university of groningen self-medication with antibiotics
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University of Groningen
Self-medication with antibiotics in Europe and its determinantsGrigoryan, Larissa
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SelfSelfSelfSelf----Medication with Antibiotics in Europe and Medication with Antibiotics in Europe and Medication with Antibiotics in Europe and Medication with Antibiotics in Europe and
its Determinants its Determinants its Determinants its Determinants
Larissa Grigoryan
Paranimfen:Paranimfen:Paranimfen:Paranimfen:
Liana Martirosyan
Jasperien van Doormaal
The studies in this thesis were funded by the European Commission Public Health
Directorate DG SANCO and Ubbo Emmius scholarship at the University of Groningen.
In addition, funding was also provided from funds of the participating institutions.
Publication of this thesis was supported by generous contributions from the Northern
Center for Healthcare Research (NCH), Faculty of Medical Sciences, University of
Groningen (RUG), department of Clinical Pharmacology and department of Medical
Microbiology, University Medical Center Groningen (UMCG) , Pfizer BV and Wyeth
Pharmaceuticals BV.
Grigoryan, Larissa
SelfSelfSelfSelf----Medication with Antibiotics in Europe and its Determinants Medication with Antibiotics in Europe and its Determinants Medication with Antibiotics in Europe and its Determinants Medication with Antibiotics in Europe and its Determinants
Dissertation University of Groningen, The Netherlands – with a summary in Dutch
ISBN: 978 90 77113 63 9
© Copyright Larissa Grigoryan, 2007
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronically, mechanically, by photocopying,
recording, or otherwise, without the prior written permission of the author.
Cover Design: Maya Saribashyan, “Antares” Media Holding, (www.antares.am), Yerevan,
Armenia
Printed by: Gildeprint BV, Enschede, The Netherlands
RIJKSUNIVERSITEIT GRONINGEN
SelfSelfSelfSelf----Medication with Antibiotics in Europe and its Determinants Medication with Antibiotics in Europe and its Determinants Medication with Antibiotics in Europe and its Determinants Medication with Antibiotics in Europe and its Determinants
Proefschrift
ter verkrijging van het doctoraat in de
Medische Wetenschappen
aan de Rijksuniversiteit Groningen
op gezag van de
Rector Magnificus, dr. F. Zwarts,
in het openbaar te verdedigen op
woensdag 26 september 2007
om 14.45 uur
door
Larissa Grigoryan
geboren op 2 november 1976
te Yerevan, Armenië
PromotoresPromotoresPromotoresPromotores::::
Prof. dr. F.M. Haaijer-Ruskamp
Prof. dr. J.E. Degener
BeoordelingscommissieBeoordelingscommissieBeoordelingscommissieBeoordelingscommissie::::
Prof. dr. T.J.M. Verheij
Prof. dr. H. Grundmann
Prof. dr. M.J.M. Bonten
ISBN: 978 90 77113 63 9
1
ContentsContentsContentsContents
Chapter Chapter Chapter Chapter PagePagePagePage
IIII General introduction 3
IIIIIIII Self-medication with antimicrobial drugs in Europe 13
Emerging Infectious Diseases 2006; 12(3): 452-9
IIIIIIIIIIII Is self-medication with antibiotics in Europe driven by 33
prescribed use?
Journal of Antimicrobial Chemotherapy, 2007;59(1): 152-156
IVIVIVIV Determinants of self-medication with antibiotics in Europe: 45
the impact of beliefs, country wealth and health care system
Submitted
VVVV Attitudes, beliefs and knowledge concerning antibiotic use and 61
self-medication: a comparative European study
Submitted
VIVIVIVI Are cultural dimensions relevant for explaining cross-national 79
differences in antibiotic use in Europe?
Submitted
VIIVIIVIIVII General Discussion 93
English summary 101
Nederlandse Samenvatting 107
Acknowledgements 115
About the author 119
List of publications 121
Northern Center for Healthcare Research and previous dissertations 123
General introduction
Chapter 1
4
General introductionGeneral introductionGeneral introductionGeneral introduction
Introduction
The discovery of penicillin by Alexander Fleming in 1928 triggered enormous progress
in medicine (1). Since the first generation of antibiotics became clinically available in the 1940s,
they have been the cornerstone of infectious disease therapy and have saved millions of lives.
However, after Abraham and Chain described a substance (penicillinase) that could inactivate
penicillin (2), Fleming warned that the misuse of antibiotics can lead to loss of their
effectiveness in the treatment of life-threatening infections. At the beginning of the 21st
century antimicrobial resistance has developed against every class of antimicrobial drug (3) and
has become a rapidly increasing global problem (3,4), with widely varying prevalence among
countries (5). Resistant bacteria can be rapidly transferred across international borders (6). An
important international issue is to avoid further increase in resistance by reducing unnecessary
and inappropriate use of antibiotics. The World Health Organization (WHO) and the European
Commission (EC) have recognized the importance of studying the emergence and
determinants of resistance and the need for strategies for its control (7,8). The European
Antimicrobial Resistance Surveillance System (EARSS) and the European Surveillance of
Antimicrobial Consumption (ESAC) both funded by the EC were set up (9,10). The purpose of
EARSS is to document variations in antimicrobial resistance over time and place and to provide
the basis for and assess the effectiveness of prevention programs and policy decisions. The
ESAC project aimed to obtain comparable and reliable data about antibiotic use in Europe. Data
for antibiotic use were reimbursement, distribution or sales data and did not include
information about the prevalence of self-medication by the general population. Information on
the prevalence of self-medication with antibiotics would be extremely valuable, in particular
when implementing programs aiming to prevent inappropriate use of antibiotics in Europe.
Relevance of self-medication with antibiotics in Europe
Prevalence of resistance is positively correlated with prescribed outpatient antibiotic
use on a national level (11-13). Southern and Eastern European countries, in particular, report
high levels of both antibiotic use and resistance (12). However, actual consumption of
antibiotics may also include self-medication, i.e. using antibiotics obtained without
prescription. Other sources of self-medication may include “left-over” antibiotics from
treatment courses prescribed earlier, antibiotics obtained from relatives, friends or other
sources. Self-medication with antibiotics may lead to a wrong choice of antibiotics, use of
General introduction
5
insufficient dosages or unnecessary treatment. This inappropriate use increases the risk of
selection of resistant bacteria (14) and may contribute to antibiotic resistance (15). Other
problems related to self-medication with antibiotics include adverse effects, drug interactions,
masked diagnoses and superinfection.
Self-medication is an important driver of antimicrobial overuse in low-income
countries (3). However, the information on self-medication with antibiotics in the high income
world is limited. In the US, several studies indicate considerable use of antibiotics obtained
from “leftovers”(16-18), a family member, directly from a pharmacy, or from a source outside
the US (19,20). For example, in the Hispanic neighborhood of New York city, antibiotics have
been found to be available without a prescription (21). In Europe, studies describing self-
medication and storage of antibiotics in Spain (22,23), Greece (24,25), Russia (26), and Malta (27)
and the UK (28) also suggest a considerable use of antibiotics without consulting a physician.
However, these studies were small or used selected samples and were not carried out in
Northern and Western Europe. Moreover, due to the different research methods used, no
meaningful comparison between countries was possible. In addition, there is little information
on “at risk” self-medication i.e. willingness to self-medicate (intended self-medication) and
opportunity for self-medication (storage of antibiotics).
Addressing the determinants of self-medication
Self-medication patterns may parallel prescribing habits of physicians (29). Several
studies have suggested that patient expectations regarding antibiotic use for self-limiting
diseases, such as upper respiratory tract infections (URTIs) may be generated by previous
inappropriate prescribing by the physician (16,30,31). A Spanish study found that self-
medication use was triggered by prescribed use of the same medication (32). This was likely to
be true for antibiotics as they were one of the commonly used medications in the study (32).
Previous prescribed use of antibiotics may be a potential determinant of self-medication.
Besides previous prescribed use other factors may influence use of self-medication with
antibiotics. Studies conducted in low-income countries found that over-the-counter sale of
antibiotics (33), misconceptions regarding the efficacy of antibiotics (34), the cost of medical
consultation and low satisfaction with medical practitioners (35) were among the factors
related to use of self-medication with antibiotics. A study in the US showed that cultural
beliefs and lack of health insurance encouraged residents from Latin-American descent to self-
medicate with antibiotics (36). In Europe, differences in attitudes to antibiotic use have been
described (37), but little is known about their effect on self-medication. Understanding the
relative importance of various determinants for self-medication in Europe is a pre-requisite to
develop effective interventions. Most health behaviors are determined by multiple factors.
According to the PRECEDE model, health behavior is influenced by predisposing factors
Chapter 1
6
(characteristics that lead to or motivated behavior such as knowledge and beliefs), enabling
factors (characteristics that facilitate or are needed to perform the particular behavior, such as
the recourses in the environment) and reinforcing factors (rewards and punishments received
from others). The PRECEDE model of behavior change (38) is a standardized theoretical
framework that has been used to design successful, large-scale health interventions (39,40).
Cultural differences between countries influencing antibiotic use in Europe
Cultural factors may play an important role in the consumption of antibiotics (41;42).
Cultural views of infectious conditions that require antimicrobial treatment differ between
countries (41). For example, many French people seeking medical care because of cough and
sputum production request to be treated by antibiotics; by contrast most Germans consider
such treatment as unnecessary overmedication (42). In another study, the Dutch respondents
were more confident that mild ailments will heal spontaneously and more skeptical about the
efficacy and side effects of medicines while the Flemish were mainly concerned with the risk of
doing nothing and “nursing one’s illness”(43). A first Pan-European study in five EC countries
and Turkey conducted in 1993(37) and extended to other continents(44) suggested that
patients’ attitudes to antibiotic use varied according to their country of residence. In particular,
the proportion of patients definitely expecting to receive antibiotics for respiratory tract
infections was the highest in Turkey, France and Spain among European countries. However,
that survey did not test whether differences were statistically significant between countries.
Moreover, no attention was given to attitudes towards self-medication with antibiotics,
awareness about antibiotic resistance and knowledge about effectiveness of antibiotics on
bacteria and viruses.
Besides cultural views on antibiotic use, the concept of culture includes broader and
general characteristics of a country such as cultural dimensions developed by Hofstede (45).
These dimensions represent culture-specific values with regard to general problems faced in all
countries and include power distance index (PDI), individualism (IDV), masculinity (MAS) and
uncertainty avoidance index (UAI). PDI is a measure for the extent a society is organized
hierarchically. It s defined as the extent to which the less powerful members of institutions and
organizations within a society expect and accept that power is distributed unequally. If a
society scores high on IDV the ties in this society between individuals are loose: a person is
expected to look after himself or herself and his or her immediate family only. By contrast, a
low IDV score points to a society that is more collectivist in nature. A high MAS-score stands for
a society in which emotional gender roles are clearly distinct: men are supposed to be assertive,
tough, and focused on material success; women are supposed to be more modest, tender, and
concerned with the quality of life. A low MAS-score means a society has a lower level of
General introduction
7
differentiation and inequity between genders. UAI is defined as the extent to which the
members of institutions and organizations within a society feel threatened by uncertain,
unknown, ambiguous, or unstructured situations. Uncertainty avoiding cultures try to
minimize the possibility of such situations by strict laws and rules, safety and security
measures and people within these cultures are more emotional. The opposite type, uncertainty
accepting cultures, are more tolerant of opinions different from what they are used to; they try
to have as few rules as possible and people within these cultures are more phlegmatic. It is
plausible that cultural dimensions also have an influence on culturally sensitive domains such
as illness behavior and use of medicines (46,47). However, very few studies have linked the
scores on cultural dimensions with diseases and illness behaviour (48). No study, to our
knowledge, investigated correlations between these cultural dimensions and use of medicines.
Objectives and structure of this thesis
This thesis aims to study the prevalence of self-medication with antibiotics in
European countries and explore its determinants with a focus on 1) prescribed use of
antibiotics, 2) predisposing and enabling factors. In addition, differences in attitudes, beliefs
and knowledge concerning antibiotic use and self-medication between countries and the
influence of cultural dimensions on antibiotic use in Europe were studied. The study was
funded by the European Commission Public Health Directorate DG SANCO.
Chapter 2Chapter 2Chapter 2Chapter 2 presents the results of the survey estimating the prevalence of self-medication with
antibiotics and prescribed use in the previous 12 months among the general population of 19
European countries (Austria, The Netherlands, Sweden, United Kingdom, Ireland, Denmark,
Italy, Malta, Luxembourg, Belgium, Spain, Israel, Romania, Czech Republic, Slovakia, Lithuania,
Slovenia, Croatia and Poland). We also studied “at risk” self-medication, including intended
self-medication and storage of antibiotics at home. The demographic characteristics associated
with such use, the types of drugs used, the sources of self-medication, the symptoms for which
antibiotics were reportedly used, and duration of use were also examined.
In Chapter 3Chapter 3Chapter 3Chapter 3 we investigate whether self-medication in Europe was triggered by prescribed use.
We studied the relationship between prescribed use and self-medication in general (for all
symptoms/diseases). We also studied the relationship between prescribed use and self-
medication for URTIs.
In Chapter 4Chapter 4Chapter 4Chapter 4, we studied the determinants of self-medication by investigating the relevance of
predisposing (attitudes, beliefs and knowledge concerning antibiotic use and self-medication)
Chapter 1
8
and enabling factors (country wealth and health care system factors) for use of self-medication
with antibiotics.
Moving beyond use of self-medication, in Chapter 5Chapter 5Chapter 5Chapter 5 we examined attitudes, beliefs and
knowledge concerning antibiotic use in general and self-medication between countries.
In Chapter 6Chapter 6Chapter 6Chapter 6, we investigate the relevance of cultural dimensions as described by Hofstede for
cross-national differences in antibiotic use.
Finally in Chapter 7Chapter 7Chapter 7Chapter 7, we discuss general findings of the studies, implications for the strategies
to prevent unnecessary and inappropriate use of antibiotics and provide recommendations for
future research.
General introduction
9
ReferencesReferencesReferencesReferences
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Chapter 1
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infections in a diverse community. J Fam Pract 1999 December;48(12):993-6.
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General introduction
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28. McNulty CA, Boyle P, Nichols T et al. Antimicrobial drugs in the home, United Kingdom. Emerg
Infect Dis 2006 October;12(10):1523-6.
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Manila, the Philippines. Inappropriate choices and doses. J Clin Epidemiol 1990;43(1):61-7.
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evidence on determinants. Soc Sci Med 2003 August;57(4):733-44.
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Chapter 1
12
43. Deschepper R, Vander Stichele RH, Haaijer-Ruskamp FM. Cross-cultural differences in lay
attitudes and utilisation of antibiotics in a Belgian and a Dutch city. Patient Education and
Counseling 2002;48(2):161-9.
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Suppl 3:S170-S173.
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46. Payer L. Medicine and culture: varietes of treatment in the United States, England, West
Germany and France. London, Victor Gollancz. 1990.
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Self-medication with antimicrobial drugs in Europe
Larissa Grigoryan, Flora M Haaijer-Ruskamp,
Johannes G M Burgerhof, Reli Mechtler, Reginald Deschepper,
Arjana Tambic-Andrasevic, Retnosari Andrajati, Dominique L Monnet,
Robert Cunney, Antonella Di Matteo, Hana Edelstein, Rolanda Valinteliene,
Alaa Alkerwi, Elizabeth A Scicluna, Pawel Grzesiowski, Ana- Claudia Bara,
Thomas Tesar, Milan Cizman, Jose Campos, Cecilia Stålsby Lundborg and Joan Birkin
Emerging Infectious Diseases 2006; 12(3): 452-9
Chapter 2
14
AbsAbsAbsAbstracttracttracttract
We surveyed the populations of 19 European countries to compare the prevalence of
antimicrobial drug self-medication in the previous 12 months and intended self-medication and
storage and to identify the associated demographic characteristics. By using a multistage
sampling design, 1,000–3,000 adults in each country were randomly selected. The prevalence
of actual self-medication varied from 1 to 210 per 1,000 and intended self-medication from 73
to 449 per 1,000; both rates were high in eastern and southern Europe and low in northern and
western Europe. The most common reasons for self-medication were throat symptoms (e.g.,
dry, inflamed, red, or sore throat, inflamed tonsils, tonsil pain). The main medication sources
were pharmacies and medication leftover from previous prescriptions. Younger age, higher
education, and presence of a chronic disease were associated with higher rates of self-
medication. Attempts to reduce inappropriate self-medication should target prescribers,
pharmacists, and the general public.
Self-medication with antimicrobial drugs in Europe
15
IntroductionIntroductionIntroductionIntroduction
Antimicrobial drug resistance is a rapidly increasing global problem (1,2), and
prevalence varying widely among countries (3). Prevalence of resistance is positively correlated
with prescribed outpatient drug use on a national level (4,5). However, actual consumption of
drugs may also include self-medication, i.e., using drugs obtained without prescription. Other
sources of self-medication may include leftover drugs from treatment courses prescribed
earlier or drugs obtained from relatives or friends. Use without medical guidance is
inappropriate because using insufficient dosages or incorrect or unnecessary drugs increases
the risk of the selection of resistant bacteria (6) and the spread of antimicrobial drug resistance
(7).
To date, the information on self-medication with antimicrobial drugs in the
industrialized world is limited. In the United States, several studies indicate considerable use of
leftovers (8–10), drugs obtained from a family member, a pharmacy, or a source outside the
country (11,12). For example, in an Hispanic neighborhood of New York City, antimicrobial drugs
are available without a prescription (13). In Europe, studies describing self-medication and
storage of antimicrobial drugs in Spain (14,15), Greece (16,17), Russia (18), and Malta (19) also
suggest considerable use of the drugs without consulting a physician. However, these studies
were small or used selected samples and were not carried out in northern and western Europe.
