Relationship of self-medication and antimicrobial resistance (AMR) in low- and middle-income countries (LMICs): a scoping review

Introduction

Background

The World Bank sorts countries into four categories based on the previous year’s gross national income (GNI) per capita. The categories include low-income, lower-middle-income, upper-middle-income, and high-income countries. Low-income countries are defined as those with a GNI per capita of $1,135 or less, lower-middle-income economies as those with a GNI per capita between $1,136 and $4,465, and upper-middle-income economies as those with a GNI per capita between $4,466 and $13,845 (1). Among the many challenges that low- and middle-income countries (LMICs) face is the inequality in access to healthcare (2). People in LMICs are in poor health because they cannot reach medical services in time (3). Because of this lack of medical services, alongside the high prevalence of diseases that come with it, LMICs are seeing an increase in the trend of self-medication (4) and antibiotic misuse (5).

Self-medication refers to the practice of acquiring and consuming medications without a doctor’s prescription, guidance, or supervision during treatment. This encompasses the use of leftover medicines stored at home, sharing drugs with family or friends, or buying over-the-counter (OTC) medications (4). The prevalence of self-medication globally was inconsistent, ranging from 32.5% to 81.5% (6). Some of the common reasons why people practice self-medication are their urge for self-care, sympathy for family members in sickness, lack of health services, poverty, ignorance, misbelief, overabundant drug advertisements, and availability of drugs in non-pharmacy establishments (6). Moreover, following these reasons are the primary issues linked to self-medication practices, which include adverse drug reactions, resource wastage, severe health risks that can result in death, and drug resistance, such as antimicrobial resistance (AMR) (6), one of the leading public health threats of the 21st century.

AMR occurs when microorganisms that cause infection survive exposure to antimicrobials, allowing them to grow and spread, and therefore leading to the emergence of drug-resistant microorganisms that are extremely difficult or impossible to treat with existing antimicrobials (7). Antimicrobials are therapeutic substances used to prevent or treat the growth of infectious microorganisms. They include agents such as antiseptics, antibiotics, antivirals, antifungals, and antiparasitic (8). In this review, however, focus was given to antibiotics.

AMR is said to be the leading cause of death around the world, killing 1.27 million directly, and 4.95 million indirectly, worldwide, with the highest burdens in low-income settings (9). Statistically, the same study found that approximately 4.95 million deaths were associated with AMR in 2019, of which 1.27 million were attributable to bacterial AMR (9). With the current death toll, it is estimated that by 2050, 10 million people will die each year due to AMR at a cumulative cost to global economic output of 100 trillion USD (7).

The World Health Organization (WHO) has affirmed that improperly using antibiotics without proper indication, administering wrong dosages, incorrect treatment duration, late or absent downscaling of treatment, poor adherence, and the use of substandard antibiotics are associated with self-medication with antimicrobials (SMA) (10) which later on contributes to AMR (11). The WHO’s first global report on antibiotic resistance estimated that 80% of antibiotics are used outside official healthcare facilities, of which 20–50% of these are used inappropriately in LMICs (12). Specifically, a study found that the prevalence of SMA in Africa ranged from 12.1% to 93.9%, with Western Africa having the highest reported prevalence (70.1%) followed by Northern Africa (48.1%) (13). Additionally, one major factor in treatment failures and the development of drug-resistant strains of typhoid in Pakistan is self-medication aided by poor access to healthcare facilities, among others (14).

Despite the abundance of studies about SMA and AMR in LMICs, continuous research about them remains crucial as both SMA practices and AMR are not static. Instead, they are continuously evolving over time due to factors such as changes in healthcare policies, availability of medications, and public awareness. Furthermore, most of the available studies focus on a single region or country considered an LMIC, only few compare and contrast SMA and AMR on the LMIC as a whole. Given that LMICs are highly diverse, prior studies may not fully represent these differences.

Objectives

This scoping review aims to study the prevalence of self-medication and AMR in LMICs as reported in existing journals screened using inclusion and exclusion criteria. Specifically, the study aims to answer the following:

• Assess the contribution of multidimensional poverty to antibiotic misuse and AMR in LMICs;
• Assess the situation of SMA in LMICs, particularly its prevalence and the common antibiotics used in the self-medication process;
• Assess the factors contributing to SMA practices, specifically cultural, socioeconomic, and healthcare-related factors.

We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-184/rc).

Methods

The scoping review was patterned in reference to the Joanna Briggs Institute methodology template for scoping reviews as a foundational guide. The main structural components of the template were adopted to ensure consistency and comprehensiveness. However, the template was not used in its entirety or without modification. Instead, the template was tailored and adapted to these components to better align with our study’s specific objectives and requirements.

