.
Buy Now: Sony PlaysStation VR In Stock Here


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Through two weeks of the NFL season there have been many players on fantasy teams who have been huge disappointments for their owners. On this week's show we'll examine these players and see if you are better off with them or without them. I'll also preview this weeks games and their fantasy implications.
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AutoComplete: McLaren's Speedtail is a 250 mph stunner
Here's what's making news on Road Show.
McLaren has been hard at work trying to come up with a worthy successor to the 1994 McLaren F1, considered by many to be the greatest car ever made, and it may have finally succeeded.
The Mclarens Speed tail is a 17 ft long 1000+ horsepower Love Letter to speed built to do in excess of 250 miles per hour, it will cost an excess of 2 million dollars, and only a hundred and six will be built.
Our man Steve [INAUDIBLE] went to the UK to see it and came back almost speechless, so that's got to be a good sign.
GM is proposing a new federal EV mandate that is in direct conflict to the goals put forth by the current presidential administration.
The General wants to see 7 million electric vehicles on the American roads by 2030, a goal which it would achieve by instituting a national zero emissions vehicle mandate, requiring all manufacturers to make 7% of their sales electric vehicles.
In the next two years, kinda like California does already.
Word around the schoolyard is that Toyota is considering resurrecting its midengined MR2 to help round out its performance lineup.
According to a European Toyota exec, the odds of it happening are pretty good.
And that gets us excited, because we could all use a little more affordable midengine mayhem in our lives, don't you think?
Find more of these stories over at theroadshow.com.
We'll talk to you Monday.
Elon Musk and Tesla vs. California's quarantine
Jeep Wrangler rolls during IIHS crash test
You suck at sim racing, so what car games should you play instead?
Tesla's Q1 earnings call was a mess
Is Harley-Davidson's LiveWire worth the money?
$10K quarantine project car challenge: Japanese edition
Oil's basically worthless now, but what does that mean for you?
Vanity plates: Love or hate?
Is the manual sport sedan dead? Cadillac doesn't think so!
AutoComplete decides which old cars deserve a remake


With a hefty 7 band line-up, the Impericon Never Say Die! Tour is back in town and set to get Manchester’s Club Academy basement hotter and louder than ever before.
With the line-up including acts such as Betraying The Martyrs, I Killed The Prom Queen and Emmure (headlining the night) it is set to be a good mix of bands from across the world, and with a packed-out venue and the first band heading to the stage let’s go…
Hand Of Mercy may be the first of seven bands on stage tonight but the crowd is out early and more than willing to get involved. The Sydney five-piece kick the tour off in style and bring to the stage a raw energy that spurs on the fervent crowd even more. Their no holds barred approach sees them throw themselves into the mix with big hitting hardcore anthems such as ‘Last Lights’ and ‘Mr Nasty Time’, with its aggressive unclean vocals and killer riff. They are full on and forceful and a great start to the evening. 7/10
Next up, fellow Sydney metalcore act Northlane take to the Club Academy stage. Frontman Adrian Fitipaldes admits that this is their first time in the UK but there is an excitement and buzz surrounding them. The pit, that was started by openers Hand Of Mercy, is back in even bigger and more violent form as the crowd throw themselves forward at Northlane’s mercy. Crowd favourite ‘Quantum Flux’ with its slow, atmospheric beginnings opens out into a musical juggernaut of hardcore mixed with melodic undertones. A force to be reckoned with. 8/10
Straight out of Myrtle Beach, South Carolina is Hundredeth. The crowd dips in ferocity slightly and isn’t ready to get quite as energetic. However, that isn’t to say Hundredeth’s set isn’t filled with ambitious, fast paced, thrashing big hitters. Raw, brutal and passion-filled tracks such as ‘Weathered Town’ are percussive and stirring, but it is the dynamic and anthemic ‘Free Mind/Open Spirit’ which turns things around and by the end of the set the crowd are won over. Frontman Chadwick Johnson throws himself amongst the crowd and suddenly they are back in the party mix. 7/10
A Parisian flavour is brought to the mix in the form of Betraying The Martyrs. The band makes their way to the stage and, before frontman Aaron Matts has even stepped up the crowd is already throwing themselves over the barrier. The set starts as it means to go on and is high octane from here on in. Betraying The Martrys don’t hold back and step things up on the Never Say Die! 2013 Tour. Inciting a wall of death by the second song, they mean business. Brutal and anthemic, and it didn’t matter that they couldn’t play a new song due to technical issues. Aaron is the perfect frontman, whilst the rest of the band provoke the same grit and energy. As the last notes of ‘Man Made Distaster’ power out, keyboardist Victor Guillet takes an almighty leap off the stage and out into the crowd. Job well done. 9/10
Betraying The Martyrs is a tough act to follow and that job falls to Australian quintet, I Killed The Prom Queen. Coming out strong, they play a mix of older material and throw in a new song or two. The crowd takes a little warming up, seemingly flagging slightly, and it is down to new song ‘To The Wolves’ to reignite the spark. Taken from the forthcoming new album, the brand’s new track is an instant favourite and the anticipation builds for the new release. ‘Sharks in Your Mouth’ closes the set out in style; it’s instantly recognisable riff soaring across the Club Academy. 8/10
|Front-man Jamie Hope in Manchester|
|I Killed The Prom Queen's Jamie Hope|
|Carnifex's Scott Lewis|
Carnifex take to the stage with an almighty energy; the room is sweltering by this point in the evening but they aren’t willing to let people have a rest yet. Commanding horns, circle pits that engulf the entire room and crowdsurfing, they know exactly what they want from a crowd. Classic songs such as ‘Lie To My Face’ incite vicious pits as everyone throws themselves full throttle into the mix. Taking time to debut a new song, ‘Die Without Hope’, leaves the crowd looking a little lost and unsure what to do with themselves. The new offering doesn’t disappoint, the crowd just crave something more familiar to get involved with. ‘Hell Chose Me’ does just this and ends the set in a furor of chaos. Carnifex is the perfect lead up to the headliners of the tour. 7.5/10
It is down to Emmure to headline tonight and finish off the Never Say Die! Tour 2013 in style, and they certainly don’t mess around. Renowned frontman Frankie Palmeri isn’t here to mess around and tonight is all about the music. With six bands having graced the stage before them it would be easy for the crowd to be weary at this point, but not with Emmure up they’re not. Their set is filled with songs from their entire back catalogue, each one proving just as popular with the rowdy audience.
|Carnifex on stage in Manchester|
Having been a band for over a decade, their live show is tight and flawless, yet still has the air of spontaneity as the band parade up and down the stage and crowd surfers appear in abundance. Set highlight has to be crowd favourite ‘MDMA’ and Emmure’s wide range entire headline set proves how their musical style transcends genres and has wide ranging appeal. Quite rightly Emmure command the largest pit of the evening and end the night with ‘When Keeping It Real Goes Wrong’. Worthy headliners. 8/10
With such a high caliber of bands here tonight it definitely upped the ante and ensured that everyone brought their A-game. Seven bands down and we don’t think that the Club Academy basement has been hotter and sweatier. Never Say Die! Tour 2013 done. 8/10


