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Patterns of antibiotic use among adults and parents in the community: A questionnaire-based survey in a Greek urban population
International Journal of Antimicrobial Agents 25 (2005) 439–443
Patterns of antibiotic use among adults and parents in the community: A questionnaire-based survey in a Greek urban population Georgia Mitsi a,∗ , Eleni Jelastopulu b , Harry Basiaris a , Athanassios Skoutelis a , Charalambos Gogos a a
Department of Internal Medicine, Medical School of University of Patras, Heroon Polytekniou 60a, 26500 Rion, Greece b Department of Public Health, Medical School of University of Patras, Heroon Polytekniou 60a, 26500 Rion, Greece Received 2 November 2004; accepted 9 February 2005
Abstract The purpose of this study was to look for factors that affect attitudes to antibiotic use in Greek urban settings. By using a questionnaire-based survey, we conducted 323 face-to-face interviews (173 adults, 150 carers of children). In the adult group, 74.6% admitted using non-prescribed antibiotics, while only 22.7% of parents had administered non-prescribed antibiotics to their children. Around 50% of adults discontinued therapy earlier, more than 10% did not follow the correct dosage instructions and about 55% admitted using leftover antibiotics. Of the parents, 18.7% discontinued therapy earlier and 7.3% admitted keeping leftover antibiotics. Our results showed that adults were likely to show unsatisfactory compliance and to use non-prescribed antibiotics, while parents were less likely to use non-prescribed antibiotics for their children and were more compliant. © 2005 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved. Keywords: Survey; Non-prescribed antibiotics; Antibiotic usage; Urban population
1. Introduction About 80% of antibiotics are used in the community and the rest are used in hospitals [1,2]. It is estimated that 20–50% of all antibiotic use is inappropriate [1], resulting in an increased risk of adverse side effects, higher costs and higher rates of antimicrobial resistance of community pathogens [3]. The determinants of antibiotic use are thus of particular importance. They include factors as diverse as the physician–patient relationship, clinical microbiology, health economics, and the most basic definitions of illness and therapy [4]. Studies have identified and examined specific causes of antibiotic misuse. Patient demand for antimicrobials has been shown to increase unnecessary prescription [5], despite the doctor’s assessment that no such need existed [6]. Such practices can, in turn, enhance patient belief of the need for antimicrobials even when they are not indicated, fur∗
Corresponding author. Tel.: +30 2610 424116; fax: +30 2610 424116. E-mail address: [email protected] (G. Mitsi).
ther increasing pressure on prescribers [7] or lead to selfadministration of non-prescribed antibiotics [8]. This questionnaire-based study was undertaken in order to assess adult and parental attitudes regarding antibiotic use in Greek urban settings. By identifying weak areas and gaps in adults’ and parents’ knowledge, more appropriate educational efforts can be applied and a more rational antimicrobials use may be achieved.
2. Methods 2.1. Study design The study was carried out in Patras (approximately 200,000 inhabitants), Greece from October 2002 through July 2003. Using a cross-sectional design, an intervieweradministered questionnaire was applied to a sample of 323 randomly selected participants in an attempt to obtain a representative sample of the urban population regarding, age,
0924-8579/$ – see front matter © 2005 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved. doi:10.1016/j.ijantimicag.2005.02.009
440
G. Mitsi et al. / International Journal of Antimicrobial Agents 25 (2005) 439–443
gender, residential district and socioeconomic status. The sample comprised of 173 adults aged 18–85 years and 150 primary carers of children younger than 12 years. Separate questionnaires were administered to adults and parents. For the parent survey, only parents, preferentially mothers, with at least one child younger than 12-year-old living in the household, were interviewed. If the mother did not live in the household, the father or the primary caregiver was surveyed. A pre-test was applied on a pilot population (n = 20) to determine whether the data would provide reliable information. Consequently two revised 19- and 21-item questionnaires for adults and for parents, respectively, collected demographic data such as age, gender, marital status, place of residence, profession, level of education and type of insurance as well as attitudes and beliefs relating to antibiotic use. The questionnaires were anonymous and verbal consent was obtained before all interviews. Interviewees were asked about the most common symptoms leading to antibiotic intake and their adherence to their most recent course of antibiotics—did they take the required number of daily doses over the full duration of the course? Participants were also asked different questions with regard to the source of prescribed and non-prescribed antibiotics (use of leftover antibiotics, over-the-counter acquisition) and their attitudes towards physicians (level of satisfaction and pressure for antibiotic prescription). Interviewees were also asked to name the most frequently used antibiotic (generic or commercial name). We examined respondents’ attitudes toward, and awareness of, antibiotic use by their age, gender, education and medical insurance status. 2.2. Statistical analysis Statistical analysis was performed using the SPSS for Windows release 10.0 (SPSS Inc., Chicago, IL, USA). Categorical data were presented as frequency of occurrence and were analysed by the χ-square test. Continuous data are presented as mean and standard deviations and were analysed by Student’s t-test. All tests were two-tailed with alpha levels of 0.05 considered significant.
