This section is categorized into four sections: (i) demographic characteristics of the respondents (ii) antibiotic use for specific diseases (iii) how people learn about antibiotics and indications for use and (iv) confusion of antibiotics with other drugs.
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(i)
Demographic characteristics of IDI and FGD respondents.
A total of 15 health professionals/dispensers including medical doctors, pharmacist, midwives/nurses, physician assistants, dispensing technicians and LCS/OTC participated in the IDI sub-study. Eleven were males and 4 were females between the ages of 32 to 50 year. Fifty-five community members participated in the FGD sub-study, of which 31 (64%) were males and 24 (44%) were females. Community members who participated in the FGD were between the ages of 20 to 50 years. Thirty community members (55%) were traders/farmers.
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(ii)
Antibiotic use for specific diseases.
Antibiotics were used to treat diseases including stomach pain, diarrhoea, gonorrhoea, wounds/sores, boils and headache. Many of these indications are not caused by bacteria, which was also confirmed by health professionals as common in the study area.
They abuse antibiotics; the most abused one is Amoxicillin. Because of headache someone will go to the drug store [LCS/OTC] and say s/he wants to buy Amoxicillin. (IDI with Medical Officer #2).
We know that antibiotics like Chloramphenicol and Tetracycline are used by some people to treat sores. Sometimes, when patients/clients have abdominal pain, they buy Tetracycline (IDI with Physician Assistant #1).
Antibiotics for stomach pain, diarrhoea, gonorrhoea, cold
Amoxicillin, Tetracycline, Metronidazole and Chloramphenicol were generally used to treat stomach aches which are not considered to be caused by bacterial, unless it concerns gastric ulcer (H pylori infection). Amoxicillin and Tetracycline are also used for gonorrhoea which is a bacterial infection (sexually transmitted infection).
I had stomach pain and the LCS/OTC attendant told me to buy the red and yellow [tetracycline] capsules and flagyl [metronidazole] because I have stomach ulcer. So anytime I realize that I am about to feel stomach pain, I take the red and yellow [Tetracycline. (FGD#2 with males, respondent #10).
Amoxicillin and Tetracycline are used by people having gonorrhoea. When they go to the drug store (LCS/OTC) they can buy the ‘red and yellow’ [Tetracycline] and Amoxicillin, and take two capsules each. (FGD#4 with males, respondent #1).
The common one is amoxicillin and some of them use it for common cold and sometimes stomach pains. (IDI with a dispensing technician at a district hospital_ respondent #1).
Stomach pain is generally attributed to having sore in the stomach [stomach ulcer]. It is therefore believed that once Amoxicillin, Tetracycline and Metronidazole could cure sores on the surface of the body, it could equally cure the sore in the stomach and vice-versa.
It’s our own thinking; you know that when you are experiencing pains in your stomach, it is sore that has developed in your stomach so you can take the tetracycline or the white antibiotic [chloramphenicol]. This is because it’s the same way that, when the sore develops on your body, you will use same tetracycline or white antibiotic [chloramphenicol]. (FGD#4 with males, respondent #1).
These antibiotic are not taken according to any dosing regimen or instruction considering that most of them are purchased without prescription from the pharmacy, LCS shops and drug peddlers;
For medicine we get from the drug stores [LCS/OTC], as soon as you start taking them and you feel you are okay, you leave the rest. (FGD#1 with males, respondent #2).
I take 2 tablets of the Flagyl [Metronidazole], and 2 of the Amoxicillin. The Flagyl is really bitter so what I do is to mash it with stone before taking since I cannot chew it due to its bitterness. (FGD#3 with males, respondent #1).
Antibiotics for treating wounds or sores
Chloramphenicol, Amoxicillin, Tetracycline, Metronidazole and Penicillin V are used for the treatment of sores on the body;
These two capsules [pointing at tetracycline and Chloramphenicol]; if someone has a sore and the person pour this one [tetracycline] into the sore and it doesn’t get healed, the person will change and use the white one [Chloramphenicol]. (FGD#4 with males, respondent #1).
These antibiotics are generally poured into the sore in different ways until the sore gets healed or antibiotics are changed if it does not work as expected.
When I recently got hurt, I poured four of the [Chloramphenicol] and mixed it with two of [Tetracycline] and I change it every 3 days for about a month. (FGD#3 with males, respondent #1).
You can mix three capsules of Chloramphenicol with shea butter and rub it on the wound. (FGD#8 with mothers of under-five children #8).
