Knowledge, attitudes, and practices regarding antibiotic use among Latinos in the United States: review and recommendations

Understanding antibiotic use in the community setting in Thailand: Does communication matter?

BACKGROUND

It is known that the misuse and overuse of antimicrobials leads to antimicrobial resistance (AMR). Effective communication between dispensers and users is thus crucial in reducing inappropriate antibiotic use.

OBJECTIVE

This study aims to gain a better understanding of communication around the use of antibiotics in the community and seeks potential implementation strategies to change dispenser and user practices in communication aspects.

METHODS

Qualitative methods were employed, including in-depth interviews with 18 drug suppliers and 16 community members, and eight focus group discussions with key informants. Data were collected in the Kanchanaburi Demographic Health Surveillance System in urban and semi-urban communities in the western region of Thailand. The thematic analysis included communication quality, communication and imbalanced power, and misconceptions and instruction. The OpenCode qualitative software program was employed.

RESULTS

The study revealed that the quality of communication was significantly influenced by the interaction of antibiotic dispensing with language and information. This interaction creates communication constraints between those dispensing antibiotics and the recipients, resulting in a less-than-optimal exchange of information. Consequently, users received limited information concerning the proper use of antibiotics. Furthermore, power imbalances and communication dynamics were perpetuated, mainly stemming from varying levels of access to and knowledge about antibiotics. This imbalance in power dynamics became evident between those dispensing antibiotics and the users. Users, as well as dispensers lacking proper qualifications, found themselves in a precarious position due to their inadequate knowledge of antibiotics. Moreover, it is noteworthy that misconceptions often conflicted with antibiotic instructions, leading to challenges in adhering to antibiotic regimens. These challenges primarily arose from misconceptions about antibiotics and concerns about potential side effects, particularly when users started to feel better.

CONCLUSIONS

The findings highlight the importance of enhancing communication between dispensers and users through future interventions. These interventions should aim to bolster user understanding of antibiotics and provide clear, trustworthy instructions for their proper usage. Investigating innovative communication methods, such as the use of QR codes, presents a promising avenue for consideration. By addressing these communication gaps, we can advocate for the appropriate utilization of antibiotics and mitigate the prevalence of AMR.

Understanding refugee and immigrant health literacy and beliefs toward antimicrobial resistance

Refugee and migrant populations have increased vulnerability to antimicrobial resistance, yet stewardship guidance is lacking. We addressed this gap through a cross-sectional survey, finding that these populations and immigrants from low and middle-income countries had lower health literacy on the issue compared to native-born Americans and those from high-income countries.

Healthcare System Distrust and Non-Prescription Antibiotic Use: A Cross-Sectional Survey of Adult Antibiotic Users

Antibiotic resistance is a major public health concern driven by antibiotic overuse. Antibiotic stewardship programs are often limited to clinical settings and do little to address non-prescription antibiotic use in community settings. This study investigates the association between non-prescription antibiotic use and healthcare system distrust in the United States and Mexico. An online survey was deployed in the United States and Mexico with enhanced sampling through in-person recruiting in the border region. Non-prescription antibiotic use was defined as having bought or borrowed non-prescription oral or injectable antibiotics within the last 3 years. The survey included a previously validated 10-item scale to measure healthcare system distrust. Logistic regression was used to model the use of non-prescription antibiotics by the level of healthcare system distrust, adjusted for demographic characteristics and antibiotic knowledge. In total, 568 survey participants were included in the analysis, 48.6% of whom had used non-prescription oral or injectable antibiotics in the last 3 years. In the fully adjusted regression model, the odds of using non-prescription antibiotics were 3.2 (95% CI: 1.8, 6.1) times higher for those in the highest distrust quartile versus the lowest. These findings underscore the importance of community-based antibiotic stewardship and suggest that these programs are particularly critical for communities with high levels of healthcare system distrust.

The New Precision Stewards?

The precision health era is likely to reduce and respond to antimicrobial resistance (AMR). Our stewardship and precision efforts share terminology, seeking to deliver the “right drug, at the right dose, at the right time.” Already, rapid diagnostic testing, phylogenetic surveillance, and real-time outbreak response provide just a few examples of molecular advances we dub “precision stewardship.” However, the AMR causal factors range from the molecular to that of global health policy. Mirroring the cross-sectoral nature of AMR science, the research addressing the ethical, legal and social implications (ELSI) of AMR ranges across academic scholarship. As the rise of AMR is accompanied by an escalating sense of its moral and social significance, what is needed is a parallel field of study. In this paper, we offer a gap analysis of this terrain, or an agenda for “the ELSI of precision stewardship.” In the first section, we discuss the accomplishments of a multi-decade U.S. national investment in ELSI research attending to the advances in human genetics. In the next section, we provide an overview of distinct ELSI topics pertinent to AMR. The distinctiveness of an ELSI agenda for precision stewardship suggests new opportunities for collaboration to build the stewardship teams of the future.

Perspectives of Syrian refugees on antibiotic use and prescribing in Dutch primary care: a qualitative study

Purpose

This study is oriented towards getting insight into the perspectives, knowledge and practices among Syrian refugees regarding antibiotic use and prescribing in Dutch primary care.

Design/methodology/approach

A thematic qualitative study was carried out using semi-structured interviews with 12 Syrian refugees living in the Netherlands. Data analysis consisted of three steps and was oriented towards the development of themes.

