University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA FACTORS ASSOCIATED WITH ANTIMICROBIAL SELF-MEDICATION IN BIRIM CENTRAL MUNICIPAL OF EASTERN REGION GHANA BY ANITA ESTHER ASAMOAH (10702728) A DISSERTATION SUBMITTED TO THE UNIVERSITY OF GHANA IN PARTIAL FULFILLMENT FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH (MPH) DEGREE. JULY, 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Anita Esther Asamoah, do hereby declare that with the exception of the references and literature review of which all are duly acknowledged where necessary, this dissertation is my original work undertaken under the supervision of Dr. Adolphina Addo-Lartey and has not been submitted for any degree in any institution. Anita Esther Asamoah Dr. Adolphina Addo-Lartey ………………………… …………………………… ( STUDENT ) ( ACADEMIC SUPERVISOR ) Date: ………………….. Date: ………………………… i University of Ghana http://ugspace.ug.edu.gh DEDICATION “Ebenezer, Hitherto Has the Lord Helped Me” To my Father, Mother and Brothers: Evans John Asamoah, Godwin Kinsley Otsibu Asamoah, Emmanuel Christopher Korankye Asamoah. Am forever grateful to Evans. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT To my Supervisor, Dr. Adolphina Addo-Lartey without whose guidance the research would not have been completed. Her personality gives me the vim to strive higher and harder as a woman. To Prof. Augustine Ankomah for the fatherly encouragements when I nearly gave up on the programme. To Dr. Daniel Evans Kasozi my Ugandan classmate turned brother, for teaching me all the topics that were difficult for me in Biostatistics and always willing to assist with my academic work. To my fellow students in Epidemiology and Disease Control, MPHIL class for believing in me and choosing me as the class representative. To the Director, Mr. James Atampiiga Avoka and the Public Health Officer Mr. Thomas Kissi of the Birim Central District Health Directorate Office. To my research assistants Appiah Akua Opokua, Ohenema Rubby Diawuo and Solomon Ampofo, all currently studying in University of Health and Allied Sciences, Ho. I am grateful. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: Self-medication is the prolonged use of medicines to treat any symptom or illness without medical prescriptions. The emergence of resistant bacteria strains is mainly associated with antimicrobial self-medication. Aim: Self-medication with antimicrobial is a health problem globally especially in low-and- middle income countries (LMIC) like Ghana, so this study investigated the prevalence and factors associated with antimicrobial in three rural communities (Akyem-Asuboa, Akyem-Manso and Akyem-Asene) in the Birim Central Municipal of the Eastern region of Ghana. Inhabitants of these communities prefer to first patronize drug stores than visiting a health facility when they are sick. Method: A cross-sectional survey was conducted in three (3) communities with a total of three hundred and fifty-six (356) participants aged 18-60 years and selected through simple random probability sampling. Data was collected using a pretested questionnaire and within six (6) weeks duration. Consent was sought from all participants before the instrument was administered to them. Questionnaire used can be found attached in appendix pages. Prevalence was determined by the last time a participant self-medicated on antimicrobial in the past nine months. Results: Prevalence of antimicrobial self-medication in Birim Central Municipal is 86% (95% CI; 82-89), the factors associated with self-medication included previous experience with symptom (p = 0.03), high cost of medical consultation (p = 0.012) and self-medication being less expensive (p = <0.001) were found to be statistically significant with antimicrobial self-medication. The most used antimicrobials were Metronidazole at78% (95% CI; 73 - 82), Penicillin-V was also known by inhabitants of the study areas as cross tablet, at 65% (95% CI; 59 - 70) and Amoxicillin was the third most used antimicrobial at 57% (95% CI 53 - 64). Respondents who had valid health iv University of Ghana http://ugspace.ug.edu.gh insurance cards but still self-medicated were 70% while catarrh (common cold) was the most common symptom 60% self-medicated for. Conclusion: The prevalence of antimicrobial self-medication was relatively high at 86% in the Birim Central Municipal of Eastern Region, Ghana. The common symptoms that caused participants to self-medicate were catarrh (common cold),skin sore and diarrhea. Self-medication on antimicrobial was reported to be less expensive, high cost of medical consultation discouraged participants from visiting health facilities and previous experience with a particular symptom was a factor in antimicrobial self-medication. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION............................................................................................................................ i DEDICATION............................................................................................................................... ii TABLE OF CONTENTS ............................................................................................................ vi LIST OF TABLES ....................................................................................................................... ix LIST OF FIGURES ...................................................................................................................... x LIST OF ABBREVIATIONS ..................................................................................................... xi CHAPTER ONE ........................................................................................................................... 1 INTRODUCTION......................................................................................................................... 1 1.1 Background ........................................................................................................................... 1 1.2 Problem Statement ................................................................................................................ 2 1.3 Justification ........................................................................................................................... 3 1.4 Objectives .............................................................................................................................. 4 1.4.1 General Objective ........................................................................................................... 4 1.4.2 Specific Objectives ......................................................................................................... 4 1.5 Conceptual Framework of Factors Associated with Antimicrobial Self-Medication ........... 5 1.5.1 Conceptual Framework Narrative .................................................................................. 6 CHAPTER TWO .......................................................................................................................... 7 LITERATURE REVIEW ............................................................................................................ 7 2.1 Antibiotics and antimicrobial resistance ............................................................................... 7 vi University of Ghana http://ugspace.ug.edu.gh 2.2 Prevalence and trend of antimicrobial self-medication ....................................................... 10 2.3 Factors associated with self-medication .............................................................................. 11 CHAPTER THREE .................................................................................................................... 14 METHODS .................................................................................................................................. 14 3.1 Study design ........................................................................................................................ 14 3.2 Study location ...................................................................................................................... 14 3.3 Variables.............................................................................................................................. 15 3.4 Sample population ............................................................................................................... 17 3.4.1 Inclusion and exclusion criteria .................................................................................... 17 3.5 Sample size determination .................................................................................................. 17 3.6 Sampling and data collection technique .............................................................................. 18 3.7 Data processing and analysis............................................................................................... 18 3.8 Ethical issues ....................................................................................................................... 20 CHAPTER FOUR ....................................................................................................................... 