Antibiotic use in children under five years of age in Northern Tanzania; the experiences of the caring mothers

doi:10.21203/rs.3.rs-1948642/v1

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Research Article

Antibiotic use in children under five years of age in Northern Tanzania; the experiences of the caring mothers

https://doi.org/10.21203/rs.3.rs-1948642/v1

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Background: Antimicrobial resistance is a serious threat to the global achievements in child health thus far. Previous studies have found high use of antibiotics in children in Northern Tanzania, but the experiences of the primary care-givers, who play a key role in accessing and administering antibiotics for the sick child, has remained largely unknown. We aimed to understand mothers’ conceptions of antibiotic use in their children, which is of importance when forming strategies to improve antibiotic use in the community.

Method: A qualitative study including eight focus group discussions with mothers of under-five children in Moshi urban and rural districts, Northern Tanzania, was performed during 2019. The discussions were recorded, transcribed verbatim, translated to English and analysed according to the phenomenographic approach.

Findings: Three conceptual themes emerged during analysis; (1) conceptions of disease and antibiotics, (2) accessing treatment and (3) administering antibiotics. Antibiotics were often perceived as a universal treatment for common symptoms or diseases in children with few side-effects. Although mothers preferred to attend a healthcare facility, unforeseen costs, long waits and lack of financial support from their husbands, pose barriers for care-seeking. However, pharmacies were perceived as a cheap and convenient option to access previously used or prescribed antibiotics. Some mothers sought advice from a trusted neighbour regarding when to seek care, thus resembling the function of the community health worker (CHW).

Conclusions: To improve antibiotic use in children under five years of age in Northern Tanzania, we suggest targeting behaviour of individuals alone will not be sufficient. Improving structures, including the healthcare system and socio-economic inequality, are needed for sustained results. In the meantime, equipping CHWs to support women in appropriate healthcare seeking for their children, may be a feasible target for intervention.

Antimicrobial stewardship

Drug resistance

Bacterial

Africa

Eastern

Research

Qualitative

Focus Groups

Antibiotics are vital in the treatment of bacterial infections in children. Meanwhile, all antibiotic use in humans, animals or agriculture is promoting the development of antimicrobial resistance (AMR).(1) This represents a serious threat to the global achievements in child health thus far.(2) Low- and middle-income countries (LMICs) are particularly vulnerable to AMR development due to weak pharmaceutical governance, lack of sanitation and limited access to safe water.(3) In recent years, antibiotic use in LMICs have increased rapidly(4) and studies from Moshi in Northern Tanzania have revealed high use of antibiotics in children even in cases of minor symptoms indicating a common cold.(5, 6) Although the primary care-givers in LMICs play a key role in accessing and administering antibiotics for their sick children, their perspective is largely unknown. In this qualitative study we sought to describe mothers’ experiences of antibiotic use in under-five children, thus contributing to the growing body of work understanding AMR as a biosocial issue.(7–9)

Study design and approach

This qualitative study was performed with a phenomenographic approach. Phenomenography is suitable when aiming to describe the different ways in which a group of people experience and understand a given phenomenon.(10) Focus group discussions (FGDs) were used, this being a form of structured discussions performed in a non-threatening environment, which encourages in-depth discussions through group-interaction.(11)

Study setting

The study was part of a larger study aiming to describe experiences of antibiotic prescription and use in under-five children in the community of Moshi Municipal (urban) and Moshi District (rural) Councils, in the Kilimanjaro region of Northern Tanzania. Results from in-depth interviews with prescribing primary healthcare workers (HCWs) have been described previously, together with the general socio-economic and health demographic of the region.(12) Almost all families in Tanzania attend routine healthcare for their children which includes immunization, growth monitoring and, at times health education.(13) Conducting FGDs with parents or guardians at the premises of a primary healthcare facility were therefore considered viable. The facilities are presented in Table 1.

