The use of non-prescribed antibiotics; prevalence estimates in low-and-middle-income countries. A systematic review and meta-analysis.

BACKGROUND: The global increase in the utilization of non - prescribed antibiotics (NPA), is concerning, with high persistence within the low and middle-income countries (LMICs). With a negative impact on the health of individuals and communities the use of NPA paves the way to the  propagation of superbugs that potentially predisposes to changes in bacterial resistance patterns, antibiotic resistance (AR) and antimicrobial resistance (AMR). This study aimed at estimating through a systematic review and meta-analysis, the prevalence of NPA utilisation and describe its primary sources in LMICs. METHODS: The study is a systematic review and meta-analysis which study protocol was registered in PROSPERO (CRD42017072954). The review used The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.  The studies searched in databases were deemed eligible if reported evidence of practices of self-medication with antibiotics (SMA) and the prevalence of NPA utilisation within adult participants from LMICs, published between 2007 to 2017. The pooled analyses were carried out using Meta XL statistical software. The pooled prevalence was calculated with a 95% confidence interval (CI). The risk of bias of the included studies was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS: The review included a total of 11 cross-sectional studies, involving 5080 participants and conducted in LMICs from Asia (India, Laos, Nepal, Pakistan, Sri Lanka and Yemen), Latin America (Guatemala), Africa (Nigeria). All studies reported existing  practices of SMA, with reported prevalence ranging from 50% to 93,8%. The pooled prevalence of SMA was 78% (95% CI: 65-89%). The main sources of NPA were; pharmacies, family and friends, old prescriptions, home cabinet and leftover antibiotics. CONCLUSION: This study revealed a high prevalence of utilisation of NPA in the studied LMICs, these were found to be twice as high in women than men and those participants aged between 18 and 40 years old. The review suggests f considering broader qualitative and comprehensive contextuallized research to better understand the nuances of NPA use. These would be benefitial to uncover uncover gray areas, inform decisions, support the (re) design and implementation of multifaceted interventions towards antibiotic stewardship and conservancy in LMICs.

Identifying the commonly used antibiotics for self-medication in urban Mozambique: a qualitative study.

OBJECTIVES: The study aimed at identifying the commonly used non-prescribed antibiotics (NPAs) and the main health conditions leading to the practices of self-medication with antibiotics (SMAs) in Maputo city, Mozambique. DESIGN: Cross-sectional qualitative study based on individual and group interviews. SETTING: The study was conducted in nine pharmacies of three socioeconomic areas of Maputo city, from October 2018 to March 2019. PARTICIPANTS: The study included 32 pharmacy clients and 17 pharmacists. The pharmacy clients included men 10 (31%) and women 22 (69%) ranging from 19 to 67 years while the pharmacists included men 6 (35,3%) and women 11 (64,7%) with ages ranging from 24 to 47 years. FINDINGS: The majority of the pharmacy clients 30 (93.75%) admitted frequent use of NPAs, 15 (88.2%) out of the 17 pharmacists admitted dispensing NPAs. While the majority of the participants (16) mentioned the use of amoxicillin, also known as 'two colours medicine', 14 mentioned the use of cotrimoxazole and seven mentioned amoxicillin with clavulanic acid. Two to five participants also used tetracycline, ciprofloxacin, azithromycin, doxycycline, erythromycin, metronidazole and phenoxymethylpenicillin. The above mentioned NPAs were used to treat self-perceived sore throat, fever, pain, cough, vaginal discharge, eye problems, the common influenza, urinary infections, respiratory tract infections, wounds and toothaches. CONCLUSIONS: Antibiotics are perceived as essential medical resources to manage health and illnesses. While taking an active role in their health-disease process, participants commonly used amoxicillin, 'two colours', cotrimoxazole and amoxicillin with clavulanic acid to manage their health and that of their families. In this sense, the practices of SMAs were perceived as part of the self-care process and not necessarily as misuse of antibiotics. A wideunderstanding of health-seeking beliefs and behaviours regarding the utilisation of antibiotics is needed to inform public health experts, health policymakers and other stake-holders in designing and implementing public health education and health promotion programsat all levels in Mozambique.

Pharmacists' practices for non-prescribed antibiotic dispensing in Mozambique.

