INVESTIGATING RATIONAL ANTIBIOTIC PRESCRIBING IN PUBLIC HEALTH CARE FACILITIES OF ZANZIBAR TANZANIA
health systems and quality improvement
Quick verdict
Zanzibar antibiotic audit of 3,459 prescriptions shows mixed WHO results; numerical contradictions and an overstated 'irrational' conclusion weaken it.
Summary
This preprint reports a descriptive cross-sectional assessment of rational antibiotic prescribing in all 30 public health facilities of Zanzibar's western urban region, Tanzania. Using WHO/INRUD prescribing indicators, the authors audited 3,459 outpatient prescriptions from 2023 (short of the 4,320 planned) and surveyed 70 conveniently sampled prescribers (91.4% clinical officers) on knowledge, attitudes, and perceptions. Prescriptions averaged 1.1 antibiotics per encounter and 4.8% included injectables, both within WHO thresholds, while generic naming (65.9%) and adherence to Zanzibar Standard Treatment Guidelines (65.7%) fell well short of the 100% targets; 99.9% of encounters documented a diagnosis. Amoxicillin dominated (34.3%), and the authors claim 68.75% of antibiotics were AWaRe 'Access' — a figure inconsistent with their own Table 6 volumes. Prescriber knowledge averaged 6.1 of 8 points; 90% claimed always following guidelines versus 65.7% observed adherence. The conclusion that 'most indicators' miss WHO standards overstates the data, since two indicators met targets. Major limitations: no inferential statistics despite promised chi-square tests, an unreported Cronbach's alpha, unvalidated knowledge/attitude cutoffs, an inconsistently computed 'rational prescribing index,' an unexplained sample shortfall, and verbal-versus-written consent discrepancies. Useful as baseline data for Zanzibar, but the numerical inconsistencies require correction before the conclusions can be trusted.
Review complete
Assessment at a glance
6
risk flags identified
● high 2
● medium 3
● low 1
5 strengths · 5 weaknesses · 5 author questions
AI text signal = Binoculars zero-shot detector score over 20 sampled passages (Fast-DetectGPT co-reported) — absence does not prove human authorship, and a flag does not imply misconduct.
Levels reflect verification complexity — not a quality score. Evolve never rates your paper.
Key claims under review
- Antibiotic prescribing averaged 1.1 antibiotics per encounter with 4.8% injections, meeting WHO thresholds, while generic naming (65.9%) and ZSTG adherence (65.7%) fell short of 100% targets.
- The authors conclude most prescribing indicators missed WHO standards, rendering prescribing 'irrational' — a claim contradicted by their own Tables 7-8, where two indicators met targets.
- Prescribers showed moderate knowledge (mean 6.1 of 8); 24.3% scored low, and 90% self-reported always following guidelines versus 65.7% observed adherence.
- AWaRe 'Access' antibiotics dominated (claimed 68.75%) with no Reserve-class prescribing, led by amoxicillin (34.3% of antibiotic records).
- 98.6% of prescribers request additional antimicrobial stewardship training, framed as the key intervention priority.
Strengths
First Zanzibar-specific baseline
The introduction credibly argues no prior study evaluates antibiotic prescribing in Zanzibar (existing Tanzanian evidence is mainland-based, e.g., Ilala district, ref 28); auditing all 30 public facilities of the western urban region yields a genuinely novel regional baseline for AMR stewardship planning.
Standard WHO/INRUD indicator framework
The five core indicators (Tables 7-8) permit direct comparison with the cited Uganda, Ethiopia and mainland-Tanzania studies; the prescription tables are largely self-consistent — Table 6 sums to 3,761 antibiotic records, reconciling with the reported mean of 1.1 antibiotics/encounter (3,761/3,459 ≈ 1.09), and Table 9 group means reproduce the overall 6.1 knowledge score.