Findings

Participants were confronted with restricted access to antibiotics in the Netherlands which was contrary to their experiences in Syria. Some of them continued to self-prescribe antibiotics, while others adhered to the Dutch General Practitioner (GP)’s advice. Especially mothers with young children took up the Dutch GP’s advice. Syrian refugees expressed health beliefs about the healing effects of antibiotics which are related to their past experiences of use and which influenced their current use. Respondents complained about the Dutch health-care system and expressed a preference for the one in Syria.

Research limitations/implications

Syrian refugees vary in their way of dealing with restricted access to antibiotics in Dutch primary care. More in-depth knowledge is required to improve refugee patient–doctor communication about antibiotic use.

Practical implications

The message that antibiotics are not needed may be challenging. Additional communication seems to be necessary to persuade Syrian refugees from self-prescribing antibiotics. Therefore, identifying refugee patient concerns and carefully counseling and communicating it with them is substantial. Developing educational toolkits consisting of various experiences of antibiotic use and ways of dealing with it can equip doctors to more adequately react to migrants’ needs for care.

Social implications

Primary care professionals seem insufficiently equipped to tackle issues related to antibiotic use amongst newly arrived migrants. Therefore, it is important to support professionals in their communication with this patient group about the proper use of antibiotics.

Originality/value

This study shows that more in-depth knowledge is needed about the strategies of newly arrived migrants and their complex reactions to treatment prescriptions with which they are not familiar.

Providing antibiotics to immigrants: a qualitative study of general practitioners' and pharmacists' experiences

BACKGROUND

If healthcare professionals perceive that patients strongly expect to be prescribed antibiotics, inappropriate prescriptions may result. As it is unknown whether this happens more often with certain patient groups, we explored whether general practitioners (GPs) and pharmacists perceived such expectations when they provided antibiotics to immigrant patients.

METHODS

Ten GPs and five pharmacists from Rotterdam, the Netherlands, were interviewed on the basis of a semi-structured topic guide. Atlas.ti software was then used to conduct a thematic analysis.

RESULTS

GPs felt that immigrant patients, especially those who had arrived recently, were more likely to expect to receive antibiotics than native Dutch patients. However, these expectations had decreased over the last years and did not always lead immigrants to exert pressure on them. Except for language barriers, the factors reported by GPs to influence their antibiotic prescribing behaviour were unrelated to patients' immigrant background. If there was a language barrier, GPs experienced greater diagnostic uncertainty and needed additional time to obtain and communicate correct information. To overcome language barriers, they often used point-of-care testing to convince patients that antibiotics were unnecessary. Although pharmacists rarely experienced problems dispensing antibiotics to immigrants, they and GPs both struggled to find effective ways of overcoming language barriers, and stressed the need for multi-language support materials.

CONCLUSION

While pharmacists rarely experience any problems providing antibiotics to immigrants, GPs regularly face language barriers with immigrant patients, which complicate the diagnostic process and communicating information in the limited available time. This sometimes leads antibiotics to be prescribed inappropriately.

A qualitative study on community use of antibiotics in Kinshasa, Democratic Republic of Congo

BACKGROUND

Resistance to antibiotics is an increasing and major threat to global health. While the large majority of antimicrobial use occurs in the community where antibiotics are available without prescription, we did not find any studies investigating community-level factors influencing the inappropriate use of antibiotics in the Democratic Republic of Congo (DRC), where non-prescription antibiotic use is prevalent.

METHODS

This qualitative study was conducted from April 1st 2019 to May 5th 2019 and consisting of in-depth semi-structured interviews, utilizing purposive and snowball sampling schemes to recruit adult heads of households in the Pakadjuma slum, in Kinshasa, DRC. Participants with differing medical and educational backgrounds were selected. We employed a thematic analysis approach to explore community knowledge and use of antibiotics in the sampled population.

RESULTS

A total of 18 participants with a median age of 35 years were interviewed. The majority was female (77.7%), had at least a secondary education (83.4%), and unemployed (61.1%). We found that participants were familiar with the term "antibiotics", but had limited knowledge of the indications and risks of antibiotics, including the risk of antibiotic resistance. Inappropriate use of antibiotics was common and there was frequent self-medication of non-prescribed medicines for a range of non-indicated conditions such as menstruation. Having limited income was the most commonly reported reason for not visiting a health facility for appropriate health care.

CONCLUSION

Inappropriate use of antibiotics is a widespread practice and is influenced by lack of adequate knowledge of antibiotic use, indications and risks, prevalent self-medication, and financial barriers to accessing appropriate health care. There is need for both community education as well as structural interventions addressing poverty in order to reduce the inappropriate use of antibiotics in the Pakadjuma slum in Kinshasa.

Epidemiology of Antibiotic Use and Drivers of Cross-Border Procurement in a Mexican American Border Community

Background

The U.S.-Mexico Border is an area of opportunity for improved health care access; however, gaps remain as to how and where U.S. border residents, particularly those who are underinsured, obtain care. Antibiotics are one of the most common reported drivers of cross-border healthcare access and a medication of particular concern since indiscriminate or inappropriate use is associated with antimicrobial resistance. In addition, many studies assessing preferences for Mexican pharmaceuticals and healthcare in U.S. border residents were done prior to 2010 when many prescription medications, including antibiotics, were available over the counter in Mexico.

Methods

Data used in this study were collected during the baseline examination of an ongoing longitudinal cohort study in Starr Country, Texas, one of 14 counties on the Texas-Mexico border. Participants self-reported the name, date of use, and the source country of each antibiotic used in the past 12 months. Logistic regression was used to determine social, cultural, and clinical features associated with cross-border procurement of antibiotics.

Results

Over 10% of the study cohort reported using antibiotics in the past 30 days with over 60% of all rounds used in the past 12 months sourced from Mexico. A lack of health insurance and generation score, a measure of acculturation, were the strongest predictors of cross-border procurement of antibiotics.