21 RESULTS .................................................................................................................................... 21 4.0 Socio-Demographic Characteristics of Respondents .......................................................... 21 4.1 Proportion of Respondents Engaged in Antimicrobial Self-Medication ............................ 22 4.2 Bivariate Analysis of Factors Associated with Antimicrobial Self-Medication ................. 26 4.3 Multivariate Analysis of Factors Associated with Antimicrobial Self-Medication ............ 28 4.4 Description of Antimicrobial by Respondents to Drug-Store Sellers ................................. 30 4.5 Common Symptoms that Cause Antimicrobial Self-Medication ........................................ 31 vii University of Ghana http://ugspace.ug.edu.gh 4.6 Sources of Information on Buying and Use of Antimicrobial by Respondents .................. 32 4.7 Duration of Treatment with Antimicrobial ......................................................................... 33 CHAPTER FIVE ........................................................................................................................ 35 DISCUSSION ........................................................................................................................... 35 5.1 Limitations and Strength of Study ...................................................................................... 38 CHAPTER SIX ........................................................................................................................... 39 CONCLUSION AND RECOMMENDATION ........................................................................ 39 6.0 Conclusion ....................................................................................................................... 39 6.1 Recommendations .......................................................................................................... 39 REFERENCES ............................................................................................................................ 41 Appendix i: Participant Information Sheet .............................................................................. 45 Appendix ii: Consent Form ........................................................................................................ 47 Appendix iii: Questionnaire ....................................................................................................... 48 Appendix: iv Ethical Clearance ................................................................................................. 53 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Study Variables ............................................................................................................... 16 Table 2: Demographic Characteristics of Respondents (N = 356) ............................................... 21 Table 3: Bivariate Analysis of Factors Associated with Antimicrobial Self-Medication N= 356 27 Table 4: Multivariate Analysis of Factors Associated with Antimicrobial Self-Medication N=356 ....................................................................................................................................................... 29 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework ................................................................................................... 5 Figure 2: Map of study sites.......................................................................................................... 15 Figure 3: Prevalence of Antimicrobial Self-Medication in Birim Central Municipal, Eastern Region, Ghana N = 356 ................................................................................................................ 23 Figure 4: Sources of Antimicrobial N = 305 ................................................................................ 24 Figure 5: Types of Antimicrobial used by Respondents ............................................................... 25 Figure 6: Number of Times Respondents had Self-Medicated in the Past Nine Months ............. 26 Figure 7: How Antimicrobial is Described by Respondents to a Seller ....................................... 30 Figure 8: Checking of Expiry Date and those with Valid NHIS .................................................. 31 Figure 9: Common Symptoms that cause Respondents to Self-Medicate on Antimicrobial ....... 32 Figure 10: Sources of Information on Use and Buying of Antimicrobial .................................... 33 Figure 11: Duration of Treatment with Antimicrobial ................................................................. 34 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ASM Antimicrobial Self-Medication CDC Centre for Disease Control and Prevention ENT Ear Nose and Throat HCAI Healthcare Associated Infection LMIC Low-and-Middle Income Countries MRSA Methicillin Resistant Staphylococcus Aureus NAP National Action Plan NHIS National Health Insurance Scheme PPS Point Prevalence Study WHO World Health Organization xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background Self-medication is defined as the continuous use of drugs to treat symptoms and illnesses without medical prescription and prolonged use of a prescribed drug for a recurrent symptom or disease without a physician's surveillance of treatment, for example, ampiclox, metronidazole, and tetracycline (Abdulraheem, Adegboye, & Fatiregun, 2016). Self-medication can reduce treatment and turnover time in health facilities, although it can save life-threatening conditions during an emergency, it can only treat a symptom but not cure disease and also comes with some health- related hazards. Some of these hazards are adverse drug reactions. Major problems as resources wastage increase resistance of pathogens to drugs, prolonged suffering, drug-to-drug reactions and antimicrobial resistance which is a current problem worldwide mostly in developing countries where there is the availability of antimicrobial without prescription (Ocan et al., 2015). The antimicrobial drug is any substance that can destroy or inhibit the growth of microorganisms and especially pathogenic microorganisms and comprises the antibiotics, antimalarial, antifungals, anti-helminthes, and antivirals but the latter is mostly not available over the counter (“About Antimicrobial Resistance | Antibiotic/Antimicrobial Resistance | CDC,”). The emergence of resistant bacteria strains is mainly associated with antimicrobial self-medication. Many factors are responsible for the current practice of self-medication in less developed countries like Ghana, which include some drugs being available over the counter, no access to health care facilities, increased rates of infectious diseases and poor regulatory practices. In the previous study in Western Ethiopia among health workers, the level of education has been seen to be an indicator in self-medication (Sado et al., 2017). 1 University of Ghana http://ugspace.ug.edu.gh 1.2 Problem Statement Antimicrobials self-medication is a global threat because it could lead to antimicrobial resistance (“WHO | Antimicrobial resistance,” 2018). It is important to note that antimicrobials are not part of over the counter drugs. However, the general public continues to have easy access to over the counter drugs in several pharmacies, drug shops and clinics (Bennadi, 2013). Antimicrobial self- medication prevalence in studies done in Pakistan and Romania was estimated at 44% to 71.4% respectively among secondary and tertiary level students. A study in Nigeria showed 85% of antimicrobial self-medication was practiced by participants. In Ghana prevalence of antimicrobial self-medication is 70% in the urban population which is 40% higher than the normal expected value (Babatunde et al., 2016; Damian, Lupusoru, & Ghiciuc, 2014; Donkor, Tetteh-Quarcoo, Nartey, & Agyeman, 2012). In a study of respiratory tract infection in adult patients in Cameroun, the prevalence of antibiotics self-medication in patients with respiratory tract infection was 41.9% (Ngu et al., 2018) Self-medication in previous studies has been linked to multi-drug antimicrobial resistance in Ghana (Agyepong, Govinden, Owusu-Ofori, & Essack, 2018). Furthermore, a study in 2011 in Ghana showed that there is a surge in resistance of bacteria to some antimicrobials (Groß et al., 2011). Antimicrobial self-medication when prevalent has many risks to the individual. Excessive antibiotics use is of serious economic implications in terms of morbidity, mortality, hospitalizations, and cost because of difficulties in infection treatments due to resistance. Moreover, drugs used as a home remedy may be counterfeit and either under or overused. It masks the signs and symptoms of latent diseases thereby worsening the situation and leading to delayed diagnosis and drug resistance. Studies have shown that antimicrobial resistance has a connection with the high use of antimicrobials agents (Agyepong et al., 2018). 