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Antibiotic sales in rural and urban pharmacies in northern Vietnam: an observational study
Open accessAbstract
BACKGROUND: The irrational overuse of antibiotics should be minimized as it drives the development of antibiotic resistance, but changing these practices is challenging. A better understanding is needed of practices and economic incentives for antibiotic dispensing in order to design effective interventions to reduce inappropriate antibiotic use. Here we report on both quantitative and qualitative aspects of antibiotic sales in private pharmacies in northern Vietnam. METHOD: A cross-sectional study was conducted in which all drug sales were observed and recorded for three consecutive days at thirty private pharmacies, 15 urban and 15 rural, in the Hanoi region in 2010. The proportion of antibiotics to total drug sales was assessed and the revenue was calculated for rural and urban settings. Pharmacists and drug sellers were interviewed by a semi-structured questionnaire and in-depth interviews to understand the incentive structure of antibiotic dispensing. RESULTS: In total 2953 drug sale transactions (2083 urban and 870 rural) were observed. Antibiotics contributed 24% and 18% to the total revenue of pharmacies in urban and rural, respectively. Most antibiotics were sold without a prescription: 88% in urban and 91% in rural pharmacies. The most frequent reported reason for buying antibiotics was cough in the urban setting (32%) and fever in the rural area (22%). Consumers commonly requested antibiotics without having a prescription: 50% in urban and 28% in rural area. The qualitative data revealed that drug sellers and customer's knowledge of antibiotics and antibiotic resistance were low, particularly in rural area. CONCLUSION: Over the counter sales of antibiotic without a prescription remains a major problem in Vietnam. Suggested areas of improvement are enforcement of regulations and pricing policies and educational programs to increase the knowledge of drug sellers as well as to increase community awareness to reduce demand-side pressure for drug sellers to dispense antibiotics inappropriately.
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“This observation parallels findings by Nga et al in Vietnam, which noted that pharmacies in residential areas were more likely to dispense antibiotics without a prescription than those in rural settings. 19”
From Evaluation of antibiotic dispensing without prescription by community pharmacies: a simulated patient study (2025) · cites this paper as [19]
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“Such inconsistency in dispensing practice will, in the long run, cost those CDROs that are adhering to the ethical and regulatory standards by losing trust of customers and eventually hurting their business [24, 40, 42, 46–49].”
From No prescription? No problem: drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies (2021) · cites this paper as [48]
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“In such environments where customer satisfaction or need is of a central value, most CDRO staff opt to respond to customer’s request and need without properly scrutinising the consequences or repercussion of their actions [24, 39, 40, 42–44, 46–48].”
From No prescription? No problem: drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies (2021) · cites this paper as [48]
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“if they experience poor satisfaction with the services of health facilities in nearby areas (e.g. prolonged waiting time due to the overcrowded services, doctors unable/unwilling to have enough consultation time with patients and less quality service) [40–42, 47–49]”
From No prescription? No problem: drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies (2021) · cites this paper as [48]
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“Nearly all (n = 10) [24, 39–43, 45, 46, 48, 49] met seven or more of the 10 JBI appraisal checklist criteria for qualitative studies.”
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“if they feel like their condition is not severe enough to visit a doctor [48]”
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“In addition, CDRO staff reported lack of knowledge regarding the regulatory frameworks governing antibiotic dispensing and/or being misinformed about these policies (e.g. assuming some types of antibiotics are permitted to be sold as OTC medicines) [48].”
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“This tells us that drivers may not be similar between urban and rural CDROs [48, 75].”
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Citations
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“These include honouring improper prescriptions, such as those that are out of date, and selling POMs without a prescription (Dua et al. 1994; Larsson et al. 2006; Kotwani et al. 2012; Nga et al. 2014).”
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“Dispensing of antibiotics without a medical prescription is a problem in many low-income and middle-income countries, where regulations are either non-existent or insufficiently enforced [13,14].”
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“In a developing country like Vietnam, purchasing and using antibiotics over the counter without prescription is popular, about 90% of antibiotics consumption for human medicine (Thi et al. 2014).”
