Journal of Infectious Diseases and Diagnosis

Knowledge, Attitude towards Antibiotic Use, Prevalence and Associated Factors for Non-Adherence among Adult Outpatients in Public Health Facilities in Edo State, Nigeria

Ekaete A. Tobin^* and Martha Okonofua Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Irrua, Edo state, Nigeria
^*Correspondence: Ekaete A. Tobin, Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Irrua, Edo state, Nigeria, Tel: +2348155368412, Email:

Received: 25-May-2020 Published: 15-Jun-2020, DOI: 10.35248/2576-389X.20.5.135

Introduction

Mediation non-adherence is a global problem that negatively impacts on therapeutic success, and deepens the economic burden placed on patients and the health system with the need for additional consultations, extra and possibly more expensive drug prescriptions, and increased hospitalization [1]. Nonadherence to prescribed antibiotics is another form of antibiotic misuse in a population. Studies have found that non-adherence has a strong causal relationship with antibiotic resistance due to failure to achieve optimum antibiotic drug concentrations. Determinants of non-adherence lie with the patient dispositions (socio-demographic, knowledge and perceptions towards antibiotics), the quality of doctor-patient relationship/ communication and factors related to the medication such as taste and dosing [2]. Common reasons cited for non-adherence to prescribed antibiotics have included a cessation of symptoms, forgetfulness, focus on other priorities, lack of information about the dose [3]. However, factors responsible for non-adherence differ across countries and interventions to improve adherence must be tailored to what obtains in a particular locality. Antibiotic resistance in Nigeria is an issue that is not fully studied and understood and yet can disrupt the already weak health system in the country. There is paucity of information on the knowledge, attitude and factors responsible for antibiotic non-adherence in Nigeria and particularly from the oil-rich south-south parts of the country. The study was undertaken to investigate the knowledge, attitude prevalence and associated factors of adult patient non-adherence to antibiotic prescription. By identifying population groups at increased risk of non-adherence, appropriately designed educational support can be provided.

Materials and Methods

Study area

The study was carried out in Edo state, in the rain forest of South-south region of Nigeria, between latitude 50 44” and 70 34” N of the equator and longitude 50 04” and 60 43” E of the Greenwich Meridian. The state has a land mass of 19,187 km², and shares boundary with Kogi State in the north, Delta in the south-east, Ondo State in the west, and Anambra State in the east. The state is divided politically into three senatorial districts and administratively into 18 Local government areas.

Study population

Study population comprised adult out-patients to government owned secondary and tertiary health facilities in the study area.

Study design

The study used an observational cross-sectional analytic study design.

Selection criteria

To be eligible to participate, persons were required to be up to 17 years, to have lived in the community for up to 6 months and were willing to give consent.

Sample size

The study is a sub-analysis of data collected from 800 participants of a cross-sectional study to assess antibiotic misuse patterns and determinants in adult populations attending outpatients clinics conducted from July to December 2018. For that study, a minimum sample size of 248 was calculated based on the formula for determination of sample size in a cross-sectional study [4], prevalence value of 82.2% for antibiotic misuse practices in a previous study [5], a 5% error margin, and a nonresponse rate of 10%.

Sampling technique

The full details of data collection are contained in another study to be published. Briefly, respondents were selected from amongst patients attending the general out-patient department of five government and one tertiary health facility in Edo central senatorial district of Edo state. The centers had previously been chosen through a multi-stage sampling technique. Respondent recruitment was carried out from Monday to Friday till the desired number of participants was reached. The first respondent each day was selected by random sampling and subsequent respondent by systematic sampling following the list of patients who were registered to see the doctor for that day. Recruitment continued till the required numbers of patients were selected. Where a selected patient was not eligible, the next person in line was approached.

Study variables

The dependent variable in this study was antibiotic nonadherence determined by a self-report of failure to commence or complete the prescribed course of treatment with antibiotics in the last episode of illness for which antibiotics were prescribed by a clinician within the past 6 months [6]. Independent variables included sex, number of years of residence in the study area, religion, age, average monthly income, Level of education, occupation, marital status, knowledge and attitudinal dispositions of respondents towards antibiotic use, perceived physician’s support, and perceived family support.