2 University of Ghana http://ugspace.ug.edu.gh The rise in antimicrobial use is through over the counter sales, internet, and self-medication. There is a surveillance project on antimicrobials globally and Ghana has joined the Global Action Policy on antimicrobial surveillance and education (Republic of Ghana, 2017) but there is ever-increasing outlets for selling antibiotics and anti-fungal without prescriptions and drug store owners dispensing under-dose antibiotics to clients. In the Eastern region of Ghana, not many studies have been done on factors associated with antimicrobials self-medication. 1.3 Justification Despite the rising trend of self-medication, there have been no studies done to investigate antimicrobial self-medication in the rural areas of Ghana. This is needed so that the authorities can put in place the necessary surveillance in affected communities. There is need to gather data in the rural communities for the Ghana National Action Plan (NAP) to be able to implement its surveillance plan on antimicrobial usage and resistance in connection with the ‘one health’ concept (Ministry of Health, 2017). This study will make known the common symptoms for which antimicrobial are self-medicated and the types of antimicrobial mostly bought from the drug sellers within the communities. The study will search the individual and community factors that influence the use of antimicrobial. 3 University of Ghana http://ugspace.ug.edu.gh 1.4 Objectives 1.4.1 General Objective The general objective is to examine the factors associated with antimicrobial self-medication in Birim Central Municipality. 1.4.2 Specific Objectives 1. To estimate the prevalence of antimicrobial self-medication in Birim Central Municipal. 2. To identify the common health conditions and symptoms for antimicrobial self- medication. 3. To determine the socioeconomic, individual, community and health facility factors associated with antimicrobial self-medication. 4 University of Ghana http://ugspace.ug.edu.gh 1.5 Conceptual Framework of Factors Associated with Antimicrobial Self-Medication Figure 1: Conceptual Framework 5 University of Ghana http://ugspace.ug.edu.gh 1.5.1 Conceptual Framework Narrative The framework explains the factors associated with antimicrobial self-medication. It comprises the dependent and the independent variables in the order of indirect, direct and proximate determinants of self-medication. The level of education attained by an individual can change his/her perception of self-medicating (Sado et al., 2017). According to Lei, Jiang, Liu, Ferrier, & Mugavin, (2018) there is a correlation between self-medication and the duration of the symptom or illness. Moreover, completing a treatment regimen of more than three days is a problem. Income level plays a vital role in either self-medicating or visiting the health facility when sick. In rural communities, the availability of a drug-store or chemist (chemical shop) that retails incomplete doses of antimicrobial leads to self-medicating with them because it comes at a lower cost than going to the hospital. Time can be a determining factor due to going to the farm and returning back home late. Individual factors range from personal decisions to family/friends influences, not having a valid health insurance card, having a previous prescription or left-over medications. The Internet plays a vital role here because most people now have access to internet on-the-go while television and radio jingles or advertisements a have negative effect too. Healthcare facility factors impede easy accessibility by the community, the cost of consultation fees, attitude of health workers and importantly waiting time. Most health facilities do not even accept the valid health insurance cards due to debt incurred by the National Health Insurance Authority since its inception. All these factors work hand-in-hand then lead to antimicrobial self-medication which, is the outcome of the framework. Over a long period when antimicrobial self-medication is not addressed antimicrobial resistance sets in. 6 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Antibiotics and antimicrobial resistance There has been a rapid increase in antimicrobial resistance over the few years and has got to a level where the future health of the public is in danger. Antimicrobial resistance is a general term referring to the resistance of bacteria, fungi, protozoa, and viruses to antibiotics, antifungals, anti- protozoa and antivirals respectively (Carlet et al., 2012). The recent epidemic of antimicrobial resistance is partly linked to the overuse of antibiotic. The most effective means of improving the use of antibiotics is unknown. In the past there was reliance on the development of new drugs to overcome resistance, however, since there is resistance by bacteria to most antibiotics that are available there should be the stringent approach to the control of excessive use of antibiotics. Unless actions are taken 10 million people are estimated to die each year by 2050 due to antimicrobial resistance, already deaths worldwide are estimated at 700,00. Drug-related side effects caused by antibiotics account for 20% of visits to emergency rooms either through self- medication or professional prescription (Williams, 2016). In the past bacteria, resistance was a problem in acute care but the rise in the use of antibiotics in out-patients has been associated with resistance in several organisms. In order to decrease the spread of drug-resistant pathogens, there is a need for preventing the emergence of resistance and most control programs focus onthe initial choice of antimicrobial (Monroe & Polk, 2000). According to Wushouer et al., (2018) it is crucial to identify the inclination between antimicrobial resistance and antibiotic use in order to understand the epidemiology and burden of antimicrobial use. The incidence rates of infection for six classes of pathogens isolated were observed and 7 University of Ghana http://ugspace.ug.edu.gh Escherichia coli was the most prevalent resistant strain both in density and proportion. There is a complex association in the clear-cut link between human antimicrobial use and resistance. Some confounding factors are pathogen-drug interactions, pathogen mutation rates, rate of pathogen transmission between human beings, animals, and their immediate environment, cross-resistance and duo-resistance to other drugs. Nosocomial infection perhaps gives a better explanation of the dynamics of resistance (Holmes et al., 2016). Epidemiological studies have shown that the emergence of resistant strains and antibiotic consumption have a direct relationship. Antibiotics worldwide have similar benefits but its overuse or inappropriate use has negative effects. Penicillin was used to control bacterial infections during world war II it shortly after that became a problem clinically which then brought about the discovery of beta-lactam antibiotics however in that same decade methicillin-resistant staphylococcus aureus (MRSA) was identified (Ventola, 2015). Staphylococcus aureus and Enterococcus are gram-positive bacteria, which are on the rise and this poses as an implication for skin and soft-tissue infections, urinary tract infections, and pneumonia which are all common healthcare-associated infections (HCAI) (Hede & Karyn Hede, 2014). There is a lack of support for clinical decision making in low- and middle-income countries like Ghana with regards to clinical tools that can assist clinicians to lower or avoid antibiotic use when unnecessary. There are basic diagnostic tests such as blood counts and cultures, urine culture and urinalysis, tests are not run in many resource-poor settings, and even if offered the patients cannot afford them. In these rural settings, antimicrobial resistance cannot be tested for in isolates of bacteria. According to Dryden, Cooke, & Davey, (2009) experts around the world have come to a general consensus that about 50% or more of antibiotics could be avoided if clinicians offer these basic tests before the prescription. In a case-control study, the risk of an antibiotic-resistant Escherichia coli urinary 8 University of Ghana http://ugspace.ug.edu.gh tract infection was found to be significantly associated with a prescription of trimethoprim a month before the study. In a Serbian study by Veličković - Radovanović et al, ( 2015) were the consumption of antibiotics and antimicrobial resistance were monitored in a tertiary care hospital for nine years, resistant to ceftriaxone in Escherichia coli increased from 22% to 47% while Proteus mirabilis increased from 31% to 60%. At a p-value of 0.05, there was a significant correlation between ceftriaxone consumption and resistance. In a systematic review of African countries, a lower level of resistance to carbapenems and fluoroquinolones were observed in all regions, however in West Africa, Klebsiella spp. resistance to ciprofloxacin was higher than the other regions. Reports reviewed showed that more than 42.6% of African countries did not have antimicrobial published data and the antibiotics prescribed in the continent have a high level of drug resistance (Tadesse et al., 2017). The resistance of Plasmodium spp. to antimalarial is a major burden on the public globally due to the widespread of antimalarial drugs and this has led to failure to eradicate malaria worldwide (Takala- Harrison & Laufer, 2015). Based on research by Argudín et al., (2017) antimicrobial agents are used on animals and this is connected to human and the environment which is a ‘One Health’ approach. The use of antimicrobial in animals creates pathogens that can spread to human by contact through the food supply and environmental pathways. The solution to the increasing antimicrobial resistance menace is comprehensive antimicrobial stewardship in Ghana and Africa through monitoring combined with data been available at the local-level, hospital-level, and community-level. 