The Role of Multidimensional Poverty in Antibiotic Misuse: A Study of Self-Medication and Non-Adherence in Kenya, Tanzania, and Uganda

Abstract

Background: Poverty is a proposed driver of antimicrobial resistance (AMR), influencing inappropriate antibiotic (AB) use in low and middle-income countries (LMICs). However, at sub-national levels, studies investigating poverty and AB use are sparse and the results inconsistent. Methods: The Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6,827 patients presenting with urinary tract infection (UTI) symptoms in Kenya, Uganda, and Tanzania. Using Bayesian hierarchical modelling, we investigated the association between multidimensional poverty and self-reported AB self-medication and treatment non-adherence (skipping a dose and not completing the course). We also analysed linked qualitative in-depth patient interviews (IDIs) (n = 82) and unlinked focus group discussions (FGDs) with community members (n = 44 groups). Findings: AB self-medication and non-adherence to treatment courses was significantly more common in the least deprived group compared with those in severe poverty. Adjustment for AB ‘knowledge’, attitudes and socio-demographics diminished the association with self-medication, but not non-adherence. IDIs and FGDs suggested that self-medication and non-adherence are driven by perceived inconvenience of the healthcare system, financial barriers, and ease of unregulated AB access. Interpretation: Structural barriers to optimal AB use exist at all levels of the socioeconomic hierarchy. Inefficiencies in public healthcare may be fuelling alternative antibiotic access points, for those who can afford it. In designing interventions to tackle AMR and reduce AB misuse, the behaviours and needs of wealthier population groups should not be neglected. Funding Information: UK National Institute for Health Research, Medical Research Council and the Department of Health and Social Care. Declaration of Interests: None. Ethics Approval Statement: Ethical approval for this project was obtained from the University of St Andrews, UK (No. MD14548, 10/09/19); National Institute for Medical Research, Tanzania (No. 2831, updated 26/07/19), CUHAS/BMC research ethics and review committee (No. CREC/266/2018, updated on 02/2019), Mbeya Medical Research and Ethics Committee (No. SZEC-2439/R. A/V.1/303030), Kilimanjaro Christian Medical College, Tanzania (No. 2293, updated 14/08/19). Uganda National Council for Science and Technology (number HS2406, 18/06/18); Makerere University, Uganda (number 514, 25/04/18); and Kenya Medical Research Institute (04/06/19, Scientific and Ethics Review Committee (SERU) number KEMRI/SERU/CMR/P00112/3865 V.1.2). For Uganda, administrative letters of support were obtained from the district health officers to allow the research to be conducted in the respective hospitals and health centres.