Moreover, because of the different research methods used, no meaningful comparison
between countries was possible. In addition, little information exists on factors that puts
person at-risk for self-medication. This survey was designed to fill that gap for 19 European
countries: Austria, the Netherlands, Sweden, United Kingdom, Ireland, Denmark, Italy, Malta,
Luxembourg, Belgium, Spain, Israel, Romania, Czech Republic, Slovakia, Lithuania, Slovenia,
Croatia, and Poland. The aim of this study was to estimate and compare the prevalence of
actual self-medication and at-risk for self-medication with antimicrobial drugs in participating
countries. The demographic characteristics associated with such use, the types of drugs used,
the sources of self-medication, the symptoms for which the drugs were reportedly used, and
duration of use were also examined.
MethodsMethodsMethodsMethods
Countries participating in the study were recruited from 2 networks of surveillance
systems: European Surveillance of Antimicrobial Consumption (20) and European Antimicrobial
Resistance Surveillance System (21). A multistage sampling design was used for sample
selection in each participating country. Within each country, a region with average prescribed
antimicrobial drug consumption was chosen. In those countries where this information was
Chapter 2
16
not available (Poland, Czech Republic, Lithuania, Croatia, and Romania), a region was selected
that was representative of the country’s population in terms of age and sex. In each region, a
city (75,000−750,000 inhabitants) and a rural area (5,000−10,000) were selected. By using
population registries, including lists of persons in the identified cities and rural areas, persons
>18 years of age were selected by simple random sampling (computer-generated random
numbers). To calculate the sample size, we needed the standard deviation of the unknown
prevalence. As the standard deviation was a function of this unknown prevalence, we took the
maximal possible value of the standard deviation (22). To obtain a precision of 0.05, the sample
size needed was 400 persons per country. To adjust for possible non-response, we selected
larger samples; sample sizes in the countries were 1,000–3,000 persons, equally distributed in
urban and rural areas. Self-administered questionnaires were mailed between March and July
2003, and reminders with a new questionnaire attached were sent 2−4 weeks later.
We developed an English questionnaire specifically for this survey, translated it into
national languages, and back translated it to ensure consistency.1 The questionnaire was pilot-
tested in each country. It could be completed either anonymously or with identifiable details to
allow a follow-up study. Questions asked about the respondent’s use of antimicrobial drugs
during the past 12 months, how they were obtained, how they were stored at home, and
whether the respondent would consider using drugs without consulting a physician. Details of
the drugs used (name of the medicine, symptom or disease coded with International
Classification of Primary Care codes [23], and duration of use) and demographic characteristics
of the respondents were included. Antibacterial drugs for systemic use (Anatomical
Therapeutic Chemical class J01) (24) were included in the analyses. Medicines erroneously
reported as antimicrobial drugs were excluded from the analyses.
Ethics or data committee approval for the survey was required in Sweden, Denmark,
Belgium, United Kingdom, Ireland, Malta, Czech Republic, Slovenia, Croatia, Romania, and
Lithuania and was obtained from the local ethics or data committees of these countries.
Respondents were classified as self-medicating if they reported that they had taken any
antimicrobial drugs in the previous 12 months without a prescription from a physician, dentist,
or nurse and as prescribed users if antimicrobial drugs had been prescribed. (Physician
respondents who reported using non-prescribed drugs were not classified as self-medicating.)
Those classified as at-risk for self-medication included those who indicated the intention to
self-medicate or store drugs at home. Intended self-medication was defined as answering
“yes” or “maybe” to the question, “In general, would you use antimicrobial drugs for yourself
without contacting a doctor/nurse/hospital?” Two estimates were used to assess storage of
drugs: a maximum estimate, including all respondents who stored antimicrobial drugs, and a
conservative estimate that excluded those respondents who stored antimicrobial drugs and
had taken the same drugs for a prescribed course in the previous 12 months.
1 A copy of the questionnaire is available from the corresponding author upon request.
Self-medication with antimicrobial drugs in Europe
17
Statistical AnalysesStatistical AnalysesStatistical AnalysesStatistical Analyses
Descriptive statistics were used to estimate the prevalence rates per 1,000 respondents
and 95% confidence intervals (CI) for actual self-medication and prescribed use in the previous
12 months and for at-risk self-medication in each country. To assess possible bias from low
response rates, we also estimated adjusted prevalence rates. We applied the continuum of the
resistance model (25), based on the assumption that late respondents most resemble non-
respondents. Late respondents in our study were those who replied after the reminder. The
adjusted prevalence is considered similar to the observed prevalence when it falls in the 95% CI
of the observed prevalence.
The effects of individual characteristics and country on antimicrobial drug self-
medication were studied with logistic regression analyses by using 3 outcome variables: actual
self-medication in the previous 12 months, storage of antimicrobial drugs, and intended self-
medication. Countries were grouped together in 3 European regions: northern and western
(Sweden, Denmark, the Netherlands, Austria, Belgium, Luxemburg, United Kingdom, and
Ireland), southern (Malta, Italy, Israel, and Spain), and eastern (Czech Republic, Slovenia,
Croatia, Poland, Slovakia, Romania, and Lithuania). This grouping was based on patterns of
prescribed use of antimicrobial drugs (4), geographic location (26), similarities in healthcare
systems, and socioeconomic development. The former socialist countries are referred to as
eastern countries. We tested possible interactions between the factors found to be significant
and set the significance at p<0.01 for interaction terms due to multiple testing. Multivariate
logistic regression was also used to study the relationship between intended self-medication,
storage, and actual self-medication in the previous 12 months. Data were analyzed by using
SPSS (version 11) for Windows (SPSS Inc, Chicago, IL, USA).
ResultsResultsResultsResults
A total of 15,548 respondents completed the questionnaires. The mean response rate of
the countries was 40% (Table 1).
Prevalence of self-medication and prescribed use
The prevalence rates of antimicrobial drug self-medication (actual and at-risk) and
prescribed use are presented separately for countries with response rates >40% and <40%
(Table 2). In both of these groups, prevalence rates for actual self-medication were highest in
eastern (in particular, Romania and Lithuania), followed by rates in southern (Malta, Spain, and
Italy) Europe.
Chapter 2
18
Table 1. G
eneral chara
Table 1. G
eneral chara
Table 1. G
eneral chara
Table 1. G
eneral characteristics of respondents in each country
cteristics of respondents in each country
cteristics of respondents in each country
cteristics of respondents in each country
* Low education was defined as incomplete primary education, completed primary education, and lower vocational or general education
† Including any of the following diseases: asthma, chronic bronchitis, emphysem
a, H
IV, cystic fibrosis, diabetes, endocarditis, tuberculosis, prostatitis, chronic
urinary tract infection, chronic osteomyeltis, peptic ulcer disease, chronic pyelonephritis or cancer
§ Rem
inders were not sent to non-respondents
Note: N
L (The Netherlands); SE (Sweden); DK (Denmark); AT (Austria); BE (Belgium); LU (Luxembourg); UK (United Kingdom); IE (Ireland); IL (Israel); M
T (M
alta);
IT (Italy); ES (Spain); CZ (Czech Republic); SI (Slovenia); HR (Croatia); PL (Poland); SK (Slovakia); RO (Romania) and LT (Lithuania)
N
ort
h a
nd W
est
South
E
ast
N
L
S
E
DK
AT
BE
LU
UK
§
IE
IL
M
T
IT
E
S
C
Z
S
I H
R
P
L
S
K
R
O
LT
Respon
se
rate
(%
) 55
69
6
3
28
54
50
23
26
18
54
21
20
59
38
31
3
2
55
4
3
25
Num
ber
of
resp
ond
ents
1,6
34
70
4
1,8
81
44
2
1,7
34
6
75
675
793
46
7
541
21
3
204
1,1
69
1,1
43
6
15
935
5
46
430
7
47
Mea
n a
ge
(yrs
) ±
SD
48
±17
54
±1
9
48
±17
49
±1
6
45
±16
46
±
18
50
±
10
48
±16
50
±1
7
46
±
16
45
±1
8
47
±
14
54
±1
5
48
±17
53
±
16
45
±18
41
±
16
50
±18
59
±
18
Fe
ma
le (
%)
58
53
56
50
55
51
58
59
61
55
61
47
36
58
55
6
0
54
4
9
35
Low
ed
ucatio
n*
(%)
30
53
60
64
32
49
40
53
19
60
37
31
45
70
10
4
2
27
4
3
32
Pre
sen
ce o
f a
ch
ron
ic
dis
ea
se
(%)†
15
14
14
15
13
15
15
17
22
21
27
18
27
20
26
2
3
23
2
7
39
Urb
an lo
cation
(%
) 48
49
49
53
50
45
58
47
36
47
51
57
48
47
58
5
2
54
4
3
54
Self-m
edication with antimicrobial drugs in Europe
19
Table 2. Actual use of system
ic antibiotics in
Table 2. Actual use of system
ic antibiotics in
Table 2. Actual use of system
ic antibiotics in
Table 2. Actual use of system
ic antibiotics in the
the
the
the last 12 months and “at risk” self
last 12 months and “at risk” self
last 12 months and “at risk” self
last 12 months and “at risk” self- ---m
edication in 19 European countries
medication in 19 European countries
medication in 19 European countries
medication in 19 European countries
Rate
per
1,0
00 r
esp
ond
ents
(95%
CI)
Co
untr
y (
regio
n in c
ountr
y)
Actu
al self-m
edic
atio
n
Pre
scri
bed u
se
Inte
nded s
elf-
medic
ation
Sto
rag
e†
(conserv
ative e
stim
ate
) S
tora
ge‡
(maxim
um
estim
ate
) C
ou
ntr
ies w
ith
resp
on
se r
ate
>40
%
N
ort
h a
nd W
est
T
he N
eth
erl
an
ds (
Tw
ente
) 1 (
0.2
-4)
15
2 (
13
4-1
70)
85 (
71-1
01)
10 (
6-1
7)
36 (
28-4
6)
Sw
ede
n (
Vastm
anla
nd)
4 (
0.9
-12)
13
5 (
10
9-1
61)
11
8 (
94-1
43)
14 (
7-2
6)
43 (
29-6
0)
Denm
ark
(F
une
n, A
arh
us,
Copen
hag
en
* )
7 (
4-1
2)
17
2 (
15
4-1
89)
13
2 (
11
6-1
47)
42 (
33-5
2)
84 (
72-9
7)
Lu
xem
burg
(w
hole
co
untr
y)
9 (
3-1
9)
28
8 (
25
2-3
24)
83 (
62-1
07)
90 (
69-1
14)
13
2 (
10
6-1
58)
Belg
ium
(E
ast F
landers
, F
lem
ish B
rab
ant)
9 (
5-1
5)
22
2 (
20
1-2
42)
80 (
67-9
5)
71 (
59-8
4)
12
3 (
10
7-1
38)
South
Malta (
whole
co
untr
y)
56 (
38-7
9)
42
2 (
38
0-4
65)
22
8 (
19
2-2
64)
156 (
125-1
86)
26
9 (
23
2-3
06)
East
C
zech R
ep
ublic
(H
radec K
rlov)
7 (
3-1
3)
25
3 (
22
8-2
79)
17
9 (
15
6-2
01)
45 (
33-5
8)
64 (
51-8
0)
Slo
vakia
(M
iddle
Slo
vakia
regio
n)
42 (
27-6
3)
56
9 (
52
7-6
12)
32
4 (
28
4-3
65)
192 (
159-2
25)
30
2 (
26
3-3
40)
Rom
ania
(D
olj)
198 (
160-2
35)
30
7 (
26
3-3
51)
43
1 (
38
3-4
78)
200 (
162-2
38)
32
1 (
27
7-3
65)
Co
un
trie
s w
ith
resp
on
se r
ate
<40
%§
N
ort
h a
nd W
est
52 (
33-7
7)
Austr
ia (
Up
per
Austr
ia)
9 (
2-2
3)
15
9 (
12
4-1
95)
73 (
49-1
03)
34 (
19-5
5)
52 (
33-7
7)
UK
(N
ott
ingha
mshire)
12 (
5-2
3)
22
1 (
18
9-2
54)
16
6 (
13
7-1
95)
33 (
21-4
9)
74 (
56-9
7)
Irela
nd (
Cork
) 14 (
7-2
5)
35
3 (
32
0-3
86)
15
0 (
12
5-1
76)
29 (
19-4
3)
10
0 (
80-1
23)
South
Isra
el (N
ort
hern
Isra
el)
15 (
6-3
1)
33
0 (
28
7-3
74)
18
7 (
15
0-2
23)
12
0 (
91-1
49)
23
6 (
19
7-2
74)
Italy
(A
bru
zzo
) 62 (
33-1
03)
51
2 (
44
4-5
80)
24
3 (
18
5-3
01)
379 (
314-4
45)
56
9 (
50
2-6
36)
Spain
(A
uto
nom
ous C
om
munity o
f M
adrid)
152 (
103-2
01)
31
5 (
25
1-3
79)
31
4 (
24
9-3
80)
260 (
200-3
20)
50
0 (
43
1-5
69)
East
S
lovenia
(Lju
blja
na r
egio
n)
17 (
10-2
6)
29
3 (
26
6-3
20)
28
0 (
25
3-3
07)
119 (
100-1
37)
18
3 (
16
0-2
05)
Cro
atia (
Za
gre
b c
ou
nty
) 31 (
19-4
8)
43
9 (
39
9-4
78)
20
5 (
17
2-2
37)
130 (
103-1
56)
21
2 (
17
9-2
44)
Pola
nd (
Pom
ors
kie
) 33 (
23-4
7)
19
9 (
17
2-2
25)
11
5 (
94-1
36)
69 (
53-8
7)
13
7 (
11
5-1
60)
Lith
ua
nia
(K
laip
ed
a,
Rie
tavas)
210 (
181-2
39)
27
5 (
24
3-3
08)
44
9 (
41
2-4
86)
177 (
149-2
04)
33
3 (
29
9-3
67)
* Although Copenhagen has population >750,000, both self-medication and prescribed use of antibiotics were not significantly different between the sample
of Copenhagen and sample of the other two Danish counties (chi square tests)
†Included only those respondents who stored antibiotics and had not taken the same antibiotics for a prescribed course in the previous 12 m
onths
‡Including all respondents who stored antibiotics
§The rates for these countries should be interpreted as first rough estim
ates
Chapter 2
20
The lowest rates were in northern and western (the Netherlands and Sweden) Europe.
The rates of at-risk self-medication also tended to be higher in southern and eastern Europe
than in northern and western Europe. The adjusted estimates of prevalence rates of
self-medication were similar to the observed rates for many of the countries.2 In Luxembourg,
Austria, Israel, Spain, and Lithuania, the adjusted rates of self-medication were consistently
higher than the observed rates, indicating that the observed rates may underestimate the
prevalence in these countries. By contrast, in Romania, Croatia, and Slovenia, the adjusted rates
were lower than the observed rates, indicating that the prevalence rates might be
overestimated in our study. We compared our estimates of antimicrobial drug self-medication
with data available from the European Union’s Eurobarometer survey in October 2002 (27). We
calculated the prevalence of drug use from “leftovers” and drugs “directly from the pharmacy”
by using the Eurobarometer data and compared these figures with the same estimates in our
study. The estimates were similar with overlapping 95% CIs (data not shown) for countries
with both high and low response rates.
Our figures differed regarding Spain, for which we found a higher prevalence of self-
medication than did the Eurobarometer. Three other studies (4,15,28) indicated an even higher
prevalence of self-medication in Spain than in our estimate.
Types of antimicrobial drugs used for self-medication and duration of use
Antimicrobial drugs from all classes were used for self-medication in countries with
response rates both >40% and <40% (Figure 1) Penicillins were the most commonly used,
representing 54% of total courses in all countries. Among the countries with response rate
>40%, southern and eastern countries used significantly more broad-spectrum penicillin for
self-medication than northern and western countries (χ2, p<0.05). This difference was
significant when the analysis was repeated and included all countries (χ2, p<0.01).
Seventeen courses of self-medication with chloramphenicol in Lithuania and 1 course in
the Czech Republic were found (data not shown). Ten courses of self-medication with
parenteral (injectable) antimicrobial drugs, namely streptomycin or gentamicin, were found in
Lithuania (data not shown). The median duration of actual self-medication was 5 days (1 to 100
days) and was significantly longer among the respondents who had chronic diseases (Mann-
Whitney U test, p<0.01).