9 University of Ghana http://ugspace.ug.edu.gh 2.2 Prevalence and trend of antimicrobial self-medication There are three (3) categories of antibiotics which are the ‘Access’, ‘Watch’ and ‘Reserve’ groups. The ‘Access’ category represents more than 50% of antibiotic consumption worldwide. These are the first- or second-line treatment for common infections and are the most common. Recent reports by the World Health Organization found that they are the most used and example is amoxicillin. The ‘Watch’ category is the broad-spectrum antibiotics like the third-generation cephalosporins, quinolones, and carbapenems which are to be used with caution due to the fact that they have a high potential of causing antimicrobial resistance. The ‘Reserve’ group can only be used to treat multi-drug resistant bacterial infections but only as a last-resort (WHO, 2018). Prevalence of resistance is influenced by sanitation, population density, tourism and migration and rate of vaccination. In a survey of Global Point Prevalence Study (Global-PPS), which was measuring antimicrobial prevalence prescribing and resistance worldwide in 53 countries, the three most prescribed antibiotics were penicillins, cephalosporins, and fluoroquinolones. Out of 41,213 prescriptions of antimicrobial, 89% were anti-bacterial agents. Antimicrobial was given to 19.8% and a multi-resistant treatment was received by 5.9%. Nosocomial infection frequency was high in Latin America, which was 11.9% compared to the 10.1% of East and South Asia (Versporten et al., 2018). Prevalence in Greece, Italy, and Argentina are 77.9%, 69.2% and 66% respectively (Garofalo, Di Giuseppe, & Angelillo, 2015; Skliros et al., 2010; Rey et al., 2018). Africa has a high rate of antimicrobial resistance because there is the prevalence of resistant bacteria (Aslam, Baig, Adnan, Saim, & Jahan, 2013). Literature has revealed that antimicrobial self-medication prevalence is higher in low-and-middle- income than developed countries. People self-medicate without full information on their proper 10 University of Ghana http://ugspace.ug.edu.gh use. A cross-sectional survey in rural areas of Sindh outskirts of Karachi with 400 participants, the prevalence was 81.25%. The most used antimicrobial was amoxicillin at 52% followed by these in order of tetracycline 16.9%, ciprofloxacin 14.8%, co-trimoxazole 11.4% and ampicillin 8.3% (Bilal et al., 2016). This, however, differs from a household study on antimicrobial self-medication in low-and- middle-income countries of which ampicillin was the most used antimicrobial (Ocan et al., 2015). The Sindh study has same result in terms of ‘the most used antimicrobial been amoxicillin’ as a retrospective survey done in the Eastern Region of Ghana in healthcare facilities to determine antimicrobial prescription rates which also had amoxicillin 26.7%, metronidazole 18.2%, flucloxacillin 8.9%, ciprofloxacin 8.2%, erythromycin 4.7%, chloramphenicol 3.4%, and co- trimoxazole 2.8% (Ahiabu, Tersbøl, Biritwum, Bygbjerg, & Magnussen, 2016). In the Kingdom of Saudi Arabia, amoxicillin was the most used antibiotic at 22.3% with a prevalence of 78.7% out of 681 participants within a military specialist health facility (Al Rasheed et al., 2016). The prevalence of antibiotics self-medication in 225 dental patients in Nigeria was 30.4% asides the traditional medicines and analgesics used for the same symptom before they made effort to go to a health facility (Afolabi, Akinmoladun, Adebose, & Elekwachi, 2010). Prevalence in Ghana is 70% among tertiary level students in Accra (Donkor, Tetteh-Quarcoo, Nartey, & Agyeman, 2012). 2.3 Factors associated with self-medication A study in Ethiopia by Shafie, Eyasu, Muzeyin, Worku, & Martín-Aragón, (2018) in some selected households in Addis Ababa community of which prevalence was 75.5% showed that the age, gender, family status and academic status of participants influenced antimicrobial self-medication. 11 University of Ghana http://ugspace.ug.edu.gh Irregular distribution to non-professional or trained rural drug store owners where over-the-counter drugs are bought is another factor. The most common type of symptoms that antibiotics are used to treat is cold/flu, though common cold cannot be cured by antibiotics yet they are available over- the-counter (Kenealy & Arroll, 2013). In Nigeria women used antimicrobial to treat menstrual symptoms like cramps, bloating, heavy bleeding and pimples (Sapkota et al., 2010). Olajide, Aremu, Esan, Dosunmu, & Raji, (2018) in a study among 162 patients of the ear, nose, and throat (ENT) clinic of a teaching hospital in Ekiti State, Nigeria, 66% of the respondents had self-medicated with topical ear drops for otological problems. Ear drops are antimicrobial and the respondents’ reasons for self-medicating was that their ailments were not severe. According to Afolabi et al., (2010) the reasons for self-medication in dental patients before visiting a health facility was that it saves time and they know what to do. Sun et al., (2015) in Shandong Province of China found out that doctors claimed they will not prescribe antibiotics for cold/flu yet 55% of 8400 prescriptions included antibiotics. And 71% of prescriptions of antibiotics were likely to come from a rural or village clinic or health facility than an urban one. Once having had a previous prescription from a health facility some patients tend to present them repeatedly to buy the same antibiotics. In some communities in Ghana, myths in some rural settings among the men are that taking antibiotics can clear the body system after having a hang-over from excessive drinking. People self-medicate based on the severity of illness; that is some kinds of illness are not worth consulting a doctor, which in turn, of course, is cost-effective and time-consuming. The rate of obtaining a hospital card especially in private clinics is too expensive for the common man. In a study among 260 residents of Wuhan in China, 51.2% relied on their experience, 27.7% on friends/peers while 19.1% relied on the internet to self-medicate. 94.5% of all participants said 12 University of Ghana http://ugspace.ug.edu.gh self-medication was effective for them (Lei et al., 2018). According to Al Rasheed et al., (2016) friend advice and a pharmacy in close proximity were common predictors of antimicrobial self- prescription in Riyadh. The question then is whether they know the side effects? In 640 children, the prevalence of antimicrobial self-prescription by parents for their children was 27.03% in a study conducted on the pediatric out-patient department of a medical college in Berhampur, India. Parents self-medicated for their children due to lack of time to consult a physician and not being able to afford consultation fee at a health facility. Pediatric self-medication was high in children with literate parents. Azithromycin and albendazole were the most used antimicrobial. No cure was achieved despite the self-prescription behavior by 61.84% of the children while 7% had adverse drug effects due to over-dosing, while under-dosing was 58.38% (Geetanjali, Sameer, K, & M, 2013). In Iran self-medication was found to be associated with gender and level of knowledge but no significant difference was found with possessing a health insurance card and self-medication (Latifi et al., 2017). In Ghana, the least of the factors was the inaccessibility of hospitals in an urban population while other factors were that self-medicating with antimicrobial was cheap and the health facilities had long queues which cause delays (Donkor et al., 2012). 13 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.1 Study design This study was a cross-sectional community based-survey design. This study was conducted among residents and indigenes of three rural communities of Birim Central Municipal in the Eastern Region of Ghana. The study estimated the prevalence of antimicrobial self-medication, the factors associated with it and the common symptoms for the self-medications. 3.2 Study location The survey was carried out in the Birim Central District Municipality. The Birim Central Municipality is one of the 26 administrative districts in the Eastern Region of Ghana. It is located in the southwestern corner of the Eastern Region and has boundaries with Kwaebibirem (to the North), Birim South District (to the West), Asikuma-Odoben-Brakwa and Agona East (to the South), and West Akyem (to the East). It has a total land area of 1,090 Km2 and a population of 144,869 of which 67.7% (98,044) live in the urban localities and 32.3% (46,825) residing in the rural areas (Ghana statistical service, 2014). 14 University of Ghana http://ugspace.ug.edu.gh Figure 2: Map of study sites Source: (Ghana statistical service, 2014). 