What drives inappropriate use of antibiotics? A mixed methods study from Bahawalpur, Pakistan

Figures & data

Table 1 Demographic characteristics of the respondents

Variables	Respondents n (%)
Age, years (mean age=34.3±13)
18–30	214 (53.5)
31–40	76 (19)
41–50	60 (15)
51–60	30 (7.5)
>60	20 (5)
Education level
Illiterate	51 (12.8)
Primary	78 (19.5)
Secondary	157 (39.3)
University	114 (28.5)
Gender
Male	220 (55)
Female	180 (45)
Monthly family income (Pakistan Rupees)
≤20,000	159 (39.8)
21,000–30,000	83 (20.8)
31,000–40,000	79 (19.8)
41,000–50,000	43 (10.8)
>50,000	36 (9)
Residency
Rural	80 (20)
Urban	320 (80)
Work in health sector
Yes	46 (11.5)
No	354 (88.5)
Purchase of antibiotics
With prescription	281 (70.3)
Without prescription	119 (29.8)
Range of courses of antibiotics per year
Do not use	61 (15.3)
1–3	99 (24.8)
4–6	50 (12.5)
>6	24 (6)
Do not know	166 (41.5)

Table 2 Level of knowledge among study participants

Knowledge level	n (%)
Good	106 (26.5)
Moderate	246 (61.5)
Poor	48 (12)

Note: Scoring assumptions: poor (0–5/15), moderate (6–10/15), good (11–15/15).

Table 3 Predictors of antibiotic knowledge: multiple linear regression analysis

Variables	Beta	SE	P-value
Illiterate	–0.153	0.030	0.007
Primary education	–0.109	0.024	0.044
University education	0.066	0.021	0.224
Urban residency	0.056	0.024	0.300

Note: Model summary: R²=0.048, P<0.0005. P-value of <0.05 was determined to be statistically significant.

Table 4 Attitude toward antibiotic use

Attitude	n (%)
Good	7 (1.8)
Moderate	192 (48)
Poor	201 (50.3)

Note: Scoring assumptions: poor (0–3/8), moderate (4–6/8), good (7–8/8).

Table 5 Predictors of attitude about antibiotic use: multiple linear regression analysis

Variables	Beta	SE	P-value
Illiterate	–0.031	0.232	0.534
University education	0.084	0.169	0.089
Male	0.097	0.148	0.042
Purchase of antibiotics without prescription	–0.182	0.163	<0.0005
Knowledge scorea	0.212	0.033	<0.0005

Note:

a Denotes continuous variable; model summary: R²=0.118, P<0.0005. A P-value of <0.05 was determined to be statistically significant.

Table 6 Questions targeting consumer practices

Statement	Yes	No
Appropriatenessa of anti-infective agent	278 (69.5)	122 (30.5)
Proper dosage regimenb of antibiotics	129 (32.3)	271 (67.8)
Proper dosage form and route of administration	343 (85.8)	57 (14.3)
Ask about side effects from pharmacist at pharmacy	114 (28.5)	286 (71.5)
After taking 2–3 doses you start feeling better.
a) Do you stop taking the antibiotics?	369 (92.3)	31 (7.8)
b) Do you save the remaining antibiotics for the next time you get sick?	322 (80.5)	78 (19.5)
c) Do you discard the remaining antibiotics?	80 (20)	320 (80)
d) Do you give the leftover antibiotics to someone else who is sick?	210 (52.5)	190 (47.5)
You take antibiotics with
a) Water	267 (66.8)	133 (33.2)
b) Juice	6 (1.5)	394 (98.5)
c) Milk	127 (3.8)	273 (96.2)
You take antibiotics
a) Before meals	74 (18.5)	326 (81.5)
b) After meals	326 (81.5)	74 (18.5)
Check the expiry date	131 (32.8)	269 (67.3)

Notes:

a Based on selection of antibiotics for their intended use (British National Formulary, Volume 67, 2014).

b Based on dosage regimen of antibiotics (British National Formulary, Volume 67, 2014).⁴⁵

Table 7 Themes, subthemes, and categories

Themes	Subthemes	Categories
Knowledge	General knowledge about antibiotics	Familiar with the term antibiotics. Low knowledge about the medical conditions to be treated with antibiotics. Unable to differentiate bacterial and viral infections.
	Antibiotic resistance	Not familiar with the term. Inadequate knowledge about antibiotic resistance. Causes of resistance were not completely known.
Attitude	Attitude regarding use of antibiotics	Concept of getting well early by using antibiotics. Thought the medicine was of poor quality in cases of antibiotic ineffectiveness.
Practices	Use of antibiotics	Use of antibiotics was inappropriate. Purchase of antibiotics based on previous antibiotic prescriptions. Use of home stock of antibiotics. Mostly did not complete the duration of therapy. Never followed the prescription strictly. Never reported side effects occurring due to antibiotics.
	Consultation with doctor	Did not consult doctors until condition got worse. Private sector doctors had high consultation fees. Public sector doctors gave short consultation time. Mostly did not follow the instructions given by the doctor.
	Consultation with pharmacist	Most of the pharmacies/medical stores did not have pharmacists. Where community pharmacists are available, people did not ask questions due to lack of awareness about the role of the pharmacist in healthcare system.
Suggestions for the improvement of healthcare system	General population-related	Patients should always consult the doctor for their illness. Antibiotics should be used as prescribed by the doctor.
	Doctor-related	Doctors should prescribe antibiotics based on conditions and avoid over-prescribing of antibiotics.
	Pharmacist-related	Availability of pharmacists at community pharmacies should be assured. Out-dated prescriptions should not be refilled to minimize self-medication.
	Government-related	Improvements in the government hospital system to make this the preferred place to go. Number of doctors should be increased so that doctors can give appropriate consultation time to their patients.

Table 8 Summary of results

What drives inappropriate use of antibiotics?
Quantitative
Knowledge of antibiotics among general public was moderate in nature.
Attitude of general public regarding the use of antibiotics was poor.
Dosage regimen of antibiotics was not appropriate.
Patients ceased antibiotic courses when they felt better, regardless of whether they had completed the course.
Education level and urban residency were significantly associated with antibiotic knowledge.
Antibiotics purchased without a prescription, knowledge score about antibiotics and male gender were the main determinants of attitudes toward antibiotic use.
Qualitative
Familiar with the term “antibiotic” but low knowledge of the medical conditions that can be treated with antibiotics.
Had insufficient knowledge about antibiotic resistance.
Inappropriate use of antibiotics included; lack of consultation with healthcare professionals, purchase of antibiotics without a prescription or with a previous prescription, use of home stock of antibiotics, sharing of antibiotic prescriptions with others and improper dosage regimen.
Low health literacy, high consultation fees of private practitioners, inadequate health facilities in government hospitals and patient overload, busy schedule of people, poor healthcare infrastructure in rural areas and unrestricted supply of antibiotics were the key factors associated with the inappropriate use of antibiotics.
It is expected that doctors would prescribe antibiotics according to condition and avoid over-prescribing of antibiotics.
Availability of a pharmacist at community pharmacies should be assured.
Out-dated prescriptions should not be refilled to minimize self-medication.
Improvement in government sector hospitals was suggested.

Joint Formulary CommitteeBritish National Formulary67LondonBMJ Group and Pharmaceutical Press2014

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