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UNIVERSITY OF GHANA 
SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
 
FACTORS INFLUENCING THE USE OF ANTIBIOTICS AMONG 
ADULTS IN THE GREATER ACCRA METROPOLIS 
 
BY 
AMA AKYAMPOMAA OWUSU-ASARE 
(10636485) 
 
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, 
LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR 
THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE 
 
 
 
JULY 2018 
 
 
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DECLARATION 
This is to declare that this dissertation is the result of my own independent research 
undertaken under supervision. Published literatures of other researches which have been cited 
have been duly acknowledged with references. 
 
Ama Akyampomaa Owusu-Asare                  Dr. Adolphina A. Addo-Lartey 
(Student)                                   (Supervisor) 
Signature: …………………..          Signature: ………………… 
Date…….…………………..          Date …..…………………... 
 
 
 
  
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DEDICATION 
This dissertation is dedicated to my mother, Beatrice Owusu who ensures that I am always a 
go-getter. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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ACKNOWLEDGEMENT 
I am grateful to God for seeing me through this course. My immense gratitude also goes to 
my husband and my kids for their support, encouragement and prayers throughout this 
course. 
To my supervisor, I say ayekoo for your constructive comments and pushing me to bring the 
best out of this research within time.  
My gratitude also goes to all the data collectors and participants who worked tirelessly with 
me under such short notice to make this research a reality. 
 
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TABLE OF CONTENTS  
DECLARATION ........................................................................................................................ i 
DEDICATION ........................................................................................................................... ii 
ACKNOWLEDGEMENT ....................................................................................................... iii 
TABLE OF CONTENTS .......................................................................................................... iv 
LIST OF TABLES ................................................................................................................... vii 
LIST OF FIGURES ............................................................................................................... viii 
DEFINITION OF TERMS ....................................................................................................... ix 
LIST OF ACRONYMS ............................................................................................................. x 
ABSTRACT .............................................................................................................................. xi 
CHAPTER ONE ........................................................................................................................ 1 
INTRODUCTION ..................................................................................................................... 1 
1.1. Background of Study ....................................................................................................... 1 
1.2. Statement of the Problem ................................................................................................ 3 
1.3. Justification of the Study ................................................................................................. 4 
1.3.1. Knowledge ................................................................................................................ 5 
1.3.2. Attitudes/Practices .................................................................................................... 5 
1.4. Research Relevance......................................................................................................... 6 
1.5 General Objective ............................................................................................................. 6 
1.6 Specific Objectives ........................................................................................................... 7 
1.7. Research Questions ......................................................................................................... 7 
CHAPTER TWO ....................................................................................................................... 8 
LITERATURE REVIEW .......................................................................................................... 8 
2.1 What are antibiotics? ........................................................................................................ 8 
2.2 Development of antibiotic resistance ............................................................................... 9 
2.3 Antibiotic use ................................................................................................................. 12 
2.3.1 Global use ................................................................................................................ 12 
2.3.2 Local use .................................................................................................................. 15 
2.4 Factors influencing consumption of antibiotics within the community setting ............. 16 
2.5 Conceptual Framework .................................................................................................. 16 
2.6.1. Demographic/socioeconomic factors ..................................................................... 18 
2.6.2. Knowledge of antibiotic and antibiotic resistance .................................................. 18 
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2.6.3. Attitudes/Practices towards antibiotic consumption ............................................... 19 
2.6.4. Access to healthcare ............................................................................................... 19 
2.7 Gaps in the literature ...................................................................................................... 20 
CHAPTER THREE ................................................................................................................. 21 
METHODOLOGY .................................................................................................................. 21 
3.1 Study design ................................................................................................................... 21 
3.2 Study location ................................................................................................................. 21 
3.3 Source and Study Population ......................................................................................... 22 
3.4.1 Inclusion criteria ................................................................................................ 22 
3.4.2 Exclusion criteria ............................................................................................... 22 
3.5 Study variables ............................................................................................................... 22 
3.5.1 Dependent variable .................................................................................................. 22 
3.5.2 Independent variables .............................................................................................. 23 
3.6 Sample and Sampling Procedure.................................................................................... 26 
3.7. Sample Size ................................................................................................................... 27 
3.8 Data collection tool/ Procedure ...................................................................................... 29 
3.9. Data processing/Management ....................................................................................... 31 
3.10. Statistical Analysis ...................................................................................................... 31 
3.11 Confidentiality, Ethical Consideration and Data security ............................................ 32 
CHAPTER FOUR .................................................................................................................... 34 
RESULTS ................................................................................................................................ 34 
4.1. Descriptive statistics of sample ..................................................................................... 34 
4.2 Level of antibiotic use .................................................................................................... 37 
4.3 Association between socio-demographic characteristics of respondents and the use of 
antibiotics ............................................................................................................................. 39 
4.4 Determinants of antibiotic usage .................................................................................... 41 
4.5 Knowledge of respondents on antibiotics ...................................................................... 43 
4.6 Association between socio-demographic characteristics of respondents and their 
knowledge level.................................................................................................................... 45 
4.7 Attitudes towards antibiotic usage ................................................................................. 46 
4.8 Association between socio-demographic characteristics of respondents and their 
attitudes towards antibiotic use. ........................................................................................... 48 
CHAPTER FIVE ..................................................................................................................... 50 
DISCUSSION .......................................................................................................................... 50 
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5.1 Types and level of antibiotics consumed ....................................................................... 50 
5.2 Knowledge about antibiotics/antibiotic resistance ......................................................... 52 
5.3 Attitudes/Practices towards antibiotic use...................................................................... 53 
5.4 Determinants of antibiotic use........................................................................................ 53 
5.5 Limitations of the study.................................................................................................. 57 
CHAPTER SIX ........................................................................................................................ 58 
CONCLUSIONS AND RECOMMENDATIONS .................................................................. 58 
6.1 Conclusion ...................................................................................................................... 58 
6.2 Recommendations .......................................................................................................... 58 
REFERENCES ........................................................................................................................ 59 
APPENDICES ......................................................................................................................... 66 
Appendix A. Questionnaire for Quantitative Studies .......................................................... 66 
Appendix B. Participant Consent Form ............................................................................... 70 
  
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LIST OF TABLES 
Table 3.1: Study variables........................................................................................................ 24 
Table 3.2: Proportionate size of samples in clusters ................................................................ 28 
Table 4.1: Descriptive characteristics of the respondents ........................................................ 35 
Table 4.2: Level of antibiotic usage among users of antibiotics .............................................. 38 
Table 4.3: Association between the characteristic of respondents and the use of antibiotics . 40 
Table 4.4: Effect of socio-demographic characteristics of respondents on the use of 
antibiotics ................................................................................................................................. 42 
Table 4.5: Knowledge of the respondents of antibiotics and antibiotic resistance .................. 44 
Table 4.6: Association between socio-demographic characteristics and knowledge level ..... 45 
Table 4.7: Attitudes of respondents towards Antibiotics ......................................................... 47 
Table 4.8: Association between socio-demographic characteristics of respondent and their 
attitudes towards antibiotics ..................................................................................................... 48 
 
  
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LIST OF FIGURES 
Figure 2.1: Antibiotic targets ..................................................................................................... 9 
Figure 2.2: Worldwide development of antibiotic resistance .................................................. 11 
Figure 2.3: Total antibiotic use in daily defined dose (DDD) against penicillin –
nonsusceptible Streptococcus pneumonia (Goossens et al, 2005) ........................................... 14 
 
 
 
  
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DEFINITION OF TERMS 
Term Definition 
Antibiotics Antibiotics are agents used to treat or prevent infectious diseases caused 
by bacteria; with a few of them having activity against protozoa. 
  
Antibiotic Antibiotic resistance is a situation that occurs when bacteria develops 
resistance resistance to antibiotics to which they were once sensitive to. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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LIST OF ACRONYMS 
ARS              Antibiotic-Resistant Strain 
CDC               Centers for Disease Control and Prevention 
DDD  Define Daily Dose 
ECDC  European Centre for Disease Control and Prevention 
EU            European Union 
FDA  Food and Drugs Authority 
NPAR  National Platform on Antimicrobial Resistance 
NAP  National Action Plan 
PHC  Population and Housing Census 
UK                 United Kingdom 
WEF  World Economic Forum  
WHO  World Health Organization 
 
 
 
 
 
 
 
 
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ABSTRACT 
Introduction: Antibiotic resistance is a global public health issue. Although antibiotic 
resistance will suffice naturally over time, increased use/misuse of antibiotics escalates the 
process. In Ghana there is a dearth of studies exploring the relationship between knowledge, 
attitude and practices on consumption of antibiotics by individuals within the community. 
The objective of this study was to determine the factors influencing antibiotic use among 
adults within the Greater Accra Metropolis in Ghana.  
Method: A cross-sectional analytical study design using interviewer-administered 
questionnaire was conducted in twenty communities of the Greater Accra Metropolis. A total 
of 470 participants were interviewed. The questionnaire assessed level of antibiotic use, 
knowledge and attitude towards antibiotic use and resistance. Descriptive analysis, bivariate 
and multivariate logistic regression using Stata version 15.0 was used to analyze the data. 
 
Results: Among the 470 respondents, 93.4% (n=439) had ever used antibiotics. The most 
commonly used antibiotic was Augmentin/Amoksiklav. About 71.1% (n=312) purchased the 
antibiotics with prescription, while 47.2% (n=207) of the respondents obtained their 
antibiotics from the hospital. About 27.3% (n=120) of the antibiotic users used the antibiotics 
to treat pain, toothache (16.2%, n=71), sore throat (14.1%, n=62), and fever (13.9%, n=61). 
The knowledge rating of respondents on antibiotic use and antibiotic resistance was about 
90.0% with a mean score of 63.1% ± 13.9%.  Majority (94.6%) of the respondents had good 
attitudes towards antibiotic use. The use of antibiotics was significantly associated with the 
age categories                    . Highest level of education and the employment 
status of the respondents were also both significantly associated with the use of 
antibiotics                                                respectively. Area 
of residence and the insurance status of respondents also showed significant association with 
the use of antibiotics,                                               
respectively. Multivariate analysis showed that females were more likely than males to use 
antibiotics (AOR 1.53, 95% CI 0.64-3.65). Participants with tertiary level of education were 
more likely to use antibiotics compared to those with no education (AOR 8.35, 95% CI 0.54-
128.72). Manual workers used more antibiotics compared to the unemployed (AOR 3.48, 955 
CI 1.11-10.87). Highest level of education, area of residence and manual worker were 
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significantly associated with antibiotic use  
(                                          
  
