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Expert Review of Anti-infective Therapy
ISSN: 1478-7210 (Print) 1744-8336 (Online) Journal homepage: https://www.tandfonline.com/loi/ierz20
Knowledge, attitude, and practice of self-
medication with antibiotics among community residents in Addis Ababa, Ethiopia
Alemtsehay Adam Bogale, Abebe Feyissa Amhare, Jie Chang, Hewan Adam Bogale, Sintayehu Tsegaye Betaw, Negatu Tadesse Gebrehiwot & Yu Fang
To cite this article: Alemtsehay Adam Bogale, Abebe Feyissa Amhare, Jie Chang, Hewan Adam Bogale, Sintayehu Tsegaye Betaw, Negatu Tadesse Gebrehiwot & Yu Fang (2019) Knowledge, attitude, and practice of self-medication with antibiotics among community residents in Addis Ababa, Ethiopia, Expert Review of Anti-infective Therapy, 17:6, 459-466, DOI:
10.1080/14787210.2019.1620105
To link to this article: https://doi.org/10.1080/14787210.2019.1620105
Published online: 24 May 2019.
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ORIGINAL RESEARCH
Knowledge, attitude, and practice of self-medication with antibiotics among community residents in Addis Ababa, Ethiopia
Alemtsehay Adam Bogalea,b, Abebe Feyissa Amhare c, Jie Changa,b,d, Hewan Adam Bogalee, Sintayehu Tsegaye Betawc, Negatu Tadesse Gebrehiwota,band Yu Fanga,b,d
aDepartment of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China;bCenter for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China;cDepartment of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University, Xi’an, Shaanxi, China;dShaanxi Centre for Health Reform and Development Research, Xi’an, China;eClinton Health Access Initiative, Boston, Ethiopia
ABSTRACT
Background: Self-medication with antibiotics, which may cause significant antibiotic resistance, is predominant in developing countries. The aim of this study is to assess the knowledge, attitude, and practice of self-medication with antibiotics among community residents in Ethiopia.
Methods: A cross-sectional study design was conducted from June to August 2017. Knowledge- Attitude-Practice questionnaire was developed and distributed to eligible household respondents in Addis Ababa and its surrounding area. Logistic regression analysis was used to identify factors asso- ciated with self-medication with antibiotics.
Results: Among the 605 invited participants, 595 respondents were participated in this study (response rate = 98.3%) and 67.3% of the respondents had reported self-medication with antibiotics in the past 6 months. The median score of knowledge about antibiotics was 3 (Inter quarter range: 2–4) of a maximum possible score of 6 and the median score of attitude was 19 (Inter quarter range: 16–22) from a maximum of 29. Self-medication with antibiotics was significantly associated with age, educational status, and average monthly income of the communities.
Conclusions: Respondents have inadequate knowledge and inappropriate practice toward rational use of antibiotics. Policies such as restricting the purchase of antibiotics without a medical prescription and educating appropriate use of antibiotics are urgently needed.
ARTICLE HISTORY Received 9 April 2019 Accepted 14 May 2019 KEYWORDS
Self-medication; antibiotics;
knowledge; attitude;
practice; Ethiopia
1. Introduction
In human medical care, antibiotics are life-saving medicines used for treatment of diseases caused by bacteria. Used prop- erly, they either kill or inhibit the growth of bacteria [1,2].
However, abuse and misuse of antibiotics among general public continues to be a significant problem and responsible for bacterial resistance in both developed and developing countries [3–5]. Antibiotics resistance has become a global public health threat [6]. It causes treatment failures and leads to increased morbidity, mortality, and healthcare cost [4,7–9].
According to the estimates of Centers for Disease Control (CDC) of the United States, two million people suffer from antibiotics-resistant infections disease in the United State every year. At least 23,000 people die from the complications of antibiotic resistance [10].
