Community-based antibiotic access and use in six low-income and middle-income countries: a mixed-method approach

Nga T T ,John Kinsman,Margaret Gyapong,Huong T L Vu,Ellen Boamah-Kaali,Samuel Afari-Asiedu,Sureeporn Punpuing,Fezile Wagner,Sabina Asiamah,Mohammad Mahbubul Karim,Osman Sankoh,Kwaku Poku Asante,Martha Ali Abdulai,Sabeena Ahmed,Proochista Ariana,Wasif Ali Khan,Olga Cambaco,Johannes John-Langba,Georgina Amankwah,Stephen Tollman,Malee Sunpuwan,F Xavier Gómez‐Olivé ,Hanh H Nguyen ,Betuel Sigaúque ,Mohammad A Matin ,Esperança Sevene ,John E Williams ,Chuc Thi Kim Nguyen ,Mary P Agyekum ,Toan Khanh Tran ,H Rogier Van Doorn ,Khátia Munguambe ,Phuc Dang Ho ,Heiman Wertheim

doi:10.1016/s2214-109x(21)00024-3

Abstract

SummaryBackgroundAntimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices.MethodsWe did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016–Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions.FindingsVietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through health-care facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia.InterpretationContextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance.FundingWellcome Trust and Volkswagen Foundation.

Highlights

We did quantitative and qualitative assessments of antibiotic access and use in six low-income and middle-income countries (LMICs) across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016–Dec 31, 2018)
Implications of all the available evidence Our study found common themes reported in previous studies in LMICs, and revealed the diversity and complexity of locally specific sociocultural determinants affecting antibiotic access and use among studied communities in six Asian and African LMICs
Supplier mapping showed that Asian sites had a higher density of antibiotic suppliers than African sites, with the highest density found in urban Thailand (5 per 1000 inhabitants) and the lowest in rural South Africa (1 per 10 000 inhabitants; table 1)

Summary

Objectives

To fill these research gaps, we aimed to use a comparative approach to assess access and use practices across communities in six LMICs in Asia (Bangladesh, Thailand, and Vietnam) and Africa (Mozambique, Ghana, and South Africa) to allow for comparison by complexities to guide future research and support the development of evidence-based interventions in promoting appropriate antibiotic use across different LMICs. For each of the studied communities, through observed metrics, we aimed to map all formal and informal suppliers of antibiotics, inventory antibiotic resources, and determine community antibiotic exposure and the appropriateness of the antibiotics supplied. We aimed to assess demographic, socioeconomic, and cultural characteristics, the accessi bility of health care, and frequency of antibiotic intake and characterise the practices involved in antibiotic demand, access, and use. We aimed to investigate health-care concepts and behaviours and socioeconomic and cultural characteristics associated with practices of antibiotic access and use in each studied context

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Results

Conclusion