Data collection

Data collection was conducted during September-November 2019. The research team (CM, EM, GN, ME and RM) was appointed and trained as previously described.(12) An interview guide (in English) was developed by ME, ML and RM and translated into Kiswahili by CM, EM, GN and RM. In Kiswahili, the English term, ‘antibiotics’ (i.e., anti-bacterial substances) has been adopted into the language; therefore, ‘antibiotics’ were also used in the translated interview guide (Additional file 1). Parents or guardians were invited to participate by a local nurse who had been briefed about the purpose of the study. Although male care-givers were accepted, no men were present to be included. The participants were given further oral and written information of the study by the team (in Kiswahili) and were asked to give their written consent to partake (Additional file 2). Each participant was asked about age, marital status, number of children and education. In total, 54 mothers were included in eight different focus groups (Table 1). Two mothers included in focus group 2 and one in focus group 6 left during the discussion due to their child being upset. The FGDs were held in a private room and the participants were all sitting in a circle together with the moderator and light refreshments were offered. The initials of each participant were placed in front of them and the moderator referred only to these to ensure confidentiality. The FGDs were moderated by CM, EM and RM with assistance from 2–3 team members (including GN and ME). Before describing their experiences of antibiotic use in under-five children, the participants were asked to define and give examples of antibiotics. All FGDs were recorded digitally and one

team member was taking notes as a complement.

Table 1

Characteristics of the focus groups
	Participating mothers					Health facility
Focus group	No. of participants	Age, years	Mean no. children	Education^a	Marital status^b	Level	Owner	Area	District^c
1	7	20–33	1.7	P (1) S (5) U (1)	M (6) S (1)	Dispensary	Public	Urban	MU
2	7	19–45	2.3	P (5) S (2)	M (4) S (3)	Health Centre	Public	Urban	MU
3	7	22–35	2.1	P (3) S (3) U (1)	M (6) S (1)	Health Centre	Private	Urban	MU
4	7	19–40	1.9	P (5) S (2)	M (6) S (1)	Health Centre	Public	Urban	MU
5	7	20–37	2.3	N (1) P (4) S (2)	M (7)	Dispensary	Public	Urban	MU
6	6	19–33	2.3	P (2) S (3) U (1)	M (6)	Dispensary	Public	Semi-urban	MU
7	6	19–39	1.8	P (5) S (1)	M (6)	Health Centre	Public	Rural	MR
8	7	21–39	1.9	P (3) S (2) U (2)	M (3) S (4)	Dispensary	Catholic organisation	Rural	MR
^aNo education (N), Primary school (P), Secondary school (S) or University degree (U)
^bMarried (M); Single (S)
^cMoshi urban (MU) or Moshi rural (MR)

Data management and analysis

All FGDs were transcribed verbatim by a team member (CM, EM, GN) who had been present in the FGD. Translations were performed by clinicians at Kilimanjaro Christian Medical Centre, Moshi, Tanzania fluent in both Kiswahili and English. Part of the translated material was back-translated by FM and RM to ensure quality and conformity of the translations. NVIVO 12 software (QRS international) was used for data management. Data analysis followed the steps as described by Sjöström and Dahlgren.(14) ME was mainly responsible for coding and presentation of data to the co-authors (FM, ML, RA, RM and SS) and the results were discussed and adapted at regular seminars. A neutral co-examiner tested the results to ensure correct data analysis through assigning uncoded quotations to these categories. Agreement was almost unanimous between the authors and the co-examiner.

Findings

During analysis of the FGDs, three conceptual themes emerged (Fig. 1), with associated categories (Table 2).