Antibiotics can be poured on sores to heal them; even flagyl [metronidazole] we grind it and pour it on the sore to heal it. (FGD#2 with males, respondent #10).
Antibiotics for boils
Cloxacillin and Flucloxacillin were generally mentioned as medicines that are used for the treatment of boils.
Cloxacillin and Flucloxacillin are basically for boils. (FGD#3 with males, respondent #1).
Sometimes when you have boils, they can give you the Flucloxacillin to reduce the swelling and pain. (FGD#6 with mothers of under-five children, respondent #6).
Antibiotics used in alcohol to treat hernia and sores in the stomach
While some respondents mentioned that they have never heard or seen such practice, others responded affirmatively and mentioned categorically the types of antibiotics which are poured into “akpeteshie” [a local gin distilled from palm tree] to treat hernia and sores in the stomach;
It’s true that some people pour antibiotics in akpeteshie and drink it to treat hernia. (FGD#4 with males, respondent #5).
Some people also pour tetracycline into “akpeteshie” and take. People prefer to use the [tetracycline] than the Flagyl [metronidazole] because the Flagyl [metronidazole], is bitter. (FGD#3 with males, respondent #5).
It also emerged that pouring antibiotics into akpeteshie is not only practiced by people who drink alcohol but some women do it after delivery to heal the sore in their wombs.
It’s not only drunkards who pour tetracycline into alcohol to drink to treat hernia; when some women deliver, they pour Chloramphenicol into the alcohol to heal the sore in their womb. (FGD#3 with males, respondent#4).
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(iii)
How people learn antibiotics will cure specific diseases.
There were five ways by which respondents learn about medicines including antibiotics and the diseases they are perceived to treat. First, respondents learn about medicines including antibiotics prescribed in hospitals and other health facilities or dispensed by pharmacies and LCS/OCT for their diseases and subsequently engage in self-medication with the same antibiotics when they experience similar symptoms. Second, respondent self-medicate with medicines including antibiotics based on recommendations of family relatives, colleagues and friends. Third, others learn from radio and television adverts. Four, drug peddlers who move from house-to-house with medicines also teach people the use of specific antibiotics. Five, some respondents learn about antibiotic use based on assumptions. As specified earlier, Amoxicillin, Tetracycline and Metronidazole were used to treat stomach ulcer based on the assumption that once these antibiotics could cure sores on the body, it could equally cure sore in the stomach. The responses below corroborate these findings;
Let’s say I am having stomach pains and I go to the hospital and the doctor prescribes Flagyl [metronidazole] for me. The next time I have the same pain [symptom] I will just go to the drugstore (LCS/OTC) to get the Flagyl. (FGD#4 with males, respondent #1).
This man [pointing at a participants] is my friend and my friend also has a friend. If he was sick and somebody told him [Chloramphenicol and tetracycline] are used to treat stomach ache and my friend hears that, the next time another person also has stomach ache he will also tell that person to go and buy the [Chloramphenicol tetracycline]...that is how all of us get to know about the medicines. (FGD#2 with males, respondent #5).
When I was little, I remember some people use to move from house to house with drugs, they taught me what the drug does. Especially with the [Amoxicillin] and [Chloramphenicol]. (FGD#5 with mothers of under-five children #2).
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(iv)
Confusion about antibiotics.
Generally, community members do not know what antibiotics are and the diseases they should be used for. Though antibiotics are used to treat bacterial diseases, respondents do not know that they are antibiotic per se and that they should be used to treat specific infectious diseases. Medicines that are in capsules referred to as ‘Topaye’ or ‘Abombelt’ in Twi (the local dialect widely spoken in study area) including antibiotics are perceived to treat specific types of diseases.
“Topaye” is any medicine that is powder and put into tiny rubbers [capsules] and can’t be taken in its powder form but when it gets into your stomach and water pours on it, it will burst, that is why it is called Tupaye [throw and burst]. (FGD#3 with males, respondent #3).
This was corroborated by health workers:
They [patients] call all of them capsules; capsules in the sense that it is covered and when you take it inside [stomach], it burst. That’s why it is called capsules [literally, throw and burst]. (IDI with a midwife).
Confusing antibiotics and pain killers
Medicines which are in a capsule (antibiotic or painkiller) are taken to treat pain associated with certain diseases. It emerged that the primary reason for taking antibiotics is to treat the pain associated with diseases but not specifically the infectious cause, even though the pain could be a result of an infectious disease.
