“Antibiotics kill things very quickly” - consumers’ perspectives on non-prescribed antibiotic use in Saudi Arabia

Although antibiotics represent one of the major improvements in public health, their misuse and overuse, as a result of self-medication and irrational prescribing and dispensing, may lead to an increased risk of antibiotic resistance [1–3]. Self-medication includes the use of medicinal products by the consumer to treat self-recognised symptoms or disorders [4]. Medicines intended for self-medication are called over-the-counter medicines and are available without a medical prescription. In Saudi Arabia, for example, the accessibility of antibiotics over-the-counter (OTC) without prescriptions is an important factor that contributes to the public’s behaviour in respect of self-medicating [5]. Findings from a study conducted in 2010 in Riyadh, Saudi Arabia, showed that antibiotics could readily be obtained without a prescription in 244 (78%) of 327 pharmacies [6].

Inappropriate self-medication practices with antibiotics may include insufficient dosage and/or frequency, the antibiotic spectrum being either too narrow or too broad, delayed antibiotic therapy in critical patients, unnecessary use of antibiotic for the wrong ailments, and receiving antibiotics from different sources such as patient’s stock, friends and family, without a medical consultation. Patients/consumers may mistakenly make self-diagnosis, with consequences such as failure to recognise symptoms that may be an indication for another disease, and failure to treat the disease effectively. In addition, when a bacterial infection is not presented, patients can expose themselves to the risks associated with antibiotics. Inappropriate utilisation of antibiotics can also lead to increased healthcare costs, poor health outcomes and increased risk of antibiotic resistance, adverse drug reactions and contraindications [7, 8].

Although self-medication with antibiotics (SMA) is common in developing countries, with an overall prevalence of 38.8% (95% CI: 29.5–48.1) [9], semi-developed countries, like Gulf countries, are not immune [3]. For example, a systematic review that included 11 various Middle Eastern countries reported that rates of antibiotic self-medication ranged from 19 to 82% [3]. The attitude towards self-medication appears to differ between Middle Eastern countries, with Gulf countries having much higher rates of self-medication compared to other Middle Eastern countries. In Saudi Arabia, for example, self-medication with antibiotics was found to range from 48 to 79% [3].

Self-medication with antibiotics is a major concern to the Ministry of Health (MOH) and public health sector in Saudi Arabia, a country whose rate of both antibiotic resistance and consumption is one of the highest in the Middle East [3, 10, 11]. Based on a review of the studies conducted in Saudi Arabia from 1990 until 2011, the prevalence of resistant bacteria ranges from 7.6 to 92.3% among gram-negative bacteria with Pseudomonas aeruginosa, Acinetobacter species and Klebsiella pneumoniae having the highest prevalence. Among the gram-positive bacteria, the prevalence of resistance ranges from 23.5 to 30.7%, with Streptococcus pneumoniae, Clostridium Difficile and Methicillin-resistant Staphylococcus aureus (MRSA) showing the highest prevalence [10].

A World Health Organisation (WHO) ([12]) report also shows extensive antibiotic resistance across the WHO Eastern Mediterranean Region. In particular, there are high levels of Escherichia coli resistance to third-generation cephalosporins and fluoroquinolones – two important and commonly used types of antibacterial medicine. Resistance to third-generation cephalosporins in Klebsiella pneumoniae is also high and widespread. In some parts of the region, more than half of Staphylococcus aureus infections are reported to be methicillin-resistant (MRSA), meaning that treatment with standard antibiotics does not work. Even globally, the WHO report reveals that a serious threat is occurring in every region of the world as regards antibiotic resistance and it has the potential to affect anyone, of any age, in any country [12]. In 2013, the Centers for Disease Control and Prevention (CDC) estimated that more than 2 million illnesses and 23,000 deaths were caused by antibiotic resistance [8].

Understanding the Saudi cultural determinants of or reasons for self-medication, and the practices, behaviours and knowledge about antibiotics represents a vital pre-requisite to design and implement effective public health interventions. Self-medication with antibiotics in Saudi Arabia is an issue that requires further investigations or studies using an in-depth interview technique.

This article presents the first study exploring a wide range of factors influencing self-medication practice, and providing a more inclusive picture of such practices and the circumstances in which they arise, providing novel evidence that SMA among this particular population is problematic in Saudi Arabia. Only four other studies have addressed the problem of SMA in Saudi Arabia [15–18]; however, none of them included the people’s perspective regarding SMA using an in-depth interview technique.