Conclusion: The number of people using antibiotics is still high despite efforts by the 
Ministry of Health to educate the public on antibiotic use and resistance. Most of the 
respondents purchased the antibiotics using a prescription and used it to treat pain, a 
condition for which antibiotics is not medically indicated. Overall, many people however had 
good knowledge and attitudes towards duration and side effects of antibiotic use. 
Highest level of education and area of residence were significantly associated with the use of 
antibiotics.
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CHAPTER ONE  
INTRODUCTION 
1.1. Background of Study 
The discovery and development of antibiotics has contributed immensely towards the treatment 
and prevention of bacteria infections. Antibiotics being the mainstay drug for bacteria infections 
have resulted in some bacteria developing resistance through various mechanisms. The 
development of this resistance has rendered many antibiotics ineffective and new and expensive 
antibiotics have to be developed to curb this menace (Laxminarayan et al, 2013). In developing 
countries, antibiotics are amongst the most commonly consumed drugs (Frieden, 2013; 
Togoobaatar et al., 2010; WHO, 2015). In developing countries, an estimated 35% of the annual 
health budget is spent on antibiotics (Isturiz& Carbon, 2000, cited in Makhado, 2009). Globally, 
the problem of antibiotic resistance is on the rise as a result of globalization and migration which 
leads to spread of bacteria resistance (WHO, 2015). The WHO defines antibiotic resistance as 
the ability of bacteria or other microbes to resist the effect of antibiotic even in the presence of 
therapeutic amounts of the antibiotic (WHO, 2015; Davies et al., 2010).  
The development of antibiotic resistance complicates treatment, increases cost of treatment, 
morbidity and mortality (WEF, 2013). A positive correlation between consumption of antibiotic 
and development of antibiotic-resistant strain has been established in many studies (Goossens et 
al., 2005). Consumption of antibiotics also exposes individuals to risks of adverse effects which 
the individual may have no knowledge of. A vicious cycle of antibiotic consumption can arise 
with individuals taking more antibiotics to treat these adverse effects which can be perceived as 
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‗new diseases‘. The global increase in the consumption of antibiotics with resultant increase in 
development of resistance has become such a huge national and global public health issue to the 
extent that the WHO in 2001, developed a global strategy for the containment of antimicrobial 
resistance. Controlling the consumption of antibiotics at the patient and community level 
especially in developing countries is one of the minimization strategies identified by the WHO.  
The inappropriate and unwarranted exposure to antibiotics predisposes individuals and the 
community at large to the possible development of antibiotic resistance (Huttner et al, 2010). 
The prevalence of antibiotic consumption varies from geographical locations (Haggett, 1994) but 
generally higher in developing countries where antibiotics can be obtained without prescription 
and where access to quality healthcare is a problem. A study conducted in the Cape Coast 
Metropolis identified about 71.5% of the population did not visit any healthcare facility when ill 
(Tagoe et al., 2010). A Jordanian study reported that about 46% of people purchase antibiotics 
without prescription (Al-Bakari et al, 2005). Different reasons have been attributed to the 
increase in consumption of antibiotics including self-medication, prescribing patterns of 
physicians, knowledge about the use of antibiotics and development of antibiotic-resistant strains 
amongst others.  
In Ghana, the National Drug Regulatory Authority recommends that antibiotics be sold and 
distributed only on a valid prescription. The prevalence of infectious disease in Ghana and most 
developing countries is high thereby increasing the consumption of antibiotics. A lot of 
antibiotics are purchased and consumed within the community without prescription. In most 
communities within Ghana, antibiotics are purchased and used than medically indicated (Tagoe 
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et al., 2010). This study therefore sought to determine the factors that influence the consumption 
of antibiotics within the community among adults residing in the Greater Accra Metropolis. 
1.2. Statement of the Problem 
Globally the use of antibiotics is on the rise with resultant increase in development of resistant 
bacteria. An individual‘s chance of dying from infection caused by antibiotic-resistant bacteria is 
about twice that compared to infections caused by non-resistant strains of the same bacteria 
(ECDC, 2011). 
An estimated 23,000 people die annually in the United States of America (CDC) with two 
million new cases of infections due to antibiotic-resistant bacteria per year. In Europe, about 
25,000 people die annually from infections due to antibiotic-resistant bacteria whiles the overall 
cost to society from treatment due to antibiotic-resistant bacteria is about 1.5 billion Euros per 
year. In Europe an estimated 2.5 million extra hospital days is due to antibiotic-resistant bacteria 
(ECDC, 2011).  
In developing countries, antibiotics alone contribute to about 35% of the annual health cost 
budget (Isturiz & Carbon, 2000). 
This pattern of bacteria resistance due to the level of consumption of antibiotics is affected by 
many factors, some of which are restricted to a geographical setting (Haggett, 1994). The 
prescription patterns of doctors, pricing, advertisement, access to quality and affordable 
healthcare, socio-economic factors and lack of enforcement of regulatory policies on distribution 
and sale of antibiotics are some of the contributory factors to development of antibiotic resistant 
bacteria strains (WHO, 2015). In Ghana even though the National Drug Regulatory Authority 
(FDA) recommends that antibiotics be sold only on a valid prescription, majority of antibiotics 
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can be obtained from most community pharmacies and chemical shops without prescription. 
Most individuals do not access hospitals when sick, with majority purchasing drugs from 
community pharmacies and licensed chemical shops (Aryee et al, 2009/2010).  A 60.7% use of 
antibiotics was established in the government health facilities within the Wassa district (Bosu et 
al., 2000). Boadu et al in 2014 also found that about 82% of prescriptions contain antibiotics. A 
study in the Cape Coast Metropolis using eleven community pharmacies found that about 80% of 
people use antibiotics (Tagoe et al., 2010). 
The use of antibiotics if not controlled and restricted to medically indicated conditions will result 
in complete inefficacy due to increased antibiotic-resistant bacteria and a ‗post antibiotic era‘ 
where bacterial infections will no longer respond to treatment with antibiotics (WHO). When this 
situation occurs, the possibility of loss of lives due to infections caused by antibiotic-resistant 
bacteria will be huge impacting negatively on the national and global economy. The World 
Economic Forum‘s Global Risks 2013 report concluded that ―whiles viruses may capture more 
headlines; arguably the greatest risk to human health comes in the form of antibiotic-resistant 
bacteria‖ (WEF, 2013). 
This study therefore sought to provide data which can inform policy/decision concerning 
antibiotic use within the community and contribute to the global fight against antibiotic 
resistance. 
1.3. Justification of the Study 
In the past 50 years the increasing use of antibiotics with resultant increase in antibiotic-resistant 
bacteria infection has become a global health concern (Gleckman et al., 1969). Over the years 
antibiotic-resistant bacteria has contributed significantly to the burden of infectious diseases and 
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the total cost involved in the treatment of these diseases (So et al., 2010). In Ghana, data 
available on the consumption of antibiotics are mostly restricted to the hospital setting where 
guidelines for management and treatment of diseases are well documented. Data regarding the 
consumption of antibiotics within the community is limited. From literature, most of the studies 
on the use/misuse of antibiotics were performed using community pharmacies (Tagoe et al., 
2010) or within the hospital setting (Bosu et al., 2000; Boadu et al., 2014) and none so far from 
literature explores the methodology of household survey. This study therefore sought to fill in 
the gaps on the factors influencing the use of antibiotics, knowledge, practices and attitudes of 
antibiotic users within the community setting using household survey.  
1.3.1. Knowledge  
According to the WHO the level of knowledge about the use of antibiotics and development of 
resistance is very low in most developing countries. Creating awareness on the development of 
bacterial resistance to antibiotics through public education could reduce the inappropriate use of 
antibiotics. Majority of individuals in developing countries cannot distinguish between 
antibiotics and other medications (Norris P, 2007). However, in the Ghanaian context, this issue 
remains unexplored.This study will thus fill this gap in the literature. 
1.3.2. Attitudes/Practices 
Globally, the consumption of antibiotics increased to about 36% from 2000 to 2010 (Van 
Boekel, 2014). The attitudes and/or practices of people towards the use of antibiotics have 
contributed significantly to this rise (Van Boekel, 2014). Many studies have been done globally 
to determine the effect of attitudes and practices of antibiotic users in relation to antibiotic 
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consumption (You et al., 2008; McNulty et al., 2007). Self-medication either with left-over 
antibiotics or antibiotics purchased without prescription have all been found to be an important 
contributory factor to the rise in increase of antibiotic use with resultant development of 
antibiotic resistant bacteria strains (Tagoe et al, 2010; Wamola, 2002). In Ghana, there is 
available literature on the effect of knowledge, attitudes and practices of prescribers on the 
consumption of antibiotics by patients (Opuku et al., 2014) but not the individual user at the 
community level. This study therefore sought to address this gap.  
1.4. Research Relevance 
The understanding of antibiotic use is imperative in developing strategies and improving upon 
existing strategies of appropriate use of antibiotics within the community. Studying the patterns 
of use of antibiotics provides such information as who uses antibiotics, types of antibiotics used, 
ailments/symptoms for which antibiotics are used, reasons for use and the sources from which 
these antibiotics are obtained. The epidemiological information obtained from such studies is 
useful in understanding the problems of antibiotic use, identify possible causes and provide 
appropriate interventions (Green et al., 1980; Norris P, 2007). This study would provide data that 
would inform public health professionals and decision-makers on the current situation of 
antibiotic use within the community and hence help in the implementation of strategies to reduce 
antibiotic consumption and the resultant development of antibiotic resistance. This study would 
also provide information for use in educational campaigns aimed at reducing antibiotic use and 
development of resistance. 
1.5 General Objective 
The general objective of the study is to determine the factors influencing the use of antibiotics 
among adult residents in the Greater Accra Metropolis. 
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1.6 Specific Objectives 
The research intends to achieve the following specific objectives: 
1. To describe the different types of antibiotics that are commonly consumed among adults 
in the Greater Accra Metropolis. 
2. To assess the level of antibiotic consumption among adults in the Greater Accra 
Metropolis. 
3. To evaluate the determinants of antibiotic consumption. 
4. To examine individual‘s knowledge, practice and attitudes with regards to the use/misuse 
of antibiotics. 
5. To determine what proportion of antibiotics consumed by individuals in this study was 
obtained with prescription as compared to over-the-counter. 
1.7. Research Questions 
The following research questions will help find answers to address the specific objectives: 
1. What is the level of antibiotic consumption among adults in the Greater Accra 
Metropolis? 
2. What are the common antibiotics and sources of antibiotics that are used among adults in 
the Greater Accra Metropolis? 
3. What factors are likely to influence an individual‘s use of antibiotics?  
4. What is the level of knowledge of antibiotics and antibiotic resistance in users?  
5. What are the practices and attitudes of individuals with regards to antibiotic use?  
  
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CHAPTER TWO 
LITERATURE REVIEW 
2.1 What are antibiotics? 
Antibiotics are agents used to treat or prevent infectious diseases caused by bacteria; with a few 
of them having activity against protozoa. Antibiotics can be of natural or synthetic origin 
(Harvey et al., 1992). Antibiotics are not effective against viruses and hence are not indicated for 
use in viral infections. The first antibiotic Penicillin notatum was discovered by Sir Alexander 
Fleming in 1928 whiles experimenting with a culture plate of Staphylococcus aureus in the 
laboratory. Mass production of this penicillin was not commercially available until about 1942 
(Aminov, 2010) leading to the ‗antibiotic era‘. Since the evolution of the ‗antibiotic era‘, 
antibiotics have played major role in the management and prevention of infectious diseases 
caused by bacteria. Antibiotics have played such a major role in health that many have come to 
see it as a ‗magic drug‘ that can cure ‗almost‘ all forms of diseases leading to overuse and hence 
the development of resistance. However antibiotics have no place in the treatment of viral 
infections (Harvey et al., 1992). Many people are also of the opinion that antibiotics are ‗safe 
drugs‘. Contrary to this, antibiotics can cause serious and life threatening side-effects including 
anaphylaxis and liver toxicity (Neugut et al., 2001; Katzung, 2009).  
Antibiotics exhibit their effect by inhibiting or killing one or more of the following areas of the 
bacteria cell: cell wall, cell membrane, protein, nucleic acid or metabolic pathway. Antibiotics 
are usually classified by their mechanism of action. The beta-lactams inhibit cell wall synthesis 
and include the penicillins, cephalosporins, monobactams and carbapenems (Neu et al., 1996).  
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Some antibiotics act by interrupting with protein synthesis of the bacteria and these include 
aminoglycosides, tetracyclines, macrolides, clindamycin, chloramphenicol and spectinomycins 
(Neu et al., 1996).The quinolone group of antibiotics acts through inhibition of DNA replication 
and include the sulphonamides and trimethoprims (Neu et al., 1996). 
 
 
 
 
 
A- Cell wall, B-Protein synthesis, 
C-DNA replication D-RNA 
synthesis E-Metabolism (sorce: 
modified according to Hacker J & 
Heesemann J, 2002) 
 
 
 
 
Figure 2.1: Antibiotic targets 
 
2.2 Development of antibiotic resistance  
Over the years bacteria have mutated genetically developing resistance against most of the 
available and commonly used antibiotics as a result of repeated use/misuse (D‘Costa et al, 2011). 
 According to the WHO, antibiotic resistance is a situation that occurs when bacteria develops 
resistance to antibiotics to which they were once sensitive to. Antibiotic resistance results from 
inappropriate use of antibiotics within the hospital and in the community setting. 
The problem of antibiotic resistance is such a huge public health problem that the WHO 
developed the WHO 2012 ‗Options for action‘ to control development of antibiotic resistance. 
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The antimicrobial option for action includes surveillance for bacterial resistance and antibiotic 
use, infection prevention, rational drug use, innovation and political support. An alarming 
number of infections such as gonorrhea, pneumonia and tuberculosis are becoming increasingly 
harder to treat with antibiotics due to bacteria resistant strains. 
Bacteria resistance occurs through the following three ways: production of antibiotic inactivating 
enzymes, alteration of target structures and changes in permeability of cell wall (Shaw et al., 
1993; Livermore, 1995; Lambert, 2002). 
Bacteria resistance can be acquired or develop intrinsically (Livermore, 1995; Lambert, 2002). 
Bacteria can acquire resistance through gene mutation or acquisition of heterologous resistance 
genes (Neu et el., 1996; Lambert, 2002). Overuse of antibiotics therefore leads to increased 
development of bacteria resistant strains and a reduced antibiotic treatment efficacy (Davies et 
al., 2010). Multidrug-resistant bacteria use several of these mechanisms. Occurrence of this 
phenomenon overtime would lead to an era where antibiotics would no longer be effective and 
management or treatment of bacterial infections would be almost impossible leading to increased 
deaths, hospitalization and healthcare costs (Davis, 1995). 
Some strains of bacteria that cause common infections within the community have developed 
resistance to antibiotics. Streptococcus pneumoniae, Haemophilus influenza are pathogens which 
cause respiratory infections that have shown increased resistance to standard therapy of 
antibiotics (Cohen, 1992). 
A study to determine the factors associated with increased mortality in community-acquired 
pneumonia concluded that increased mortality was associated with penicillin and cefotaxime 
resistant pneumococcal bacteria (Feikin et al., 2000). 
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In Ghana, some studies concluded that bacteria resistance to antibiotics such as ampicillin, 
tetracycline, chloramphenicol and co-trimoxazole could be as high as 70% (Newman et al., 
2011). From literature, one area that has been researched most when it comes to antibiotics is the 
prescribing habits of doctors. Most research into antibiotics also took place within the primary 
care setting. Little literature is available on the contribution of the patient to antibiotic 
consumption within the community setting. Many studies have established a positive correlation 
between antibiotic consumption and development of ARS (Goossens et al., 2005).  
Globally, countries with high consumption of antibiotics have high rate of development of ARS 
(Bronzwaer Slam, 2002). 
Below is a diagram showing the worldwide development of antibiotic resistance. 
 
Source: Molton, 2013 
Figure 2.2: Worldwide development of antibiotic resistance 
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Most bacteria have developed resistance towards the older generation of antibiotics 
(Sulfonamides, penicillins etc) as a result of overuse and inappropriate use. By 1983, penicillin-
resistant enterococcus had been discovered, Vancomycin-resistant enterococcus in 1987 and 
Linezolid-resistant enterococcus in the late 1990s (Molton, 2013). 
 
2.3 Antibiotic use 
2.3.1 Global use 
A study which examined the total worldwide use of antibiotics (in-patient and out-patient) 
showed that there were differences in the way antibiotics were used across the different countries 
involved. The differences arose in both the purpose of antibiotic use as well as the types of 
antibiotics used. The study concluded that antibiotics constituted 3-5% of prescriptions in 1983 
(Col et al., 1987). Emerging countries used more antibiotics than developed countries (Col et al., 
1987) with emerging countries using tetracyclines and amoxicillins compared to ampicillin in 
developed countries (Col et al., 1987). A drug utilization study by McManus et al. comparing the 
retail sales of antibiotics across selected countries using the WHO‘s Defined Daily Dose 
approach showed the order of consumption of antibiotics of these countries from the highest to 
the lowest: France, Australia, United States, Canada, Italy, United Kingdom and West Germany 
(McManus et al., 1997). The study also showed that antibiotic sales grew from 2% in the United 
States to 5% in West Germany from 1989 to 1994 (McManus et al., 1997).  
A study done in 1978 in the United States demonstrated a sharp increase in antibiotic use within 
the years 1965 to 1973 with a decline of about 7.5% between 1973 and 1977 (Finkel, 1978). The 
use of antibiotics in England rose by 10% between 1990 and 1991 (Davey et al., 1996) with 
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Scotland having an increase of 12% in 1993 (Davey et al., 1996). The types of antibiotics used 
were commonly ampicillin and quinolones. 
The majority of antibiotics were prescribed and used within the community practice with about  
 
80.4% of antibiotics used in Canada prescribed by a family practitioner (Health et al., 1997).  
 