Self-medication with antibiotics (SMA), defined as antibio- tics use by individuals to treat symptoms/diseases without medical professional advice or prescription, is an important cause of antibiotics misuse，and may accelerate antibiotics resistance [4,11]. A review study reported that SMA has been strongly linked with the development of human pathogen resistance [12]. Moreover, inappropriate use of antibiotics
through self-medication may cause significant adverse effects such as antibiotic resistance, drug-drug interactions, and drug toxicity including death [4,13,14]. SMA is prevalent in both developing and developed countries with loose enforcement of prescription-only regulations [15,16]. SMA is prevalent in different countries among general population as studies reported. For instance, in Southeast Asia countries ranges from 7.3% to 85.59%, in Middle East ranges from 19% to 82% [4,17]. Former studies reported that the overall preva- lence of antimicrobial self-medication among different popu- lation in low and middle income countries (LMICs) were 38.8%
[18]. Moreover, a systematic review in Ethiopia indicates that the prevalence self-medication ranged from 17% to 77.1%, and inappropriate use of medicine was associated with increasing the prevalence of antimicrobial self-medication [18,19]. Thus, such types of practice will become with a serious health-related problem including emergence of antimicrobial resistance [20].
Over the counter sales of antibiotics was common practice among community pharmacies. In some studies involving pharmacy professionals in Qatar and Saudi Arabia among community pharmacy, the main reasons for the nonprescrip- tion sale of antibiotics were the pharmacy owner’s influence in
CONTACTYu Fang [email protected] Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
2019, VOL. 17, NO. 6, 459–466
https://doi.org/10.1080/14787210.2019.1620105
© 2019 Informa UK Limited, trading as Taylor & Francis Group
maximizing profit and weak regulatory mechanisms [21,22]. In addition, in Ethiopia, the negative roles of costumer’s pressure and disagreement between professionals in inappropriate use of medications have also been reported [23]. Therefore, strong regulatory enforcement and community awareness are both required to halt the nonprescription sale of antibiotics.
A prior study done in the communities of Bahir Dar city, Ethiopia reported that the prevalence of inappropriate use of antibiotics was 30.9% [24]. The use of prescription-only medica- tions including antibiotic agents without medical professional advices has become alarmingly high in Ethiopia [20]. A few surveys conducted among selected households, and university students in Ethiopia revealed a high prevalence of self-medica- tion [8,19,20]. Moreover, nonprescription sale of antibiotics were the most commonly dispensed agents among community pharmacies in Addis Ababa, Ethiopia [23]. However, studies on people’s knowledge, and attitude relating to prevalence of SMA in general population is still scarce. Updated research is needed on SMA among general public in Addis Ababa, Ethiopia.
Therefore, this study was aimed at assessing the knowledge, attitude, and the existing practices toward self-medication with antibiotics as well as factors among community residents in Addis Ababa and its surrounding area, Ethiopia. These findings may help to implement effective interventions, reduce miscon- ceptions and inappropriate use of antibiotics.
2. Methods
A quantitative, cross-sectional study design was conducted in Addis Ababa city and its surrounding area from June through August 2017.
2.1. Ethics approval and consent to participates
Ethical clearance was obtained from the Biomedical Ethics Committee of Xi’an Jiaotong University (no. 2017–202) and from health bureau, Ethiopia. Before starting the interview, data collectors informed the study subjects about the purpose the study to get respondents informed consent. Oral consent
was obtained in advance from each selected study partici- pants. They were told that their information to be kept con- fidential and used only for the research purpose and code was used.
2.2. Study areas
Addis Ababa is the diplomatic capital of African Union, and capital city of Ethiopia. Addis Ababa has a population of 3,384,569 according to the 2007 population counts, with strong annual growth rate of 3.8%. Its total area is 540 km2 and it has 10 subcities, 112 districts, and the city divided into 328 dwelling association.
2.3. Sampling
Samples were selected by using multistage sampling tech- nique. In the first stage, 2 subcities (Kirkos and Akaki kality) were selected from 10 subcities of Addis Ababa by using simple random sampling method. Then four districts were proportionally selected from both selected subcities by using simple random sampling. Then 605 households were proportionally selected from the selected districts by using systematic sampling methods. Each selected sampling deter- mined by the Kth value; which was the number of total selected households divided by number of selected sam- pling households. Then every Kth value of households was interviewed; however, the first household was selected ran- domly. During the data-collection period, the house num- bers were used as sampling frames. If one household was unwilling to participate, the next household would be taken.
Then heads of households (representative of families) were interviewed until we reached to the final sample size.
Respondents lived in the past six months were included in the study. Participants with healthcare profession, commu- nication defects like listening and speaking of the local language, having mental problems, and less than 18 years old were excluded from the study.