BackgroundAhiabu, M., Magnussen, P., Bygbjerg, I. C., & Tersbøl, B. P. (2018) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2018.01.013 · Cited by 42
“Similar trends have been found in other developing countries.(67,68) Through the interaction of rural medicine outlet attendants with clients, it was obvious that attendants shared in some community misperceptions about the use of antibiotics and these also explain why attendants agreed to sell quantities less than th…”
ResultHospital-acquired colonization and infections in a Vietnamese intensive care unit
Thuy, D. B., Campbell, J. I., Nhat, L. T. H., Hoàng, N. V. M., Hảo, N. V., Baker, S. G., Geskus, R. B., Thwaites, G. E., Châu, N. V. V., & Thwaites, L. (2018) · PLoS ONE · doi:10.1371/journal.pone.0203600 · Cited by 42
Survey of the pattern of antibiotic dispensing in private pharmacies in Nepal
Nepal, A., Hendrie, D. V., Robinson, S., & Selvey, L. A. (2019) · BMJ Open · doi:10.1136/bmjopen-2019-032422 · Cited by 42
Challenges in the management of community pharmacies in Malaysia
Kho, B. P., Hassali, M. A., Lim, C. J., & Saleem, F. (2017) · Pharmacy Practice · doi:10.18549/pharmpract.2017.02.933 · Cited by 44
“Pharmacists seemed to concede that accommodating customers’ demands is the only pragmatic choice for survival.(37) The widespread nature of this practice in developing countries suggests an inherent systemic flaw in prevailing pharmacy legislations, particularly the lack of dispensing separation.”
BackgroundPokharel, S., Adhikari, B., Johnson, T., & Cheah, P. Y. (2024) · BMJ Global Health · doi:10.1136/bmjgh-2023-012874 · Cited by 44
“40 41 For example, informal stores in Thailand sell unlabelled drug packets called ‘yaa chud’ that contains antimicrobials.”
BackgroundAccess, excess, and ethics—towards a sustainable distribution model for antibiotics
Heyman, G., Cars, O., Bejarano, M.-T., & Peterson, S. (2014) · Upsala Journal of Medical Sciences · doi:10.3109/03009734.2014.904958 · Cited by 40
“Regrettably the Vietnamese DRA is not enforcing existing drug laws, and this practice continues unpunished (16).”
BackgroundInfluentialHanh, N., Ho, D. P., Huong, V. T. L., Tran, K. T., Tran, T. D., Nguyen, T. K. C., van Doorn, H. R., Nadjm, B., Kinsman, J., & Wertheim, H. F. L. (2019) · BMC Public Health · doi:10.1186/s12889-019-7812-z · Cited by 40
“A study conducted in 2010 reported a high proportions of antibiotics being sold without prescription: ~ 90% in both urban and rural pharmacies [8].”
BackgroundResultInfluentialSelf-citationDương, H. A., Phung, T. V., Nguyen, T. N., Thi, L. P., & Viet, P. H. (2021) · Journal of Analytical Methods in Chemistry · doi:10.1155/2021/6631797 · Cited by 40
“In fact, inappropriate use of antibiotics is common practice in many countries consisting of Vietnam where these compounds are easily delivered for self-limiting upper respiratory tract diseases without any prescriptions [46].”
BackgroundDrivers of antibiotic use in Vietnam: implications for designing community interventions
McKinn, S., Trinh, D. H., Drabarek, D., Trieu, T. T., Nguyen, P. T. L., Cao, T. H., Dang, A. D., Nguyen, T. A., Fox, G. J., & Bernays, S. (2021) · BMJ Global Health · doi:10.1136/bmjgh-2021-005875 · Cited by 40
Törümküney, D., Kundu, S., Vu, G. V., Nguyen, H. A., Pham, H. V., Kamble, P., Lan, N. T. H., & Keles, N. (2022) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/dkac214 · Cited by 39
Tran, H. H., Ehsani, S., Shibayama, K., Matsui, M., Suzuki, S., Nguyen, M. B., Tran, D. N. M., Tran, V. P., Tran, D. L., Nguyen, H. T. H., et al. (2015) · European Journal of Clinical Microbiology & Infectious Diseases · doi:10.1007/s10096-015-2345-6 · Cited by 39
“A combination of a high infectious diseases burden, unrestricted access to antibiotics and poor infection control measures contribute to the emergence of antibiotic resistance in Vietnam [9, 10].”
