Assess, compare community-based antibiotics access and consumption

This study will assess and compare community-based antibiotic access and consumption, and the factors that underpin them, in six countries in Africa and Asia. It will be of particular interest to compare Asia, where over-use of antibiotic use is common, with Africa, where access to antibiotics is more limited (though still uncontrolled). We will use a combination of quantitative and qualitative approaches to systematically investigate understandings about, and use of antibiotics, as well as related health-seeking behaviour and the wider context that affects these behaviours. The results of this study can inform the design of community-based interventions to promote rational antibiotic use in LMICs. 

Study significance & study rationale

Antibiotics are life-saving medicines whose role alongside vaccination and improvements in the social determinants of disease has a profound worldwide impact on individual and public health.1 Lack of access denies these benefits, whilst antimicrobial use and particularly their overuse and misuse, drives AR through selection pressure.Therefore, any unnecessary antibiotic use should be discouraged to reduce antibiotic pressure, while on the other hand ensuring that those who need antibiotics have access to them.

Two recent reports on antimicrobial resistance have illustrated the importance of conducting studies in LMICs where data are scarce and the problem is significant.1, 2 Overuse and misuse of antimicrobials is facilitated in many places by their over the counter (OTC) availability without prescription. Even where this is not the case, access to antibiotics and prescribing practices vary hugely between and often within countries.3 Studies indicate that antibiotic access is lower in Africa as compared to Asia and in particular OTC access appears to be more common in Asia as compared to Africa. For instance, in Vietnam up to 80-90% of antibiotic drug dispensing takes place without prescription and in Thailand OTC antibiotic sales are common in grocery stores without a pharmacy license.4, 5 Data from five African countries show that 30% of the obtained antibiotics were without a prescription, much lower as observed in Asia.4, 6, 7 There are a number of factors, ranging from individual characteristics, to broader economic constraints, cultural norms, social frameworks, healthcare provision and even political structures which can influence how antibiotics can be used.

To be effective, interventions to promote appropriate use of antibiotics in the community would need to consider the wide range of settings where antibiotics may be mis-used.  These range from hospitals to formal and informal drug outlets, households and agriculture. Improving rational use of antibiotics necessitates acknowledgement of the social and cultural factors in the community. However, the factors affecting misuse of antibiotics in LMIC settings with a high burden of infectious diseases remain largely unexplored. This study will provide important new information on community-based human antibiotic use in Asia and Africa and provide potential targets for community-based interventions that can be implemented within various global contexts. The proposed use of standardized methods to study antibiotic use in six LMICs at different levels of economic development is innovative and will lead to important new insights regarding antibiotic use behaviour in LMICs.

Aim of the project

The overall aim of the project is to compare community-based antibiotic access and consumption practices across a range of low and middle-income countries (LMICs) in Asia and Africa in order to inform the design of, and identify targets for community-based intervention strategies that may be used to promote rational antibiotic use. This project provides a standardized framework for appraising current antibiotic use patterns, demand and access, which may subsequently be used in other LMICs.

Research questions

  1. Who are the main suppliers, both legal and illegal, of antibiotics in the studied communities and which antibiotics (registered and unregistered) are supplied?
  2. What are the social, cultural and economic factors that affect antibiotic demand and use in the six sampled LMICs and how do these differ between these countries?
  3. What is the level of community awareness in the six sampled LMICs about antibiotics, antibiotic resistance and their indications for use?
  4. What are the health care-seeking behaviours that lead to antibiotic demand and use in the six sampled LMICs and how does this relate where antibiotics are sourced from? 

Study design


A mixed methods study of quantitative and qualitative approaches will be adopted to assess and compare community-based antibiotic consumption practices in six LMICs in Asia and Africa within the framework of the Capability Approach (see below). The study is iterative in nature in that each round of data collection builds on the previous one (Figure 1).

Figure 1. Sequence of qualitative and quantitative work. Analysis and triangulation will be ongoing over the course of the project, and the outcome will comprise suggestions for development of an intervention. The process of data collection, analysis, and triangulation will all happen in an iterative, temporally concurrent fashion.

Study country and site selection

The project will take place in rural communities of six countries in Africa and Asia that have been chosen based on their income status in 2013, with two countries representing lower income countries (LIC), two representing lower middle income countries (MIC-L), and two representing upper middle income countries (MIC-U). Using the World Bank classification of LMIC (criteria for 2014), we selected the following countries: Bangladesh and Mozambique as LICs, Vietnam and Ghana representing MIC-L, and Thailand and South Africa representing MIC-U. Low-income economies are defined as those with a gross national income (GNI) per capita of $1,045 or less in 2013; lower-middle-income countries have a GNI per capita of  $1,045 to $4,125 and upper-middle-income economies range from $4,126 to S12,746.

In Table 1 we present for each country several key health indicators to compare with the similar indicators for the selected cohort sites presented in Table 2 below. Table 1 clearly illustrates several striking differences between Asian and African countries regarding LMIC classification regarding key indicators with generally African countries showing lower life expectancies and lower human development index (HDI). HDI is a composite index measuring average achievement in three basic dimensions of human development: a long and healthy life, knowledge and a decent standard of living (source: http://hdr.undp.org/en). This study will allow us also to explore how these differences between countries affect the access to appropriate antibiotics and how antibiotics are used. 

To facilitate the study, the chosen countries all contain an INDEPTH community-based study site. INDEPTH (International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries) is a global network of Health and Demographic Surveillance Sites (HDSSs), with 45 member centres and 52 HDSS field sites that study the life events of ~3million people under continuous demographic surveillance in 20 LMICs in Africa, Asia and Oceania. The network was set up in 1998 and has developed tools to measure, map and track the socio-demographic impact of cause-specific morbidity and mortality in LMIC populations using comparable methodologies in different countries.8, 9 INDEPTH can provide a readily available and relevant sampling frame and is therefore uniquely positioned to answer pressing questions on health in community settings, including AR. Several INDEPTH sites have been expressing interest for the last five years to study antibiotic use and resistance within their communities as they consider it a health emergency. For this purpose a Working Group was set up to consider research options that could be considered for INDEPTH.  This study proposal is a product of that Working Group.