The required sample size was estimated using a single population proportion formula with 95% CI, 5% margin of error, and 23.3% prevalence of self-medication [25], antici- pated design effect 2, and nonresponse rate of 0.1. Finally, the total sample size of households was 605.
2.4. Study instruments
Literature reviews of similar former studies were conducted to identify the quality of items for the study instrument. Based on the former studies search, the study questionnaire was adopted from validated surveys that were previously used in Kuwait, China, Ethiopia, and Sweden, and were customized based on the local context [13,25–28]. The data were pre- tested on 5% of total sample size population taken from out of study area to check the validity and reliability of the tool.
Necessary modifications were made and pretest data were discarded in the final analysis. Moreover, the questionnaire was translated to a local language, Amharic, then transplanted back into English and checked for consistency.
Article highlights
● About 67.3% of participants had self-medicated with antibiotics in the past six months in the community residents in Addis Ababa.
● Participants had misconception and misbeliefs about the use of antibiotics self-medication.
● The majority of participants (82.3%) purchased antibiotics without a prescription from pharmacy/drug store.
● The most frequent used antibiotics for self-medication were amox- icillin and cotrimoxazole.
● About 45.6% of the participants got information to practice self- medication with antibiotics from pharmacists.
● Most of participants had history of discontinuation, forgetting anti- biotic doses, duration, and frequency during the course of treatment, and sharing antibiotics with others.
● About 56.3% of respondents reported that left over antibiotics stored at home for future use.
● A majority of the participants (60.3%) mentioned the previous experi- ence as the most common reason to use antibiotics.
● The determinants of self-medication with antibiotics were age, edu- cational status, and income.
460 A. A. BOGALE ET AL.
The questionnaire includes four parts. The first part, which contained nine questions, was designed to obtain socio-demographic characteristics such as age, sex, marital status, monthly income, occupation, and educational status.
The second part investigated the respondents’ knowledge of antibiotics and this part contained six questions, assessed using ‘yes,’ and ‘no’ responses. The third part, which contains six questions, was assessed respondents’ attitudes regarding self-medication with antibiotics. Five- point Likert scale (1 = strongly disagree; 2 = disagree;
3 = uncertain; 4 = agree; 5 = strongly agree) was used to determine the attitudes regarding participants’self-medica- tion with antibiotics. The fourth part investigated the respondents’ practice of self-medication with antibiotics and contained 14 questions. These questionnaires were designed to assess the utilization practice of antibiotics among communities.
2.5. Data collection and analysis
Data were collected by pharmacists and health extension work- ers using a structured questionnaire interview. In addition, data collectors were adequately trained on the administration and checking of completeness of the questionnaire. To avoid any biases and to assure the quality of data, we have cross-checked the consistency and completeness of our data after data collec- tion. We have discarded incomplete data. By this method, we could minimize missing information. The data collectors were holding common utilize antibiotics to remind respondents which antibiotics they had used. This was used to minimize recall bias.
All data files entered into Ep-info for recording of variables and data combined and analyzed by using IBM-SPSS version 24.0 software for Windows. Descriptive statistics and logistic regression analysis was performed to identify factors asso- ciated with SMA.Pvalue of < 0.05 was considered statistically significant.
The responses from the knowledge, attitudes, and practice sections were assessed by calculating the frequency and per- centage. Knowledge related questions were estimated using a scoring scheme, with score of 0 for incorrect response and 1 for correct response. The knowledge score was calculated as a continuous variable by summing the participant’s number of correct answer and ranging from 0 to 6. The correct answers of the knowledge items were‘Yes’for Q10 and Q11 and‘No’for Q12- Q15. Attitude-related questions were assessed using the five-point Likert scales scoring scheme. Only Q19 was appropri- ate attitude item and scores of 1, 2, 3, 4, and 5 were assigned to it. Conversely, scores of 5, 4, 3, 2, and 1 were assigned to each inappropriate attitude item (Q16–Q18, Q20, and Q21).
For quantitative analysis, the median score >80% of the pos- sible maximum score was considered good, between 60% and 80% was considered moderate and <60% was considered poor [27,29]. The median score for the knowledge, and attitudes parts were compared based on the demographics of the respondents.
The distribution of median score is not normally distributed and Kruskal–Wallis test were used to evaluate associations between the median score and the characteristics of participants.
