The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda

Dominique L Green; Katherine Keenan; Kathryn J Fredricks; Sarah I Huque; Martha F Mushi; Catherine Kansiime; Benon Asiimwe; John Kiiru; Stephen E Mshana; Stella Neema; Joseph R Mwanga; Mike Kesby; Andy G Lynch; Hannah Worthington; Emmanuel Olamijuwon; Mary Abed Al Ahad; Annette Aduda; John Mwaniki Njeru; Blandina T Mmbaga; Joel Bazira; Alison Sandeman; John Stelling; Stephen H Gillespie; Gibson Kibiki; Wilber Sabiiti; Derek J Sloan; Matthew T G Holden; V Anne Smith; Arun Gonzales Decano; Antonio Maldonado-Barragán; David Aanensen; Nyanda E Ntinginya; Alison Elliott; Madeleine Clarkson

doi:10.1016/S2214-109X(22)00423-5

The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda

Dominique L Green, Katherine Keenan^*, Kathryn J Fredricks, Sarah I Huque, Martha F Mushi, Catherine Kansiime, Benon Asiimwe, John Kiiru, Stephen E Mshana, Stella Neema, Joseph R Mwanga, Mike Kesby, Andy G Lynch, Hannah Worthington, Emmanuel Olamijuwon, Mary Abed Al Ahad, Annette Aduda, John Mwaniki Njeru, Blandina T Mmbaga, Joel BaziraAlison Sandeman, John Stelling, Stephen H Gillespie, Gibson Kibiki, Wilber Sabiiti, Derek J Sloan, Matthew T G Holden, V Anne Smith, Arun Gonzales Decano, Antonio Maldonado-Barragán, David Aanensen, Nyanda E Ntinginya, Alison Elliott, Madeleine Clarkson

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

Abstract

Background

Poverty is a proposed driver of antimicrobial resistance, influencing inappropriate antibiotic use in low-income and middle-income countries (LMICs). However, at subnational levels, studies investigating multidimensional poverty and antibiotic misuse are sparse, and the results are inconsistent. We aimed to investigate the relationship between multidimensional poverty and antibiotic use in patient populations in Kenya, Tanzania, and Uganda.

Methods

In this mixed-methods study, the Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6827 outpatients (aged 18 years and older, or aged 14–18 years and pregnant) with urinary tract infection (UTI) symptoms in health-care facilities in Kenya, Tanzania, and Uganda. We used Bayesian hierarchical modelling to investigate the association between multidimensional poverty and self-reported antibiotic self-medication and non-adherence (ie, skipping a dose and not completing the course). We analysed linked qualitative in-depth patient interviews and unlinked focus-group discussions with community members.

Findings

Between Feb 10, 2019, and Sept 10, 2020, we collected data on 6827 outpatients, of whom 6345 patients had complete data; most individuals were female (5034 [79·2%]), younger than 35 years (3840 [60·5%]), worked in informal employment (2621 [41·3%]), and had primary-level education (2488 [39·2%]). Antibiotic misuse was more common among those least deprived, and lowest among those living in severe multidimensional poverty. Regardless of poverty status, difficulties in affording health care, and more familiarity with antibiotics, were related to more antibiotic misuse. Qualitative data from linked qualitative in-depth patient interviews (n=82) and unlinked focus-group discussions with community members (n=44 groups) suggested that self-medication and treatment non-adherence were driven by perceived inconvenience of the health-care system, financial barriers, and ease of unregulated antibiotic access.

Interpretation

We should not assume that higher deprivation drives antibiotic misuse. Structural barriers such as inefficiencies in public health care, combined with time and financial constraints, fuel alternative antibiotic access points and treatment non-adherence across all levels of deprivation. In designing interventions to reduce antibiotic misuse and address antimicrobial resistance, greater attention is required to these structural barriers that discourage optimal antibiotic use at all levels of the socioeconomic hierarchy in LMICs.

