Inappropriate use of antibiotics among communities of Gondar town, Ethiopia: a threat to the development of antimicrobial resistance
Erku et al. Antimicrobial Resistance and Infection Control
Inappropriate use of antibiotics among communities of Gondar town, Ethiopia: a threat to the development of antimicrobial resistance
Daniel Asfaw Erku 0 1
Abebe Basazn Mekuria 2
Sewunet Admasu Belachew 1
0 Department of clinical pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar , P.O. Box: 196, Gondar , Ethiopia
1 Department of Clinical Pharmacy, School of Pharmacy, University of Gondar Chechela Street, Lideta Sub city Kebele , 16 Gondar , Ethiopia
2 Department of Pharmacology, School of Pharmacy, University of Gondar Chechela Street, Lideta Sub city Kebele , 16 Gondar , Ethiopia
Background: The emergence of antimicrobial resistance, the main cause of morbidity and mortality from otherwise treatable infections, is largely attributed to the inappropriate use of antimicrobials. However, data on the extent of inappropriate use of antibiotics in the community is scarce in Ethiopia. The aim of present study is to document the extent of inappropriate use of antibiotics and its associated factors among the communities of Gondar, Northwest Ethiopia. Methods: A community based cross-sectional survey was conducted on a total of 650 participants in Gondar town, northwest Ethiopia from December 1, 2016 to January 30, 2017. Descriptive statistics, univariate and multivariate logistic regression analysis were also performed to express different variables and to examine factors associated with inappropriate use of antibiotics. Results: According to the finding of our study, 315 (48.5%) of the participants took antibiotics in the past 1 year, of which 115 (35.9%) of them used inappropriately. Amoxicillin (72%) was the most commonly utilized antibiotics and respiratory tract infection (40.9%) was the most common disease condition to which antibiotics had been sought. About 36.8% of the respondents got antibiotics from community drug retail outlets without a prescription and 67.9% of respondents had discontinued the use of antibiotics once their symptoms subside. Low educational status (AOR = 5.01, 95% CI = 2.62-9.34), being employed (AOR = 2.12, 95% CI = 1.81-7.29) and unsatisfied with health care services provided (AOR = 5.41, 95% CI = 2.71-14.21) were found to be strong predictors of inappropriate use of antibiotics use among the community. Conclusion: Inappropriate use of antibiotics was found to be considerably high in the communities of Gondar, northwest Ethiopia. Taking into consideration the heightened importance of comprehensive knowledge in the rational use of antibiotics, different stakeholders working in the public health sectors should provide a comprehensive and customized education to the public so as to improve their knowledge about antibiotics. It is also essential to adopt a strong and explicit line of actions towards the accessibility of antibiotics without a valid prescription in community medicine retail outlets.
Inappropriate use; Antimicrobials; Drug resistance; Community; Ethiopia
The emergence of antimicrobial resistance (AMR), the
main cause of morbidity and mortality from otherwise
treatable infections, is largely attributed to the use, over
use or misuse of antimicrobials [
]. The development of
AMR coupled with the downturn in the development of
new antimicrobials in the pharmaceutical industry creates
unexpected challenges in the effective management of
]. Annually, multi-drug resistant (MDR)
bacteria is estimated to claim the lives of more than 20,000
patients in North America, 25,000 patients in Europe and
more than 90,000 patients in Southern Asia [
A number of researchers underlined the relationship
between the inappropriate use of antimicrobials in the
community and the emergence of antimicrobial resistance [
According to WHO (World Health Organization), more
than two third of all antibiotics are used in the
community, of which about 30% is used inappropriately [
to this, interventions focusing on the in the community
such as improving access to medical services, reducing
unnecessary use of antibiotics, taking a full course of
treatment, and not sharing medications with other people are
]. Many previous studies documented
factors associated with inappropriate use of antibiotics
including culture [
], educational status [
], residency [
marital status [
], age [
], health insurance [
] and level
of satisfaction with the health care services [
storing antibiotics at home .