3. Results
3.1. Socio-demographic characteristics of respondents Among the 605 invited participants, 595 respondents partici- pated in this study (response rate = 98.3%). Most of respon- dents (38.2%) aged 18–30 years. More than half of participants were female (58.7%). About 32% (precisely 31.9%) had a col- lege and above education whereas 8.4% were unable to read and write. Nearly half of respondents were married (46.7%) and 21.2% had monthly income 500 ETB.
3.2. Knowledge
More than half of respondents (58.7%) had no knowledge of antibiotics which they had used and 63.4% of respondents were unaware that antibiotic overuse can cause antibiotic resistance (Table 1). Approximately 46% (precisely 45.7%) of respondents incorrectly believed that antibiotics and anti-inflammatory drugs are the same drugs, and more than half of respondents incor- rectly believed that antibiotics can be purchased without pre- scription. The median (IQR) knowledge score of respondents was 3 (2–4) from a maximum possible score of 6. This result demonstrated that the respondents had poor knowledge toward antibiotics. There is no statistically significant difference in the median knowledge score regarding rational use of anti- biotics between different demographic groups (Table 2).
3.3. Attitudes
Figure 1 illustrates the respondents’ attitudes regarding rational use of antibiotics. Nearly half of respondents incor- rectly believed that antibiotics are used for common colds (49.9%) and 36.7% agreed that expensive antibiotics are more effective and with less side effect. Forty-seven percent of participants agreed that the effectiveness of treatment would be reduced if the full course of antibiotic treatment was not completed. However, 35.8% respondents believed that intravenous medication is more efficacious than oral medicine. In case of attitude score, the median (IQR) score was 19 (16–22) from a maximum of 29, which indicated a moderate attitude toward SMA. The results of the median attitude score based on demographics of the respondents revealed that people living in Addis Ababa surrounding have a higher attitude score than those living in Addis Ababa, the difference is statistically significant (P = 0.001; Kruskal–Wallis test), as illustrated inTable 2.
Table 1.Knowledge on self-medication with antibiotics among residents in Addis Ababa and its surrounding community (n= 595).
Variables
Frequency (%) Do you know antibiotics that you have used Yes 246 (41.3) Antibiotic overuse can result in antibiotic resistance Yes 218 (36.6) Antibiotic can be used to treat viral infections Yes 275 (46.2) Antibiotics and anti-inflammatory drugs are the same
drugs
Yes 272 (45.7) Antibiotic can be purchased without prescription Yes 317 (53.3) Is it okay to stop taking antibiotic when symptoms are
improving
Yes 214 (36.0)
3.4. Practices
The majority of the respondents (74.5%) explain ill experiences in the last six months. Among those, about 84.9% had used antibiotics for treatment, and 67.3% of them had practiced self-medication with antibiotics; 66.1% had a history of dis- continuation of treatment, whereas 62.2% had a history of forgetting the dose, duration, frequency, and route of admin- istration of the antibiotic. About 30.3% of respondents were sharing antibiotics with friends, families, and relatives. About 56.3% of participants stored antibiotics at their home. More than half of respondents who had such types of leftover of medicines kept in their cabinet (43.7%). Among those who had SMA practice, 52.4% of respondents didn’t check the expiry date of antibiotics during purchasing or before taking.
Among participants, 60.1% had practiced antibiotics self- medication for the treatment of upper respiratory tract infec- tion (URTI). Other illness symptoms for which participants reported SMA were common cold (32.6%), febrile illness (28.7%), diarrhea (27.1%), and malaria (3.7%).
Figure 2depicts antibiotics which respondents used with- out prescription among Addis Ababa and its surrounding community. Amoxicillin (55.7%) was determined as the most likely group of medicines used for self-medication among those practicing self-medication, followed by cotrimoxazole, ciprofloxacin, amoxicillin with clavulanic acid.
Figure 3illustrates reasons of using antibiotics without pre- scription. A majority of the participants (60.3%) reported that a previous experience was the most common reason, followed by mild illness, save time and money, and for emergency use.
This study showed that 45.6% of the participants had got- ten information from pharmacists to practice SMA. Other most common sources of information on SMA were friends and relatives, doctors and nurses, internet, and read packaging label. Figure 4 depicts the sources of antibiotics used for self-medication. Majority of the participants (82.3%) obtained
Table 2.Median knowledge and attitude score based on demographics.
