Influences on use of antibiotics without prescription in low- and middle-income countries: a qualitative evidence synthesis

Problem

Self-medication with antibiotics is common practice in many Low- and Middle-Income Counties (LMIC). These antibiotics are bought over the counter, without prescription, from retail pharmacies or drug sellers. This persists despite improved regulatory frameworks to control access that have been implemented in most LMIC over the last decade, since antibiotic resistance became recognised as a global threat. A better understanding of what continues to drive self-medication practices in LMIC is needed. This review synthesised the qualitative evidence on influences on perceptions and practices in relation to self-medication with antibiotics in LMIC.

Approach

A systematic search was conducted of relevant medical, international and social science databases including MEDLINE, CINHAL, EMBASE, WHOLIS, GIM, LILACS, and Anthropology Plus. Searching, screening and data extraction followed standard methods. Quality appraisal was done using Popay’s tool and used to inform the order in which studies were incorporated into the synthesis. A meta–ethnographic approach was used for synthesis, starting with translation of studies and using line of argument approach to develop the final themes.

Findings

The search identified 78 eligible studies with relevant evidence and the synthesis produced six themes. Antibiotics were understood as a powerful, potentially dangerous but effective medicine for treating infections. This perception was strongly influenced by the common experience of being prescribed antibiotics for infections, both individually and collectively. This contributed to an understanding of antibiotics as a rational treatment for infection symptoms that was sanctioned by medical authorities. Public health Antimicrobial Stewardship messaging that emphasised the dangers of antibiotics tended to reinforce the perception of antibiotics as powerful and therefore efficacious. Accessing antibiotics from medical professionals was often difficult logistically and financially. In contrast, antibiotics were readily available over the counter from local outlets. People viewed treating infection symptoms with antibiotics as a rational self-care practice, although they were concerned about the risks to the individual and only took them when they believed they were needed.

Consequences

Primary health care systems need to be strong and well-resourced if regulations to restrict antibiotic access to prescription only are to succeed. Self-medication with antibiotics is strongly influenced by clinical prescribing of antibiotics. Therefore, interventions to reduce overuse of antibiotics in LMIC need to address both clinical practice and community self-medication practices together. There are potential lessons for high income countries, such as the UK, where the pharmacy first initiative has just started. This initiative is designed to both reduce pressures on primary care appointments and increase access to antibiotics for uncomplicated infections. Access is quite strictly controlled but this is major change that will influence public perceptions and practice. Understanding what has happened elsewhere, may help anticipate any unintended consequences.