A study from Kenya, Tanzania, and Uganda finds that: 'Antibiotic misuse was more common among those least deprived, and lowest among those living in severe multidimensional poverty... Self-medication and treatment non-adherence were driven by perceived inconvenience of the health-care system, financial barriers, and ease of unregulated antibiotic access'. Citation, summary and a comment from me below.
CITATION: The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda
Dominique L Green et al. The Lancet Global Health - Articles| volume 11, issue 1, e59-e68, january 01, 2023
Open Access Published: January, 2023 DOI:https://doi.org/10.1016/S2214-109X(22)00423-5
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00423-5/fulltext
SUMMARY
Background: Poverty is a proposed driver of antimicrobial resistance, influencing inappropriate antibiotic use in low-income and middle-income countries (LMICs). However, at subnational levels, studies investigating multidimensional poverty and antibiotic misuse are sparse, and the results are inconsistent. We aimed to investigate the relationship between multidimensional poverty and antibiotic use in patient populations in Kenya, Tanzania, and Uganda.
Methods: In this mixed-methods study, the Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6827 outpatients (aged 18 years and older, or aged 14–18 years and pregnant) with urinary tract infection (UTI) symptoms in health-care facilities in Kenya, Tanzania, and Uganda. We used Bayesian hierarchical modelling to investigate the association between multidimensional poverty and self-reported antibiotic self-medication and non-adherence (ie, skipping a dose and not completing the course). We analysed linked qualitative in-depth patient interviews and unlinked focus-group discussions with community members.
Findings: Between Feb 10, 2019, and Sept 10, 2020, we collected data on 6827 outpatients, of whom 6345 patients had complete data; most individuals were female (5034 [79·2%]), younger than 35 years (3840 [60·5%]), worked in informal employment (2621 [41·3%]), and had primary-level education (2488 [39·2%]). Antibiotic misuse was more common among those least deprived, and lowest among those living in severe multidimensional poverty. Regardless of poverty status, difficulties in affording health care, and more familiarity with antibiotics, were related to more antibiotic misuse. Qualitative data from linked qualitative in-depth patient interviews (n=82) and unlinked focus-group discussions with community members (n=44 groups) suggested that self-medication and treatment non-adherence were driven by perceived inconvenience of the health-care system, financial barriers, and ease of unregulated antibiotic access.
Interpretation: We should not assume that higher deprivation drives antibiotic misuse. Structural barriers such as inefficiencies in public health care, combined with time and financial constraints, fuel alternative antibiotic access points and treatment non-adherence across all levels of deprivation. In designing interventions to reduce antibiotic misuse and address antimicrobial resistance, greater attention is required to these structural barriers that discourage optimal antibiotic use at all levels of the socioeconomic hierarchy in LMICs.
COMMENT (NPW): The authors note that 'Health-care attitudes were measured by responses to the question: “what source(s) of information about medicines/drugs do you use when you are sick?”'. However, I was unable to find the responses to that question. They also report that 'Greater familiarity with antibiotics (recognising four or more antibiotics from the drug card) was associated with higher odds of self-medication and skipping a dose'. It would be interesting to learn more about the links between knowledge of when and how antibiotics should be used and how they are used in practice, both for prescibers and users.
Best wishes, Neil
Dr Neil Pakenham-Walsh, HIFA Coordinator
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