Demographic characteristics
Knowledge score media (IQR) P
value
Attitude score media (IQR) P
value Sex
Female 3 (2–4) 0.063 19 (16–22) 0.864
Male 3 (2–4) 19 (16–22)
Age (years)
18–30 3 (2–4) 0.600 19 (16–22) 0.741
31–40 3 (2–4) 19 (17–22)
41–50 3 (2–4) 19 (16–22)
51–60 3 (2–4) 18 (16–20)
>60 3 (2–4) 19 (16–22)
Location
AA 3 (2–4) 0.178 18 (16–21) 0.001
AAS 3 (2–4) 20 (16–22)
Marital status
Single 3 (2–4) 0.937 19 (16.25–22) 0.126
Married 3 (2–4) 18 (16–21)
Divorced 3 (2–4) 20 (17–22)
Widowed 3 (1.5–4) 19 (16–22)
Educational status Unable to read and write
3 (2–5) 0.378 19 (16–22) 0.957 Able to read and
write
3 (2–4) 19 (16–22)
Primary 3 (2–4) 19 (16–22)
Secondary 3 (2–4) 19 (16–22)
College and above
3 (2–4) 19 (16–22)
Occupation
House wife 3 (2–4) 0.083 18 (16–22) 0.884
Daily labor 2 (2–3.75) 19 (16–22)
Gov’t/NGO 3 (2–4) 19 (16–22)
Trader 3 (2–4) 19 (17–22)
Student 3 (2–4) 19 (16–22)
Pensioner 3 (2–4) 19 (16–22)
Other 2 (1.25–3) 19 (16–22)
Income (ETB)
500 2 (2–3) 0.077 20 (17–22) 0.182
501–1000 2 (2–3) 18 (16–22)
1001–2000 3 (1–4) 18.5 (16–21)
2001 3 (1–4) 19 (16–22)
IQR = Interquartile range, AA = Addis Ababa, AAS = Addis Ababa Surrounding Gov’t = Government, NGO = nongovernment organization, ETB = Ethiopian birr
Figure 1.Attitudes on self-medication with antibiotic among residents in Addis Ababa and its surrounding community (n= 595).
462 A. A. BOGALE ET AL.
antibiotics from pharmacy/drug store, followed by private health institution.
3.5. Factors associated with self-medication with antibiotics
As reported inTable 3, logistic regression model showed that age, educational status, and income were significantly and negatively
associated with SMA. Those aged between 18–30 years [(odds ratio) OR: 8.45; 95% CI (2.55–27.96)], 31–40 years [OR: 4.20; 95% CI (1.36–12.93)], and 41–50 years [OR: 3.22; 95% CI (1.05–9.87)] were more prone to have SMA than those aged greater than 60 years old. Those who are unable to read and write were more likely to practice SMA than those who completed college and above [OR:
6.39; 95% CI (1.45–28.19)]. Participants with income between 501– 1000 ETB were more likely to self-medicate with antibiotics com- pared with participants whose incomes were above than 2000 ETB [OR: 2.55; 95% CI (1.18–5.50)]. No statistically significant difference was found in SMA between different groups of participants in terms of residence, gender, marital status, and occupational status.
4. Discussion
The current study reported the gaps in terms of knowledge, attitude, and practice of SMA in the Addis Ababa and its sur- rounding populations. In addition, high prevalence of SMA and other inappropriate practices regarding antibiotic use, such as keeping leftover antibiotics for future use and sharing antibiotics with others were identified among Addis Ababa residents.
This study revealed that the prevalence of self-medication with antibiotics among Addis Ababa communities was 67.3%,
Figure 2.Antibiotics respondents used without prescription among Addis Ababa and its surrounding community (multiple responses).
Figure 3.Reasons to use antibiotics without prescription among Addis Ababa and its surrounding community (multiple responses).
Figure 4.Source of antibiotics for self-medication among Addis Ababa and its surrounding community.
Table 3.Association of socio-demographic characteristics and SMA within the last six months in Addis Ababa communities.