BackgroundSelf-citationGu, B., Zhou, M., Xing, K., Pan, S., Cao, Y., HUANG, Y., Zhuang, L., Liu, G., & Tong, M. (2015) · Epidemiology and Infection · doi:10.1017/s0950268814003446 · Cited by 40
Hoang, P. H., Awasthi, S. P., Nguyen, P., NGUYEN, N. L. H., Nguyen, D. T. A., Le, N. H., Dang, C. V., Hinenoya, A., & Yamasaki, S. (2017) · Journal of Veterinary Medical Science · doi:10.1292/jvms.16-0639 · Cited by 39
“One reason could be due to improper use of antimicrobials for human in Vietnam where antimicrobials can be purchased over the counter without a prescription and there is no sanction for non-compliance of drug law regulations [28].”
BackgroundSelf-citationHoa, N. Q., Lan, P. T., Phuc, H. D., Chúc, N. T. K., & Lundborg, C. S. (2017) · Global Health Action · doi:10.1080/16549716.2017.1327638 · Cited by 38
Self-citationEl-din, M. Z., Samy, F., Mohamed, A. A., Hamdy, F., Yasser, S., & Ehab, M. (2018) · Current Medical Research and Opinion · doi:10.1080/03007995.2018.1544119 · Cited by 38
Community pharmacy staff’s response to symptoms of common infections: a pseudo-patient study
Zawahir, S., Lekamwasam, S., & Aslani, P. (2019) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-019-0510-x · Cited by 38
Genotyping and macrolide-resistant mutation of Bordetella pertussis in East and South-East Asia
Koide, K., Yao, S.-M., Chiang, C., Thuỷ, P. T. B., Nga, D. T. T., Huong, D. T., Điền, T. M., Ork, V., Vutthikol, Y., Sovannara, S., et al. (2022) · Journal of Global Antimicrobial Resistance · doi:10.1016/j.jgar.2022.10.007 · Cited by 35
Self-citationFactors influencing the inappropriate use of antibiotics in the Rupandehi district of Nepal.
Nepal, A., Hendrie, D., Selvey, L., & Robinson, S. (2020) · International Journal of Health Planning and Management · doi:10.1002/hpm.3061 · Cited by 35
Mboya, E. A., Davies, M. L., Horumpende, P. G., & Ngocho, J. S. (2020) · PLoS ONE · doi:10.1371/journal.pone.0239388 · Cited by 35
Wulandari, L. P. L., Khan, M. S., Liverani, M., Ferdiana, A., Mashuri, Y. A., Probandari, A. N., Wibawa, T., Batura, N., Schierhout, G., Kaldor, J. M., et al. (2021) · BMJ Global Health · doi:10.1136/bmjgh-2021-004993 · Cited by 37
Nguyen, N. V., Do, N. T. T., Vu, D. T. V., Greer, R. C., Dittrich, S., Vandendorpe, M., Pham, T. N., Dieu, N. T. T., Thái, P. Q., Khuong, V. T., et al. (2022) · The Lancet Regional Health - Western Pacific · doi:10.1016/j.lanwpc.2022.100611 · Cited by 34
Self-citationLanyero, H., Eriksen, J., Obua, C., Lundborg, C. S., Nanzigu, S., Katureebe, A., Kalyango, J. N., & Ocan, M. (2020) · PLoS ONE · doi:10.1371/journal.pone.0235164 · Cited by 33
The Progress of Global Antimicrobial Resistance Governance and Its Implication to China: A Review
Yin, J., Wang, Y., Xu, X., Liu, Y., Lu, Y., & Sun, Q. (2021) · Antibiotics · doi:10.3390/antibiotics10111356 · Cited by 33
Fosfomycin and nitrofurantoin: classic antibiotics and perspectives
dos Santos, C., dos Santos, L. S., & Franco, O. L. (2021) · The Journal of Antibiotics · doi:10.1038/s41429-021-00444-z · Cited by 34
Bumbangi, F. N., Llarena, A., Skjerve, E., Hang’ombe, B. M., Mpundu, P., Mudenda, S., Mutombo, P. B., & Muma, J. B. (2022) · Microorganisms · doi:10.3390/microorganisms10081684 · Cited by 34
“However, these studies were conducted in rural areas, which could explain their lower reporting rates of AMR as access to and therefore misuse of antibiotics are more prominent in urban areas [54,55].”