Table 2

Themes and categories that emerged in the analysis
1. Theme	Conceptions of disease and antibiotics
1.1 Category:	Causes of common childhood diseases
1.2 Category:	Antibiotics are a remedy for common symptoms
1.3 Category:	Antibiotics are used to treat specific diseases
1.4 Category:	Antibiotics are a universal treatment
2. Theme	Conceptions of accessing treatment
2.1 Category:	Home treatment is used before seeking healthcare
2.2 Category:	Healthcare facilities are trustworthy
2.3 Category:	Healthcare facilities may not be accessible or satisfactory
2.4 Category:	Pharmacies are cheap and convenient
3. Theme	Conceptions of administering medication
3.1 Category:	Understanding and receiving instructions
3.2 Category:	Storing and re-using the medication
3.3 Category:	Adherence to prescription

1. Theme: Conceptions of disease and antibiotics

The first theme relates to conceptions of the causes of common childhood diseases and why antibiotics were used. In describing disease, the mothers used the term ‘magonjwa’, the Kiswahili word which refers to any disease, not specific for infectious disease. The mothers frequently referred to ‘dawa’ which is a term for any biomedical drug.

1.1 Category: Causes of common childhood diseases

This category comprises a broad variety of statements with explanations for common childhood diseases. Origins for symptoms or infections were often found in the natural environment of the child.

“Mafua (flu) is caused by hali ya hewa (weather) and wind (…) [it] can also be caused by dust or harufu kali (strong smell) used by the mothers (…) Or when the child eats something contaminated.” (FGD 7)

Cough was a common symptom, either described with the term, ‘kifua’ (literal translation ‘chest’, also used for any chest infection) or ‘kikohozi’, perceived to have different causes such as teething, dust, cold or swallowing infected amniotic fluid at birth. The mothers also described behavior that could lead to disease, such as letting the child play in dirty water or inadequate hygiene. At times, the mothers described disease-causing microbes using the general terms, ‘mdudu’ (bug) or ‘vijidudu’ (germ). However, in no statement was virus mentioned as a cause of disease. Upon probing, a mother described bacteria as follows:

“To my understanding these [bacteria] are wadudu (bugs) who live in water or foods that are not covered well.” (FGD 3)

1.2 Category: Antibiotics are a remedy for common symptoms

Statements in this category reveals that the mothers perceived antibiotics as a remedy for common symptoms including fever, cough and diarrhea. Antibiotics were, in these cases perceived to be similar to paracetamol or cough syrup. Cough was commonly treated with antibiotics, as shown in the following statement:

“There are many types of kikohozi (coughs), the one for kifua kikuu (pulmonary tuberculosis) and the kikohozi cha kawaida (normal cough). The kawaida (normal) is the one we use antibiotics.” (FGD 7)

Some mothers described previous use of non-antibiotic remedies for common symptoms, who were now using antibiotics instead:

“(…) this matumbo (intestinal pain) is common [in infants] (…) as for my children I gave them amoxicillin. Previously we gave them Gripe water [containing sodium bicarbonate/herbs] but this has been banned and [now] I usually buy these dawa (medicines) from the pharmacy.” (FGD 7)

1.3 Category: Antibiotics are used to treat specific diseases

This category illustrates conceptions of antibiotics as a treatment for some, specific diseases. Antibiotics were in these cases perceived as different to symptomatic treatment, but statements show that they might not be perceived as specific for bacterial infections.

“Antibiotics are dawa (medication) prescribed to you if, for example, you have tested positive for malaria or amoebic diseases and they are different from paracetamol.” (FGD 3)

However, in some statements, antibiotics were described as different from treatments for fungii or parasites.

“I think malaria [is not treated with antibiotics] because mostly when one has malaria, mseto (a mixed anti-malarial drug) or Fansidar (Sulfadoxine–Pyrimethamine) is prescribed and the person is cured. I have never seen a person with malaria and antibiotics prescribed for them.” (FGD 1)

1.4 Category: Antibiotics are a universal treatment

The fourth category illustrates the conception of antibiotics as a universal treatment, used to treat or prevent most symptoms or diseases in children.

“It [antibiotics] is a dawa (medicine) that treats many diseases, even if you have malaria, because it contains so many ingredients. If the child has cough and flu the antibiotics treats them all.” (FGD 7)

According to the statements, antibiotics were also perceived as protecting the body or strengthening the children’s immune system.