In this study, the frequency of SMA among participants was high and it was associated with various inappropriate antibiotic use behaviours such as altering or stopping antibiotic-taking, either when feeling better (to relieve the body) or when feeling worse (to alleviate adverse effects). This shows that customers are not passive recipients of care. Rather, they sometimes develop their own way of taking their antibiotics based on their circumstances or what makes sense to them. Thus, assessing participants’ beliefs, fears and expectations and exploring their practices regarding antibiotic use are necessary to prevent irrational use of antibiotics.

An exploration of factors influencing self-medication behaviour among study participants revealed many similarities with evidence from the Middle Eastern literature [3], although some differences were also found which may appear to be specific to the Saudi population. For example, in line with the Middle Eastern literature, lack of a strong regulatory enforcement mechanism to improve rational use of antibiotics, and gaps in terms of knowledge, attitudes and practices regarding antibiotic use – such as keeping leftover antibiotics for future use, sharing antibiotics with others, self-diagnosis and people’s desire to buy antibiotics in sub-therapeutic quantities in order to treat illness or not to become ill, belief that antibiotics can speed up recovery and eradicate any infection – were all found to be possible reasons for SMA. Past successful experience with similar illness and knowledge of the drugs that were prescribed previously, low economic status, lack of health insurance and lack of access to healthcare were also reasons contributing to the rise of SMA.

In terms of reasons for SMA specific to this particular population, the current study identified some beliefs and practices about antibiotic use that have not been adequately described in the literature to date, such as beliefs participants held about Western brands of antibiotics and topical antibiotics, taking antibiotics while travelling abroad or being away from home for ‘just in case’ purposes, and using a short course of antibiotics during the holy month of Ramadan or while travelling abroad to enable quick recovery. In addition to these beliefs and practices, the stigma of getting an infection upon going to hospital to consult a doctor, and perceptions about healthcare providers and healthcare system, such as paternalism and ignoring the patient’s perspective during medical consultations, issues relating to the organisation of the healthcare system and the impact of this on access to healthcare services or antibiotic supply appeared to be findings specific to the Saudi population. If not addressed, these factors may lead to unanticipated adverse events, complications of incorrect use or misuse, delay in seeking professional help and antibiotic resistance. By uncovering factors influencing self-medication behaviour, the study can provide insight when designing future interventions to promote safe, rational and effective use of antibiotics.

Strengthening the role of pharmacists from traditional drug dispenser to more effective healthcare provider is required to improve the rational use of antibiotics. Pharmacists are the key healthcare providers with the training, skills and knowledge associated with the profession required to minimise self-medication behaviours. Thus, it is vital to recognise and use their potential. Pharmacists in many European countries already have the ability to take on additional responsibilities and roles to promote the rational use of antibiotics. For example, many new forms of rapid diagnostics/point-of-care testing (PoCT) are being developed that will give simple-to-use and inexpensive approaches of deoxyribonucleic acid/ribonucleic acid (DNA/RNA)-based recognition of potentially multiple pathogens from a single sample [19]. These new forms of PoCT can make it possible to provide the correct treatment immediately and foster antimicrobial stewardship and tackle antibiotic resistance, when they become available. Antibiotic stewardship is defined as promoting the appropriate selection, dose, duration and route of administration of antibiotics [19–21]. In the United Kingdom, some pharmacies in London are conducting PoCT linked to sore throat and, if bacterial tonsillitis infection is identified, are supplying penicillin-V (or, clarithromycin in case of allergy) [19–21]. This is made possible through pharmacy-based patient group direction (PGD). PGDs provide a legal framework that permits the supply and/or administration of specified medicine(s), by certain registered healthcare providers, to a pre-defined group of patients, without the need for an instruction or a prescription from a provider [19, 22].

This study provided evidence that 60% of participants had insufficient knowledge about antibiotics. There was also no or little recognition of the impact of SMA on antibiotic resistance. The insufficient knowledge about antibiotics could be translated into various inappropriate antibiotic use practices and negative outcomes such as antibiotic resistance, treatment failures and toxicity. Studies from the Middle Eastern literature have reported similar knowledge deficits among Middle Eastern populations [3]. The insufficient knowledge about antibiotics and antibiotic resistance among participants could be related to the lack of patient education and counselling provided by healthcare providers. It has been argued that knowledge is a prerequisite of preventive health behaviour and can motivate patients to take an active role in the treatment of their disease [23].

