An assessment of community antibiotic use in six low- and middle-income countries (LMICs) in Asia and Africa indicates that antibiotics are frequently obtained without a prescription, more so in Asia than Africa. Still, access to antibiotics, the situations in which they are used, and reasons for using them without a prescription varies by country.
In a study published last week in The Lancet Global Health, an international team of researchers found that more than a third of individuals and households in Bangladesh, Vietnam, Thailand, Ghana, Mozambique, and South Africa reported obtaining antibiotics without a prescription or self-medicating with antibiotics. Use of antibiotics without a prescription was most widespread in Vietnam and Bangladesh, and antibiotics in general were more widely available in the Asian countries.
While previous research has shown that antibiotics are commonly used without a prescription in LMICs, the results of surveys and interviews conducted by the researchers reveal the diversity and complexity of locally specific factors that affect antibiotic access and use in LMICs. The authors say that findings suggest messages to reduce unnecessary and inappropriate antibiotic use in these countries need to understand these factors and be tailored to different settings.
"There is no 'one-size-fits-all' solution," study co-author Heiman Wertheim, PhD, a professor of clinical microbiology at Radboud University Medical Center, said in a press release.
Antibiotics more widely available in Asian countries
The study, which was led by researchers at the Oxford University Clinical Research Unit in Vietnam and conducted from July 2016 through December 2018, involved in-depth interviews and focus-group discussions with consumers and antibiotic suppliers in urban, rural, and suburban communities in the six countries, along with quantitative longitudinal household surveys. Targeted populations included men and women ages 18 to 60, those over 60, and mothers caring for children under the age of 5. The researchers also mapped all formal and informal antibiotic suppliers in the communities.
The aim was to investigate accessibility to healthcare and antibiotics in the six countries, and understand the socioeconomic and cultural characteristics associated with antibiotic access and use.
Supplier mapping showed that the Asian sites had a higher density of antibiotic suppliers than African sites, with the highest density found in urban Thailand (5 suppliers per 1,000 inhabitants) and the lowest found in rural South Africa (1 per 10,000 inhabitants). Vietnam (65%) and Bangladesh (52%) had the highest proportion of non-licensed antibiotic providers.
Exit interviews with 8,214 customers who bought antibiotics from 140 suppliers showed that 35% had obtained them without a prescription, and that the proportion of antibiotics obtained without a prescription was highest in Vietnam (55.2%), Bangladesh (45.7%), and Ghana (36.1%), but less so in Mozambique (8%), Thailand (3.9%), and South Africa (1.2%).
Surveys of 6,190 households with 25,274 individuals showed that 37% reported self-treatment with antibiotics. In cases of mild illness, drug stores were the predominant first point of contact for household members in Bangladesh (91%) and Vietnam (72.5%), while public healthcare facilities were the primary first point of contact in South Africa (95.1%) and Mozambique (80.9%). In all countries, public healthcare facilities were predominantly chosen for more severe illness.
Convenience, trust cited as factors
The household surveys and focus groups conducted by the research team revealed that for mild illness, most respondents said they chose where to get antibiotics based on the convenience of the location. For many in the Asian countries, pharmacies were the most convenient option.
"If I want to buy a Yaa Chud [a poly-pharmaceutical pack containing antibiotics], I just walk to the grocery nearby," said a 68-year-old woman from Thailand in an interview.
Trust was also a factor in making pharmacies the first choice. "When I have mild symptoms, I always go the drug store first," a 25-year-old Vietnamese woman said in a focus group discussion. "I don't even know the name [of the medications] and their effect because I trust them completely."
In Bangladesh, participants in focus groups reported that public health services are considered low standard, with few types of antibiotic available.
"A common theme was self-treatment being less time consuming, cheaper, and overall more convenient than using public health services," the authors wrote.
In Mozambique and South Africa, however, trust and convenience were cited as the main reasons for choosing public healthcare facilities for antibiotics. Limited access to antibiotics, government policies on antibiotic sales, and availability of free healthcare were also factors in those countries, which may in part explain the low proportion of antibiotics obtained without a prescription.
The household surveys also revealed that misperceptions about antibiotics were common in Bangladesh, Mozambique, and Ghana, especially in regards to what antibiotics do and when they should be taken. And in all sites, suppliers and consumers could not always distinguish antibiotics from other commonly sold medications, like pain relievers, with antibiotics often distinguished by shape and color. There was also limited knowledge of antibiotic resistance and potential adverse effects from antibiotics across all countries.
Analysis of antibiotics consumption using the World Health Organization's AWaRe (Access, Watch, and Reserve) classification system showed that Access-group antibiotics, or antibiotics with the lowest resistance potential, were predominant in all countries except for Bangladesh. There, 74.6% of defined daily doses were for Watch-group antibiotics, which are broader-spectrum drugs that are not recommended for routine use because of their higher potential for resistance.
Different interventions needed
The authors say the findings point to several different interventions that could be pursued. Non-compliance with laws regarding antibiotic sales—found to be widespread in the low-income and lower middle-income countries but not in the two upper middle-income countries, Thailand and South Africa—suggests better enforcement of those laws, using context-adjusted models, could be part of the solution. Clear labelling, so that consumers can distinguish an antibiotic from other commonly sold medications, is another.
And given the role that drug stores were found to play, they also suggest that community pharmacists need to be educated about their role promoting prudent antibiotic use, and empowered to play that role.
"Although prescription-only regulations for antibiotics might not be practical for many LMICs, easy access to antibiotics, particularly to broad-spectrum antibiotics in rural settings in Asia, raises concerns about high levels of antibiotic use outside the formal health-care system and will require interventions that target both the supply and demand sides to reduce inappropriate antibiotic use," they wrote.
The authors also say educational interventions and use of rapid diagnostic tests in the public health system could help improve appropriate antibiotic use in these settings.
The study was funded by the Wellcome Trust and Volkswagen Foundation.
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