CULTURE OF ANTIBIOTIC USE FOR UPPER RESPIRATORY INFECTIONS

AMONG PATIENTS WHO VISITED COMMUNITY PHARMACIES IN DEBRE

BIRHAN

By

Aychluhm Tatek (B. Pharm)

Advisor: Professor Mirgissa Kaba and Kalkidan Solomon

A Qualitative study submitted to the Department of preventive medicine,

School of Public health of Addis Ababa University of the requirement for
medical Anthropology assignment

School of Pharmacy

College of Health Sciences

Addis Ababa University

April 2022

Addis Ababa, Ethiopia

Acknowledgements
First and foremost, praises and thanks to the Almighty God, for His showers of blessings
throughout my short research.

I am also heartily thankful to my advisor Professor Mirgissa and Kalkidan Solomon, who had
been helping, encouraging and guiding me from the inception to the final report preparation of
the research report.

My gratitude also goes to all the study participants who cooperated me in filling the
questionnaire. Without their support, this is research would not have been possible.

Last but not least, I thank community pharmacists who supported me by coordinating the
participants.

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Table of Contents page

Acknowledgements.................................................................................................................................. i
Table of Contents .................................................................................................................................... ii
Abbreviations/Acronyms ....................................................................................................................... iii
Abstract .................................................................................................................................................. iv
1. Introduction .................................................................................................................................... 1
1.1. Background ............................................................................................................................. 1
1.2. Statement of the problem ...................................................................................................... 2
1.3. Significance of the Study ......................................................................................................... 2
2. Conceptual framework ................................................................................................................... 3
3. Objective ......................................................................................................................................... 3
3.1. General Objectives .................................................................................................................. 3
3.2. Specific Objectives .................................................................................................................. 3
4. Methodology................................................................................................................................... 4
4.1. Study Design............................................................................................................................ 4
4.2. Study setting ........................................................................................................................... 4
4.3. Source and Study Population .................................................................................................. 4
4.4. Sample Size Determination and Sampling Techniques ........................................................... 4
4.5. Participant Inclusion and Exclusion Criteria............................................................................ 4
4.5.1. Inclusion Criteria ............................................................................................................. 4
4.5.2. Exclusion Criteria............................................................................................................. 5
4.6. Data Collection and Management .......................................................................................... 5
4.6.1. Data Collector ................................................................................................................. 5
4.6.2. Data Collection Instruments ........................................................................................... 5
4.7. Data Quality Assurance ........................................................................................................... 5
4.8. Data Entry, Clean up and Analysis .......................................................................................... 5
4.9. Ethical consideration and clearance ....................................................................................... 5
5. Findings ........................................................................................................................................... 5
6. Discussion........................................................................................................................................ 9
7. Conclusion .................................................................................................................................... 12
8. References .................................................................................................................................... 13
Annex .................................................................................................................................................... 15

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Abbreviations/Acronyms

AB: Antibiotic

ABs: Antibiotics

AMR: Antimicrobial resistance

HCPs Health care professionals

KAP: Knowledge, Attitude, and Practice

URTIs: Upper respiratory infections

WHO: Word Health Organization

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Abstract

Introduction: AMR is a global problem. The WHO states that “Antibiotic resistance is one of
the major threats to global health, food security, and development today” (WHO,2018).
Inappropriate use and misuse of ABs play a large role in this accelerating problem. Suboptimal
use of ABs is affected by many stakeholders involved in the different steps of the medicine use
chain, i.e., prescribers and their practices, the actual availability of ABs, pharmacy dispensing
practices and patients’ behaviors.

Objective: To assess antibiotics knowledge, attitude, and practice among patients who visited
community pharmacies in Debre Birhan.

Methods: The qualitative, semi-structured interviews followed a guide organized by major

themes such as common symptoms, consultations with doctors and external influences in
decision-making. Patient participants were recruited via convenience sampling. 15 interviews
were conducted among patients using ABs for URTIs purchased with or without prescription.
Data was analyzed using a direct content analysis.

Result: Self-medication with ABs seemed a common practice among patients without
prescription; in some cases, patients tried to persuade pharmacists into selling them ABs
without prescription. Factors, such as time spent going to the doctor, need of a sick leave or
self-persuasion, influenced the decisions of whether or not to seek the doctor for symptoms of
URTIs. Knowledge of ABs and AMR was generally low; however, some patients with
apparently good knowledge practiced self-medication from time to time. Family members and
friends were often involved in decisions about how to handle symptoms of URTIs, especially
among those patients using ABs without prescription. Some patients had noticed ABs
awareness campaigns, and from these a very few reported having learned something important
from them.