In Ethiopia, there are signs of irrational use of
antibiotics by the community, patients as well as by health care
providers. According to the baseline survey conducted by
Food, Medicine and Healthcare Administration and
Control Authority of Ethiopia (FMHACA), about two third of
patients (70%) patients who visited outpatient clinics have
had one or more antibiotics prescribed with a percentage
of irrational prescribing close to 40% [
]. A number of
studies underlined the role of the general public in the
emergence and spread of antibiotic resistance [
According to WHO, improving public access to medical
facilities, reducing unnecessary and irrational use of
antimicrobials, taking prescribed antimicrobials to their full
course of therapy and not sharing medication with other
people are some of the key issues of the general public in
the fight against antimicrobial resistance . However,
the extent of inappropriate use of antibiotics in the urban
and rural community settings has not yet been fully
explored in Ethiopia. The present study aimed to document
inappropriate use of antibiotics and its associated factors
among the communities of Gondar, Northwest Ethiopia.
Study design and setting
A community based cross-sectional survey was
conducted from December 1, 2016 to January 30, 2017 to
determine inappropriate use of antibiotic among the
communities Gondar town, northwest Ethiopia. We
collected data between December 2016 and January 2017 as
this season is associated with higher cases of infectious
disorders and other common parasitic infections in
Ethiopia. This study was approved by the ethical
committee of School of Pharmacy, University of Gondar with
an approval number of UoG-SoP-123/2016. Written
informed consent from the participants was also obtained
before conducting this study. Participants’ information
obtained was kept confidential.
Population and sampling
Gondar town, the study area, is found in Amhara
regional state and is located 750 km Northwest of Addis
Ababa (the capital city of Ethiopia). According the
recent population and housing census report, Gondar
town has a total of 207, 000 population [
]. The town
has a total of 12 administrative zones (areas),1 referral
hospital, and 1 defense hospital and 5 health centers.
Single population proportion formula was used with the
assumption of 95% confidence interval, 5% margin of
error, the prevalence (p) of inappropriate use of
antibiotics (30.9%) [
] and 5% for possible non-response to
determine a final sample size of 720. Multistage stratified
random sampling technique was used to select
households in administrative areas (kebeles). Five
administrative areas were selected randomly to get a representative
sample. The number of households to be interviewed in
each administrative area was determined in proportion
with the total number of households found in each
kebeles. A systematic random sampling method was then
used to select the study participants. Lottery method was
used to select a respondent whenever more than one
eligible respondent found in the selected household.
Data collection was performed by five well trained final
year pharmacy students through interviewer-administered
questionnaire. The tool was created by modifying items in
a previously used instrument regarding knowledge and
use of antibiotics in the community [
], and items were
thoroughly reviewed for relevance by a team of experts
including experienced clinical pharmacists and public health
experts. The survey instrument was further pre-tested on
45 households who were not included in the final analysis
and relevant modifications were instituted before the
commencement of actual data collection. The
questionnaire asks respondents about the socio-demographic
characteristics and knowledge as well as the use of
antibiotics. Investigators took different antibiotics (in all
dosage forms) with them to show participants whether they
know and/or use the antibiotics in the last 1 year. In our
study, inappropriate use of antibiotics is defined as the
non-prescription use of antibiotics for themselves and/or
their family members, or the use of leftover antibiotics or
the use of prescribed antibiotics for a reason other than its
intended for [
All the statistical analyses were done using Social Sciences
(SPSS) software version 21.0 for Windows (SPSS Inc.,
Chicago, IL). Frequencies and percentages were used to
express different variables. Uivariate and multivariable
logistic regressions were used to come up with predictors of
inappropriate use of antibiotics. Associations with
significance level of less than 0.20 (p < 0.20) in the univariate
analysis were included in the multivariate logistic
regression analysis. The results were adjusted for patients’
demographic and disease characteristics. OR with 95% CI were
also computed along with corresponding p-value (p < 0.05)
as cut off points for determining statistical significance.
