The result are presented below according to seven themes that emanated form the analysis process namely: a) customers’ perceived need for self-management of illness, b) customers’ understanding medicines, c) expectations and concerns when practicing SMA, d) the importance of time in the self-management of illness, e) the past successful experience with antibiotics, f) the antibiotics used for self-medication and g) the main illnesses leading to SMA.
Demographics of participants
Participants who presented purchased NPA were included men 10 (31%) and women 22 (69%) ranging in age from 19 to 67 years old. The average age was 35 years old. The researcher identified four levels of education: primary (1st–7th graders), secondary (8th–12th graders), and first degree (university graduate level). Table 1. Shows the demographic characteristics of customers with variation in age (range: 19 – 67), education level (range from primary to a university degree), and gender (with 22 women and 10 men participants). Table 2. shows the demographic characteristics of pharmacists with variation in age (range: 24 – 47), professional training and years of professional experience (range: 1 – 12).
Customers’ purchased antibiotics
During the recruitment, process participants were invited to show the medicines that they had purchased, which the researcher took note of. Together with antibiotics, some participants had purchased other medicines, such as analgesics, anti-inflammatory, and corticosteroids. The list of purchased medicines is presented below (Table 3).
The perceived need for self-management of illness
The need to take responsibility for their own health was noticed, their comments evidenced the need and right to seek cure and treatment for illness, as indicated in their sentiments:
“I just bought cotrisha (cotrimoxazole), I have to treat my cough problem“ (Customer 12).
“If I feel sick or one of my kids, I need to take care and seek a cure” (Customer 7).
“When I feel sick? It depends on the problem …but I make sure I treat myself” (FGD 2).
Understanding medicines, expectations and concerns when practicing SMA
A questions explored the participants understanding of medicines, their expectations are regarding taking antibiotics without prescription. Two participants said:
“Medicines are very important, as they treat our diseases…hmm when I take medicines I hope to recover fast” (Customer 5).
“They are goods! In fact, they (medicines) are very important after all they help to combat some pathologies that the immune system cannot itself, we take and use them willing to get rid of illness and go on with life”(Customer 1).
Participant’s concerns using NPA were assessed throughout the question: do you have any concerns and fears regarding your SMA attitude? What are your fears when you use these medicines? Despite the majority referring that they had never had problems with self-medication, two in the FGD expressed some fear related to the use of the drugs but did not express any guilty or regret taking NPA, as they were wanted to treat their conditions despite possible bad outcomes. They remembered that they had experiencing problems, such us diarrhoea and skin allergies after taking amoxicillin and cotrimoxazole tablets:
“Medicines they help, but sometimes depends on your body… I once took cotrimoxazole and got pimples and dark itching skin…but the cough disappeared” (customer, FGD2).
“we took then to became well…me, I got diarrhoea after taking these famous tablets (amoxicillin), the pharmacists said I shouldn’t take with milk or after eating yogurt”(customer, FGD1).
The time management in the self-management of illness
The time spent at the pharmacy when seeking health care plays an important role in the practice of SMA. Participant’s complaint about the long time they needed to spend in the health facilities waiting to be seen. They noted that time is a precious resource and is not worth spending many hours or the whole day, knowing that they can adopt other therapeutic itineraries, such us going to seek advice and request medicines from the pharmacy, two participants said:
“I went to the hospital with him, stayed there all day and a nurse gave a skin cream and savlon (antiseptic liquid) to wash the wounds, which did not work”(customer 9).
"Most of the times you just get to the public hospital to find out that the nurse or doctor is late, you wait forever to be assisted and when assisted you get the prescription, but they have a shortage of drugs…so you should go buy at outside private pharmacies, which is simply a good thing" (customer 17 ).
Past successful experience with antibiotics
In this study, participants often stressed that they knew about antibiotics from their own or relatives’ successful past experiences. This experience appeared to be considered when a new sickness event appears, and when individuals have to take decision on the strategies to seek health care. The following was stated by two:
"I got the prescription before when I had to seek medical appointment! Hmmm...This time I have same difficulties swallowing, but they are almost finishing so I need more of this (antibiotic- azithromycin)." (Customer 1).
