Improving antibiotic use in low-income countries: an overview of evidence on determinants

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Abstract

The inappropriate use of antibiotics has often been identified as a problem in effective health care delivery. High levels of antibiotics use, often clinically unnecessary, have led to a steady increase in drug resistance. Low-income countries, home to the majority of the world's population, are believed to have an important role in this phenomena. Effective intervention in these practices is often constrained by the paucity of information on determinants of antibiotic use.

This review provides information from studies on the factors that influence the use of antibiotics by health providers, dispensers and community members in low-income countries. A proper understanding of these factors should be seen as a precondition for the development of more effective policies and programmes to address inappropriate antibiotic use.

The review encompasses physicians’ practices, the role of drug dispensers, and the influences on patterns of drug use across community members. Although a set of papers with useful research data was identified, probably the most important finding of the review was the scarcity of research. If interventions into antibiotic use are to be effective, future research must explore in more depth the socio-cultural rationality of antibiotic usage. The most productive approach would be to combine quantitative studies of the patterns of antibiotic use with the rich variety of qualitative methods like case simulations, focus group discussions, in-depth interviews, informal interviews, or illness diaries to explore determinants.

Research programmes alone are unlikely to improve antibiotic use. Priority programme activities would include a carefully designed mix of activities by governments, health delivery systems, health training institutions, professional societies, pharmaceutical companies, consumer organisations, and international organisations. Strategies that lean too heavily on professional education are unlikely to result in large-scale or long-lasting improvement.

Introduction

Diseases of bacterial origin are a major cause of morbidity and mortality in low-income countries. Many of these conditions can be prevented with improved personal hygiene, immunisation, and environmental sanitation, but antibacterial drugs are still the main therapy for many of them. This key role of antibiotics has led to high levels of consumption and spending for this category of drugs. In low-income countries, antibiotics are available to the public from a variety of sources, including hospitals and pharmacies (Bartoloni et al., 1998; Cohen, 1992); licensed medicine stalls and drugstores (Bartoloni et al., 1998; Calva, 1996); and roadside stalls and hawkers (Bartoloni et al., 1998; Okeke, Lamikanra, & Edelman, 1999). They can be purchased without a prescription in most low-income countries, even when this practice is illegal. This widespread availability has lead to inappropriate use by patients and health care providers, and a steady increase in drug resistance.

Drug use is influenced by cultural preferences and beliefs (Van der Geest, 1987). Antibiotics may even be culturally reinterpreted, or ‘indigenised’ (Haak & Hardon, 1988). People draw these originally ‘foreign’ objects into their own world by clothing them with explanations and meanings from their own culture. Antibiotics do not escape this reality. However, despite these ethnographic accounts of antibiotic use, the factors that determine poor antibiotic usage practices are not yet well understood. Much literature on drug use has been generated in recent years, but most documents go little further than the mere quantitative aspects of antibiotic use (for example, rates, percentages and costs). Similarly, recommendations for improvement go little further than calling for a ‘change of attitude’, training activities to improve inappropriate practices, and implementing national drug policies.

The World Health Organization recently released its Global Strategy for the Containment of Antimicrobial Resistance (WHO, 2001). This document reflects the consensus of experts from industrialised and non-industrialised countries on how to address the growing problem of resistance to antimicrobials. Resistance to first-line drugs is said to ‘cost money, livelihoods, and lives and threatens to undermine the effectiveness of health delivery programmes’, or even pose ‘a threat to global stability and national security’. Non-industrialised countries, home to the majority of the world's population, have an important role in the emergence of global resistance. The Strategy proposes a variety of measures, including reducing the burden of disease and improving access to appropriate antimicrobials. But, as the WHO document asserts, ‘antimicrobial use is influenced by an interplay of the knowledge, expectations and interactions of prescribers and patients, economic incentives, characteristics of the health system(s), and the regulatory environment’. Hence, reducing global antibiotic resistance is as much an issue of behavioural change, as changing health systems and development of new antibiotics. Sadly, this is where the Strategy gives much less guidance.

This study set out to review available reports in the world literature on factors that influence the use of antibiotics by prescribers, dispensers and community members in low-income countries. It analyses available information and recommends changes in health policies of a number of stakeholders. More detailed findings of this study have been described elsewhere (Radyowijati & Haak, 2001).