“Because most times it [antibiotics] is dawa yenye kinga (protective medication) in the body and they are not so strong for children under the age of 5 years.” (FGD 2)

Few statements show little or no conception of antibiotics but did, in contrast describe antibiotics as ‘strong’. Nevertheless, antibiotics were often perceived as a comprehensive treatment with little or no harmful side-effects.

2. Theme: Conceptions of accessing treatment

The second theme involves conceptions of how the mothers access treatment for their sick child, including possible barriers and preferences. The mothers often used ‘hospitali’ (hospital) to describe any primary healthcare facility or district hospital, ‘daktari’ (doctor) was used to refer to HCWs regardless of education level and ‘duka la dawa’ or, sometimes ‘pharmacy’ was used to refer to any level of community pharmacy.

2.1 Category: Home treatment is used before seeking healthcare

The statements in this category revealed that, before seeking care for their sick child, some mothers were accustomed to treating their child at home, primarily to reduce fever or pain. Some mothers administered paracetamol at home, whilst use of traditional or herbal medicine was not mentioned. The mothers agreed that if there was no improvement, the child was brought in to be seen by an HCW.

“If we give a child dawa (medicine) without consulting a daktari (doctor), if it takes two days without recovery, we go and tell the daktari that we have given the child this dawa (…) so as the daktari can know which test to take and what the real problem is.” (FDG 2)

Several statements showed that the mothers have sought medical advice from a nurse or experienced mother in the neighborhood regarding the treatment of their sick child.

“I am lucky, I live very close to a nesi (nurse) so when the child gets sick, I go to her even at night. She gives me dawa (medicine) and advises me that if the child does not get better, to take him to the hospitali (hospital) the next day.” (FDG 7)

2.2 Category: Healthcare facilities are trustworthy

This category comprises conceptions of healthcare facilities as trusted institutions and HCWs as the most qualified to assess the sick child. According to the statements, the main reasons why the mothers preferred seeking care at a healthcare facility was so that the child would undergo a physical examination and to be given treatment and/or advice. When asked if it would be a problem if the HCW did not prescribe medicine, a participant explained:

“I will not agree if [the child] has not been checked for temperature; to me it will be a problem. (…) I will agree with him as long as investigations have been taken and knowing the status [of the child] is progressing well.” (FGD 2)

Thus, provided that the HCW performed a thorough investigation which revealed no need of prescribed treatment, the mothers often felt reassured and satisfied. Some also shared experiences of adverse events when a child had not been seen by an HCW. Such experiences enforced the perception of the healthcare facilities as the safest option:

“There is also our neighbor whose child died [because] the child was sick and the parents did not take her to the hospitali (hospital), instead they bought dawa (medicine) from the shop. So, when my child is sick even at night, I go to the hospitali (…) I never buy dawa from the shops.” (FGD 5)

2.3 Category: Healthcare facilities may not be accessible or satisfactory

There were several constraints faced by the mothers to accessing treatment at the healthcare facilities and, on occasions the visits did not meet with their expectations. Although public healthcare facilities were supposed to provide free treatment for children under five years, there could be hidden costs such as transportation, registration and paying for medicines that may be out of stock. However, these costs were often not apparent to their husbands who provided the money.

“(…) they say that treatment for children less than five years is free (…) it is true that the consultation is free, but then the daktari (doctor) tells you we do not have this dawa (medicine), go and buy in the duka la dawa (pharmacy) (…) you have to go and ask for money from the man and he tells you ‘I don’t have money, take this bus fare, go and get the child treated’. You tell [him] but he insists that treatment is free for children.” (FGD 3)

Further, some statements described situations in which the mothers were not satisfied with the care provided at the healthcare facility. These included inadequate soothing of a child’s cough, which may lead them to consult the pharmacy staff. Others had experienced long waits at the healthcare facility, without receiving care for their sick child or, disrespectful treatment from the HCWs.