Eight Pakistani nationals on board a boat were arrested with heroin worth around Rs 150 crore off the Gujarat coast in the Arabian Sea early on Thursday morning, the state Anti-Terror Squad said.
Investigation revealed that the contraband, weighing 30 kg, was meant to be transported to Punjab by road after landing on the Gujarat coast via the sea route, the Anti-Terrorist Squad (ATS) said in a release.
Deputy Superintendent of Police, ATS, Bhavesh Rozia had learnt from his sources that a Pakistan-registered boat 'Nooh, carrying heroin, would arrive at the Gujarat coast near Jakhau port of Kutch district during early hours of Thursday, it said.
Based on the tip-off, officials of the Gujarat ATS reached Jakhau and formed a joint team with the Indian Coast Guard.
The team members boarded the Coast Guard's interceptor boat and started patrolling the sea near the International Maritime Boundary Line (IMBL), close to the Jakhau coast late Wednesday night, the Anti-Terror Squad or ATS said.
As per the tip-off, the patrolling team spotted the boat 'Nooh' in the Indian waters, around 40 nautical miles from the Jakhau coast, during early hours of Thursday, it said.
The joint team apprehended eight Pakistani men on board the boat and seized 30 kg of heroin, a psychotropic drug, from their possession, the ATS said.
The value of the seized drug is around Rs 150 crore in the international market, the release said.
The boat carrying the eight Pakistani men was later towed to the Coast Guard station in Jakhau for further investigation into the matter, the ATS said.
(Except for the headline, this story has not been edited by NDTV staff and is published from a syndicated feed.)