Audit + survey triangulation reveals a bias signal
AWaRe lens with encouraging stewardship signals
Workforce profile for targeting interventions
Weaknesses
Headline conclusion contradicts the authors' own tables
AWaRe percentages do not match the underlying data
No inferential statistics; unvalidated instruments
Sampling and index-construction slippage
Ethics and editorial quality gaps
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Scope & Claims
This medRxiv preprint (posted September 17, 2026; not peer reviewed) reports a descriptive, cross-sectional, retrospective audit of antibiotic prescribing in all 30 public health facilities (8 health centers, 22 dispensaries) of Zanzibar's western urban region, covering outpatient prescriptions from January to December 2023, plus a knowledge-attitude-perception (KAP) survey of 70 prescribers. The authors claim that 'most of the prescribing indicators... did not meet the WHO's standard requirements, thus irrational,' that prescriber knowledge is moderate (mean 6.1/8), and that barriers include guideline adherence gaps and unmet training needs. The stated novelty is credible: the introduction argues, plausibly, that no prior study evaluates antibiotic prescribing specifically in Zanzibar (existing Tanzanian evidence is mainland-based, e.g., Ilala district, ref 28).
The remaining sections cover Methodology Assessment, Statistical Evidence, Results & Reproducibility, Limitations & Risks, and Verdict & Recommendations.
- All 5 strengths & 5 weaknesses, analyzed in detail
- 6 risk flags with severity, section & reviewer questions
- Methods & statistical evidence assessment
- 5 questions a peer reviewer would ask
- Full six-dimension evaluation report & recommendations
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Frequently asked questions
What did the Zanzibar antibiotic prescribing study find?
It audited 3,459 outpatient prescriptions across all 30 public health facilities of Zanzibar's western urban region during 2023. Average antibiotics per encounter (1.1) and injection use (4.8%) met WHO targets, while generic-name prescribing (65.9%) and adherence to Zanzibar's Standard Treatment Guidelines (65.7%) fell well short of the 100% ideal. Amoxicillin was the most used antibiotic (34.3% of antibiotic records).
Is antibiotic prescribing in Zanzibar rational according to WHO standards?
Mixed. Two of the five WHO/INRUD indicators assessed met the standards (1.1 antibiotics per encounter versus a ≤2 threshold; 4.8% injections versus a <25% ceiling), and 99.9% of prescriptions documented a diagnosis. Generic prescribing and guideline adherence, both around 66% versus a 100% target, were the weak points. The authors' own conclusion that most indicators are 'irrational' overstates their tables, which show two indicators performed well.
How many prescribers were surveyed and what did they know?
Seventy prescribers — mostly diploma-level clinical officers (91.4%) — answered a knowledge, attitude and perception questionnaire. The mean knowledge score was 6.1 of 8 points, with 24.3% scoring low. Ninety percent self-reported always following the Zanzibar treatment guidelines and essential medicines list, but the prescription audit observed only 65.7% actual adherence, a gap suggesting social desirability bias.
Are the study's numbers reliable?
The prescription tables are mostly internally consistent (drug counts, district and sex splits all reconcile), but there are real contradictions: the claimed 68.75% AWaRe 'Access' share matches the count of drug types, not prescription volumes (which give about 82%), one computed index does not follow the paper's own formula, a diagnosis percentage appears mistyped, and no statistical tests or reliability coefficients are reported. Treat specific percentages with caution until the authors correct them.
About this review
This is an AI-generated preliminary review by Evolve.Pub, produced from the openly available text of the paper. It is not peer review and does not represent the authors' views. The canonical record of the paper is at the publisher link above.
- medRxiv watermark text interleaves nearly every paragraph of the extraction, and Table 10 appears displaced into the Discussion, so section/table layout may not match the actual PDF.
- The appendices (structured data-collection form, questionnaire items) are absent from the extracted text, so instrument quality can only be judged from the Methods prose.
- Author name spellings differ between metadata (Swalehe) and byline (Swallehe); the review assumes these are the same two persons.
- No figures or appendix tables were analyzable; all checks are arithmetic cross-checks of the reported tables.
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