3. Results The adult survey was completed by 173 (93.5%) of 185 individuals who were approached. Of those who did not agree to complete the survey, three were non-Greek speaking, six refused and three did not complete it for other reasons. The parent survey was completed by 150 (95.0%) of 158 individuals. The non-participants included three who refused, three who did not speak Greek and two who failed to complete the survey for other reasons. There were no overlaps between groups. All the respondents lived in urban areas and were white Caucasians.
3.1. Adult questionnaires The demographic characteristics of the adult population are shown in Table 1 and the patterns of antibiotic use are presented in Table 2. Respondents with higher education tended to be more satisfied with their physicians (P = 0.009). Only 2.9% admitted of applying pressure to their doctor for antibiotic prescriptions. Men were more likely not to follow correct dosage instructions than women (P = 0.048). Around 75% admitted using non-prescribed antibiotics. The use of non-prescribed antibiotics was reported more frequently by women (P = 0.027), by individuals with higher education (P = 0.02) and by older age groups (P = 0.007). Nearly 20% did not check the expiry dates of left-over antibiotics, although individuals with higher education were more careful about this (P = 0.043). The generic or market name of the antibiotic was correctly mentioned by 73.0%. The most commonly used was amoxiTable 1 Demographic characteristics of our adult and parent population Adults (n = 173)
Adult parents (n = 150) All females
Mean age in years (S.D.)
77 (44.5%)/96 (55.5%) 40.1 (19.8)
Age groups (%) <30 30–49 50–70 >70
45.7 22 20.2 12.1
Marital status (%) Married Not married
46.2 53.8
Gender (male/female, %)
37.4 (4.24) ≤35a >35a
All married
Number of offspring(s) (%) No children 60.1 1 9.2 2–3 27.2 >3 3.5 Occupation (%) Civil servant Business Farmer Student Not employed Retired
20.2 12.1 8.7 38.2 9.8 11.0
Education (%) No or primary Secondary Tertiary
12.7 33.0 54.3
Insurance (%) Public Private Both Uninsured
75.1 12.1 11.6 1.2
a
42.0 58.0
N/A 14.7 72.7 12.7
N/A
Ab Bb Cb
38.7 38.0 23.3 82.7 10.0 7.3 0.0
Age groups in parent population. Education groups in parent population: (A) none of the parents with higher education (>12 years), (B) one parent with higher education and (C) both parents with higher education; (N/A) non-applicable/non-available. b
G. Mitsi et al. / International Journal of Antimicrobial Agents 25 (2005) 439–443 Table 2 Patterns of antibiotic use among the adult population
Table 3 Patterns of antibiotic use among the parents of small children (≤12 years) Adult parents (n = 150) (%)
Adults (n = 173) (%) How often do you visit your doctor per year? None 19.6 1–2 39.2 3 23.5 >5 17.7 What is the level of satisfaction with the medical services provided by your doctor? Low 22.9 Medium 54.2 High 22.9 How many times did you undergo antibiotic treatment during the last year? None 27.5 1–2 37.3 ≥3 35.2 For which symptoms Temperature (>37.0 ◦ C) Soar throat Ear pain Nasal congestion combination
23.1 16.2 9.8 8.1 42.8
Do you follow correct dosage instructions? Yes 88.8 No 11.2 Do you discontinue therapy once your symptoms subside? Yes 46.7 No 53.3 Do you keep leftovers for future use? Yes 54.6 No 45.4 How often do you use non-prescribed antibiotics? Never 25.4 Rarely 54.3 Often 12.7 Very often 7.5 What is their source? Leftovers Friends and family Pharmacist Others
30.2 22.3 40.4 7.1
cillin (27.7%) followed by the combination of amoxicillin and clavulanic acid (23.1%) and clarithromycin (10.4%). Only 4.8% named another drug as an antibiotic, for instance paracetamol (2.3%), whereas 22.2% could not name any antibiotic. Thirteen percent stated that their attitude towards antibiotics use would change if they were uninsured. 3.2. Parents questionnaires The demographic characteristics of the parent population are described in Table 1 and the patterns of antibiotic use are presented in Table 3. All participants were married women. Antibiotic prescription for their children during the last 3 months was reported by 27.3% of the respondents. Respon-
441
Have you administered antibiotics without a doctor’s prescription during the last 3 months? Yes 1.3 No 98.7 Do you follow correct dosage instructions? Yes 99.3 No 0.7 Do you discontinue therapy once your symptoms subside? Yes 18.7 No 78.7 Not sure 2.7 Do you keep leftovers for future use? Yes No
7.3 92.7
Have you ever used non-prescribed antibiotics? Often 2.7 Rarely 20.0 Never 77.3 How often has your prescription been modified by your pharmacist? Rarely 0.7 Never 99.3
dents with higher education were more likely not to follow correct dosage instructions (P = 0.002). Parents with more children tended to use left-over antibiotics more often than parents with one child only (P = 0.03). When respondents were asked to name an antibiotic 85.2% answered correctly by giving the generic or market name. The most common was amoxicillin (36.7%) followed by the combination of amoxicillin and clavulanic acid (21.3%) and cefaclor (12.7%); 2.8% named a non-antibiotic and 12.0% could not name any antibiotic. Four percent replied that their attitude towards antibiotics use would change if they were uninsured. When the patterns of antibiotic use between adults and parents of small children were compared, all studied parameters (correct dosage, discontinuation of therapy, use of left-over antibiotics and change of attitude if uninsured) were significantly different (Table 4).