Variables
Self-medicated with antibiotic (n= 254)
n(%) AOR (95% CI)
Sex
Female 146 (57.5) 0.893 (0.528–1.510)
Male (Ref.) 108 (42.5) 1.000
Age (years)
18–30 124 (48.8) 8.445 (2.550–27.961)**
31–40 60 (23.6) 4.200 (1.364–12.933)*
41–50 43 (16.9) 3.216 (1.049–9.866)*
51–60 13 (5.1) 2.469 (0.703–8.663)
>60 (Ref.) 14 (5.5) 1.000
Location
AA 146 (57.5) 0.821 (0.510–1.320)
AAS (Ref.) 108(42.5) 1.00
Marital status
Single 110 (43.3) 0.520 (0.192–1.407)
Married 109 (42.9) 0.587 (0.266–1.298)
Divorced/
Widowed (Ref.)
35 (13.8) 1.000
Educational status Unable to read and write
26 (10.2) 6.385 (1.446–28.185)*
Read and write 41 (16.1) 1.999 (0.771–5.183)
Primary 31 (12.2) 1.237 (0.515–2.968)
Secondary 75 (29.5) 1.456 (0.739–2.869)
College and above (Ref.)
81 (31.9) 1.000
Occupation
House wife (Ref.) 35 (13.8) 1.000
Daily labor 18 (7.1) 0.572 (0.203–1.611)
Gov’t/NGO 83 (32.7) 1.824 (0.718–4.633)
Trader 33 (13.0) 1.508 (0.569–3.998)
Student 60 (23.6) 1.890 (0.628–5.690)
Other 25 (9.8) 1.195 (0.437–3.263)
Income (ETB) 1.508 (0.569–3.998)
500 (Ref.) 46 (18.1) 1.000
501–1000 74 (29.1) 2.549 (1.181–5.502)*
1001–2000 42 (16.5) 1.076 (0.471–2.456)
2001 92 (36.2) 1.422 (0.622–3.250)
* = significantly associated with SMA at P < 0.05,** = significantly associated with SMA atP< 0.001, ETB = Ethiopian birr, AA = Addis Ababa, AAS = Addis Ababa surrounding
which is higher than studies done in Egypt (23.3%), the United States (25.4%), Indonesia (7.3%), and Kuwait (27.5%) [16,28,30,31]. However, it is comparable with studies done among Chinese university students (47.9%) and children (48.2%), and among Pakistani nonmedical university students (47.6%) [13,16,30–33]. The above difference may be due to the different levels of awareness on rational use of antibiotics across the community, difference in educational status, income, access of modern health facilities, and cultural prefer- ences and beliefs of the study participants [34,35].
This study found that over 46% of respondents incorrectly believed that antibiotics could be helpful for viral infections. It is similar with studies conducted in Karachi city in Pakistan and China [27,33]. It is noted that antibiotics don’t have any effects against viruses; however, they may be helpful to treat bacterial super infections of underlying viral diseases [36].
About 36% of respondents incorrectly thought that they could stop treatment as soon as their symptoms had disap- peared in current study and in line with study done in Kuwait and Lebanon [15,28]. Ceasing antibiotic treatment as soon as the symptoms subside may put the patient at risk of relapse with resistant pathogenic bacteria [28,37]. Thus, incomplete courses of treatment or irrational antibiotic use may lead to spread of antibiotics resistance.
Approximately half of respondents incorrectly believed that antibiotics can cure the common cold in this study, which is in line with the former study done in Lebanon [15]. More than 58.5% of participants agreed that the effectiveness of treat- ment would be reduced if the full course of antibiotic treat- ment was not completed. However, 50.1% respondents believed that intravenous medication more efficacious than oral medicine, which is approximately similar result with the previous study done in China (42.6%), and greater than the other study done in China (39%) [27,38]. The possible reasons for these types of differences are may be based on individuals’ attitude and previous treatment experience.
This study found that the main source of information of antibiotics were pharmacists, followed by friends/relatives.
This shows that pharmacists are responsible for the extensive antibiotic misuse in community. Studies conducted in Euro- Mediterranean region and developing countries have been reported that pharmacists were the main source of informa- tion for SMA [18,39].
The current study pharmacies/drug stores were the main source of antibiotics. Similarly, most of studies have revealed that antibiotics are often available without a prescription in community pharmacy, drug store, and other drug retail outlets including venues such as supermarkets [13,18,19,27,32,40].
Moreover, the US study was done in immigrants reveled that pharmacy or store were the main source of antibiotics used without a prescription [16]. Thus, pharmacists could play an important role in educating patients, rationalizing antibiotic use, and stopping antibiotic sales without a prescription [41].
