Demographic characteristics of caregivers.
The 16 caregivers that participated and were interviewed in the study were from Zomba District and were all females. Eleven of them were married while three were divorced and one was widowed and one had never married before. Eleven caregivers attended up to primary education and only two caregivers attended tertiary education while three had a secondary school education (Table 1).
Table 1: Characteristics of caregivers, 16 women
Number of Children Alive
Seventh Day Adventist
Ability to read/write
Use of thumb
Not employed/ House wife
Self-employment/ Small Business
Area of Residence
KNOWLEDGE ABOUT ANTIBIOTICS USE AND RESISTANCE
Most caregivers did not know about the name “antibiotics”, rather they were familiar with only a few examples of the antibiotics and the conditions which are treated by antibiotics. Familiar examples of the antibiotics were Bactrim, Amoxycillin, and Penicillin, including Flagyl (Metronidazole).
“Yes, I know these drugs like amoxicillin, Bactrim, Penicillin, and Flagyl, because I have used them when my child was sick at different times, however, I did not know that they are called antibiotics. We just say it's a medicine like any other” Caregiver # 3.
However, some caregivers referred to anti-malarial drugs, and pain killers as antibiotics, for example, Lumefantrine Artemether (LA), Fansidar (Sulfadoxine/Pyrimethamine), Panado, Brufen Aspirin, Cafinol, and Flagyl. They admitted to having used them many times as antibiotics. Some caregivers didn’t know the injectable antibiotics, such as Benzylpenicillin (X-pen), Gentamycin, and Ceftriaxone.
“I know, these are malaria drugs, LA, Fansidar, Amoxicillin, Brufen, Panadol, Bactrim, and Flagyl. Those are the ones I know, but then they are some which are difficult to mention. The ones I know and I use at my house. I use them mostly when my child is sick, and also when I am sick. so, like when my child is sick. at the hospital, they use the injection ones, but I also know penicillin, used for sores”. - Caregiver # 1.
According to the caregivers’ antibiotics are used to treat cough, sore throat, and diarrhoea. Amoxycillin, and Bactrim are mostly used to treat cough and sore throat whilst Penicillin is used to treat body aches and sore throat. Some caregivers know Bactrim is used for fever and malaria treatment while Flagyl is used to treat diarrhoea.
“Bactrim is given as a substitute, for malaria drug when the child has fever and diarrhoea, whilst Amoxicillin is also given when the child is coughing and when the cough comes with fever” - Caregiver #3
The caregivers were aware of the administration time for antibiotics to children, for example, it was indicated that Amoxicillin and Flagyl are given three times a day whilst Bactrim is given twice a day. However, there were challenges with caregivers in knowing the duration of the said antibiotics to be given to children. It was also noted that the caregivers administer the antibiotics according to the HCWs instructions.
“I give amoxicillin in the morning, afternoon, and the evening, while Bactrim is given twice a day in the morning and the evening. Mostly I give the medication according to the advice of nurse and doctors, but sometimes if I forget I ask my neighbours to help me on how to give the drugs to my child”- Caregiver # 9
Despite having limited knowledge of antibiotic resistance (ABR), some caregivers reported that they are aware that at some point antibiotics can stop working if used inappropriately among children. This was highlighted when the caregivers said that nowadays amoxicillin is not treating cough as it used to be in the past.
“The antibiotics can destroy the body, especially to the kids when the antibiotics are used inappropriately. I have once stopped giving my child the drugs because I saw that the antibiotics, I was giving my child, she responds slowly, so to give my child this antibiotic, after 3 days you see that my child has responded and got better yah”- Caregiver # 3.
Some of the caregivers were of the view that antibiotic resistance arises when caregivers don’t finish the dosage of antibiotics given at the hospital, when they share the drugs with others, and when they buy the drugs from the market without the advice from the hospital workers because you might use drugs which are expired.
“Usually, the side effects arise when you have been given drugs at the hospital for the child and you don’t finish the dosage or you share them with your friend and if you just buy the medicine at the market without the advice from the health care workers, because u can buy wrong or expired drugs-Caregiver #13.
Sources of information on antibiotics use and resistance.
The caregivers indicated that health care workers are the main source of information about antibiotics. However, some caregivers said that they know and learn about antibiotics from friends and relatives in their communities, whilst one caregiver said she learned about antibiotics from school and the media.