Study instruments

Data was collected using pretested interviewer-administered questionnaire designed by the researcher through extensive literature search on the subject matter to ensure validity, and with technical input from experts in the field of AMR. Variables included in the instrument for measure were demographic characteristics of the respondent, their general knowledge about antibiotics- antibiotic action, side effects, need for a prescription, resistance; attitude towards antibiotic-use and adherence to prescribed antibiotics in the last illness episode were collected. Knowledge about antibiotics was assessed using 6 questions that sought binary responses of Yes, No or “ I don ’ t Know ” depending on correctness of the answers regarding antibiotics in general and 3 regarding antibiotic resistance.

Attitudinal dispositions towards self-medication and adherence to prescribed antibiotics was assessed using 5 items with a 5- point Likert style response format as ‘strongly agree’, ‘agree’, ‘not sure’ to ‘disagree’, and ‘strongly disagree’.

Data analysis

All data were coded and entered into the computer-assisted software SPSS for Windows version 21, (SPSS Inc., Chicago, IL, USA) for statistical analysis. To simplify presentation of the responses to attitudinal statements in the text, “strongly agree” or “agree” were grouped as “agreed”, and “strongly disagree” or “ disagree ” grouped as disagreed [7,8]. A scoring system was applied to measure the respondents’ knowledge and attitudes towards antibiotics. In computing individual scores for knowledge, one mark was awarded for each correct answer and zero (0) for each wrong or ‘I am not sure’ answer. The antibiotic knowledge score was obtained on a continuous variable by adding up the respondent’ number of correct responses to the knowledge statements [8]. Thus, the range of total knowledge score was 0 to 9 for any respondent, so scores<50th percentiles were classified as having low knowledge, and>75th percentiles as good knowledge. Those between 50th- 75thpercentile were said to have average knowledge [9,10]. Thus, total knowledge score will be graded as poor (0-4), average (5-6) and good (7-9).

For attitude, one point was awarded for each appropriate response (strongly agree or agree for positive statement and strongly disagree or disagree for negative statement) and zero for each inappropriate or uncertain response, with the highest possible score as 20. Attitude was graded as negative or positive depending on total scores obtained by the respondent for the sections. A grade was negative if the respondent’s total score fell<50th percentile, and positive if>50th percentile of the total.

Descriptive data were presented in frequency tables with percentages calculated. Measures of central tendency- mean and standard deviation for interval scale, were used to summarize quantitative data. Chi-square test of independence (χ²) was performed to identify variables that were associated with antibiotic non-adherence, the dependent variable. A p value less than 0.05 was considered as statistically significant. Risk factors of non-adherence with p<0.05 in the bivariate analysis were included in multivariate logistic regression analysis to determine those that were independently associated with the dependent variable. Odds ratios (OR), 95% confidence intervals (CI), and p values were calculated for each independent variable.

Results

Demographic characteristics

One hundred and forty-seven (28.2%) respondents out of 521 who had ever used antibiotics in the last 6 months had obtained a doctor’s prescription in the last illness encounter. Females were slightly more than males in number (51.7% and 48.3% respectively), respondents with tertiary level of education (49.7%), married (56.5%) and those self-employed (34.0%) were in the majority shown in Table 1.

Table 1: Socio-demographic characteristics of respondents (N=147).

A greater proportion of respondents knew that antibiotics were effective against bacterial infections, 82.3%, while slightly more respondents opined that antibiotics were effective against viral infections (50.4%). Knowledge gaps were observed in the use of antibiotics to treat common cold mentioned by 89.1% of respondents, cessation of treatment when symptoms improved (61.9%), and the need for a prescription (78.1%), shown in Table 2.

Table 2: Respondents’ general knowledge of antibiotics (n=147).

A greater proportion of respondents had poor knowledge, (41.5%), 31.3% had average knowledge, and 27.2% had good knowledge of antibiotics. Majority would stop antibiotics if their symptoms improved, shown in Table 3.