Conclusion: Several features of patients’ knowledge, attitudes and regarding AB use in daily
life in Debre Birhan have been documented through carrying out and analyzing 15 interviews.
Many of the identified patterns can be claimed to be involved in increasing the risk of AMR.

Key words: Antibiotics; Antimicrobial resistance; Qualitative; Knowledge;

Attitude; Practice; Patient perspective; Debrebirhan; Community pharmacy
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1. Introduction

1.1. Background

Antimicrobial resistance (AMR) is a global problem. The World health organization (WHO) states
that “AMR is one of the major threats to global health, food security, and development today”
(WHO,2018). Inappropriate use and misuse of ABs play a large role in this accelerating problem.
Suboptimal use of ABs is affected by many stakeholders involved in the different steps of the
medicine use chain, i.e., prescribers and their practices, the actual availability of ABs, pharmacy
dispensing practices and patients’ behaviors. Inappropriate use is influenced by both attitudes
towards and knowledge of ABs, which are factors on an individual level; however, these factors
are affected by the context in which patients and health care professionals (HCPs) live and practice
((Horvat OJ. et al, 2017); (Zajmi D. et al, 2017); and (Kaae S. et al., 2017)).

In spite of the increasing number of governments around the world devoting attention and
resources to revert and reduce AMR (Amin et al., 2020), AMR continues to threaten the effective
AB treatment of an increasing range of infections caused by bacteria, parasites and fungi (Ferri et
al., 2017).

Bacterial resistance to ABs in infectious processes has been increasing in recent years and has
become a serious public health problem (CDC, 2013). And also, WHO stated that bacterial
resistance to ABs is one of the main health problems worldwide, as it prolongs hospital length of
stay, increases treatment costs and, even more seriously, considerably increases mortality related
to infectious diseases (WHO, 2017).

In order to strengthen appropriate ABs use and to prevent further AMR, a deeper and more nuanced
understanding of patients’ and HCPs’ knowledge, attitudes and actual behaviors related to AB is
needed. Studies on this have been carried out during the recent years in a number of WHO
European Region countries. The combination of multiple aspects involved in patients’ and HCPs’
AB decision-making imply that these processes are more complex than previously reported (Kaae
et al., 2017; Arianit et al., 2019; Kaae et al., 2020)

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 1.2. Statement of the problem

The assessment of knowledge, attitude, and practice (KAP) of patients and health professionals
toward ABs has become the prominent in the AB use due to the practice of HCPs and the patient’s
behavior on antibiotics. And also, there is a problem that I had observed with patients’ use of ABs,
pharmacy practices of selling ABs without prescriptions and physicians’ prescribing behaviors in
Debre Birhan. To address these problems, I need for a deeper understanding of why these situations
occur. The aim of the study was therefore to explore the KAP of users, pharmacists and prescribers
towards ABs. Since I have a limited time to address all of the users, pharmacists and physicians’
perspectives, I preferred to did with the patients or users for the time being.

1.3. Significance of the Study

This study aimed to enhance the KAP of the patients toward AB use. The patients have to have
knowledge about ABs to decrease an increased rate of AMR. Currently as findings indicate that
AMR is not only from the HCPs practice but it is also from patients’ behavior of AB use.

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2. Conceptual framework

3. Objective

3.1. General Objectives

• To assess the KAP of patients on ABs use in Debrebirhan

3.2. Specific Objectives

• To assess patients’ knowledge towards ABs use

• To determine patients’ attitude towards ABs use

• To evaluate patients’ practice towards ABs use

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 • To assess patients’ knowledge on AMR

4. Methodology

4.1. Study Design

According to Shabani Z. and Redican K. (2018) as the aim was to, more in-depth, explore KAP of
AB use, a qualitative approach was most appropriate. The qualitative study was conducted by
interviewing the patients individually. Semi-structured, individual; interviews were conducted
with two groups of people; these were: Patients who recently received a prescription for the ABs,
and patients who recently received the ABs without a prescription (i.e., bought it directly at a
pharmacy), were from the key persons in the process of handling and using ABs other than the
HCPs.

4.2. Study setting

The study was conducted at community pharmacies in Debrebirhan town. Debrebirhan is one of
the oldest towns in Ethiopia located about 130 km northeast of Addis Ababa. It also located at a
highland area and has an elevation of 2,840 meters above sea level. It was an early capital of
Ethiopia and was one of the capitals of the kingdom of Shewa. Today, it is the administrative
center of the Semien Shewa Zone of the Amhara Region. The town has more than 105,000
population.