“Sometimes there are few staff at the facility; you get there early in the morning and wait till evening without service! For example, yesterday we waited for a long time (…) a child fainted due to seizures because the fever was severe.” (FGD 2)

2.4 Category: Pharmacies are cheap and convenient

This category describes reasons for approaching pharmacies in the first instance to obtain treatment for the sick child. Firstly, accessing treatment at the pharmacies were perceived as being cheap. Further, the mothers found a justification for not attending the healthcare facility when buying medicines which had been used or prescribed previously. Whilst some mothers asked for a specific antibiotic, others consulted the pharmacy staff.

“Sometimes due to distance [to the healthcare facility] (…) I take the child to the pharmacy and explain how the child is coughing. Because the pharmacist has studied, he gives dawa (medication).” (FGD 1)

Thus, pharmacy staff were trusted. In addition, the pharmacies were also perceived as being more accessible as they were situated closer to the families’ homes and had longer opening hours. However, some pharmacy staff did not provide medicine unless the child had been seen by an HCW.

“There are times when we go to the duka la dawa (pharmacy) and if we tell them we haven’t attended the hospitali (hospital) we are denied to get the dawa (medicine). They often advise young children to start at the hospitali. (FGD 4)

3. Theme: Conceptions of administering medication

The third theme relates to conceptions concerning how medicines were, or should be, handled and administered to children.

3.1 Category: Understanding and receiving instructions

The first category involves perceptions of how and by whom instructions are given to the mothers when prescribing a medicine for her child. The mothers largely agreed with the following statement:

“The daktari (doctor) just writes the prescription form and you get all other information at the dispensing window.” (FGD 2)

In general, the mothers claimed that the instructions provided were easy to understand and some stressed the importance of understanding the instructions to avoid adverse events. However, others were hesitant in asking the HCW to clarify if the instructions were difficult or contradicting.

“To be honest I [personally] do not ask questions. The daktari (doctor) writes the prescription, [but] I don’t know how to read so I don’t know anything, even English I don’t know… Someone else when you ask him [the doctor] gets angry. Mostly amoxicillin is the one I can read [identify], even the day my child was given 25 injections I did not ask.” (FGD 8)

According to the statements, fear of being rebuked by the HCW if raising questions or concerns led to a lack of understanding about the prescribed treatment.

3.2 Category: Storing and re-using the medication

This category comprises conceptions on how medicine for children should be stored and possible re-usage in subsequent disease episodes. The mothers were often advised by the HCWs on these issues.

“For example, you buy dawa (medicine) after being investigated and found with a problem, the nurse tells me to use the dawa, and to keep the remaining one safe and it can be used again when the symptoms recur.” (FDG 3)

Although the mothers knew less about differences in mode of action between the different medicines, they generally perceived medicines which were ready to use (mainly paracetamol) as being eligible for to re-usage whilst those diluted with water (mainly antibiotics) should be discarded. However, some mothers did not re-use medicines to avoid the risk of them expiring or, since the child may suffer from a different disease.

“It depends what kind of dawa (medication), if it is liquid, it means after 7 days it will expire (…). But be careful, because the baby may have other symptoms which are not like the ones before, so it will be better to go to the hospitali (hospital).” (FGD 8)

3.3 Category: Adherence to prescription

The last category includes statements describing experiences of adhering to the prescribed treatment course and any perceived motives or barriers in doing so. Whilst most mothers stated they would finish the prescribed course, some did not as their children often became well before the end of the course. When explaining why it is important to adhere to the prescribed interval, a participant stated:

“If you don’t give dawa (medication) on a prescribed time it will make the mdudu (bug) acting like kazimia (fainting). When he wakes up the problem starts again.” (FGD 1)

Thus, according to the statement, not adhering to prescription may lead to failure to eradicate the pathogen and consequently disease recurrence. However, the mothers experienced medicine administration on the prescribed hours as a challenge, due to their daily chores.