This report has to be seen against a background of antibiotics often being perceived as ‘strong’ medicine: capable of curing almost any kind of disease. Perceived effectiveness of antibiotics can even reach magic proportions. When asked an opinion about the popular antibiotic Ambra-Sinto® (Tetracycline-HCl), a respondent in a Brazilian study remarked:

If Ambra-Sinto® does not help, nothing will! (Haak, 1988, p. 1424)

It is this background which has made it so difficult to achieve lasting change in antibiotic consumption patterns.

Poor use of antibiotics not only creates resistance, it also leads to poor quality of health care. With this review we hope to contribute to improving the quality of health care in developing countries.

Section snippets

Methods

A database of studies on determinants of antibiotic use, prescribing and dispensing in low-income countries was initiated by searching Medline, Popline, AIDSline, and the Social Science Citation Index for journal articles, reports, reviews, abstracts, posters and newsletters. The search covered all years of existence of these databases. The full electronic databases of WHO (WHOLIS), WHO/PAHO (Lilacs), WHO EMRO, and Scielo (Brazil), as well as the drug use bibliography composed and updated by

Results

A total of 37 acceptable studies were found. The studies cover four geographical regions, with 21 from Asia, 9 from Africa, 6 from Latin America and one from the Middle East (Table 1). From China, only two studies were received. Most studies were carried out in the early and mid 1990s. No studies were identified from Newly Independent States (NIS or former Soviet Union), francophone Africa, or the Pacific region.

Of the selected studies, two-thirds had no specific disease focus, and addressed

Determinants of antibiotic prescribing

Research on antibiotic prescribing (see Fig. 2) often focussed on demonstrating that prescribers have inappropriate knowledge on use of antibiotics. Lack of trust, or poor-quality laboratory services, inappropriate peer norms and poor modelling by seniors, drug supply issues, economic incentives, fear of poor clinical outcomes, and the desire to meet patient demand, are other determinants on which some research work is available. Only one study explored the influence of folk beliefs on

Determinants of antibiotic dispensing

Drug dispensers have a great deal of influence on community drug use. People often prefer to purchase drugs directly from pharmacies for a variety of reasons, including the fact that more value is placed on drugs than on the medical consultation (Van der Geest, 1982; WHO, 1998). Dispenser studies into antibiotic use often focussed on the desire to meet customer demand and on economic incentives of antibiotic sales (see Fig. 3).

Pharmacies are often the first source of advice for patients who

Determinants of community antibiotic use

Community determinant studies (see Fig. 4) tended to investigate the sources from which community members acquire antibiotics or information on them, or a variety of folk beliefs on indications and effectiveness of these drugs. Determinants such as knowledge on antibiotic use, economic considerations, marketing influences, were hardly researched.

Drug store customers in the Philippines, India, Mexico and Brazil based their decisions to buy antibiotics on advice that was given by friends or

Discussion

Antibiotics, are part of daily life in low-income countries. As a consequence, a ‘culture’ has been built up around antibiotics, their indications, efficacy, dosing and duration of use, sometimes combining traditional and biomedical concepts. Most of the available literature on antibiotic use focuses on the quantitative aspects: for example, which antibiotics are prescribed, dispensed or used, at what price, for what problem, and whether a prescriptions was presented. Little information is

Conclusion

In this review of the world's literature only a few studies could be identified that satisfied a minimum level of methodological quality and that presented more than simple quantitative data. From large areas in the world, no suitable studies of determinant were available at all. Few of the studies had strong research designs, comparable to analytical studies carried out in industrialised countries. Our review only identified 37 published and unpublished papers, issued at any point in time.

Acknowledgements

Professionals of a variety of institutions helped us in identifying the literature that make up the bulk of this review. Their help is very much appreciated. Dennis Ross-Degnan (Harvard Medical School and Harvard Pilgrim Health Care, Boston, USA) and Jon Simon (Centre for International Health, Boston University, Boston, USA) deserve special mention for their continued support at all stages in preparing this review and commenting on earlier versions. This review of literature was supported by a

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