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According to a study released March 7, half of San Francisco International Airport's runways could sink underwater by 2100, The New York Times reported.
The study, published in Science Advances by Manoochehr Shirzaei of Arizona State University and Roland Bürgmann of the University of California, Berkeley, reveals that sea level rise poses more of a threat to the Bay Area than previously thought. The reason? A phenomenon known as subsidence, or land sinking.
Shirzaei and Bürgmann found that previous flood-risk maps based on sea-level-rise projections were too conservative because they did not take local land subsidence (LLS) into account. This is a big problem for San Francisco, since parts of its coast lie on top of compacting landfills and mud deposits that are subsiding by a rate of 10 millimeters per year. "The maps estimating 100-year inundation hazards solely based on the projection of sea level rise from various emission scenarios underestimate the area at risk of flooding by 3.7 to 90.9%," they wrote in their abstract.
The report contains revised flood-risk maps that account for the combined impact of LLS and sea level rise (SLR) based on different emissions scenarios.
The map on the right shows the combined impact of LLS and SLR if we meet the goals of the 2015 Paris agreement; the map on the left show revised water levels if no effort is made to reduce carbon dioxide emissions. Science Advances
In addition to the San Francisco airport, Shirzaei and Bürgmann's work revealed that Foster City, Union City and Treasure Island are particularly at risk. Treasure Island has recently been the target of development, and as many as 8,000 homes are set to be built there, California Magazine reported.
Caption: The top row of maps shows how much land could be underwater due to LLS alone by 2100; the middle row shows land threatened by SLR given a business-as-usual emissions scenario; the bottom row shows the combined impact of both. Science Advances
The findings give new urgency to a lawsuit brought by the cities of San Francisco and Oakland against the five largest investor-owned fossil-fuel producing companies, contending the companies understood the link between their activities and man-made climate change, and demanding they foot the bill for seawalls and other infrastructure adjustments.
The study underscores the fact that no matter how green a city attempts to be, it is still at the mercy of global decisions when it comes to climate change, as Oliver Milman pointed out in an article for The Guardian.
"San Francisco can lay claim to being one of the greenest cities in the U.S., through its embrace of clean energy, mandated recycling and banning of single-use plastic bags, yet it faces a steep challenge to avoid the ravages of sea level rise," Milman wrote.
The study also has implications beyond San Francisco, since it suggests other low-lying areas might be in more danger than previously thought if subsidence is taken into account.
"You look at places like Bangladesh, Jakarta—sea level rise is a critical issue," Bürgmann told California Magazine. While the new projections might be scary, they also improve cities' ability to plan for the future. "Our approach allows for refined and accurate assessment, and that can help drive rational responses," Bürgmann said.
EcoWatch Daily Newsletter
By Alina Petre, MS, RD (CA)
Veganism refers to a way of living that attempts to minimize animal exploitation and cruelty. For this reason, vegans aim to exclude all foods containing meat, poultry, fish, eggs, dairy and honey from their diet (1).
'Finally!': Court Orders EPA to Stop Stalling Potential Ban on Pesticide Tied to Brain Damage in Kids
By Jessica Corbett
In a ruling welcomed by public health advocates, a federal court on Friday ordered the Trump administration to stop stalling a potential ban on a pesticide linked to brain damage in children, giving regulators until mid-July to make a final decision.
At EcoWatch, our team knows that changing personal habits and taking actions that contribute to a better planet is an ongoing journey. Earth Day, happening on April 22, is a great reminder for all of us to learn more about the environmental costs of our behaviors like food waste or fast fashion.
To offer readers some inspiration this Earth Day, our team rounded up their top picks for films to watch. So, sit back and take in one of these documentary films this Earth Day. Maybe it will spark a small change you can make in your own life.
By Shuchi Talati
Solar geoengineering describes a set of approaches that would reflect sunlight to cool the planet. The most prevalent of these approaches entails mimicking volcanic eruptions by releasing aerosols (tiny particles) into the upper atmosphere to reduce global temperatures — a method that comes with immense uncertainty and risk. We don't yet know how it will affect regional weather patterns, and in turn its geopolitical consequences. One way we can attempt to understand potential outcomes is through models.
By Julia Conley
Green groups on Saturday celebrated the latest federal ruling aimed at preventing President Donald Trump from rolling back environmental regulations that were put in place by his predecessor.

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Baringo County Government’s approach to the improvement of access to water solutions is multipronged. Our water projects target to reduce distances that our people cover to get clean water, provide sufficient quantities for domestic use and enough to adequately water our livestock within their localities. Wherever possible, we strive to harness water sources to surpass this and provide water for irrigation and industrial use.
Since 2013, over 200 water supply projects have been rolled out, among them 15 government funded bore- holes, 100 gravity systems, 23 water pans, rehabilitation of 61 existing water supply schemes, and pipeline extensions for water projects in 30 wards. These has resulted to increase of access to water from 35% to over 60%,as over 400,000 resi- dents and their livestock are accessing this precious commodity. This translates to an estimated population of 400,000 people getting water.
With the expected completion of second Phases of Kirandich and Chemususu (handed over to the County Government by H.E President Uhuru Kenyatta recently) dams, we expect access-to-water levels to surpass the 80% mark. Each of the two dams has the capacity to supply enough water to support industrial investments in the county.
With support worth KShs 1.3 billion from Japan Government through JICA, we are sinking an additional 100 boreholes which we expect to be fully operational by the end of 2016.
Good progress is therefore being witnessed in ensuring Baringo communities, our various institutions and trading centers are supplied with clean water. The implementation of 13 irrigation scheme projects in the last three years has increased land under irrigation by over 2,000 acres. A number of schemes developed have been the target for expansion as second and third phases with the intention of realizing additional 3000 acres coverage of land under irrigation. This will bring the total land under irrigation to 10,070 acres and place us well on the path to not only being food secure, but also to being a surplus food producing county.