“For example, you are required to give dawa (medication) at 6:00am. Instead, I struggle to wash my dishes and finish my work so I can give the dawa to my child. [But] the time I have been prescribed by the daktari (doctor) to give the child dawa has already passed!” (FGD 3)

The detrimental effects of rising AMR, disproportionally affecting LMICs, necessitates an understanding of what drives inappropriate antibiotic use in the local context. Preschool children undergo a high number of infections yearly and studies from low malaria endemic areas in Tanzania suggest most acute febrile illness in children are, in fact viral.(15, 16) However, determining when a child needs professional care or treatment and navigating how to seek help still pose a great challenge for primary care-givers in LMICs, where child mortality remains high. We performed FGDs with mothers in urban and rural Moshi, Tanzania on their experiences of antibiotic use in children. Below we discuss our findings in the context of previous studies addressing antibiotic use from a social science perspective.

The ambition of the Tanzanian government is to provide free healthcare for children under five years. However, women in our study disclose hidden costs that pose barriers for care-seeking. These includes travels, long waits at the healthcare facility (leading to loss of possible daily income), dubious costs for registration and purchase of prescribed medicine from pharmacies. These barriers were similar to those found in a qualitative study on mothers’ healthcare seeking behaviour in relation to childhood pneumonia symptoms, carried out in urban Moshi.(17) In the face of severe resource constraints, reducing some of these costs by purchasing antibiotics from a nearby pharmacy may indeed be viewed as a ‘rational’ behaviour. Poor supply chains are a common challenge to the healthcare system in Tanzania causing shortage of medicines including antibiotics. This may affect prescribing practices at public facilities as shown by our previous study(12) where poor families were more likely to be prescribed antibiotics that were available at the facility free of charge, rather than those most suitable for the infection. Low socioeconomic status may therefore be a determinant for irrational use of antibiotics in children. However, for some mothers it was not an absolute deficit of money but rather restricted access to household money and lack of support from the husband, that led them to primarily access treatment from the pharmacy. The socio-cultural norm of women caring for the young or sick children was apparent in our study as no men were present to be included in the FGD. In what way gender structures affect AMR is currently an understudied area. However, this topic needs to be addressed in order that future interventions will avoid ignoring or even contributing to gaps and inequalities in society.(18)

In the FGDs, some women stated that they would be disappointed if not prescribed an antibiotic by the HCW when seeking care for their sick child. This expectation may be coherent with what Denyer-Willis and Chandler(7) describe as the ‘pharmaceuticalisation’ of healthcare. In resource limited settings, this is reflected in the use of algorithms resulting in the provision, or not, of particular medicines rather than clinical attention. However, as the discussion developed, the women explained that what they were actually seeking was a proper investigation of the sick child. Thus, expectation of antibiotics may be seen as a compensation for care, whilst the mother’s greater wish was for a clinical assessment and reassurance.(19) Likewise, parents in high-income countries are mainly concerned with receiving a diagnosis and being reassured that the child is not severely ill, although this may be misinterpreted as expectations of antibiotics by clinicians.(20, 21) In our previous interviews, HCWs indeed expressed expectations that the women wanted antibiotics prescribed for their children,(12) which illustrates similar ‘dissonant views’ between parents and HCWs in Northern Tanzania.(21) The need for addressing the unequal power relations between mother and HCWs was shown in some citations where the mothers expressed a fear of being rebuked by the HCW if raising questions or concerns. Targeted communication training for HCWs on the importance of sensitively exploring the real concerns or expectations of parents and providing appropriate information about treatment are very much needed, although limited time for each consultation due to high demand may cripple such interventions. This highlights that continued strengthening of the healthcare systems in LMICs, rather than focusing on behaviour of the individual alone is crucial for improving antibiotic stewardship.(8)

Our study confirms that community pharmacies are perceived as forming an integral part of the healthcare system in Tanzania.(22) Although mothers preferred seeking care at healthcare facilities for their children, pharmacy staff were also trusted and were perceived as ‘educated’. Availability of antibiotics from Accredited Drug Dispensing Outlets (ADDOs, also named type II pharmacies) has been a strategy to limit usage of local retail drug shops and improve access to effective medicines in rural and peri-urban areas of Tanzania.(23) Whilst type I pharmacies are supposed to be run by a registered pharmacist, type II pharmacies can be run by anyone who has completed a five weeks’ training course. However, while antibiotics are classified as prescription-only drugs in Tanzania, the majority of community pharmacies breach this upon customer request,(23–25) possibly due to the impact of market forces.(23) In this study, women primarily attending a pharmacy described either having requested a specific antibiotic they had previously used or having consulted the staff. In line with previous studies,(23–25) only a few statements described pharmacy staff refusing to sell antibiotics without prescription.