Original language	English
Pages (from-to)	e59-e68
Number of pages	10
Journal	The Lancet Global Health
Volume	11
Issue number	1
Early online date	13 Dec 2022
DOIs	https://doi.org/10.1016/S2214-109X(22)00423-5
Publication status	Published - 1 Jan 2023

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This output contributes to the following UN Sustainable Development Goals (SDGs)

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Prof M Holden MRC: Holistic approach to unravel antibacterial resistance in East Africa (HATUA)
Holden, M. (PI), Gillespie, S. H. (CoI), Keenan, K. L. (CoI), Kesby, M. (CoI), Lynch, A. (CoI), Sabiiti, W. (CoI), Sloan, D. J. (CoI) & Smith, V. A. (CoI)
Medical Research Council
1/05/18 → 30/04/21
Project: Standard
Kesby/Keenan HATUA: Holistic Approach to Unravel Antibacterial resistance in East Africa (HATUA)
Kesby, M. (PI) & Keenan, K. L. (CoI)
Medical Research Council
1/05/18 → 31/03/22
Project: Standard

Cite this

Green, D. L., Keenan, K., Fredricks, K. J., Huque, S. I., Mushi, M. F., Kansiime, C., Asiimwe, B., Kiiru, J., Mshana, S. E., Neema, S., Mwanga, J. R., Kesby, M., Lynch, A. G., Worthington, H., Olamijuwon, E., Abed Al Ahad, M., Aduda, A., Njeru, J. M., Mmbaga, B. T., ... Clarkson, M. (2023). The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda. The Lancet Global Health, 11(1), e59-e68. https://doi.org/10.1016/S2214-109X(22)00423-5

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title = "The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda",

abstract = "BackgroundPoverty is a proposed driver of antimicrobial resistance, influencing inappropriate antibiotic use in low-income and middle-income countries (LMICs). However, at subnational levels, studies investigating multidimensional poverty and antibiotic misuse are sparse, and the results are inconsistent. We aimed to investigate the relationship between multidimensional poverty and antibiotic use in patient populations in Kenya, Tanzania, and Uganda.MethodsIn this mixed-methods study, the Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6827 outpatients (aged 18 years and older, or aged 14–18 years and pregnant) with urinary tract infection (UTI) symptoms in health-care facilities in Kenya, Tanzania, and Uganda. We used Bayesian hierarchical modelling to investigate the association between multidimensional poverty and self-reported antibiotic self-medication and non-adherence (ie, skipping a dose and not completing the course). We analysed linked qualitative in-depth patient interviews and unlinked focus-group discussions with community members.FindingsBetween Feb 10, 2019, and Sept 10, 2020, we collected data on 6827 outpatients, of whom 6345 patients had complete data; most individuals were female (5034 [79·2%]), younger than 35 years (3840 [60·5%]), worked in informal employment (2621 [41·3%]), and had primary-level education (2488 [39·2%]). Antibiotic misuse was more common among those least deprived, and lowest among those living in severe multidimensional poverty. Regardless of poverty status, difficulties in affording health care, and more familiarity with antibiotics, were related to more antibiotic misuse. Qualitative data from linked qualitative in-depth patient interviews (n=82) and unlinked focus-group discussions with community members (n=44 groups) suggested that self-medication and treatment non-adherence were driven by perceived inconvenience of the health-care system, financial barriers, and ease of unregulated antibiotic access.InterpretationWe should not assume that higher deprivation drives antibiotic misuse. Structural barriers such as inefficiencies in public health care, combined with time and financial constraints, fuel alternative antibiotic access points and treatment non-adherence across all levels of deprivation. In designing interventions to reduce antibiotic misuse and address antimicrobial resistance, greater attention is required to these structural barriers that discourage optimal antibiotic use at all levels of the socioeconomic hierarchy in LMICs.",