Conclusions

Factors previously associated with cross-border acquisition of antibiotics are still present despite changes in 2010 to prescription drug regulations in Mexico. These results may be used to inform future public health initiatives to provide culturally sensitive education about responsible antibiotic stewardship and to address barriers to U.S. healthcare and pharmaceutical access in medically underserved, impoverished U.S.-Mexico border communities.

Clinical Factors Implicated in Antibiotic Resistance in Helicobacter pylori Patients

Helicobacter pylori is a common gastric pathogen associated with multiple clinical syndromes, including cancer. Eradication rates of H. pylori remain suboptimal despite the progress made in the past few decades in improving treatment strategies. The low eradication rates are mainly driven by antibiotic resistance of H. pylori. Non-invasive molecular testing to identify patients with antibiotic-resistant H. pylori represents a promising therapeutic avenue, however this technology currently remains limited by availability, costs, and lack of robust validation. Moreover, there is insufficient evidence to demonstrate that resistance-testing-based treatment approaches are superior to appropriately designed empiric strategies. Consensus guidelines recommend use of proven locally effective regimens; however, eradication data are inconsistently generated in several regions of the world. In this review, we describe several clinical factors associated with increased rates of antibiotic resistant H. pylori, including history of previous antibiotic exposure, increasing age, female gender, ethnicity/race, extent of alcohol use, and non-ulcer dyspepsia. Assessment of these factors may aid the clinician in choosing the most appropriate empiric treatment strategy for each patient. Future study should aim to identify locally effective therapies and further explore the clinical factors associated with antibiotic resistance.

Perceptions of Responsibility for Antibiotic Resistance: Implications for Stewardship Campaigns

Widespread public engagement with antibiotic stewardship is essential to stem the rising incidence of antibiotic-resistant infections; however, campaigns that focus on increasing knowledge have not been effective. Beliefs about who is responsible for causing and solving antibiotic resistance (AR) likely influences engagement in antibiotic stewardship behaviors. This study assesses the U.S. public's AR causal and solution responsibility attributions and the capacity for changing these attributions to inform future antibiotic stewardship campaigns. U.S. participants (N= 1,014) diverse across race, education, and geographic region were surveyed on their beliefs about responsibility for AR for themselves, the general public, healthcare providers, scientists, and drug companies. Substantial percentages of participants held causal and solution beliefs about antibiotic resistance that likely inhibit antibiotic stewardship behaviors. Participants' beliefs that they and the general public are responsible for causing and solving AR were lower than their beliefs that healthcare providers, scientists, and drug companies are responsible. Beliefs about causal responsibility for any given person or group were significantly and positively associated with beliefs about solution responsibility for that same person or group. Responsibility beliefs differed by age, education level, and racial/ethnic background. Results highlight the need for antibiotic stewardship campaigns to incorporate responsibility attribution messaging to motivate stewardship.

Community knowledge and practices regarding antibiotic use in rural Mozambique: where is the starting point for prevention of antibiotic resistance?

BACKGROUND

Antibiotic misuse and other types of unnecessary use of antibiotics can contribute to accelerate the process of antibiotic resistance, which is considered a global concern, mostly affecting low-and middle-income countries (LMICs). In Mozambique there is limited evidence on community knowledge and practices regarding antibiotics and antibiotic resistance. As part of the ABACUS project, this paper describes knowledge and practices of antibiotic use among the general population in the semi-rural district of Manhiça to inform evidence-based communication intervention strategies for safer antibiotic use.

METHODS

The study was conducted in Manhiça, a semi-rural district of Southern Mozambique. Sixteen in-depth interviews and four focus group discussions (FGDs) were conducted with community members to explore lay knowledge and practices regarding antibiotics and awareness of antibiotic resistance. The qualitative data was analysed using a combination of content and thematic analysis. The SRQR guidelines for reporting qualitative studies was performed.

RESULTS

Although participants did not hold any consistent knowledge of antibiotics, their visual recognition of amoxicillin (distinct red yellow capsule) was acceptable, but less so for different types and brands of antibiotics. The majority of participants were aware of the term 'antibiotic', yet the definition they gave was rarely backed by biomedical knowledge. Participants associated antibiotics with certain colours, shapes and health conditions. Participants reported common habits that may contribute to resistance: not buying the full course, self-medication, sharing medicines and interruption of treatment. Most had never heard of the term 'antibiotic resistance' but were familiar with the phenomenon. They often understood the term 'resistance' as treatment failure and likened 'resistance' to non-compliance, ineffective medication, disease resistance or to an inability of the physical body to respond to it.

CONCLUSION

There is a broad understanding of the importance of medication compliance but not specifically of antibiotic resistance. In addition, there is a recognized gap between knowledge of responsible drug compliance and actual behaviour. Future qualitative research is required to further explore what determines this behaviour. The existing ability to visually identify amoxicillin by its distinct red and yellow appearance is informative for future awareness and behavioural change campaigns that may incorporate visual aids of antibiotics.

Parental knowledge and practice on antibiotic use for upper respiratory tract infections in children, in Aksum town health institutions, Northern Ethiopia: a cross-sectional study

Introduction

worldwide, antibiotics are the most commonly prescribed and abused drugs for upper respiratory tract infections. Acute upper respiratory infections are common in children who attend childcare and preventing transmission of disease in health setting depends on actions by parents and staff. Therefore the objective of this study is to assess the parental knowledge and practice on antibiotic use for upper respiratory tract infections in children, in Aksum town health institutions, northern Ethiopia, 2018.