Out of 720 households approached, 650 of them give
consent and included in the study giving a response rate
of 90.3%. The mean age of participants was 33.19 years
with a standard deviation of ± 10.82. The majority of
respondents were females (74.9%) and the mean family
size was 4.2 with a standard deviation of ± 2.32. Details
of socio-demographic characteristics of study
participants are shown in Table 1.
According to the finding of our study, nearly half
(48.5%) of the participants took antibiotics in the past 1
year, of which 200 (63.5%) used for themselves and 115
(36.6%) used for family members. Amoxicillin (72%) was
the most commonly utilized antibiotics followed by
Amoxicillin-clavulanate combination (26%) and
Doxycycline (19%). Commonly utilized antibiotics are depicted in
Fig. 1. Respiratory tract infection (40.9%), mechanical
injury/wound (27%) and acute diarrhea (19.1%) were the
three most common disease conditions to which
antibiotics had been taken. More than half of the respondents
(53%) got antibiotics from community drug retail outlets
without a prescription (36.8%) or shared from family
member or neighbor (19.1%) (Table 2).
Among participants who took antibiotics, 115 (35.9%)
of them used inappropriately. Majority of participants
answered incorrectly on the use of amoxicillin (80.8%)
tetracycline (60.9%) and ciprofloxacin (76%). Nearly
twothird of respondents (67.9%) responded that they had
discontinued the use of antibiotics once their symptoms gone.
Predictors of inappropriate antibiotics use
Logistic regression analysis was employed to assess
possible associations between different sociodemographic
variables and respondent’ inappropriate use of
antibiotics (Table 1). According to the results from
bivariate logistic regression, factors that were associated
with inappropriate use of antibiotics included age,
educational status, employment status and satisfaction with
health care services. Variables that were significantly
associated with inappropriate use of antibiotics in the
bivariate analysis (those with p-value < 0.20) were further
examined in multivariate logistic regression. Having
other variables controlled, educational status,
employment status and satisfaction with health care services
remained to be significant in the multivariate logistic
model. The odds for inappropriate antibiotics use among
respondents who were unable to read and write were
4.01 times higher than respondents with tertiary
education. Similarly, the odds for inappropriate antibiotics use
among respondents who are employed were 2.12 times
higher than respondents who are unemployed.
Furthermore, those who are unsatisfied with the health care
services provided were 4.41 times more likely to practice
inappropriate use of antibiotics than those who are
satisfied with the health care services provided.
Inappropriate use of antibiotics, the key driver of
antimicrobial resistance, is mounting at an alarming rate
and the condition is conceivably worse in many
developing countries including Ethiopia [
]. According to the
finding of our study, 315 (48.5%) of respondents took
antibiotics in the past 1 year, of which 200 (30.8%) used
for themselves and 115 (17.7%) used for family
members. The prevalence of self-medication reported in this
study is comparable to the study done in three towns of
northwest Ethiopia (27.5%) [
], but higher than studies
conducted in Bahir Dar, Ethiopia (18%) [
] and Euro-Mediterranean region (19.1%) [
Moreover, the prevalence of family medication in our
study was slightly higher than the study done in Bahi Dar
], but much lower than the study conducted in china
]. Amoxicillin and Amoxicillin-clavulanate
combination were the two most commonly utilized
antibiotics and respiratory tract infection was the most common
disease problem to which antibiotics had been sought.
Similar findings were also reported in the study conducted
in Uganda [
], Indonesia [
], Guatemala [
different parts of Ethiopia [
], which reported that
Amoxicillin was the most commonly used antibiotics. Similarly,
in a study conducted in three selected towns of northwest
Ethiopia, respiratory tract symptom was the most
commonly reported complaint for self-medication .
It is widely believed that antimicrobial resistance can
potentially arise from inadequate dosing and
discontinuation of the full course of treatment [
]. In our
study, one third of respondents (32.1%) discontinued the
use of antibiotics once their symptoms were gone.
This finding is higher compared with the study done
in in Kuwait (24%) . But, it is lower than other
studies conducted in Malaysia and Greece [
This antibiotic misuse may put the patient at risk of
relapse with drug resistant bacteria.