A study by Fries at al. in Denmark showed that the most common ailments for which antibiotics 
were used included tonsillitis (16%), sinusitis (12%), conjunctivitis (11%), urinary tract 
infections (11%) and otitis media (8%) (Friss et al.,1987).  A similar study in Norway concluded 
that antibiotics were indicated in the treatment of bronchitis (14%), colds (8%), tonsillitis (8%), 
sinusitis (7%) and pneumonia (5%) (Davey et al., 1996). A study involving 1005 participants in 
the United States also concluded that the five commonest ailments antibiotics were medically 
indicated for were cough, sore throat, fever, nasal congestion and earache (McCaig et al., 1995). 
In the EU, outpatient antibiotic use has increased slightly in 1997 with a DDD of 0.05 per 1000 
inhabitants per day in a quarter (Fabbrietti et al., 2011). 
 
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Figure 2.3: Total antibiotic use in daily defined dose (DDD) against penicillin –
nonsusceptible Streptococcus pneumonia (Goossens et al, 2005) 
 
Interestingly, China consumes more antibiotics than any other country in the world with the 
WHO estimating that about 80% of patients admitted to hospitals are administered some form of 
broad spectrum antibiotics with 58% receiving multiple courses of antibiotics (Mensah et al., 
2016) compared to the global consumption of 30%. 
A study among Yerevan adult population concluded that about 12.5% of the participants did self-
medicate with antibiotics (Martirosyn, 2014). A study in Yemen by Abdulkareem et al concluded 
that about 51% of prescriptions contained antibiotics (Abdulkareem, 2011). 50.1% of 
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prescriptions were found to contain antibiotics in a study conducted in the Osun state of Nigeria 
(Boadu, 2014). 
Antibiotics are commonly used in developing countries as a result of the high rate of infections. 
This has been worsened as a result of the increase in the number of people living with the human 
papilloma virus (HIV) (Acheson et al., 2001).  In developing countries antibiotics are often 
misused due to the ease at which they can be obtained and the lack in regulation of antibiotics.  
Over the years antibiotic resistant strains have been seen in pneumococcal meningitis, typhoid 
fever and tuberculosis.  
2.3.2 Local use 
A study by Donkor et al showed that 30% of tertiary students in Accra consume antibiotics 
within a month with about 70% of the participants taking antibiotics without prescription 
(Mensah et al., 2016); similar to a study in community pharmacies within the Cape Coast 
Metropolis (Tagoe et al., 2010). Most of the studies found amoxicillin to be the most commonly 
used antibiotic without prescription with cold and cough accounting for the ailments for which 
people used antibiotics (Mensah et al., 2016). A study in eleven community pharmacies in the 
Cape Coast Metropolis concluded that about 71.5% of antibiotics were purchased by participants 
without prescription. The same study found that more males (59.2%) consume antibiotics 
compared to females (40.8%). 
A hospital study in the Wassa district concluded that about 60.7% of the hospital records of 700 
outpatients contained antibiotics (Bosu et al., 2010). Another study conducted in public health 
dispensaries and facilities also concluded that 43.3% of prescriptions contain antibiotics 
(Arhinful et al., 2009).  
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2.4 Factors influencing consumption of antibiotics within the community setting  
Antibiotic-Resistant Strains (ARS) are commonly found within the hospital setting. Recently 
however, due to the high use of antibiotics within the community, ARS is increasingly on the rise 
within the community setting (Levy, 2002). Factors accounting for the rise in antibiotic 
consumption within the community setting apart from medically indicated use include but not 
limited to over- prescription of antibiotics by physicians, self-medication, sharing of stored 
antibiotics, sale of antibiotics as a ‗commodity‘ in most developing countries, inability to access 
effective and affordable healthcare, imbedded attitudes and beliefs that antibiotics can cure every 
form of ailment, lack of knowledge on safe and proper use of antibiotics and literacy level 
(Okeke, 2005; Hardon et al., 2004). The assumption whether real or not that patients expect the 
prescriber to include antibiotics in their prescriptions cannot be ruled out. Characteristics of the 
individual user as well as demographics also determine whether an individual will consume 
antibiotics or not (Green et al., 1980). Antibiotics are ideally prescribed after a diagnostic test of 
bacterial infection; but this is not the case in practice. It has also been hypothesized that wrong 
estimates is a key factor in the unnecessary use of antibiotics (Buetow et al., 1997). For the 
purposes of this work, the factors that would be studied include socioeconomic factors, 
knowledge, attitudes/practices and access to healthcare. 
2.5 Conceptual Framework 
The conceptual framework that guides the study involves both dependent and independent 
variables as shown in figure 2.4 
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 Figure 2.4: Conceptual framework guiding the study 
The independent variables include knowledge, access to healthcare, attitudes and practices 
towards antibiotic consumption which is the dependent variable. Aiken (2002) opined that, 
practices that individuals engage in are a manifestation of first their knowledge and attitudes 
towards a phenomenon.  The conceptual framework depicts that an individual‘s socio-economic 
factors (Age, Sex and educational status, occupation) is linked closely with the level of 
knowledge which in turn influences their attitudes and practices towards antibiotic consumption. 
The socio-economic factors would also impact on the individual‘s ability to access healthcare. 
Relevant literature relating to these has been presented below.   
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2.6.1. Demographic/socioeconomic factors 
Demographic and socio-economic factors such as sex, age, area of residence, educational level 
and income affect the use of antibiotics in the community (Radyowijati, 2002). Based on 
socioeconomic factors, people avoid the cost of visiting the doctor and resort to purchasing 
antibiotics for symptoms such as headache and cold (Widayati, 2011). 
From literature, the relationship/association between educational levels and antibiotic use is 
inconsistent (Widayati, 2011). 
2.6.2. Knowledge of antibiotic and antibiotic resistance 
Many studies have been performed with regards to the knowledge of the general public on the 
use/misuse of antibiotics and found that there is little or no understanding (Palmer et al., 1997; 
Mainous et al., 1997; Wilson et al., 1999). The knowledge individuals have on antibiotic 
use/misuse is actually related to and can affect other factors such as atitudes, behaviours and 
compliance (Mainous et al, 1997). In many developing countries, antibiotics are perceived to be 
‗miracle drugs‘ that can cure almost all forms of ailment and as such are taken for treatment and 
prevention of common ailments such as cold, diarhoea, fever and headache (Abellanosa, 1996). 
Many individuals cannot distinguish between antibiotics and other medications (Norris P, 2007). 
Many people use antibiotics in the treatment of viral infections where they are not medically 
indicated. The general knowledge of individuals with respect to the use of antibiotics in most 
commonly occurring infections within the community have been shown to be low in most studies 
(Murray, 1991). In a study by Palmer and Bauchners, many of the participants said antibiotics 
could be used to treat ear infections (93%), throat infections (83%), cough (58%), fever (58%) 
and cough (32%) (Levy, 2002). In another study, 55% of the participants said antibiotics were 
indicated in viral infections with 21% correctly responding that antibiotics were indicated in 
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bacterial infections and not viral infections (Goossens, 2009). A cross sectional study of self-
medication among tertiary students in Accra showed that 49% of the participants had poor 
knowledge about the consequences of antibiotic misuse/abuse (Donkor et al., 2012). 
 
2.6.3. Attitudes/Practices towards antibiotic consumption 
Many studies have found that attitudes and behavior affect the way individuals perceive and 
consume antibiotics (Conner et al., 2005; Rimer et al., 2005). 
A study in Cyprus found that many patients would expect their physician to prescribe antibiotics 
in the management of earache(51%), fever (41%)  or sore throat (27%) with 6% of the study 
participants admitting that they would purchase antibiotics over the counter if their physician had 
previously prescribed it for them (Rouusounides et al, 2011).  
 
2.6.4. Access to healthcare 
Antibiotics are generally available in developing countries; however the use of antibiotics is 
often restricted to those who can afford them. In most hospital settings in developing countries 
firstline antibiotics such as ampicillin, cloxacillin, gentamicin, penicillin etc are used due to their 
affordability (Eneaji, 2017). This has led to the development of bacteria resistant strains in 
conditions which hitherto could be treated with these antibiotics. The cost of providing 
antibiotics is as low as 0.13 pence per patient in most developing countries (Vuylsteke, 2004). 
This comparatively low sum cannot be afforded by most developing countries. Access to quality 
antibiotics still remains a huge problem in most developing countries. 
Most laboratories in developing countries are not fully equipped to carry out sensitivity testing 
before antibiotics are administered (Ochiai et al, 2008). Where these laboratories are available, 
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they tend to be too expensive for the average patient to afford. This has led to the culture where 
most physicians prescribe antibiotics without sensitivity testing leading to the increase in the 
development of antimicrobial resistance (Ochiai et al, 2008).  
Studies in the community with regards to antibiotics have shown that individuals tend to 
alternate providers to obtain their antibiotics in order to save time, save cost and have the 
freedom to purchase these drugs whenever needed (Hardon, 1987). A study by Okeke in 2005 
discovered that about 72% of Nigerians used antibiotics when it came to treatment of diarhoea 
with about 80% purchasing antibiotics without prescription even though they had free medical 
care (Okeke, 2005).Financial constraints, long queues/waiting hours also contribute to self-
medication with antibiotics among community users (Corbett et al., 2005; Larson et al., 2006).  
 
 
2.7 Gaps in the literature  
This section presents a summary of the gaps in literature concerning the issues under study. To 
begin with, there is limited literature on the prevalence of antibiotic consumption in Ghana. Most 
of these studies only looked at the effect of socio-demographic factors that influence an 
individual to consume antibiotics. Almost all the studies reviewed used purposive sampling 
which is a non-probability sampling approach with a high level of bias if used in quantitative 
studies. No literature on studies performed in Ghana used the household survey method. None of 
the studies on the Ghanaian context have focused on factors influencing antibiotic consumption 
as well as the effect of knowledge, attitudes and practices of the individual towards antibiotic 
consumption. 
  
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CHAPTER THREE 
METHODOLOGY 
3.1 Study design 
To achieve the general and specific objectives of this research study, a cross-sectional 
community-based household survey using interviewer-administered questionnaire was 
undertaken in the Greater Accra Metropolis. 
3.2 Study location 
The Greater Accra Metropolis is bordered to the north by the Ga West Municipal district, to the 
west by the Ga South Municipal district, to the east by La Dadekotopon Municipal district, and 
to the south by the Gulf of Guinea. The metropolis is sub-divided into eleven (11) districts with a 
total population of about 1,665,086 representing 42 percent of the region‘s total population and a 
household population of 1,599,914 with a total number of 450,748 households. The average 
household size is 3.7 persons per household (PHC, 2010). The total population of adults aged 15 
years and above is 1,316,895 (PHC, 2010). 
There are 72 communities and 76 electoral areas. The districts include Ablekuma Central, 
Ablekuma North, Ablekuma South, Ashiedu Keteke, La, Ayawaso Central, Ayawaso East, 
Ayawaso West, Okaikoi North, Okaikoi South, and Osu Klottey. 
The populations of both sexes aged 15 years and above in the five districts are: 397,409 
(Ablekuma South, North and Central), 214,501 (Ashiedu Keteke & La), 90,926 (Osu Klotey), 
290,845 (Ayawaso West, East & Central) and 246, 815 (Okaikoi South and North) (PHC, 2010). 
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Half of the population eleven years and above (52%) is literate in both English and Ghanaian 
language, with 40% literate in English language alone. English and Ghanaian languages are the 
main means of communication (PHC, 2010). More than a third of both sexes are engaged in sales 
and services work (PHC, 2010) 
3.3 Source and Study Population 
The source population included all individuals resident in the Greater Accra Metropolis during 
the study period. The study population however included all individuals aged 18 years and above 
resident in Ablekuma (Central, North and South), Ayawaso (Central, East and West), Osu 
Klottey, La, Ashiedu Keteku and Okaikoi (North and South). 
3.4.1 Inclusion criteria 
 All Ghanaian individuals aged 18 years and above residing within the Greater Accra 
Metropolis during the study period. 
3.4.2 Exclusion criteria 
 Foreigners and visitor‘s residing within the selected sub-metros did not form part of the 
study. 
 Individuals aged less than 18 years. 
 All health facilities, pharmacies and licensed chemical shops. 
3.5 Study variables  
This section presents the variables, their definitions and scale of measurement in the study. 
3.5.1 Dependent variable 
 Antibiotic use/consumption.  
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3.5.2 Independent variables 
The independent variables are: 
 Socio-demographic characteristics – such as age, sex, educational status and 
employment.  
 Knowledge of antibiotics – participant‘s understanding of what antibiotics are, uses of 
antibiotics and what antibiotic resistance is. 
 Attitudes towards consumption of antibiotics – participants‘ inert feelings and 
perceptions towards consumption of antibiotics measured on the Likert scale. 
 Practices relating to consumption of antibiotics - manner in which participants‘ act 
towards consumption of antibiotics based on their knowledge and attitudes measured on 
the Likert scale. 
 Access to healthcare – holder of insurance (private or public). 
  