3.3 Variables The dependent variable was self-medication with antimicrobial and this was determined as the taking of antibiotics, antimalarial, antifungals and anti-helminths without any prescription from a physician within the past nine (9) months among participants. The independent variable comprises individual and community factors. Such as socio- demographic characteristics like age, sex, marital status, level of education attained, occupation, time, access to a healthcare facility, and national health insurance card. Some other variables are a distance of health facilities from the community, queues, and socio-economic status. 15 University of Ghana http://ugspace.ug.edu.gh Table 1: Study Variables DEPENDENT VARIABLE VARIABLE INDICATOR MEASUREMENT Antimicrobial Self- Self-prescription of any antimicrobial Interview by Medication in the past nine (9) months Questionnaire INDEPENDENT VARIABLES VARIABLES INDICATORS MEASUREMENT Socio-demographic Age Interview Characteristics Gender Marital Status Educational Level Occupation Individual Factors Self-decision Interview Access to Information Left-over Medication Advice from Friend Previous Prescription No Health Insurance Card Stage and Type of Illness Community Factors Access to Antimicrobial without Interview Prescription Lower Costs Availability of Drug Store, Time Cultural Norms / Myths Television / Radio Jingles Health Facility Factors Waiting Time at Facility Interview Inaccessible Facility Cost Availability of Health Worker Distance to Facility Health Worker Attitude 16 University of Ghana http://ugspace.ug.edu.gh 3.4 Sample population The study population included resident members of the three rural communities aged between eighteen to sixty (18 – 60) years. All three communities are listed on the map of the study location. 3.4.1 Inclusion and exclusion criteria All residents of a community that fell within the age range of the sample population were eligible to participate in this study after giving their consent. 3.5 Sample size determination The sample size or estimated proportion was calculated from a previous study of which the prevalence was 70% in Ghana (Donkor et al., 2012). [Z 2 2 1-α/2 P (1-P)] / d Prevalence, P = 0.7 (Z )2 1 - α/2 = 1.96 × 1.96 = 3.8416 Z= Reliability co-efficient. d = 0.05, 0.05 × 0.05 = 0.0025 1 – 0.7 = 0.3 Substituting for all values [3.8416 × 0.7 × 0.3] / 0.0025 = 322.69 10% of 322.7 = 32.3 = 33 33 + 323 = 356 10% of the calculated sample was added to the sample size to cater for non-response of participants. Therefore, the total sample size used was 356 (Charan & Biswas, 2013). 17 University of Ghana http://ugspace.ug.edu.gh 3.6 Sampling and data collection technique This is a cross-sectional study design with multi-stage sampling. Communities were selected by random sampling of the communities in the District and each community was taken as a natural cluster. The number of respondents per community was selected proportionately according to the population base. The population of each community was taken from the 2010 census database (Ghana statistical service, 2014) and proportional sampling was used to determine the number of participants to be interviewed in each community. The communities were Akyem-Asuboa (n= 79), Akyem-Manso (n= 130) and Akyem-Asene (n= 147), making a total number of participants N= 356. The first house was selected by using a pivot at a landmark point on the map and following the direction in a clockwise direction. Selection of houses was done by simple random sampling and the first participant was selected by simple random sampling in a household after which every other third house was visited. Administering of research instrument commenced early in the mornings before eligible participants go to the farm/market place till in the evening when everyone returns home. Interviews were conducted after participants gave their consent to investigators. Samples of antimicrobial medicines were shown to participants so that they have a good understanding of the kind of drugs referred to in the questionnaires. 3.7 Data processing and analysis Data were processed with Microsoft excel then exported into Stata 15/IC version for analysis. Descriptive analysis was performed on the characteristics of respondents and frequency tables tabulated to calculate the prevalence of antimicrobial self-medication using median and proportion were appropriate. Chi-square test was performed to determine associations between demographic characteristics and antimicrobial self-medication. Logistic regression was used to determine 18 University of Ghana http://ugspace.ug.edu.gh factors that independently affect or influence self-medication in the study population. Bivariate analysis threshold was set at 0.2 and significant levels were 0.05. 19 University of Ghana http://ugspace.ug.edu.gh 3.8 Ethical issues Ethical approval and permission from the study site Approval for the study was obtained from the Ghana Health Service Ethics Review Committee through the School of Public Health, the District Health Directorate, the Member of Parliament, District Assembly Office and the village heads and assemblymen were duly informed. Informed consent and the right to leave research Participants were made to understand the content of the consent form before they signed and risk of participating in the study was made clear to them. Participants were also informed about their right to leave the research without any reasons. Privacy and confidentiality Confidentiality was guaranteed because asides the principal investigator and project supervisor no one will be privy to the answered questionnaires and consent forms. Disclosure and interview duration The research which was for academic purpose was disclosed to participants before they signed the consent forms and the duration of interview did not exceed 15 minutes. Data usage and security Data collected was used for the sole purpose of this study and only principal investigator and supervisor had access to it. Conflict of interest I declare no conflict of interest. 20 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Socio-Demographic Characteristics of Respondents A total of 356 respondents participated in the study. Of the 356 respondents, 188 (53%) were males. The median age was 35 (IQR, 26 – 48.5). Majority of the respondents, 133/356 (37%) were married and nearly half of them, 41% (149/356) were of basic school level of education. About three-quarter of the respondents was employed in the informal sector mainly artisans, farmers, and traders (Table 2). Table 2: Demographic Characteristics of Respondents (N = 356) Characteristics Number of Respondents Percentages (%) p - Value Median Age (IQR) 35 (26 – 48.5) Sex of Respondents 0.14 Male 188 53 Female 168 47 Marital Status 0.53 Single 100 28 Married 133 37 Cohabiting 79 22 Divorced 24 7 Widowed 20 6 Educational Level 0.92 Primary 41 12 21 University of Ghana http://ugspace.ug.edu.gh Junior High School (JHS) 149 42 Senior High School / Middle 121 34 School Tertiary 30 8 None 15 4 Occupational Status 0.51 Unemployed 54 14 Employed in Formal Sector 27 8 Employed in Informal Sector 273 77 Other Specify 2 1 Income in Ghana Cedis 0.05 (GHS) 100-200 105 29 201-400 81 23 401-700 50 14 701-1100 39 11 >1100 25 7 Gets Support from Family 56 16 4.1 Proportion of Respondents Engaged in Antimicrobial Self-Medication Three hundred and five (305) of the 356 respondents (86%; 95% CI 82 - 89) practiced self- medication. Of the 305 respondents that practiced self-medication, 83% (252) reported buying the medicines from the village drugstore, 11% (34) bought from a pharmacy in the district headquarter, Akyem-Oda while 6% (19) got the medicines from left-over medication (Figures 3 and 4). Of the 22 University of Ghana http://ugspace.ug.edu.gh 356 participants, 57% and 54% respectively reported having administered antimicrobial without prescription to children 0 – 17 years and the elderly above 60 years. No 14% Yes 86% Yes No Figure 3: Prevalence of Antimicrobial Self-Medication in Birim Central Municipal, Eastern Region, Ghana N = 356 23 University of Ghana http://ugspace.ug.edu.gh 6.00% 11.00% 83.00% Pharmacy in District Headquarter Village Drugstore Left Over Medication Figure 4: Sources of Antimicrobial N = 305 24 University of Ghana http://ugspace.ug.edu.gh Among the 305 who self-medicated on antimicrobial 237/305 (78%) used Metronidazole (95% CI; 73 - 82), 198/305 (65%) used Penicillin-V (known to community members as cross tablet) (95% CI 59 - 70) and Amoxicillin at 57% was the third most used antimicrobial (95% CI; 53 - 64). Grisofluvin, Ciprofloxacin, Doxycycline, Erythromycin and Azithromycin were in the “others” category at10%, (95% CI; 7 - 14) Figure 5. 90% 80% 78% 70% 65% 60% 57% 55% 48% 50% 40% 30% 21% 22%19% 20% 13% 10% 10% 2% 0% Types of Antimicrobial Figure 5: Types of Antimicrobial used by Respondents 25 Percentage of Respondents N=305 University of Ghana http://ugspace.ug.edu.gh The respondents were required in this question to state the number of times they had practiced antimicrobial self-medication in the past nine months. Figure 6 shows that majority of respondents 128/305 (42%) had used antimicrobial twice in the past nine months. The least respondents which is the “other” category comprises having used antimicrobial more than four times to ten times as reported in the questionnaire. 