Since patients frequently visit pharmacies to obtain antibiotics for self-medication, pharmacists are well placed to improve rational use of antibiotics among pharmacy customers. The community pharmacists should take an active role in different public-health initiatives relating, for instance, to the restriction of irrational dispensing of antibiotics and enhancing public awareness of the importance of stopping self-medication without correct diagnosis and of the rising issue of antibiotic resistance infection in the society [19, 24]. With patient counselling, pharmacists are also in a great position to identify and correct any false beliefs patients might have and address any concerns they might have, in order to make sure they have a better understanding of the rational use of antibiotics.

Since antibiotics in Middle Eastern countries can be obtained without prescription, research on effective strategies to limit unnecessary antibiotic use should target doctors’, pharmacists’ and patients’ knowledge and behaviours. Thus, addressing the knowledge gap and implementing multifaceted behaviour change interventions are likely to be effective. Malta, for example, has introduced a European Antibiotic Awareness Day [25] in an attempt to increase knowledge and awareness among the Maltese public, prescribers and pharmacists, and ensure that regulations are enforced. Consequently, self-medication has fallen from 19% of Maltese respondents admitting taking antibiotics without a prescription in 2001 to 2% in 2016 [26, 27]. While awareness campaigns and education are often recommended [28, 29], interventions targeted specifically at changing behaviour are more likely to be effective.

The key to successful strategies for managing antibiotic resistance is to promote behaviour modification besides providing relevant information on proper antibiotic use [30]. Behavioural theories, such as the theory of planned behaviour [31] and the stages-of-change model [32], and social science methods have been suggested as suitable approaches to better understand factors influencing prescribing practices [33] but no behavioural theories have been suggested or developed in order to understand factors that influence self-medication behaviour among the general public.

After classifying a patient into one of these stages, the pharmacist can develop appropriate interventions to assist the patient in moving towards the next stage. Individuals may cycle through the stages several times before achieving long-term behaviour change. Rewards, reminders and monitoring techniques may be needed for individuals in later stages of behaviour change, but, for patients in earlier stages, discussion of available OTC alternatives and consciousness raising that focuses on the disadvantages of SMA and advantages of stopping this ‘habit’ are needed. However, the application of TTM to influence self-medication practice among the general public is limited, and its efficacy within this context remains unclear. When applied correctly, TTM may provide the necessary approach to promote sustained behaviour change among targeted populations.

This study also detected the important role of patients’ families in their infection management in general and in antibiotic-taking in particular. Families were frequently quoted as an important source of support, providing advice and supply of antibiotics to participants. In line with published studies in Kuwaiti culture [36], Saudi people value family intimacy and have the advantage of cohesive and supportive family networks. Healthcare providers need to be aware of this, as some patients may obtain false or inaccurate information or advice from their families and initiate changes in their antibiotic intake or take inaccurate antibiotics accordingly. In this study, all participants were living with their families. This suggests that a family-centred approach to education by healthcare providers may also be beneficial. It has been reported that personal interaction in the form of counselling or group sessions might be more successful than simply handing out written material; such group sessions may be useful as a reference or refresher of patients’ knowledge but should not replace ongoing patient education and counselling that should be provided by healthcare providers (HCPs).

Law enforcement and stricter governmental policy regarding the sale of antibiotics without prescription in retail pharmacies and irrational antibiotic usage are also needed. In Chile, for example, after drawing up prescription-only regulations, consumption of oral antibiotics in the community pharmacies remarkably decreased [37]. In Saudi Arabia, prescription-only regulations are embedded in the Drug Law. However, there is no penalty for non-compliance, despite these regulations. This may explain why, to date, no pharmacy has been penalised for antibiotic dispensing without medical prescription. Self-medication is viewed as more economical and convenient than visiting a HCP, as there is a lack of enforcement of the regulations.

Robust antimicrobial use surveillance systems are essential to combat antibiotic resistance. In most European countries, there is a long tradition of monitoring the use of medicines but this should also be implemented in Middle Eastern countries. Antimicrobial stewardship courses in the pharmaceutical and medical postgraduate and undergraduate curricula are also required. The information provided in these courses should stress the importance of the roles of the pharmaceutical and medical professions in fostering the rational use of antibiotics.

The study indicates that SMA is common practice in Saudi Arabia. By uncovering factors influencing self-medication behaviour among the public, the study can provide insight when developing future interventions to improve prudent, safe and effective use of antibiotics.