2 The “adjusted” estimates for each country are available from the corresponding author upon request.
Self-medication with antimicrobial drugs in Europe
21
Figure 1. Use of major groups of antibiotics for actual selfFigure 1. Use of major groups of antibiotics for actual selfFigure 1. Use of major groups of antibiotics for actual selfFigure 1. Use of major groups of antibiotics for actual self----medication in 17 countries* medication in 17 countries* medication in 17 countries* medication in 17 countries*
*Excluding countries that reported less than 5 self-medication courses
†includes systemic amphenicols (J01B), aminoglycosides (J01G), combinations of systemic antibiotics
(J01R) and other systemic antibiotics (J01X)
**number of courses (taken in the previous 12 months) per 1,000 respondents per country
Note: DK (Denmark); CZ (Czech Republic); LU (Luxembourg); BE (Belgium); SK (Slovakia); MT (Malta); RO
(Romania); AT (Austria); UK (United Kingdom); IL (Israel); IE (Ireland); SI (Slovenia); PL (Poland); HR
(Croatia); IT (Italy); ES (Spain); and LT (Lithuania)
Reasons for self-medication and sources
A throat symptom (including red or sore throat), teeth or gum symptoms, and
bronchitis were the most common reasons for self-medicating (Figure 2). Eye infection, pain,
prostatitis, urogenital infection, headache, and “bad health” were among the other reasons for
self-medication (data not shown). In countries with response rates >40%, a throat symptom
was also the most common, followed by symptoms of the teeth or gums (Figure 2). Symptoms
such as inflammation, skin infection, or diarrhea were reported only in countries with lower
response rates. Self-medication for pyelonephritis or pyelitis was reported only in Lithuania;
diarrhea was reported in Lithuania (10 patients; 9 used chloramphenicol), Austria (1 patient),
and United Kingdom (1 patient).
Countries with response rate >40% Countries with response rate <40%
0%
20%
40%
60%
80%
100%
DK CZ LU BE SK MT RO AT UK IL IE SI PL HR IT ES LT
rela
tive f
req
uen
cy
broad-spectrum penicillins (J01CA) narrow-spectrum penicillins (J01CE)
other penicillins (J01CF and J01CR) macrolides and lincosamides (J01F)
tetracyclines (J01A) sulphonamides and trimethoprim (J01E)
systemic cephalosoprins (J01DA) systemic quinolones (J01M)
other†
7** 9 10 1214 17 19 23 3642 65 66 162258 31211 37
Chapter 2
22
Figure 2. Prevalence of actual selfFigure 2. Prevalence of actual selfFigure 2. Prevalence of actual selfFigure 2. Prevalence of actual self----medication by symptoms or diseases classified by ICPC codes (rates per medication by symptoms or diseases classified by ICPC codes (rates per medication by symptoms or diseases classified by ICPC codes (rates per medication by symptoms or diseases classified by ICPC codes (rates per
1,000 1,000 1,000 1,000 respondents and 95%CI)respondents and 95%CI)respondents and 95%CI)respondents and 95%CI)
* * * * Symptoms or diseases with rates less than 1 per 1000 respondents, including eye infection,
pain, prostatitis, urogenital infection, headache and “bad health”
For intended self-medication as with actual self-medication, a sore throat was the most
common symptom, followed by urinary tract infection and toothache (Figure 3). When
including only those countries that had response rates >40%, sore throat and urinary tract
infection were also the most common symptoms (Figure 3).
rates per 1,000 respondents
0 2 4 6 8 10
Other*
Cough(R05)
Sinus symptom complaint, other(R09)
Tonsillitis acute(R76)
Laryngitis, tracheitis, acute(R77)
Pneumonia(R81)
Pyelonephritis/pyeltis(U70)
Fever(A03)
Diarrhoea(D11)
Respiratory infection, other(R83)
Skin infection, other(S76)
Ear infections(H70)
Inflammation/infection, not specified
Cystitis/urinary infection(U71)
Influenza(R80)
Upper resp.infection(R74), sneezing/nasal congestion(R07)
Acute bronchitis/bronchiolitis(R78)
Teeth/gum symptom/complaint(D19)
Throat symptom/complaint(R21)
All countries
Countries with response rate >40%
Self-medication with antimicrobial drugs in Europe
23
Figure3. The prevalence of intended selfFigure3. The prevalence of intended selfFigure3. The prevalence of intended selfFigure3. The prevalence of intended self----medication per prmedication per prmedication per prmedication per predefined symptom (rates per 1,000 edefined symptom (rates per 1,000 edefined symptom (rates per 1,000 edefined symptom (rates per 1,000
respondents and 95% CI) respondents and 95% CI) respondents and 95% CI) respondents and 95% CI)
In eastern countries, the major source of self-medication was the pharmacy without
prescription (309 courses, 68%), followed by leftover medications (120 courses, 26%). By
contrast, in southern, northern, and western countries use of leftover medication was more
prevalent (46 courses [51%] in southern countries and 35 courses [44%] in northern and western
countries), followed by medications obtained directly from the pharmacy (41 courses [46%] in
southern countries and 15 courses [19%] in northern and western countries). Among other
sources of self-medication were drugs obtained from relatives or friends (52 courses, 8%, in all
countries), drugs that were stored after being obtained abroad (10 courses, 2%, in all countries),
and drugs obtained over the Internet (3 courses, all in Lithuania).
0 20 40 60 80
Other infections/diseases
Diarrhoea
Sinusitis
Ear infections
Runny nose/cold
Bronchitis
Cough
Fever
Influenza
Toothache
Urinary tract infections
Sore throat
All countries Countries with response rate >40%
rates per 1,000 respondents
Chapter 2
24
Effects of Individual Characteristics
The effects of demographic characteristics and chronic disease on actual self-
medication, intended self-medication, and storage of antimicrobial drugs are shown in Table 3.
Sex and location (urban or rural) had no significant relevance in any of the 3 models.
Respondents from southern and eastern countries were more likely to self-medicate (adjusted
odds ratio [OR] 6.8, 95% CI 4.8−9.7, and 7.5, 5.7−10.0, respectively) than respondents from
northern and western countries. Younger age, higher educational level, and presence of a
chronic disease were all significantly associated with self-medication. Similar results were
obtained for the relationship between demographic characteristics and storage of
antimicrobial drugs, by using the conservative estimate of storage. Younger age, higher
educational level, and presence of a chronic disease were also significant predictors of intended
self-medication. Presence of a chronic disease increased the risk of intended self-medication,
but this effect diminished with increasing age. We repeated all analyses including only those
countries that had response rates >40% and obtained similar results. We also repeated these
analyses separately for early and late respondents and obtained similar results. iii
Relation between intended self-medication, storage, and actual self-medication
Intended self-medication and storage are both predictors of actual self-medication. A
significant relationship was found between intended self-medication and storage. Intended
self-medication was a strong predictor for actual self-medication for both respondents who
stored drugs (OR 20.9, 95% CI 15.5−28.2) and those who did not (OR 17.8, 95% CI 14.0−22.7).
However, for those who did not intend to self-medicate, storage also predicted higher actual
self-medication (OR 3.5, 95% CI 2.2−5.6). When the analyses were repeated, including only those
countries that had response rates >40%, similar results were obtained.
iii Results are available on request from the corresponding author.
Self-m
edication with antimicrobial drugs in Europe
25
Table 3. Effects of dem
ographic characteristics on actual and “at risk” self
Table 3. Effects of dem
ographic characteristics on actual and “at risk” self
Table 3. Effects of dem
ographic characteristics on actual and “at risk” self
Table 3. Effects of dem
ographic characteristics on actual and “at risk” self- ---m
edication with systemic antibiotics
medication with systemic antibiotics
medication with systemic antibiotics
medication with systemic antibiotics
* North and W
est includes Sweden, D
enmark, The Netherlands, Austria, Belgium, Luxemburg, U
nited Kingdom, Ireland; South includes Israel, M
alta, Italy, and
Spain; East includes Czech Republic, Slovenia, Croatia, Poland, Slovakia, Romania and Lithuania
† Low education was defined as incomplete primary education, completed primary education, and lower vocational or general education
‡including any of the following diseases: asthma, chronic bronchitis, emphysem
a, H
IV, cystic fibrosis, diabetes, endocarditis, tuberculosis, prostatitis, chronic
urinary tract infection, chronic osteomyeltis, peptic ulcer disease, chronic pyelonephritis or cancer
Adju
ste
d O
dd
s R
atio
(95
% C
I)
Dete
rmin
ants
Actu
al self-m
ed
ication
Sto
rage
(co
nserv
ative
estim
ate
) In
ten
de
d s
elf-m
ed
icatio
n
Ag
e
0.9
85
(0.9
79
-0.9
92)
0.9
77 (
0.9
73-0
.982)
0.9
84
(0.9
80
-0.9
87)
R
eg
ion in E
uro
pe*
No
rth a
nd
We
st
South
E
ast
1 (
refe
ren
ce
) 6.7
76
(4.7
52
-9.6
62)
7.5
29
(5.6
76
-9.9
85)
1
5.1
01 (
4.2
40-6
.137)
3.3
11 (
2.8
68-3
.822)
1
2.2
33
(1.9
09
-2.6
13)
2.8
51
(2.5
77
-3.1
54)
E
du
catio
n
low
edu
ca
tio
n†
hig
h e
ducatio
n
1 (
refe
ren
ce
) 1.3
57
(1.0
95
-1.6
80)
1
1.6
90 (
1.4
70-1
.943)
1
1.2
33
(1.1
16
-1.3
61)
C
hro
nic
dis
ease
‡ no c
hro
nic
dis
ea
se
an
y ch
ron
ic d
ise
ase
1 (
refe
ren
ce
) 1.8
88
(1.4
97
-2.3
83)
1
1.2
25 (
1.0
38-1
.446)
1
2.3
20
(1.5
94-3
.378)
Ag
e×
an
y ch
ron
ic d
ise
ase
0.9
89
(0.9
82
-0.9
96)
Expon
entia
l (c
onsta
nt)
0.0
12
0
.08
3
0.2
19
Chapter 2
26
DiscussionDiscussionDiscussionDiscussion
Self-medication with antimicrobial drugs occurred in all countries that participated in
this survey. We included the data from both countries that had high and low response rates. In
most of the countries with low response rates (except Spain), no other information is available
about self-medication, an often overlooked issue. The second reason for including these
countries was that low response was not a problem of this study only, but a general problem of
surveys in these countries (29,30). This finding implies that if we want to include information
about these countries, the results may be biased. In addition, debate is growing that low
response is less problematic in affecting survey estimates than previously assumed (31).
Nevertheless, the prevalence rates of self-medication in countries with low response rates
should be considered as a rough estimate and interpreted as an indication that the problem
exists.
Antimicrobial drug self-medication prevalence varies widely among different European
regions, with the highest rates in eastern and southern countries, and the lowest in northern
and western. Besides actual self-medication, intended self-medication is clearly relevant: it is a
strong predictor of actual self-medication. Intended self-medication has a much higher
prevalence than actual self-medication, indicating that the population at-risk is much larger
than those who have actually self-medicated in the previous 12 months. Another risk factor for
actual self-medication is the availability of drugs at home; opportunity encourages use. Our
findings contribute to the growing evidence that estimates of antimicrobial drug use that are
based on prescription data only are likely to underestimate actual consumption in both Europe
and the United States (11,32). Our European estimates are low in comparison with those from a
recent study in the US Hispanic community that showed that ≈20% of the respondents
acknowledged getting drugs without a prescription in the United States (32). The only
comparable high rates were found in Spain, Romania, and Lithuania, where they ranged from
9% to 18%. However, these figures should be compared with caution because our estimates
refer to acquiring drugs without prescription in the last 12 months and the United States study
refers to ever acquiring them.
We found that many persons used antimicrobial drug leftovers from previous
prescriptions, as was the case in reports from the United States (8−10,12). Drugs could be left
over because extra tablets were dispensed (in many countries pharmacies dispense drugs per
package, not exact number of tablets) or because of patient noncompliance. Noncompliance
may result in 2 inappropriate courses if the patient does not take the amount of medication
prescribed and self-medicates later. Earlier findings indicated lower compliance in Italy and
Spain than in Belgium, France, and the United Kingdom (33). In Italy, 41% of the interviewees
who had taken drugs in the previous 12 months saved part of the course for future use,
whereas only 4% of British interviewees reported this behavior (33).
Self-medication with antimicrobial drugs in Europe
27
In general, respondents’ self-diagnosed disorders were self-limiting and antimicrobial
drugs would not have been indicated. In contrast to studies in developing countries, this study
identified few cases of self-medication for sexually transmitted diseases (34,35). Only 2
respondents in Lithuania reported self-medication for “gynaecological infection” that might
have been a sexually transmitted infection.
In this survey, persons who were more prone to self-medicate with antimicrobial drugs
were younger persons, more educated, and had chronic diseases. This finding corresponds to
those of studies conducted in the United States and Greece, which also found that higher
educational status is associated with misuse of drugs (8,17). This relationship cannot be directly
attributed to educational status. The interpretation of symptoms is also relevant. Previously, a
study in the United States showed that persons with a higher education level tended to believe
that antimicrobial drugs were less effective for upper respiratory infections with clear
discharge but more effective with discoloured discharge (36).
Antimicrobial drug self-medication is a cause for concern because it may contribute to
the spread of antimicrobial drug resistance. Self-treatment with a drug that is ineffective
against the causative organism or with an inappropriate dosage may increase the risk of
selection of resistant organisms that are difficult to eradicate. These resistant organisms may
then be transferred into the community. Our findings illustrate that adverse effects are
aggravated by self-medication when unnecessary drugs, such as chloramphenicol, tetracycline,
and aminoglycosides, are taken. Other problems related to self-medication include drug
interactions, masked diagnoses, and superinfection.
Our results are comparable to those of other studies such as the Eurobarometer study
(14,19,27). A study on antimicrobial drug storage among Spanish households showed that 42%
of Spanish households had drugs at home, including those currently used (14). This finding is
comparable to the prevalence of drugs stored (50%) in our study. In Malta, a higher prevalence
(19%) of self-medication was found (19) than in our study, perhaps because the study included
self-medication in the previous 2 years, while our study included the previous 12 months.
Furthermore, the pattern of the prescribed use of drugs in different regions of Europe in our
study is similar to that found in the study by Goossens et al., which was based on information
from national databases (4).
A strength of our study is that we used the same methods and comparable samples in
all countries, which facilitated an overview of the European situation. The low response rate in
some countries is a limitation of our study, however. Although we calculated the prevalence
rates adjusted for non-response, they are based on the assumption that respondents who
replied after the reminder most resemble non-respondents.
As with all self-reported data, results of this survey have the potential for recall bias,
underreporting, or overreporting. We attached the list of the most commonly used
antimicrobial drugs in each country to the questionnaires to reduce recall problems. To
Chapter 2
28
discourage underreporting of self-medication, the questions about drug use were formulated
in a neutral way in which the source of the drug could be chosen from 6 predefined sources or
“other source.” Substantial variation in the prevalence rates of antimicrobial drug self-
medication among the European regions suggests that cultural (37) and socioeconomic factors
play a role, as do disparities in health care systems such as reimbursement policies, access to
health care, and drug dispensing policies. Another factor is the acquisition of antimicrobial
drugs from pharmacies without prescription, which occurred most frequently in eastern
European countries. Although over-the-counter sale of antimicrobial drugs is illegal in all
participating countries, there is clearly a need to enforce the law in some countries.
Antimicrobial drug self-medication is a cause for concern in Europe. Even the lowest
prevalence, 1 person per 1,000 respondents, implies that 10,000 persons in a population of
10,000,000 are self-medicating annually. Our study indicates a high prevalence of self-
medication in countries that reported high resistance levels (southern and eastern countries).
Even in the countries with low actual self-medication, substantial intended self-medication
and drug storage occurs. Efforts to reduce inappropriate use of antimicrobial drugs should
include the issue of self-medication and should involve prescribers, pharmacists, and the
general public. The number of tablets dispensed in pharmacies should be limited, and patients
should be instructed to discard their leftover drugs. Large-scale public campaigns, such as
those recently launched in the United States, Canada, Belgium, and Australia (38), should
include detailed instructions and emphasize the potential risks of using antimicrobial drugs
without medical guidance.
AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements
This study was funded by a grant from DG/Sanco of the European Commission
(SPC2002333), the European Commission Public Health Directorate DG SANCO, and the
participating institutions.
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Is self-medication with antibiotics in Europe driven
by prescribed use?
Larissa Grigoryan, Johannes G M Burgerhof,
Flora M Haaijer-Ruskamp, John E Degener, Reginald Deschepper,
Dominique L Monnet, Antonella Di Matteo, Elizabeth A Scicluna,
Ana- Claudia Bara, Cecilia Stålsby Lundborg, Joan Birkin, on behalf of the SAR group
Journal of Antimicrobial Chemotherapy, 2007;59(1): 152-156
Chapter 3
34
Abstract Abstract Abstract Abstract
BackgroundBackgroundBackgroundBackground:::: Self-medication with antibiotics may increase the risk of inappropriate use and
the selection of resistant bacteria. One of the triggers for using self-medication may be past
experience with antibiotics prescribed by health professionals. We examined the association
between prescribed use and self-medication with antibiotics.
MethodsMethodsMethodsMethods:::: A population survey was conducted in 19 European countries, covering 15 548
respondents. Multinomial logistic regression analysis was used to study the relationship
between prescribed use and self-medication for all symptoms/diseases and for upper
respiratory tract infections (URTIs).
ResultsResultsResultsResults:::: The association between prescribed use and self-medication was modified by source of
self-medication, region in Europe and education. This association was consistently stronger for
self-medication from leftovers than from other sources, primarily directly from a pharmacy. It
was stronger also for respondents from Northern/Western Europe than respondents from
Eastern Europe and Southern Europe and those with low education. Prescribed use for URTIs
(minor ailments such as throat symptom, influenza, etc.) increased the likelihood of self-
medication with leftover antibiotics for these symptoms/diseases in all European regions.
ConclusionsConclusionsConclusionsConclusions:::: Our study shows consistent associations between prescribed use and self-
medication with antibiotics from leftovers, but has not been able to support the hypothesis
that self-medication from other sources than leftovers is triggered by earlier prescribed use.