author = "Green, {Dominique L} and Katherine Keenan and Fredricks, {Kathryn J} and Huque, {Sarah I} and Mushi, {Martha F} and Catherine Kansiime and Benon Asiimwe and John Kiiru and Mshana, {Stephen E} and Stella Neema and Mwanga, {Joseph R} and Mike Kesby and Lynch, {Andy G} and Hannah Worthington and Emmanuel Olamijuwon and {Abed Al Ahad}, Mary and Annette Aduda and Njeru, {John Mwaniki} and Mmbaga, {Blandina T} and Joel Bazira and Alison Sandeman and John Stelling and Gillespie, {Stephen H} and Gibson Kibiki and Wilber Sabiiti and Sloan, {Derek J} and Holden, {Matthew T G} and Smith, {V Anne} and Decano, {Arun Gonzales} and Antonio Maldonado-Barrag{\'a}n and David Aanensen and Ntinginya, {Nyanda E} and Alison Elliott and Madeleine Clarkson",

note = "Funding: UK National Institute for Health Research, UK Medical Research Council, and the Department of Health and Social Care.",

year = "2023",

month = jan,

day = "1",

doi = "10.1016/S2214-109X(22)00423-5",

language = "English",

volume = "11",

pages = "e59--e68",

journal = "The Lancet Global Health",

issn = "2214-109X",

publisher = "Elsevier",

number = "1",

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Green, DL, Keenan, K , Fredricks, KJ, Huque, SI, Mushi, MF, Kansiime, C, Asiimwe, B, Kiiru, J, Mshana, SE, Neema, S, Mwanga, JR, Kesby, M , Lynch, AG , Worthington, H , Olamijuwon, E , Abed Al Ahad, M, Aduda, A, Njeru, JM, Mmbaga, BT, Bazira, J, Sandeman, A, Stelling, J, Gillespie, SH, Kibiki, G, Sabiiti, W , Sloan, DJ , Holden, MTG , Smith, VA, Decano, AG, Maldonado-Barragán, A, Aanensen, D, Ntinginya, NE, Elliott, A & Clarkson, M 2023, 'The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda', The Lancet Global Health, vol. 11, no. 1, pp. e59-e68. https://doi.org/10.1016/S2214-109X(22)00423-5

TY - JOUR

T1 - The role of multidimensional poverty in antibiotic misuse

T2 - a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda

AU - Green, Dominique L

AU - Keenan, Katherine

AU - Fredricks, Kathryn J

AU - Huque, Sarah I

AU - Mushi, Martha F

AU - Kansiime, Catherine

AU - Asiimwe, Benon

AU - Kiiru, John

AU - Mshana, Stephen E

AU - Neema, Stella

AU - Mwanga, Joseph R

AU - Kesby, Mike

AU - Lynch, Andy G

AU - Worthington, Hannah

AU - Olamijuwon, Emmanuel

AU - Abed Al Ahad, Mary

AU - Aduda, Annette

AU - Njeru, John Mwaniki

AU - Mmbaga, Blandina T

AU - Bazira, Joel

AU - Sandeman, Alison

AU - Stelling, John

AU - Gillespie, Stephen H

AU - Kibiki, Gibson

AU - Sabiiti, Wilber

AU - Sloan, Derek J

AU - Holden, Matthew T G

AU - Smith, V Anne

AU - Decano, Arun Gonzales

AU - Maldonado-Barragán, Antonio

AU - Aanensen, David

AU - Ntinginya, Nyanda E

AU - Elliott, Alison

AU - Clarkson, Madeleine

N1 - Funding: UK National Institute for Health Research, UK Medical Research Council, and the Department of Health and Social Care.