Methods

a facility-based cross-sectional study design was adopted involving 384 parents of children visited governmental health facilities in Aksum town from February to March, 2018. Respondents were selected based on the proportion of nurses in the health facilities. SPSS version 22 was applied for data entry and analysis.

Results

the total number of questionnaires was 384 resulting in a 100% response rate. Almost half of the parents had poor knowledge of the use of antibiotics in children for URTIs 183(47.7%), followed by 156(40.6%) moderate knowledge and 45(11.7%) good knowledge. Practices regarding antibiotic use in children with URTI varied. Only 12.8% of the parents did not always follow the doctors´ advice regarding antibiotic use. In this study has reported many areas in which parental awareness on antibiotic use for acute URTI is considered inadequate, consequently inappropriate knowledge and practices.

Conclusion

nearly half of the parents attending the physicians for their children with URTI expected to get antibiotics.

A Descriptive Study Using an Intercept Survey: Knowledge, Attitudes, Beliefs, and Behaviors About Systemic Antibiotic Use in Adults Who Reported a Wound Within the Previous Year

PURPOSE

This project examined knowledge, attitudes, beliefs, and behaviors about systemic antibiotic use for persons who reported a wound within the previous year.

DESIGN

Secondary data analyses of 505 adults from a cross-sectional, prospective, intercept survey where every fifth adult was randomly approached to participate.

SUBJECTS AND SETTING

Twenty-six participants (5.15% of the parent sample) stated having a wound within the previous year.

METHODS

Participants were "interviewed" using the Facilitators and Barriers to Consumer Use of Antibiotics questionnaire that included demographics, health, information sources, antibiotic knowledge, attitudes, beliefs, and behavior questions. Hierarchical agglomerative cluster analysis was used to find clusters of items on the attitude, beliefs, and behavior questions.

RESULTS

Sample demographics included 15 women and 11 African Americans, and 17 had some college education. Knowledge about antibiotics had a mean correct score of 10 out of 15 (67%) questions. Higher antibiotic knowledge was significantly related to higher education (rs = 0.69, P < .001). There were 2 attitude and beliefs clusters: most participants (>85%) recognized the need for medical supervision of antibiotic use (cluster 1), and beliefs about the need for antibiotics to prevent illness or treat wounds varied in 27% to 62% of participants (cluster 2). There were 4 behavior clusters: almost all participants 96% (cluster 1) filled and took the antibiotic if prescribed; greater than 71% (cluster 2) disagreed with unapproved methods of obtaining antibiotics; greater than 87% (cluster 3) used prescribed antibiotics correctly; and 36% of participants heard about antibiotic resistance through television or radio or Internet (40%) (cluster 4).

CONCLUSIONS

Knowledge about antibiotics was low, while attitudes were positive. These findings support the need for research and evidence-based information on the role of antibiotics in wound care.

The Association between Changes in External Environment Caused by Migration and Inappropriate Antibiotic Use Behaviors among Chinese University Students: A Cross-Sectional Study

Objectives: This study aims to explore how changes in external factors caused by migration impact antibiotic use behaviors among Chinese university students in comparison to their peers from host areas and origin areas. Migration status was determined by host universities and origin areas, which were broadly defined as eastern vs. western regions in China. Methods: This study analyzed secondary data from a cross-sectional study conducted in China about the antibiotic use behaviors of university students in 2015. Students were divided into four groups: eastern local students (E-Es), western local students (W-Ws), eastern–western migrant students (E-Ws), and western–eastern migrant students (W-Es). Results: After controlling for gender, grade, major, hometown (rural or urban), and parents’ education, E-Ws reported a significantly higher odds of asking for antibiotics (OR = 2.13; 95% CI = 1.54–3.03; p < 0.001) and taking antibiotics prophylactically (OR = 1.85; 95% CI = 1.32–2.56; p < 0.001) compared with E-Es; W-Es reported a significantly lower odds of asking for antibiotics (OR = 0.56; 95% CI = 0.37–0.83; p < 0.01) and taking antibiotics prophylactically (OR = 0.57; 95% CI = 0.41–0.81; p < 0.01) compared with W-Ws. Discussion: Regional differences likely interacted with students’ migration status in forming different antibiotic use behaviors. Factors including financial incentives and loose regulations of antibiotic over-prescription by health providers and peer influence may contribute to worsened antibiotic use behaviors among E-Ws.

Use of Antibiotics Without a Prescription in the U.S. Population: A Scoping Review

BACKGROUND

Use of antibiotics without a prescription may increase unnecessary and inappropriate drug use or doses as well as global risk for antimicrobial resistance.

PURPOSE

To perform a scoping review of research on the prevalence of nonprescription antibiotic use in the United States and to examine the factors that influence it.

DATA SOURCES

Searches of PubMed, EMBASE, CINAHL, Scopus, and relevant Web sites without language restrictions from January 2000 to March 2019.

STUDY SELECTION

Studies reporting nonprescription use of antibiotics, storage of antibiotics, intention to use antibiotics without a prescription, and factors influencing nonprescription use.

DATA EXTRACTION

Two reviewers independently screened citations and full texts and performed data abstraction.

DATA SYNTHESIS

Of 17 422 screened articles, 31 met inclusion criteria. Depending on population characteristics, prevalence of nonprescription antibiotic use varied from 1% to 66%, storage of antibiotics for future use varied from 14% to 48%, and prevalence of intention to use antibiotics without a prescription was 25%. Antibiotics were obtained without a prescription from various sources, including previously prescribed courses, local markets or stores, and family or friends. Reported factors contributing to nonprescription use included easy access through markets or stores that obtain antibiotics internationally for under-the-counter sales, difficulty accessing the health care system, costs of physician visits, long waiting periods in clinics, and transportation problems.