4. Discussion The aim of this questionnaire-based study was to assess adult and parental knowledge, attitudes, and experiences regarding antibiotic use. The findings suggest that both adults and parents represent an important source of antibiotic misuse. The study revealed a high use (74.6%) of non-prescribed antibiotics in the Greek urban adult population (54.3% rarely, 12.7% often and 7.5% very often). Other studies have reported lower percentages of about 20% [8,9]. The reasons for the increased use of non-prescribed antibiotics in the popula-
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Table 4 Comparison of the patterns of antibiotic use between adults and parents of small children (≤12 years) Questions
Adults (n = 173) (%)
Parents (n = 150) (%)
P-value
Do you follow correct dosage instructions? Yes 88.8 99.3 No 11.2 0.7
0.01
Do you discontinue therapy once your symptoms subside? Yes 46.7 18.7 No 53.3 81.3
<0.0001
Have you ever used non-prescribed antibiotics? Very often 7.5 0.0 Often 12.7 2.7 Rarely 54.3 20.0 Never 25.5 77.3 Would your attitude towards antibiotics use change if you/family were uninsured? Yes 13.3 4.0 No 86.7 96.0
<0.0001
0.007
tion studied are not clear. Cultural differences, level of education, and/or medical awareness may play a role. However, one of the most important factors is the increased availability of antibiotics over-the-counter in Greece. All patients have access to antibiotics since a prescription is required but not necessary for their acquisition. The relative importance of over-the-counter sales and pharmacists’ attitudes towards antibiotics are currently under investigation. In a Pan-European survey (Greece was not included) [10], it was noted that it was possible to get antibiotics directly from the pharmacist without prescription in the nine countries studied, even where this practice was illegal. Women, individuals with higher education and older patients used non-prescribed antibiotics more frequently. Similar results concerning patients with higher levels of education have been reported [9]. One could speculate that older and more educated individuals believe they have a certain amount of ‘medical savvy’ and may be, therefore, more likely to feel comfortable making a diagnosis of their illness and their need for antibiotics. Furthermore, women’s involvement in childraising and their disease management could alter their selfmedication attitudes, leading to misuse of antibiotics. About half of the respondents discontinued therapy early, once their symptoms subsided, without consulting their physician. About one-third admitted of using left-over antibiotics without a prescription and about one-tenth did not follow recommended dosage instructions. In an earlier study, only 60% of adults admitted taking all of a prescribed course and about 20% had shared an antibiotic [11]. In another study, 78% of adults reported that feeling better justified stopping antibiotics and about one-third thought that saving antibiotics for future use was acceptable [12]. Left-over use, incorrect dosage and early therapy discontinuation are well recognised attitudes related to antibiotic compliance and misuse [3]. A recent international survey [10] reported that compliance is generally unsatisfactory. Overall, only 69% of respondents
completed their most recent course of antibacterial treatment and 24% saved part of the course for future use. Although patient pressure on doctors to prescribe antibiotics is not a novel situation and has been often related to misuse, our results revealed that only 2.9% admitted applying pressure to their doctor. MacFarlane et al. [6] report that 72% of patients with respiratory tract infections wanted antibiotics and also expected them to be prescribed. More than a quarter actually asked for an antimicrobial, whilst those wanting antibiotics were five times more likely to have them prescribed [6]. The low percentage in our survey may be attributed to the characteristics of our population and the availability of antibiotics ‘over-the-counter’. Adults in urban settings are usually well-insured and have regular, longstanding relationships with their physicians and are, therefore, more likely to accept a decision to withhold antibiotics [13]. In an attempt to clarify if the interviewees were familiar with antibiotics, they were asked to name an antibiotic by its generic or market name. Surprisingly, the majority of adults and parents replied correctly. Our survey did not intend to evaluate knowledge of antibiotics among patients, but to study patterns of use. A study of consumer attitudes towards antibiotic use [14] revealed that misguided beliefs and expectations were associated with lack of awareness of the dangers of antibiotic use. The results of the study also showed that there is an important problem with administration of non-prescribed antibiotics by parents. In the overall survey population, 22.7% admitted to this practice (considerably lower than that of the adult population (P < 0.0001). The use of left-over antibiotics was low (7.3%). Parents in our urban-based population who have better access to health insurance and health care providers may also have easier access to ‘leftover’ antibiotics. This factor alone may play a major role in the higher prevalence of antibiotic misuse for parents of children in the urban setting. In a similar study conducted in community and urban settings [13], parents admitted administering non-prescribed antibiotics to 12.1% versus 4.0%, respectively. However, this actual percentage is probably higher when one considers the number of parents who were unlikely to admit to an improper practice with their children. In our study, 78.7% of parents did not discontinue therapy once their children’s symptoms had subsided. In another paediatric study, a high proportion of parents (78%) reported having given their children the full prescribed course of an antibiotic [15]. In the survey by Collett et al. [16] administering the complete course of an antibiotic was almost always claimed. The results of the comparison of the patterns of antibiotic use between adults and parents of small children suggested that parents are more likely to treat themselves inappropriately rather than their children. A much higher misuse rate in the adult population was also found by Edwards et al. [13]. In our study, almost none of the parents admitted to applying pressure to their paediatrician for antibiotics prescription. Collett et al. [16] reported that 19% of parents asked for