“These drugs I got to know them from the hospital, like when I come here, they tell you that the way the child is feeling, we are going to give you these drugs, this type of drug, for example, amoxicillin if the child is coughing so you get to know that ooh! so this is the name of this drug”. -Caregiver #1
“I knew these drugs when my baby was sick, and I went to the hospital to receive them and from school, I got to know them. From my neighbours also I got to know about the names of the antibiotics” - Caregiver #3.
PRACTICES OF CAREGIVERS ON ANTIBIOTIC USAGE.
Caregivers indulge in self-medication with antibiotics. The practice of self-medication facilitates indiscriminate use of antibiotics among the caregivers. The sources of antibiotics used in self-medication are; buying antibiotics without a prescription, using leftover antibiotics at home, and sharing the antibiotics with friends and relatives.
a) Buying antibiotics without prescription.
The caregivers usually buy the antibiotics to administer to their children (self-medication) from the store (Hawker), a drug store, or a pharmacy without proper prescription and instructions from the health care workers.
“Sometimes when my child is sick, I just go to the shop and buy the medication, because I know that this cough and sores will need Bactrim or amoxicillin so yea, I just buy what they have and give my child”- Caregiver # 6.
b) The use of left-over antibiotics.
The caregivers use left-over antibiotics frequently at home. Usually, these are the remaining antibiotics from previous illnesses of their children. Sometimes they buy and keep them in readiness for a future illness since the under-five children fall sick regularly. Mostly the left-over antibiotics are used for similar conditions that the children were treated for previously and in some instances, the caregivers use the antibiotics in minor and self-limiting conditions.
“I keep antibiotics in my house to use when my child gets sick, the same antibiotics I get from the hospital or the ones I bought if left I make sure to keep them safe, so when my child falls ill, I just use the same. Mostly I use Bactrim and amoxicillin” -Caregiver # 13.
“When my child falls sick suddenly and the condition is serious, I don’t hesitate to use the left-over antibiotics or if I don’t have, I rush to my neighbours to ask for drugs or buy. The hospital is far and sometimes there is no medicine there so it’s better to help your child before it’s too late”. Caregiver #11.
c) Sharing of antibiotics
Caregivers, get antibiotics from friends and relatives. However, some caregivers acknowledged that the tendency of buying and sharing antibiotics is not good since they end up sharing expired drugs or some drugs may not necessarily work for the condition of their child. Otherwise, this is done just to relieve the symptoms of the child and sometimes it’s more convenient than just rushing to the hospital with any illness, especially minor illnesses.
“It’s not a secret, the antibiotics we share. For example, if your child is sick u reach out to your neighbour or your relative for any antibiotic, they have so that u can use it on your sick child. Yes, indeed I can agree that it’s a bad practice to share these antibiotics because you can get an antibiotic which can’t work on your child or maybe it's expired or different from the condition”- Caregiver # 12
ADMINISTRATION OF ANTIBIOTICS
Mostly, antibiotics are administered orally and parentally as prescribed, however, some caregivers use a small teaspoon whilst the HCWs use calibrated cups and syringes in the ward.
a) Instruments that are used to administer the antibiotics.
The caregivers use a small teaspoon to administer the oral antibiotics in a tablet or a suspension form. Some caregivers emphasized that they give the correct dosage according to the HCWs instructions, whilst some of them were not sure if indeed the small spoon is equivalent to the dose to be given to the child (Figure 1). However, some caregivers say it’s easy to administer using the teaspoon since some children cannot take and swallow the tablet and the suspended antibiotic by themselves.
“I use the small teaspoon to give the antibiotics to my child. If it’s the tablets then I mix with water to dissolve them whilst for the suspension ones like amoxicillin syrup I just drop them on the teaspoon and give them. It’s very easy with the spoon since my child cannot swallow the tablets”-Caregiver # 12.
Some caregivers do not complete the prescribed antibiotic doses for their children at home. This usually occurs when they feel that the child’s condition has improved and they perceive that the child is fine and they conclude that there is no need to finish the treatment.
“It happens that after giving the medication to the child there is a great improvement and now the child is fine and able to eat and play with friends. Now I see that at this point it’s not good to continue giving the medication because it might be too much to the body since the disease is now gone.” Caregiver # 11.
b) Storage of Antibiotics
The caregivers store the antibiotics in a plastic bag in a cool place to avoid damaging them and they keep them away from their children. Caregivers said that they practice this to prevent water, and sunlight damage the antibiotics.
“When I receive the drugs from the hospital, I put them in a plastic pack, and some in plain papers. when we get home, I transfer them to a plastic paper and store in a bag out of reach of children”- Caregiver# 6