by Dr Christie Cabral,  Senior Lecturer, Centre for Academic Primary Care and Professor Helen Lambert, Professor of Medical Anthropology, Bristol Medical School, University of Bristol

Antibiotic resistance: a key problem

Antibiotics are life-saving drugs that treat infections caused by bacteria. However, every time antibiotics are used, bacteria can become resistant to them, making infections harder to treat. This is called antimicrobial resistance (AMR). In 2011, Dame Sally Davies, then the UK’s Chief Medical Officer, helped to make AMR a government priority. Since then, strategies have been created to help conserve antibiotics and keep them effective. These strategies are called antimicrobial stewardship (AMS) and are used in the UK and around the world.

However, there’s a major problem: it’s hard to figure out quickly which infections are caused by bacteria and need antibiotics, especially when medical tests are not available, which is most places outside hospitals. This leads to high use of antibiotics and which in turn increases the risk of AMR.

Global antimicrobial stewardship: key challenges

In the UK and most High-Income Countries (HIC), only qualified doctors and certain other health professionals can prescribe antibiotics. But in many low- and middle-income countries (LMIC), antibiotics can be bought over the counter (OTC) without a prescription. This is common in settings where government health services are under-funded, overcrowded or hard to access, leading people to seek care from other sources, including pharmacies, shops and markets that sell medicines.

In fact, many people in these countries rely on OTC purchasing of potentially life-saving medicines, including antibiotics, from these sources which may even be part of an official plan to make sure everyone can get healthcare.

“There is a scarcity of qualified doctors … no standard government health facilities … the unavailability of medicine is a common issue” (from Nizame et al 2021))

Understanding self-medication with antibiotics in LMIC

We reviewed 78 studies from different LMIC to understand why people often buy and use antibiotics without a prescription. These studies reported people’s ideas about antibiotics and their reasons for using them.

Some of the reasons people self-medicate with antibiotics

Poor living conditions: Many people in LMIC live in poor conditions with inadequate sanitation and unsafe water supplies, which means they get infections more often. Poor people often have low-paying or unstable jobs and can’t afford to miss work, even when they’re sick.

“If I take 3 tablets and I go to sell food and I do not pass out, then next week I will do the same. That means [medicines] are a part of my life.” (from Nabirye et al 2021))

Experience with doctors: In many LMIC, doctors often prescribe antibiotics for common non-bacterial illnesses like coughs, fever, or pain. This creates the perception that antibiotics are the best solution for many health problems because they are approved for this use by doctors.

“When my child got sick the first time I took him to hospital. My child took drugs according to a prescription and recovered, so from then onwards, I have just gone out and bought the same drug” (from Le et al 2011))

Belief in the power of antibiotics: People believed that antibiotics were a powerful treatment because of their experiences of being prescribed them and of recovering from illness after taking antibiotics, but also because antibiotics are Western medicines that are considered ‘strong’.

Commercial influences on sales: In countries where people pay directly for healthcare, the market for antibiotics can also be influenced by the profit motive. Antibiotic sales may be driven more by commercial than by actual medical needs.

“In my neighborhood, [the pharmacy storekeeper] was the savior. (…) Anytime you have symptoms, you visit him and get an injection. (…) I think half the neighborhood had contact with antibiotics because of him.” (from Aponte-Gonzalez et al 2019))

Reasons people may choose not to take antibiotics

Cost vs. benefits: People weigh the cost and potential harm from taking antibiotics against the potential benefit. People did not pay for or take antibiotics unless they really believed that they needed them.

While many studies focus on people’s lack of knowledge about antibiotics, our review shows that the bigger issue is the combination of economic, social, and environmental factors. These influences shape how people use antibiotics and the way healthcare systems operate.

We used a model called the socio-ecological model to show how society, environment, and healthcare systems all play a role in shaping antibiotic use.

What can be done globally?

If doctors and pharmacists continue to recommend antibiotics for common infections, public education campaigns may not be enough to change things. Health professionals are a key part of the solution, even in places where antibiotics are easy to get from local shops. People do think about the risks and costs of taking antibiotics before they decide to use them, which offers another opportunity to intervene.

Many countries are trying to improve access to healthcare by including medicine shops and pharmacies in their healthcare systems. For this to work, AMS strategies need to be part of the plan. These strategies should address both the role of local medicine sellers and the commercial pressures that drive use of antibiotics.

What can be done in the UK?

People who move to the UK from countries where antibiotics are widely used for symptoms like fever, cough, or pain may find our healthcare system confusing. When a UK doctor says it’s “just a virus” and doesn’t prescribe antibiotics, patients may feel their concerns are ignored.

In the UK, doctors are already under pressure, and the demand for care is high. Sometimes, doctors prescribe antibiotics if they believe patients expect them or to finish consultations quickly. Unfortunately, there’s often not enough time to discuss the patient’s past experiences and explain UK guidelines on antibiotic use.

One solution could be to co-create healthcare programmes with input from migrant communities. This would help people understand why antibiotics are used differently in the UK and support acceptance of guidelines that recommend fewer prescriptions.

Further information

Full paper: Influences on use of antibiotics without prescription by the public in low- and middle-income countries: a systematic review and synthesis of qualitative evidence. Christie Cabral, Tingting Zhang, Isabel Oliver, Paul Little, Lucy Yardley, Helen Lambert. October 2024. Published in JAC-Antimicrobial Resistance.

World AMR Awareness Week is 18-24 November. For more about the campaign, visit the World Health Organization website.