Database details

PubMed

PubMed is a complimentary resource designed to aid in the search and retrieval of biomedical and life sciences literature. The PubMed database houses over 37 million citations and abstracts of biomedical literature. The citations in PubMed mainly originate from fields such as biomedicine, health, life sciences, behavioral sciences, chemical sciences, and bioengineering. PubMed allows users to search across several National Library of Medicine (NLM) literature resources, including:

• MEDLINE: the largest part of PubMed consists primarily of citations from journals selected for MEDLINE; articles indexed with Medical Subject Headings (MeSH) and curated with funding, genetic, chemical, and other metadata.
• PubMed Central (PMC): a full-text archive that includes articles from journals selected by NLM for archiving (both current and historical) and individual articles archived to comply with funder policies.
• Bookshelf: a full-text archive containing books, reports, databases, and other documents relevant to biomedical, health, and life sciences.

Embase

Embase is a comprehensive source for medical literature, offering relevant and up-to-date results derived from the Emtree indexing of full-text content and the use of specialized search terms. It facilitates the use of the PICO (Population, Intervention, Comparison, and Outcome) method for searches, enabling users to quickly develop advanced queries to explore deeply indexed content. It allows for the creation of precise, high-recall queries through full-text indexing using the Emtree thesaurus. With millions of records updated daily, Embase provides extensive coverage of biomedical literature, including content not available in MEDLINE. Users can construct advanced searches with multiple query options and automatically convert PubMed searches into Embase format. Additionally, Embase supports evidence-driven searches by allowing users to add terms and synonyms from Emtree and preview the results of altering the search scope.

Scopus

Scopus is a reliable, comprehensive, and multidisciplinary abstract and citation database. Its artificial intelligence-powered tools help identify emerging trends and accelerate research by navigating vast amounts of information. This allows researchers to gain a deeper understanding of topics, generate new insights, and improve research experience. Scopus also provides superior coverage of emerging markets, offering access to high-quality research from developing countries not found in other databases. It delivers precise citation results and detailed author profiles, supporting informed decision-making.

Cochrane

Cochrane generates authoritative and reliable information by gathering and summarizing research evidence to support informed treatment decisions. It produces trusted, timely synthesized evidence addressing key health and care questions and advocates for evidence-based health and care. Cochrane prioritizes evidence that aids those in greatest need, guided by its scientific strategy.

Google Scholar

Google Scholar offers a straightforward method to extensively search for scholarly literature across various disciplines and sources, including articles, theses, books, abstracts, and court opinions from academic publishers, professional societies, online repositories, universities, and other websites. It ranks documents similarly to researchers, considering the full text, publication source, authorship, and citation frequency and recency in other scholarly works.

National Institutes of Health (NIH)

The NIH is a prominent government agency dedicated to medical research, with a mission to support a wide range of studies to advance knowledge and translate discoveries into practical applications. the NIH offers an extensive database, including PubMed, which houses biomedical literature and MEDLINE citations; ClinicalTrials.gov, a registry of clinical studies; and NIH RePORTER, which provides access to reports and data on NIH-funded research activities.

Search strategy and selection criteria

The search strategy aimed to locate published articles from the aforementioned databases. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search strategy for reporting the names of the relevant databases/information sources (see online table available at https://cdn.amegroups.cn/static/public/jphe-23-184-1.pdf). The search strategy, including all identified keywords and index terms, was adapted for each included database and/or information source. The reference list of all included sources of evidence was screened for additional studies. References to systematic reviews on similar topics were included in the study.

The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search strategy for reporting the names of the relevant databases/information sources. The search strategy includes all identified keywords and index terms adapted for each included database and/or information source. Articles that answer or provide insight to at least two research objectives and are in line with the inclusion and exclusion criteria were selected to be included in the study. The criteria shown in Table 1 were created to screen and choose literature eligible for the review based on the objectives.

From the aforementioned criteria, the search strategies shown in Table 2 were used to identify and gather relevant literature in line with the objectives of the study.

Literature search

Inclusion criteria

This review encompasses studies meeting specific inclusion criteria, including those with documented evidence of self-medication and AMR. Studies demonstrating a discernible relationship between self-medication practices and AMR are also considered. The scope extends to studies that assess the impact of self-medication on the development and spread of AMR, specifically on investigations conducted in LMICs. Furthermore, only studies conducted within the past 11 years [2013–2023] are included to ensure relevance and currency.

Exclusion criteria

To maintain the precision and relevance of this review, studies published in 2012 and earlier are excluded. Additionally, studies presenting evidence of prescribed medication usage and those needing more data regarding the relationship between self-medication and AMR are excluded from the analysis. Furthermore, studies conducted outside the context of LMICs are not considered within the scope of this review. These exclusion criteria are implemented to streamline the review’s focus and enhance the quality of the findings.

Study selection

The selection of studies for this scoping review followed a systematic and transparent process guided by the outlined eligibility criteria in Table 1. Predefined eligibility criteria were followed to systematically identify articles that met the scope of the scoping review. Studies were screened by title, abstract, and full-article screening to identify articles that met the scope of the scoping review. The group reviewed titles from the selected databases, paying close attention to relevant keywords, as outlined in Table 2, and then exported eligible titles to Google Drive for further review. To assess the relevance of articles, reviewers applied eligibility criteria during the subsequent abstract screening stage. The reviewers then examined the articles that passed the abstract screening at the full-article screening stage. This systematic approach identified a comprehensive set of studies for inclusion in the scoping review. Figure 1 shows the schematic representation of the process of study selection.