4.3. Source and Study Population

Patients who were coming to the community pharmacies with or without prescription for the
request of antibiotics were the study population and the ABs users of the town were the source
population.

4.4. Sample Size Determination and Sampling Techniques

The qualitative study of 15 patients were selected with convenience sampling technique and the
patients who were willing to give their consent were participate on the interview.

4.5. Participant Inclusion and Exclusion Criteria

4.5.1. Inclusion Criteria

Inclusion criteria was individuals who were coming to the community pharmacies with or without
prescription for ABs.

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 4.5.2. Exclusion Criteria
Exclusion criteria was individuals who refused to give their consents.

4.6. Data Collection and Management

4.6.1. Data Collector

All the data were collected with myself by interviewing the patients and document their opinions.
Before data collection, the purpose, confidentiality and significance of the study were explained
and questionnaires were administered to the voluntary patients through interview. The
completeness of the collected data was checked on the same day.

4.6.2. Data Collection Instruments

The questionnaire was prepared based on previous literature done by Arianit J. et al. (2019). The
tool has two major categories: patients with prescription and patients without prescription for
URTIs.

4.7. Data Quality Assurance

Pre-testing was carried out on 3 patients. Based on this, all the necessary modification such as
restructuring the questionary, skip pattern of the instrument and general procedures of the research
were made.

4.8. Data Entry, Clean up and Analysis

The data was collected from the individual was done by interviewing qualitative questionnaire to
the patients from April 6-8, 2022. The collected data were interpreted as the patient’s qualitative
idea without modification. The patients’ individual opinions were written with quotation.

4.9. Ethical consideration and clearance

Support letter was obtained from the Department of preventive medicine, school of public health,
college of health sciences of Addis Ababa university. Respondents were informed about the
purpose of the study, and why and how they were selected. They were also assured about the
confidentiality of the information obtained and the fact that their participation was voluntary.

5. Findings
This section presents the main results for patients with and without prescription of an AB within
Debrebirhan town.

Patients With Prescriptions

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Patients with prescription agreed to participate in the study were 9 out of whom 4 were females.
The age span of these were from 22 to 50 years old and all had grade 8 to first degree educational
level.

Common Symptoms Related to AB Use

Symptoms often reported by patients with prescriptions included runny nose, dry cough, fever,
loss of voice and sore throat. The duration of symptoms varied from 2 to 10 days. Often, patients
waited from 1 to 5 days before going to the doctor, hence experiencing persisting symptoms.

Use of Leftovers, Checking Internet and the Influence of Friends and Family

Some patients said they would not use medicine from the home cabinet; one of the patients
answered the question with “No, it is better to consult a doctor to avoid complications. My mom
is of the same opinion that it is better to go to the doctor. She is a doctor specialist and she knows
better” (female, 23). Others were of a different opinion “I’ve always got a supply of ABs at home”
(female, 50). She also stated frequent use of AB.

Few patients searched the Internet for information about their symptoms online, but one
specifically said he searched for the clinical guidelines. Others had used the Internet on previous
occasions to find out how an AB works in the body and how to take them: “I know that ABs do
not always help and the organism can get used to it. I learned it from the Internet” (male, 25).

Often patients discussed their symptoms with relatives including parents, children and spouse
before seeking the doctor: “Well, I talked with my father and he told me to better go to the doctor”
(male, 25); or “I discussed them with my husband” (female, 48). The recommendations that
patients often received from their family members were to go to a doctor.

Particularities of Consultations With Doctors and Choice of AB

The reasons for going to the doctor were either to get a treatment for their persisting sickness, often
when symptoms were unknown to get a confirmation of their own diagnosis, to get a sick leave or
to get both treatment and a sick leave. Hence, visits to public sector doctors were more popular
when the patient was in need of getting a note to justify absence from job or studies. During the
consultations with doctors, patients said they were examined (throat examination and lung
auscultation) and asked about symptoms. In some cases, tests of blood, urine, and x-ray were
conducted at the time of the consultations with their doctors.

Three patients said they did not receive a clear and specific diagnosis. Two patients did not report
any diagnosis, often as they did not remember it. The rest four reported specific diagnoses such as
acute respiratory illness, acute laryngitis, tonsillitis and sinusitis. The patients were almost never
consulted in the choice of AB or treatment options, although they were given instructions on how

6
to use AB: “The doctor asked for the symptoms and listened to the lungs, prescribed treatment. He
didn’t say the diagnosis, I didn’t ask” (male, 25).

