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

Dominique L. Green, Katherine Keenan, Sarah I. Huque, Mike Kesby, Martha F. Mushi, Catherine Kansiime, Benon Asiimwe, John Kiiru, Stephen E. Mshana, Stella Neema, Joseph R. Mwanga, Kathryn J. Fredricks, Andy G. Lynch, Hannah Worthington, Emmanuel Olamijuwon, Mary Abed Al Ahad, Annette Aduda, Blandina T. Mmbaga, Joel Bazira, Alison SandemanJohn Stelling, Stephen Henry Gillespie, Gibson Kibiki, Wilber Sabiti, Derek J. Sloan, Matthew T. G. Holden, Hatua Consortium

Research output: Working paperPreprint


Background: Poverty is a proposed driver of antimicrobial resistance (AMR), influencing inappropriate antibiotic (AB) use in low and middle-income countries (LMICs). However, at sub-national levels, studies investigating poverty and AB use are sparse and the results inconsistent.

Methods: The Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6,827 patients presenting with urinary tract infection (UTI) symptoms in Kenya, Uganda, and Tanzania. Using Bayesian hierarchical modelling, we investigated the association between multidimensional poverty and self-reported AB self-medication and treatment non-adherence (skipping a dose and not completing the course). We also analysed linked qualitative in-depth patient interviews (IDIs) (n = 82) and unlinked focus group discussions (FGDs) with community members (n = 44 groups).

Findings: AB self-medication and non-adherence to treatment courses was significantly more common in the least deprived group compared with those in severe poverty. Adjustment for AB ‘knowledge’, attitudes and socio-demographics diminished the association with self-medication, but not non-adherence. IDIs and FGDs suggested that self-medication and non-adherence are driven by perceived inconvenience of the healthcare system, financial barriers, and ease of unregulated AB access.

Interpretation: Structural barriers to optimal AB use exist at all levels of the socioeconomic hierarchy. Inefficiencies in public healthcare may be fuelling alternative antibiotic access points, for those who can afford it. In designing interventions to tackle AMR and reduce AB misuse, the behaviours and needs of wealthier population groups should not be neglected.

Funding Information: UK National Institute for Health Research, Medical Research Council and the Department of Health and Social Care.
Original languageEnglish
Publication statusPublished - 2021

Publication series

NameSSRN Electronic Journal


  • Multidimensional poverty
  • Antibiotic misuse
  • AMR
  • LMICs


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