Several studies conducted in different parts of the
globe reported that antimicrobials are purchased
without a valid prescription and could be simply
possessed regardless of policies prohibiting such practice
]. In our study, over half of the respondents
got antibiotics from community drug retail outlets
without a valid prescription or shared from family
member or neighbor. In a simulated study conducted in
Addis Ababa, Ethiopia to assess the non-prescription sale
of medications, antibiotics were obtained without any
valid prescription from 75.9% of community
]. Similar findings were also reported in
studies conducted elsewhere [
]. The high prevalence
of non-prescription sale and access of antibiotics in
our study could be due, in part, to the lack of
appropriate national regulations and explicit line of actions
in the sales of antimicrobials in community drug
retail outlets. Furthermore, patients may prefer to go
directly to pharmacies rather than visiting a hospital
due to a number of reasons including ease of
accessibility, shorter waiting time and accommodate patients’
ability to pay [
According to the finding of our study, 115 (35.9%)
of respondents used antibiotics inappropriately.
Having other variables controlled, low educational status,
being employed and unsatisfied with health care
services provided are found to be strong predictors of
inappropriate use of antibiotics use in the multivariate
logistic model. Several other studies have also
reported that lower educational status [
engagement with regular job [
] and being unsatisfied
with health care services [
] were associated with
inappropriate use of antibiotics. The low educational
status of participants, which may render them to have
insufficient knowledge on use of antibiotics, could
have a weighty impact on the rational use of
antimicrobials and development of antimicrobial resistance
in the community. Hence, a customized educational
campaign regarding the rational use of antibiotics and
its impact on the development of antimicrobial
resistance should be provided to the community.
Furthermore, the relative lack of time to visit health care
facilities during working hours, along with having
pocket money in respondents with a regular job may
render them to purchase antibiotics directly from
community drug retail outlets without visiting health
care facilities, ultimately increasing the potential for
inappropriate use of these medications. Moreover, lack
of satisfaction with health care services provided may
discourage people to seek medical care from
hospitals, encouraging them to look for other options for
the management of their medical condition .
Limitation of the study
Even though this survey highlights an area of research
where there is lack of literature in Ethiopia, caution
should be exercised when generalizing to other regions
in Ethiopia as the study was a cross-sectional and
conducted only in Gondar, northwest Ethiopia.
Nevertheless, this survey has significant implications for
promoting the rational use of antibiotics and contain
the development of antimicrobial resistance in the
The results of the present study revealed that
inappropriate use of antibiotics is high and associated
with low educational status, engagement in regular
job and being unsatisfied with health care services.
Our findings emphasize the need to form and deliver
a comprehensive and multifaceted interventions
including providing a customized education to the
public so as to improve their knowledge about antibiotics
and change their attitude to limit self-medication.
Moreover, it is essential to adopt a strong and explicit
line of actions towards the accessibility of antibiotics
without a valid prescription. A larger national scale
and multi centered survey that includes more diverse
participants is warranted to validate our findings and
to provide more accurate findings. In addition, we do
recommend upcoming studies to focus on
identification of areas to antibiotic treatment failure and
referral to healthcare facilities due to infectious diseases
AMR: Antimicrobial resistance; AOR: Adjusted odds ratio; CI: Confidence
interval; FMHACA: Food, medicine and healthcare administration and control
Authority of Ethiopia; MDR: Multi-drug resistant; OR: Odds ratio;
SPSS: Statistical package for the social sciences; USD: United States Dollar;
WHO: World Health Organization
The authors are thankful to all the participants of the survey. The authors
also acknowledge the support of School of pharmacy, University of Gondar
in facilitating the data collection process.
No financial support was gained to conduct the study.
Availability of data and materials
All relevant materials and data supporting the findings of this study are
contained within the manuscript.
All the authors involved in the conceptualization of the study, data collection
supervision and write up of the first draft of the manuscript as well as submission
of the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
This study was approved by the ethical committee of School of Pharmacy,
University of Gondar with an approval number of UoG-SoP-123/2016. Written
informed consent from the participants was also obtained before conducting
this study. Participants’ information obtained was kept confidential.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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