The most common ABs chosen by doctors were amoxicillin and co-amoxiclav. Two patients
specifically mentioned that they were in favor of the doctor’s decision to prescribe AB, thereby
illustrating them reflecting over the doctor’s decision: “Well, naturally it was a doctor who choose
to prescribe me an AB, and I agreed” (female, 48). According to the patients, doctors spent more
time on explaining how to use the AB, than discussing why it was needed.

Encounter at the Pharmacy

Patients described the choice of pharmacy as based on convenience, either because they lived or
worked close to the pharmacy or the pharmacy were at the health facility or clinic itself, or because
of economic reasons (city budget pharmacy or having a discount card). Often patients reported
that the pharmacists did provide instructions on how to use the AB but not on special
considerations regarding the use of it.

Patients’ Knowledge About AB Treatments and Reactions Towards AMR Campaigns

Patients often mentioned that Abs kill bacteria and some said that ABs do not work on viruses. For
example, one patient said “As people say, they kill germs and bacteria” (female 48), another patient
said “I think they just kill the infection. Probably, not only the infection, but they kill also good
bacteria” (male, 45). Some patients said that they did not know how ABs work in the body. For
example, that the body can get used to ABs and that it gets weaker: I know that antibiotics do not
always help and the organism can get used to it” (female, 39), “Once I heard that antibiotics destroy
our own immunity” (male, 22). A few patients described that Abs should be used only in severe
cases, one patient additionally mentioned that it was acceptable only when prescribed by the
doctor: “When ABs are really necessary to a person and the doctor prescribes them” (male, 30).
Only one patient specifically referred to AB resistance “when taking them in the case of a non-
bacterial infection, it may result in antibiotic resistance later” (male, 24).

The sources of knowledge mentioned were TV, leaflet of the medicine, internet, books,
pharmacists and doctors. In general, patients had not noticed any AB campaigns.

Patients Without Prescription

Patients without prescription agreed to participate in the study were 6 out of whom 2 were females.
The age span of these were from 21 to 59 years old and all had grade 10 to first degree educational
level.

Common Reported Symptoms

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Repeatedly patients without prescription experienced symptoms like severe sore throat, sneezing,
cough, headache, fatigue and fever. The symptoms had lasted between 3 and 6 days before getting
an AB: ‘I had my nose congested, running nose, constant sneezing, also fever and headache’ (male,
52). In many cases, patients had experienced the symptoms in an earlier illness episode and got a
diagnosis (such as bronchitis, tonsillitis, sinusitis, pharyngitis), thus suspecting that the same was
happening now.

Motivations to Avoid Consulting a Doctor

Most of the patients avoided going to the doctor because they did not want to take a sick leave or
had no time: “I did not have time for a doctor at all; I was busy in my work” (male, 36). Another
mentioned that it is a waste of time, as the doctor rarely will prescribe AB or the patient knew for
sure which AB they would prescribe: “They prescribe the same things every time and I know what
they will prescribe me” (male, 45). Other reasons included that the condition was not serious
enough to seek the doctor ‘I thought the illness was not so serious to seek a doctor, and I felt myself
satisfactory’ (male, 52), or that there was no need as they themselves knew the diagnosis “You
only go to the doctor when experiencing specific symptoms for the first time: Because this is not
the first time this illness occurs” (female, 33).

Use of Leftovers, Checking Internet and the Influence of Friends and Family

Nearly half of the patients checked the home medicine cabinet and found some ABs. One patient
said: “I checked and found 10 capsules of amoxicillin from a previous illness and started taking
it” (male, 21). Another found Ciprofloxacin and then started self-medicating with this for fever,
cough and pain when swallowing: “when checking the home medicine cabinet, and I found a
suitable AB. We bought it last time when our daughter fell ill” (female, 59). However, some of
participants responded that they checked their medicine cabinets, but did not find any AB or that
the medicines were not sufficient. For example, in one case, the cabinet was checked, one tablet
of AB was found: “I gave it to my wife. She felt better, so we decided that she needed to take a
course of this AB” (male, 45).

A few patients check their symptoms online. Patients repeatedly discussed their symptoms with
their relatives or partners before going to the pharmacy and were encouraged to take AB: ‘Yes, I
told to my friend and she said that I needed an AB from the community pharmacy’ (female, 33).

Choice of Pharmacy and Choice of ABs

Patients made their choice of pharmacy on whether the pharmacy would normally sell AB without
a prescription or not: “This is not the first time I have taken ABs, thus I already know where the
pharmacies are strict, where they will immediately tell me: ‘Give me the prescription’ and where
I can just come and buy an AB” (female, 33). And also, some patients said that they choice the
pharmacy where they could buy their AB was from their friends or relatives’ pharmacy. when

8
patients knew exactly the name and dosage of AB they needed and displayed absolute confidence
when buying the AB at a pharmacy.