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an antibiotic prescription and even more (31%) thought that sometimes paediatricians failed to prescribe antibiotics when necessary. These differences may be explained by different paediatrician–parent communication patterns. Other factors such as the need for a quick recovery in order to return to child care could further contribute to the parental misuse of antibiotics [17] in communities that depend on institutional rather than family child care.
actually require antibiotics, why full daily doses must be respected, absence of any impact of antibiotic therapy on the immune system, danger of keeping part of a course for future uncontrolled use and the need for a prescription for getting antibiotics from the pharmacist, could be some of the issues. Educational campaigns on antibiotics, their uses and limitations for the general public, are needed as part of any attempt to improve rational use of antimicrobials.
5. Limitations and future directions
References
This study has certain limitations that merit discussion. First, our urban population is more likely than the general population of our country to have health insurance and to come from the middle to upper socioeconomic classes. Another limitation is that patients are asked several questions about their or their children’s past use of antibiotics, which may lead to recall bias. Although the survey is administered face-to-face by a single interviewer the possibility that respondents may misinterpret or misunderstand questions should be considered. Relying on patients’ interviews is an acceptable tool in medical research, but it is a subjective tool that may create biases resulting from difficulties in communication, cultural differences and language problems. Several studies have shown that patients often do not have accurate knowledge of antibiotics. Hong et al., for example, found that patients often could not identify whether a medication was an antibiotic or not and that many patients considered ‘antibiotics’ to be any prescription medication [18]. Another limitation is the cross-sectional nature of this study. Each participant was assessed only once, and the study was not designed to detect recent changes in opinion. Furthermore, the indicators used measured self-reported behaviour not actual behaviour. Larger-scale studies are needed that have a more heterogeneous population mix to define further the scope of patient antibiotic misuse. The role of pharmacists and other health professionals should be explored. Future studies are also needed to determine whether local resistance patterns, to common outpatient antimicrobials, reflect the self-prescribing patterns of our patients. The key results of this study are that adults in urban settings of our country were very likely to use non-prescribed antibiotics. Furthermore, when they used prescribed antibiotics, their compliance was unsatisfactory. On the other hand, parents used less non-prescribed antibiotics for their children and were more compliant. These results point to a serious problem that suggests policy changes may be required in the area of prescription and control of drugs. It would also be useful to increase the general awareness of the public regarding antibiotic use and the consequences of misuse: what diseases
[1] Wise R, Hart T, Cars O, et al. Antimicrobial resistance. Is a major threat to public health. BMJ 1998;317:609–10. [2] Cars O, Molstad S, Melander A. Variation in antibiotic use in the European Union. Lancet 2001;357:1851–3. [3] Cizman M. The use and resistance to antibiotics in the community. Int J Antimicrob Agents 2003;21:297–307. [4] Avorn J, Harvey K, Soumerai SB, et al. Information and education as determinants of antibiotic use: report of Task Force 5. Rev Infect Dis 1987;9(Suppl. 3):S286–96. [5] Bauchner H. Parent’s impact on antibiotic use. APUA Newslett 1997;15:1–3. [6] Macfarlane J, Holmes W, Macfarlane R, et al. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ 1997;315:1211–4. [7] Little P, Williamson I, Warner G, et al. Open randomised trial of prescribing strategies in managing sore throat. BMJ 1997;314: 722–7. [8] Borg MA, Scicluna EA. Over-the-counter acquisition of antibiotics in the Maltese general population. Int J Antimicrob Agents 2002;20:253–7. [9] Richman PB, Garra G, Eskin B, et al. Oral antibiotic use without consulting a physician: a survey of ED patients. Am J Emerg Med 2001;19:57–60. [10] Pechere JC. Patients’ interviews and misuse of antibiotics. Clin Infect Dis 2001;33(Suppl. 3):S170–3. [11] Kandakai TL, Price JH, Telljohann SK, et al. Knowledge, beliefs, and use of prescribed antibiotic medications among low-socioeconomic African Americans. J Natl Med Assoc 1996;88:289–94. [12] Branthwaite A, Pechere JC. Pan-European survey of patients’ attitudes to antibiotics and antibiotic use. J Int Med Res 1996;24:229–38. [13] Edwards DJ, Richman PB, Bradley K, et al. Parental use and misuse of antibiotics: are there differences in urban vs. suburban settings? Acad Emerg Med 2002;9:22–6. [14] Vanden Eng J, Marcus R, Hadler JL, et al. Consumer attitudes and use of antibiotics. Emerg Infect Dis 2003;9:1128–35. [15] Palmer DA, Bauchner H. Parents’ and physicians’ views on antibiotics. Pediatrics 1997;99:E6. [16] Collett CA, Pappas DE, Evans BA, et al. Parental knowledge about common respiratory infections and antibiotic therapy in children. South Med J 1999;92:971–6. [17] Bauchner H, Pelton SI, Klein JO. Parents, physicians, and antibiotic use. Pediatrics 1999;103:395–401. [18] Hong JS, Philbrick JT, Schorling JB. Treatment of upper respiratory infections: do patients really want antibiotics? Am J Med 1999;107:511–5.