Preventing leftovers may be one effective way of preventing self-medication. This can be
achieved by ensuring that the amount dispensed corresponds to the amount prescribed, by
educating patients and by making doctors aware that prescribing for minor ailments may
increase the risk of self-medication for such ailments.
Is self-medication with antibiotics in Europe driven by prescribed use?
35
IntroductionIntroductionIntroductionIntroduction
Self-medication with antibiotics may lead to a wrong choice of antibiotics, use of
insufficient dosages or unnecessary therapy. This inappropriate use increases the risk of
selection of resistant bacteria (1) and may contribute to antibiotic resistance (2). Previous
studies have shown that self-medication with antibiotics occurs in the United States and
Europe, in particular for colds and upper respiratory tract symptoms (3,4). The rates of
antibiotic prescribing for upper respiratory tract infections (URTIs) remain at high levels (5),
although the majority of these illnesses have a viral cause. This may imply that one of the
triggers for using self-medication by people can be a past experience with prescribed use of
antibiotics.
A study in Spain found that the main reason for using self-medication was a previous
medical prescription of the same medication (6). This is likely to be true for antibiotics as they
were one of the commonly used pharmacological groups in this study (6). Moreover, several
studies suggested that unrealistic patient expectations regarding the need for antibiotics may
be generated by previous inappropriate prescribing by the physician (3,5,7). Information about
the relationship between prescribed antibiotic use and self-medication with antibiotics can be
helpful in designing interventions to prevent self-medication. To date, no study has explored
this relationship. We investigated whether prescribed use triggers self-medication with
antibiotics in European countries.
MethodsMethodsMethodsMethods
A cross-sectional survey was conducted simultaneously in 19 European countries.
Countries participating in two European networks of surveillance systems [European
Surveillance of Antimicrobial Consumption (8) and European Antimicrobial Resistance
Surveillance System (9)] were invited to participate in this study. The following countries
agreed to participate: Austria, The Netherlands, Sweden, the UK, Ireland, Denmark, Italy, Malta,
Luxembourg, Belgium, Spain, Israel, Romania, Czech Republic, Slovakia, Lithuania, Slovenia,
Croatia and Poland. The design of the study, the characteristics of the respondents in each
country and the prevalence rates of self-medication and prescribed use in each country have
been published elsewhere (4). A multistage sampling design was used for sample selection in
each participating country. Within each country, a region with average prescribed antibiotic
consumption was chosen and in each chosen region a middle-size city and rural area were
selected. Questionnaires were mailed to adults randomly selected in the identified cities and
rural areas.
Chapter 3
36
Questions included the respondent’s use of antibiotics during the past 12 months, name
of the medicine, source, symptom or disease, coded with ICPC (10) and demographic
characteristics. Symptoms and diseases included in this study were self-reported. When the
reported symptom overlapped with a disease (i.e. cough and bronchitis) only the disease was
included. Only antibacterials for systemic use, ATC class J01 (11) were included in the analyses.
Respondents were classified as self-medicating if they reported that they had taken any
antibiotic in the previous 12 months without a prescription from a physician, dentist or a nurse
and as prescribed users if antibiotics had been prescribed in the same time period.
In this study, we studied the relationship between prescribed use and self-medication
in general (for all symptoms/diseases). We also studied the relationship between prescribed
use and self-medication for URTIs. URTIs were classified as cough, sneezing/nasal congestion,
throat symptom, sinus symptom, sinusitis, upper respiratory infection, acute tonsillitis,
influenza and strep throat). These minor ailments are very common in the general population
(12,13). Each adult experiences at least two colds per year (12,13). We may therefore assume that
all respondents had experienced at least one of these in the previous 12 months.
Statistical analyses
Multinomial logistic regression analysis was used to study the relationship between
prescribed use of antibiotics and self-medication with antibiotics in general (for all
symptoms/diseases) and for URTIs. All 15 548 respondents were included in each regression
analysis. In the multinomial logistic regression for antibiotic use in general, we considered
three groups as follows: (i) respondents who used leftover antibiotics for self-medication; (ii)
respondents who used self-medication with antibiotics obtained directly from a pharmacy or
other source; and (iii) as a reference group respondents who did not self-medicate. We
examined separately self-medication with leftover antibiotics and self-medication with
antibiotics obtained from other sources as a stronger relation must be expected between
prescribed use and self-medication with leftovers. In the multinomial logistic regression for
URTIs, the reference group consisted of the people who did not self-medicate for URTIs,
including respondents who did not self-medicate and those who used self-medication for other
symptoms.
The models were adjusted for the factors associated with self-medication use (region in
Europe, education, age and presence of a chronic disease) based on earlier results (4). Countries
were grouped together in regions (Northern/Western Europe, Southern Europe and Eastern
Europe) based on combination of different criteria as described elsewhere (4). Education was
categorized into low (incomplete primary education, completed primary education and lower
vocational or general education) and high (intermediate or higher vocational or general
education, college or university). In order to identify effect modifiers we tested for each model
possible statistical interactions between prescribed use and other determinants of self-
Is self-medication with antibiotics in Europe driven by prescribed use?
37
medication (14). We tested interactions between prescribed use and determinants found to be
significant and set the significance at P < 0.01 for interaction terms. Data were analysed using
SPSS (version 12) for Windows (SPSS, Inc., Chicago, IL, USA).
ResultsResultsResultsResults
Of the 15 548 respondents who completed the questionnaires, 206 had used both
prescribed antibiotics and self-medication (Figure 1). Of these 206 respondents, 95 (46%) used
leftover antibiotics for self-medication and 111 (54%) used antibiotics obtained directly from a
pharmacy or other source. In both subgroups many respondents used prescribed antibiotics
and self-medication for the same symptoms/diseases or used the same antibiotic for both
(Figure 1).
Figure 1. Flow chart describing antibiotic use in the last 12 months by the respondents Figure 1. Flow chart describing antibiotic use in the last 12 months by the respondents Figure 1. Flow chart describing antibiotic use in the last 12 months by the respondents Figure 1. Flow chart describing antibiotic use in the last 12 months by the respondents
279 only used self-medication
with antibiotics (of whom 78 used
leftovers and 201 directly from a
pharmacy or other source*)
206 used both
prescribed antibiotics
and self-medication
3653 only used prescribed
antibiotics only
15548 completed the questionnaires 11410 did not use antibiotics
95 self-medications with
leftover antibiotics from a
previous prescription
111 self-medications
directly from a pharmacy
or other* source
71 for the same
symptom/disease†
69 with the same
antibiotic‡
59 for the same
symptom/disease†
44 with the same
antibiotic‡
* including antibiotics obtained from relatives/friends, directly from a pharmacy/store from abroad or the
Internet
† prescribed use and self-medication for the same symptom/disease
‡ the same antibiotic for prescribed use and self-medication
Chapter 3
38
URTIs were the most common reasons for self-medication in all three European regions
(44% of all respondents who used self-medication in Northern/Western Europe, 56% in
Southern Europe and 41% in Eastern Europe). The second most common reasons were teeth or
gum symptoms in Southern (16%) and Eastern (19%) Europe and cystitis/urinary infection in
Northern/Western Europe (13%).
The use of prescribed antibiotics was associated with self-medication with antibiotics
in the previous 12 months. The unadjusted odds ratio (OR) was 3.6 (95% CI 2.6–4.8) for self-
medication with leftover antibiotics and 1.6 (95% CI 1.3–2.0) for self-medication from other
sources. The first group in the multinomial logistic regression included 173 respondents who
used leftover antibiotics for self-medication (including 95 who had been prescribed antibiotics
and 78 who had not). The second group included 312 respondents who used self-medication
with antibiotics obtained directly from a pharmacy or other source (including 111 who had been
prescribed antibiotics and 201 who had not). The reference group is comprised of those who did
not self-medicate (including 3653 who had been prescribed antibiotics and 11 410 who had not).
Significant statistical interactions were found between prescribed use of antibiotics
and region in Europe and prescribed use and education (P < 0.001 for both interaction terms).
Based on these interactions in the multinomial logistic model, we calculated the ORs within
each region of Europe for both self-medication with leftovers and self-medication from other
sources (Table 1). As expected, the relationship between prescribed use and self-medication
with leftover antibiotics was stronger than with self-medication from other sources; however,
this was only significant in Northern/Western and Eastern regions (Table 1). In Southern Europe
we saw the same tendency, but the associations were not significant. Educational level was the
second effect modifier. Prescribed use was a stronger determinant of self-medication in the
lower educated respondents than in the higher educated respondents. The relationship
between prescribed use and self-medication from sources other than leftovers was significant
only in Northern/Western Europe, again with a stronger association among respondents with
lower education.
For URTIs, a significant association was found between prescribed use and self-
medication with leftover antibiotics. The unadjusted OR was 7.2 (95% CI 4.6–11.1) for self-
medication with leftover antibiotics and 1.7 (1.1–2.8) for self-medication from other sources. The
first group in the multinomial logistic regression included 84 respondents who used self-
medication for URTIs with leftover antibiotics (including 35 who had been prescribed an
antibiotic for URTIs and 49 who had not). The second group included 129 respondents who
used self-medication with antibiotics obtained directly from a pharmacy or other source
(including 19 who had been prescribed an antibiotic for URTIs and 110 who had not). The
reference group includes those who did not self-medicate for URTIs (including 15063 who did
not self-medicate and 272 who used self-medication for other symptoms/diseases).
Table 1.
Table 1.
Table 1.
Table 1. The effect of prescribed use on
The effect of prescribed use on
The effect of prescribed use on
The effect of prescribed use on self
self
self
self- ---m
edication in subgroups of regions in Europe and educational level
medication in subgroups of regions in Europe and educational level
medication in subgroups of regions in Europe and educational level
medication in subgroups of regions in Europe and educational level
* Northern/W
estern Europe includes Sweden, D
enmark, The Netherlands, Austria, Belgium, Luxembourg, U
nited Kingdom and Ireland; Southern Europe includes
Malta, Italy, Spain and Israel; and Eastern Europe includes Czech Republic, Slovenia, Croatia, Poland, Slovakia, Romania and Lithuania
† adjusted for presence of chronic diseases and age
‡ Low education was defined as incomplete primary education, completed primary education, and lower vocational or general education
Ad
juste
d
OR
† (
95
% C
I)
Within
Nort
hern
/ W
este
rn E
uro
pe
* W
ithin
South
ern
Euro
pe
Within
Ea
ste
rn E
uro
pe
Self-m
ed
ication
Am
ong r
esp
ond
ents
w
ith low
edu
cation
‡
Am
on
g
respo
nd
ents
w
ith
hig
h
edu
cation
Am
ong
respo
nd
en
ts
with low
ed
uca
tion
Am
ong
respo
nd
ents
w
ith h
igh e
du
catio
n
Am
ong
resp
ond
en
ts
with low
ed
uca
tion
*
Am
ong
re
sp
ond
ents
w
ith h
igh
e
du
catio
n
W
ith lefto
ver
antib
iotics
15.7
4 (
6.1
3-4
0.4
2)
8.6
0 (
3.6
8-2
0.1
2)
2.1
9 (
0.9
5-5
.06)
1.2
0 (
0.5
9-2
.43)
3.2
6 (
1.6
8-6
.32)
1.7
8 (
1.0
7-2
.97)
With a
ntibio
tics o
bta
ined
dir
ectly
from
pharm
acy o
r oth
er
so
urc
e
4.0
3 (
1.8
1-
8.9
6)
2.2
1 (
1.0
4-
4.7
0)
1.9
4 (
0.8
7-4
.30
) 1.0
6 (
0.5
0-2
.23)
1.5
5 (
0.9
8-2
.45)
0.8
5 (
0.6
0-1
.20)
39
Is self-medication with antibiotics in Europe driven by prescribed use?
Chapter 3
40
A significant interaction was found between prescribed use and region in Europe (P <
0.001). In Northern/Western Europe, respondents who had used prescribed antibiotics for
URTIs had a 37.45 (95% CI 9.89–141.75) higher odds of self-medication for URTIs. The effects
were smaller in Southern Europe (OR 3.64, 95% CI 1.60–8.25) and Eastern Europe (3.64, 1.96–
6.74). These associations were not significant for self-medication from sources other than
leftovers (1.96, 0.45–8.67 in Northern/Western Europe, 1.58, 0.51–4.87 in Southern Europe and
1.06, 0.59–1.93 in Eastern Europe). No interaction was found between prescribed use and
education for URTIs.
DiscussionDiscussionDiscussionDiscussion
To our knowledge, this is the first study exploring the relationship between prescribed
antibiotic use and self-medication with antibiotics. The association between prescribed use
and self-medication in general implies that antibiotics prescribed for one symptom/disease
may be used both as self-medication for (repeated) episodes of the same symptom/disease
and for another symptom/disease. The association for URTIs implies that prescribed use for
URTIs increases the probability of self-medication for URTIs.
Our results indicate an association between prescribed use and self-medication with
antibiotics in general from a leftover source in Northern/Western and Eastern Europe. In both
regions the effect of prescribed use was larger in lower educated respondents. One could
hypothesize that respondents with low education are less aware about the consequences of
repeating prescriptions of the doctors for the same symptom/disease or for another
symptom/disease. This effect of education disappeared when looking at the relation between
prescribed use and self-medication for URTIs. The effect of prescribed use on self-medication
for URTIs with leftover antibiotics in all European regions was the same for both educational
levels. For self-medication from sources other than leftovers the associations did not reach
statistical significance. This might be due to a lack of statistical power to detect a smaller
effect.
A limitation of our study is the low response rate in some of the countries. However,
the results were similar after exclusion of countries with response rates below 40% (data not
shown). Therefore, we believe that the bias resulting from non-response did not result in an
overestimation of the relationships reported in this study. A second limitation is that no data
were available about actual occurrence of URTIs. However, evidence indicates that practically
everybody experiences such symptoms/diseases more than once a year (12,13). Therefore, we
based our analysis on the assumption that all respondents have had at least one URTI in the
previous year.
Our findings indicate that preventing leftovers from prescribed courses may be one
effective way of preventing self-medication with antibiotics. This can be done by technical
Is self-medication with antibiotics in Europe driven by prescribed use?
41
measures, such as promoting the dispensing of the exact numbers of tablets or by educating
patients. In addition, doctors should be aware that prescribing for minor ailments may also
increase the risk of self-medication for such ailments. The effect to be expected may be the
strongest in Northern/Western Europe, but in that part of Europe self-medication is low,
implying that the absolute effect would be limited. In Eastern European countries, though self-
medication with antibiotics obtained directly from pharmacies is the most common, the
absolute expected effect may be more pronounced, since self-medication from leftovers occurs
frequently (4). In Southern Europe, the relevance of prescribed use seems to be limited to using
leftovers for self-medication for URTIs. This may imply that the respondents from Southern
Europe are more ‘cautious’ and tend to repeat prescriptions of the doctors only for URTIs. In
Northern/Western and Eastern Europe respondents may repeat prescriptions of the doctors
not only for URTIs but also for other symptoms/diseases or use self-medication for a different
symptom/disease. However, in both cases there is reason for concern. URTIs are usually not an
appropriate indication for the use of antibiotics, so in these cases antibiotics should not be
used either prescribed or as self-medication. The use of leftover antibiotics for a variety of
indications without professional advice is just as inappropriate. In both cases action should be
undertaken to prevent the use of leftovers.
Besides leftovers, self-medication from other sources should be prevented. In the
future, the problem of self-medication with antibiotics might be aggravated also because of
increased accessibility of the Internet as a source of buying antibiotics without a prescription.
Strengthening pharmacy regulations and educating the public may prevent self-
medication directly from the pharmacy or from other sources.
In conclusion, our study shows consistent associations between prescribed use and self-
medication from leftovers, but has not been able to support the hypothesis that self-
medication from other sources than leftovers is triggered by earlier prescribed use.
AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements
We are grateful to Reli Mechtler (Austria), Arjana Tambic- Andrasevic (Croatia),
Retnosari Andrajati (Czech Republic), Robert Cunney (Ireland), Hana Edelstein (Israel), Rolanda
Valinteliene (Lithuania), Alaa Alkerwi (Luxembourg), Pawel Grzesiowski (Poland), Thomas Tesar
(Slovakia), Milan Cizman (Slovenia) and Jose Campos (Spain) for participation in the design of
the study and data collection. The study was funded by the European Commission Public
Health Directorate DG SANCO. In addition, funding was also provided from funds of the
participating institutions. The researchers of this study have been independent of funding
source.
Chapter 3
42
Transparency declarationsTransparency declarationsTransparency declarationsTransparency declarations
None to declare.
ReferReferReferRefereeeencesncesncesnces
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with the development of bacterial resistance in acutely ill patients during therapy. Antimicrob
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2. Guillemot D, Carbon C, Balkau B et al. Low dosage and long treatment duration of beta-lactam:
risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA 1998; 279:365-
370.
3. Richman PB, Garra G, Eskin B, Nashed AH, Cody R. Oral antibiotic use without consulting a
physician: a survey of ED patients. Am J Emerg Med 2001; 19:57-60.
4. Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JGM et al. Self-medication with antimicrobial drugs
in Europe. Emerg Infects Dis 2006; 12:452-459.
5. Belongia EA, Schwartz B. Strategies for promoting judicious use of antibiotics by doctors and
patients. BMJ 1998; 317317317317:668-671.
6. Moral Serrano S, Aguaron Joven E, Adan Gil FM et al. Do the patients medicate themselves
correctly? Aten Primaria 1994; 13131313:242-246.
7. Hong JS, Philbrick JT, Schorling JB. Treatment of upper respiratory infections: do patients really
want antibiotics? Am J Med 1999; 107107107107:511-515.