Figure 1 Schematic representation of study selection. AMR, antimicrobial resistance; LMICs, low- and middle-income countries.

Data extraction

The screened articles were thoroughly read and understood to allow efficient data extraction and article characterization. A full-text review was performed to gather the information necessary to answer the objectives extracted by using a standardized extraction sheet, which is composed of the following domains: author and year, objectives, sample characteristics, study design, data collection and instruments, factors and prevalence of SMA or AMR, common types of antimicrobial drugs used, and the study’s key findings. The extraction sheet was used in the online table (available at https://cdn.amegroups.cn/static/public/jphe-23-184-1.pdf).

Collating and summarizing the findings

The articles were collected to recognize the relationship between self-medication and AMR, and the findings were summarized. From the data extraction process of the full-text articles, study characteristics, methodologies, key findings and population involved were assessed to identify relevant and recurring themes present in relation to the research objectives. Discussions and key findings in the articles were described, as well as trends and phenomena, presenting themes that were prevalent and common among reviewed articles observed using the extraction sheet. The identified themes were used to answer the research objectives. The following themes are identified:

• Current status of AMR and prevalence of SMA;
• Common antimicrobials used for self-medication;
• Cultural, socioeconomic, and healthcare-related factors influencing SMA;
• Contribution of multidimensional poverty to antibiotic misuse and subsequent AMR in LMICs.

Then, the search strategy made was applied in the database selected. The studies were screened by charting relevant data such as the research design, objectives, sample characteristics, data collection methods and instruments, and key findings (see online table available at https://cdn.amegroups.cn/static/public/jphe-23-184-1.pdf). Each member of the group, composed of five members, reviewed around 5–6 full-text articles and charted relevant data as to aid the screening process for each study’s eligibility to be included in the review. After screening, all members contributed to checking the consistency and redundancy of the data gathered. Data that were charted in the extraction sheet (see online table available at https://cdn.amegroups.cn/static/public/jphe-23-184-1.pdf) were assessed if they fit the inclusion and exclusion criteria by the researchers that were assigned to review the article. Those that deviate from the set criteria were not included in the review.

Results

Characteristics of the included studies

The search strategy identified 119 studies, all underwent title and abstract screening for eligibility. A total of 28 articles were retrieved and again screened based on their full-text version. This screening excluded three articles, leaving 25 articles for the scoping review (Figure 1). These studies were published in the years 2013 to 2023 and were executed using methodologies such as cross-sectional study (15-25), mixed-methods approach (5,26-28), scoping review (29), systematic review and/or meta-analysis (13,28,30-34), qualitative study (35), literature review (36,37), and situational analysis (38). The number of participants in the included studies ranged from 30 to 25, 274 participants. Moreover, the data of these studies were collected through questionnaires (5,15,17,19-23,25,27,29), interview (5,18,24,27,35,38), illness recall method (26), two-phase mapping approach (29), literature search and screening (13,30,31), mixed studies review (32), and systematic review protocol and random effects meta-analysis (33). Furthermore, they were undertaken on different LMICs such as Indonesia (15,31), India (28,31,35), Ghana (21,26,27), Pakistan (25,29,34), Nigeria (17,34), Africa (13,27,30), Bangladesh (27,32), Mozambique (24,27), Vietnam (27,38), Thailand (27), Kenya (5), Tanzania (5), Uganda (5), Cambodia (18), Democratic Republic of Congo (18), Nepal (18,34), Sudan (18), Lebanon (19), Cameroon (20), Guatemala (22,34), Anuradhapura (23), Laos (34), Sri Lanka (34), and Yemen (34). Detailed characteristics and an overview of the findings of each study are shown in the online table (available at https://cdn.amegroups.cn/static/public/jphe-23-184-1.pdf).

Contribution of multidimensional poverty to antibiotic misuse and subsequent AMR in LMICs

Theme 1: effects of poverty on medication handling

Poverty significantly influences how individuals manage and utilize medications, often leading to the practice of self-medication. Three key studies provide a comprehensive view of this phenomenon, highlighting the underlying factors and the disparities across socio-economic groups. Several studies investigated self-medication practices, identifying that financial constraints and time pressures are primary motivators (5,15,16,27). Individuals with chronic illnesses often self-medicate because they perceive little benefit in repeated medical visits when the treatment remains unchanged. For those experiencing mild illnesses, the costs associated with healthcare, including direct expenses and lost wages, deter them from seeking professional medical advice. The studies found a high prevalence of self-medication in urban slums, with 34.5% of respondents across all age groups engaging in the practice. These revealed that self-medication is more common among the illiterate and those with education levels beyond middle school. Education was identified as a significant factor influencing self-medication behaviors, with those having higher educational attainment being less likely to self-medicate.