BackgroundAziz, M. M., Haider, F., Rasool, M. F., Hashmi, F. K., Bahsir, S., Li, P., Zhao, M., Alshammari, T. M., & Fang, Y. (2021) · Antibiotics · doi:10.3390/antibiotics10050482 · Cited by 31
“However, as recommended in previous research [25,28,32,38], participants in this study suggested adequate training of staff in community pharmacies and structured public awareness campaigns about AMR.”
ResultA qualitative study on community use of antibiotics in Kinshasa, Democratic Republic of Congo
Shembo, A. K. P., Musumari, P. M., Srithanaviboonchai, K., Tangmunkongvorakul, A., & Dalleur, O. (2022) · PLoS ONE · doi:10.1371/journal.pone.0267544 · Cited by 30
“Many studies suggest that the majority of antimicrobial use occurs in the community, where such drugs are readily available and can be obtained even without a prescription [17, 18].”
BackgroundAmoxicillin Quality and Selling Practices in Urban Pharmacies and Drug Stores of Blantyre, Malawi
Chikowe, I., Bliese, S. L., Lucas, S., & Lieberman, M. (2018) · American Journal of Tropical Medicine and Hygiene · doi:10.4269/ajtmh.18-0003 · Cited by 30
Nguyen, K. D., Tran, T. N., Nguyen, M.-L. T., Nguyen, H. A., Nguyen, H. A., Vu, D. H., Nguyen, V.-D., & Bagheri, H. (2018) · Journal of Clinical Pharmacy and Therapeutics · doi:10.1111/jcpt.12754 · Cited by 28
Zawahir, S., Le, H., Nguyen, T. A., Beardsley, J., Duc, A. D., Bernays, S., Viney, K. A., Cao, T. H., McKinn, S., Tran, H. H., et al. (2021) · BMJ Global Health · doi:10.1136/bmjgh-2021-006475 · Cited by 28
“This is important to address, given the considerable TB case-detection gap observed in Vietnam, 19 and highlights the importance of strengthening partnerships between the private and public sectors in order to achieve the WHO End TB targets.”
BackgroundDiwan, V., Sabde, Y., Byström, E., & Costa, A. D. (2015) · The Journal of Infection in Developing Countries · doi:10.3855/jidc.5694 · Cited by 28
Biedenbach, D. J., Giao, P. T., Vân, P. H., Tuyet, N. S. M., Nga, T. T. T., Phuong, D. M., Trung, N. V., & Badal, R. E. (2016) · Clinical Therapeutics · doi:10.1016/j.clinthera.2016.07.172 · Cited by 28
Lubell, Y., Do, N. T. T., Nguyen, K. V., Ta, N. T. D., Tran, N. H. T., Hung, T. M., Hoang, L. B., Shrestha, P., van Doorn, H. R., Nadjm, B., et al. (2018) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-018-0414-1 · Cited by 28
“The vast proportion of antibiotics dispensed for ARI through private pharmacies without prescription in Viet Nam needs to be properly considered [25].”