"I know these tablets (amoxicillin with Clavulanic acid) I went to a doctor before…months ago (…)" (Customer 2).
According to the pharmacists, patients take advantage of physicians’ prescriptions and medical information from past experiences or other sources, such as the internet, to the point that they can request the less popular and even more potent non-prescribed antibiotics. Two pharmacists expressed:
“the internet is doing its part in this process…it looks like we are all health care professionals now, and it looks fine until you get into troubles ”( Pharmacist 3).
"Patient seeks medical help at the hospital or clinic, once, then twice, the doctor or nurse prescribes the same antibiotic for any pain amoxicillin, for any cough…cotrimoxazole, so people get confidence in a certain antibiotic..." (Pharmacist 8).
Which antibiotics were used for self-medication?
During the interviews, with the support of the national list of imported antibiotics, participants were asked to indicate or talk about antibiotics (other than the ones purchased) they have used without prescription despite having purchased NPA, two participants from the high socio-economic area denied any past use of antibiotic without prescription:
“…No, I've never used it before without the paper…I’m buying for the first time.”(Customer 18).
“Without a prescription?! I never used antibiotics, today I bought to complete the dose” (Customer14).
The remaining participants mentioned they have used a variety of antibiotics, such us amoxicillin cotrimoxazole, azithromycin, metronidazole, amoxicillin with acid clavulanic, tetracycline, doxycycline and erythromycin. As the quotes below indicate:
“I used azithromycin and (…) I used the cotrimoxazole” (Customer 10).
“I already used erythromycin once to my child…and I already used cotrimoxazole and azithromycin, yes.” (Customer 3).
‘’I ask the pharmacist for “two colours” used to treat inside wounds” (Customer 2).
"We live in a very dusty environment, so time to time we have a cough and blocked nose, I bought cotrisha (cotrimoxazole), they treat cough very well“ (Customer 17).
The list of antibiotics purchased by the participants shows that amoxicillin was the most purchased (customers), with participants requesting the simple amoxicillin, or the one combined with clavulanic acid one to treat various health conditions. This was endorsed by two customers and mentioned in one FGD, where participants confessed using amoxicillin, and amoxicillin with clavulanic acid:
“I think amoxicillin…I use a lot even for the family, yes… amoxicillin and the other white one for cough, cotrisha (cotrimoxazole).” (Customer 9).
“If you have on your list…I bought the new amoxicillin the big white tablets…I think is with acid something…It is for a respiratory problem.”(Customer 11).
“ what I see…hum…we use a lot of that amoxicillin, I see many people, friends, family using hmmm using the “two colours capsules” and now there is a better one with an acid…white one, expensive but also good...” the other participants agreed. (Customers FGD 1).
Pharmacists corroborated that the most commonly dispensed and/or sold antibiotics in a daily basis are amoxicillin 500mg, popularly known as “two colours” (presented in half yellow and half red colours), followed by amoxicillin with clavulanic acid and cotrimoxazole:
“Amoxicillin, cotrimoxazole, oh yes! The most wanted, they request much more amoxicillin in capsules with two colours” (B. Pharm).
“Hum amoxicillin for example, in one month in a high demand pharmacy mine like you dispense between 5000 to 10000 pills…it sells a lot.”(Pharm, Technician, ).
“Amoxicillin…the majority requests and purchase…” (Pharm. Technician).
“Oh cotrimoxazole! Yeah, a lot, many HIV positive customers use cotrimoxazole as a prophylactic…we do sell that and the combined amoxicillin.”(B. Pharm).
The growing prevalence of sexually transmitted infections (STI) has contributed to the increased demand for some antibiotics that were previously only known by the physicians and pharmacists. They contend that these antibiotics are well known by customers, evidencing that they have information about them, which they request for self-diagnosed problems.