The study of Torres et al. explored the socioeconomic disparities in self-medication practices. Their findings indicated a higher prevalence of self-medication among individuals from lower socio-economic backgrounds. This group often has less knowledge about proper medication use, leading to a greater likelihood of non-prescribed antibiotic (NPA) utilization. The study emphasizes the need for educational programs tailored to improve public knowledge and promote responsible medication practices. The association between low socioeconomic status, deficient knowledge, and increased self-medication highlights the critical need for targeted interventions to mitigate these risks (34).

The sources of advice for self-medication among different socio-economic groups in Guatemala City has also been examined (22). They found that individuals from lower socio-economic backgrounds frequently sought advice from family or friends, whereas those from higher socio-economic backgrounds were more likely to consult pharmacy technicians, although they also relied on family advice. The findings suggest that higher socio-economic status individuals recognize the value of professional advice, setting a foundation for policy development aimed at enhancing the role of pharmacists in guiding self-medication practices (22).

Collectively, these studies underscore the profound impact of poverty on medication handling. Financial constraints and limited access to professional healthcare drive lower socio-economic groups to self-medicate, often relying on informal sources of advice. The higher prevalence of self-medication among these groups reflects broader systemic issues, including inadequate education and healthcare infrastructure. Addressing these challenges requires comprehensive educational initiatives and policy interventions to promote safe and informed medication practices, particularly among vulnerable populations. Shown in Table 3 are the studies that discussed the impact of poverty on the healthcare of LMICs.

Theme 2: AMR in the prevalence of self-medication

The incidence of self-medication and AMR are strongly related, creating a disturbing loop that increases the risk of using antibiotics that would be deemed ineffective (18). The analysis of the selected studies reveals a significant link between socio-economic status and the prevalence of self-medication, contributing to the growing concern of AMR.

It was found that the reasons behind self-medication motivation and practices are financial constraints and time pressures (15). Individuals often resort to self-medication for chronic illnesses, believing that repeated visits to healthcare providers yield no new treatments. For mild illnesses, the direct costs of healthcare and the indirect costs of lost wages drive self-medication. This study highlighted a high prevalence of self-medication in urban slums, with 34.5% of respondents engaging in the practice. Notably, self-medication was more prevalent among the illiterate and those with higher levels of education beyond middle school. Education emerged as a crucial factor influencing self-medication, with lower education levels correlating with higher self-medication rates (15).

Torres et al. identified significant differences in self-medication prevalence between socio-economic groups (28). Individuals from lower socio-economic backgrounds exhibited higher rates of self-medication, largely due to insufficient knowledge and limited livelihood resources (28).

Ramay et al. explored the sources of advice for self-medication among different socio-economic groups in Guatemala City (22). The study found that individuals from lower socio-economic backgrounds often sought advice from family or friends. In contrast, those from higher socio-economic backgrounds were more likely to consult pharmacy technicians. Despite this, both groups still relied on family advice. The study highlighted a gender disparity, with women more frequently visiting pharmacies for self-medication and perceiving minimal risk in its practice. These findings indicate that individuals of higher socioeconomic status value professional advice, suggesting a potential avenue for policy development to enhance the role of pharmacists in guiding self-medication practices (22).

The pervasive practice of self-medication, particularly among lower socio-economic groups, poses a significant risk for AMR. Financial constraints and lack of access to professional healthcare drive these populations to self-medicate, often with inadequate knowledge and reliance on informal advice. This behavior contributes to the improper use of antibiotics, such as taking them for viral illnesses or skipping recommended dosages, which can lead to the development of resistant strains of bacteria (31). Antibiotics being readily available over the counter exacerbates the problem, allowing for unrestricted access and uncontrolled usage. Incomplete treatment regimens resulting from self-medication further contribute to the survival and mutation of bacteria, enhancing their resistance. Accurate diagnosis and targeted antibiotic prescriptions are impeded by the lack of expert supervision (24).

Comprehensive approaches are required to address this complex relationship, including increased access to healthcare, regulatory controls over the availability of antibiotics, increased efforts to raise public awareness and educate the public, and the promotion of responsible antibiotic use to reduce the risks associated with AMR (29).

The situation of SMA in LMICs

Theme 1: prevalence of SMA in LMICs

SMA is a common practice in LMICs. Studies recorded a prevalence rate of 91.4% among university students in Nigeria, 78.18% among Indian dental students, 19.1% in Lithuania, and 22% in Turkey (34). In another study, the prevalence of SMA in Africa ranges from 12.1% to 93.9%, with Western Africa having the highest reported prevalence of 70.1%, followed by Northern Africa with 48.1% (13). Similarly, it was also revealed that 56.2% of 136 first-year students of Kwame Nkrumah University of Science and Technology, Ghana, purchased antibiotics without a prescription, and 78.3% of them expressed satisfaction with the outcome (21). Other studies reported a prevalence rate of 70% of 418 respondents in Guatemala City (22), 2.6% in women, and 2.8% in men out of 384 dwellers of Anuradhapura (23).