Table 3: Respondents’ attitude towards antibiotic use.

Slightly more respondents had negative attitude, 74(50.3%) than positive attitude 73(49.7%) towards antibiotic use.

75(51.0%) respondents did not complete the prescribed treatment during the last encounter, while 72(49.0%) claimed they completed the course of treatment [11]. Common reasons given for non-adherence in the last illness experience included the feeling of improvement in health 49(65.3%), experience of side effects, 9(12.0%), exhaustion of the quantity that was bought, 5(5.3%) and forgot to continue 4(5.3%).

Respondents’ completion of prescribed antibiotics in the last treatment encounter was only significantly associated with age of the respondent, as respondents who were older than 60 years had a greater proportion who had completed than those who did not (p<0.01). Adherence to antibiotic regimen was not significantly associated with level of education, sex, occupation, marital status, employment status, number of years of residence or income, shown in Table 4.

Table 4: Association between demographic characteristics with treatment adherence.

The patient ’ s perception of the quality of support he/she received from the doctor was significantly associated with treatment adherence, (OR 0.04, 95% CI 0.15-0.94, p=0.04). Respondents failure to complete treatment was also significantly associated with attitude towards antibiotic use (OR 0.48, 95% CI 0.24-0.95, p=0.04). Knowledge about antibiotics was not significantly associated with completion of drugs, shown in Table 5.

Table 5: Associated factors with treatment non- adherence (n=147).

Discussion

The awareness by the majority that antibiotics were effective against bacteria, and ignorance about their effect on viruses and treatment of common cold has also been documented in other studies [12-14]. Most respondents thought antibiotics could be stopped when symptoms cleared, and a prescription was not always necessary. Although knowledge was not significantly associated with treatment compliance, as opposed to some other studies [15], these misconceptions need to be addressed through counseling by the prescriber and during dispensing of the antibiotic. The high proportion of non-adherent respondents is similarly reported in other studies [12,16,17]. On the contrary, high completion rates have been documented in some studies [17,18]. Primary reason for cessation of antibiotic was the improvement in health condition. This tallies with the observation that only one-third of respondents were uncomfortable with ending their treatment if they felt better. Other studies concur with this finding [19]. Interestingly, when it came to altering the dose of antibiotic, the majority preferred to consult their clinician. The experience of side-effects and exhaustion of quantity bought were other common reasons given by the respondents for non-adherence and have been reported in other studies. Sometimes symptoms perceived to be side-effects of a drug may indeed just be related to the disease process itself, so it is important that dispensers inform patients of what to expect when taking a drug to avoid discontinuation. The study did not find demographic variables to be significantly associated with treatment adherence, similar to other studies [17]. On the other hand, having a negative attitude towards antibiotic use, the elderly and having little or no family or clinician support were significantly associated with noncompletion of antibiotics at bivariate analysis. Multivariate analysis left only attitude and clinician’s support as predictive of adherence. This finding highlights the role that the providerpatient relationship plays in improving treatment outcome [17,20]. Encouragement and positive reinforcement from the provider when rendering care as opposed to poor communication about the benefits, instructions for use, and side effects of medications contributes to adherence and should be encouraged.

Conclusion

Antibiotic non-adherence is a challenge in Nigeria that cuts across all socio-demographic groups but can be influenced by addressing the quality of the doctor-patient relationship and improving attitude towards antibiotic use through targeted health education programs to correct misconceptions about antibiotics and their usage.

Declarations

Ethics approval and consent to participate

Approval for the study was obtained from the Ethical committee of the Irrua Specialist Teaching Hospital. Approval for the inclusion of the study site and participants was also sought from the facility heads of the hospitals where the study was conducted. Informed consent was duly obtained from all study participants.

Authors' contributions

ET conceived the study, ET and NA developed the protocol. Both authors were involved in data collection, analysis and writing the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors are grateful to the data collectors, and all the field workers who were involved in data collection.

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