“I don’t know who taught customers about azithromycin and doxicilin…but many customers request these for their reported symptoms related to STI’s”( B. Pharm).
“Amoxicillin combination with clavulanic acid always sells, but nowadays doxycycline and Azytro (azithromycin)…they request a lot.”(Pharm. Technician).
“interestingly I see some changes, some clients don’t want the common “two colours”…they now use a lot azytro (azotomycin), doxycycline, for complaints of urinary tract infection, sore throat for …yeah” (B.Pharm).
From the pharmacists’ point of view, clients are knowledgeable about even the more potent antibiotics, and suspect that they are taking advantage of physicians’ prescriptions that were previously less well known, now being requested for self-medication. Two experienced pharmacists argued:
“What I see is trending, even with the prescriptions, is azithromycin and doxycycline, and also cipro (cyproflaxin)… and I think self-medicated patients are also following that trend…maybe…” (B. Pharm).
“before it was…let me say “fancy” to prescribe amoxicillin with clavulanic acid…but now I see prescriptions of azithromycin, ciprofloxacin…then the customers are now learning and purchasing as well, laughs”(B. Pharm).
“You know azithromycin and doxycycline? There are days that I receive 4 or more patients with different prescriptions for the same antibiotic from the same prescriber… and interestingly now we can see that people are now requesting azithromycin and doxycycline for SMA…” (BPharm.).
The pharmacists admitted that they perpetuate the practice of SMA by dispensing NPA as shown in the passages below:
“We, pharmacists, know all the consequences of NPA dispensing, we know. But when you get to the position at the pharmacy as a magic trick you tend to forget all.” (BPharm.).
“The person has fever and cough or pain and comes to the pharmacy…?!! There is a concerning deliberated behaviour of self-medication…and we pharmacists we do contribute” (Pharm. Technician).
Pharmacists not only recognize the increasing practice of SMA, with customers requesting more of the recent and broad-spectrum antibiotics but noted with concern that is not only the growing attitude of self-medication, but also the wrong utilization of self-prescribed antibiotics. Their argument is that customers request antibiotic in small quantities which do not allow then to complete at least a 3- or 5-days course;
“a patient self-medicating with antibiotics, for example, accesses cotrimoxazole and take just 10 tablets for 2 days, or amoxicillin and take for 3 days…they are doing it wrong either”. (B.Pharm).
“Some customers buy 10 capsules of amoxicillin 500mg, which only takes 3 days…see it’s another problem then”. (Pharma. Technician)
Which illnesses drive the practices of self-medication with antibiotics?
All the participants expressed their intention to recover from a bad health condition as the main motive for seeking medication. They mentioned sore throat, fever, cough, vaginal discharge, eye problem, common flu, urinary infection, respiratory infection, wounds, and toothaches, as the illnesses for which they self-medicated with antibiotics. Two participants said:
“… the weather is bad so I got fever in the night and now I have cough and pain, I know these tablets (amoxicillin with clavulanic acid) will treat me.” (Customer 26).
“… these (azithromycin and amoxicillin) are to treat this sore throat and the fever I have, this (chloramphenicol) is for my eyes.” (Customer 22).
“Hum…I have to get rid of the pain when going to the toilet…then I bought these medicines (doxycycline and cotrimoxazole vaginal cream) and the cream to apply (Customer 21).
This was endorsed by pharmacists, who reported that most customers purchase antibiotics, and some share the health problems for which they request them. They indicated that they mainly dispensed NPA for colds, flu, cough, sore throat, tract respiratory problems, vaginal discharge, eye problems, fever and pain, dental pain and urinary infections.
“The person has fever and cough or pain and comes to the pharmacy…request antibiotics!!” (Pharma. Technician).
“People buy amoxicillin for flu, cotrimoxazole for cough…they want tetracycline and chloramphenicol for eyes, many complaints.” (B. Pharma).
“Some complain of cough with mucus and difficulty breathing…some young ladies buy amoxicillin with cotrimoxazole for vaginal discharge…most share with me since I’m a lady also…laughs” (Pharma. Technician).