45% 42% 40% 35% 30% 25% 19% 20% 15% 15% 10% 10% 8% 6% 5% 0% Once Twice Three Times Four Times I don’t Know Others Figure 6: Number of Times Respondents had Self-Medicated in the Past Nine Months 4.2 Bivariate Analysis of Factors Associated with Antimicrobial Self-Medication On bivariate analysis of the factors associated with antimicrobial self-medication, previous experience with symptom (p = 0.03), high cost of medical consultation (p = 0.012) and self- medication being less expensive (p = <0.001) were found to be statistically significant with antimicrobial self-medication, Table 3 shows all the corresponding chi-square values, crude odds ratio, and significant values. 26 Percentage of Respondents N=305 University of Ghana http://ugspace.ug.edu.gh Table 3: Bivariate Analysis of Factors Associated with Antimicrobial Self-Medication N= 356 Factors Yes n(%) N o n(%) X2 p- Value Minor Illness / Nothing Serious 274 (77) 82 (23) 0.66 0.42 No Health Insurance (NHIS) card 71 (20) 285 (80) 0.004 0.95 Long Waiting Time at Clinic 106 (30) 250 (70) 0.52 0.47 Less Expensive 243 (68) 113 (32) 12.35 <0.001 High Cost of Medical Consultation 46 (13) 310 (87) 6.36 0.012 Previous Experience with Symptoms 76 (21) 280 (79) 4.72 0.03 No Time to go to the Hospital 92 (26) 263 (74) 2.90 0.23 NHIS does not cover some drugs 123 (34) 233 (66) 0.01 0.90 Nurses are Rude 49 (14) 307 (86) 0.19 0.67 Hospital Far but Drugstore near 45 (13) 311 (87) 0.06 0.80 As First Aid 18 (5) 338 (95) 0.96 0.33 Others Specify 26 (7) 330 (93) 0.03 0.87 27 University of Ghana http://ugspace.ug.edu.gh 4.3 Multivariate Analysis of Factors Associated with Antimicrobial Self-Medication The module was adjusted for other variables and previous experience with symptoms (p = 0.008), less expensive (p = 0.02), high medical consultation (p = 0.03) were found to be significantly associated factors that cause antimicrobial self-medication Table 4. 28 University of Ghana http://ugspace.ug.edu.gh Table 4: Multivariate Analysis of Factors Associated with Antimicrobial Self-Medication N=356 Variables COR p-Value AOR 95% CI p-Value Less Expensive 2.86 <0.001 2.44 (1.14-5.22) 0.02 No Time to go to the Hospital 0.62 0.23 0.64 (0.28-1.46) 0.29 NHIS does not cover some drugs 0.96 0.93 0.79 (0.39-1.63) 0.54 Nurses are Rude 0.83 0.67 0.99 (0.40-2.47) 0.99 High Cost of Medical Consultation 8.64 0.012 9.93 (1.27-77.54) 0.03 Hospital Far but Drug-Store is Near 0.89 0.80 0.93 (0.34-2.56) 0.89 Minor Illness / Nothing Serious 1.32 0.42 1.89 (0.82-4.36) 0.13 No Health Insurance (NHIS) Card 1.02 0.95 1.63 (0.64-4.16) 0.30 Long Waiting Time at Clinic 1.28 0.47 1.50 (0.64-3.52) 0.35 Previous Experience with Symptoms 2.79 0.03 3.96 (1.42-11.02) 0.008 As First Aid 0.56 0.33 0.83 (0.23-3.00) 0.78 Others 0.91 0.87 1.34 (0.36-4.92) 0.66 29 University of Ghana http://ugspace.ug.edu.gh 4.4 Description of Antimicrobial by Respondents to Drug-Store Sellers There were four different means of describing any type of antimicrobial to the seller as reported by respondents. Almost 70% (N = 305) bought antibiotics by name and those who obtained antibiotics through a previously used packet 33% and by symptoms description were 23% (N = 305). Those who used the color of the antibiotics to explain to the seller were 28% (Figure 7). 80% 70% 68% 60% 50% 40% 33% 30% 28% 23% 20% 10% 0% By Colour By pre-used Packet By the name By Symptom Figure 7: How Antimicrobial is Described by Respondents to a Seller 30 Number of Respondents N=305 University of Ghana http://ugspace.ug.edu.gh Valid Health Insurance cardholders were 70% out of those who self-medicated, and there was no statistical significance between antimicrobial self-medication and having or not having a valid health insurance card. Of the 305 respondents, 37% never checked expiry dates of medicines (Figure 8). 250 213 200 191 150 114 100 92 50 63% 37% 70% 30% 0 Check Expiry Date Valid NHIS Yes No Figure 8: Checking of Expiry Date and those with Valid NHIS 4.5 Common Symptoms that Cause Antimicrobial Self-Medication The reported symptoms of antimicrobial self-medication were catarrh 60%, skin sore 40%, diarrhea 27%, stomach and abdominal pain 7%, body pains 15% and others which comprises 31 Number of Respondents N=305 University of Ghana http://ugspace.ug.edu.gh genital discharge and pain, breast discharge and pain, clearing of body system and alcohol hang over was 47% (Figures 9). 70% 60% 60% 50% 47% 40% 40% 30% 27% 20% 16% 10% 7% 0% Cattarh Skinsore Diarrhea Stomach Pain Body Pain Others Figure 9: Common Symptoms that cause Respondents to Self-Medicate on Antimicrobial 4.6 Sources of Information on Buying and Use of Antimicrobial by Respondents Respondents had various sources of obtaining information on the type of antimicrobial to buy the highest was through previous prescription 35%, the least source of information was through spouse at 5% Figure 10. 32 Number of Respondents N=305 University of Ghana http://ugspace.ug.edu.gh 8% 8% 35% 18% Previous Prescription Friend Suggested Spouse Suggested Family Members 5% Parents Others 26% Figure 10: Sources of Information on Use and Buying of Antimicrobial 4.7 Duration of Treatment with Antimicrobial After commencing treatment with antibiotics 45% never complete the course and do away with the medicines after symptoms disappear, only 15% reported completing the course and when respondents get tired of swallowing the antibiotics 9% stops the treatment Figure 11. 33 University of Ghana http://ugspace.ug.edu.gh 50% 45% 45% 40% 35% 30% 25% 19% 20% 15% 15% 12% 10% 9% 5% 0% After Few Days After Symptoms When Antimicrobial At Completion of When I Get Tired of Regardless of Disappear even if Runs Out Course Swallowing Outcome Course not Completed Figure 11: Duration of Treatment with Antimicrobial 34 PERCENTAGE OF RESPONDENTS N=305 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION This study was conducted within two weeks among residents of three communities Akyem- Manso, Akyem-Asuboa, Akyem-Asene in Eastern Region and found prevalence of antimicrobial self-medication to be 86% and this is high compared to a study among tertiary students in Accra. This could be due to the fact that this research was in the rural communities which have economic status rather lower than those in the urban areas (Donkor et al., 2012). A similar study in the rural areas of Sindh in Karachi found prevalence to be 81% which is almost similar to this study whose prevalence is 86%. The mean age of respondents was 35 in contrast to the study in Karachi which the mean age was 49 (Bilal et al., 2016). This difference in the mean age is statistically significant (p = <0.001) and the difference can be explained by the fact that in this study there was age limitation of 18 – 60 years while the Bilal et al (2016) study recruited all patients coming to the Out-Patient Department (OPD) of the hospital. No age limitation was mentioned in that study. Income had no association with antimicrobial self-medication but on logistic regression analysis using the categories, the odds of antimicrobial self-medication in the those whose income < GHS 100 was 0.2 times the odds of antimicrobial self-medication in those who received income between GHS 100 – 200 (reference group). This implies having a lower income was a factor in antimicrobial self-medication. The most used antimicrobial were metronidazole at 78% (95% CI; 73 - 82), Penicillin-V at 65% (95% CI; 59 - 70) and Amoxicillin was the third most used antimicrobial at 57% (95% CI; 53 - 64) compared to the study by (Donkor et al., 2012) which found Amoxicillin as the most used antimicrobial at 24%. The most self-prescribed antimicrobial according to (Bilal et al., 2016) was Amoxicillin at 52% but in this study, it was the third most self-prescribed antimicrobial. Griseofulvin, Doxycycline, and Azithromycin were in the “others” 35 University of Ghana http://ugspace.ug.edu.gh category at 10% (95% CI; 7 - 14). The main source of antimicrobial was from the village drugstore at 76% (231/305) and the significant factors for self-medication were reported as self-medication been less expensive (p= <0.001) and previous experience with symptoms (p= 0.03). The percentage of those who used left-over medication was 6% and this is lower compared to a study in Saudi Arabia with 48% using left-over medications (Aziz & Kamel, 2019). A sample of antimicrobial medicines was shown to respondents to guide against recall bias. Metronidazole (Flagyl) was the most common antimicrobial self-medicated within the total number of respondents at 76% (95% CI; 71 - 80), Penicillin-V, known to the inhabitants of the three communities as “cross tablet” was the second most used at 64% (95% CI; 58 - 68) while the least was the “I do not know” category at 2% (95% CI; 0.9 - 4) but on interaction with respondents the descriptions and color were similar to Doxycycline from the samples shown to respondents. The “others” category consists of Doxycycline, Grisofluvin, Ciprofloxacin, Erythromycin and Azithromycin (Figure 5). Antibiotics has three categories Access, Watch and Reserve categories. AWaRe