Patterns of antibiotic use among adults and parents in the community: A questionnaire-based survey in a Greek urban population Georgia Mitsi a,∗ , Eleni Jelastopulu b , Harry Basiaris a , Athanassios Skoutelis a , Charalambos Gogos a a
Department of Internal Medicine, Medical School of University of Patras, Heroon Polytekniou 60a, 26500 Rion, Greece b Department of Public Health, Medical School of University of Patras, Heroon Polytekniou 60a, 26500 Rion, Greece Received 2 November 2004; accepted 9 February 2005
Abstract The purpose of this study was to look for factors that affect attitudes to antibiotic use in Greek urban settings. By using a questionnaire-based survey, we conducted 323 face-to-face interviews (173 adults, 150 carers of children). In the adult group, 74.6% admitted using non-prescribed antibiotics, while only 22.7% of parents had administered non-prescribed antibiotics to their children. Around 50% of adults discontinued therapy earlier, more than 10% did not follow the correct dosage instructions and about 55% admitted using leftover antibiotics. Of the parents, 18.7% discontinued therapy earlier and 7.3% admitted keeping leftover antibiotics. Our results showed that adults were likely to show unsatisfactory compliance and to use non-prescribed antibiotics, while parents were less likely to use non-prescribed antibiotics for their children and were more compliant. © 2005 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved. Keywords: Survey; Non-prescribed antibiotics; Antibiotic usage; Urban population
1. Introduction About 80% of antibiotics are used in the community and the rest are used in hospitals [1,2]. It is estimated that 20–50% of all antibiotic use is inappropriate [1], resulting in an increased risk of adverse side effects, higher costs and higher rates of antimicrobial resistance of community pathogens [3]. The determinants of antibiotic use are thus of particular importance. They include factors as diverse as the physician–patient relationship, clinical microbiology, health economics, and the most basic definitions of illness and therapy [4]. Studies have identified and examined specific causes of antibiotic misuse. Patient demand for antimicrobials has been shown to increase unnecessary prescription [5], despite the doctor’s assessment that no such need existed [6]. Such practices can, in turn, enhance patient belief of the need for antimicrobials even when they are not indicated, fur∗
Corresponding author. Tel.: +30 2610 424116; fax: +30 2610 424116. E-mail address: [email protected] (G. Mitsi).
ther increasing pressure on prescribers [7] or lead to selfadministration of non-prescribed antibiotics [8]. This questionnaire-based study was undertaken in order to assess adult and parental attitudes regarding antibiotic use in Greek urban settings. By identifying weak areas and gaps in adults’ and parents’ knowledge, more appropriate educational efforts can be applied and a more rational antimicrobials use may be achieved.