Most of the patients bought Amoxicillin 500mg. All patients recalled the exact name and dosage
of the AB they bought. While Others purchased ABs included Amoxiclav, Azithromycin,
Ciprofloxacin. The patients often choose the AB and the dosage based on what they saw on the
Internet, or according to s/he received a prescription for such AB in the past. In the majority of
cases, the selling of antibiotics without prescription was straightforward. Some patients said that
“Yes, you can buy it without a prescription in the private community pharmacy.” Some patients
reported they used AB without prescription from 3 up to 6 times a year.

Patients’ Knowledge About AB Treatments, and Reactions Towards AMR Campaigns

Most patients talked about ABs killing infections, but only a few mentioned antibiotic resistances
as a problem, and often they said that they did not have any sound knowledge about ABs. However,
one patient mentioned that ABs cannot be used for viruses. one patient answered that AB should
not be used when there is an antibiotic resistance, and others said that it should not be used when
the body can recover by itself.

Half of the patients said that optimally doctors should prescribe AB for a confirmed diagnosis, or
at least someone with medical education should suggest ABs. Few patients knew about AB´s
potential impact on the gut and some of the patients talked about allergy related to ABs. More than
half of the patients said they did not see or did not remember any campaigns regarding use of ABs.
But one patient reported coming across a campaign: “yes, I heard that it is advisable to consult a
doctor in the case of a cold and not to self-medicate. And not start taking antibiotics on your own,
as they can be unnecessary” (male, 36). One other patient described that he had noticed specific
AB campaigns but had not paid any attention to them: “Well, there were some but I did not read
carefully nor paid much attention” (male, 45). He mentioned brochures he saw while waiting for
doctors in the hospital. The knowledge the respondents said they gained from campaigns
concerned prohibition to use AB unnecessary or without doctor’s prescription and the fact that AB
works on bacteria, but not viruses.

6. Discussion
Self-medication did not seem an uncommon practice in Debrebirhan town; however, in some
cases, patients had to insist and encourage pharmacists to get an AB without prescription. Factors
such as time spent going to the doctor, need of a sick leave and self-persuasion influenced the
decisions whether or not to consult doctors for URTIs symptoms. Knowledge of AB and AMR
was in general low; however, even some patients with high knowledge self-medicated at times.
Family members and friends were often involved in decisions around how to handle symptoms of
URTIs. Some patients had noticed AB campaigns, and of them few said they had learnt something
important about ABs from them.
9
Practice of Self-Medication

Practice of self-medication was identified in this particular study and described by patients using
ABs without prescriptions and how they made pharmacists give them ABs anyway. Attention on
how to support pharmacies and pharmacists to comply with current regulations appear to be of
importance. In studies done in Europe countries the confirmed former identified practices such as:
a) confirmation-seeking of symptoms by patients; b) how to respond appropriately to these by
searching the internet and/ or discussing it with friends and families; and c) checking/using ABs
from the home cabinets. However, this study identified some additional new important elements
in these practices. For example, how patients can get both encouraged but also scared when
searching the internet and their specific reflections about using leftover ABs. Hence, this study
shows that these processes influence the patients’ further choice of action regarding use of AB,
and therefore must to be investigated more in-depth in the future.

Low Awareness of AMR Related Threats

There was a great variation of knowledge about AB among the interviewees. Very few patients
can talk knowledgeably about the AMR and its future impact on the health of the community. Most
of the interviewees had not knowledge about the AMR and the related threats it cause. Studies
showed that although AMR might be perceived as a future big problem for the community, there
is little appreciation of the individual impact to it (Bakhit et al., 2019). This study’s results also
show that poor awareness of AMR and believing that antibiotics were effective for URTIs were
more often reported among those participants using ABs without prescription. This perception is
in line with the findings from Roope et al. in the quantitative study conducted in the UK with an
online survey among the general public (Roope et al., 2015).

Poor Impact of Scarce Campaigns

Even though a few patients described specific messages given in the campaigns such as: the need
to consult a doctor; ABs don´t kill viruses; not to start self-medicating with ABs, AB campaigns
seemed to have very limited effect. The scarce impact of information campaigns or even the
paradoxical consequence of information or awareness-raising campaigns has been previously
documented (Bakhit et al., 2019; Röing et al., 2020). Bakhit et al. showed that information
campaigns to reduce AMR might risk a paradoxical consequence of actually increasing public
demand for antibiotics (Bakhit et al., 2019). The qualitative Swedish studies conducted by Röing
et al. highlight the fact of designing better-suited and more inclusive public educational campaigns
that put more emphasis on behavior change (Röing et al., 2020).