is the new acronym set as new tool to contain rising resistance. In this study, most of the antimicrobial consumed were in the Access category which represents 50% of antibiotic consumption worldwide with the exception of Flucoxacilin which is unclassified. Erythromycin and Ciprofloxacin were in the Watch category and are supposed to be used with caution, this finding is same as a study in India among health care workers who self-prescribed this group of antibiotics (Mathur, Chopra, Mudey, & Nayak, 2015). None of the antibiotics under the Reserve category was found to be self-prescribed in the study. Penicillin-V was reported by the respondents to be very effective against body pains and any type of skin cuts, sores from farming to rashes. It is ground into powder and applied on cuts to aid quick healing. None of the literature reviewed mentioned Penicillin-V tablet. The frequency of antimicrobial use was 42% for respondents who 36 University of Ghana http://ugspace.ug.edu.gh had used antimicrobial twice, 15% for those who had self-prescribed once and those who had self- medicated for more than four times to ten times were 8%. After adjusting for other factors, previous experience with symptom and antimicrobial self- medication been less expensive were significantly associated with antimicrobial self-medication. Respondents who had previous experience with symptoms were almost four times likely to self- medicate with antimicrobial when compared to those who did not have previous experience with symptoms (AOR = 3.96; 95% CI; 1.42 - 11.02 ; p = 0.008). Similarly, the odds of antimicrobial self-medication in respondents who reported antimicrobial to be less expensive were twice the odds of antimicrobial self-medication in those who did not report it to be less expensive (AOR = 2.44; 95% CI; 1.14 - 5.22 ; p = 0.02) and those who perceived medical consultation fee as high were almost ten times likely to self-medicate with antimicrobial when to compare to those who could afford high medical consultation (AOR 9.9; 95% CI; 1.27 - 77.54 p = 0.03) Table 4. These findings are similar to a study in Ghana by Donkor et al (2012). When buying antimicrobials 68% (n= 305) of respondents reported mentioning the names of the medicines even though the study was in rural communities, 23% bought the medicines by explaining their symptoms while 33% go to the drugstore with/or show the seller an already used packet. The respondents who had valid health insurance cards were 70% but still self-medicated and this was similar to a study in China that also found no association between antimicrobial self- medication and having a valid health insurance card (Lei et al., 2018). When purchasing medicines, it is important to check expiry dates but in this study, 37% never checked expiry dates and this could be due to the majority of respondents saying they trust the seller will not sell expired medicines to them, although some respondents say it is due to lower level or none attainment of basic education. Common symptoms that caused antimicrobial self-medication were catarrh at 37 University of Ghana http://ugspace.ug.edu.gh 60%, skin sore 40%, genital discharge and pain, breast discharge and pain, clearing of the body system and alcohol hangover was 47% were the second-highest symptoms (Figures 9). Cold cannot be cured by antibiotics and general body pains have nothing to do with consuming antibiotics, so in the long run, it leads to antimicrobial resistance. Source of information for most respondents was based on the previous prescription which was 35%, friends’ suggestion was 26%, spouse suggestion was 5% and suggestion from parents was 8% and this is similar to a study done in Sudan (Awad, Eltayeb, Matowe, & Thalib, 2005). For antimicrobial it is best to complete course as prescribed by the medical personnel but in this study 45% of respondents reported they discontinue use of the medicines after symptoms disappear even if the course is not completed, 19% discontinue after a few days, 12% purchase just the dose their money is able to buy and when it runs out they stop, respondents who discontinue use when they get tired of swallowing were 9%. Those who reported completing the course of prescription were only 15% in contrast to the study by Donkor et al (2012). 5.1 Limitations and Strength of Study The limitation of this study is recall bias by respondents, some may have forgotten the exact month they last self-medicated on antimicrobial. The strength is that interviews were conducted in local language Twi because the study was in rural communities. 38 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATION 6.0 Conclusion The prevalence of antimicrobial self-medication in Birim Central Municipal was 86%, the three antimicrobial most self-prescribed were Metronidazole 78%, Penicillin-V 65% and Amoxicillin 57% (n= 305). The common symptoms that caused respondents to self-medicate were catarrh 60%, skin sore, genital discharge, clearing of alcohol hangover and body pain. The significant factors associated with antimicrobial self-medication were self-medication been less expensive (p= 0.02), high cost of medical consultation (p= 0.03) and previous experience with symptom (p= < 0.008). 6.1 Recommendations Based on the study findings the following recommendations are provided: 1. Educational programs aimed at promoting the rational use of antibiotics should be taken into the rural communities. Selling of antibiotics should be regulated in the rural communities by the Ghana Health Service in conjunction with the Food and Drugs Board. 2. The Watch category of antibiotics should only be available to the public on strict prescription from health facilities. The registered sellers should be cautioned on the sales of incomplete doses of antimicrobial by the Food and Drugs Board. 3. Task force should be set up by the various district health directorate and raid the drugstores of rural communities. 4. Antimicrobial medicines should be optimized and surveillance strengthened. There should be understanding of antimicrobial resistance through television and radio and awareness improvement. 39 University of Ghana http://ugspace.ug.edu.gh 5. The health facilities should be stocked with medicines by the Ghana Health Service so the patients do not have cause to go buy incomplete doses from the drug stores. 6. 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Retrieved from http://www.moh.gov.gh/wp-content/uploads/2018/04/AMR-POLICY-A5_09.03.2018- Signed.pdf Rey, M., Pessacq, P., Berruezo, L., Torre, V., Baldoni, N., Margot, A., & Otermin, F. (2018). Antibiotic Self-Medication: prevalence and behavior description. International Journal of Infectious Diseases, 73, 222. https://doi.org/10.1016/J.IJID.2018.04.3918 Sado, E., Kassahun, E., Bayisa, G., Gebre, M., Tadesse, A., & Mosisa, B. (2017). Epidemiology of self-medication with modern medicines among health care professionals in Nekemte town, western Ethiopia. BMC Research Notes, 10(1), 533. https://doi.org/10.1186/s13104- 017-2865-5 Sapkota, A. R., Coker, M. E., Rosenberg Goldstein, R. E., Atkinson, N. L., Sweet, S. J., Sopeju, P. O., … Ojo, K. K. (2010). Self-medication with antibiotics for the treatment of menstrual symptoms in southwest Nigeria: a cross-sectional study. BMC Public Health, 10(1), 610. https://doi.org/10.1186/1471-2458-10-610 Shafie, M., Eyasu, M., Muzeyin, K., Worku, Y., & Martín-Aragón, S. (2018). Prevalence and determinants of self-medication practice among selected households in Addis Ababa community. PLOS ONE, 13(3), e0194122. https://doi.org/10.1371/journal.pone.0194122 Skliros, E., Merkouris, P., Papazafiropoulou, A., Gikas, A., Matzouranis, G., Papafragos, C., … 43 University of Ghana http://ugspace.ug.edu.gh Sotiropoulos, A. (2010). Self-medication with antibiotics in rural population in Greece: a cross-sectional multicenter study. BMC Family Practice, 11(1), 58. https://doi.org/10.1186/1471-2296-11-58 Sun, Q., Dyar, O. J., Zhao, L., Tomson, G., Nilsson, L. E., Grape, M., … Lundborg, C. S. (2015). Overuse of antibiotics for the common cold – attitudes and behaviors among doctors in rural areas of Shandong Province, China. 