LIMITATION

Scarce evidence and heterogeneous methods and outcomes.

CONCLUSION

Nonprescription antibiotic use is a seemingly prevalent and understudied public health problem in the United States. An increased understanding of risk factors and pathways that are amenable to intervention is essential to decrease this unsafe practice.

PRIMARY FUNDING SOURCE

None.

"Antibiotics kill things very quickly" - consumers' perspectives on non-prescribed antibiotic use in Saudi Arabia

Background

In recent decades, the Kingdom of Saudi Arabia has seen an exponentially growing antibiotic resistance, which is exacerbated by the use of antibiotics without a prescription and other various factors. However, no published data are available on factors influencing non-prescription use of antibiotics among the general public in Saudi Arabia using an in-depth interview technique.

Methods

Semi-structured interviews were carried out with 40 Saudi participants from the Eastern Province of Saudi Arabia, selected via snowball sampling technique. Participants were enrolled based on the following inclusion criteria: 18 years of age or older and had self-medicated themselves with antibiotics in the past two years. Data collection was continued until data saturation was attained. Interviews were audiotaped, transcribed verbatim and analysed using NVivo 10 software.

Results

Participants (80% female) had a mean (SD) age of 30 years (10.2). Self-medication with antibiotics was associated with various inappropriate antibiotic use behaviours and negative outcomes such as antibiotic resistance, treatment failures and adverse events. Interviews revealed that different reasons contribute to the rise of self-medication with antibiotics, ranging from difficulty accessing healthcare services, participant’s cultural beliefs and practices, lack of knowledge about antibiotics and antibiotic resistance, and weak regulatory enforcement.

Conclusions

The findings of the present study will aid in generating data that may provide an insight when designing future interventions to promote public health awareness regarding safe and effective use of antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6088-z) contains supplementary material, which is available to authorized users.

Non-prescribed antibiotic use and general practitioner service utilisation among Chinese migrants in Australia

Non-prescribed antibiotic use occurs worldwide and is an important contributor to antibiotic resistance. Social and health system factors were related to the practice of self-medication with antibiotics. This study aims to investigate the practice of non-prescribed antibiotic use, and to assess the impact of primary health service access and use on this practice among Australian Chinese migrants. Four-hundred and twenty-six participants, who self-identified as Chinese and who had been residing in Australia for at least 12 months, were recruited through several Australian Chinese social websites to participate in an online health survey about antibiotic use and health services use from July to October 2013. Logistic regression analyses were conducted to assess the associations between health services utilisation factors and the use of non-prescribed antibiotics. In total, 20.2% (86/426) participants reported having used antibiotics without medical consultation in the last 12 months. Of 170 antibiotic users, 50.6% (86/170) used antibiotics without medical consultation. Chinese migrants who self-evaluated as 'satisfied' with the experiences of GP services were less likely to self-medicate with antibiotics. In addition, Chinese migrants without any perceived barriers to using primary health services in Australia were less likely to use non-prescribed antibiotics. Among Australian Chinese migrants, over half of antibiotic users admitted that they had used antibiotics without medical consultation. Participants with positive experience and perception of primary health services, primarily GP services, had a lower risk of using non-prescribed antibiotics.

Australian consumer perspectives, attitudes and behaviours on antibiotic use and antibiotic resistance: a qualitative study with implications for public health policy and practice

BACKGROUND

Consumers receive over 27 million antibiotic prescriptions annually in Australian primary healthcare. Hence, consumers are a key group to engage in the fight against antibiotic resistance. There is a paucity of research pertaining to consumers in the Australian healthcare environment. This study aimed to investigate the perspectives, attitudes and behaviours of Australian consumers on antibiotic use and antibiotic resistance, to inform national programs for reducing inappropriate antibiotic consumption.

METHOD

Semi-structured interviews with 32 consumers recruited via convenience and snowball sampling from a university population in South East Queensland. Interview transcripts were deductively and inductively coded. Main themes were identified using iterative thematic analysis.

RESULTS

Three themes emerged from the analysis, to elucidate factors affecting antibiotic use: (a) prescription type; (b) consumer attitudes, behaviours, skills and knowledge; and (c) consumer engagement with antibiotic resistance. Consumers held mixed views regarding the use of delayed antibiotic prescriptions, and were often not made aware of the use of repeat antibiotic prescriptions. Consumers with regular general practitioners were more likely to have shared expectations regarding minimising the use of antibiotics. Even so, advice or information mediated by general practitioners was influential with all consumers; and helped to prevent inappropriate antibiotic use behaviours. Consumers were not aware of the free Return of Unwanted Medicines service offered by pharmacies and disposed of leftover antibiotics through household waste. To engage with mitigating antibiotic resistance, consumers required specific information. Previous public health campaigns raising awareness of antibiotics were largely not seen by this sample of consumers.

CONCLUSIONS

Australian consumers have specific information needs regarding prescribed antibiotics to enable appropriate antibiotic use behaviours. Consumers also have expectations for high quality general practice consults conducted in a manner that increases consumer confidence in the treatment decision, regardless of whether an antibiotic is prescribed. To reduce inappropriate consumption of antibiotics and to more fully engage Australian consumers in mitigating antibiotic resistance, changes in health policy and practice are required.

Physicians' knowledge, perceptions, and attitudes toward antimicrobial prescribing in Riyadh, Saudi Arabia

OBJECTIVES

To assess knowledge, perceptions, and attitudes toward antimicrobial prescribing among physicians practicing in Riyadh, Saudi Arabia.