Studies have shown a relatively weak negative association between individuals with sufficient
health literacy and the likelihood of a recent history of AB use (Salm et al., 2018). Although I did
not include health literacy in my study, I did find that sometimes a relatively good knowledge of
AB was not aligned with attitudes towards ABs. This might indicate that providing knowledge on
10
AB use, and AMR alone does not suffice to contain the spread of AMR and that specific behavior
change actions are needed. This important learning outcome also should be considered when we
exactly designing a better-suited future AB campaigns (Röing et al., 2020).

Interpretation of Behaviors and Essential Differences Between Participants With and

Without Prescription

Participants’ motivations to use AB for URTIs can be understood through the lens of 4 major
phenomenological concepts: time, intentionality, perception and agency (SGaD, 2021). Time-
related considerations seem to have influenced many participants to choose a shortcut and self-
medicate. Confronted with similar symptoms that those experienced in the past, the need to use
time to go to the doctor is perceived as a waste of time for those using ABs without prescription.
It is also perceived as a waste of time to be sick, and the interviewees expressed the wish to go
back to work as soon as possible and continue with their everyday duties and responsibilities and
avoid loss of income due to illness. Time is also a determinant factor for those choosing to go to a
doctor, especially for those wanting to get a sick leave, a paper documenting that they are actually
sick and need to take days of work off, time off. Whether there is a correlation between the type
of work or the socioeconomic status of the participant and the wish to safe time or take time off,
my study cannot say, but time is definitively a category that showed up during many conversations
with the interviewees.

A further question could be, in the light of more appropriate knowledge about how AB works and
the AMR threats, my data shows that even when an acceptable level of knowledge is present and
appropriate, participants decided to self-medicate and thus use AB without any prove of their
actual need. Time and its use seem to be a more significant factor than a rational use of AB. To
change subjective perceptions of time and temporality seem to exceed any health promotion
campaign targeted towards a more appropriate use of AB, as it is a category firmly embedded in
our societal rhythms. Nevertheless, being aware of its importance might be useful to shape future
awareness raising campaigns.

Participants’ behaviors are also driven by intentionality. Many participants using ABs without
prescription referred to a very clear pattern of intentionality when choosing a pharmacy to get AB,
and it was clear to see that, beyond issues related to the prize of AB, knowing whether a given
pharmacist will be more or less open to sell AB without prescription was a determinant factor for
choosing a pharmacy. Patients will scan the landscape of available pharmacies until they find that
specific one that will sell ABs without a prescription being presented, accepting hand written
prescriptions, or not collecting the prescription once the AB has been sold.

This study shows that patients’ perceptions of the need for ABs are strongly linked with their
behaviors, sometimes more than knowledge about AB. Perceiving a need for AB is thus subjective
and changeable and it is time and space dependent. Participants expressed the importance of
consulting others, but they also often expressed that they had already had the symptoms for at least
11
2 days or even longer. The perception of severity of symptoms and thus in need of AB was not the
determinant differential factor between patients with and without prescription, as it was the
subjective perception of need. To tackle perceptions in healthcare is a considerable challenge that
can often be solved by a point-of-care test rather than by conviction, knowledge or sensitization.

Patients’ actions are driven not by theoretical wondering of future consideration about AMR, but
about practical concern, and this is what drives their sense of agency. The phenomenology of
agency sustains that, in order to cope, in order to take action, we do not need a very high order of
consciousness, and that sometimes a very thin, pre-reflexive awareness suffice. We do see this
pattern in the way the interviewees explained why they took action and went to the doctor or when
directly to the pharmacy. An even more pragmatic approach can be intuited among those going
directly to the pharmacy. It is perhaps unrealistic to expect deeper reflections for their rationale
behind using AB without prescription. It would be perhaps more appropriate to expect a deeper
reflection of their actions among healthcare professionals.

7. Conclusion
Several features of patients’ knowledge, attitudes and regarding AB use in daily life in Debre
Birhan have been documented through carrying out and analyzing 15 interviews. Many of the
identified patterns can be claimed to be involved in increasing the risk of AMR. These include
patients’ reliance on own judgements and self-medication, that may lean on previous illness and
therapy history, information from the Internet or family and friends. Other patterns identified were
assumed lack of time to see the doctor, relatively easy access to ABs without prescription at
pharmacies or leftovers in medication cabinets at home, and not enough knowledge about proper
use of ABs. These findings can serve as a basis to build future initiatives to follow proper use of
ABs.