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The table below provides the variables to be studied with their associated definitions and scales 
of measurement. 
Table 3.1: Study variables 
Variable to be studied Definition Scale of measurement 
Age Grouped as 18-24, 25-34, 45- Categorical 
54, 55-64, over 65 
18-24 = 1, 25-34 = 2 
45-54 = 3, 55-64 = 4 
Over 65 = 5 
Gender Defined as male or female Dichotomous 
1=male 
2= female 
Education None (No formal education at Ordinal 
all) 
None = 1 
Basic (Completed JHS based 
on current GES system) Basic = 2 
Medium (completed Senior Medium = 3 
Secondary School based on 
current GES system) Graduate = 4 
Graduate (Completed any 
tertiary institution, or holds or 
studying masters/PHD) 
 
Employment Unemployed (Not working at Nominal 
all) 
Unemployed = 1 
Skilled worker (any formal 
job) Skilled worker = 2 
Manual worker (non-formal Manual worker = 3 
jobs)  
  
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Holder of insurance Yes (subscribes to national or Categorical 
private insurance) 
Yes = 1 
No (Does not subscribe to 
national or private insurance No = 2 
or insurance has expired) 
Antibiotic use/consumption Yes (used antibiotics within Categorical 
(Dependent variable) the last six months) 
Yes =1 
 No (not used antibiotics 
before) No = 2 
 
Type(s) of antibiotic used Commonly used antibiotics Categorical 
arranged in alphabetical order 
Augmentin/Amoksiklav = 1 
Ampicillin = 2 
Cloxacillin =3 etc 
How antibiotic was obtained Prescription (prescribed by a Categorical 
qualified physician) 
Prescription = 1 
OTC 
OTC = 2 
Left overs (antibiotics from 
previous prescription or OTC)  Left overs = 3 
Both (prescription and OTC) Both = 4 
Condition(s) antibiotic was Headache Categorical 
taken for (Reason for using 
antibiotics) Cold, Cough, Sorethroat Headache =1 
Fever Cold, Cough, Sorethroat = 2 
Toothache Fever = 3 
Stomach pain Toothache = 4 
itching Stomach pain = 5 
Others  Itching = 6 
 Others  = 7 
 
Place antibiotic was obtained Hospital Categorical 
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Community pharmacy Hospital = 1 
Licensed chemical shop Community pharmacy = 2 
Peddlers Licensed chemical shop = 3 
Others (internet etc) Peddlers = 4 
Others = 5 
Knowledge score (regarding Right answers coded as 1 Ordinal 
antibiotic use) 
Wrong or do not know coded Right  – 1 
as 0 
Wrong =  0 
Do not know = 0 
Knowledge score (regarding Right answers coded as 1 Dichotomous 
antibiotic resistance) 
Wrong or do not know coded Right  – 1 
as 0 
Wrong =  0 
 
 
 
Attitude score Based on the Likert scale Ordinal 
Strongly agree, Slightly Strongly agree = 1 
Agree, Neither agree nor 
disagree, Slightly disagree, Slightly Agree – 2  
Strongly disagree Neither agree nor disagree  = 3 
Slightly disagree = 4  
Strongly disagree = 5 
 
3.6 Sample and Sampling Procedure 
The survey was conducted in the Greater Accra Metropolis from June 5, 2018 to June 10, 2018. 
The eleven districts within the Greater Accra Metropolis were stratified into five clusters as 
follows; Ablekuma (consisting of Ablekuma South, Ablekuma North and Ablekuma Central), 
Ayawaso (Consisting of Ayawaso West, Ayawaso East and Ayawaso Central), Okaikoi 
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(consisting of Okaikoi North and Okaikoi South), Ga South (consisting of Ashiedu Keteke and 
La) and Osu Klottey. The known communities within these selected districts were listed 
independently and randomize using ‗randbetween‘ an excel tool to obtain the communities to 
work in. Four communities were selected from each of the five clusters giving a total of twenty 
communities. The sample size was distributed proportionately among the twenty communities. 
At the community, a street was identified and the ‗days-code‘ was used to determine which 
household to visit first. In each household, all individuals aged 18 years and above who 
consented to take part in the study were administered questionnaires by the research assistant 
after explaining the background and intentions of the study. 
Systematic sampling using a one in three gap was used to identify the next household to be 
included in the study until the sample size of 470 was achieved. 
3.7. Sample Size 
The sample size used in the study was four-hundred and seventy (470) which was computed 
using the Cochran formula (Cochran, 1968) with a sampling error of 5%, confidence interval of 
95% and a prevalence of antibiotic use in developing countries of 50% (Boadu, 2014). 
The sample size was computed as follows: 
z2pq 
n = 
d2 
Where: 
z = 1.96 
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P = Proportion of the population estimated to consume antibiotics in developing countries (p) = 
50% = 0.5 
d = confidence level (0.5) 95% 
q = 1-P thus 1- 0.5 = 0.5 
(1.96)2(0.5)(0.5) 
n=  = 384 
(0.05)2 
Non response margin: from literature, the non-response rate for household surveys could be as 
high as 35%; adjusting for non-response rate of 22%; 
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Sample Size = 384 * = 84.48 
100 
 
Thus: 384 +84.48 = 468.48 individuals which was approximated to 470 participants. 
The samples were proportionately divided between the five clusters as follows: 
Table 3.2: Proportionate size of samples in clusters 
District Proportional sample 
Ablekuma (South, Central & North) 112 
Ayawaso (East, West & Central) 102 
Osu Klotey 72 
Okaikoi (South & North) 97 
Ashiedu Keteku (Ga south) 87 
Total 470 
 
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3.8 Data collection tool/ Procedure 
To achieve the general and specific objectives of the study, an interviewer-administered 
structured questionnaire consisting of five sections was used to collect information on the 
participants. The design of the questionnaire was based on previous studies (Pechere et al., 2007; 
Curry et al., 2006). It consisted of the sections to assess the prevalence of antibiotic use (six 
questions), socio-demographic information (six questions), knowledge about antibiotics (five 
questions), knowledge about antibiotic resistance (four questions) and attitude/practice towards 
antibiotic use (seven questions on the Likert scale). 
The socio-demographic section was designed to obtain some characteristics of the participants 
that may influence antibiotic use.  
The antibiotic use section was designed to obtain information on the prevalence of antibiotic use, 
the types of antibiotics commonly used and where they are obtained, the conditions the 
antibiotics were used to treat and the place and mode of purchase of the antibiotics.  
The knowledge sections were designed to evaluate the basic knowledge of participants with 
regards to the duration antibiotics should be taken, types of diseases antibiotics can be used to 
treat, side effects of antibiotics, whether left-over antibiotics can be taken from friends/family, 
familiarity with the term antibiotic resistance, who antibiotic resistance affect and whether 
antibiotic resistance is a problem in Ghana. 
The attitude towards antibiotic use section was designed to determine the attitudes/practices of 
participants towards purchase of antibiotics, when antibiotics can be taken, sharing of antibiotics, 
coercing doctors to prescribe antibiotics, completing antibiotics as scheduled, side-effects of 
antibiotics and repeated use of antibiotics in treatment of similar illness. The responses were 
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based on a five point Likert type scale which ranged from strongly agrees, slightly agree, neither 
agree nor disagree, slightly disagree and strongly disagree. 
The questionnaire was designed in English but administered to the participants in a language 
acceptable to both the interviewer and the participants. Almost all the interviews were 
administered in English, Twi or Ga. Samples of commonly consumed antibiotics were shown to 
participants who had no education background. In some instances, participants with no 
educational background described the antibiotics consumed or gave the local names of these 
antibiotics. 
The questionnaires were administered by trained research assistants who had previous 
experience in data collection and understood the methodology used in this study; 
notwithstanding the principal investigator went through the modalities to administer the 
questionnaire as well as the appropriate translations from English to Ghanaian language where 
applicable to ensure uniformity. 
The questionnaire was pre-tested on 20 participants to ensure appropriateness and 
comprehensiveness in achieving the general and specific objectives of the study. There were no 
modifications on the questionnaire after pre-testing since it was found to be appropriate and 
comprehensive to achieve the stated objectives and answer the research questions in the study. 
Averagely, ten minutes was required to complete each questionnaire per participant. The data 
were then entered into excel spreadsheet and various parameters analyzed using stata version 
15.0. 
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 3.9. Data processing/Management 
Data collected were checked for completeness and/or inconsistencies and entered into excel 
spreadsheet 2013 using double-entry method. The data were then imported into Stata version 
15.0 for cleaning, validation and analysis. 
3.10. Statistical Analysis 
After the data were imported into Stata version 15.0, cleaned and validated, it was analyzed for 
various parameters. Descriptive analysis was performed on the characteristics of the participants 
using the information under the socio-demographic section. Frequencies and proportions were 
computed for the characteristics of respondents and the outcome variables. Completed age in 
years was calculated by subtracting the respondents‘ years of birth from 2018, the year the data 
was collected. The completed age in years was also categorized into the intervals 18-24 years, 
25-33 years, 34-40 years and above 40 years. Mean and standard deviation was calculated for the 
age in years.  
Frequencies and proportions were computed for statements and questions on antibiotic 
knowledge and attitudes towards antibiotics. Each right answer under the knowledge questions 
was scored one (1) and each wrong answer scored zero (0). There were 13 questions in total. The 
total score for each respondent was then converted to 100 to determine their overall knowledge. 
After which the mean, standard deviation, median score, lower and upper quartiles were 
computed for. The percentage scores were categorized into two. Participants with scores below 
50% were deemed as having low level knowledge of antibiotics and participants with scores of 
50% and above were deemed to have high level knowledge of antibiotics.  
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Similar case was done for attitudes of respondents towards antibiotics. The questions of attitudes 
on knowledge towards antibiotics were on a 5 point Likert type scale (1 = strongly agree, 2 = 
agree, 3 = neutral, 4 = disagree, 5 = strongly disagree) and there were a total of seven (7) items. 
The highest total possible score for all 7 items was 35 after all positive items was reversed to 
negative items. The score for each respondent was converted to 100 to determine their overall 
attitude score. The higher the participant‘s score on attitudes, the poorer their attitudes towards 
antibiotic use. The percentage scores were categorized into two; participants who scored below 
50% were deemed to have good attitudes towards antibiotic use and those who scored 50% and 
above were deemed to have poor attitudes towards antibiotics. 
The chi-square test of association was used to determine association between the demographics 
and the outcome variables (thus antibiotic use, knowledge on antibiotics, knowledge on 
antibiotic resistance and attitudes towards antibiotics).  
The binary logistic regression model was used to determine antibiotic use/consumption. Results 
were expressed as Odds Ratio (OR) with 95% Confidence Interval (CI) with a two-tailed p value 
≤ 0.05 considered statistically significant in all the analyses. 
3.11 Confidentiality, Ethical Consideration and Data security 
Participation in the study was voluntary without any compensation. Written informed consent 
was obtained from each participant after the background and motives of the study were explained 
to them.  
Anonymity of participants was assured by assigning ID numbers to the participants instead of 
using their names. Data obtained from the study is maintained under the strict confidentiality and 
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accessible to only the institution and the principal researcher and used for publications related to 
this study only. The data would be destroyed after five years.  
Ethical approval was obtained from the Ghana Health Service Ethics Review Committee (GHS-
ERC Number: GHS-ERC:077/02/18) and written consent obtained from the Accra Metropolitan 
Assembly (AMA). 
  
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CHAPTER FOUR 
RESULTS 
4.1. Descriptive statistics of sample 
A total of 470 respondents were recruited into the study. Majority of the respondents were males 
(n = 247, 52.6%) and the remaining females (n = 223, 47.5%). The mean age of respondents was 
35.7 ± 11.2 years. Most of the respondents were between the ages of 25 to 33 years (n = 162, 
34.5%) and a few of them were between the ages of 18 to 24 years (n = 65, 13.8%). About 26% 
(n=216) of the respondents had tertiary as their highest level of education. A few of the 
respondents (n = 16, 3.4%) had no formal education. More than half (56.2%) of the respondents 
were skilled workers, 19.4% were manual workers and 24.5% of the respondents were 
unemployed. Most of the respondents had health insurance (n = 362, 77%). Majority (93.4%, n = 
439) of the respondents had used antibiotics before and the remaining 6.4% (n=31) had never 
used antibiotics before. The characteristics of the respondents are presented in table 4.1 below. 
  
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Table 4.1: Descriptive characteristics of the respondents 
Characteristics of respondents Frequency (N= 470) Proportion (100%) 
Sex of respondent   
Male 247 52.55 
Female 223 47.45 
Age in years(mean ± SD) (35.65 ± 11.23)  
18-24 years 65 13.83 
25-33 years 162 34.47 
34-40 years 121 25.74 
Above 40 years 122 25.96 
Highest level of education   
None 16 3.40 
Basic 81 17.23 
Medium 157 33.40 
Tertiary 216 45.96 
Employment status   
Skilled worker 264 56.17 
Unemployed 115 24.47 
Manual worker 91 19.36 
Area of residence   
Ablekuma 112 23.83 
Osu clottey 72 15.32 
Ga south 87 18.51 
Okaikoi 97 20.64 
Ayawaso 102 21.70 
Insurance status   
Yes 362 77.02 
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No 108 22.98 
Use of antibiotics   
Yes 439 93.40 
No 31 6.60 
SD: standard deviation 
  
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4.2 Level of antibiotic use 
Of the total 439 respondents who had ever used antibiotics, 49 (11.2%) were currently using 
antibiotics, 87 (19.8%) had used antibiotics less than a month ago and 128 (29.2%) had used 
antibiotics more than a year ago. The most common antibiotics used were Augmentin/ 
Amoksiklav (n = 115, 26.2%), followed by Cloxacillin (n = 109, 24.8%). About 8.9% of the 
respondents used other antibiotic such as Flucloxacillin, Zithromax, etc. A high percentage 
(71.1%, n = 312) of the antibiotic users purchased antibiotics by prescription. About 28.9% (n = 
127) of the antibiotic users purchased the antibiotics without prescription. Most respondents 
obtained those antibiotics from the hospitals (n = 207, 47.2%), 25.7% (n = 113) of them 
purchased their antibiotics from a community pharmacy. Very few of the participants got their 
antibiotics from street peddlers (n = 20, 4.6%), at home (n = 9, 2.1%) and from friends/relatives 
(n = 5, 1.1%). About 27.3% (n = 120) of the antibiotic users used antibiotics for pain relief, 
16.2% (n = 71) used antibiotics for toothaches and 14.1% of them used antibiotics for treatment 
of sore throat. Table 4.2 below shows detailed description on the level of antibiotic usage by 
respondents. 
  