In the current study the most common reason of SMA including previous experience, mild illness, save time and money, and for emergency use. Besides, some other studies reported that the most frequent reasons cited for self-medica- tion with antibiotics were previous experience, less expensive,
minor illnesses, assumed knowledge on antibiotics, and emer- gency use [8,20].
SMA occurred for different indications and with different antibiotic classes. However, in this study amoxicillin and cotri- moxazole were predominated while systematic study in Middle East showed that amoxicillin and amoxicillin–clavulanic acid combination were predominated [4]. In addition, studies were conducted in Indonesia and WHO Southeast Asia region revealed that amoxicillin was predominated [17,31]. High con- sumption of amoxicillin and cotrimoxazole without prescrip- tion were maybe due to availability in drug retail outlets and at home among study population. It may also be due to the perception of less side effects [42]. This study found that the most common symptoms for which the respondents would self-medicate were mainly those related to the URTIs. These are predominantly viral in origin and therefore not treatable with antibiotics. This finding is concordant with reported results from studies in the Euro-Mediterranean region and developing countries [18,39].
The findings of this study suggest association between the SMA to the low monthly income background, age, and educa- tional status. The findings are similar to that of a study in Middle East countries [4]. In addition, studies reported that gender, age, socio-economic status, marital status, and health insurance as factors of SMA [15,24,31].
We found that there is a misconception that there is a need for antibiotics for symptoms or treated symptomatically such as URTI, common cold, and fever, which could be self-limited. This finding is similar with that of study done in Indonesia and Kuwait [28,31]. This thought is usually present among people with low educational status, according to the findings. Hence, healthcare providers in Ethiopia should be more proactive; they should advise against the use of antibiotics and refer patients to dispensaries and pharmacies for consultations. Monitoring important factors that have influenced self-medication may help to reduce prevalence of SMA use among the communities.
For example, promoting literacy among communities is impor- tant to reduce antibiotic misuse and prevent the occurrence of adverse effects of treatment and antibiotic resistance.
The study has some limitations. First, there are potential recall biases in self-reported SMA. However, to enhance users to recall specific antibiotics and to minimize recall bias, data collectors were holding common utilize antibiotics as sample to remind respondents which antibiotics they had used.
Second, the generalizability of this study might be limited since the study was only conducted in Addis Ababa and its surroundings. However, the sample size for this survey was reasonably large and respondents with diverse demographic and socioeconomic features were sampled, which might help counteract this limitation. The third limitation was the cross- sectional study design by itself has limited ability to confirm the causality of different variables. Thus, future study needs to replicate this finding using longitudinal study design.
5. Conclusions
SMA was common practice among community of Addis Ababa and its surrounding area, which was significantly
464 A. A. BOGALE ET AL.
associated with age, educational status and average monthly income of the communities. Respondents have inadequate knowledge, and moderate attitude toward anti- biotic use. They had a misunderstanding, misconception, and irrational use toward antibiotics. This is the leading cause of antibiotic resistance. Thus, enforcement of antibio- tic policies such as restricting the purchase of antibiotics without a medical prescription, educating professionals and general public to appropriately prescribe, and use of anti- biotics are urgently needed. The government, the Ministry of Health, and health authorities should work together to halt inappropriate use of antibiotics. Pharmacists should play a crucial role by practicing within the expected frame- work of their profession and inform clients about the nega- tive consequences of SMA.
Acknowledgments
Authors are grateful to Addis Ababa health bureau for their cooperation during data collection and Xi’an Jiaotong University for the approval of the proposal. Due thanks should be given to the respondents and data collectors.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Funding
This work was supported by the ‘Young Talent Support Plan’, ‘High Achiever Plan’ of Health Science Center, Xi’an Jiaotong University, and the Central University Basic Research Fund (2015qngz05).
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Author contributions
AA Bogale, AF Amhare, ST Betaw, and HA Bogale have made substantial contributions to the design of the work; reviewed the relevant literature, analyzed the data, and interpreted the results. J Chang and NT Gebrehiwot have contributed to the conceptualization, statistical analyses, and revised the manuscript. Y Fang revised the paper and supervised the study. All authors agreed with the results and approved the final manuscript.
ORCID
Abebe Feyissa Amhare http://orcid.org/0000-0001-5252-3653
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