Theme 2: common types of antimicrobial drugs used in self-medication practices

In LMICs, SMA, including a wide range of commonly used drug classes, is a significant public health concern. Among cell wall synthesis inhibitors, broad-spectrum penicillins like amoxicillin are especially common. According to studies, 41% of antibiotics are controlled by the WHO Watch Group, further illustrating their crucial role in antimicrobial stewardship (13).

It was found out that 78% of students studying in healthcare programs of Ghana self-medicate with amoxicillin (21), while 26.5% of people use it in sub-Saharan Africa (30). Nguyen et al. also report that amoxicillin is frequently used to treat respiratory infections in children (38). The practice extends to penicillins and leftover medicines from previous treatments in Ghana (26) and beta-lactamase-labile penicillins (18). Moreover, it was also reported that cephalosporins are used as a treatment for acute respiratory infections in children (38), while the third-generation cephalosporins are becoming more prevalent in India (31). Tetracyclines, including doxycycline, were also found to contribute significantly to protein synthesis inhibition (22,36). Other antimicrobial agents such as macrolides (18), azithromycin (29), trimethoprim/sulfamethoxazole (22,36), ciprofloxacin (18,23,29), and metronidazole (36) were also seen to be involved in self-medication practices. Shown in Table 4 are the summary of antibiotics mentioned and the corresponding literature supporting them.

Factors contributing to SMA in LMICs

Theme 1: cultural factors influencing AMR

Previous experience with antibiotics

The study conducted by Aditya et al. (15). in 2017 revealed that a significant number of respondents (51.4%) admitted to self-medicating with antibiotics without a prescription (15). The decision to self-medicate was often influenced by the respondents’ previous experiences with antibiotics, indicating a reliance on familiarity and past outcomes with the medication (15). Additionally, qualitative data from patient interviews and focus-group discussions in the study conducted by Green et al. in 2023 indicated that previous experiences with antibiotics played a role in influencing self-medication practices (5). Patients who perceived their illness symptoms as mild or moderate were more likely to refrain from consulting healthcare professionals due to their prior successful use of antibiotics (33). This self-efficacy belief among patients, rooted in previous illness experiences, significantly impacts the decision to self-medicate with antibiotics (33). Furthermore, in the study by Torres et al. in 2021, subjects reported that they practiced self-medication with antibiotics based on prior knowledge or experience, often after being prescribed by physicians in the past. Their decision to self-medicate was influenced by their familiarity with specific antibiotics they had used before, such as azithromycin tablets and cotrimoxazole cream, which led them to self-diagnose and self-treat symptoms with antibiotics instead of seeking medical assistance (24).

Cultural acceptance of self-medication

The phenomenon of self-medication, particularly with antibiotics, represents a significant public health concern globally. Research spanning multiple continents and cultural contexts underscores the multifaceted reasons driving this practice, from socioeconomic factors to cultural norms. Understanding the socioeconomic determinants underpinning self-medication behaviors is crucial, noting a pervasive cultural endorsement of self-medication practices within communities (15). This stance is reinforced by findings from Ahiabu et al., which illustrate the cultural nuances of self-medication, evident in practices where antibiotics and traditional remedies are combined for therapeutic purposes, including wound healing (26). Such practices not only reflect a cultural assimilation of biomedical and indigenous knowledge systems but also highlight a critical gap in public health knowledge regarding the appropriate use of antibiotics.

Expanding this discourse, the commonplace nature of NPA usage encompasses countries in Africa (Mozambique, Ghana, South Africa) and Asia (Bangladesh, Vietnam, Thailand) (27). The documented lack of awareness about the necessity to complete antibiotic courses and the potential harm of indiscriminate antibiotic use underscores a critical need for robust public health education. Similarly, in different jurisdictions such as Jordan and Greece, the historical efficacy drives the self-administration of antibiotics, even in contexts where primary healthcare services are accessible (19).

Moreover, investigations in developing settings like Cameroon reveal that limited access to formal healthcare services and prevailing cultural beliefs foster a reliance on self-medication (20). This insight is paralleled by research in rural Tanzanian contexts, further evidencing the cultural acceptance and practice of self-medication (5). Moreover, compelling evidence of self-medication practices among health trainees and within diverse socioeconomic groups in Guatemala City were seen, suggesting a cultural normalization and perceived empowerment derived from self-medicated care (21,22).

Conversely, Rathish et al. offer a contrasting perspective from Sri Lanka, where antibiotic self-medication is less prevalent yet driven by the convenience of access for minor ailments, hinting at a nuanced cultural acceptance (23). On the global landscape of self-medication, delineating prevalent practices, motivations, and sources of information that inform self-medication in countries ranging from Nigeria to Nepal and Ethiopia, emphasizing the global and culturally ingrained nature of this phenomenon (28,34).