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Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence survey. The Lancet Global Health, 6(6), e619–e629. https://doi.org/10.1016/S2214-109X(18)30186-4 WHO | In the face of slow progress, WHO offers a new tool and sets a target to accelerate action against antimicrobial resistance. Retrieved July 3, 2019, from https://www.who.int/news- room/detail/18-06-2019-in-the-face-of-slow-progress-who-offers-a-new-tool-and-sets-a- target-to-accelerate-action-against-antimicrobial-resistance WHO. (2018). WHO | Wide differences in antibiotic use between countries, according to new data from WHO. WHO. Retrieved from http://www.who.int/medicines/areas/rational_use/oms-amr-amc-report-2016-2018-media- note/en/ WHO | Antimicrobial resistance. (2018). WHO. Retrieved from http://www.who.int/antimicrobial-resistance/en/ Williams, D. N. (2016). Antimicrobial resistance: Are we at the dawn of the post-antibiotic era? Journal of the Royal College of Physicians of Edinburgh, 46(3), 150–156. https://doi.org/10.4997/JRCPE.2016.302 Wushouer, H., Zhang, Z. X., Wang, J. H., Ji, P., Zhu, Q. F., Aishan, R., & Shi, L. W. (2018). Trends and relationship between antimicrobial resistance and antibiotic use in Xinjiang Uyghur Autonomous Region, China: Based on a 3 year surveillance data, 2014–2016. Journal of Infection and Public Health, 11(3), 339–346. https://doi.org/10.1016/j.jiph.2017.09.021 44 University of Ghana http://ugspace.ug.edu.gh APPENDIX Appendix i: Participant Information Sheet SCHOOL OF PUBLIC HEALTH, COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON Research Title: FACTORS ASSOCIATED WITH ANTIMICROBIAL SELF- MEDICATION IN BIRIM CENTRAL MUNICIPALITY. Introduction: My name is ANITA ESTHER ASAMOAH, a graduate student of University of Ghana, School of Public Health. I am carrying out a research to know the prevalence of antimicrobial self-medication in Birim Central Municipal in partial fulfillment for the award of a post-graduate degree in Public Health. All details of this sheet and the consent form will be explained. Background: Antimicrobial resistance is a global threat now and improper use of antibiotics has been seen to be a leading cause of increased resistant strains of bacteria. Self-medication is the use of medicines without prescription from a medical personnel and this is due to various factors of which this study will unravel. Purpose of study: The purpose of the study is to know the prevalence of antimicrobial self- medication and the common symptoms that lead to self-medication. Compensation: You will be compensated for your time for agreeing to participate in the study. The interview will take 15 – 20 minutes. Benefit: The information will be used to the benefit of the community on the National Action Plan stewardship in Ghana. 45 University of Ghana http://ugspace.ug.edu.gh Potential Risk or discomfort: Participating in this study is voluntary and you can withdraw at any point at your own discretion. Some questions too might be embarrassing and you may choose not to answer. Voluntary participation: Participation in this research is completely voluntary and you can withdraw at any point without having to explain and your responses can be reviewed at the end of the interview. Confidentiality: Any information you share with me will not be disclosed to anyone except the research team and it is solely for academic purpose but could be published at some point. Your name will not be mentioned in any part of the literature. Provision of information and consent form: A copy of the information sheet and consent form will be given to you after you have understood and signed or thumb printed to take home. Contact for additional information: Any questions about this research can be directed to me, Anita E. Asamoah on 0544737389 HANNAH FRIMPONG (Mobile: 0243235225) GHS- ETHICAL REVIEW COMMITTEE and DR. ADOLPHINA ADDO-LARTEY (Mobile: 0544132970) PROJECT SUPERVISOR UNIVERSITY OF GHANA. 46 University of Ghana http://ugspace.ug.edu.gh Appendix ii: Consent Form PARTICIPANT’S STATEMENT I, ___________________________ after thorough explanation in the language I understand from the principal investigator and or translator has understood what the study is about and willing to participate voluntarily. I am aware it is for academic purpose. ENGLISH TWI Signature / Thumb print ____________________ Date ________________ TRANSLATOR’S STATEMENT I certify that the benefits, risk and nature of the study were translated to the participant in clear vernacular understood by him/her. All questions were answered and the participant has agreed voluntarily to take part in the study. Name of translator ____________________ Signature________________ Date ___________ DECLARATION BY WITNESS (IF PARTICIPANT CANNOT READ) I was present when the benefits, risks and nature and purpose of the study were read to the participant and agreed to voluntarily participate in the study. Name ___________________ Signature ____________________ Date ___________________ PRINCIPAL INVESTIGATOR’S STATEMENT AND SIGNATURE I certify that the participant has been given thorough explanation and has accepted to participate knowing fully well all the information on the participants’ sheet. Name ________________ Signature _________________ Date _______________ 47 University of Ghana http://ugspace.ug.edu.gh Appendix iii: Questionnaire QUESTIONNAIRE FOR RESPONDENTS This is a study on Factors Associated with Antimicrobial Self-Medication in Birim Central Municipal of Eastern Region. All information you provide is confidential and so no name is REQUIRED and signing of the consent form is compulsory please. A. Socio-demographic characteristics 1. Age as at last birthday ----------------- A1 2. Gender M ______ F ______ VARIABLE RESPONSE CODE 3 Marital status 0) Single A2 1) Married 2) Cohabiting 3) Divorced 4) Widowed 4 Educational status 0) Primary A3 1) JHS 2) SHS 3) Tertiary 4) None 5 Occupational 0) Student A4 status 1) Not employed 2) Govt. employee 3) Trader 4) Farmer 5) Gets support from relatives 48 University of Ghana http://ugspace.ug.edu.gh B. Antimicrobial self-medication 1. When was the last time you were sick? B1 Currently 3 months 6 months 9 months More Others ago ago ago than 1 specify year 2. When you were sick where did you go for treatment? B2 Hospital Pharmacy / Drugstore Traditional herbalist Drug hawkers Others specify 3. When was the last time you used an antibiotic, antimalarial, antifungal or anthelminthic? B3 Currently 3 months 6 months 9 months More Others ago ago ago than 1 specify year 4. Why did you choose the above place in question 2 for treatment? B4 Cost Long waiting time at facility Less expensive I like the workers or persons Others specify 5. Was it prescribed by a physician? Yes No B5 6. If yes, did you complete the course or follow the dosage? Yes No B6 7. If No, how did you know the type of antimicrobial to buy? B7 Previous prescription Suggestion from a friend Others specify 8. Have you ever self-medicated for your child or elderly family member? Yes No B8 9. If yes for above how old? _________ B9 49 University of Ghana http://ugspace.ug.edu.gh 10. Why do you self-medicate with antimicrobial? B10 Minor illness / Nothing serious Long waiting time at clinic High cost of medical consultation Previous experience with symptoms Others specify 11. Have you ever taken antibiotics from anyone when sick? Yes No B11 12.Where do you mostly get your antimicrobial from? B12 Buy from a pharmacy in the district headquarter (Akim Oda) From the village drug store Left over medication From the hospital (private / govt.) Others specify 13. What are the names of the antimicrobial you normally buy /use without prescription? B13 Metronidazole (Flagyl) Amoxicillin Ampiclox Tetracycline Co-trimoxazole De-wormer Any type of ACTs / Quinine (Malaria medicine) Ketoconazole / Flucloxacillin (alias Cross tablet) Others (Please specify) 14. What are the common symptoms that make you self-medicate? B14 Cold, catarrh and cough Dental pain (kaka) Skin sore Ear, nose, throat pain Diarrhea Eye infection (e.g. Apollo) Menstrual pain and vaginal discharge To clear hang-over of alcohol (white) Pain when urinating To clear my body system Acne Others specify (write below) 50 University of Ghana http://ugspace.ug.edu.gh Penile or Breast pain and or discharge C. Individual reasons and knowledge 1. Do you have a valid health insurance card? Yes No C1 2. Why do you prefer to buy antibiotic rather than go to a hospital? C2 No money Expensive consultation fee No time The NHIS card does not cover some drugs Nurses are rude so I don’t like them The hospital is far but the drug store is near Others specify 3. Do you have any idea of what happens when antimicrobial is under used, over used or misused? Yes--- No--- C3 4. If yes to above, which best explains your idea or understanding? C4 Bacterial resistance Adverse effects Prolonged treatment Increased cost Others specify 5. Have you ever had an adverse reaction from any antimicrobial? Yes No C5 6. What were the reactions? Tick more if appropriate C6 Nausea Vomiting Diarrhea Rashes Drug resistance Others specify 7. Do you always check the expiry date of these drugs? Yes No C7 8. What do you think happens when you take too much of antibiotics? C8 Nothing happens I do not know It clears the infection 51 University of Ghana http://ugspace.ug.edu.gh It may not fight against infection well again Others specify 9. Do you think you can treat common cold with antibiotics? C9 Yes I can Not sure No I cannot Others specify 10. How many times did you treat yourself with antimicrobial in the past one year? C10 Once Twice Thrice Four times More than five times Others specify 11. When do you normally stop taking antibiotics? C11 After a few days regardless of outcome After symptoms disappear A few days after recovery After the antibiotics ran out At the completion of the course After consulting a doctor/pharmacist Others specify 12. What do you think about self-medication with antibiotics for self-health care? C12 Good practice Acceptable practice Not acceptable practice 13. When buying antimicrobial from a drug store how do you describe it? C13 By color By a pre-used packet 52 University of Ghana http://ugspace.ug.edu.gh Appendix: iv Ethical Clearance 53