METHODS

A questionnaire was developed and distributed to physicians working in hospitals in Riyadh, Saudi Arabia between June and August 2013. The results were analyzed using Stata 12 software.

RESULTS

Two hundred and twelve (84.8%) full responses were returned. Most respondents perceived antimicrobial resistance as a significant problem in their daily practice (119, 56.1%) and at a national level (148, 69.8%). Inappropriate empirical therapy (101, 47.6%) and excessive use of antimicrobials in healthcare settings (66, 31.1%) were believed to be the main contributors to increasing bacterial resistance. Respondents favor treating infection rather than colonization (98, 46.2%), and physician education (74, 34.9%) as the most effective interventions to reduce antimicrobial resistance. Many respondents (95, 44.8%) do not feel confident in their knowledge of antimicrobial prescribing. Two-thirds of the respondents (135, 63.7%) have local antimicrobial guidelines, of which 90 (66.7%) felt were useful. Most respondents (160, 75.5%) considered their local infectious diseases service to be very helpful.

CONCLUSION

There are considerable unmet training and education need for physicians in the area of antimicrobial prescribing. Local antimicrobial guidelines need revision to ensure they are more relevant and helpful for medical practitioners.

Antibiotic Resistance of Helicobacter pylori Among Male United States Veterans

BACKGROUND & AIMS

The most recent information published on resistance of Helicobacter pylori to antibiotics in a large population in the United States is more than 10 years old. We assessed the susceptibility of H pylori to antibiotics among patients in a large metropolitan hospital, as well as demographic, clinical, and lifestyle factors associated with antimicrobial resistance.

METHODS

We performed a cross-sectional study of a random sample of 656 patients (90.2% men) from a cohort of 1559 undergoing esophagogastroduodenoscopy with collection of gastric biopsies from 2009 through 2013 at the Houston Veterans Affairs Medical Center. We performed culture analyses of gastric tissues to detect H pylori. The minimum inhibitory concentrations of amoxicillin, clarithromycin, metronidazole, levofloxacin, and tetracycline were determined by the Epsilometer test. Logistic regression analysis was performed to estimate the association between risk factors and antimicrobial resistance.

RESULTS

Biopsies from 135 subjects (20.6%) tested positive for H pylori; 128 of these were from men (94.8%). Only 65 strains were susceptible to all 5 antibiotics. The prevalence of resistance to levofloxacin was 31.3% (95% confidence interval [CI], 23.1%-39.4%), to metronidazole it was 20.3% (95% CI, 13.2%-27.4%), to clarithromycin it was 16.4% (95% CI, 9.9%-22.9%), and to tetracycline it was 0.8% (95% CI, 0.0%-2.3%). No isolate was resistant to amoxicillin. Clarithromycin resistance increased from 9.1% in 2009-2010 to 24.2% in 2011-2013. In multivariate analysis, prior treatment of H pylori infection and use of fluoroquinolones were significantly associated with clarithromycin and levofloxacin resistance, respectively.

CONCLUSIONS

H pylori resistance to clarithromycin increased between 2009 and 2013; resistance to metronidazole remains high in infected men in the United States. The high frequency of resistance to levofloxacin is a new and concerning finding.

Prevalence of Parental Misconceptions About Antibiotic Use

BACKGROUND

Differences in antibiotic knowledge and attitudes between parents of Medicaid-insured and commercially insured children have been previously reported. It is unknown whether understanding has improved and whether previously identified differences persist.

METHODS

A total of 1500 Massachusetts parents with a child <6 years old insured by a Medicaid managed care or commercial health plan were surveyed in spring 2013. We examined antibiotic-related knowledge and attitudes by using χ(2) tests. Multivariable modeling was used to assess current sociodemographic predictors of knowledge and evaluate changes in predictors from a similar survey in 2000.

RESULTS

Medicaid-insured parents in 2013 (n = 345) were younger, were less likely to be white, and had less education than those commercially insured (n = 353), P < .01. Fewer Medicaid-insured parents answered questions correctly except for one related to bronchitis, for which there was no difference (15% Medicaid vs 16% commercial, P < .66). More parents understood that green nasal discharge did not require antibiotics in 2013 compared with 2000, but this increase was smaller among Medicaid-insured (32% vs 22% P = .02) than commercially insured (49% vs 23%, P < .01) parents. Medicaid-insured parents were more likely to request unnecessary antibiotics in 2013 (P < .01). Multivariable models for predictors of knowledge or attitudes demonstrated complex relationships between insurance status and sociodemographic variables.

CONCLUSIONS

Misconceptions about antibiotic use persist and continue to be more prevalent among parents of Medicaid-insured children. Improvement in understanding has been more pronounced in more advantaged populations. Tailored efforts for socioeconomically disadvantaged populations remain warranted to decrease parental drivers of unnecessary antibiotic prescribing.

In-home antibiotic storage among Australian Chinese migrants

OBJECTIVES

To estimate the prevalence of in-home antibiotic storage among Australian Chinese migrants and to identify the risk factors associated with storing antibiotics at home.

METHODS

Four hundred and sixty-nine Chinese migrants in Australia who were recruited through Chinese social websites completed an online questionnaire about antibiotic use. Logistic regression analysis was conducted to assess the associations between possible risk factors and storing antibiotics at home.

RESULTS

According to the web-based survey, 220 (47%) out of 469 participants reported having antibiotics stored at home. Previous use of antibiotics, bringing antibiotics in from outside Australia, and a pro-attitude to the use of leftover antibiotics were significantly associated with storing antibiotics at home after adjusting for age, gender, and household annual income. Participants who self-reported an awareness of antibiotic side effects or resistance had a slightly higher but not significant risk of storing antibiotics at home.

