Main findings
Community drug sellers often do not have adequate biomedical knowledge of the antimicrobial agents and the disease processes. However they are commonly used as source of advice or information for the antimicrobial agents obtained and used over-the-counter. Settings in which individuals are highly educated tend to have relatively low levels of use of antimicrobial self-medication. Therefore promotion of literacy among communities is an important target to minimize antimicrobial self-medication in LMICs. Due to their prior successful use of antimicrobial agents, individuals in most communities tend to believe that they are able to manage subsequent illness without consulting a physician. This is a potential risk factor for inappropriate drug use since most patients lack knowledge of the disease process and the medicines used in self-medication. In the review, adverse effects of antimicrobial self-medication were rarely reported in the articles from most studies in LMICs.
Responsible self-medication has the potential of being an important alternative to the formal healthcare system, providing patients the opportunity of accessing immediate healthcare [
50]. However in most communities especially of developing countries, in addition to accessing medicines designated as over-the-counter, individuals also use prescription only medicines without any medical supervision. Such a practice is not likely to benefit patients especially in the case of antibiotics as it’s associated with potential risks to both the patient and community. The reason (s) why individuals decide to use medicines designated as prescription only without any guidance from a health professional are unique to different settings and are reflective of a matrix of health system, societal, economic and health factors [
11]. Therefore establishing these factors is a critical step in designing and implementation of interventions against irresponsible self-medication. The current review also presents estimate of the prevalence of antibiotic self-medication and the associated clinical outcomes in communities of LMICs.
In this review, the prevalence of antimicrobial self-medication in LMICs was 38.8 % and is consistent with the findings (39 %) of a previous review on global antimicrobial self-medication [
3]. The use of antibiotics without a prescription occurs globally despite their prescription only legal status in most countries [
3]. Our review revealed that the prevalence of non-prescription antibiotic use in LMICs is similar to the global rate. However the high levels of poverty as individuals cannot afford full antibiotic course and illiteracy potentially increase the likelihood of risks associated with non-prescription antibiotic use in LMICs [
19]. For example development of antibiotic resistance, a consequence of inappropriate drug use commonly associated with self-medication causes higher mortality in LMICs compared to the developed nations [
51]. Our review also showed that the prevalence of antibiotic self-medication varied in different regions. This could be due to the difference in the effectiveness of enforcement of regulations on antibiotic self-medication in different resource limited countries. However, there was significant heterogeneity in the outcome of studies included in the review even after we performed sub-group analysis (region and risk of bias). Therefore we could not combine the included studies in a meta-analysis.
Self-medication has potential benefits which are shared among patients, healthcare professionals, healthcare system, and the pharmaceutical industry. For the industry; increased access to the products results in more profits; health professionals avoid unnecessary consultations with patients having minor symptoms; healthcare costs to government are reduced as individuals meet their healthcare bills and patients gain greater empowerment thus improving patient-clinician relationship [
10]. A study included in this review reported rapid resolution of disease symptoms among participants [
52]. Others showed that using antimicrobial self-medication, saves time, is affordable, and convenient. These positive attributes of self-medication, further reinforce community use of antimicrobial self-medication in management of prevalent illnesses. However, it should be noted that the potential benefits associated with self-medication will only be achieved if it’s done responsibly and the medicines used are safe, efficacious and information leading to their safe use is easily accessible to the communities [
11].
The underlying challenges of health systems in most LMICs such as inadequate healthcare potentially influence use of self-medication [
11]. In addition, the lack of policies or their inadequate implementation enables easy over-the-counter access of antibiotics [
53]. A previous study in northern Uganda found that over half (59.3 %) of community members who practiced antimicrobial self-medication were not aware of any restrictions on their non-prescription use in the country [
54]. This occurs in spite of the existence of national drug policy formulated in 2002 which limits antibiotics to prescription only use. Furthermore, most LMICs face the challenge of irregular supply of drugs to the public health facilities which limits community access to healthcare. This coupled with the high burden of infectious diseases in these countries makes the private sector an important alternative source of healthcare [
6]. However, the profit oriented nature of service delivery in this sector in addition to the inadequate supervision, influence over-the-counter sale of antibiotics despite their prescription only legal status. The question facing most LMICs who suffer high burden of infectious diseases is how to balance improved access to antibiotics for individuals with true infectious diseases through self-medication while at the same time ensuring appropriate use.