2. Methods 2.1. Study design The study was carried out in Patras (approximately 200,000 inhabitants), Greece from October 2002 through July 2003. Using a cross-sectional design, an intervieweradministered questionnaire was applied to a sample of 323 randomly selected participants in an attempt to obtain a representative sample of the urban population regarding, age,
0924-8579/$ – see front matter © 2005 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved. doi:10.1016/j.ijantimicag.2005.02.009
440
G. Mitsi et al. / International Journal of Antimicrobial Agents 25 (2005) 439–443
gender, residential district and socioeconomic status. The sample comprised of 173 adults aged 18–85 years and 150 primary carers of children younger than 12 years. Separate questionnaires were administered to adults and parents. For the parent survey, only parents, preferentially mothers, with at least one child younger than 12-year-old living in the household, were interviewed. If the mother did not live in the household, the father or the primary caregiver was surveyed. A pre-test was applied on a pilot population (n = 20) to determine whether the data would provide reliable information. Consequently two revised 19- and 21-item questionnaires for adults and for parents, respectively, collected demographic data such as age, gender, marital status, place of residence, profession, level of education and type of insurance as well as attitudes and beliefs relating to antibiotic use. The questionnaires were anonymous and verbal consent was obtained before all interviews. Interviewees were asked about the most common symptoms leading to antibiotic intake and their adherence to their most recent course of antibiotics—did they take the required number of daily doses over the full duration of the course? Participants were also asked different questions with regard to the source of prescribed and non-prescribed antibiotics (use of leftover antibiotics, over-the-counter acquisition) and their attitudes towards physicians (level of satisfaction and pressure for antibiotic prescription). Interviewees were also asked to name the most frequently used antibiotic (generic or commercial name). We examined respondents’ attitudes toward, and awareness of, antibiotic use by their age, gender, education and medical insurance status. 2.2. Statistical analysis Statistical analysis was performed using the SPSS for Windows release 10.0 (SPSS Inc., Chicago, IL, USA). Categorical data were presented as frequency of occurrence and were analysed by the χ-square test. Continuous data are presented as mean and standard deviations and were analysed by Student’s t-test. All tests were two-tailed with alpha levels of 0.05 considered significant.
3. Results The adult survey was completed by 173 (93.5%) of 185 individuals who were approached. Of those who did not agree to complete the survey, three were non-Greek speaking, six refused and three did not complete it for other reasons. The parent survey was completed by 150 (95.0%) of 158 individuals. The non-participants included three who refused, three who did not speak Greek and two who failed to complete the survey for other reasons. There were no overlaps between groups. All the respondents lived in urban areas and were white Caucasians.
3.1. Adult questionnaires The demographic characteristics of the adult population are shown in Table 1 and the patterns of antibiotic use are presented in Table 2. Respondents with higher education tended to be more satisfied with their physicians (P = 0.009). Only 2.9% admitted of applying pressure to their doctor for antibiotic prescriptions. Men were more likely not to follow correct dosage instructions than women (P = 0.048). Around 75% admitted using non-prescribed antibiotics. The use of non-prescribed antibiotics was reported more frequently by women (P = 0.027), by individuals with higher education (P = 0.02) and by older age groups (P = 0.007). Nearly 20% did not check the expiry dates of left-over antibiotics, although individuals with higher education were more careful about this (P = 0.043). The generic or market name of the antibiotic was correctly mentioned by 73.0%. The most commonly used was amoxiTable 1 Demographic characteristics of our adult and parent population Adults (n = 173)
Adult parents (n = 150) All females
Mean age in years (S.D.)
77 (44.5%)/96 (55.5%) 40.1 (19.8)
Age groups (%) <30 30–49 50–70 >70
45.7 22 20.2 12.1
Marital status (%) Married Not married
46.2 53.8
Gender (male/female, %)
37.4 (4.24) ≤35a >35a
All married
Number of offspring(s) (%) No children 60.1 1 9.2 2–3 27.2 >3 3.5 Occupation (%) Civil servant Business Farmer Student Not employed Retired
20.2 12.1 8.7 38.2 9.8 11.0
Education (%) No or primary Secondary Tertiary
12.7 33.0 54.3
Insurance (%) Public Private Both Uninsured
75.1 12.1 11.6 1.2
a
42.0 58.0
N/A 14.7 72.7 12.7
N/A
Ab Bb Cb
38.7 38.0 23.3 82.7 10.0 7.3 0.0
Age groups in parent population. Education groups in parent population: (A) none of the parents with higher education (>12 years), (B) one parent with higher education and (C) both parents with higher education; (N/A) non-applicable/non-available. b
G. Mitsi et al. / International Journal of Antimicrobial Agents 25 (2005) 439–443 Table 2 Patterns of antibiotic use among the adult population
Table 3 Patterns of antibiotic use among the parents of small children (≤12 years) Adult parents (n = 150) (%)
Adults (n = 173) (%) How often do you visit your doctor per year? None 19.6 1–2 39.2 3 23.5 >5 17.7 What is the level of satisfaction with the medical services provided by your doctor? Low 22.9 Medium 54.2 High 22.9 How many times did you undergo antibiotic treatment during the last year? None 27.5 1–2 37.3 ≥3 35.2 For which symptoms Temperature (>37.0 ◦ C) Soar throat Ear pain Nasal congestion combination
23.1 16.2 9.8 8.1 42.8
Do you follow correct dosage instructions? Yes 88.8 No 11.2 Do you discontinue therapy once your symptoms subside? Yes 46.7 No 53.3 Do you keep leftovers for future use? Yes 54.6 No 45.4 How often do you use non-prescribed antibiotics? Never 25.4 Rarely 54.3 Often 12.7 Very often 7.5 What is their source? Leftovers Friends and family Pharmacist Others