8. European Surveillance of Antimicrobial Consumption. Available at URL:
http://www.ua.ac.be/esac (Accessed 24 July, 2006).
9. European Antimicrobial Resistance Surveillance System. Available at URL:
http://www.earss.rivm.nl (Accessed 24 July, 2006).
10. World Organization of Family Doctors (WONCA) International Classification Committee.
International Classification of Primary Care ICPC-2. New York: Oxford University Press; 1998.
11. WHO Collaborating Centre for Drug Statistics Methodology. ATC index with DDDs 2002. Oslo,
Norway: WHO Collaborating Centre for Drug Statistics Methodology; 2002.
Is self-medication with antibiotics in Europe driven by prescribed use?
43
12. Heikkinen T, Jarvinen A. The common cold. Lancet 2003; 361361361361:51-59.
13. Garibaldi RA. Epidemiology of community-acquired respiratory tract infections in adults.
Incidence, etiology, and impact. Am J Med 1985; 78787878:32-37.
14. Douglas DG, Altman JM. Practical statistics for medical research. London, Chapman and Hall, 1991.
Determinants of self-medication with antibiotics in
Europe: the impact of beliefs, country wealth and
health care system
Larissa Grigoryan, Johannes G M Burgerhof, John E Degener,
Reginald Deschepper, Cecilia Stålsby Lundborg, Dominique L Monnet,
Elizabeth A Scicluna, Joan Birkin, and Flora M Haaijer-Ruskamp, on behalf of the SAR consortium
Submitted
Chapter 4
46
Abstract Abstract Abstract Abstract
We studied the impact of predisposing (attitudes, beliefs and knowledge) and enabling
factors (country wealth and health care system factors) on self-medication with antibiotics in
Europe. In total, 1101 respondents were interviewed in 11 countries. A multilevel analysis with
two levels (country and respondent) was performed. Among the predisposing factors, positive
attitudes towards appropriateness of self-medication with antibiotics for bronchitis and
incorrect beliefs about antibiotics for minor ailments were related to higher likelihood of self-
medication. Among the enabling factors at country level, country wealth (higher GDP) and
dispensing the exact number of tablets in the pharmacies were independently associated with
lower likelihood of self-medication. At individual level, perceived availability of antibiotics
without a prescription was related to increased probability of self-medication. Interventions
aimed at preventing self-medication with antibiotics should include public education, stricter
control over the laws influencing sale of antibiotics and dispensing the exact number of tablets
of prescribed antibiotics in pharmacies.
Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and
health care system
47
IntroductionIntroductionIntroductionIntroduction
Self-medication with antibiotics occurs among the population in Europe, in
particular in Southern and Eastern countries (1,2). Several studies in the United States (US) have
also shown considerable self-medication with antibiotics obtained from leftovers from
previous courses, at a local pharmacy or outside the country (3-6). The most common reasons
for self-medication were colds and upper respiratory tract symptoms (1,4) which are self-
limiting and mostly caused by viruses. This inappropriate use may contribute to antibiotic
resistance (7) which is reaching alarming levels in Southern and Eastern Europe (8).
Most health behaviours are determined by multiple factors and interventions that
address several key factors are likely to be the most successful (9,10). The PRECEDE model of
behaviour change (11) is a standardized theoretical framework that has been used to design
successful, large-scale health interventions (12,13). According to the PRECEDE model, health
behaviour is influenced by predisposing factors (characteristics that lead to or motivate
behaviour such as knowledge and beliefs), enabling factors (characteristics that facilitate or are
needed to perform the particular behaviour, such as resources in the environment) and
reinforcing factors (rewards and punishments received from others).
The determinants of self-medication with antibiotics in low-income countries include
over-the-counter sale of antibiotics (14), the cost of medical consultation, low satisfaction with
medical practitioners (15), and misconceptions regarding the efficacy of antibiotics (16). Studies
in the US showed that recent immigrants from Latin American countries, where antibiotics are
available over- the-counter, had the greatest expectations for antibiotics for upper respiratory
infections (3,17). The cultural beliefs and a lack of health insurance were other possible
determinants of self-medication with antibiotics for these immigrants (3). In Europe,
differences in attitudes to antibiotic use have been described (18), but little is known about
their effect on self-medication. In the present study we examined the impact of predisposing
(attitudes, beliefs and knowledge) and enabling factors (country wealth and the health care
system factors) on self-medication with antibiotics in Europe.
MethodsMethodsMethodsMethods
Face to face structured interviews were conducted in 12 countries. Countries were
selected to represent Northern/Western (Austria, The Netherlands, Sweden, United Kingdom
and Belgium), Southern (Italy, Malta, Israel and Spain) and Eastern (Czech Republic, Lithuania
and Croatia) European regions. Because of data collection problems, Spain was excluded from
the analyses. Data were collected between October 2003 and May 2004, after approval of the
appropriate institutional review boards. This study is a follow-up from a European survey
Chapter 4
48
estimating prevalence of both self-medication and prescribed use of antibiotics (1). In this
previous survey we used a multistage sampling design. Within each country, a region with
average prescribed antibiotic consumption was chosen and in each chosen region a middle-
sized city and rural area were selected. Questionnaires were mailed to 1000-3000 randomly
selected adults in each country, who were equally distributed in urban and rural areas. The
characteristics of the respondents in each country and the prevalence rates of self-medication
and prescribed use in each country are described elsewhere (1).
This follow-up study was limited to respondents in 12 countries willing to be
interviewed. We aimed to recruit at least 100 respondents in each country, 50 users of self-
medication and 50 non-users, both equally distributed in urban and rural areas. If the number
of self-medication users willing to be interviewed was less than 50 in a country, non-users of
self-medication were added to achieve 100 respondents. In Lithuania, the number of non-users
willing to be interviewed did not reach 50, therefore, self-medication users were added.
Respondents who failed to identify antibiotics correctly (for example confusing antibiotics with
painkillers) were excluded from the study.
The questionnaire for interviews was developed in English, translated into national
languages, and back translated to English to ensure consistency. Pre-testing of the questions
took place in each country. Interviewers from all countries were trained in a collaborative
workshop. The first two interviews with respondents were “training interviews” and were
immediately followed by an in-depth discussion between the trainer and the interviewer.
These first two interviews were excluded from the analysis.
In this study, we have included individual characteristics of the interviewees as well as
characteristics of the country of residence. Predisposing factors included individual data on
attitudes, beliefs and knowledge concerning antibiotic use and self-medication (table 1).
Enabling factors included both individual and country data. Individual data comprised
perceived availability of antibiotics without a prescription, and reimbursement of prescribed
antibiotics. Country data included the Gross Domestic Product (GDP) per capita and dispensing
regulations. Attitudes, beliefs and knowledge concerning antibiotic use and self-medication
were assessed with items measured on a Likert scale, partly derived from other studies
(6,19,20). Items were grouped in scales and the mean scores were computed for each scale,
after reversing those items that were worded in opposite direction (i.e. “antibiotics can kill
bacteria”). Higher scores for each scale represented more inappropriate attitudes, beliefs or
knowledge.
Dimensionality of the data was assessed by factor analysis which revealed four scales,
consistent with the conceptual basis. Items were included in a factor (scale) when the factor-
loading was > 0.40. The first scale assessed attitudes towards appropriateness of self-
medication with antibiotics for bronchitis (table 1). Bronchitis was chosen because antibiotics
might be indicated for treatment (21) and it is considered as a serious illness by lay people (22).
Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and
health care system
49
The other scales addressed beliefs about antibiotics for minor ailments (table 1), attitudes
towards situational use of antibiotics and knowledge about the effectiveness of antibiotics on
bacteria and viruses. As shown in table 1, all four scales showed satisfactory reliability
(Cronbach’s alpha and mean inter-item correlation). The respondents’ knowledge about health
dangers associated with taking antibiotics was assessed with an open-ended question, “Are
you aware of any dangers to your health or the health of other people associated with taking
antibiotics?” derived from another study (6). We classified the answers into two categories:
knowledge of antibiotic resistance and knowledge of adverse effects of antibiotics (including
allergies/reactions, antibiotics may kill “friendly”/good flora, diarrhoea, vomiting etc.).
Table 1. Scales of attitudes, beliefs and Table 1. Scales of attitudes, beliefs and Table 1. Scales of attitudes, beliefs and Table 1. Scales of attitudes, beliefs and knowledge, including the underlying itemsknowledge, including the underlying itemsknowledge, including the underlying itemsknowledge, including the underlying items
I. Inappropriate attitudes towards appropriateness of self-medication with antibiotics for bronchitis (α=0.9)||
Items included:* Just imagine you have bronchitis. How appropriate is it in your view to get antibiotics without a prescription?
-…Over the weekend in a normal situation -…Over the weekend with an important event coming up -…On holiday abroad -…You have no time to go to the doctor -…When it is difficult to contact the doctor -…When the doctor has no time to see you immediately -…When a consultation with a doctor is too expensive -…When you have a good experience with taking this antibiotic -…When your doctor always prescribes you this antibiotic -…When the pharmacist advises you which antibiotic to take II. Incorrect beliefs about antibiotics for minor ailments (α=0.7)|| Items included† When one has a sore throat, one should take antibiotics to prevent getting a more serious illness When one gets a cold antibiotics help to get better more quickly By the time you yourself are sick enough to visit a doctor with a bad cold, you usually expect a prescription for antibiotics You usually know if you yourself need an antibiotic for a sore throat before seeing a doctor Most of your friends/relatives think people should take an antibiotic for a cold III. Inappropriate Attitudes towards situational use of antibiotics (0.6)¶ Item included† The use of antibiotics when you are sick in order to remain active (work, family, study) is appropriate The use of antibiotics when you are sick for helping to get through an important event (exam, funeral, wedding) is appropriate IV. Incorrect knowledge about the effectiveness of antibiotics on bacteria and viruses (0.3)¶ Item included‡
Antibiotics can kill bacteria§ Antibiotics can kill viruses
* Measured on a 5 point scale (1=”completely inappropriate” and 5=”completely appropriate”)
† Measured on a 5 point scale (1=”strongly disagree” and 5=”strongly agree”)
‡ Measured on a 4 point scale (1=”strongly disagree” and 4=”strongly agree”)
§ For this item coding was reversed (1=“strongly agree” and 4=”strongly disagree”)
|| Cronbach alpha
¶ mean inter-item correlation (mean inter-item correlation is presented because the scale contains only
2 items)
Chapter 4
50
Perceived availability of antibiotics from pharmacies without a prescription was
assessed by the question, “Could you tell me if it is possible for you to get an antibiotic directly
from the pharmacy without prescription?” The responses for this item were “yes, easily”, “yes,
sometimes”, “no” and “do not know”. We asked about perceived availability of antibiotics
directly from pharmacy because illegal acquisition of antibiotics without prescription from
pharmacies occurs frequently in some countries (1).
For the question about the reimbursement of antibiotics we classified the answers in
three categories “full reimbursement”, “patient co-payment” and “no reimbursement”.
Reimbursement was measured at the individual level, because within a country different
reimbursement schemes are available for individuals.
Respondents were asked whether they had ever taken an antibiotic without a
prescription. They were classified as users of self-medication if they reported that they had ever
taken any antibiotic without a prescription from a physician, dentist or a nurse. Self-medication
included use of antibiotics obtained directly from pharmacy, leftovers from treatment courses
prescribed earlier, obtained from relatives or friends or other sources.
Sociodemographic information included age, educational level and presence of a
chronic disease. Education was categorized as low (incomplete primary education, completed
primary education and lower vocational or general education) or high (intermediate or higher
vocational or general education, college or university).
Data on GDP per capita were retrieved from the 2004 World Health Organization’s core
health indicators (23) and information on regulations regarding the dispensing of exact
numbers of tablets or per package size was provided by country co-investigators of this study
(table 2).
Statistical analysisStatistical analysisStatistical analysisStatistical analysis
Chi-square tests were used to compare users and non-users of self-medication for
differences in categorical variables (sex, education, presence of a chronic disease, location,
predisposing and enabling factors) and a t-test was used for differences in age. SPSS (version
12) for Windows (SPSS, Inc, Chicago, IL) was used. Variables that were statistically significantly
different between users and non-users of self-medication (p<0.05) were considered for
inclusion into the multilevel regression analyses. Due to data’s hierarchical nature multilevel
logistic regression analysis was applied. In the present analysis, the levels were: respondents
(level 1) and countries (level 2). Multilevel analysis allows to split total variance of self-
medication and to attribute it to each level. We used the partitioning of the variance based on
the threshold representation as suggested by Snijders and Bosker (24). The analysis was
performed in three steps. Firstly, an “intercept-only model” was created, which included only
Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and
health care system
51
countries (level 2) and did not include any explanatory variables. This model revealed each
level’s contribution to variation. Secondly, explanatory variables on the individual level which
where significantly different between users and non-users of self-medication were included.
Finally, variables at country level were added. The contribution of each determinant in
the multilevel analysis was expressed as odds ratio (OR) and a 95% confidence interval (CI).
Interaction terms were examined for the significant determinants. MLwiN version 2.00 was
used to test multilevel logistic regression models.
Table 2. Country characteristics (n=11)Table 2. Country characteristics (n=11)Table 2. Country characteristics (n=11)Table 2. Country characteristics (n=11)
* Data retrieved from the 2004 World Health Organization’s core health indicators
† PPP$, Purchase Power Parity dollar or “international dollar”. This is a common currency unit that takes
into account differences in the relative purchasing power of various currencies.
ResultsResultsResultsResults
In total 1101 respondents were interviewed. Eleven respondents who failed to identify
what was an antibiotic were excluded from the analyses. The mean response rate of the
countries was 89%. Table 3 summarizes the difference between users and non-users of self-
medication in demographic characteristics, predisposing and enabling factors. General
characteristics (age, sex, education, presence of a chronic disease and location) were not
Country Dispensing regulations for prescribed antibiotics in pharmacies
Per capita GDP* in PPP$ †
Czech Republic Exact number of tablets 18,598
Israel Exact number of tablets 22,731
The Netherlands Exact number of tablets 31,143
United Kingdom Exact number of tablets 31,308
Croatia Per package size 11,406
Lithuania Per package size 12,572
Malta Per package size 18,308
Italy Per package size 27,952
Sweden Per package size 30,336 Belgium Per package size 31,481
Austria Per package size 31,648
Chapter 4
52
significantly different between users and non-users of self-medication (table 3). Users of self-
medication had significantly more inappropriate attitudes towards self-medication with
antibiotics for bronchitis than non-users (21% versus 7%). The same trend was observed for
beliefs about antibiotics for minor ailments and attitudes towards situational use of antibiotics
(table 3). Incorrect knowledge about the effectiveness of antibiotics on bacteria and viruses
was slightly higher among non-users of self-medication, though the difference was not
statistically significant. Non-awareness about antibiotic resistance was significantly higher
among users of self-medication. By contrast, non-awareness about adverse effects was
significantly higher among non-users of self-medication.
As shown in table 3, significant differences between users and non-users of self-
medication were also observed with respect to enabling factors i.e. perceived availability of
antibiotics directly from pharmacies and reimbursement of prescribed antibiotics. Users of self-
medication were more likely to perceive that antibiotics are available directly from pharmacies
without prescription. Users of self-medication were less likely to receive complete
reimbursement for prescribed antibiotics and more likely to get no reimbursement at all.
As shown in table 4, “the intercept only” model showed that variation on country level
contributed considerably to the model (18%) though most variation was explained by the
individual characteristics of respondents (82%). The total variance explained by the second
model including factors at the individual level was 32%. The residual variance at the country
level decreased (7%), indicating that a part of the differences between countries had been
explained by the information on the individual level. After adding variables at the country level,
the proportion of total variance explained by the third model was 38%. The between-country
residual variance was 2% and the residual variance at the individual level was 60%.