PY - 2023/1/1

Y1 - 2023/1/1

N2 - BackgroundPoverty is a proposed driver of antimicrobial resistance, influencing inappropriate antibiotic use in low-income and middle-income countries (LMICs). However, at subnational levels, studies investigating multidimensional poverty and antibiotic misuse are sparse, and the results are inconsistent. We aimed to investigate the relationship between multidimensional poverty and antibiotic use in patient populations in Kenya, Tanzania, and Uganda.MethodsIn this mixed-methods study, the Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6827 outpatients (aged 18 years and older, or aged 14–18 years and pregnant) with urinary tract infection (UTI) symptoms in health-care facilities in Kenya, Tanzania, and Uganda. We used Bayesian hierarchical modelling to investigate the association between multidimensional poverty and self-reported antibiotic self-medication and non-adherence (ie, skipping a dose and not completing the course). We analysed linked qualitative in-depth patient interviews and unlinked focus-group discussions with community members.FindingsBetween Feb 10, 2019, and Sept 10, 2020, we collected data on 6827 outpatients, of whom 6345 patients had complete data; most individuals were female (5034 [79·2%]), younger than 35 years (3840 [60·5%]), worked in informal employment (2621 [41·3%]), and had primary-level education (2488 [39·2%]). Antibiotic misuse was more common among those least deprived, and lowest among those living in severe multidimensional poverty. Regardless of poverty status, difficulties in affording health care, and more familiarity with antibiotics, were related to more antibiotic misuse. Qualitative data from linked qualitative in-depth patient interviews (n=82) and unlinked focus-group discussions with community members (n=44 groups) suggested that self-medication and treatment non-adherence were driven by perceived inconvenience of the health-care system, financial barriers, and ease of unregulated antibiotic access.InterpretationWe should not assume that higher deprivation drives antibiotic misuse. Structural barriers such as inefficiencies in public health care, combined with time and financial constraints, fuel alternative antibiotic access points and treatment non-adherence across all levels of deprivation. In designing interventions to reduce antibiotic misuse and address antimicrobial resistance, greater attention is required to these structural barriers that discourage optimal antibiotic use at all levels of the socioeconomic hierarchy in LMICs.

AB - BackgroundPoverty is a proposed driver of antimicrobial resistance, influencing inappropriate antibiotic use in low-income and middle-income countries (LMICs). However, at subnational levels, studies investigating multidimensional poverty and antibiotic misuse are sparse, and the results are inconsistent. We aimed to investigate the relationship between multidimensional poverty and antibiotic use in patient populations in Kenya, Tanzania, and Uganda.MethodsIn this mixed-methods study, the Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6827 outpatients (aged 18 years and older, or aged 14–18 years and pregnant) with urinary tract infection (UTI) symptoms in health-care facilities in Kenya, Tanzania, and Uganda. We used Bayesian hierarchical modelling to investigate the association between multidimensional poverty and self-reported antibiotic self-medication and non-adherence (ie, skipping a dose and not completing the course). We analysed linked qualitative in-depth patient interviews and unlinked focus-group discussions with community members.FindingsBetween Feb 10, 2019, and Sept 10, 2020, we collected data on 6827 outpatients, of whom 6345 patients had complete data; most individuals were female (5034 [79·2%]), younger than 35 years (3840 [60·5%]), worked in informal employment (2621 [41·3%]), and had primary-level education (2488 [39·2%]). Antibiotic misuse was more common among those least deprived, and lowest among those living in severe multidimensional poverty. Regardless of poverty status, difficulties in affording health care, and more familiarity with antibiotics, were related to more antibiotic misuse. Qualitative data from linked qualitative in-depth patient interviews (n=82) and unlinked focus-group discussions with community members (n=44 groups) suggested that self-medication and treatment non-adherence were driven by perceived inconvenience of the health-care system, financial barriers, and ease of unregulated antibiotic access.InterpretationWe should not assume that higher deprivation drives antibiotic misuse. Structural barriers such as inefficiencies in public health care, combined with time and financial constraints, fuel alternative antibiotic access points and treatment non-adherence across all levels of deprivation. In designing interventions to reduce antibiotic misuse and address antimicrobial resistance, greater attention is required to these structural barriers that discourage optimal antibiotic use at all levels of the socioeconomic hierarchy in LMICs.

U2 - 10.1016/S2214-109X(22)00423-5

DO - 10.1016/S2214-109X(22)00423-5

M3 - Article

SN - 2214-109X

VL - 11

SP - e59-e68

JO - The Lancet Global Health

JF - The Lancet Global Health

IS - 1

ER -

The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda

Abstract

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Prof M Holden MRC: Holistic approach to unravel antibacterial resistance in East Africa (HATUA)

Kesby/Keenan HATUA: Holistic Approach to Unravel Antibacterial resistance in East Africa (HATUA)

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