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Table 4.2: Level of antibiotic usage among users of antibiotics 
Level of antibiotic usage Frequency (N= 439) Proportion (100%) 
Last time used   
Currently using 49 11.16 
< 1 month 87 19.82 
1-6 months 90 20.50 
6-12 months 85 19.36 
>12 months 128 29.16 
Most used antibiotics   
Penicillin 92 20.96 
Augmentin/Amoksiklav 115 26.20 
Ampicillin 84 19.13 
Cloxacillin 109 24.83 
Others (Flucloxacillin, Zithromax, etc.) 39 8.88 
Purchase by prescription   
Yes 312 71.07 
No 127 28.93 
Place of purchase   
At the hospital 207 47.15 
Community pharmacy 113 25.74 
License chemical shop 85 19.36 
Street peddlers 20 4.56 
Had at home 9 2.05 
Friends/ relatives 5 1.14 
Treatment condition     
Headache 6 1.37 
Cold 24 5.47 
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Cough 31 7.06 
Sore throat 62 14.12 
Fever 61 13.90 
Toothache 71 16.17 
Pain 120 27.33 
Itching 18 4.10 
Others (chicken pox, rashes, etc.) 46 10.48 
 
 
4.3 Association between socio-demographic characteristics of respondents and the use of 
antibiotics 
Majority (92.3%, n = 228) of the 247 male respondents had used antibiotics before and 94.6% (n 
= 211) of the 223 female respondents had used antibiotics before. Most (81.5%) of the 
respondents aged between 18 and 24 years had used antibiotics before and about 95% of the 
respondents in each of the age categories 25-33 years , 34-40 years  and above 40 years had used 
antibiotics before. The use of antibiotics was significantly associated with the age 
categories                    . Highest level of education                
      and the employment status                      of the respondents were also both 
significantly associated with the use of antibiotics. Area of residence                
       and the insurance status                     of respondents also showed 
significant association with the use of antibiotics. Refer to table 4.3 for further test of association 
between antibiotic usage and the socio-demographic factors. 
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Table 4.3: Association between the characteristic of respondents and the use of antibiotics 
  Usage of antibiotics   
Characteristics of respondents Total  Yes No      -value 
 n (%) n (%) 
Sex of respondent    1.0161 0.313 
Male 247 228 (92.31) 19 (7.69)   
Female 223 211 (94.62) 12 (5.38)   
Age in years    17.339 0.001** 
18-24 years 65 53 (81.54) 12 (18.46)   
25-33 years 162 154 (95.06) 8 (4.94)   
34-40 years 121 115 (95.04) 6 (4.96)   
Above 40 years 122 117 (95.90) 5 (4.10)   
Highest level of education    32.3125 <0.001*** 
None 16 15 (93.75) 1 (6.25)   
Basic 81 65 (80.25) 16 (19.75)   
Medium 157 146 (92.99) 11 (7.01)   
Tertiary 216 213 (98.61) 3 (1.39)   
Employment status    17.9588 <0.001*** 
Skilled worker 264 256 (96.97) 8 (3.03)   
Unemployed 115 98 (85.22) 17 (14.78)   
Manual worker 91 85 (93.41) 6 (6.59)   
Area of residence    12.5591 0.014* 
Ablekuma 112 111 (99.11) 1 (0.89)   
Osu clottey 72 65 (90.28) 7 (9.72)   
Ga south 87 76 (87.36) 11 (12.64)   
Okaikoi 97 92 (94.85) 5 (5.15)   
Ayawaso 102 95 (93.14) 7 (6.86)   
Insurance status    4.6405 0.031* 
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Yes 362 343 (94.75) 19 (5.25)   
No 108 96 (88.89) 12 (11.11)   
n: cell frequency. %: row percentage. χ2: Pearson‘s chi-square value. *: p-value <0.05. **: p-value <0.01. ***: p-
value <0.001. 
 
4.4 Determinants of antibiotic usage 
The logistic regression model below was used to identify the determinants of antibiotic usage. 
From the table, the odds of a female using antibiotic were 1.47 times the odds of a male using 
antibiotic when no adjustment was accounted for (UOR 1.47, 95% CI: 0.7–3.1). When age, 
education, employment status, area of residence, insurance status, knowledge level and attitudes 
of a person towards antibiotics were adjusted for, the odds of a female using antibiotics was 1.53 
times the odds of a male using antibiotics (AOR: 1.53, 95% CI: 0.6–3.7). The odds of an 
individual with tertiary level of education using antibiotics was 4.7 times the odds of an 
individual with no formal education when no adjustment was accounted for (UOR 4.7, 95% CI: 
0.5–48.3). In all, the educational level of individual was a significant determinant of use of 
antibiotics when no adjustment was accounted for (p < 0.001). After controlling for sex, age, 
employment status, area of residence, insurance status, knowledge level and attitude of an 
individual towards antibiotics, the odds of an individual with tertiary level of education using 
antibiotics was 8.35 times the odds of an individual with no formal education (95% CI: 0.54 - 
128.72). Level of education was also a significant determinant of antibiotic use when 
adjustments were made (p<0.001). From the adjusted logistic model in table 4.4 below, highest 
level of education and area of residence were significant determinants of the use of antibiotics 
(p<0.05). More information is shown in table 4.4. 
 
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Table 4.4: Effect of socio-demographic characteristics of respondents on the use of 
antibiotics 
 Unadjusted effect  Adjusted effect 
 UOR 95% CI   -value  AO 95% CI   -value 
R 
Sex of respondent   0.311    0.339 
Male 1    1   
Female 1.47 (0.69- 0.316  1.53 (0.64- 3.65) 0.339 
3.09) 
Age in years   0.005**    0.2806 
18-24 years 1    1   
25-33 years 4.36 (1.69- 0.002**  2.66 (0.85- 8.28) 0.092 
11.24) 
34-40 years 4.34 (1.55- 0.005**  1.92 (0.51- 7.21) 0.333 
12.19) 
Above 40 years 5.30 (1.78- 0.003**  2.93 (0.8- 10.73) 0.104 
15.8) 
Highest level of   <0.001**    <0.001**
education * * 
None 1    1   
Basic 0.27 (0.03- 2.2) 0.222  0.36 (0.04  -3.56) 0.384 
Medium 0.88 (0.11- 0.91  1.64 (0.15- 17.59) 0.684 
7.33) 
Tertiary 4.73 (0.46- 0.19  8.35 (0.54- 0.128 
48.31) 128.72) 
Employment status   <0.001**    0.873 
* 
Unemployed 1    1   
Skilled worker 5.55 (2.32- <0.001**  1.90 (0.62- 5.85) 0.265 
13.28) * 
Manual worker 2.46 (0.93- 0.071  3.48 (1.11- 10.87) 0.032* 
6.52) 
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Area of residence   0.005**    <0.001**
* 
Ablekuma 1    1   
Osu clottey 0.08 (0.01- 0.7) 0.022*  0.07 (0.01- 0.65) 0.019* 
Ga south 0.06 (0.01- 0.008**  0.06 (0.01- 0.48) 0.009** 
0.49) 
Okaikoi 0.17 (0.02- 0.104  0.29 (0.03- 2.74) 0.282 
1.44) 
Ayawaso 0.12 (0.01- 0.051  0.24 (0.03- 2.21) 0.207 
1.01) 
Insurance status   0.0418    0.851 
Yes 1    1   
No 0.44 (0.21- 0.035*  0.91 (0.34- 2.41) 0.851 
0.95) 
Knowledge level   0.1033    0.849 
Low 1    1   
High 2.33 (0.9- 6.01) 0.08  0.89 (0.26- 3.02) 0.849 
Attitude towards   0.03*    0.939 
antibiotics 
Poor  1    1   
Good 3.65 (1.28- 0.016*  0.95 (0.24- 3.81) 0.939 
10.4) 
UOR: Unadjusted odds ratio. AOR: Adjusted odds ratio. *: p-value <0.05. **: p-value <0.01. ***: p-value <0.001. 
overall significant of a variable are in bold fonts.  
 
4.5 Knowledge of respondents on antibiotics 
Of the 470 respondents interviewed, 68.1% (n = 320) knew how long antibiotics could be taken, 
81.3% (n = 382) of them knew that antibiotics could be used to treat bacteria infections, and 
95.1% (n = 447) of the respondents answered correctly to whether antibiotics could be used to 
treat headache. The overall mean score of knowledge in percentage was 69.1% ± 13.9%. A tenth 
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of the respondents had low knowledge on antibiotics and 90% of the respondents had high 
knowledge on antibiotics. Refer to table 4.5 for further information on knowledge of respondents 
on antibiotics. 
Table 4.5: Knowledge of the respondents of antibiotics and antibiotic resistance 
Right answer 
Question/ statement of about antibiotics n (%) 95% CI 
How long should I take antibiotics for? 320 (68.09) (63.86- 72.31) 
Antibiotics can be used to treat bacterial infections. 382 (81.28) (77.74- 84.82) 
Antibiotics can be used to treat viral infections. 197 (41.91) (37.44- 46.39) 
Antibiotics can be used to treat Headache. 447 (95.11) (93.15- 97.06) 
Antibiotics can be used to treat fever. 354 (75.32) (71.41- 79.23) 
Antibiotics can be used to treat malaria. 292 (62.13) (57.73- 66.53) 
Antibiotics can be used to treat diarrhoea. 334 (71.06) (66.95- 75.18) 
I can take antibiotics from my friends when I have similar illness 369 (78.51) (74.78- 82.24) 
Do antibiotics have side effects? 400 (85.11) (81.88- 88.34) 
Have you heard of antibiotics resistance before? 329 (70.00) (65.84- 74.16) 
Antibiotics resistance can occur when I don‘t use antibiotics the right way. 367 (78.09) (74.33- 81.84) 
Antibiotic resistance does not affect me, my family or friends. 340 (72.34) (68.28- 76.40) 
Antibiotics resistance is not a problem in Ghana. 93 (19.79) (16.17- 23.40) 
Overall score on knowledge  
Mean score of knowledge in percentage (mean ± SD) 69.13 ± 13.93 
Median score of knowledge in percentage (median, (LQ – UQ)) 69.23 (61.54 – 76.92) 
Knowledge rating  
Low level of knowledge (n (%)) 47 (10.00) 
High level of knowledge (n (%)) 423 (90.00) 
n: cell frequency. %: cell percentage. SD: standard deviation. LQ: Lower quartile. UQ: Upper quartile. CI: 
confidence interval. 
 
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4.6 Association between socio-demographic characteristics of respondents and their 
knowledge level 
Of the 247 male respondents, 223 (90.3%) of them had high level of knowledge on antibiotics 
and of the 223 female respondents, 200 (89.7%) of them had high level of knowledge on 
antibiotic usage. 87.7% (n = 57) of the respondents in the age range 18 to 24 years had high level 
of knowledge on antibiotics, 91.4% (n = 148) of the 162 respondents in the age range 25 to 33 
years also had high level of knowledge on antibiotics. Level of knowledge was significantly 
associated with highest level of education                     , employment 
status                     , area of residence                      and insurance 
status                    . Table 4.6 shows further information on the Pearson‘s chi-
square test of association between the socio-demographic factors and level of knowledge of the 
respondents. 
 
Table 4.6: Association between socio-demographic characteristics and knowledge level  
  Knowledge level   
Characteristics of Total  Low High    p-value 
respondents  n (%) n (%) 
Sex of respondent    0.0465 0.829 
Male 247 24 (9.72) 223 (90.28)   
Female 223 23 (10.31) 200 (89.69)   
Age in years    1.8356 0.607 
18-24 years 65 8 (12.31) 57 (87.69)   
25-33 years 162 14 (8.64) 148 (91.36)   
34-40 years 121 10 (8.26) 111 (91.74)   
Above 40 years 122 15 (12.3) 107 (87.7)   
Highest level of education    62.9581 <0.001*** 
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None 16 7 (43.75) 9 (56.25)   
Basic 81 21 (25.93) 60 (74.07)   
Medium 157 17 (10.83) 140 (89.17)   
Tertiary 216 2 (0.93) 214 (99.07)   
Employment status    15.3092 <0.001*** 
Skilled worker 264 14 (5.3) 250 (94.7)   
Unemployed 115 20 (17.39) 95 (82.61)   
Manual worker 91 13 (14.29) 78 (85.71)   
Area of residence    35.1821 <0.001*** 
Ablekuma 112 6 (5.36) 106 (94.64)   
Osu clottey 72 3 (4.17) 69 (95.83)   
Ga south 87 5 (5.75) 82 (94.25)   
Okaikoi 97 7 (7.22) 90 (92.78)   
Ayawaso 102 26 (25.49) 76 (74.51)   
Insurance status    23.274 <0.001*** 
Yes 362 23 (6.35) 339 (93.65)   
No 108 24 (22.22) 84 (77.78)   
Antibiotic usage    3.2272 0.072 
Yes  439 41 (87.23) 398 (94.09)   
No  31 6 (12.77) 25 (5.91)   
n: cell frequency. %: row percentage. χ2: Pearson‘s chi-square value. *: p-value <0.05. **: p-value <0.01. ***: p-
value <0.001. 
 