CONCLUSIONS

Approximately half of the participants in this study had antibiotics stored at home. The risk of using the antibiotics stored at home without medical consultation is of concern. Education programs need to target those with high-risk behaviours to curtail the inappropriate practice of antibiotic use and storage among Australian Chinese migrants.

Patterns of antibacterial use and impact of age, race/ethnicity, and geographic region on antibacterial use in an outpatient medicaid cohort

STUDY OBJECTIVES

To describe patterns of outpatient antibacterial use among California Medicaid (Medi-Cal) fee-for-service system beneficiaries, and to investigate the influence of demographic factors-age, race/ethnicity, state county, and population density-on those patterns.

DESIGN

Retrospective analysis of administrative claims data.

DATA SOURCE

Medi-Cal fee-for-service system claims database.

PATIENTS

All outpatient Medi-Cal fee-for-service system beneficiaries enrolled between 2006 and 2011 who had at least one systemic antibacterial claim.

MEASUREMENTS AND MAIN RESULTS

Rates of antibacterial prescribing and the proportion of broad-spectrum antibacterial use were measured over the study period and among age, racial/ethnic, and geographic (county) groups. Of the 10,018,066 systemic antibacterial claims selected for analysis, antibacterial prescribing rates decreased from 542 claims/1000 beneficiaries in 2006 to 461 claims/1000 beneficiaries in 2011 (r = -0.971, p=0.0012; τ-b = -1.00, p=0.009). Among age groups, children had the highest rate of use (605 claims/1000 beneficiaries, χ(2) (2) = 320,000, p<0.001); among racial/ethnic groups, Alaskan Natives and Native Americans had the highest rate of use (1086/1000 beneficiaries, χ(2) (5) = 197,000, p<0.001). Broad-spectrum antibacterial prescribing increased from 28.1% (95% confidence interval [CI] 28.1-28.2%) to 32.7% (95% CI 32.6-32.8%) over the study period. Senior age groups and whites received the highest proportions of broad-spectrum agents (53.4% [95% CI 52.5-54.3%] and 36.6% [95% CI 36.6-36.7%], respectively). Population density was inversely related to both overall antibacterial use (ρ = -0.432, p=0.0018) and broad-spectrum antibacterial prescribing (ρ = -0.359, p<0.001). The rate of prescribing decreased over the study period for all antibacterial classes with the exception of macrolides and sulfonamides. Amoxicillin was the most frequently prescribed agent.

CONCLUSION

Overall and broad-spectrum antibacterial use in the Medi-Cal fee-for-service program are less than that observed nationally. Significant variations in prescribing exist between age and racial/ethnic groups, and heavily populated areas are associated with both less antibacterial use and less broad-spectrum antibacterial prescribing. Studies are needed to determine the reasons for the observed differences in antibacterial use among demographic groups.

Reasons for self-medication and perceptions of risk among Mexican migrant farm workers

Although the frequency of self-medication among Mexican migrants has been well-documented in the public health literature, the multiple reasons for this practice are poorly understood. Most studies point to migrants' cultural preferences for Mexican medications, their prior experiences in countries where antibiotics are loosely regulated, and their lack of access to health care as the primary factors behind their self-medication. Based on participant observation and in-depth interviews with 23 Mexican migrants in a farm working community in the interior of California, we argue that occupational vulnerability is an equally important factor that encourages self-medication. All 23 of our interviewees reported having engaged in some degree of self-medication, notable in this location 8 h from the US-Mexico border. Among interviewees, occupational vulnerability represented an even more important factor influencing self-medication than lack of health insurance or lack of legal documentation. While interviewees did express a preference for Mexican medications as more potent and effective, this did not necessarily translate to a preference for using them without a doctor's supervision. Finally, we show that rather than remaining unaware of the risks of following this custom "transported from Latin America", Mexican migrants devised an elaborate hierarchy of resort of the safest self-medication practices to follow.

Self-medication in adult Latin American immigrants in Seville

OBJECTIVE: To estimate the prevalence of non-prescription pharmaceutical use in the Latin American immigrant population. METHOD: A descriptive, cross-sectional study of a representative sample of 190 immigrants. We used a questionnaire based on the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: In the past six months, 77.4% of the sample self-medicated. The prevalence of consumption of antiinflammatory and non-prescription analgesics was the highest, followed by antibiotics. A statistical difference was observed in non-prescription use of antibiotics by gender. CONCLUSION: The consumption of pharmaceuticals without a medical prescription in the Latin American immigrants in the city of Seville is high.

Changing parents' opinions regarding antibiotic use in primary care

Parents' wish for antibiotics is a significant determinant of antibiotic prescription for their children. The objective of the study was to assess the effect of an educational intervention on parents' attitudes towards antibiotic use. Parents accompanying their children to primary pediatric clinics of Jerusalem-Hashfela District of Maccabi Healthcare Services responded to a survey regarding their wish for antibiotic treatment. Two groups of parents were surveyed: A (control) in a pre-intervention period and B (intervention) during the intervention period. The intervention included posters, pamphlets, and drawing booklets for children in the waiting rooms. A per-protocol analysis that included from group B only parents that stated they noticed the educational material (B1) was also performed. Eight hundred and sixty-eight parents were surveyed during the pre-intervention period and 688 parents during the intervention period. Children's median age was 4 years (8 days-16 years). Most (86%) of the parents were mothers. Groups were similar in socio-demographic characteristics and children's medical complaints. Factors associated with parent's low expectation for antibiotics were a general negative attitude to antibiotics (OR 1.66, 95% CI 1.20-2.30), current upper respiratory tract symptoms (OR 0.29, 95% CI 0.21-0.39), advanced knowledge regarding antibiotics (OR 1.72, 95% CI 1.26-2.34), and being in group B (intervention) (OR 1.47, 95% CI 1.08-2.00). The effect of the intervention was greater in the per-protocol analysis (OR 1.75, 95% CI 1.20-2.55). A simple educational intervention was effective in reducing parents' expectation for antibiotics but was significantly more effective when parents reported they noticed the campaign. Improving parents' knowledge regarding antibiotics can reduce parents' wish for antibiotic treatment.