BACKGROUND: Antibiotics are the most frequently used medicines worldwide with most of the countries defining these as prescription-only medicines. Though, dispensing non-prescribed antibiotics represent one of the chief causal factors to the irrational use of antibiotics that paves the way to the development of antimicrobial resistance. OBJECTIVE: We aimed at describing the practices and the enablers for non-prescribed antibiotic dispensing in Maputo city, Mozambique. METHODS: A qualitative study was conducted, between October 2018 and March 2019, in nine private pharmacies randomly selected across Maputo city. Eighteen pharmacists were contacted and seventeen enrolled through snowball sampling. In-depth interviews were conducted, audiotaped, and transcribed verbatim. Transcripts were coded and analysed though thematic analysis with guidelines from Braun and Clark. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist by (Tong, 2007) was performed. RESULTS: Out of seventeen, fifteen pharmacists admitted non-prescribed dispensing of antibiotics. Common antibiotic dispensing practices included; dispensing without prescription, without asking for a brief clinical history of patients, without clear explanation of the appropriate way of administering, without advising on the side effects. Reasons for non-prescribed antibiotic dispensing are linked to patients' behaviour of demanding for non-prescribed antibiotics, to the patients expectations and beliefs on the healing power of antibiotics, to the physicians' prescribing practices. Other reasons included the pressure for profits from the pharmacy owners, the fragile law enforcement, and absence of accountability mechanisms. CONCLUSIONS: The practices of non-prescribed antibiotic dispensing characterize the 'daily life' of the pharmacists. On the one hand, the patient's demand for antibiotics without valid prescriptions, and pharmacist's wish to assist based on their role in the pharmacy, the pressure for profits and on the understanding of the larger forces driving the practices of self-medication with antibiotics - rock. On the other hand, pharmacists are aware of the legal status of antibiotics and the public health consequences of their inappropriate dispensing practices and their professional and ethical responsibility for upholding the law - hard place. Highlighting the role of pharmacists and their skills as health promotion professionals is needed to optimizing antibiotic dispensing and better conservancy in Mozambique.

Pharmacists' practices for non-prescribed antibiotic dispensing in Mozambique

BACKGROUND: Antibiotics are the most frequently used medicines worldwide with most of the countries defining these as prescription-only medicines. Though, dispensing non-prescribed antibiotics represent one of the chief causal factors to the irrational use of antibiotics that paves the way to the development of antimicrobial resistance. OBJECTIVE: We aimed at describing the practices and the enablers for non-prescribed antibiotic dispensing in Maputo city, Mozambique. METHODS: A qualitative study was conducted, between October 2018 and March 2019, in nine private pharmacies randomly selected across Maputo city. Eighteen pharmacists were contacted and seventeen enrolled through snowball sampling. In-depth interviews were conducted, audiotaped, and transcribed verbatim. Transcripts were coded and analysed though thematic analysis with guidelines from Braun and Clark. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist by (Tong, 2007) was performed. RESULTS: Out of seventeen, fifteen pharmacists admitted non-prescribed dispensing of antibiotics. Common antibiotic dispensing practices included; dispensing without prescription, without asking for a brief clinical history of patients, without clear explanation of the appropriate way of administering, without advising on the side effects. Reasons for non-prescribed antibiotic dispensing are linked to patients' behaviour of demanding for non-prescribed antibiotics, to the patients expectations and beliefs on the healing power of antibiotics, to the physicians' prescribing practices. Other reasons included the pressure for profits from the pharmacy owners, the fragile law enforcement, and absence of accountability mechanisms. CONCLUSIONS: The practices of non-prescribed antibiotic dispensing characterize the 'daily life' of the pharmacists. On the one hand, the patient's demand for antibiotics without valid prescriptions, and pharmacist's wish to assist based on their role in the pharmacy, the pressure for profits and on the understanding of the larger forces driving the practices of self-medication with antibiotics - rock. On the other hand, pharmacists are aware of the legal status of antibiotics and the public health consequences of their inappropriate dispensing practices and their professional and ethical responsibility for upholding the law - hard place. Highlighting the role of pharmacists and their skills as health promotion professionals is needed to optimizing antibiotic dispensing and better conservancy in Mozambique

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Patterns of self-medication with antibiotics in Maputo City: a qualitative study.

Background: Mozambique classifies but does not yet enforce antibiotics as prescription-only-medicine (POM) allowing the public access to a variety of antibiotics that otherwise are provided on prescription. This contributes to the growing practice of self-medication with antibiotics (SMA) which systematically exposes individuals to the risk of developing antibiotic resistance, antibiotic side effects and increases the health service costs and morbidity. This study aimed at describing the patterns of SMA among Maputo city pharmacy customers. Methods: A qualitative study conducted between October 2018 and March 2019 was developed with thirty-two pharmacy customers and seventeen pharmacists. Using convenience sampling, customers were recruited after buying antibiotics without prescription from nine private pharmacies. Of the thirty-two participants, twenty participated in in-depth interviews and twelve in two focus groups discussions (FGD) with six participants each. Purposive sampling and a snowball technique were used to recruit pharmacists. The transcripts were coded and analyzed using latent content analysis. Nvivo 11 was used to store and retrieve the data. The COREQ (Tong, 2007) checklist for interviews and FGD was performed. Results: Customers admitted practices of SMA, pharmacists admitted dispensing a variety of antibiotics without prescription. Non-prescribed antibiotics (NPA) were obtained through five different patterns including; using the generic name, describing the physical appearance and using empty package, describing symptoms or health problem to pharmacists, using old prescriptions and sharing antibiotics with family, friends, and neighbors. Conclusion: Different patterns of SMA are contributing to the indiscriminate use of antibiotics among customers. The NPA utilization is perceived as an expression of self-care where participants experience self-perceived symptoms and indulge in self-treatment as a method of caring for themselves. Moreover, antibiotics are mostly used to treat diseases that do not necessarily need antibiotics. Strong and effective public health education and promotion initiatives should be implemented to discourage inappropriate utilization of antibiotics and SMA practices.