BackgroundSelf-citationMachado‐Alba, J. E., Valladales‐Restrepo, L. F., Gaviria‐Mendoza, A., Machado‐Duque, M. E., & Figueras, A. (2020) · Antibiotics · doi:10.3390/antibiotics9070389 · Cited by 27
Zawahir, S., Le, H. T. T., Nguyen, T. A., Beardsley, J., Dang, A. D., Bernays, S., Viney, K. A., Cao, T. H., Drabarek, D., Tran, H. H., et al. (2022) · The Lancet Regional Health - Western Pacific · doi:10.1016/j.lanwpc.2022.100447 · Cited by 27
Ghiga, I., & Lundborg, C. S. (2016) · Journal of Pharmaceutical Policy and Practice · doi:10.1186/s40545-016-0061-y · Cited by 27
“From a pharmacist’s point of view, dispensing antibiotics upon request to patients that selfmedicate can be influenced by them knowing the patient –leading to complacency to patient’s request as shown by research conducted in Spain [8] and Portugal [9] or it can be a consequence of insufficient knowledge from the phar…”
BackgroundCortez, J., Rosário, E., Pires, J. E., Taborda Lopes, J., Francisco, M., Vlieghe, E., & Brito, M. (2017) · International Journal of Infectious Diseases · doi:10.1016/j.ijid.2017.05.011 · Cited by 26
“Worldwide, the large majority of antimicrobial use occurs in the community, where such drugs can readily be obtained, even without a prescription (Nga do et al., 2014; Landers et al., 2010; Hoa et al., 2009).”
BackgroundDetection of antibiotics in chicken eggs obtained from supermarkets in Ho Chi Minh City, Vietnam
Yamaguchi, T., Okihashi, M., Harada, K., Konishi, Y., Uchida, K., Ngoc, M. H., Bui, L. T., Nguyen, T. D., Phan, H. B., Bui, H. D. T., et al. (2017) · Journal of Environmental Science and Health Part B · doi:10.1080/03601234.2017.1293457 · Cited by 26
“In addition, the high number of small-scale farms in Vietnam, the lack of information regarding antibiotics and the relative ease of obtaining veterinary drugs from pharmacies [19] further complicate the regulation of residual antibiotics in Vietnam compared with the situation in developed countries.”
ResultWertheim, H. F. L., Chúc, N. T. K., Punpuing, S., Khan, W. A., Gyapong, M., Asante, K. P., Munguambe, K., Gómez-Olivé, F. X., Ariana, P., John-Langba, J., et al. (2017) · Wellcome Open Research · doi:10.12688/wellcomeopenres.11985.1 · Cited by 25
“Ethical statement The protocol was reviewed by the Oxford University Tropical Research Ethics Committee (OxTREC, Reference: 31-15), and the local ethical committees of each participating study site including: (1) Vietnam Ministry of Health (MoH) Institutional Review Board (IRB)(6670/QD-BYT); (2) Institute for Populati…”
MethodSelf-citationTran, H. M., Truong, V. T., Ngo, T. M. N., Bui, Q. P. V., Nguyen, H. C. B., Le, T. T. Q., Mazur, W. M., Chung, E. S., Cafardi, J. M., Pham, K., et al. (2017) · PLoS ONE · doi:10.1371/journal.pone.0189421 · Cited by 25
Cephalosporin‐resistant Escherichia coli isolated from farm workers and pigs in northern Vietnam
Dang, S. T. T., Bortolaia, V., Nhật, T. T., Le, H. Q., & Dalsgaard, A. (2018) · Tropical Medicine & International Health · doi:10.1111/tmi.13054 · Cited by 24
“coli in at least one of three sampling times over a 12-month study period [13] which is a percentage similar to what we observed and which the authors proposed was due to improper use of antimicrobials among people [32].”
ResultTran, D. N. M., Tran, H. H., Matsui, M., Suzuki, M., Suzuki, S., Shibayama, K., Pham, T. D., Phuong, T. T. V., Dang, D. A., Trinh, H. S., et al. (2016) · European Journal of Clinical Microbiology & Infectious Diseases · doi:10.1007/s10096-016-2784-8 · Cited by 23
Self-citationKawaguchi‐Suzuki, M., Hogue, M. D., Khanfar, N. M., Lahoz, M. R., Law, M. G., Parekh, J., Zairina, E., Hong, J., Robles, Y., & Vo, T. V. (2019) · American Journal of Pharmaceutical Education · doi:10.5688/ajpe7215 · Cited by 23
“Many Vietnamese find it cheaper and faster to buy drugs directly from pharmacies than to seek help first from medical practitioners.(54)”
BackgroundTrung, N. V., Nhung, H. N., Carrique-Mas, J. J., Mai, H. H., Tuyen, H. T., Campbell, J. I., Nhung, N. T., Minh, P. V., Wagenaar, J. A., Mai, N. T. N., et al. (2016) · BMC Microbiology · doi:10.1186/s12866-016-0827-z · Cited by 22
Self-citationNagaraj, M. (2015) · JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH · doi:10.7860/jcdr/2015/12940.6119 · Cited by 22
“, showed that frequent reported reason for buying antibiotic was cough in urban setting and fever in the rural setting [7].”