Antibiotic identification, use, and self-medication for respiratory illnesses among urban Latinos

PURPOSE

The purpose of this study was to describe the extent to which antibiotic and nonantibiotic medications commonly used for upper respiratory infections (URIs) were correctly identified by a sample of urban dwelling Latinas and the association of medication identification with antibiotic use and self-medication.

DATA SOURCES

One hundred women completed an interview and were asked to identify whether a list of 39 medications (17 antibiotics, 22 nonantibiotics) were antibiotics or not, whether anyone in the household had used the medication, their ages, and the source of the medication.

RESULTS

Overall, participants correctly identified 62% of nonantibiotics and 34% of antibiotics. Seventy three (73%) women in the study reported antibiotic use by at least one member of the household in the past year. Among users, self-medication was reported in 67.2% of antibiotics for adults, but in only 2.4% of children. There was no difference in antibiotic recognition between those who self-medicated and those who did not, but antibiotic self-medication was associated with a significantly lower recognition of nonantibiotics (p= .01).

IMPLICATIONS FOR PRACTICE

Measures to improve antibiotic utilization should address self-medication and consider the cultural and social context in which antibiotic use occurs.

Nonprescription antibiotic therapy: cultural models on both sides of the counter and both sides of the border

Antibiotic resistance is a global public health threat exacerbated by medically unwarranted or improper antibiotic use. Pharmacy counters at the U.S.-Mexico border provide an example of where lay decisions to use antibiotics in ways considered "risky" may be initiated and negotiated. We test how cultural and public health knowledge of antibiotics is distributed among pharmacy staff, local Mexican clients, and U.S. medical tourists in the bordertown of Nogales using a cultural consensus tool. We find that shared cultural models across these groups include public health statements; however, other shared statements are likely to reinforce antibiotic sales at pharmacy counters by those on both sides of the purchase as economic, rather than therapeutic, encounters. From a public health perspective, border pharmacy counters are not a location where increased "safe" knowledge about antibiotic use is being transmitted. However, we do find a positive relationship between "safe" knowledge and reductions in risky behavior.

Preferences among immigrant Hispanic women for written educational materials regarding upper respiratory infections

The need for culturally appropriate health education materials for Hispanic populations has been widely recognized, and Spanish-language materials are available through a number of private and governmental organizations. We convened two focus groups to elucidate preferences regarding how health-related messages are obtained and to identify which educational materials available in Spanish were preferred by 26 recently immigrated Hispanic homemakers who had received 15 different bimonthly written documents as part of a community-based clinical trial to prevent household transmission of colds and influenza. Participants gave three primary reasons for volunteering to participate in the study: to provide better care for their children (96.2%, 25/26), to get information (96.2%, 25/26), and to get free products (47.1%, 8/17). Their primary sources of health-related information were relatives and friends (42.9%, 6/14), clinicians (35.7%, 5/14), mass media (14.3%, 2/14) or the emergency room (7.1%, 1/14); none mentioned the internet. Materials using either a question and answer or true/false format were clearly preferred, even when other options were more colorful or had lower reading levels. Printed educational materials may be ineffective unless they include a more systematic assessment of the user's perceived needs for the information as well as consideration of format. In this population, a question and answer or true/false format and materials that could be shared with their children were greatly preferred.

Effect of intensive education on knowledge, attitudes, and practices regarding upper respiratory infections among urban Latinos

BACKGROUND

Although upper respiratory infections (URIs) take a major social and economic toll, little research has been conducted to assess the impact of educational interventions on knowledge, attitudes, and practices of community members regarding prevention and treatment of URIs, particularly among recently immigrated urban Latinos who may not be reached by the mainstream healthcare system.

OBJECTIVES

The objective of this study was to assess the impact of a culturally appropriate, home-based educational intervention on the knowledge, attitudes, and practices regarding prevention and treatment of URIs among urban Latinos.

METHODS

Using a pretest-posttest design, Spanish-language educational materials available from sources such as the Centers for Disease Control and Prevention were adapted based on feedback from community focus groups and provided to households during an in-person home visit every 2 months (generally three to four visits). Outcome data regarding knowledge, attitudes, and practices were collected in home-based interviews using an 85-item instrument adapted and pilot tested from three other validated instruments. Nonparametric and multiple linear regression analyses were used to summarize data and identify predictors of knowledge scores.

RESULTS

Four hundred twenty-two households had complete data at baseline and 6 months. Knowledge and attitude scores were improved significantly, and use of alcohol hand sanitizer and rates of influenza vaccine were increased significantly (all p <.01).

DISCUSSION

Although this home-based educational intervention was successful in improving knowledge, attitudes, and self-reported practices among urban Latinos regarding prevention and treatment of URIs, further research is needed to determine the cost-effectiveness of such a person-intensive intervention, the long-term outcomes, and whether less intensive interventions might be equally effective.