domain: agronomy


text:
Banana Grape Smoothie
1 cup plain yogurt
For better taste, keep the bananas & grapes in a freezer at least 30 minutes before preparation.
Then add the bananas and grapes into a blender
Add yogurt and mix until it is a smooth liquid.
Add the ice and blend until crushed.
Then add milk, until you receive the desired thickness of drink.

domain: food


ASUS Dual-Band AC3100 4x4 Wireless PCIe Adapter PCE-AC88
ASUS PCE-AC88 Wireless NIC PCIe, 1000+2167Mbps, External magnetic antenna base, NitroQAM (1024-QAM) technology, AiRadar
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Date Issued: 20th Oct 2008
Home networking let’s you do great things that aren’t possible with standalone PCs. Printers can be shared between PC, so there’s no need to buy one for each machine.
Date Issued: 19th Jun 2008
WiFi is a wonderful thing. You can take your laptop anywhere in your house and access the Internet, or access your network from the garden. However, it does introduce the grim possibility of somebody else doing exactly the same, without you ever knowing. This guide seeks to make you aware of various security terms and ideas associated with wireless networking and what you should consider when setting up a wireless network.
Date Issued: 26th Oct 2006
As a growing number of homes contain more than one computer, their users must find ways to network them. The primary purpose for creating a home network tends to be to provide Internet access to all computers within the house. There are other good reasons, however. These include enabling LAN gaming, data backups from one machine to another and the sharing of music within the home.


Item cannot be shipped to the following state(s): AK,GU,HI,PR,VI
This exclusive Home Depot Bundle, the QT5680-8B1-1M, is the perfect surveillance solution for home or business. It comes with four hi-resolution 600 TVL cameras and four 450 TVL CCD cameras. Both cameras are weatherproof so regardless of where they are mounted, they are sure to stand guard in almost all weather conditions. The DVR comes with Real Time D1 recording on all channels which ensure a larger, clearer playback and recorded image. Simultaneously record, watch live footage, playback footage, backup files and manage your DVR all from a computer or compatible smart phone/tablet. An HDMI port allows you to run the video feed to a high definition TV for a higher quality image. This DVR also uses H.264 Compression system which results in a smaller file size so you can get even more use out of the pre-installed 1 Terabyte hard drive. The cameras all come with quality infrared LEDs to keep your property safe no matter the time of day. Avoid having to purchase another monitor or occupy your current TV or monitor by connecting the DVR to the included HD monitor. This bundle is literally ready for install and use with all necessary cables, power adaptors and the monitor needed so no need to deal with the hassle of purchasing other components. Set up is easy and your DVR includes Universal Plug and Play (UPnP) to forward ports for a seamless remote monitoring set up. A helpful startup wizard guides you through the set up process as well.


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Tucked away in the surroundings of the medieval village of Megalochóri are the enchanting villas of the Vedema resort. The villas have an authentic, modern feel. The complex is traditionally handcrafted to reflect the warmth and sophistication suitable for the island of Santorini. The interiors are thoughtfully designed by integrating the fresh, angular lines of Cycladic architecture with antique furniture from the island that offers luxurious living space and exclusive artwork.
These villas feature fully equipped kitchens including tableware and dishwasher. Furthermore, room service is available 24/7. Prefer to eat out? Then there are a few options.
Restaurant Alati originated from the 400-year-old wine cellar, made of distinctive stone walls that give the dining house an enchanting atmosphere. Inside or on the terrace, enjoy the creative Mediterranean-inspired menu. The Pergola Pool Restaurant offers you an American buffet breakfast, traditional Greek dishes or Mediterranean barbecues and snacks. Sit by the pool and enjoy an American breakfast buffet, traditional Greek dishes, Mediterranean barbecues and snacks. Or opt for 'Private Dining', upon prior reservation, enjoy five- or seven-course degustation menus that highlight the numerous flavours of Santorini.
Located on the western side of the island of Santorini, the Vedema Resort is surrounded by a traditional stone wall and surrounded by emerald vineyards, in an intimate setting just 7 km from Santorini Airport and 5 km from the port.
The villas are located 7 km from Thira National Airport.
Transfers are available from Thira airport for 65 euros.
There is free parking at the hotel.

