Background

Community-based antibiotic access and use have received less attention than prescription behaviours in formal healthcare settings. We have little understanding of antibiotic use in the community, which is considered a key driver of antibiotic resistance.

Studies revealed a high prevalence of self-medication: accessibility, affordability, healthcare facility conditions, and health-seeking behaviour were found to be the main determinants of self-medication in studied LMICs.

To fill these research gaps, in ABACUS I, we used a comparative mixed-method approach to compare community-based antibiotic access and use practices across communities in six LMICs in Asia (Bangladesh, Thailand, and Vietnam) and Africa (Mozambique, Ghana, and South Africa) to allow for comparison by national income status and identify supply and demand drivers. Within the existing INDEPTH surveillance network, ABACUS I was powered to identify the contextual complexities and differences between countries with different income levels, policy frameworks, and cultural norms.

Vietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time-consuming, cheaper, and overall more convenient than accessing them through healthcare facilities.

Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia.

The gained insight into antibiotic practices in different LMICs could inform the design of context-adjusted models for interventions to effectively address the usage of antibiotics and contain antibiotic resistance in these resource-constrained settings.

ABACUS I found common themes reported in previous studies in LMICs but also revealed the diversity and complexity of locally specific sociocultural determinants affecting antibiotic access and usage among studied communities in six Asian and African LMICs.

The identified factors serve as targets for the development of context-tailored interventions to effectively address the misuse of antibiotics and contain antibiotic resistance in LMICs.

In ABACUS II – based on the finding of existing confusion regarding how to identify antibiotics – we build the case for an international system that harmonises the appearance and thus improves the identification of oral solid formulations of antibiotics both for consumers and providers. We will consider the potential negative effects as well.

Aims

We have formulated the following key goals:

1. Assess the potential impact of and obstacles to standardising the physical appearance of commonly used oral antibiotics on formal and informal suppliers as well as consumers in the six ABACUS countries;
2. Design, with key stakeholders and experts, an approach and prototypes that improve (for both suppliers and consumers) the appropriate identification of oral antibiotics;
3. Perform a health economics analysis related to the inappropriate identification of oral antibiotics and the potential impact of introducing the standardised designs;
4. Assess the proportion of substandard and falsified oral antibiotics among three commonly sold antibiotics in four of the six ABCUS countries (Mozambique, Bangladesh, Ghana, and Vietnam).