Finally, Nguyen et al. highlight a concerning trend of unsupervised antibiotic use in pediatric care within the community of Ba Vi, with a notable shift in antibiotic preference over time, indicative of evolving practices in self-medication (38). This trend is mirrored in various African countries, spotlighting the array of factors influencing self-medication practices, including varied population demographics from university students to civil servants (13). Shown in Table 5 are the discussed main cultural factors affecting self-medication and the corresponding literature supporting them.

Theme 2: socio-economic factors influencing AMR

Sociodemographic factors contribute significantly to AMR patterns. Infections are more common in young and older adults aged 18 to 40 years, often leading to higher antibiotic use (32,34). Cultural practices and behaviors, such as the widespread use of antibiotics without prescription in some societies, can also exacerbate antibiotic resistance. In addition, the cultural belief that antibiotics heal all diseases influences how attitudes and behaviors are shaped by social representations of drugs (24). Gender roles and healthcare-seeking behaviors may also influence a patient’s exposure to antibiotics and adherence to them. It is more common for people to select medicines and use them in self-treatment without seeking professional advice, and it may depend on their understanding of disease symptoms and pharmaceutical effects (26,29).

Regarding socio-economics, healthcare access remains crucial (5). Health disparities, such as those that affect low-income communities or regions with limited healthcare infrastructure, can lead to delayed or inadequate treatment, leading to resistant strains (28,35).

Education appears to be a significant socioeconomic factor influencing AMR (13,22). Lack of health literacy may result in inappropriate self-medication or premature discontinuation of prescribed courses (19,33). Antibiotic use should be promoted responsibly through education, both targeted at healthcare professionals and the general public.

In addition to economic factors, antibiotic consumption is influenced by patients’ financial circumstances, as patients in strained financial circumstances might self-prescribe or buy antibiotics without professional guidance (38). In addition, antibiotic availability and pricing can be affected by the pharmaceutical industry (25).

Lastly, the socioeconomic structure of agricultural settings is also critical. Using antibiotics for growth promotion or disease prevention in livestock can result in suboptimal animal husbandry practices by small-scale farmers with limited resources (37). AMR is further complicated by agricultural use, which increases the number of resistant bacteria and genes in the environment. Shown in Table 6 are the discussed main socioeconomic factors affecting self-medication and the corresponding literature supporting them.

Theme 3: healthcare-related factors influencing AMR

AMR in LMICs is found to be influenced by healthcare-related factors that are generally classified into three categories as shown in Table 7: access to healthcare, structural challenges in healthcare systems, and quality of healthcare.

Access to healthcare

Some of the factors that influence a patient’s decision to self-medicate with antibiotics are the long waiting time to access healthcare facilities and perceived drug unavailability at health facilities, limited range and poor-quality services offered at facilities within rural communities, and poor transportation network limiting access to healthcare (26,28). In addition to these, the problem of professional healthcare workers’ unavailability in medicine outlets was also seen as a contributing factor as to how patients often receive inaccurate drug information (26).

However, the provision of too much access to drugs also leads to AMR as patent medicine vendors (PMVs) are found to be promoting self-medication to the community by providing an abundance of drugs without the advice and prescription from the physicians (17). This is seconded by Torres et al. where participants from Maputo City, Mozambique admitted that SMA is evident because there is an easy access to antibiotics in most private pharmacies in their area (28), and Do et al. stating that having access to drug stores for health care and for information increases household antibiotic use (27). Additionally, the consumers of drugs in NCT Delhi, India rely over pharmacies as the first line of treatment in case of minor ailments of which the easy accessibility of these retail pharmacies makes it easier for them to seek antibiotics (35). When these consumers were asked for the reason as to why they seek antibiotics directly from the pharmacies, their major reasons are limited public healthcare services and costly private healthcare services (35).

Structural challenges in healthcare systems

Weak health delivery systems and poorly regulated pharmaceutical sectors are seen to be factors of SMA leading to AMR. These poor regulations encourage the widespread sale of prescription medicines, including antibiotics, without physician’s prescription (26). For instance, an overall pooled estimate of 69% of antibiotic request in Sub-Saharan African countries, were dispensed without prescription, 51.4% of 146 respondents from Sayang Village, West Java Indonesia are using antibiotics without prescription (15), 83% of antibiotic transactions in pharmacies and 100% transactions in rural medicine outlets in eastern and southern regions of Ghana were without prescription (26), 62.9% of the patient-respondents of Mboppi Baptist Hospital, Duola, Cameroon bought antibiotics without prescription from pharmacists while 18.9% of them purchased it from chemists, otherwise known as “roadside drug vendors” (20), and 59.9% of PMVs from Sokoto Metropolis, Nigeria were found to always sell antibiotics to clients without prescription (17).