The key determinants of antimicrobial self-medication in LMICs included; severity of illness, economic status, past successful use and educational level. Most community members do not visit a health professional prior to initiating treatment due to the associated costs such as time, travel expenses and consultation charges [
55]. The high level of poverty in communities of most LMICs in addition to the fact that patients can purchase antibiotics over-the-counter using any amount of money influence antibiotic use practices [
11]. The prevalent belief in self-efficacy among patients due to past illness experiences further impacts on the use of antibiotic self-medication. Community members with a high level of education were more likely to use antimicrobial self-medicate possibly due to the exposure and increased awareness on health [
56]. Patients who assessed the symptoms of their illnesses as mild or moderate were more likely not to consult a healthcare professional. However, lack of biomedical knowledge of the disease symptoms is likely to increase the risk of inappropriate antibiotic use practices such as stopping treatment when symptoms resolve [
11], delay in seeking appropriate treatment which may potentially result in more severe disease. Delay in seeking medical care has been associated with increased mortality among patients suffering from treatable infections such as malaria [
57]. The decision by individuals in communities to use self-medication is as a result of complex interaction of various factors such as quality of healthcare, regulatory environment, burden of disease, economic factors and belief [
11]. Therefore interventions to mitigate antibiotic self-medication especially in LMICs need to specifically focus on these primary factors.
The review established inappropriate practices in antibiotic self-medication in communities of LMICs. These included, not completing dose, sharing drugs, stopping use of drugs when symptoms improve and inaccurate indication. The use of antibacterial agents in treatment of common cold was reported in studies done in Jordan [
21], Iran [
24], Palestine [
30], Vietnam [
43], and Sudan [
19]. Not completing the dose of antibiotics carries a risk of clinical failure. Previous studies done in children with mild pneumonia using 3 day and 5 day amoxicillin found non-compliance as the main reason for treatment failure [
58,
59]. The majority of studies included in the review reported self-medication using multiple antimicrobial agents. The use of more than one antibiotic during an illness episode is indicative of the uncertainty of the cause of illness. These inappropriate practices potentially increase the risk of mistreatment, adverse drug reactions, resistance development and drug interactions [
6,
7,
10]. This is further worsened by the high burden of infectious diseases in addition to the limited therapeutic choices in most LMICs [
6]. Antibiotic resistance is likely to add further financial strain to the healthcare system which is already faced with the challenge of inadequate funding. This is especially the case as patients with resistant infections are likely to stay longer in hospitals and the need to use more expensive second line antibiotic drugs. Agencies such as World Health Organization (WHO), World Self-medication Industry (WSMI) and the ministries of health of LMICs need to establish specific interventions focusing on these common inappropriate antibiotic use practices.
The review found that drug sellers, previous successful use, drug leaflets, past prescriptions and friends or relatives were the main sources of drug information in self-medication. Drug leaflets are an important source of information, however poor readability makes using them challenging to use [
6]. In addition, the high level of illiteracy in LMICs further limits the effectiveness of leaflets as a source of information. Providing this information in indigenous languages in addition to well written information could improve the usefulness of drug leaflets in these settings [
6]. Prescription practices of physicians in communities are likely to influence antibiotic use behavior of the local population as patients commonly refer to old prescriptions in choosing medicines used in self-medication [
11]. Interventions such as retention of prescriptions in the pharmacy could help mitigate use of old prescriptions in making treatment decisions in communities [
60]. Drug sellers in most of the developing countries have less impetuous of knowing biomedical information of the drugs they sell as they assume that patients know what they want and for them they know the price [
50]. In Lao People’s Republic, over half (59 %) of drug dispensers are not knowledgeable about the drugs that they were selling [
61]. However, in this review drug sellers were frequently reported as a source of information for antibiotics obtained over-the-counter despite their potential lack of biomedical knowledge of these drugs. This increases the risk of misinforming their clients on the antibiotic agents accessed over-the-counter. Non-prescription use of antibiotics without relevant information on how to take them, indications, adverse effects and contraindications could potentially expose patients to the risk of inappropriate drug use [
62]. Health personnel in communities of LMICs are thus an important target for sensitization, monitoring and support supervision.
The review had some limitations, variation in the techniques of data collection and reporting in the primary studies which were included. There was a potential of bias in the included studies due to; method of analysis, recall, selection and social desirability. This invariably has an effect on the findings of the primary studies. For example, majority of studies used recall period of more than six months while others did not report the duration of recall used during data collection. In a previous study [
63], it was found that a recall period of more than one month was significantly associated with the risk of recall bias. The use of non-random methods in participant recruitment in addition to not validating the data collection tools was common in most surveys and could potentially have an effect on the study outcomes. There was high heterogeneity in the studies reviewed possibly due to lack of standardized criteria of survey data collection. We were unable to access some articles during the study selection in spite of all the efforts taken. The studies included in the review rarely reported on the negative outcomes of antibiotic self-medication experienced by community members. This could be due to limited knowledge of the antibiotic medicines that they used in self-medication [
34].