Throughout the FGDs, antibiotics were frequently mixed up with other drugs such as paracetamol. The terms for antibiotics, bacteria and viruses have been adapted from English and brought into the Kiswahili language, but were rarely applied by women in our study. Instead, the Kiswahili terms for medicine (dawa), bug (mdudu) or disease (magonjwa) rather than infection, were used but encompass a more broad-brush meaning. The conception of antibiotics as a universal treatment for sick children was apparent and may be influenced by this generalized language. The perception of antibiotics as capable of curing almost any disease has been previously described in LMICs.(26) However, the conception of antibiotics as ‘strong’ was not prevailing in our data, rather the emphasis on antibiotics as a comprehensive treatment with few or no harmful side-effects. As antibiotics have become part of the infrastructure in LMICs,(27) their familiarity may also have reduced their perceived ‘strength’. Whilst a deeper knowledge of the effect of antibiotics was lacking among the mothers, the practical knowledge on administering and storing antibiotics was seemingly better. In cohesion, a recent study from South Africa concluded from observations that most advice given by HCWs was pragmatic, whilst not including information of self-care or antibiotic resistance, due to the limited time spent with each patient.(28) The few women in our study who had heard of antibiotic resistance perceived that development of resistance was associated with finishing the prescribed course too soon or frequent use of antibiotics. These were also the two most common beliefs among the public found in a systematic review of studies mainly performed in high-income countries.(29) Antibiotic resistance was described by the mothers as a concern for, or within the individual not as a public health problem, similarly as expressed by the HCWs in our previous study(12) and by patients and prescribers in South Africa.(28)

Appropriate healthcare seeking is important for the safety of patients and the efficacy of healthcare providers. In children, safe home practices with non-antibiotic remedies for minor illnesses should be promoted together with how to recognize danger signs so as to not delay care-seeking in serious situations. In line with previous findings,(17) this study shows that mothers who felt unsure seek out an experienced nurse or mother in the neighbourhood, for advice as to whether the child needs professional care. This resembles the role of the community health workers (CHWs) in Tanzania, trained volunteers who work at the frontline of communities.(30) In recent years, CHWs are being integrated into the healthcare system to bridge the country’s critical shortage of educated HCWs.(30, 31) A recent report on AMR and social science identifies three areas to address antibiotic use, namely practice, structures and networks.(8, 32) Whilst practice has generally been assumed to be improved by increased public awareness of AMR, social scientists have suggested that in LMICs precarity (lack of predictability or security) and weak social support are more important determinants of antibiotic use.(33–35) Although women in this study had very limited knowledge of AMR, these recent findings suggest educational activities will not be sufficient to improve their use of antibiotics. Further, structures such as healthcare systems, market driven antibiotic sales and income and gender inequalities are clearly affecting antibiotic use in children in Northern Tanzania. However, the increase in AMR requires action that cannot wait until these issues are fully resolved. Thus, a feasible way forward could be equipping networks, involving an increased presence of CHWs to support women in appropriate healthcare seeking for their children and in consequence, advocating for the prudent use of antibiotics. A promising area of intervention is providing CHWs with mobile health solutions (mHealth) to improve their performance and efficacy.(36)

Strength and limitations

Although all women in the FGDs were encouraged to share their unique experiences, older women with several children were in general more confident in speaking compared to the younger women. This may be a reflection of added experience on the topic, but also a consequence of sociocultural norms.(11) However, if participants had been divided into different FGD according to age, fewer sites could have been included resulting in a loss of variability. Nonetheless, the fact that some FGDs were observed by a western, female researcher did not seem to affect the openness of the discussions which may be attributed to the local researchers taking the leading role in interacting with the participants and moderating the FGDs in the participants’ native language. The majority of focus groups (6/8) were carried out in an urban or semi-urban area. The voices of women in this study are thus mainly from urban areas or rural areas with reasonable access to healthcare. Future studies should explore areas with more restricted access to healthcare and how this affects healthcare seeking for children in relation to antibiotics. It should be noted that the FGDs were carried out before the Covid-19 pandemic, if this have had an effect on the conceptions of disease and antibiotics needs to be addressed by future studies.