Evidence of factors influencing self-medication with antibiotics in LMICs: a systematic scoping review protocol.

BACKGROUND: The Sustainable Development Goals (SDGs) emphasize the need for strengthening the capacity of all developing countries in the early warning, risk reduction and management of national as well as global health risks. Despite there being a considerable amount of effort in controlling and promoting the rational use of antibiotics, studies show that the practice of self-medication with antibiotics (SMA) systematically exposes individuals to the risk of antibiotic resistance and other antibiotic side effects. The proposed scoping review aims to map literature on the factors influencing self-medication with antibiotics in low- and middle-income countries (LMICs). METHODS AND ANALYSIS: The adopted search strategy for this scoping review study will involve electronic databases including PubMed, Web of Knowledge, Science Direct, EBSCOhost (PubMed, CINAHL, MEDLINE), Google Scholar, BioMed Central and World Health Organization library. A two-stage mapping strategy will be conducted. Stage 1 will screen studies through examining their titles and screening abstracts descriptively by focus and method as stipulated by the inclusion and exclusion criteria. In stage 2, the researchers will extract data from the included studies. A parallel screening and data extraction will be undertaken by two reviewers. In accessing the quality of the included studies, the researchers will utilize the mixed methods appraisal tool (MMAT, version 11). The NVivo computer software (version 11) shall be used to classify, sort, arrange and examine relationships in the data, and to extract the relevant outcomes and for the thematic analysis of the studies. DISCUSSION: The study anticipates finding relevant studies reporting evidence on the factors influencing self-medication with antibiotics in LMICs. The evidence obtained from the included studies will help guide future research. The study findings will be disseminated electronically and in print with presentations being done at relevant platforms, i.e. conferences related to antibiotic use, antimicrobial resistance, health seeking behaviour and the use of medicines. SYSTEMATIC REVIEW REGISTRATION: Prospero Registration Number: CRD42017072954.

Mental health care policy environment in Rivers State: experiences of mental health nurses providing mental health care services in neuro-psychiatric hospital, Port Harcourt, Nigeria.

BACKGROUND: Mental health services for Rivers State and surrounding States in the Niger Delta region of Nigeria are provided only at the neuropsychiatric Rumuigbo Hospital in Port Harcourt City, Rivers State, Nigeria. The study explored mental health nurses' experiences of providing mental health services at the hospital in an attempt to understand policy implications, identify difficulties and challenges of delivering mental health care services. METHODS: A qualitative study using in-depth interview was conducted among 20 mental health nurses working at the neuropsychiatric Rumuigbo Hospital. This was reviewed within the Townsend mental health policy template of context and resources domains. RESULTS: A lack of political support and senior position in the Ministry of Health hinders service delivery, the prevalence of institutionalized stigma, a lack of training, and system failure to provide services at all levels of care is hampering service delivery. The inadequate allocation of resources for hospital renovations and equipment is preventing appropriate client care, as does the lack of funding for drugs, the cost of which makes them unaffordable, affecting clients staying on treatment. CONCLUSION: Education and training of mental health care professionals should be given priority to remedy human resource shortage, provide incentives to motivate health professionals for psychiatric practice, and move toward decentralization of care into general health care services. Information should be provided at all levels to overcome the myths surrounding the causes of mental illnesses, to reduce stigma and discrimination of the affected and their families.

Caregiving experiences of families of persons with serious mental health problems in the Niger Delta region of Nigeria.

Mental health services are provided at Rumuigbo Hospital, a single facility that renders psychiatric services in Rivers State and surrounding states in the Niger Delta region of Nigeria. Psychiatric services are not provided at primary health-care clinic or district hospitals, and access to this service can be problematic for many caregivers due to the time and costs involved. Therefore, this study explored the family caregiving experiences of persons with serious mental health problems in terms of the mental health-care policy and health systems environment. A qualitative study using a purposive sampling technique was conducted among 20 caregivers attending a neuropsychiatric clinic in Port Harcourt, Rivers State, Nigeria. The results show that 78% of caregivers lived outside Port Harcourt and 65% had no regular monthly income. Stigma, poor knowledge in managing symptoms of ill relatives, financial implications, lack of support network, and absence of community outreach clinics were found to affect family caregiving experiences. Policies need to be developed and implemented that provide mental health care through primary health-care services to ameliorate families' financial burden, enable early diagnosis and treatment, reduce the need to travel, and improve the quality of life of family caregivers.