Patients think “capsules” is medicine which relieves pain associated with diseases. That’s why when they get abdominal pain, they take it. So they take “capsules” as pain medication. Antibiotics in capsules is the most consumed antibiotics by the public. They take the “capsule” to reduce the pain but they don’t know its antibiotic. (IDI with a nurse).
Most of the common antibiotics which are easily accessible in the study area, some painkillers and other medicines are also in capsules as such they are considered as medicines in the same category.
Painkillers such as diclofenac, tramadol and even brufen are usually in capsules depending on the company likewise the common antibiotics. (IDI with Physician Assistant #1)
Most of the common antibiotics are in capsules except the stronger generic like Amoxicillin/clavulanic acid which is in tablet. Amoxicillin, Doxycycline etc are in capsules. We have this one, tramadol capsules which is a painkiller but it is in capsules. (IDI with Medical Officer #1).
Confusing antibiotics due to colours
Locally, medicines including antibiotics were identified or described with colours because people do not know the names of these medicines. Antibiotics were identified and referred to with colours such as red, red and yellow, white, green, black capsules.
So we have the red capsule [Tetracycline], white capsule [Chloramphenicol] and we consider [flucloxacillin, cloxacillin] as black capsules. (FGD#3 with males, respondent #3).
The identification of antibiotics with colours appeared to be confusing considering that some antibiotics in capsules have similar colour. Typical examples are Amoxicillin and Tetracycline which are both in red and yellow capsules. There was some level of consensus among community members and dispensers at LCS/pharmacy that tetracycline is referred to as “red and yellow” and Amoxicillin is called by its name.
We are used to mentioning the amoxicillin as compared to the other one [Tetracycline]; we just call it red and yellow because we are not used to the name. (FGD#4 with males, respondent #5).
Its tetracycline they are referring to when they say red and yellow, the light red and yellow is what they called amoxicillin. They are never confused about colours. (IDI with a dispensing technician at a private pharmacy_ respondent #1).
Some community members mentioned that the colours of Amoxicillin and Tetracycline are confusing.
Actually the colours of these two drugs [Amoxicillin and tetracycline] are confusing. [Tetracycline] has been in the system for a very long time since my childhood before [Amoxicillin] was introduced. (FGD#1 with males, respondent #3).
Also, there was evidence of disagreement as to which medicines (tetracycline or amoxicillin) is really referred as ‘red and yellow’ among health professionals.
When patients say red and yellow they [patients] mostly refer to amoxicillin but amoxicillin is not the only red and yellow coloured drug and that’s the problem. (IDI with Medical Officer #1)
Yes! It is the tetracycline they [patients] refer to as red and yellow, but for some people when you put the tetracycline and amoxicillin side by side the person gets a bit confused. (IDI with a midwife)
The use of amoxicillin and tetracycline interchangeably
Whilst some community members indicated that Amoxicillin and Tetracycline were the same others emphasized that the two antibiotics were used to treat different disease conditions.
The two [Amoxicillin and Tetracycline] are the same. I have ever sent a child to go and buy “red and yellow” [Tetracycline] on about three occasions and the child returned with Amoxicillin. When I followed up I was told they treat the same illness. (FGD#1 with males, respondent #10).
Amoxicillin and Tetracycline are for different purposes; each medicine is for a specific purpose even though they are both antibiotics. (FGD#6 with mothers of under-five children #3).
Some health professionals and community members were of the view that amoxicillin and tetracycline were sometimes used interchangeably due to the similarity in colours.
It is true that people do mix them up especially the older people. When they send you to buy [Amoxicillin] and buy [Tetracycline], they can hardly see the difference. (FGD#1 with males, respondent #8).
They even mix them [Tetracycline and Amoxicillin] for instance; they [patients] take two capsules of each instead of two capsules of only one. They use them interchangeably because they don’t know the names, the description given can result in purchasing the wrong one. (IDI with Licenced chemical seller #1).
Contrary to the above, some community members mentioned that though the colours of Amoxicillin and Tetracycline are both “red and yellow”, the colours are distinct and cannot be used interchangeably.
Amoxicillin and Tetracycline cannot be used interchangeably because the red and yellow of Tetracycline is deep and that of Amoxicillin is light. For the Tetracycline people really know it so if you mistakenly give them Amoxycillin they will know. (FGD#2 with males, respondent #3).