4.7 Attitudes towards antibiotic usage 
The overall mean score of the attitudes of respondents toward antibiotic usage was 81.47% ± 
16.9%. Half of the respondents scored between 68.6% and 94.3%. Most of the respondents had 
good attitudes towards antibiotics (n = 443, 94.3%) and a few of them had poor attitudes toward 
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antibiotic usage (n = 27, 5.7%). Detail information on attitudes of respondents towards antibiotic 
usage is in table 4.7. 
Table 4.7: Attitudes of respondents towards Antibiotics 
 Strongly Agree Neutra Disagr Strongly 
agree l ee disagree 
Attitudes of respondents n (%) n (%) n (%) n (%) n (%) 
It is okay to buy antibiotics 33 (7.04) 101 54 31 250 (53.3) 
without prescription (21.54) (11.51) (6.61) 
Antibiotics can be taken 24 (5.11) 84 (17.87) 65 39 (8.3) 258 
anytime I feel sick (13.83) (54.89) 
I can give my left over 25 (5.32) 48 (10.21) 38 28 331 
antibiotics to friends and (8.09) (5.96) (70.43) 
family complaining of similar 
illness 
It is okay to ask a doctor to 42 (8.94) 33 (7.02) 64 47 (10) 284 
give me antibiotics when am (13.62) (60.43) 
ill 
It is always good to complete 349 64 (13.62) 33 12 12 (2.55) 
your antibiotic course (74.26) (7.02) (2.55) 
Antibiotics do not have any 30 (6.38) 34 (7.23) 39 (8.3) 31 (6.6) 336 
side-effects (71.49) 
I will use antibiotics anytime 38 (8.09) 92 (19.57) 77 35 228 
am ill because it is safe (16.38) (7.45) (48.51) 
Overall score on attitudes      
Mean score of Attitudes in percentage (mean ± SD) 81.47 ± 16.91 
Median score of attitudes in percentage (median, (LQ – UQ)) 85 (68.57 – 94.29) 
Attitudes rating  
Poor attitude (n (%)) 27 (5.74) 
Good attitude (n (%)) 443 (94.26) 
n: cell frequency. %: cell percentage. SD: standard deviation. LQ: Lower quartile. UQ: Upper quartile 
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4.8 Association between socio-demographic characteristics of respondents and their 
attitudes towards antibiotic use. 
Majority (95.1%) of the male respondents had good attitudes towards antibiotics and 93.3% of 
the female respondents had good attitudes towards antibiotics. About 89.2%, 92%, 96.7% and 
97.5% of the respondents with the age ranges 18-24 years, 25-33 years, 34-40 years and 41 years 
and above respectively had good attitudes towards antibiotics. Age group was significantly 
associated with attitudes of respondents towards antibiotics                    . Attitude 
of respondent towards antibiotic was significantly associated with highest level of 
education                      and insurance status                     . 
Detailed information can be read from table 4.8. 
Table 4.8: Association between socio-demographic characteristics of respondent and their 
attitudes towards antibiotics 
  Attitudes toward antibiotics   
Characteristics of Total  Good Poor     p-value 
respondents  n (%) n (%) 
Sex of respondent    0.7554 0.385 
Male 247 235 (95.14) 12 (4.86)   
Female 223 208 (93.27) 15 (6.73)   
Age in years    8.3476 0.039* 
18-24 years 65 58 (89.23) 7 (10.77)   
25-33 years 162 149 (91.98) 13 (8.02)   
34-40 years 121 117 (96.69) 4 (3.31)   
Above 40 years 122 119 (97.54) 3 (2.46)   
Highest level of education    37.411 <0.001*** 
3 
None 16 15 (93.75) 1 (6.25)   
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Basic 81 65 (80.25) 16 (19.75)   
Medium 157 150 (95.54) 7 (4.46)   
Tertiary 216 213 (98.61) 3 (1.39)   
Employment status    4.3539 0.113 
Skilled worker 264 254 (96.21) 10 (3.79)   
Unemployed 115 105 (91.3) 10 (8.7)   
Manual worker 91 84 (92.31) 7 (7.69)   
Area of residence    15.230 0.004** 
1 
Ablekuma 112 111 (99.11) 1 (0.89)   
Osu clottey 72 66 (91.67) 6 (8.33)   
Ga south 87 81 (93.1) 6 (6.9)   
Okaikoi 97 95 (97.94) 2 (2.06)   
Ayawaso 102 90 (88.24) 12 (11.76)   
Insurance status    21.304 <0.001*** 
4 
Yes 362 351 (96.96) 11 (3.04)   
No 108 92 (85.19) 16 (14.81)   
Antibiotic usage    6.6097 0.01* 
Yes  439 417 (94.13) 22 (81.48)   
No  31 26 (5.87) 5 (18.52)   
n: cell frequency. %: row percentage. χ2: Pearson‘s chi-square value. *: p-value <0.05. **: p-value <0.01. ***: p-
value <0.001. 
 
 
 
 
 
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CHAPTER FIVE 
DISCUSSION 
5.1 Types and level of antibiotics consumed 
The general objective of this study was to determine the factors influencing the use of antibiotics 
among adults in the Greater Accra Metropolis. 
The study showed that about 93.4% of the respondents had ever used antibiotics with 51.2% 
having used antibiotics within the past six months. This is consistent with other studies that also 
found that between 50.1% - 80% of respondents had used antibiotics (Tagoe et al., 2010; Andre 
et al., 2010). A study in eleven community pharmacies in Cape Coast concluded that 71.5% of 
participants had used antibiotics (Tagoe et al., 2010) while a study in Canada found that 80.4% 
of respondents used antibiotics within the community setting (Andre et al., 2010). A multi 
country survey on antibiotic resistance found that 73% of the respondents had used antibiotics 
within the past six months (WHO, 2015). 
In many parts of the world especially developing countries, sensitivity tests are not performed 
before antibiotics are administered giving rise to the common dispensing of broad spectrum 
antibiotics. This study confirmed that the use of broad spectrum antibiotics is common with 
26.2% (n=115) of the 439 antibiotic users using Augmentin/Amoksiklav which are all broad 
spectrum antibiotics composed of Amoxicillin and clavulanic acid. This is in line with other 
studies that found that the commonly used antibiotic was the broad spectrum antibiotic 
amoxicillin (Tagoe et al., 2010). In England and Scotland, studies revealed that ampicillin is 
commonly used (Andre et al., 2010). Another study also found that people in developed 
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countries commonly used tetracyclines and amoxicillin compared to ampicillin use in developing 
countries (Andre et al., 2010). 
Following closely to the use of Augmentin/Amoksiklav was cloxacillin (24.8%), penicillin 
(21%), ampicillin (19.3%) and others accounting for only 8.9% of antibiotics used. 
About 71.1% (n=312) of the respondents who had ever used antibiotics in this study obtained 
their antibiotics with prescription while a moderate 28.9% purchased antibiotics without 
prescription. This is in line with a WHO multi country survey in Nigeria that found that 75% of 
the respondents purchased their antibiotics with prescription given to them by a doctor or nurse 
(WHO, 2015). The finding however contradicts a study in Cape Coast in eleven community 
pharmacies that found that 71.5% of the respondents purchased antibiotics without prescription 
(Tagoe et al., 2010). 
In the present study, the antibiotics were purchased from hospital (47.2%) and community 
pharmacy (25.7%) where prescription would be required before antibiotics are dispensed. This 
was also confirmed with the finding that about 94.8% of the study participants were holders of 
insurance (public or private) and can therefore afford to visit hospitals and pay for their 
healthcare contrary to a study that found that 71.9% did not attend hospital when ill (Tagoe et al., 
2010). 
This study found that majority of the respondents who had ever used antibiotics, used them to 
treat pain (27.3%) a condition for which antibiotics is not medically indicated. Earlier studies had 
found that respondents commonly used antibiotics to treat cold or sore throat or any of the 
commonly occurring upper respiratory infections (Tagoe et al., 2010).  
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5.2 Knowledge about antibiotics/antibiotic resistance 
About 68.1% of the respondents knew how long antibiotics should be taken. About 81.3% of the 
respondents said antibiotics could be used to treat bacterial infections. However when asked if 
antibiotics could be used to treat viral infections, 58.1% of the respondents answered in the 
affirmative. These conflicting views support the argument that many individuals do not 
understand the differences between bacteria and viruses and the role antibiotics play in both 
(Mckee et al., 1999).  
About 70% of the respondents were familiar with the term antibiotic resistance but did not think 
antibiotic resistance affects them, their family or friends (72.3%) or that antibiotic resistance was 
a problem in Ghana (93%). This goes to emphasize the need to expand education on antibiotic 
use and antibiotic resistance in order to curb the growing menace of antibiotic resistance. About 
85.1% of the respondents knew that antibiotics have side-effects. 
The mean knowledge score of the respondents was 69.1% ± 13.9% with a median score of 
69.2% (69.5% – 76.9%). Many (90%) of the respondents had high level of knowledge rating. 
The high knowledge score could be due to the fact that about 79.4% of the respondents had 
medium to tertiary education. 
Over the past two years, the Ministry of Health has intensified its actions on campaigns aimed at 
curbing antibiotic resistance culminating in the formation of the National Platform on 
Antimicrobial Resistance (NPAR). The NPAR has carried some sensitization activities to create 
awareness to both the public and health practitioners on antibiotic use and resistance which could 
have accounted for the high knowledge of respondents on antibiotic issues. 
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In April 2018, the National Action Plan (NAP) on Antimicrobial use and Resistance was 
launched, less than two months before this survey was carried out. This could have created 
public awareness which could account for the high knowledge score seen in this research. 
5.3 Attitudes/Practices towards antibiotic use 
About 53.3% of the respondents strongly disagreed with buying antibiotics without prescription 
and 60.5% strongly disagreed with coercing doctors to prescribe antibiotics. Most (74.3%) 
respondents strongly agreed that it is always good to complete a course of antibiotics and 48.5% 
strongly disagreed with the statement that ‗I will use antibiotics anytime am ill because it is 
safe‘. The mean attitudinal score towards antibiotic use was 81.5% ± 16.9% with 94.3% of the 
respondents having good attitudinal rating. This is positively correlated with the fact that 
majority of the respondents had high level of knowledge on antibiotics. This shows that 
educational campaigns and sensitivity activities being undertaken are positively impacting on the 
attitudes of individuals towards antibiotic use and should be given all the needed support to 
continue. These positive attitudes towards antibiotic use however contradict findings in a Kuwait 
study that found that individuals had negative attitudes towards antibiotic use (Awad et al., 
2015). 
5.4 Determinants of antibiotic use 
Logistic regression analysis was performed to determine the factors that are significantly 
associated with antibiotic usage. 
The results showed that in both the adjusted and unadjusted models, females were more likely to 
use antibiotics than males. This was however, not statistically significant (p = 0.339). The 
unadjusted odds ratio showed that females had 1.47 (95% CI: 0.69 – 3.09) times the odds of 
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using antibiotics than men. Upon adjusting for age, education, employment status, area of 
residence, insurance status, knowledge level and attitudes, the odds ratio increased to 1.53 (95% 
CI: 0.64 – 3.65) times. Although this was found not to be statistically significant, the increase in 
odds ratio shows that there is no confounding. This finding agrees with other studies (Al-
Ramahi, 2013). This could be explained by the fact that females are commonly affected by 
urinary tract infections (UTIs) for which self-medication with antibiotics are a possibility. 
Overall, the sex of the respondents was not found to be a statistically significant determinant of 
antibiotic use.  
Age was not found to be a significant determinant of antibiotic use (p = 0.2806) after adjustment. 
Age in many previous studies has been found to have varying effect on antibiotic use. Age was 
positively associated with a study in Sweden (Andre et al, 2010), Switzerland (Andre et al, 2010) 
and across Europe (Goossen et al., 2010).  A study in Hungary however, found no association 
between age and antibiotic use (Goossen et al., 2010).  
Highest level of education was statistically significantly associated with antibiotic use in both the 
adjusted and unadjusted models (p < 0.001). It would have been expected that higher levels of 
education should lead to reduced antibiotic use. This was found not to be so in this study with 
respondents with tertiary education having 8.35 (95% CI: 0.54–128.72) higher odds of antibiotic 
use compared to those with no education. This could be due to the fact that educated people may 
have better jobs and higher income and hence can afford to purchase antibiotics which can be 
relatively expensive. 
The employment status of the respondents was significantly associated with antibiotic use (p < 
0.001) in the unadjusted model with skilled workers having 5.6 (95% CI: 2.32 – 13.28) higher 
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odds of using antibiotics compared to unemployed respondents. Although employment status 
overall was not found to be significantly associated with antibiotic use (p = 0.873) upon 
adjusting for age, sex, education, area of residence, insurance status, knowledge level and 
attitudes, manual workers were found to have significant association with antibiotic use (p = 
0.032) with 3.48 (95% CI: 1.11 – 10.87) higher odds of using antibiotics compared to the 
unemployed. This is in line with the results obtained under the conditions for which respondents 
used antibiotics where majority of the respondents indicated that they took antibiotics to treat 
pain. Manual workers engage in a lot of physical work that could lead to pain at the end of the 
day. Given that studies have found that people find it difficult to differentiate between pain 
killers and antibiotics (WHO, 2015), manual workers may end up buying antibiotics instead of 
pain relievers to manage their pain leading to the high use of antibiotics with the associated 
antibiotic resistance. 
Not having health insurance was found to be significantly associated with antibiotic use (p = 
0.035) in the unadjusted model. This was however not the case after adjustment for factors such 
as age, sex, education, employment status, area of residence, knowledge level and attitudes. 
Being a holder of insurance card was not a significant determinant of antibiotic use in this study 
(p = 0.851). Area of residence of respondents was found to be significantly associated with 
antibiotic use in the crude analysis (p = 0.005) and after adjustment for potential confounders (p 
< 0.001). This could be explained by the fact that infection patterns change with geographical 
location. The higher the infection rates the more likely the chances of individuals using 
antibiotics (Haggett, 1994). 
 In the bivariate analysis, age, area of residence, insurance status, highest level of education and 
employment status were all positively associated with attitudes towards antibiotic use. Sex was 
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found not to be associated with attitudes towards antibiotic use. This is not surprising since the 
attitudes of a person is a sum of their environmental, cultural, social and economic experiences 
which both sexes have an equal chance of exposure. Overall, attitude was found not to be 
significantly associated with antibiotic use (p = 0.939). This is in contrast to a study in Kuwait 
that found that participants had negative attitudes towards antibiotic consumption. A study in 
Hong Kong, UK, Sweden and Malaysia however found that the consumption of antibiotics was 
positively linked to the attitudes of participants (You et al., 2008; McNulty et al., 2007). 
Insurance status, area of residence, employment status and highest level of education were all 
found to be significantly associated with the knowledge level of respondents (p < 0.001). Age 
and sex of respondents did not influence the knowledge level of the respondents. Knowledge of 
respondents was found not to be associated with antibiotic use in both the bivariate and logistic 
regression analysis. This is in line with many studies in developing countries where the use of 
antibiotics is independent on the knowledge of participants (Tagoe et al., 2010;  Awad Al et al., 
2015). Many studies also identified that knowledge and attitudes of participants were not always 
in line with their antibiotic use (Zafar et al., 2008; Suiafan et al., 2012). A study found that better 
knowledge about antibiotics among medical students did not decrease their prevalence of 
antibiotic use compared to non-medical students (Zafar et al., 2008; Suiafan et al., 2012). 
 
Area of residence was found to be significantly associated with the use of antibiotics in this 
study. This compares to other studies that found that the place a participant resided was 
positively correlated with the use of antibiotics with people in rural areas more likely to use 
unprescribed antibiotics than people in urban areas (Berzanskyte et al., 2006). The area one 
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resides has an influence on their health-related behavior, rate of infection, access to healthcare 
etc which all tends to affect antibiotic use. 
5.5 Limitations of the study 
This study should be interpreted bearing in mind the following potential limitations. The study 
design is cross-sectional and hence temporal associations cannot be established. The measure of 
antibiotic use was self-report (based on respondents‘ telling the interviewer whether they had 
used antibiotics or not). This depends on the respondents‘ ability to remember information on 
their use of antibiotics leading to recall bias. There could be potential under-reporting on socially 
undesirable behaviors and over-reporting on socially desirable behaviors although this would be 
corrected to some extent with the use of identification numbers instead of the names of the 
participants. The time period used in collecting the information due to the cross-sectional nature 
of the study may not be the most appropriate since information on the knowledge and attitudes of 
respondents to antibiotic use could not be verified. Notwithstanding the above, the findings of 
this study provide useful information on the prevalence, knowledge, attitudes and practices that 
could be used as a basis for future studies and education on antibiotic use and antibiotic 
resistance. 
 