domain: design


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I have Borderline Personality Disorder comorbidity with Bipolar II which gives me the ability to use my unpredictable emotions in my art. I also have dyslexia which helps much with my creative nature naturally I am a person of the right side of the brain. My goals for the future would be to keep improving and developing my art skills and become a recognised portrait artist/tattooist. This privilege of being featured on Mental Spaghetti will help to give people the opportunity to view my work and help to reduce the stigma and raise awareness for mental health.”
Art from the Margins has notified me that a panel discussion on the life of Madge Gill has been uploaded to youtube.
“Chaired By David O Flynn from Bethlem Hospital, and featuring Roger Cardinal, the coiner of the term Outsider Art, as well as Vivienne Roberts who researched into the mediumistic side of art for the retrospective. Reflecting on her work is the main focus of the discussion, as well as Outsider Art more broadly.”
“Hello. My name is Edward and I hate myself. Don’t worry, it’s nothing you’ve said or done. I always have done. I always will. I am a hateful person. The fact that other people don’t seem to hate me just makes me hate myself more. Self-loathing is my most loyal lifetime companion.
Sometimes it’s a good thing. Keeps you on the straight and narrow. Makes you respectful and mindful of other people’s feelings. Sometimes it’s the grit in the oyster that makes a pearl. Sometimes it makes me funny, because there’s only so much hatred of yourself you can contain before you have to start radiating it outwards. The other option is that you just let it destroy you. I’m not about to do that. I hate myself too much to let myself off lightly.
I have suffered with depression pretty much my entire adult life, and been treated and medicated for it for much of that time. The current drug that I am on, Sertraline, is very good in many ways. It tackles the anxiety which made me completely unable to function in any way. It’s made me more friendly and open as a result. In short, it’s given me all the tools I need to go the final few yards.
The final few yards are always the hardest, though. My cancerous self-loathing is so malign and insistent that it chewed CBT up and spat it out. It’s not something which wants to be reasoned with by my conscious self.
A lot of people have noted how cutesy, happy and child-friendly my art is. This surprises many people who know me who maybe expect a screaming black hole of darkness. All I can say is, that’s just the way it emerges. Pretty much all of it comes from my subconscious and based on what LOOKS RIGHT to me. I’m not a talented enough artist to make anything do my specific bidding, so it is what it is. I think if you look at a lot of my work again though, and just scratch the surface just right, you can see glimpses of the horrors.
I don’t want to come across like Brian Topp from Spaced, painting fear, terror and loathing. But I know that it must be in there. My art offers me hope too, though, because there’s also much in the way of happiness, positivity and humanity on display as well and that means that that must be in there too.
At the moment, though, I still hate myself. And, for the record, I hate this picture. How do you do?”
If you would like to see more of Edward’s work, please click here.
Currently on at the Mayor Gallery is an exhibition of Sylvia Plath’s black and white illustrations called ‘Her Drawings’. The exhibition features beautiful line drawings of countryside, meticulously detailed scenes of sailing boats and pots and pans as well as pretty little subjects like flowers and conkers.
It is well known that as Plath and Ted Hughes travelled around they both sketched. I’ve seen some of her drawings in biographies and other books but this is the first time the collection of drawings, done whilst on Honeymoon with Hughes in 1956, have ever been shown.
The drawings are all on sale with only 4 of 59 remaining unsold. A friend recently went to the exhibition and made the point that while it is not groundbreaking art, the work is very interesting and important, but more than anything it is your last chance to see the collection before it is sold off to various buyers and split up.
Sylvia Plath would have been 79 this year had she not taken her own life in 1963.
‘Her Drawings’ runs from November 2 until December 16 2011.
“Chato Stewart is a husband, father and mental health advocate. He is an artist and the cartoonist behind the Mental Health Humor cartoons. He creates positive, provoking, and sometimes even funny cartoons! The cartoons are drawn from his personal experience of living with Bipolar Disorder. Mr. Chato Stewart strongly believes that there is power behind humor. His motto is humor gives help, hope and healing. His goal and mission is to tap into humor and use it as a positive tool to cope with the serious and debilitating effects of mental illness.
Chato started blogging in 2008 as part of his Mental Health Humor Project. His cartoons have been used by many in the mental health community. Currently he is blogging on Psych Central Network and BP Hope Magazine offerering his Words of The Wisdomless.
Chato B. Stewart is a Florida board Certified Recovery Peer Specialist – A (CRPS-A) and NAMI member. Chato is also the 1st place winner of the DBSA 2009 Facing Us Video Contest. In his powerful public service announcement, he tells his personal story of living with a mental illness through a montage of his cartoons. Adding to his little list of accomplishments is being part of the 2010 DBSA Stand-Up for Mental Health comedy night and being invited back for the 2011 Conference to be a Stand-Up comic in the show.”
-text taken from www.chatobstewart.com.

