Pharmacists' and Pharmacy Students' Attitudes and Practices related to Providing Syringes to People who Inject Drugs in Tajikistan Open Access

Abstract

Introduction. In Tajikistan, people who inject drugs (PWID) are disproportionately affected by the HIV and HCV epidemics, and may have limited access to sterile syringes in pharmacies. This dissertation pursues the following Specific Aims: 1) to explore the meanings and processes of stigmatization of and discrimination against PWID; 2) to assess pharmacists' practices, attitudes and associated factors related to the provision of sterile needles and syringes to PWID in Tajikistan; 3) to assess pharmacy students' attitudes and associated factors related to provision of sterile needles and syringes to PWID.

Methods. For Aim 1 we collected qualitative data via one-one-one semi-structured interviews with 28 pharmacists and students in Dushanbe and Kulob cities and analyzed data using thematic analysis methods. Aim 2 and Aim 3 comprised the cross-sectional quantitative components of the study. For Aim 2 we conducted syringe purchase attempts that were linked to survey among the random sample of 232 pharmacists in Dushanbe and Kulob. For Aim 3 we collected data via survey of 240 students of Pharmacy Department of Tajik State Medical University in Dushanbe. We applied structural equation modeling to data collected within Aim 2 and Aim 3 to test theory-driven models explaining pharmacists' syringe sale practices and students' willingness to sell syringes to PWID.

Results. Aim 1. Qualitative analysis results showed that stigma is one of the main drivers of pharmacists' refusal to provide syringes to PWID. Perceiving PWID as sinners, and individuals who destroy their own lives, families and society, pharmacists see provision of syringes as abetting moral transgression and crime. Policy and policing factors also affect pharmacists' willingness to provide syringes.

Aim 2. We found that syringes can be purchased without prescription in the majority (87.9%, n=204) of sampled pharmacies. Agreeing to sell syringes was associated with the reported intent to provide syringes without prescription (ß=0.36, p<0.001), lower stigma against PWID (ß=-0.43, p=0.01), and stronger social conservatism (ß=0.35, p=0.02). Pharmacists' stigmatization of PWID was directly associated with social conservatism (ß=0.47, p<0.001) and inversely with university-level education (ß=-0.28, p<0.001).

Aim 3. Students' willingness to provide syringes positively correlated with favorable attitudes towards provision of syringes to PWID (ß=0.47, p<0.001), and negatively with stigma against PWID (ß=-0.19, p=0.02) and social conservatism (ß=-0.25, p=0.002). Attitudes towards provision of syringes were negatively associated with stigma against PWID (ß=-0.21, p=0.01). Stigma also positively correlated with social conservatism (ß=0.35, p<0.001).

Conclusion: Our study demonstrated availability of over-the-counter syringes in urban pharmacies of Tajikistan and emphasized the role of stigma in shaping pharmacists' syringe sale practices. Future research should focus on developing anti-stigma educational interventions targeting pharmacists and pharmacy students to ensure uninterrupted access of PWID to clean syringes.

Table of Contents

Chapter 1: Introductory Literature Review
Introduction ...........................................................................................................1
Access to Syringes as HIV prevention..........................................................................1
Potential Determinants of PWID Access to Syringes in Pharmacies ..................................2
Gaps in Scientific Knowledge of Pharmacists' Syringe Sale Behaviors ..............................4
Significance of the Research ......................................................................................5
Theoretical framework ..............................................................................................6
Chapter 2: Pharmacists' stigmatization of people who inject drugs (PWID) in

Tajikistan: sociocultural context and implications for promoting prevention services
Abstract ...............................................................................................................12
Introduction ..........................................................................................................14
Methods................................................................................................................18
Results .................................................................................................................20
Discussion .............................................................................................................36
Tables ..................................................................................................................44
References ............................................................................................................45
Chapter 3. Structural equation modelling of pharmacists' attitudes and practices

about selling sterile syringes to people who inject drugs in Tajikistan
Abstract ...............................................................................................................50
Introduction ..........................................................................................................52
Methods................................................................................................................55
Discussion .............................................................................................................68
Tables ..................................................................................................................73
References ............................................................................................................85
Chapter 4. Structural equation modelling of pharmacy students' attitudes related to
providing sterile syringes to people who inject drugs in Tajikistan
Abstract ................................................................................................................91
Introduction .......................................................................................................... 92
Methods................................................................................................................ 94
Results ................................................................................................................ 101
Discussion ............................................................................................................ 103

Tables ................................................................................................................. 108
References ............................................................................................................120
Chapter 5: Summary and Conclusions
Introduction ...........................................................................................................123
Summary of Key Findings..........................................................................................124
Practical Implications................................................................................................129
Strengths and Limitations .........................................................................................130
Directions for Future Research ...................................................................................131
Conclusion .............................................................................................................133
Figures...................................................................................................................134
References .............................................................................................................135

About this Dissertation

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School	Laney Graduate School
Department	Behavioral Sciences and Health Education
Degree	PhD
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health Education, Health Psychology, Behavioral
Keyword	HIV Prevention Tajikistan Injection Drug Use Pharmacy Stigma
Committee Chair / Thesis Advisor	Dunkle, Kristin, South African Medical Research Council Wong, Frank Y, Emory University
Committee Members	Haardoerfer, Regine, Emory University Cooper, Hannah, Emory University Zule, William, RTI International

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