 
 
 
 
 
 
 
  
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CHAPTER SIX 
CONCLUSIONS AND RECOMMENDATIONS 
6.1 Conclusion 
This study found that majority of people still use antibiotics despite efforts of the Ministry of 
Health to create awareness on the use of antibiotics and potential association of antibiotic 
resistance. Augmentin/Amoksiklav was the commonly used antibiotics with majority obtaining 
their antibiotics on prescription. People however had good knowledge and attitudes towards 
antibiotic use. Highest level of education, area of residence and being a manual worker were 
found to be significant determinants of antibiotic use in this population. 
6.2 Recommendations 
A. MINISTRY OF HEALTH 
 Current efforts by the Ministry of Health to educate the public on antibiotics use and 
resistance should be expanded and intensified. In addition, Non-Governmental 
Organizations and Civil Society Organizations should join the Ministry of Health to fight 
the development of antibiotic resistance.  
B. PRESCRIBERS 
 Prescribers should be encouraged to perform sensitivity testing before administering 
antibiotics.  
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REFERENCES 
Abellanosa, I., & Nichter, M. (1996). Antibiotic prophylaxis among commercial sex workers in 
Cebu City, Philippines: patterns of use and perceptions of efficacy. Sexually transmitted 
diseases, 23(5), 407-412. 
 
Abdulkareem, M. (2011). Al-Shami et al. The Quality of Prescriptions with Antibiotics in 
Yemen. Journal of Clinical and Diagnostic Research, 5(4), 808-812. 
 
Acheson, D., & Allos, B. M. (2001). Campylobacter jejuni infections: update on emerging issues 
and trends. Clinical infectious diseases, 32(8), 1201-1206 
 
Acquah, S. E., Quaye, L., Sagoe, K., Ziem, J. B., Bromberger, P. I., & Amponsem, A. A. (2013). 
Susceptibility of bacterial etiological agents to commonly-used antimicrobial agents in 
children with sepsis at the Tamale Teaching Hospital. BMC infectious diseases, 13(1), 89. 
Al-Ramahi, R. (2013). Patterns and attitudes of self-medication practices and possible role of 
community pharmacists in Palestine. International journal of clinical pharmacology and 
therapeutics, 51(7), 562-567. 
 
Al-Bakri, A. G., Bustanji, Y., & Yousef, A. M. (2005). Community consumption of antibacterial 
drugs within the Jordanian population: sources, patterns and appropriateness. International 
journal of antimicrobial agents, 26(5), 389-395. 
 
Aminov, R. I. (2010). A brief history of the antibiotic era: lessons learned and challenges for the 
future. Frontiers in microbiology, 1, 134. 
André, M., Vernby, Å., Berg, J., & Lundborg, C. S. (2010). A survey of public knowledge and 
awareness related to antibiotic use and resistance in Sweden. Journal of Antimicrobial 
chemotherapy, 65(6), 1292-1296. 
 
Antibiotics Aren‘t Always the Answer, http://www.cdc.gov/features/getsmart/. Accessed 11 
October 2017  
Antibiotic resistance, http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/. 
Accessed 11 October 2017 
Antimicrobial resistance, http://www.who.int/mediacentre/factsheets/fs194/en/. Accessed 11 
October 2017 
Awad, A. I., & Aboud, E. A. (2015). Knowledge, Attitude and Practice towards Antibiotic Use 
among the Public in Kuwait. PLoS ONE, 10(2), e0117910. 
http://doi.org/10.1371/journal.pone.0117910 
Berzanskyte, A., Valinteliene, R., Haaijer-Ruskamp, F., Gurevicius, R., & Grigoryan, L. (2006). 
Self-medication with antibiotics in Lithuania. International journal of occupational medicine 
and environmental health, 19(4), 246-253. 
59 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 
Boadu, E. A. (2014). The use of antibiotics and the pattern of antimicrobial resistance at SDA 
Hospital, Kumasi, Ghana (Doctoral dissertation). 
Bosu, W. K., & Ofori-Adjei, D. (2000). An audit of prescribing practices in health care facilities 
of the Wassa West district of Ghana. West African journal of medicine, 19(4), 298-303. 
 
Bronzwaer, S. L., Cars, O., Buchholz, U., Mölstad, S., Goettsch, W., Veldhuijzen, I. K., ... & 
Degener, J. E. (2002). The relationship between antimicrobial use and antimicrobial 
resistance in Europe. Emerging infectious diseases, 8(3), 278. 
Buetow, S. A., Sibbald, B., Cantrill, J. A., & Halliwell, S. (1997). Appropriateness in health care: 
application to prescribing. Social science & medicine, 45(2), 261-271. 
 
Burns, N., & Grove, S. K. (2009). Appraisal synthesis and generation of evidence. The practice 
of nursing research. 6th ed. Philadelphia: WB saunders.Creswell, J. W., & Clark, V. L. P. 
(2007). Designing and conducting mixed methods research. 
Cochran, W. G. (1968). Errors of measurement in statistics. Technometrics, 10(4), 637-666. 
 
Cohen, M. L. (1992). Epidemiology of drug resistance: implications for a post—antimicrobial 
era. Science, 257(5073), 1050-1055. 
 
Col, N. F., & O'Connor, R. W. (1987). Estimating worldwide current antibiotic usage: report of 
Task Force 1. Reviews of infectious diseases, 9(Supplement_3), S232-S243. 
 
Corbett, K. K., Gonzales, R., Leeman-Castillo, B. A., Flores, E., Maselli, J., & Kafadar, K. 
(2005). Appropriate antibiotic use: variation in knowledge and awareness by Hispanic 
ethnicity and language. Preventive medicine, 40(2), 162-169. 
 
Conner, M., & Norman, P. (2005). Predicting health behaviour. McGraw-Hill Education (UK). 
 
Curry, M., Sung, L., Arroll, B., Goodyear-Smith, F., Kerse, N., & Norris, P. (2006). Public views 
and use of antibiotics for the common cold before and after an education campaign in New 
Zealand. The New Zealand Medical Journal (Online), 119(1233). 
 
D‘Costa, V. M., King, C. E., Kalan, L., Morar, M., Sung, W. W., Schwarz, C., ... & Golding, G. 
B. (2011). Antibiotic resistance is ancient. Nature, 477(7365), 457. 
 
Davey, P. G., Bax, R. P., Newey, J., Reeves, D., Rutherford, D., Slack, R., ... & Wilson, J. 
(1996). Growth in the use of antibiotics in the community in England and Scotland in 
1980-93. BMJ: British Medical Journal, 312(7031), 613. 
 
Davies, J. (1995). Vicious circles: looking back on resistance plasmids. Genetics, 139(4), 1465. 
 
60 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Davies, J., & Davies, D. (2010). Origins and evolution of antibiotic resistance. Microbiology and 
molecular biology reviews, 74(3), 417-433. 
Donkor, E. S., Tetteh-Quarcoo, P. B., Nartey, P., & Agyeman, I. O. (2012). Self-medication 
practices with antibiotics among tertiary level students in Accra, Ghana: a cross-sectional 
study. International journal of environmental research and public health, 9(10), 3519-
3529. 
Eneaji, C. J. (2017). Utilization of Antibiotics among Pediatrics Visiting a Nigerian Hospital 
(Doctoral dissertation). 
Eng, J. V., Marcus, R., Hadler, J. L., Imhoff, B., Vugia, D. J., Cieslak, P. R., ... & Hawkins, M. 
A. (2003). Consumer attitudes and use of antibiotics. Emerging infectious diseases, 9(9), 
1128. 
Feglo, P., Adu-Sarkodie, Y., Ayisi, L., Jain, R., Spurbeck, R. R., Springman, A. C., ... & Walk, 
S. T. (2012). Emergence of a 1 novel ESBL-producing, fluoroquinolone-resistant clone of 
extraintestinal pathogenic Escherichia coli in Kumasi, Ghana. Journal of Clinical 
Microbiology, JCM-03006.Fishbein, M. &Ajzen, I. (1975).Belief, attitude, intention and 
behavior: An introduction to theory and research. Menlo Park, CA: Addison-Wesley 
 
Feikin, D. R., Schuchat, A., Kolczak, M., Barrett, N. L., Harrison, L. H., Lefkowitz, L., ... & 
Stefonek, K. R. (2000). Mortality from invasive pneumococcal pneumonia in the era of 
antibiotic resistance, 1995-1997. American journal of public health, 90(2), 223. 
 
Finkel, M. J. (1978). Magnitude of antibiotic use. Annals of internal medicine, 89(5_Part_2), 
791-792. 
 
Fabbretti, A., Gualerzi, C. O., & Brandi, L. (2011). How to cope with the quest for new 
antibiotics. FEBS letters, 585(11), 1673-1681. 
 
Frieden T. Antibiotic resistance threats. Cdc. 2013:22-50. doi:CS239559-B.  
 
Friis, H., Bro, F., Mabeck, C. E., & Vejlsgaard, R. (1989). Use of antibiotics in general practice 
in Denmark in 1987. Scandinavian journal of infectious diseases, 21(5), 551-556. 
Gill, P., Stewart, K., Treasure, E., & Chadwick, B. (2008). Methods of data collection in 
qualitative research: interviews and focus groups. British dental journal, 204(6), 291. 
Goossens, H., Ferech, M., Vander Stichele, R. (2005); Elseviers, M., Outpatient antibiotic use in 
Europe and association with resistance: a cross-national database study.The Lancet, 
365(9459): p. 579–587. 
Given, L. M. (Ed.). (2008). The Sage encyclopedia of qualitative research methods. Sage 
Publications. 
Green, L. W., Kreuter, M. W., Deeds, S. G., Partridge, K. B., & Bartlett, E. (1980). Health 
education planning: a diagnostic approach. 
61 
 
University of Ghana  http://ugspace.ug.edu.gh
 
 
Haggett, P. (1994). Geographical Aspects of the Emergence of Infectious Diseases. Geografiska 
Annaler. Series B, Human Geography, 76(2), 91-104. doi:10.2307/490592 
 
Hardon, A., Hodgkin, C., Fresle, D., & World Health Organization. (2004). How to investigate 
the use of medicines by consumers. 
 
Harvey, R. A., Clark, M. A., Finkel, R., Rey, J. A., & Whalen, K. (2012). Lippincott’s illustrated 
reviews: Pharmacology (Vol. 526, pp. 530-541). Philadelphia: Wolters Kluwer. 
Harvey, A., Champe, C., Mycek, M. J., Gertner, S. B., & Perper, M. M. (1992). Pharmacology 
(Lippincot's Illustrated Reviews). 
 
Health, C., & The, C. I. D. S. (1997). Controlling antimicrobial resistance. An integrated action 
plan for Canadians. Canada communicable disease report= Releve des maladies 
transmissibles au Canada, 23, i. 
 
Huttner, B., Goossens, H., Verheij, T., & Harbarth, S. (2010). Characteristics and outcomes of 
public campaigns aimed at improving the use of antibiotics in outpatients in high-income 
countries. The Lancet infectious diseases, 10(1), 17-31. 
 
Karras, D. (2006). Antibiotic misuse in the emergency department. Academic Emergency 
Medicine, 13(3), 331-333. 
Katzung BG ed. (2009).Chemotherapeutic drugs. In: Basic and Clinical Pharmacology 11th 
Edition. McGraw Hill, Boston, PP. 773-831 
Lambert, P. A. (2002). Mechanisms of antibiotic resistance in Pseudomonas aeruginosa. Journal 
of the royal society of medicine, 95(Suppl 41), 22. 
Larson, E., & Grullon-Figueroa, L. (2004). Availability of antibiotics without prescription in 
New York City. Journal of Urban Health, 81(3), 498. 
Larson, E., Lin, S. X., & Gomez-Duarte, C. (2003). Antibiotic use in Hispanic households, New 
York city. Emerging infectious diseases, 9(9), 1096. 
Laxminarayan, R., Duse, A., Wattal, C., Zaidi, A. K., Wertheim, H. F., Sumpradit, N., ... & 
Greko, C. (2013). Antibiotic resistance—the need for global solutions. The Lancet 
infectious diseases, 13(12), 1057-1098. 
Levy, S. B. (2002). Factors impacting on the problem of antibiotic resistance. Journal of 
Antimicrobial Chemotherapy, 49(1), 25-30. 
Livermore, D. M. (1995). beta-Lactamases in laboratory and clinical resistance. Clinical 
microbiology reviews, 8(4), 557-584. 
 
Mainous AG. 3rd, 1.oorob RJ, Oler MJ, Haynes OM. Patient knowledge of upper 
          respiratory infections: implications for antibiotic expectations and \llI.lIe<:CSSlU 
62 
 
University of Ghana  http://ugspace.ug.edu.gh
 
          utilization. 1 Fam Pract 1997; 45:75-83. 
 
Martirosyan, L. (2014). Survey on Self-medication with Antibiotics in Yerevan (Doctoral 
dissertation). 
 
Mason, M. (2010, August). Sample size and saturation in PhD studies using qualitative 
interviews. In Forum qualitative Sozialforschung/Forum: qualitative social research (Vol. 
11, No. 3). 
 
McCaig, L. F., & Hughes, J. M. (1995). Trends in antimicrobial drug prescribing among office-
based physicians in the United States. Jama, 273(3), 214-219. 
 
McManus, P., Hammond, M. L., Whicker, S. D., Primrose, J. G., Mant, A., & Fairall, S. R. 
(1997). Antibiotic use in the Australian community, 1990-1995. The Medical Journal of 
Australia, 167(3), 124-127. 
 