domain: artistic


‘Everything comes to an end at some point, I will try to enjoy the last few races’ – Sebastian Vettel
Scuderia Ferrari German driver Sebastian Vettel comments from the press conference ahead of the 2020 Belgian Grand Prix at the Circuit de Spa-Francorchamps:
“I have complete confidence in the guys in my garage and I see it as a sign of respect to give everything I can. We had difficult but also successful moments together. Everything comes to an end at some point. I will try to enjoy the last few races with Ferrari. Seventh place is not what we want to be fighting for, it was a damage control result. In the midfield there is always an exciting battle. I will keep doing my job, I am always optimistic and I see first of all the opportunities, then the problems. – Sebastian explained – ” Everybody likes this track but it’s a bit different this year. What happened last year is still in everyone’s heads… The moment you arrive at the track it’s coming up. Last year to be honest I didn’t want to get back in the car on Sunday morning.”
When asked on his future and how he feels that this might be his last time at the Spa circuit for the time being, Sebastian Vettel said: “I can come here at any time! Whether I am allowed to drive fast with my car, we will see. I think it will not be my last time here.”
When asked about his best memory in Spa: “The track itself has a certain myth and character. I also think I won here, in 2018 and before that, I think in 2013 and 2011, I’m not sure, maybe not in 2011, I can’t remember (haha).” – the German driver added.
The post ‘Everything comes to an end at some point, I will try to enjoy the last few races’ – Sebastian Vettel appeared first on Scuderia Fans.


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Airbnb To Start Taxing Michigan Rentals
If you know of people that use Airbnb or you use it yourself just know there will be an extra charge on it next month. Airbnb has formalized an agreement with Michigan's Department of Treasury to collect the 6% use tax on rentals of 30 days or less.
Based on 2016 numbers, that means at least $1.5 million will funnel from Airbnb customers to the state. According to the Michigan Dept. of Treasury Michigan levies a 6 percent use tax on nightly rental charges when the duration is less than one month.
Bust just know that starting July 1, Airbnb customers booking in Michigan will automatically find the 6% tax when they make the purchase.
You can find out more about it here.


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Hearts and Flowers: Valentine’s Day Nail Art
I heart nail art. And although I'm not a massive celebrator of Valentine's Day, I do enjoy the holiday, because I do a ton of heart and floral designs, which are two of my favorites. For this look, I've combined the two, so every girl can get hearts and flowers for Valentine's Day! Here's how:
1. Paint your nails with your base color. I chose a pinkish red (Parade by Liz Earle) and white (White by Mash) and alternated the polish colors. You can always do this nail art design with just one base color but I think it looks more interesting with two different polish colors.
2. Using a small paintbrush, draw on the hearts in the opposite nail polish color. I like to use a dotting tool or a nail art pen for this step. To draw a pretty heart, try this technique. Draw three dots in a triangle to mark the size and placement. Then start at the top and work your way down to the point, filling in the design.
3. Using a small brush or dotting tool draw 5 small dots for a flower and fill in the middle if necessary. (I used Refresh Mint by China Glaze, Out of the Blue by Nail Art, and Berry Cosmo by Barry M.)
4. Repeat this with your other colors.
5. Using a thin brush, dotting tool or nail art pen, outline your design in black acrylic paint.
6. Seal your design with a Seche Vite topcoat, and your design is done!
Here's a Pin-able version of all the steps with a finished shot, too. Have fun with it!
For more great nail art tutorials and tips from Alice, check out OneNailtoRuleThemAll!