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Annex
Part one

Qualitative interview for Culture of Antibiotic use for URTI @Debrebirhan

Interview-guide – Patients with prescription

Introduction
• Introduce yourself and introduce the study. Tell what the interview will be used for.
• Ask permission to record the interview on tape
• Assure anonymity of the interviewee
• Ask the interviewee to introduce her/him-self, including age, occupation and where they
live
Last face-to-face consultation with physician leading to prescription for an AB for an URTI
Process of diagnosis of AB
• When was the last time you got a prescription for an URTI (should be within the last 3
months)
• What was the situation – what were the symptoms of the patient – for how long?
• Did you have any idea what kind of disease you were suffering from?
• Did you come here by your own initiative or were you encouraged by family, colleagues
or friends?
• Which doctor did you seek – why this doctor?
• What did you want from the doctor?
• What did you expect from the doctor?
• How did the consultation go? What happened? What was said – by whom?
• Did the doctor make a diagnosis/ examine you? If yes, how and do you know what the
diagnosis was?
Why a specific AB was chosen / Satisfaction with AB prescription process
• Who chose to use an AB? / Were you involved in this decision?
• If the doctor solely made the decision – was any explanation given why to use an AB?
• What AB was chosen? (With regard to product name, form and strength)
• Were you involved in the decision of what specific AB to use?
• If yes, please describe how. If the doctor chose the AB, did he/she explain why to use this
specific AB?
• Did the doctor give any instructions on how to use the AB?
• If yes – which ones? Were the instructions given written or orally?
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 • Were you satisfied with the way the consultation went?
• If yes, why? If no, why not?
Where was the AB purchased/ Satisfaction with AB purchase process?
• Where did you purchase the AB prescribed by your GP?
• Why did you choose this place?
• Please describe the circumstances of the purchase? What happened? What was said – by
whom?
• Were you involved in which specific AB was purchased? (due to generic substitution or
availability of the drug in the etc.) If yes, please describe how.
• Did the pharmacist give any instructions on how to use the AB? If yes – what were they?
• Was the instruction given written or orally?
• Were these instructions similar to the ones provided by the doctor?
• If the pharmacist changed your medicine to another brand - how did you feel about this?
• Were there any challenges with regard to the purchase in terms of price; was the drug in
stock in the store, etc.?
• How much medicine did you purchase? Did you purchase all the necessary AB
immediately? If not, why so?
• Were you satisfied with the way the purchase went? If yes, why? If no, why not?
Use of AB/ Satisfaction with AB use
• When you came home - how did you use the AB? (How many tablets/ dosages per day for
how long?)
• Did this use correspond with the instructions given by the doctor or pharmacist? If yes,
why? If no, why not?
• Did you experience any challenges with taking the AB? If yes, which ones
• Did the AB alleviate or cure your symptoms? If yes, please explain how and how quickly?
• Did the original symptoms reoccur?
AB use in general
The last time compared to other times
• Have you had AB prescribed before?
• If yes, approximately how many times? When did it take place?
• What were the symptoms – for how long?
• Did you have any idea what kind of disease you were suffering from?

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 • Did the consultations you had with your doctor at these times resemble the last time you
received a prescription? Did you also receive a prescription at these times?
• Was the diagnosis carried out the same way as the last time you had an AB consultation?
If no, describe how it usually took place.
• Was the way the AB was chosen previously similar to the last time you had an AB
prescription? If no, please describe how it usually took place.
• Did the doctor give similar instructions about how to use AB compared to the last time you
had an AB prescription? If no, please describe how it usually took place.
• Did you suffer previously from any of these symptoms without seeking a GP? If yes, why
(at these times) not think it was necessary to seek a GP?
• Did the visits to the pharmacy where you previously purchased your AB prescription
resemble the last time you purchased the AB?
• Were you previously involved in which AB was purchased in the same way as the last time
you purchased an AB If no, please describe how it usually took place?
• Did the pharmacists previously give you instructions about AB use in the same way as the
last time you purchased an AB? If no, please describe how it usually took place.
• The way you took your AB treatment – does this resemble how you took AB before
(number of days, compliance with advice of GP or pharmacist, etc.)
Knowledge and attitudes about when to use AB
• Can you explain what AB does in your body?
• From where do you have this knowledge?
• In which situations do you think AB should be used?
• Why do you think that AB should be given in these situations?
• Where do you have this knowledge from? Do you ever discuss these issues with family,
friends, colleagues? If so, do you all agree on these matters?
• Are there situations in which you think AB should not be used?
• Which situations are these?
• Why do you think that AB should not be used in these situations? Where do you have this
knowledge from?/ Do you ever discuss these issues with family, friends, colleagues? If so,
do you all agree on these matters?