McNulty, C. A., Boyle, P., Nichols, T., Clappison, P., & Davey, P. (2007). Don't wear me out—
the public's knowledge of and attitudes to antibiotic use. Journal of Antimicrobial 
Chemotherapy, 59(4), 727-738. 
 
McNulty, C. A., Boyle, P., Nichols, T., Clappison, P., & Davey, P. (2007). The public's attitudes 
to and compliance with antibiotics. Journal of Antimicrobial Chemotherapy, 60(suppl_1), 
i63-i68. 
 
Mensah, K. B., & Ansah, C. (2016). Irrational use of antibiotics and the risk of diabetes in 
Ghana. Ghana medical journal, 50(2), 107-114. 
 
Mongolia. Bulletin of the World Health Organization, 88(12), 930-936. 
 
Murray, B. E. (1991). New aspects of antimicrobial resistance and the resulting therapeutic 
dilemmas. Journal of Infectious Diseases, 163(6), 1185-1194. 
 
Napolitano, F., Izzo, M. T., Di Giuseppe, G., & Angelillo, I. F. (2013). Public knowledge, 
attitudes, and experience regarding the use of antibiotics in Italy. PloS one, 8(12), e84177. 
 
Neugut Al, Ghatak AT, Miller Rl (2001). Anaphylaxis in the United States: an investigation into 
its epidemiology. Arch. Intern. Med. 161: 15-21  
 
Newman, M. J., Frimpong, E., Donkor, E. S., Opintan, J. A., & Asamoah-Adu, A. (2011). 
Resistance to antimicrobial drugs in Ghana. Infection and drug resistance, 4, 215. 
Norris, P. (2007). Interventions to improve antimicrobial use: evidence from ICIUM 2004. 
Geneva: WHO, 1. 
Nys, S., Okeke, I. N., Kariuki, S., Dinant, G. J., Driessen, C., & Stobberingh, E. E. (2004). 
Antibiotic resistance of faecal Escherichia coli from healthy volunteers from eight 
developing countries. Journal of Antimicrobial Chemotherapy, 54(5), 952-955. 
63 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Obeng-Nkrumah, N., Twum-Danso, K., Krogfelt, K. A., & Newman, M. J. (2013). High levels 
of extended-spectrum beta-lactamases in a major teaching hospital in Ghana: the need for 
regular monitoring and evaluation of antibiotic resistance. The American journal of tropical 
medicine and hygiene, 89(5), 960-964. 
Ochiai, R. L., Acosta, C. J., Danovaro-Holliday, M., Baiqing, D., Bhattacharya, S. K., Agtini, M. 
D., ... & Wain, J. (2008). A study of typhoid fever in five Asian countries: disease burden 
and implications for controls. Bulletin of the world health organization, 86, 260-268. 
Okeke, I. N., Laxminarayan, R., Bhutta, Z. A., Duse, A. G., Jenkins, P., O'Brien, T. F., ... & 
Klugman, K. P. (2005). Antimicrobial resistance in developing countries. Part I: recent 
trends and current status. The Lancet infectious diseases, 5(8), 481-493. 
Palmer DA, Bauchner H. Parents' and physicians' views on antibiotics. Pediatrics 
1997; 99:E6. 
 
Pechère, J. C., Hughes, D., Kardas, P., & Cornaglia, G. (2007). Non-compliance with antibiotic 
therapy for acute community infections: a global survey. International journal of 
antimicrobial agents, 29(3), 245-253. 
 
Perone, J. S., & Tucker, L. (2003). An exploration of triangulation of methodologies: 
Quantitative and qualitative methodology fusion in an investigation of perceptions of 
transit safety (No. NCTR-416-08.1,).Rubin, H. J., & Rubin, I. (2005).Qualitative 
interviewing: The art of hearing data. Thousand Oaks, California: Sage Publications. 
Radyowijati, A., & Haak, H. (2002). Determinants of antimicrobial use in the developing world. 
Johns Hopkins University, Office of Design and Publications. 
 
Rimer, B. K., & Glanz, K. (2005). Theory at a glance: a guide for health promotion practice . 
Rouusounides, A., Papaevangelou, V., Hadjipanayis, A., Panagakou, S., Theodoridou, M., 
Syrogiannopoulos, G., & Hadjichristodoulou, C. (2011). Descriptive study on parents‘ 
knowledge, attitudes and practices on antibiotic use and misuse in children with upper 
respiratory tract infections in Cyprus. International journal of environmental research and 
public health, 8(8), 3246-3262. 
Shaw, K. J., Rather, P. N., Hare, R. S., & Miller, G. H. (1993). Molecular genetics of 
aminoglycoside resistance genes and familial relationships of the aminoglycoside-
modifying enzymes. Microbiological reviews, 57(1), 138-163. 
 
Suaifan, G. A., Shehadeh, M., Darwish, D. A., Al-Ije, H., Yousef, A. M. M., & Darwish, R. M. 
(2012). A cross-sectional study on knowledge, attitude and behavior related to antibiotic 
use and resistance among medical and non-medical university students in Jordan. African 
Journal of Pharmacy and Pharmacology, 6(10), 763-770. 
Tagoe, D. N. A., & Attah, C. O. (2010). A Study of Antibiotic Use and Abuse in Ghana: a case 
study of the Cape Coast Metropolis. The Internet Journal of Health, 11(2). 
64 
 
University of Ghana  http://ugspace.ug.edu.gh
 
Teddlie, C., & Tashakkori, A. (2009). Foundations of mixed methods research: Integrating 
quantitative and qualitative approaches in the social and behavioral sciences. Sage. 
 
Togoobaatar, G., Ikeda, N., Ali, M., Sonomjamts, M., Dashdemberel, S., Mori, R., & Shibuya, 
K. (2010). Survey of non-prescribed use of antibiotics for children in an urban community 
in  
 
Van Boeckel, T. P., Gandra, S., Ashok, A., Caudron, Q., Grenfell, B. T., Levin, S. A., & 
Laxminarayan, R. (2014). Global antibiotic consumption 2000 to 2010: an analysis of 
national pharmaceutical sales data. The Lancet Infectious Diseases, 14(8), 742-750. 
 
Vuylsteke, B. (2004). Current status of syndromic management of sexually transmitted infections 
in developing countries. 
 
Wamola, I. A. (2002). Minimising antibiotic resistance to Staphylococcus aureus in developing 
countries. East African medical journal, 79(11), 574-579. 
 
Widayati, A., Suryawati, S., de Crespigny, C., & Hiller, J. E. (2011).  Self-medication with 
antibiotics in Yogyakarta City Indonesia: a cross sectional population-based survey. BMC 
research notes, 4(1), 491. 
 
Wilson AA. Crane LA. Banett PH, Gonzales R. Public beliefs and use of 
        antibiotics for acute respiratory illness. 1 Gm lntem Med 1999; 14:658-62. 
 
Yin, R. K. (1994). Case study research: Design and Methods, Applied social research methods 
series, 5. Biography, Sage Publications, London. 
 
You, J. H. S., Yau, B., Choi, K. C., Chau, C. T. S., Huang, Q. R., & Lee, S. S. (2008). Public 
knowledge, attitudes and behavior on antibiotic use: a telephone survey in Hong Kong. 
Infection, 36(2), 153-157. 
 
Yuill, C., Crinson, I., & Duncan, E. (2010). Key concepts in health studies. Sage. 
Zafar, S. N., Syed, R., Waqar, S., Zubairi, A. J., Vaqar, T., Shaikh, M., ... & Saleem, S. (2008). 
Self-medication amongst university students of Karachi: prevalence, knowledge and 
attitudes. Journal of the Pakistan Medical Association, 58(4), 214. 
 
 
 
  
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APPENDICES 
Appendix A. Questionnaire for Quantitative Studies 
School of Public Health 
University of Ghana 
College of Health Sciences 
This questionnaire seeks to assess the factors influencing the use of antibiotics among adults in 
the Accra Metropolis. I wish to assure you that this is an academic study and all information 
provided shall strictly be used for academic purposes. You are also assured of absolute 
confidentiality and anonymity. There is thus no right or wrong answer. 
 
Part 1  Socio – Demographic Characteristics 
Please respond to the questions by ticking [√] the answer that reflects your opinion.   
Location of residence…..                                              Number of cluster…………………… 
Participant Number…..Language used in interview……………… 
Time interview started…………   Time interview ended………………… 
Name of interviewer……………      Date of interview……………………. 
1. Gender.    Male [  ]        Female [  ] 
2. In which year were you born?................... 
 
3. What was your age at your last birthday? 
Age.    18 - 24 [  ]   26 -33 [  ]   34-40 [  ]  Above 40 [  ] 
4. What is your level of education? 
None   [  ]                    Basic [  ]                         Medium [  ]    Tertiary [  ]     
5. What work do you do? 
Skilled worker [   ]                Unemployed [   ]                  Manual worker [  ]    
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6. Do you hold any form of insurance? 
Yes [   ]                      No[   ]                 
Part 2   Antibiotic use 
1. Do you use antibiotics?  
Yes [   ]                       No[   ]                 
2. When was the last time you used an antibiotic? 
Currently using [   ]     last month [   ]       6 months[   ]     
One year [   ]     More than one year [   ]                  Never[   ]                  
3. What type of antibiotic do you usually use? 
Penicillin[   ]              Augmentin/Amoksiklav[   ]           Ampicillin[   ]                 
Cloxacillin[   ]                  Cloxacillin[   ]                 Others (please state type)………. 
4. Did you buy the antibiotics with a prescription? 
Yes[   ]                     No [   ]                  
5. Where did you buy or get the antibiotics? 
At the hospital [   ]              Community pharmacy [   ]         License chemical shop [   ]                 
Street peddlers [   ]               Had at home [   ]                 Friend or relative [   ]    
6. What condition did you use the antibiotic to treat? 
 Headache[   ]               Cold [   ]                Cough [   ]                 Sorethroat[   ]                
Fever[   ]               Toothache[   ]               Stomach pain[   ]                itching[   ]               
Others[   ]                
Part 3 knowledge about antibiotics 
1. How long should I take an antibiotic for? 
Anytime I feel better [   ]               When I have taken all the antibiotics as instructed by 
doctor/pharmacist [   ]       Don‘t know [   ]                         
2. Antibiotics can be used to treat these diseases 
Bacteria infections [   ]               viral infections [   ]               headache [   ]          fever [   ]               
malaria [   ]       Diarrhea [   ]                
3. I can take antibiotics from my friends and family when I have a similar illness 
Yes[   ]                   No[   ]                
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4. Do antibiotics have side-effects? 
5. Yes [   ]                   No[   ]                
 
Part 4  Knowledge about antibiotic resistance 
1. Have you heard of the term antibiotic resistance? 
Yes [   ]                   No [   ]                
2. Antibiotic resistance can occur when I don‘t use antibiotics the right way 
Yes [   ]                   No[   ]                
3. Antibiotic resistance does not affect me, my family or friends 
Yes [   ]                   No[   ]          
4. Antibiotic resistance is not a problem in Ghana 
Yes [   ]                   No [   ]          
Part 5Attitude towards antibiotic use 
Strongly agree Slightly Neither Strongly Slightly 
agree agree nor disagree disagree 
disagree 
 It is okay to buy      
antibiotics without 
1 
prescription 
 Antibiotics can be      
taken anytime I 
2 
feel sick 
 I can give my left      
over antibiotics to 
3 
friends and family 
complaining of 
similar illness 
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 It is okay to ask a      
doctor to give me 
4 
antibiotics when 
am ill 
 It is always good to      
complete your 
5 
antibiotic course 
6. Antibiotics do not      
have any side-
effects 
7 I will use      
antibiotics anytime 
am ill because it is 
safe 
 
Thank You for your participation. 
 
  
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Appendix B. Participant Consent Form 
Informed Consent Form 
Title of project: Factors influencing the use of antibiotics among adults in the Greater Accra 
Metropolis. 
Background 
My name is Ama Akyampomaa Owusu-Asare, a student from the School of Public Health, 
University of Ghana, Legon. I am conducting a study on the factors influencing the use of 
antibiotics among adults in the Greater Accra Metropolis. 
Procedures  
The study will involve answering questions in the form of closed and open ended questionnaire. 
You are under no obligations to participate in the study. It will be appreciated if you could 
participate in this study. This is purely an academic research which forms part of my work for 
the award of a Master‘s Degree in Public Health. 
Confidentiality and Anonymity 
In this study, your anonymity is assured.  We will not be collecting or retaining any information 
about your identity. The records of this study will be kept strictly confidential. We will not 
include any information in any report that may be published that would make it possible to 
identify you.  
Risks and Benefits 
The study when completed would inform health policy makers about the way antibiotics are 
consumed in Ghana and the necessary actions that ought to be taken to reduce the development 
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of antibiotic-resistant strains thus acting as a feedback mechanism to health authorities. There are 
no risks associated with participating in this study. 
Right to Refuse 
Participation in this study is voluntary and you can choose not to answer any individual question 
or all questions. You are at liberty to withdraw from the study at any time. However, I will 
encourage you to fully participate in the study since your answers are much needed. 
Before taking consent 
Do you have any questions you wish to ask about the study? Yes/No 
If yes, please, indicate the questions below………………………………………………………. 
………………………………………………………………………………………………………
……………………………………………………………………………………………………... 
Voluntary Consent 
I have read the information given above, or the information above has been read to me and I 
understand. I have been given a chance to ask questions concerning this study; questions have 
been answered to my satisfaction. I now voluntarily agree to participate in this study knowing 
that I have the right to withdraw from this study at any time. 
…………………………………. …………. ……………… ………….. 
Name of Respondent                                     Date                  Thumbprint                  Signature 
………………………………….. ………… ……………… …………….. 
Name of Researcher                                       Date                  Thumbprint                  Signature 
 
 
 
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Researcher’s Statement 
I, the undersigned, have explained this consent to the subject in English language/ Twi/ Ewe/Ga, 
and that she/he understands the purpose of the study, procedures to be followed, as well as the 
risks and benefits of the study. 
The participant has fully agreed to participate in the study. 
Signature of Interviewer ……………………………………… 
Date ………………………………… 
Address ………………………………………………………. 
If you have any questions please contact 
Researcher: Ama Akyampomaa Owusu-Asare (0244213009). 
Administrator of the GHS-ERC: 0243235225 / 0507041223 
 
 
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