BackgroundAntimicrobial stewardship in private pharmacies in Wakiso district, Uganda: a qualitative study
Musoke, D., Lubega, G. B., Gbadesire, M. S., Boateng, S., Twesigye, B., Gheer, J., Nakachwa, B., Brown, M. O., Brandish, C., Winter, J. A., et al. (2023) · Journal of Pharmaceutical Policy and Practice · doi:10.1186/s40545-023-00659-5 · Cited by 22
“The misuse and overuse of antimicrobials, which is inclusive of self-medication and the dispensing of drugs without a prescription, is a leading driver of AMR in humans [71, 72].”
BackgroundExploring the Socioeconomic Importance of Antimicrobial Use in the Small-Scale Pig Sector in Vietnam
Coyne, L., Benigno, C. C., Giang, V. N., Hương, L. Q., Kalprividh, W., Padungtod, P., Patrick, I., Ngoc, P. T., & Rushton, J. (2020) · Antibiotics · doi:10.3390/antibiotics9060299 · Cited by 21
Nguyen, C. T., Nguyen, H. T., Boyer, L., Auquier, P., Fond, G. B., Khánh, Đ. N., Dang, A. K., Do, H. P., Latkin, C. A., Ho, R., et al. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1176730 · Cited by 21
“Indeed, 91% of antibiotics sold in Vietnam were without a prescription (65), which was even higher than that of countries in Asia such as Thailand (37.”
Background
Metadata
- Authors
- Nga, D. T. T., Chuc, N. T. K., Hoa, N. P., Hoa, N. Q., Nguyen, N. T. T., Loan, H. T., Toan, T. K., Phuc, H. D., Horby, P., Van Yen, N., Van Kinh, N., & Wertheim, H. F.
- Affiliations
- Oxford University Clinical Research Unit (VN)
- Hanoi Medical University (VN)
- Institute of Mathematics (VN)
- University of Oxford (GB)
- Corresponding author
- Nga, Do Thi Thuy
- Nguyen, Nguyen Thi Thuy
- Venue
- BMC Pharmacology and Toxicology
- Published
- 2014-02-20
- Volume
- 15
- Issue
- 1
- Pages
- 6-6
- ISSN
- 2050-6511 (ISSN-L)
- PMC
- PMC3946644
- OpenAlex
- W2164556138
- Cited by
- 228
- References
- 23
- Citations by year
- 2026: 10 · 2025: 13 · 2024: 17 · 2023: 18 · 2022: 28 · 2021: 31 · 2020: 17 · 2019: 26 · 2018: 25 · 2017: 16 · 2016: 15 · 2015: 9 · 2014: 3
- FWCI
- 11.97
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Pharmacology and Toxicology (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Greater South Information System
- Funders
- Wellcome Trust
- Topics
- Health Sciences › Medicine › Infectious Diseases › Antibiotic Use and Resistance
- Health Sciences › Health Professions › Pharmacy › Pharmacy and Medical Practices
- Health Sciences › Nursing › Issues, ethics and legal aspects › Pharmaceutical industry and healthcare
- Keywords
- antibiotic sales, prescription drug sales, inappropriate antibiotic use, antibiotic resistance, private pharmacies, urban-rural differences, Hanoi, Vietnam
- MeSH terms
- Anti-Bacterial Agents, Commerce, Nonprescription Drugs, Health Knowledge, Attitudes, Practice, Pharmacies, Surveys and Questionnaires, Rural Population, Urban Population, Vietnam, Drug Resistance, Bacterial
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