Moreover, there are also countries in LMICs where little to no strong pharmaceutical regulations about prescription drugs exist. An example is Guatemala, where there is no law requiring a pharmacist to be present in the pharmacies, nor requiring prescription for antibiotic use—both of which leads to irrational use of antibiotics and prevalence of AMR in the country. Some of the reasons behind the absence of such regulation were identified by the study as (I) the authorization of unregulated vendors to sell antibiotics to maintain reasonable access to it and (II) the competition among the pharmacy chains (22).

Furthermore, in instances where regulations and guidelines are present, lack of awareness to those regulations can also bring consequences. In the National Capital Territory (NCT) of Delhi, India, antibiotic consumers were unaware of existing directives for the sale and purchase of antibiotics which come under prescription drugs, therefore they often seek antibiotics without a prescription (35). Similarly, in some hospitals in sub-district of Bangladesh, either their physicians are unaware of the treatment guidelines or there are no standard treatment guidelines available for them to follow resulting in the common prescription of antibiotics to treat fever, common colds, and other minor ailments (32).

These studies therefore strengthened the claim of Ahiabu et al. (26) and Aslam et al. (29), that the problem of SMA can be traced to inconsistencies in public health policies about the role of medicine outlets in healthcare delivery.

Quality of healthcare

Despite high levels of knowledge on the cause and prevention of AMR, practices favorable to its development can still be widely evident in a community as in the case in Sokoto Metropolis, Nigeria (17). It was found that 34% of the PMVs never washed their hands before dispensing antibiotics to patient, 40.6% never counsel clients on the need to complete recommended dose of antibiotics, 15.2% never checked expiry dates before selling it to their clients, 24.4% always purchase drugs in bulk from the open market instead of pharmaceutical companies where quality is assured, and 45.7% of them never screen purchased drugs for counterfeit medicines (17).

Moreover, low quality of drug counseling was also seen as the reason as to why leftover medicines from previous treatments, poor adherence, and low public awareness of antibiotic use and misuse are seen in communities (26). A worse case was seen in NCT Delhi, India, where untrained non-pharmacist staff are the ones who often deal with patients (35). This is seen to be of major concern as these staff are not aware of AMR and the appropriate use of antibiotics to avoid such, therefore, are not qualified enough to ensure that patients are knowledgeable about their medicines before they leave the pharmacy. For instance, an evident consequence of lack of drug counseling by healthcare professionals was seen in the community of Sayang Village, West Java Indonesia, where patients tend to stop antibiotic medication after symptoms subsided due to lack of knowledge (15).

It was also seen that the quality of the primary care of infectious diseases are limited by the tight resources most institutions have. Specifically, this makes diagnostics difficult and less accurate as most hospitals find expensive and high-quality infrastructure for infectious disease diagnostics not profitable. This, in addition to high workloads and staff shortages, are considered as important drivers for the frequent inappropriate antibiotic prescriptions.

Discussion

Main findings

Across the reviewed articles, it was found that poverty in LMICs increases individual’s likelihood of leaning towards self-medication in hopes to cure their illness while avoiding the costs and time associated with professional healthcare visits. One of the reported effects of poverty in LMICs, as found on the articles, is self-medication particularly, with antibiotics. Having this said, SMA was long known to be a major driver of AMR. In the reviewed articles, the following reasons were seen as to how SMA leads to AMR: the use of antibiotics without proper guidance from physicians, alongside the insufficient knowledge of individuals on proper use of antibiotics often leads to improper use of antibiotics; self-medication often leads to incomplete or incorrect dosages, therefore, contributing to the survival and mutation of bacterial, enhancing their resistance; and the usage of antibiotics without proper diagnosis may further contribute to the development of resistant bacterial strains.

Furthermore, it was found that SMA is common in LMICs, but with substantial variations across regions and populations. However, despite these variations, it is observed that respiratory problems, fevers, and gastrointestinal problems were the most common symptoms prompting self-medication. According to the reviewed articles, among the many antimicrobials available in the market, the classifications of antimicrobials most commonly used for SMA includes cell wall synthesis inhibitor (broad spectrum penicillin and cephalosporin), protein synthesis inhibitor (tetracycline, macrolide, and trimethoprim/sulfamethoxazole), and DNA synthesis inhibitor (fluoroquinolone and nitroimidazole). Approximately 65.5% of these drugs were purchased from pharmacies, followed by leftovers and drug shops. There were 12 studies that found that self-medication was associated with inappropriate drug use practices such as not completing the dose and sharing medicines within family relatives and friends, which is a subject of concern.

The scoping review also looked into the common factors leading to SMA and AMR across the reviewed articles. The observed common cultural factors that affect SMA in the articles are the patient’s previous experience with antibiotics and the cultural acceptance of SMA. Furthermore, the common socioeconomic factors influencing SMA seen across the articles includes gender, educational levels, income disparities, and level of awareness regarding SMA and AMR. Lastly, access to healthcare, structural challenges in healthcare systems, and the quality of healthcare, were seen as the recurring healthcare-related factors affecting AMR in LMICs.