30.2 22.3 40.4 7.1
cillin (27.7%) followed by the combination of amoxicillin and clavulanic acid (23.1%) and clarithromycin (10.4%). Only 4.8% named another drug as an antibiotic, for instance paracetamol (2.3%), whereas 22.2% could not name any antibiotic. Thirteen percent stated that their attitude towards antibiotics use would change if they were uninsured. 3.2. Parents questionnaires The demographic characteristics of the parent population are described in Table 1 and the patterns of antibiotic use are presented in Table 3. All participants were married women. Antibiotic prescription for their children during the last 3 months was reported by 27.3% of the respondents. Respon-
441
Have you administered antibiotics without a doctor’s prescription during the last 3 months? Yes 1.3 No 98.7 Do you follow correct dosage instructions? Yes 99.3 No 0.7 Do you discontinue therapy once your symptoms subside? Yes 18.7 No 78.7 Not sure 2.7 Do you keep leftovers for future use? Yes No
7.3 92.7
Have you ever used non-prescribed antibiotics? Often 2.7 Rarely 20.0 Never 77.3 How often has your prescription been modified by your pharmacist? Rarely 0.7 Never 99.3
dents with higher education were more likely not to follow correct dosage instructions (P = 0.002). Parents with more children tended to use left-over antibiotics more often than parents with one child only (P = 0.03). When respondents were asked to name an antibiotic 85.2% answered correctly by giving the generic or market name. The most common was amoxicillin (36.7%) followed by the combination of amoxicillin and clavulanic acid (21.3%) and cefaclor (12.7%); 2.8% named a non-antibiotic and 12.0% could not name any antibiotic. Four percent replied that their attitude towards antibiotics use would change if they were uninsured. When the patterns of antibiotic use between adults and parents of small children were compared, all studied parameters (correct dosage, discontinuation of therapy, use of left-over antibiotics and change of attitude if uninsured) were significantly different (Table 4).
4. Discussion The aim of this questionnaire-based study was to assess adult and parental knowledge, attitudes, and experiences regarding antibiotic use. The findings suggest that both adults and parents represent an important source of antibiotic misuse. The study revealed a high use (74.6%) of non-prescribed antibiotics in the Greek urban adult population (54.3% rarely, 12.7% often and 7.5% very often). Other studies have reported lower percentages of about 20% [8,9]. The reasons for the increased use of non-prescribed antibiotics in the popula-
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Table 4 Comparison of the patterns of antibiotic use between adults and parents of small children (≤12 years) Questions
Adults (n = 173) (%)
Parents (n = 150) (%)
P-value
Do you follow correct dosage instructions? Yes 88.8 99.3 No 11.2 0.7
0.01
Do you discontinue therapy once your symptoms subside? Yes 46.7 18.7 No 53.3 81.3
<0.0001
Have you ever used non-prescribed antibiotics? Very often 7.5 0.0 Often 12.7 2.7 Rarely 54.3 20.0 Never 25.5 77.3 Would your attitude towards antibiotics use change if you/family were uninsured? Yes 13.3 4.0 No 86.7 96.0
<0.0001
0.007
tion studied are not clear. Cultural differences, level of education, and/or medical awareness may play a role. However, one of the most important factors is the increased availability of antibiotics over-the-counter in Greece. All patients have access to antibiotics since a prescription is required but not necessary for their acquisition. The relative importance of over-the-counter sales and pharmacists’ attitudes towards antibiotics are currently under investigation. In a Pan-European survey (Greece was not included) [10], it was noted that it was possible to get antibiotics directly from the pharmacist without prescription in the nine countries studied, even where this practice was illegal. Women, individuals with higher education and older patients used non-prescribed antibiotics more frequently. Similar results concerning patients with higher levels of education have been reported [9]. One could speculate that older and more educated individuals believe they have a certain amount of ‘medical savvy’ and may be, therefore, more likely to feel comfortable making a diagnosis of their illness and their need for antibiotics. Furthermore, women’s involvement in childraising and their disease management could alter their selfmedication attitudes, leading to misuse of antibiotics. About half of the respondents discontinued therapy early, once their symptoms subsided, without consulting their physician. About one-third admitted of using left-over antibiotics without a prescription and about one-tenth did not follow recommended dosage instructions. In an earlier study, only 60% of adults admitted taking all of a prescribed course and about 20% had shared an antibiotic [11]. In another study, 78% of adults reported that feeling better justified stopping antibiotics and about one-third thought that saving antibiotics for future use was acceptable [12]. Left-over use, incorrect dosage and early therapy discontinuation are well recognised attitudes related to antibiotic compliance and misuse [3]. A recent international survey [10] reported that compliance is generally unsatisfactory. Overall, only 69% of respondents