Determinants of self-m
edication with antibiotics in Europe: the im
pact of beliefs, country wealth and health care system
Table 3. Re
Table 3. Re
Table 3. Re
Table 3. Respondent characteristics according to use of self
spondent characteristics according to use of self
spondent characteristics according to use of self
spondent characteristics according to use of self- ---m
edication (n=1090)
medication (n=1090)
medication (n=1090)
medication (n=1090)
* Percentage of respondents who answ
ered to at least 75%
of the item
s in the dim
ension incorrectly
† p values refer to chi-square tests for nominal variables and t-test for age
Va
riab
les
Users
of
se
lf-m
ed
ica
tion
(n=
25
1)
Non-u
sers
of
se
lf-
med
ication
p v
alu
e†
Gen
era
l ch
ara
cte
risti
cs
Mean
ag
e (
ye
ars
± S
D)
49 ±
15
49±
15
0.7
4
Fem
ale
(%
) 5
5
55
0.9
6
Low
edu
cation
(%
) 2
6
29
0.4
1
Pre
sen
ce o
f a
chro
nic
dis
ea
se
(%
) 2
6
21
0.0
7
Urb
an
lo
cation
(%
) 5
3
50
0.3
4
Pre
dis
po
sin
g f
acto
rs
Ina
ppro
pri
ate
attitud
es t
ow
ard
s s
elf-m
ed
ica
tio
n w
ith
an
tib
iotics f
or
bro
nchitis
(%
)*
21
7
<0.0
01
Incorr
ect
be
liefs
abo
ut a
ntibio
tics f
or
min
or
ailm
ents
(%
)*
21
7
<0.0
01
Inap
pro
pri
ate
att
itud
es t
ow
ard
s s
itua
tio
na
l u
se
of
an
tib
iotics (
%)*
2
4
12
<0.0
01
Incorr
ect kn
ow
ledg
e a
bou
t th
e e
ffe
ctive
ne
ss o
f antibio
tics o
n b
acte
ria
an
d v
iru
se
s (
%)*
1
5
17
0.4
4
Non-a
wa
ren
ess a
bo
ut
an
tib
iotic r
esis
tan
ce
(%
) 6
0
47
<0.0
01
No
n-a
ware
ne
ss a
bou
t ad
ve
rse
eff
ects
of
an
tib
iotics (
%)
4
1
50
0.0
1
En
ab
lin
g f
ac
tors
Pe
rceiv
ed p
ossib
ility
of
obta
inin
g a
ntib
iotics d
ire
ctly
from
pha
rmacie
s
No (
%)
38
64
Ye
s e
asily
(%
) 2
3
7
Ye
s s
om
etim
es (
%)
33
14
Do n
ot kn
ow
(%
) 6
15
<0.0
01
R
eim
burs
em
en
t of
pre
scrib
ed a
ntibio
tics
No r
eim
burs
em
ent
(%)
38
21
Patien
t co
-pa
yme
nt (%
) 4
6
53
Com
ple
te r
eim
burs
em
en
t (%
) 1
6
26
<0.0
01
53
Chapter 4
54
Table 4. Variance partition (%) in the Table 4. Variance partition (%) in the Table 4. Variance partition (%) in the Table 4. Variance partition (%) in the multilevel analysis* multilevel analysis* multilevel analysis* multilevel analysis*
Empty model
(intercept-only model)
Model including variables at the individual level‡
Model including individual and country level variables§
Variance explained 0 32 38 Residual variance at the country level (n=11)
18 7 2
Residual variance at the individual level (n=916†)
82 61 60
* * * * based on the threshold representation as suggested by Snijders and Bosker (24) † total number is lower because respondents with missing values were excluded ‡ including variables which were significantly different between users and non-users of self-medication in the univariate analyses § including also dispensing regulations for prescribed antibiotics in pharmacies and per capita GDP
The results of the multilevel logistic regression analysis including those variables that
were significantly different between users and non-users of self-medication in the univariate
analyses are presented in table 5. Among the five predisposing factors, only two were
statistically significant in the final multilevel logistic regression. As expected, respondents who
had more inappropriate attitudes towards self-medication with antibiotics for bronchitis had
higher likelihood of actual self-medication (OR 2.13, 95% CI 1.70-2.66). Having incorrect beliefs
about antibiotics for minor ailments was also independently associated with higher likelihood
of self-medication. Inappropriate attitudes towards situational use of antibiotics and non-
awareness about antibiotic resistance and adverse effects of antibiotics were not associated
with use of self-medication anymore in the multilevel analysis.
Among the four enabling factors, three were significant determinants of self-
medication (table 5). Country wealth (higher GDP per capita) was related to a lower likelihood
of self-medication. Dispensing the exact number of antibiotics was associated with a
decreased risk of self-medication (OR 0.51, 0.27-0.98). Respondents who perceived antibiotics
as easily or sometimes available directly from pharmacies, had a higher risk of self-medication
whereas those who answered “do not know” had a lower risk compared to respondents
perceiving that antibiotics are not available (table 5). Reimbursement of prescribed antibiotics
was not independently associated with use of self-medication in the multilevel regression
analysis. No statistical interaction was found between the determinants of self-medication in
the multilevel logistic regression analysis.
Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and
health care system
55
Table 5Table 5Table 5Table 5. Multilevel model of the relationship between predisposing and enabling factors and use of self Multilevel model of the relationship between predisposing and enabling factors and use of self Multilevel model of the relationship between predisposing and enabling factors and use of self Multilevel model of the relationship between predisposing and enabling factors and use of self----
medicationmedicationmedicationmedication
* Mean score computed for each dimension; higher score indicates more inappropriate attitudes and
more incorrect beliefs
Determinants Actual self-medication Odds Ratio (95%CI)
Predisposing factors At individual level: Inappropriate attitudes towards self-medication with antibiotics for bronchitis *
2.13 (1.70-2.66)
Incorrect beliefs about antibiotics for minor ailments * 1.76 (1.32-2.34) Inappropriate attitudes towards situational use of antibiotics* 0.89 (0.72-1.09) Non-awareness about antibiotic resistance 0.94 (0.62-1.42) Non-awareness about adverse effects 0.84 (0.57-1.24)
Enabling factors At country level: Per capita Gross Domestic Product (GDP) 0.95 (0.92-0.99) Dispensing exact number of tablets in pharmacies
No Yes
Referent
0.51 (0.27-0.98) At individual level: Perceived possibility of obtaining antibiotics directly from pharmacy
No Yes, easily
Yes sometimes Don’t know
Referent 2.51 (1.40-4.48) 2.06 (1.28-3.32) 0.36 (0.16-0.79)
Reimbursement of prescribed antibiotics No reimbursement Patient co-payment
Complete reimbursement
Referent
1.22 (0.68-2.17) 0.81 (0.42-1.57)
Chapter 4
56
DiscussionDiscussionDiscussionDiscussion
To our knowledge, the present study is the first one that includes an analysis of
predisposing and enabling factors to evaluate determinants of self-medication with antibiotics
in Europe. Positive attitude towards appropriateness of self-medication with antibiotics and
incorrect beliefs about antibiotics for minor ailments, i.e. sore throat and common cold, were
predisposing factors for use of self-medication. The perceived availability of antibiotics from
pharmacies without a prescription was the main enabling factor at the individual level. Other
enabling factors included country characteristics, i.e. country wealth (GDP per capita) and
dispensing regulations for prescribed antibiotics in pharmacies. Country wealth and dispensing
exact number of prescribed tablets in pharmacies were independently associated with lower
self-medication. Dispensing antibiotics per package size can produce leftovers which, in a
previous study, have been shown to substantially contribute to self-medication, with 36 % of
those who self-medicated using leftovers (25).
In general, determinants of self-medication must be sought primarily at the level of
the individual and much less as a characteristic of a country, though the latter may be relevant
as well. In the present study, we were able to explain almost all variance at the country level
with the included determinants. However, the 60% residual variance at the individual level
indicates that much remains to be explained. It is not clear why the wealth of a nation is an
important determinant of self-medication with antibiotics. One might hypothesize that wealth
could indicate a more structured health care system, with adequate accessibility to health care.
Attitudes towards situational use of antibiotics, awareness about antibiotic resistance and
adverse effects, and reimbursement of prescribed antibiotics were associated with self-
medication in the univariate analyses, but became non-significant in the multilevel analysis.
This might be because of the correlations between these factors and the determinants of self-
medication that remained significant in the multilevel model. In particular, awareness about
antibiotic resistance was correlated with beliefs about antibiotics for minor ailments and
awareness about adverse effects was correlated with the attitude towards self-medication
with antibiotics. Attitude towards situational use of antibiotics was correlated with both these
determinants. Reimbursement of prescribed antibiotics was correlated with the perceived
availability of antibiotics directly from pharmacies.
Our findings are consistent with the results of other studies, indicating that availability
of antibiotics without prescription and misconceptions about the efficacy of antibiotics
influence self-medication with antibiotics (3,14-16). Studies in low-income countries showed
that the cost of medical consultation and low satisfaction with medical practitioners were also
related to self-medication with antibiotics (15). In our study, the scale measuring the attitude
towards appropriateness of self-medication with antibiotics consisted to a large extent of
items indicating practical barriers for consulting a doctor, such as time constraints and
Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and
health care system
57
expense, as appropriate reasons for self-medication. Despite the fact that we do not know to
what extent such difficulties in accessing health care actually exist in the countries included in
this study, this attitude was clearly relevant as a determinant of self-medication. Further
research in actual accessibility may clarify the issue further. Satisfaction with medical
practitioners may also influence use of self-medication. The effect of satisfaction with medical
practitioners on the appropriate use of antibiotics for mild respiratory tract infections was
investigated in another European study (26). Low patient satisfaction was correlated with less
compliant behavior, whereas involving the patient more fully in the management of their
illness was related to a lower probability of antibiotic misuse. Satisfaction with medical
practitioners may also influence use of self-medication. Another area where additional studies
are needed is the relevance of reinforcing factors for use of self-medication, which were not
included in this study. Attitudes and behavior of health personnel may reinforce use of self-
medication with antibiotics. In our earlier study we found that previous prescribed use of
antibiotics for upper respiratory tract infections (URTIs) increased the likelihood of self-
medication with leftover antibiotics from previous courses for these symptoms/diseases
although URTIs are usually not an appropriate indication for the use of antibiotics (25).
Additional information on individual-level factors, such as doctor-patient relationship, patient
satisfaction and perceived accessibility to health care will increase our understanding of
determinants of self-medication with antibiotics in Europe.
A limitation of our study is its reliance on self-reported data about self-medication with
antibiotics. Another limitation is that our population sample may not be representative of the
general population in the studied countries. Nevertheless, our findings have implications for
understanding the relative importance of various determinants for use of self-medication, the
need for additional information and the needed interventions to prevent self-medication with
antibiotics.
Our results suggest that interventions aimed at reducing and preventing self-
medication with antibiotics in Europe should focus on both predisposing and enabling factors.
Public education aimed at predisposing factors should emphasize the potential risks of using
self-medication and the inappropriateness of antibiotic therapy for URTIs. Education will be
effective only when coupled with strategies aimed at modifying enabling factors. One of the
important, potentially modifiable enabling factors facilitating self-medication is absence of
enforcement of the laws regulating the sale of antibiotics. Over–the-counter sale of antibiotics
is illegal in all participating countries and enforcing the law would prevent self-medication.
Dispensing regulation is another enabling factor. To prevent self-medication with antibiotics,
prescribed antibiotics should not be dispensed according to package size. Dispensing exact
number of antibiotic tablets in pharmacies as implemented in the United Kingdom, The
Netherlands, The Czech Republic and Israel, as well as in the United States, could be promoted
in other countries.
Chapter 4
58
In conclusion, our study identified several determinants of self-medication with
antibiotics, both at individual and country level. Interventions aimed at preventing self-
medication with antibiotics should be directed primarily at diminishing the availability of
antibiotics without a prescription, at facilitating the dispensation of the exact numbers of
antibiotic tablets, and at educating the general public to reduce misconceptions about the use
of antibiotics for minor ailments.
Ethics approvalEthics approvalEthics approvalEthics approval
Ethics or data committee approval for the survey was required in six countries
(Belgium, United Kingdom, Malta, Czech Republic, Croatia, and Lithuania) and was obtained
from the local ethics or data committees of these countries.
FundingFundingFundingFunding
The study was funded by the European Commission Public Health Directorate DG
SANCO. In addition, funding was also provided from funds of the participating institutions. The
researchers of this study have been independent of funding source.
The SARThe SARThe SARThe SAR----consortium consortium consortium consortium
Antonella Di Matteo (Consorzio Mario Negri Sud, Santa Maria Imbaro, Chieti, Italy);
Arjana Tambic-Andrasevic (University Hospital for Infectious Diseases, Zagreb, Croatia);
Retnosari Andrajati (Faculty of Pharmacy, Charles University, Prague, Czech Republic); Hana
Edelstein (Ha'Emek Medical Center, Afula, Israel); Rolanda Valinteliene (Institute of Hygiene,
Vilnius, Lithuania); Reli Mechtler (University of Linz, Linz, Austria); Luc Deliens (Vrije Universiteit
Brussel, Brussels, Belgium); and Greta Van der Kelen (Vrije Universiteit Brussel, Brussels,
Belgium)
Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and
health care system
59
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14. Lansang MA, Lucas-Aquino R, Tupasi TE, et al. Purchase of antibiotics without prescription in
Manila, the Philippines. Inappropriate choices and doses. J Clin Epidemiol 1990;43(1):61-7.
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903.
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Survey of Knowledge, Attitudes, and Experience in Wisconsin and Minnesota. Prev Med 2002
Mar;34(3):346-52.
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60
Attitudes, beliefs and knowledge concerning
antibiotic use and self-medication: a comparative
European study
Larissa Grigoryan, Johannes G M Burgerhof, John E Degener,
Reginald Deschepper, Cecilia Stålsby Lundborg, Dominique L Monnet,
Elizabeth A Scicluna, Joan Birkin, and Flora M Haaijer-Ruskamp, on behalf of the SAR consortium
Submitted
Chapter 5
62
SummarySummarySummarySummary
Purpose.Purpose.Purpose.Purpose. Although the relevance of cultural factors for antibiotic use has been recognized, few
studies exist in Europe. We compared public attitudes, beliefs and knowledge concerning
antibiotic use and self-medication between 11 European countries.
MethodsMethodsMethodsMethods. In total, 1101 respondents were interviewed on their attitudes towards
appropriateness of self-medication with antibiotics and situational use of antibiotics, beliefs
about antibiotics for minor ailments, knowledge about the effectiveness of antibiotics on
viruses and bacteria and awareness about antibiotic resistance. To deal with the possible
confounding effect of both use of self-medication and education we performed stratified
analyses, i.e. separate analyses for users and non-users of self-medication, and for respondents
with high and low education. The differences between countries were considered relevant
when regression coefficients were significant in all stratum-specific analyses.
Results.Results.Results.Results. Respondents from the UK, Malta, Italy, Czech Republic, Croatia, Israel and Lithuania
had significantly less appropriate attitudes, beliefs or knowledge for at least one of the
dimensions compared with Swedish respondents. The Dutch, Austrian and Belgian
respondents did not differ from Swedish for any dimension.
Conclusions.Conclusions.Conclusions.Conclusions. The most pronounced differences were for awareness about resistance, followed
by attitudes towards situational use of antibiotics. Awareness about antibiotic resistance was
the lowest in countries with higher prevalence of resistance.
Attitudes , beliefs and knowledge concerning antibiotic use and self-medication: a comparative
European study
63
IntroductionIntroductionIntroductionIntroduction
Large variations in outpatient antibiotic use between countries have been reported
(1,2). It has been suggested that cultural determinants may have an impact on differences in
outpatient antibiotic use in the United States (US) and Germany (3,4) resulting in different
resistance prevalences in respiratory pathogens on a national level. Different opinions and
traditions regarding how to treat infectious conditions in different countries have been
described (5). Studies in the US reported ethnic and cultural differences in levels of public
knowledge and attitudes concerning antibiotic use and awareness of antibiotic resistance (6-
8). A first Pan-European study in five EC countries and Turkey conducted in 1993 (9) and
extended to other continents (10) suggested that patients’ attitudes to antibiotic use varied
according to their country of residence. In particular, the proportion of patients definitely
expecting to receive antibiotics for respiratory tract infections was highest in Turkey, France
and Spain among European countries. However, this survey did not test if differences were
statistically significant between countries. Moreover, no attention was given to attitudes
towards self-medication with antibiotics, which varies widely between countries (11),
awareness about antibiotic resistance and knowledge about effectiveness of antibiotics on
bacteria and viruses.
Understanding cultural differences in the public’s attitudes, beliefs and knowledge is a pre-
requisite to develop effective educational interventions. The aim of this study was to explore
attitudes, beliefs and knowledge concerning antibiotic use and self-medication and compare
them between countries.
Subjects and methodsSubjects and methodsSubjects and methodsSubjects and methods
Subjects
Face to face structured interviews were conducted in 12 countries. Countries were
selected to represent Northern/Western (Austria, The Netherlands, Sweden, United Kingdom
and Belgium), Southern (Italy, Malta, Israel and Spain) and Eastern (Czech Republic, Lithuania
and Croatia) European regions. Because of data collection problems, Spain was excluded from
the analyses. Data were collected between October 2003 and May 2004, after approval of the
appropriate institutional review boards. This study is a follow-up from a European survey
estimating prevalence of both self-medication and prescribed use of antibiotics. In this
previous survey we used a multistage sampling design. Within each country, a region with
average prescribed antibiotic consumption was chosen and in each chosen region a middle-
sized city and rural area were selected. Questionnaires were mailed to 1000-3000 randomly
selected adults in each country, who were equally distributed in urban and rural areas. The
Chapter 5
64
characteristics of the respondents in each country and the prevalence rates of self-medication
and prescribed use in each country are described elsewhere (11).
This follow-up study was limited to respondents in 12 countries willing to be
interviewed. We aimed to recruit at least 100 respondents in each country, 50 users of self-
medication and 50 non-users, both equally distributed in urban and rural areas. If the number
of self-medication users willing to be interviewed was less than 50 in a country, non-users of
self-medication were added to achieve 100 respondents. In Lithuania, the number of non-users
willing to be interviewed did not reach 50, therefore, self-medication users were added.
Respondents who failed to identify antibiotics correctly (for example confusing antibiotics with
painkillers) were excluded from the study.
Survey instrument
We developed an English structured interview, translated it into national languages,
and back translated it to English to ensure consistency. Pre-testing of the questions took place
in each country. Interviewers from all countries were trained in a collaborative workshop. The
first two interviews with respondents were “training interviews” and were immediately
followed by an in depth discussion between the trainer and the interviewer. These first two
interviews were excluded from the analysis.
The questions included attitudes towards antibiotic use and self-medication with
antibiotics, beliefs about antibiotics for minor ailments, knowledge about the effectiveness of
antibiotics on bacteria and viruses and awareness of any health dangers associated with taking
antibiotics. Each of these domains was assessed with a series of items, partly derived from
other studies (8,12,13). The instrument contained 5-point Likert scale statements (table 1) and
one open ended question.