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 • Have you ever seen public campaigns addressing AB use? If yes, what can you remember
from these campaigns? Did the campaigns affect you in any way? If yes, in which way? If
no, why not?
Currently comes for:
Finalizing interview
• Thank the interviewee for their time.
• Ask if they have any additional comments to what was said during the interview
• Tell the interviewee what will happen to the recordings now
Part two
Qualitative interview for Culture of Antibiotic use for URTI @Debrebirhan

Interview-guide – Patients without prescription

Introduction
• Introduce yourself and introduce the study. Tell what the interview will be used for.
• Ask permission to record the interview on tape
• Assure anonymity of the interviewee
• Ask the interviewee to introduce her/him-self, including age, occupation and where they
live
Last time when purchased an AB for upper respiratory tract infection without a prescription
Process of diagnosis of AB/ Where was AB purchased
• When was the last time you purchased an AB for a respiratory tract infection?
• What was the situation – what were the symptoms of the patient – for how long?
• Did you have any idea what kind of disease you were suffering from?
• Did you come by your own initiative or were you encouraged by family, colleagues or
friends?
• Why did you seek the pharmacy and not a physician?
• What pharmacy did you choose? – why this place?
• What did you want from the pharmacy visit?
• What did you expect from the pharmacy visit?
• How did the consultation go? What happened? What was said – by whom?
• Did the pharmacist make a diagnosis or did you simply order a specific AB?
• If a diagnosis was made - what was your diagnosis? Did the pharmacist examine you? If
yes, please describe how?
Why a specific AB was chosen / Satisfaction with AB purchase process
• Which AB was chosen?
• Who chose the AB? (With regard to product name, form and strength)
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 • If it was the pharmacist – did they give any explanation?
• If it was the patient – why did you choose this specific AB?
• If the pharmacist and the patient collaborated – please describe the conversation.
• Did the pharmacist give any instructions on how to use the AB? If yes – which ones?
• Were the instructions given written or orally?
• Did the pharmacist change your medicine to another brand? If yes, how did you feel about
this?
• Were you satisfied with the way the purchase went? If yes, why? If no, why not?
• Were there any challenges with regard to the purchase in terms of price; was the drug in
stock in the store, etc.?
• How much medicine did you purchase?
• Did you purchase all the necessary AB immediately? If not, why so?
Use of AB/ Satisfaction with AB use
• When you came home how did you use the AB? (How many tablets/ dosages per day for
how long?)
• Did this use correspond the instructions given by the pharmacist? If yes, why? If no, why
not?
• Did you experience any challenges in taking the medicine?
• Did the AB alleviate or cure your symptoms? If yes, please explain how and how quickly?
AB use in general
The last time compared to other times
• Have you purchased AB medicine before without prescription?
• If yes, approximately how many times? When did it take place?
• What were your symptoms at that time?
• Did you usually purchase AB without prescription in the same or in different pharmacies?
Please explain the reasons for choosing either the same or different pharmacies
• Did the consultations you had with the pharmacist previously resemble the last time you
purchased an AB?
• Was a diagnosis made during your previous visits where you purchased an AB? If yes or
no, how did it take place?
• Who usually decides which AB to use?
• If you simply give an order usually when purchasing AB - which AB did you usually
choose? Why did you choose these ones?
• If the pharmacist chose the AB – have they ever given any explanations for these choices?

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 • Did the pharmacist previously give similar instructions about how to use AB compared to
the last time you purchased an AB? If no, please describe how it usually took place?
Knowledge and attitudes about when to use AB
• Can you explain what AB does in your body?
• Where do you have this knowledge from?
• In which situations do you think AB should be used?
• Why do you think that AB should be given in these situations?
• Where do you have this knowledge from?
• Do you ever discuss these issues with family, friends, colleagues? If so, do you all agree
on these matters?
• Are there situations in which you think AB should not be used?
• Which situations are these?
• Why do you think that AB should not be used in these situations?
• Where do you have this knowledge from?
• Do you ever discuss such issues with family, friends, colleagues? If so, do you all agree on
these matters?
• Have you ever seen public campaign addressing AB use? If yes, what can you remember
from these campaigns? Did the campaigns affect you in any way? If yes, in which way? If
no, why not?
Currently coming for:
Finalizing interview
• Thank the interviewee for spending their time with you
• Ask if their have any additional comments to what was said during the interview
• Tell the interviewee what will happen to the recordings now

20