This study has portrayed the experiences of mothers in Northern Tanzania on antibiotic use in their under-five children, revealing the precarity that largely affects the women as they access treatment and administer medication to their sick children. To improve antibiotic use in children under five years of age in this area, we suggest targeting behaviour of the individual alone will not be sufficient. Improving structures, including the healthcare system and socio-economic inequality, are needed for sustained results. In the meantime, equipping CHWs to support women in appropriate healthcare seeking for their children, may be a feasible target for intervention.

CHW; community health worker, FGD; focus group discussion, HCW; healthcare worker, LMIC; low- and middle-income country.

Ethics

The study was approved by the National Institute for Medical Research in Dar es Salaam (Vol. IX/3106) and the Kilimanjaro Christian Medical University College Research Ethics and Review Committee in Moshi, Tanzania (No. 2415). Approvals from local Medical Officers and Administrators were obtained as previously described.(12) All participants were given oral and written information of the study in Kiswahili (Additional file 2) and gave their written consent to partake.

Consent for publication

Not applicable.

Data availability statement

Anonymised datasets analysed and generated during this study are available from the corresponding author upon reasonable request.

Competing interests

None to declare.

Funding

The study was funded by Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden.

Authors’ contributions

The study was designed in close collaboration between FM, ME, RM and SS with advice from ML and RA. Data collection was performed by CM, EM, GN, ME and RM with supervision from FM. Transcription of the FGDs was performed by CM, EM, GN and RM. Data analysis was mainly performed by ME, in close contact with RM. The findings were regularly discussed at online seminars with FM, ME, ML, RA, RM and SS. All authors read and approved of the final version of the manuscript.

Acknowledgments

We express our sincere thanks to all women who took the time to participate in the FGDs and share their experiences. Sincere thanks to Dr. Rune Philemon, senior pediatrician at Kilimanjaro Christian Medical Centre, Moshi, Tanzania who provided significant insights for the team concerning antibiotic use in common childhood illnesses. We express our gratitude to Dr. Sia E. Msuya who were of great importance in the initial planning of the study. Our gratitude also to Dr. Hans Olomi and Today J Rambau, who undertook translations of the transcripts from Kiswahili into English.

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No competing interests reported.

Additionalfile1.pdf
Additional file 1. Focus group guide for parents or guardians (English/Kiswahili)
Additionalfile2.pdf
Additional file 2. Participant Information Sheet and Consent forms (English/Kiswahili)

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Editorial decision: Major revision
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Antibiotic use in children under five years of age in Northern Tanzania; the experiences of the caring mothers

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Version 1

Abstract

Figures

Background

Methods

Study design and approach

Study setting

Data collection

Data management and analysis

Findings

1. Theme: Conceptions of disease and antibiotics

1.1 Category: Causes of common childhood diseases

1.2 Category: Antibiotics are a remedy for common symptoms

1.3 Category: Antibiotics are used to treat specific diseases

1.4 Category: Antibiotics are a universal treatment

2. Theme: Conceptions of accessing treatment

2.1 Category: Home treatment is used before seeking healthcare

2.2 Category: Healthcare facilities are trustworthy

2.3 Category: Healthcare facilities may not be accessible or satisfactory

2.4 Category: Pharmacies are cheap and convenient

3. Theme: Conceptions of administering medication

3.1 Category: Understanding and receiving instructions

3.2 Category: Storing and re-using the medication

3.3 Category: Adherence to prescription

Discussion

Strength and limitations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1