Respondents’ knowledge about health dangers associated with taking antibiotics was
assessed with an open-ended question, “Are you aware of any health dangers to your health or
the health of other people associated with taking antibiotics?” derived from another study (12).
We classified the answers into two categories: knowledge of antibiotic resistance and
knowledge of adverse effects of antibiotics (including allergies/reactions, antibiotics may kill
“friendly”/good flora, diarrhoea, vomiting etc.).
Sociodemographic information included age, sex, educational level, presence of a
chronic disease, and place of residence (rural or urban). Education was categorized as low
(incomplete primary education, completed primary education and lower vocational or general
education) or high (intermediate or higher vocational or general education, college or
university).
Attitudes , beliefs and knowledge concerning antibiotic use and self-medication: a comparative
European study
65
Respondents were asked whether they had ever taken an antibiotic without a
prescription. They were classified as users of self-medication if they reported that they had ever
taken any antibiotic without a prescription from a physician, dentist or a nurse.
Construction of scales measuring attitudes and beliefs
An exploratory factor analysis was performed to demonstrate the dimensionality of the
data. The selection of the number of components to be rotated was based on the “eigenvalue
greater 1” criterion. We set a cut-off value of 0.40 for factor loadings as inclusion criterion in a
factor. After Varimax rotation factor analyses revealed four underlying constructs, which were
consistent with the conceptual basis for the scales (table 1). Reliability of each subset of items
was computed using Cronbach’s alpha and mean inter-item correlation. As described in table 1,
all four scales showed satisfactory reliability. The first scale was attitudes towards
appropriateness of self-medication with antibiotics for bronchitis (table 1). Bronchitis was
chosen because antibiotics might be indicated for treatment (14) and it is considered as a
serious illness by lay people (15). The other scales were beliefs about antibiotics for minor
ailments (table 1), attitudes towards situational use of antibiotics and knowledge about the
effectiveness of antibiotics on bacteria and viruses. The mean scores were computed for each
scale, after reversing those items that were worded in opposite direction (i.e. “antibiotics can
kill bacteria”). Higher scores for each scale represented less appropriate attitudes, beliefs or
knowledge.
Data analysesData analysesData analysesData analyses
To analyse the differences between countries, regression analyses were used with the
outcome variable being each of the dimensions of attitudes, beliefs and knowledge. Multiple
linear regression analysis was used for continuous variables (attitudes towards
appropriateness of self-medication with antibiotics for bronchitis, beliefs about minor
ailments, attitudes towards situational use of antibiotics and knowledge about the
effectiveness of antibiotics on bacteria and viruses) and logistic regression for binary variables
(knowledge of antibiotic resistance and adverse effects of antibiotics).
The number of users and non-users of self-medication as well as those with low and high
education willing to be interviewed differed between countries. To deal with the possible
confounding effect of both use of self-medication and education, we performed stratified
analyses, i.e. studying the differences between the countries separately for users and non-users
of self-medication, and for participants with high and low education. The differences between
countries were considered relevant when regression coefficients were significant in all
stratum-specific analyses.
Chapter 5
66
Table 1. Exploratory factor analysis
Table 1. Exploratory factor analysis
Table 1. Exploratory factor analysis
Table 1. Exploratory factor analysis
F
acto
r lo
adin
g
Item
†
1
2
3
4
Just
imagin
e y
ou h
ave b
ronchitis
. H
ow
appro
priate
is it in
your
vie
w t
o g
et
antibio
tics w
ithout
a p
rescription
?
…O
ver
the w
eeke
nd in a
norm
al situatio
n
0.7
…O
ver
the w
eeke
nd w
ith a
n im
port
ant
event
co
min
g u
p
0.8
…O
n h
olid
ay a
bro
ad
0.6
…Y
ou h
ave n
o t
ime to g
o t
o t
he d
octo
r 0.8
…W
hen it is
difficult t
o c
onta
ct
the d
octo
r 0.9
…W
hen the d
octo
r has n
o tim
e t
o s
ee y
ou im
media
tely
0.8
…W
hen a
consultation w
ith a
docto
r is
to
o e
xp
ensiv
e
0.7
…W
hen y
ou h
ave a
good e
xperie
nce w
ith t
akin
g t
his
antibio
tic
0.4
…W
hen y
our
docto
r alw
ays p
rescribes y
ou this
antibio
tic
0.4
When the p
harm
acis
t advis
es y
ou w
hic
h a
ntibio
tic to take
0.5
When o
ne h
as a
sore
thro
at,
one s
hould
take a
ntibio
tics t
o p
revent g
ett
ing a
more
serio
us illn
ess
0.6
W
hen o
ne g
ets
a c
old
antibio
tics h
elp
to g
et
bett
er
more
quic
kly
0.7
B
y t
he tim
e y
ou y
ours
elf a
re s
ick e
no
ug
h t
o v
isit a
docto
r w
ith a
bad c
old
, you u
sually
exp
ect
a p
rescri
ption f
or
antibio
tics
0.5
You u
sually
kn
ow
if yo
u y
ours
elf n
eed a
n a
ntibio
tic f
or
a s
ore
thro
at
befo
re s
eein
g a
docto
r
0.4
M
ost of
yo
ur
frie
nds/r
ela
tives t
hin
k p
eople
should
take a
n a
ntibio
tic f
or
a c
old
0.5
T
he u
se o
f a
ntibio
tics w
he
n y
ou a
re s
ick in o
rder
to r
em
ain
active (
work
, fa
mily
, stu
dy)
is a
ppro
pri
ate
0.7
The u
se o
f a
ntibio
tics w
he
n y
ou a
re s
ick f
or
help
ing to g
et
thro
ugh a
n im
port
ant
eve
nt
(exa
m, fu
nera
l, w
eddin
g)
is
appro
priate
0.7
Antibio
tics c
an k
ill b
acte
ria*
0.5
A
ntibio
tics c
an k
ill v
iruses
0.6
Cro
nbach a
lph
a
α=
0.9
α
=0.7
α
=0.8
α
=0.4
M
ea
n inte
r-item
corr
ela
tio
n
0.5
0.3
0.6
0.3
Notes: Only loadings with an absolute value >0.40 are shown in the table. Factor 1, attitudes towards appropriateness of self-medication with antibiotics for
bronchitis (1=”completely inappropriate” and 5=”completely appropriate”); factor 2, beliefs about antibiotics for minor ailments (1=”strongly disagree”-
5=”strongly agree”); factor 3, attitudes towards situational use of antibiotics(1=”strongly disagree”-5=”strongly agree”); factor 4, knowledge about the
effectiveness of antibiotics on bacteria and viruses (1=”strongly disagree” and 4=”strongly agree”)
* For this item coding was reversed (1=“strongly agree” and 4=”strongly disagree”)
†Three statements were not included because of low loadings on all factors
Attitudes , beliefs and knowledge concerning antibiotic use and self-medication: a comparative
European study
67
The effects of other possible confounding variables (presence of a chronic disease,
gender, age, and place of residence) were considered in all analyses. Sweden was used as a
reference country in all analyses as it has the lowest prevalence of total antibiotic use i.e.
prescribed use and self-medication (11). Data were analysed using SPSS (version 12) for
Windows (SPSS, Inc, Chicago, IL).
Results Results Results Results
In total 1101 respondents were interviewed. The mean response rate of the countries was
89%. General characteristics of the respondents in each country are shown in table 2. The
number of users of self-medication differed between the countries because of the variation in
both prevalence of self-medication and willingness to be interviewed between the countries
(table 2). In comparison to the respondents in the previous survey (11), interviewees in the
follow-up study more often had a high education, but were similar with regard to age, sex,
presence of a chronic disease, and place of residence (urban/rural). Eleven respondents who
failed to identify what was an antibiotic were excluded from the analyses.
There was a wide variation in the percentage of respondents who answered incorrectly to
at least 75% of the items for each dimension between the countries (table 3). In most of the
countries this percentage was low. High percentages were obtained in Lithuania and Malta for
three dimensions. In the UK high percentage was found regarding the attitudes towards
appropriateness of self-medication with antibiotics for bronchitis.
More inadequate knowledge was reported about the effectiveness of antibiotics on
viruses (on average, 54% of the respondents answered incorrectly) than on bacteria (22%
answered incorrectly, data not shown). Overall, non-awareness of antibiotic resistance was
high (approximately half of the respondents) with a wide variation between countries, from
87% in Malta to 29% in Belgium. Non-awareness of adverse effects of antibiotics was also high
(48%) with less variation between countries (table 3).
Chapter 5
68
Table 2. General characteristics of interviewees in each participating European country
Table 2. General characteristics of interviewees in each participating European country
Table 2. General characteristics of interviewees in each participating European country
Table 2. General characteristics of interviewees in each participating European country
* Low education was defined as incomplete primary education, completed primary education, and lower vocational or general education
† Including any of the following diseases: asthma, chronic bronchitis, emphysema, HIV, cystic fibrosis, diabetes, endocarditis, tuberculosis, prostatitis, chronic
urinary tract infection, chronic osteomyeltis, peptic ulcer disease, chronic pyelonephritis or cancer
Coun
try
Respon
se
ra
te (
%)
No.
respo
nd
en
ts
inte
rvie
we
d
No.
users
of
self-
me
dic
atio
n
Mean
ag
e
(years
± S
D)
Fem
ale
(%
)
Lo
w e
du
cation
le
vel*
(%
)
Pre
sen
ce o
f a
ch
ron
ic
dis
ea
se
s†(%
)
Urb
an
location
(%)
Nort
he
rn a
nd
we
ste
rn
Th
e N
eth
erl
and
s
92
116
3
43±
11
69
10
16
48
Sw
eden
9
4
103
13
50±
18
56
36
15
58
Au
str
ia
88
101
19
47±
13
55
50
13
60
Belg
ium
9
2
99
1
8
43±
15
65
20
13
45
United K
ingd
om
5
7
95
1
5
50±9
54
30
16
50
Sou
thern
M
alta
9
2
99
2
9
48±
15
57
61
32
51
Isra
el
100
100
17
51±
14
65
5
22
36
Italy
100
80
1
7
45±
15
59
39
33
51
Ea
ste
rn
Cze
ch R
ep
ublic
7
7
100
21
50±
13
30
29
25
50
Cro
atia
8
7
96
3
6
54±
15
47
1
26
58
Lith
uan
ia
97
101
63
58±
17
42
32
34
52
Attitudes , beliefs and knowledge concerning antibiotic use and self-medication: a comparative European study
69
Table 3. Percentage of interviewees who
Table 3. Percentage of interviewees who
Table 3. Percentage of interviewees who
Table 3. Percentage of interviewees who had inappropriate attitu
had inappropriate attitu
had inappropriate attitu
had inappropriate attitudes, beliefs and knowledge concerning antibiotic use, self
des, beliefs and knowledge concerning antibiotic use, self
des, beliefs and knowledge concerning antibiotic use, self
des, beliefs and knowledge concerning antibiotic use, self- ---medication and antibiotic
medication and antibiotic
medication and antibiotic
medication and antibiotic
resistance by country
resistance by country
resistance by country
resistance by country
* Percentage of respondents who answered “completely appropriate” or “appropriate” to at least 75% of the items for attitudes towards appropriateness of
self-medication with antibiotics for bronchitis; “strongly agree” or “agree” to at least 75% of the items for beliefs about antibiotics for minor ailments,
attitudes towards situational use of antibiotics; and “strongly disagree” or “disagree” to “antibiotics can kill bacteria” and “strongly agree” or “agree” for
“antibiotics can kill viruses”.
Perc
en
tag
e o
f in
terv
iew
ee
s w
ho a
nsw
ere
d to a
t le
ast
75%
of
the ite
ms in t
he
dim
en
sio
n incorr
ectly*
P
erc
enta
ge o
f in
terv
iew
ees w
ho
a
nsw
ere
d in
corr
ectly
Coun
try
Attitud
es t
ow
ard
s
appro
pri
ate
ne
ss o
f se
lf-m
edic
atio
n w
ith
antibio
tics fo
r bro
nchitis
Be
liefs
abo
ut
antibio
tics f
or
min
or
ailm
en
ts
Att
itud
es t
ow
ard
s
situ
atio
nal use o
f antibio
tics
Know
ledg
e a
bou
t th
e e
ffe
ctive
ne
ss
of
an
tib
iotics o
n
bacte
ria
an
d
vir
use
s
Aw
are
ne
ss
abo
ut
an
tib
iotic
resis
tan
ce
Aw
are
ne
ss
ab
ou
t ad
vers
e
effe
cts
Sw
eden
2
2
2
9
3
3
60
Th
e N
eth
erl
and
s
5
2
8
11
4
3
57
Au
str
ia
4
5
5
22
3
9
44
Belg
ium
5
1
12
16
2
9
58
Unite
d K
ingd
om
33
5
22
15
3
2
19
Malta
2
60
32
48
8
7
31
Isra
el
5
3
16
10
4
7
65
Ita
ly
3
0
8
9
6
9
55
Cze
ch R
ep
ub
lic
11
5
4
22
4
0
36
Cro
atia
9
6
25
6
5
5
54
Lith
uan
ia
35
2
3
26
13
8
3
50
Overa
ll 10
1
0
14
16
5
0
48
Chapter 5
70
Country of residence was associated with each dimension of attitudes, beliefs and knowledge
when adjusting for use of self-medication, education, presence of a chronic disease, sex, age,
and place of residence (tables 4 and 5). Differences significant in all stratum-specific analysis
were found for the UK, Malta, Italy, Czech Republic, Croatia, Israel and Lithuania. Respondents
from these countries were consistently significantly different compared with respondents from
Sweden for at least one of the dimensions (tables 4 and 5). The Dutch, Austrian and Belgian
respondents were not significantly different from Swedish for any of the dimensions.
Lithuanian interviewees responded differently on the most dimensions from Swedish, with
more positive attitudes towards both self-medication and situational use of antibiotics,
stronger beliefs in antibiotics for minor ailments and less knowledge about both antibiotics
and antibiotic resistance. Similar significant differences were noted in Malta with the
exception of attitudes towards appropriateness of self-medication for bronchitis. In particular,
beliefs in antibiotics for minor ailments were very strong in Malta (table 4). Italian
interviewees had more positive attitudes towards situational use of antibiotics and less
knowledge of both antibiotics and antibiotic resistance. More positive attitudes towards self-
medication and situational use of antibiotics and lower knowledge of antibiotic resistance
were noted in Croatia. Interviewees in the UK, Czech Republic and Israel differed only for one
dimension from Sweden, indicating more positive attitudes towards self-medication in the UK
and Czech Republic and lower knowledge of antibiotic resistance in Israel. No country was
significantly different from Sweden concerning awareness about adverse effects of antibiotics
(data not shown).
Attitudes , beliefs and knowledge concerning antibiotic use and self-medication: a comparative European study
71
Table 4. Results of multiple regression analyses relating respondent characteristic to attitudes, beliefs and knowledge
Table 4. Results of multiple regression analyses relating respondent characteristic to attitudes, beliefs and knowledge
Table 4. Results of multiple regression analyses relating respondent characteristic to attitudes, beliefs and knowledge
Table 4. Results of multiple regression analyses relating respondent characteristic to attitudes, beliefs and knowledge
Notes: β =regression coefficient; CI=95% confidence interval;
Higher coefficients indicate more positive attitudes towards self-medication and situational use of antibiotics; stronger beliefs in antibiotics for
minor ailments; and less knowledge about the effectiveness of antibiotics on bacteria and viruses.
• not significant
� not significant in all stratum specific analyses (by education and by self-medication)
* adjusted for place of residence (rural/urban)
† adjusted for sex
Presence of a chronic disease and age were not significant in any of the analyses
Pre
dic
tors
Att
itud
es t
ow
ard
s
ap
pro
pria
tene
ss o
f se
lf-
med
icatio
n w
ith
antib
iotics f
or
bro
nchitis
Belie
fs a
bo
ut a
ntibio
tics f
or
min
or
ailm
ents
A
ttitud
es t
ow
ard
s s
itua
tio
na
l u
se
of
antibio
tics
Kn
ow
ledge
ab
out
the e
ffe
ctiven
ess
of an
tib
iotics o
n b
acte
ria a
nd v
iruses
β
*
CI
β
CI
β
CI
β†
CI
Co
untr
y
Sw
eden
re
fere
nt
re
fere
nt
re
fere
nt
re
fere
nt
United K
ingd
om
1.0
4
(0.8
0;
1.2
8)
•
�
�
Malta
•
1.2
5
(1.0
6;
1.4
4)
1.0
0
(0.7
3;
1.2
7)
1.0
4
(0.8
4;
1.2
3)
Italy
�
•
0.5
4
(0.2
5;
0.8
2)
0.5
7
(0.3
7;
0.7
7)
Isra
el
�
�
•
�
C
ze
ch R
ep
ublic
0.4
1
(0.1
7;
0.6
5)
•
•
�
C
roatia
�
�
(0.0
2;
0.4
1)
0.8
5
(0.5
7;
1.1
3)
�
L
ith
uan
ia
1.0
4
(0.7
9;
1.2
8)
0.6
2
(0.4
3;
0.8
2)
0.8
4
(0.5
6;
1.1
2)
0.6
9
(0.5
0;
0.8
9)
Th
e N
eth
erl
and
s
�
•
�
�
A
ustr
ia
•
•
�
�
Belg
ium
•
�
•
�
N
o u
se
of
self-m
ed
ication
refe
rent
re
fere
nt
re
fere
nt
re
fere
nt
U
se
of
se
lf-m
edic
atio
n w
ith
an
tib
iotics
0.6
4
(0.5
1;
0.7
7)
0.3
9
(0.2
9;
0.4
9)
0.3
1
(0.1
6;
0.4
6)
-0.1
1
(-0.2
2;
-0.0
1)
Lo
w e
du
ca
tio
n
refe
rent
re
fere
nt
re
fere
nt
re
fere
nt
Hig
h e
du
ca
tion
•
-0
.20
(-
0.3
0; -0
.10
) -0
.24
(-
0.3
8; -0
.10
) -0
.25
(-
0.3
5;
-0.1
5)
Chapter 5
72
Table 5. Logistic regression analysis of awareness about antibiotic resistanceTable 5. Logistic regression analysis of awareness about antibiotic resistanceTable 5. Logistic regression analysis of awareness about antibiotic resistanceTable 5. Logistic regression analysis of awareness about antibiotic resistance
Notes: lower OR indicates poor awareness about antibiotic resistance. The Netherlands, Austria, UK,
Belgium and Czech Republic were not significantly different from Sweden in the stratified analyses
Use of self-medication, sex and age were not significant
* adjusted for presence of a chronic disease and place of residence (rural/urban)
Discuss Discuss Discuss Discussionionionion
Our survey results showed significant differences in levels of public attitudes, beliefs and
knowledge concerning antibiotic use, self-medication and antibiotic resistance in Europe.