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The Jaguars addressed half of their four targeted needs on the first day of free agency.
Quarterback Cleo Lemon joined wide receiver Jerry Porter in the acquisition category, as Lemon signed a contract Friday to become the Jaguars' new backup quarterback. Quarterback and wide receiver were considered to be two of the Jaguars' four need positions. The other two are defensive end and safety.
"We come into camp with solid depth behind David (Garrard) and we anticipate that Cleo will be the two, and obviously we feel good about the depth there at the quarterback position," head coach Jack Del Rio told reporters on Friday.
Backup quarterback became a role of distinct need when the Jaguars decided to allow last year's backup, Quinn Gray, to enter unrestricted free agency. Veteran Todd Bouman was signed to a contract earlier in the week, and the Jaguars might even select a quarterback in the draft.
"We took a look at the guys that were available, wanted to find a good fit and pursued a couple of guys that elected to either stay where they were or move on with an opportunity to start. We went through our list pretty aggressively; wanted to make sure that we acquired a good solid backup and wanted to make sure we got that handled. We feel like we have," Del Rio said.
Lemon, 28, logged time as a starter last year with the Dolphins. He had seven starts last season and led the Dolphins in passing with 173 completions in 309 pass attempts for 1,773 yards, six touchdowns and six interceptions. Lemon, 6-2, 215, was originally signed as an undrafted free agent by the Ravens out of Arkansas State in 2002.
Meanwhile, veteran defensive tackle Marcus Stroud was busy trying to find a team that might trade with the Jaguars for his services. The Jaguars had given Stroud, who is coming off two seasons that were compromised by an ankle injury, permission to seek a trade.
"Obviously, it's a production-based business," Del Rio said when asked why Stroud is being allowed to seek a trade. "Sometimes an opportunity to reignite, rejuvenate what you're about, what you want to be going forward; sometimes that's necessary. It may not occur. It may be that he's back here. I don't think you can get too far ahead of the story. I think it is what it is. Right now he's a Jaguar and his agent has permission to look for an opportunity, but there's not a fire sale."
Asked about looking for players at other positions of need, Del Rio said: "We've been looking at several positions and a couple of key guys were targeted and in some cases the money has gone through the roof, through the stratosphere and quite a ways up from there.
"We have an interest in certain players at certain positions. Again, you can manufacture; you can't pay a guy to be the next great player at his position and just because you paid him a lot of money he is that guy. Evaluate the talent, assign a value to him, try and operate and negotiate within those values. So, in a couple of cases we find ourselves in that situation where we're looking more toward preparing for the draft and looking for the next wave, the next level of free agents to come on the market," Del Rio added.
Defensive end, of course, is the Jaguars' most intense area of need. It is also the highest-priced position to address in free agency.
"The guys that can rush the passer, the guys that can protect the quarterback, they're premium positions. They always have been. Defensive end, offensive tackle, corner, quarterback; those are premium positions and if you're trying to get talent at those positions in an open market, it can get pretty steep," Del Rio said.
On another front, Del Rio confirmed that talks have begun between the Jaguars and Garrard on a new contract. "Oh, yeah, that's underway," Del Rio added.


“To infinity and beyond” is what 21 kids in grades six through 12 should have shouted Tuesday at Community Park. They raced to each of the planets (and Pluto) in honor of the summer solstice as part of the Mamie Doud Eisenhower Public Library`s teen summer reading program.
The Geocache Planet Race challenged the teens to use a GPS device to find 10 locations, each representing a planet, scattered around the park. After finding 10 clues, they had to answer questions about which planets they had found. They received a point for each correctly answered clue.
“It wasn`t so much reading, but it was definitely learning,” said Gigi Yang, manager of the library`s Young Adult Department. “They had to learn how to use a GPS and how to work together.”
Environmental Systems Research Institute Inc. (ESRI) teamed with the library to put on the program.
Esther Worker, ESRI Denver Education account manager and Broomfield resident, mapped the location of the sun and distance of the planets from the sun in the park with the help of ESRI`s mapping software.
Worker is part of the Education Outreach Program at ESRI that works with libraries and schools to bring spatial literacy — knowledge of GPS, Geological Information System software and remote imaging and sensing — to teens.
“Geocache gives kids the chance to learn how to recognize patterns, distances with a geographic component,” Worker said. “When kids have spatial literacy, they have another way to navigate their world.”
Many of the teens found the Geocache portion of the day interesting and puzzling.
“It required a lot of searching and figuring out the GPS,” said Alex Luberger, 14.
The next part of the program included several games based on the planetary theme. The four teams worked together to learn and play the games. “I liked the water game,” said Paige Lewis, 11, referring to the game called “Filling Earth`s Oceans.”
For the game the teens had to fill a bowl with water, carry it on their heads and bow down to pour the water into a jug. The object, however, was not to fill the jug, but to stay dry. The team member who stayed the driest received the most points.
Another popular game was the “Uranus Spinning Bowl.” This required the teens to spin around 10 times, and then throw a hula-hoop through two cones acting as a goal. Unfortunately the wind was working against some of the teams.
Yang enjoyed the “Mars Rover” game the most. The participants had to ride a small tricycle through an obstacle course and retrieve a lava rock before returning to home base.
“I liked seeing them help each other and cheer each other on,” Yang said.
The teens encouraged one another and learned a little more about their solar system through fun games and the Geocache race.
“We`ve found that students who engage in spatial literacy are better problem solvers and critical thinkers,” Worker said. “And they are more involved in the community because they are learning about all these new things within the community.”


