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 journalArticlepeer-review

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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 languageEnglish
Pages (from-to)e59-e68
Number of pages10
JournalThe Lancet Global Health
Volume11
Issue number1
Early online date13 Dec 2022
DOIs
Publication statusPublished - 1 Jan 2023

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