Situation in wider literature

This scoping review aligns with broader literature on self-medication and AMR in LMICs. It has been repeatedly demonstrated that antibiotics are used without prescription, due to factors such as easy access to drugs, a lack of regulatory enforcement, and public misconceptions. Numerous studies have shown that university students and the general public self-medicate with antibiotics, which supports the findings of this review.

As a major contributor to AMR, pharmacies are also critical to the dissemination of antibiotics, often without proper prescriptions. Other studies have also reported that pharmacies and drug shops are common sources of antibiotics, mainly because there is no strict regulatory framework and there is a high demand for quick and convenient healthcare solutions. Moreover, leftover drugs and antibiotics are commonly shared among family and friends, emphasizing the widespread nature of these practices and their contribution to AMR.

A number of global studies have also identified economic constraints, healthcare accessibility problems, and cultural practices as significant factors driving antibiotic misuse, supporting the socioeconomic determinants of self-medication observed in this review. Consequently, self-medication becomes a coping mechanism for economic hardships and inadequate healthcare infrastructure in a complex landscape.

Limitations of the study

Self-medication and AMR in LMICs are the subjects of this scoping review, which has several strengths that make it significant and reliable. A comprehensive search strategy with clearly defined inclusion and exclusion criteria is one of the most notable strengths of the study. The use of multiple databases, such as PubMed, Embase, Google Scholar, and the NIH, ensures a thorough exploration of relevant literature. A 11-year publication time frame [2013–2023] also enhances the relevance and currency of the study. Incorporating rigorous study selection stages and independent screening lends credibility to identifying pertinent articles. Although only published articles were used, there are limitations, such as publication bias. Additionally, the scoping review may face challenges in synthesizing diverse study methodologies, potentially impacting the analysis’s depth. Despite these limitations, the study’s strengths contribute to its value in providing a comprehensive overview of self-medication and AMR in LMICs.

The study also adds a useful layer of specificity to the findings by examining self-medication patterns in detail, including the symptoms commonly treated with antimicrobials, as well as the types of antimicrobials used most frequently. To curb SMA, there is a need to have a nuanced understanding that aids in identifying critical intervention points. Additionally, self-medication is caused by socio-economic and cultural factors, which illustrates that the problem is multifaceted and that solutions should be equally comprehensive. Furthermore, pharmacies and leftover drugs have been identified as primary sources of antimicrobials, which underscores the need for targeted regulatory measures. Its practical relevance is enhanced by these insights, which offer policymakers and public health officials actionable information for the design of more effective interventions against AMR in LMICs.

Conclusions

By using defined search strategies and keywords, the study was able to focus on literature across multiple databases that have been published within the last 11 years. The mentioned literature demonstrated evidence of SMA and AMR. Having this said, the current study was able to identify several contributing factors to self-medication practices. For instance, people aged 18–40 years tend to use more antibiotics than the other age groups. Additionally, antibiotic use is also influenced by cultural practices and beliefs that antibiotics heal all diseases, therefore, often leading to self-treatment without seeking professional advice. Lack of health literacy, especially about antibiotics and antibiotics use, and financial constraints were also seen as factors leading to SMA and, ultimately, to AMR.

Moreover, the study also found that in some LMICs, particularly in Nigeria, even though the majority of the population was aware of the causes and risks of AMR, the practices that are favorable to its development were still being implemented and are still widely prevalent. This implies that simply educating the population is not enough to control the increasing cases of AMR. Instead, a more proactive approach must be taken, especially in the LMICs, where interventions are currently being limited by tight time and financial resources.

The results also highlight the persistent and alarming practice of antibiotic self-medication in LMICs. The widespread use of antibiotics without a prescription presents a serious risk to public health. Accessibility, cost, and health-seeking behavior are some of the elements that influence this practice, and they all point to the need for focused initiatives to address and lessen the problem. Evidence suggests that healthcare practitioners may limit self-medication and encourage responsible antibiotic usage, which is important in drug adherence. Furthermore, it is clear that self-medication habits significantly influence AMR, which heightens the worry for world health. Effective interventions are urgently needed to address the rising problem of antimicrobial self-medication in LMICs, given the strain on healthcare systems and the promotion of AMR as a result.

Researchers should conduct longitudinal studies to determine if self-medication practices lead to the development of AMR more definitively in the future. Intervention studies that test the effectiveness of different strategies in reducing self-medication rates are also needed. These include community education programs, stricter regulatory policies, and improved healthcare accessibility. Better healthcare guidance and education could also be provided by integrating technology, including mobile health platforms. For self-medication to be mitigated, governments, healthcare providers, and international organizations will need to work together to design and implement policies. Sustainable health improvements in LMICs require addressing socio-economic barriers and raising public awareness of SMA and AMR dangers through targeted campaigns.

Acknowledgments

The authors would like to thank Ellize Guilliana Javier for her primary contribution in the conception of the study. The authors would also like to express deep gratitude to the University of Santo Tomas-Faculty of Pharmacy for fostering a supportive and encouraging academic environment that was instrumental in the conception and completion of this study.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-184/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-184/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-184/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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