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Arugula, pepita, and Parmesan salad
- 6-8 cups loosely packed arugula (ideally farm-fresh, dirty and spicy, not the prewashed stuff though this is acceptable if you are pressed for time)
- 1/4- 1/2 cup hulled pumpkin seeds (pepitas, with the shell removed)
- shaved Parmesan cheese to taste, about 1/2 cup (good Grana Padano does nicely as well)
- dressing of 1 teaspoon Dijon mustard, 1 teaspoon apple cider vinegar, 2 teaspoons pumpkin seed oil, and 2 teaspoons olive oil
- Salt and pepper to taste
- Wash and dry the arugula well. This may involve soaking it in several changes of water until it runs clear, spinning it dry, and wrapping in in toweling and leaving it in the fridge for a few hours. Or maybe not.
- Toast the pumpkin seeds in a heavy skillet until they swell and pop but do not burn. Put in a dish to cool for a few minutes.
- Shave the Parmesan using a vegetable peeler. This is a great way to use up the cheese next to the rind that is difficult to grate. The rinds themselves should of course be saved and used in vegetarian soups, to which they add a deep umami flavor.
- Put the mustard in a small dish, whisk in the vinegar, and then whisk in the oils. (I used a fork -- I am using whisk hear as a verb without reference to the specific implement.) Dip in a leaf to taste, and whisk in more oil or vinegar as needed.
- Put the arugula in a large salad bowl, add pumpkin seeds and shaved cheese, salt and pepper to taste, and drizzle on the dressing. Toss very well. It may not seem like enough dressing, but it probably is if you have enough room and patience to toss it. If not, add a bit more oil and vinegar, going light on the vinegar.


5G smartphones are in the Indian market for more than a year, and till now, there is no 5G network coverage in India. The first few 5G smartphones were launched back in February 2020 and, those were the flagship smartphones powered by the Snapdragon 865. So, the question arises, are 5G smartphones worth buying? The answer to the question is not as simple as the question is. Certainly, few factors can answer your question.
Availability of the 5G in India
In India, many smartphone companies have already introduced 5G smartphones under various price brackets. But, due to the lack of 5G network availability, it is more like a marketing gimmick rather than a feature. The reason behind the unavailability of the 5G network is the allotment of the 5G bands in India. The 5G bands will be allotted to the cellular carriers after the auctioning of those bands. The auction of the 5G bands will be governed by the Telecom Regulatory Authority of India (TRAI). According to a Parliamentary standing committee report, the 5G spectrum auction is expected to happen in the coming few months and the 5G will be commercially available by late 2021 or early 2022.
Also, it has to be noted that if 5G commercially launched in early 2022 then, it might take another six to ten months for proper functioning and expansion of the 5G network. However, big telecom players like Airtel and Jio made their separate statements on 5G. In Reliance’s Annual General Meeting (AGM), Mukesh Ambani says that their company has developed a complete fifth-generation wireless network solution from scratch. Also, Airtel has already tested 5G in their Hyderabad tech lab.
Compatibility with different 5G bands
Many tech reviewers often use the word futureproof while mentioning any 5G smartphone. The word ‘futureproof’ means the 5G smartphones are ready for the future 5G network rollover. But, it isn’t always true for every 5G mobile. The ability of any 5G mobile to receive a 5G network is determined by the supported bands of that particular frequency. There are a total of 3 frequency ranges that are required for the 5G network, if any smartphone supports all the 3 frequency ranges then, that the particular smartphone is futureproofed.
Must Read: 5 Best Smartphones Under 20000 in 2021
The 3 frequency spectrum for the 5G network is the low Band spectrum that is the sub 1GHz spectrum, the Mid-Band spectrum that is between 1GHz to 6GHz, and finally, the High-Band spectrum that is mmWave. According to some reports, TRAI is planning to auction only the Mid-Band spectrum but, the Indian telecom operators are requesting TRAI to consider the auctioning of the mmWave bands.
In the Indian smartphone market, there are many 5G smartphones, from flagships to mid-range smartphones. These smartphones claimed to be the 5G smartphones but, the truth lies under the hood. Some smartphones support a total of 13 5G bands like the iPhone 12 series, and some smartphones like the OnePlus 9 series that support only 2 mid-band spectrum. Samsung flagships support low-band and mid-band spectrum. Also, some mid-range like the Realme X7 series support a mixture of low-band and mid-band spectrum. To know more about 5G bands refer to Wikipedia.
Longevity of the 5G smartphones
However, the answer to the question “Are 5G Smartphones Worth Buying” is quite controversial. It is to note that many mid-range smartphones tend to perform well for the two to three years of their purchase. The SoC in the mid-range smartphones became slow even for the day-to-day task after a duration of over 2-3 years. However, flagships tend to perform way better than any mid-range smartphones. Due to the powerful SoC of any flagship, the smartphone will perform well for at least a period of 3-4 years. Also, it is to note that flagships like the OnePlus 9 series lack the basic 5G features.
To summarise the answer to the question “Are 5G Smartphones Worth Buying”, we recommend you to choose your 5G device wisely. If you choose a smartphone that lacks particular 5G bands, which may affect the user experience during the rollover of the 5G network. But it is better not to rush for a 5G smartphone without the availability of the 5G network.