completed their most recent course of antibacterial treatment and 24% saved part of the course for future use. Although patient pressure on doctors to prescribe antibiotics is not a novel situation and has been often related to misuse, our results revealed that only 2.9% admitted applying pressure to their doctor. MacFarlane et al. [6] report that 72% of patients with respiratory tract infections wanted antibiotics and also expected them to be prescribed. More than a quarter actually asked for an antimicrobial, whilst those wanting antibiotics were five times more likely to have them prescribed [6]. The low percentage in our survey may be attributed to the characteristics of our population and the availability of antibiotics ‘over-the-counter’. Adults in urban settings are usually well-insured and have regular, longstanding relationships with their physicians and are, therefore, more likely to accept a decision to withhold antibiotics [13]. In an attempt to clarify if the interviewees were familiar with antibiotics, they were asked to name an antibiotic by its generic or market name. Surprisingly, the majority of adults and parents replied correctly. Our survey did not intend to evaluate knowledge of antibiotics among patients, but to study patterns of use. A study of consumer attitudes towards antibiotic use [14] revealed that misguided beliefs and expectations were associated with lack of awareness of the dangers of antibiotic use. The results of the study also showed that there is an important problem with administration of non-prescribed antibiotics by parents. In the overall survey population, 22.7% admitted to this practice (considerably lower than that of the adult population (P < 0.0001). The use of left-over antibiotics was low (7.3%). Parents in our urban-based population who have better access to health insurance and health care providers may also have easier access to ‘leftover’ antibiotics. This factor alone may play a major role in the higher prevalence of antibiotic misuse for parents of children in the urban setting. In a similar study conducted in community and urban settings [13], parents admitted administering non-prescribed antibiotics to 12.1% versus 4.0%, respectively. However, this actual percentage is probably higher when one considers the number of parents who were unlikely to admit to an improper practice with their children. In our study, 78.7% of parents did not discontinue therapy once their children’s symptoms had subsided. In another paediatric study, a high proportion of parents (78%) reported having given their children the full prescribed course of an antibiotic [15]. In the survey by Collett et al. [16] administering the complete course of an antibiotic was almost always claimed. The results of the comparison of the patterns of antibiotic use between adults and parents of small children suggested that parents are more likely to treat themselves inappropriately rather than their children. A much higher misuse rate in the adult population was also found by Edwards et al. [13]. In our study, almost none of the parents admitted to applying pressure to their paediatrician for antibiotics prescription. Collett et al. [16] reported that 19% of parents asked for
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an antibiotic prescription and even more (31%) thought that sometimes paediatricians failed to prescribe antibiotics when necessary. These differences may be explained by different paediatrician–parent communication patterns. Other factors such as the need for a quick recovery in order to return to child care could further contribute to the parental misuse of antibiotics [17] in communities that depend on institutional rather than family child care.
actually require antibiotics, why full daily doses must be respected, absence of any impact of antibiotic therapy on the immune system, danger of keeping part of a course for future uncontrolled use and the need for a prescription for getting antibiotics from the pharmacist, could be some of the issues. Educational campaigns on antibiotics, their uses and limitations for the general public, are needed as part of any attempt to improve rational use of antimicrobials.
5. Limitations and future directions
References
This study has certain limitations that merit discussion. First, our urban population is more likely than the general population of our country to have health insurance and to come from the middle to upper socioeconomic classes. Another limitation is that patients are asked several questions about their or their children’s past use of antibiotics, which may lead to recall bias. Although the survey is administered face-to-face by a single interviewer the possibility that respondents may misinterpret or misunderstand questions should be considered. Relying on patients’ interviews is an acceptable tool in medical research, but it is a subjective tool that may create biases resulting from difficulties in communication, cultural differences and language problems. Several studies have shown that patients often do not have accurate knowledge of antibiotics. Hong et al., for example, found that patients often could not identify whether a medication was an antibiotic or not and that many patients considered ‘antibiotics’ to be any prescription medication [18]. Another limitation is the cross-sectional nature of this study. Each participant was assessed only once, and the study was not designed to detect recent changes in opinion. Furthermore, the indicators used measured self-reported behaviour not actual behaviour. Larger-scale studies are needed that have a more heterogeneous population mix to define further the scope of patient antibiotic misuse. The role of pharmacists and other health professionals should be explored. Future studies are also needed to determine whether local resistance patterns, to common outpatient antimicrobials, reflect the self-prescribing patterns of our patients. The key results of this study are that adults in urban settings of our country were very likely to use non-prescribed antibiotics. Furthermore, when they used prescribed antibiotics, their compliance was unsatisfactory. On the other hand, parents used less non-prescribed antibiotics for their children and were more compliant. These results point to a serious problem that suggests policy changes may be required in the area of prescription and control of drugs. It would also be useful to increase the general awareness of the public regarding antibiotic use and the consequences of misuse: what diseases
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