Respondents from all participating southern and eastern countries had less appropriate
attitudes, beliefs or knowledge compared with Swedish respondents at least for one of the
dimensions. With the exception of the UK, respondents from northern and western countries
did not differ from respondents in Sweden for any of the dimensions. British respondents had
more positive attitudes towards self-medication with antibiotics for bronchitis. This finding is
in line with the results of a survey conducted in the UK showing that respondents had great
expectations for antibiotics for the symptoms of acute lower respiratory tract illness. In
particular, 72% of previously well adults consulting with these symptoms wanted a
prescription for antibiotics from their general practitioner (16). Other countries demonstrating
more positive attitudes towards self-medication for bronchitis were Lithuania and Czech
Republic.
Evidence indicates that patients may influence antibiotic prescribing through overt
requests for antibiotics or non-overt pressure (17-20). We found that respondents in southern
and eastern countries had stronger beliefs about the need for antibiotics for minor ailments,
more positive attitudes towards use of antibiotics in different situations and less accurate
knowledge about the effectiveness of antibiotics in killing bacteria and viruses. Higher levels of
misconceptions in southern and eastern countries may in some part explain the high levels of
Predictors OR* 95% Confidence intervals
Country Sweden reference
Israel 0.40 (0.21;0.75) Italy 0.21 (0.11; 0.43)
Malta 0.10 (0.05; 0.22) Croatia 0.32 (0.17; 0.60)
Lithuania 0.09 (0.04; 0.18) Education
Low education referent High education 2.44 (1.71; 3.46 )
Attitudes , beliefs and knowledge concerning antibiotic use and self-medication: a comparative
European study
73
antibiotic use seen in these countries (11). The most pronounced differences between countries
were for awareness about antibiotic resistance, followed by attitudes towards situational use
of antibiotics. In general, there was no consistency between all dimensions, i.e. higher score on
one dimension did not lead to higher scores for the other dimensions.
The respondents from northern and western countries were similar in their beliefs about
antibiotics for minor ailments. A study comparing patients’ views on respiratory tract
symptoms and antibiotics in The Netherlands, UK and Belgium also found that the respondents
in these three countries were similar in their perception of effectiveness of antibiotics to
prevent these symptoms from deteriorating and to speed recovery (21).
Overall, only half of the respondents in our survey were aware about antibiotic resistance.
This awareness was the lowest in countries with higher prevalence of resistance. Our average
results for Europe are comparable to the US data from 1998-1999, reporting that 48% of the
respondents being aware of health dangers associated with taking antibiotics of whom 58%
were aware of antibiotic resistance (12). Other US data have shown much higher levels of such
awareness (73% in Colorado), but this could be due to a difference in methodology in the latter
study that used a closed-response statement instead of an open question (6).
Differences in implementing drug regulations that affect the availability of antibiotics in
different countries can play an important role in misconceptions about antibiotics (7). In the
US, recent immigrants from Mexico, where antibiotics are available over the counter, had the
greatest expectations for antibiotics for upper respiratory infections and the least
understanding of the problem of inappropriate use and antibiotic resistance (6). Our study
indicates high levels of misconceptions concerning antibiotic use and resistance in southern
and eastern European countries where acquisition of antibiotics from pharmacies without
prescription occurs frequently (11), despite the fact that this is against the law. In addition to
these regulatory aspects, other differences in health care systems such as drug prices and
reimbursement policies may also influence the attitudes of the public towards antibiotic use
and self-medication.
The results of our study are limited by small sample size in each country. The selection of
the samples was non-random and the samples of the countries differed in the proportion of
both users of self-medication and respondents with high education. To deal with possible
confounding effects of both self-medication use and education, we used a conservative
approach considering as relevant only those differences which were significant in all stratum-
specific analyses. As a consequence, we might have underestimated differences between
countries.
Our results indicate that, while the inappropriate attitudes and knowledge in the other
domains are clustered in a few countries, lack of awareness of antibiotic resistance and adverse
effects is a problem in all the participating European countries. This is an indication that most
people in these countries still do not realize enough that excessive use of antibiotics is
Chapter 5
74
associated with serious risks affecting individuals as well as the ecosystem as a whole (22).
Continuous efforts are needed to reduce these misconceptions. Strategies to improve the
situation however, will have to be country-specific in view of the different problems identified
in this study. Such attitude shifts have occurred before for example in public’s beliefs about
tobacco use and saturated fat consumption (22). Public-education campaigns have been
shown to be effective in changing attitudes and knowledge about antibiotic use and resistance
as well (18, 23). This will require concerted action of the medical world in collaboration with
patient organisations and policy makers with a long-term view. Our study indicates that the
need for public-education campaigns is strong in countries reporting high resistance levels i.e.
southern and eastern European countries.
One single campaign, however, may not be enough for changing the attitudes of the general
public. A national campaign targeting both the general public and health professionals was
undertaken in Malta in 2002-2003 (24). However, despite the efforts of this campaign we
found high levels of misconceptions concerning antibiotic use in Malta in our study. This
campaign was done only once using posters, brochures and sporadic media slots to inform the
public. More intensive (such as involving the mass media or other multi-faceted approaches)
and focused strategies should be used, which have been found to be effective (18). In contrast
to Malta, a national Swedish project named STRAMA (25) has been continuously implementing
activities in multidisciplinary groups including prescribers, pharmacists and general public
since 1995. Although not proved, it is believed that STRAMA through its activities has had a
positive effect on increasing the knowledge in Sweden regarding antibiotic use and resistance.
Repeated national campaigns were also conducted in Belgium (26). In our study awareness
about antibiotic resistance was the highest in Belgium, which might be related to these
campaigns.
In conclusion, our study showed clear cultural differences in levels of public attitudes, beliefs
and knowledge concerning antibiotic use, self-medication and antibiotic resistance in 11
European countries. The levels of misconceptions contributing to inappropriate use were the
highest in southern and eastern countries, indicating a strong need for public education
campaigns in these countries. Awareness about antibiotic resistance was the lowest in
countries reporting high prevalence of resistance.
Key pointsKey pointsKey pointsKey points
We found cultural differences in public attitudes, beliefs and knowledge concerning
antibiotic use, self-medication and antibiotic resistance in 11 European countries.
The levels of misconceptions contributing to inappropriate use were the highest in southern
and eastern countries, indicating a strong need for public education campaigns in these
Attitudes , beliefs and knowledge concerning antibiotic use and self-medication: a comparative
European study
75
countries. Awareness about antibiotic resistance was the lowest in countries reporting high
prevalence of antibiotic resistance.
Ethics approvalEthics approvalEthics approvalEthics approval
Ethics or data committee approval for the survey was required in six countries (Belgium,
United Kingdom, Malta, Czech Republic, Croatia, and Lithuania) and was obtained from the
local ethics or data committees of these countries.
The SARThe SARThe SARThe SAR----consortiumconsortiumconsortiumconsortium
Antonella Di Matteo (Consorzio Mario Negri Sud, Santa Maria Imbaro, Chieti, Italy); Arjana
Tambic-Andrasevic (University Hospital for Infectious Diseases, Zagreb, Croatia); Retnosari
Andrajati (Faculty of Pharmacy, Charles University, Prague, Czech Republic); Hana Edelstein
(Ha'Emek Medical Center, Afula, Israel); Rolanda Valinteliene (Institute of Hygiene, Vilnius,
Lithuania); Reli Mechtler (University of Linz, Linz, Austria); Luc Deliens (Vrije Universiteit
Brussel, Brussels, Belgium); and Greta Van der Kelen (Vrije Universiteit Brussel, Brussels,
Belgium).
AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements
This study was funded by a grant from DG/Sanco of the European Commission (SPC2002333),
the European Commission Public Health Directorate DG SANCO, and the participating
institutions.
Conflict of interest statementConflict of interest statementConflict of interest statementConflict of interest statement
None to declare.
Chapter 5
76
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Are cultural dimensions relevant for explaining
cross-national differences in antibiotic use in
Europe?
Reginald Deschepper, Larissa Grigoryan,
Cecilia Stålsby Lundborg, Geert Hofstede, Joachim Cohen, Greta van der Kelen,
Luc Deliens, and Flora M Haaijer-Ruskamp on behalf of the SAR consortium
Submitted
Chapter 6
80
AbstractAbstractAbstractAbstract
Objectives:Objectives:Objectives:Objectives: To explore whether differences between national cultures as described in
Hofstede’s model of cultural dimensions (Power Distance, Individualism, Masculinity and
Uncertainty Avoidance) are associated with cross-national differences in use of antibiotics
(prescribed and non-prescribed).
Methods:Methods:Methods:Methods: A survey on reported use of systemic antimicrobial drugs in the last 12 months (SAR-
study) was conducted in 19 European countries. Country-level data from this survey were
correlated to country-specific scores of cultural dimensions obtained from Hofstede. Results
were verified by doing the same for data from 3 other studies on antibiotic use.
Results: Results: Results: Results: The SAR-study resulted in a response rate higher than 20% in 17 countries for which
scores on the cultural dimensions were also available. The three other studies provided data on
antibiotic use for 27 European countries in total, for which scores of cultural dimensions were
also available. Significant positive correlations were found between Power Distance and
prescribed (0.59) and non-prescribed (0.54) use of antibiotics. Data from the other 3 studies
gave similar results. Uncertainty Avoidance was not significantly correlated with the data on
antibiotic use from the SAR-study but was significantly positively correlated to the antibiotic
use as reported in the three other studies. Individualism was significantly negatively correlated
with self-medication (-0.41), but not with prescribed antibiotics. No significant correlations
between Masculinity and antibiotic use were found.
ConclusionsConclusionsConclusionsConclusions: Of the dimensions of national culture, in particular Power Distance seems to be
associated with antibiotics use. Campaigns aimed at more rational antibiotics use thus require
good understanding of national culture.
Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe?
81
IntroductionIntroductionIntroductionIntroduction
Antibiotics are important and widely used medicines (1,2). There is, however, a growing
concern that the use and especially the unnecessary use of these medicines leads to resistance,
avoidable costs and adverse reactions (1-3). Hence, a more prudent use of antibiotics has been
advocated (4).
There are considerable cross-national differences in public attitudes towards antibiotics
use (5) as well as in actual use of prescribed antibiotics (2,6,7) and self-medications with
antibiotics (8). These cross-national differences in use of antibiotics can only partially be
explained by epidemiological differences and differences in health care structure. Cultural
factors also are known to play an important role in illness behaviour and consumption of
antibiotics (9). Most cross-cultural comparisons are about factors directly related to illness
behaviour (e.g. labelling and presumed causes of illnesses). Few studies have explored the
broader and general cultural characteristics of a country that at first sight are not directly
related to illness behaviour (10). One of the difficulties in many studies is that the concept of
culture is often used as a general concept for all inexplicable cross-national differences. It is
also hard to operationalise the concept of culture into quantifiable measures that can be used
in comparative studies.
A possible solution is the use of cultural dimensions. These dimensions are aspects from
which a culture can be compared with other cultures. They provide a relatively general
framework for analysis that can be easily applied because it reduces the complexities of culture
and its interactions into quantifiable dimensions (11-13). Based on surveys in more than 50
countries, Hofstede initially found 4 cultural dimensions on which countries can be scored: (i)
Power Distance, (ii) Individualism, (iii) Masculinity and (iv) Uncertainty Avoidance. Power
Distance refers to the degree of hierarchy in a country, it has been defined by Hofstede as the
extent to which the less powerful members of organizations and institutions accept and
expect that power is distributed unequally. Individualism refers to the prevalence of the
interests of an individual versus the group. This dimension is defined as the degree to which
individuals are integrated into groups. Masculinity, as opposed to femininity, refers to a culture
in which the emotional roles between the genders are clearly separated; masculine cultures are
for instance very assertive and competitive. Uncertainty Avoidance deals with a society's
tolerance for uncertainty and ambiguity; this cultural dimension indicates to what extent a
culture programs its members to feel either uncomfortable or comfortable in novel, unknown
or surprising situations. Later, a fifth dimensions (Long Term versus Short Term Orientation)
was found, based on Asian studies. While the influence of cultural dimensions on illness
behaviour and use of medicines has been suggested in previous studies (14,15), very few studies
have actually linked the scores on cultural dimensions with diseases and illness behaviour (16)
Chapter 6
82
and, to our knowledge, no study did this with regard to use of antibiotics. The aim of this study
is to explore whether cultural dimensions, are associated with cross-national differences in the
prescribed use of antibiotics and self-medication with antibiotics.
MaterialsMaterialsMaterialsMaterials and methodsand methodsand methodsand methods
Data on prescribed use of antibiotics and self-medication were obtained from a survey in
2003 on reported use of systemic antimicrobial drugs in the last year in 19 European countries
(SAR: Self-medication with antibiotics and Resistance in Europe). A multistage sampling design
was used in each participating country. Within each country, a region with average prescribed
antibiotic consumption was chosen, based on available national data on use of medicines. In
each region an urban (with a population 75,000- 350,000) and a rural area (population 5,000-
10,000) were selected. Persons > 18 years of age were randomly selected from population
registries in the selected regions. The questionnaire was developed specifically for this survey
in English, translated into national languages, and back-translated for consistency. The
questionnaire is available in English from the corresponding author. More information is
provided elsewhere (8). Respondents were classified as self-medicating if they reported that
they had taken any antimicrobial drugs in the previous 12 months without a prescription from a
physician, dentist, or nurse and as prescribed users if antimicrobial drugs had been prescribed.
For all countries in the SAR-study with a response rate higher than 20%, prevalence of reported
self-medication and prescribed use of antibiotics in the previous 12 months per 1000
population were estimated (8). To verify whether the findings based on our data were
consistent with results based on other studies and other European countries, we also made use
of country-data on outpatient antibiotic use published by the European Surveillance on
Antimicrobial Consumption (2), on reported use of antibiotics in the last year published by
Eurobarometer (7), and on outpatients antibiotics sales using IMS data (6). In contrast to the
data of the SAR-study, these other studies could not differentiate between prescribed
antibiotics and self-medication with antibiotics.
Data on cultural dimensions were obtained from Hofstede (13). We only used the 4 initial
dimensions because data about the fifth dimension (Long Term Orientation) were only
available for a limited number of countries. Scores on these dimensions, called indexes,
indicate the relative positions of countries with regard to each other. For an initial set of 40
countries they were derived from carefully matched samples of employees in different national
subsidiaries of the same multinational corporation (17). These relative positions turned out to
be remarkably stable over time; they were replicated in a number of successive studies by
different researchers using a variety of other matched samples of respondents (for an overview
see Hofstede, 2001). Later additions used a simplified questionnaire, the Values Survey Module
1994 (18). It consists of 20 content questions and 6 demographic questions. The most recently
Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe?
83
published lists contain index values on the first four dimensions for 74 countries and regions
(13). Spearman’s correlation coefficient rho was used to calculate correlations between country-
aggregated use of antibiotics and country-specific scores of cultural dimensions.
ResResResResultsultsultsults
There were 17 countries from the SAR-study (including 14,877 respondents) for which we
had information on reported self-medication with antibiotics, prescribed use of antibiotics in
the last 12 months and the scores on Hofstede’s cultural dimensions (table 1). Via the ESAC-
study (24 countries), the Eurobarometer study (15 countries) and the study by Cars et al (15
countries) we disposed over similar data for in total 27 European countries (2,6,7).
Significant positive correlations were found for Power Distance Index with prescribed use
of antibiotics (0.59) and self-medication (0.54). Comparison with data available from other
studies and other countries demonstrated significant correlations in the same directions (table
2). The Individualism Index is significantly negatively correlated with self-medication of
antibiotics (-0.41). Moderate but non-significant correlations were found for prescribed use in
the SAR-study and antibiotic use as reported in the other 3 studies. The Masculinity Index
correlates moderately but non-significantly with self-medication (0.31) and prescribed use
(0.42). This is consistent with the correlations based on the other studies. The finding of a
positive correlation of Uncertainty Avoidance Index with self-medication (0.43) and prescribed
use (0.32) is consistent with those of the other data sets. The correlations based on data of the
SAR-study are however not significant, which they are for the data based on the other studies.
The differences between correlation coefficients for prescribed use and self-medication are
very small with regard to Power Distance and Individualism. For Masculinity and Uncertainty
Avoidance they are somewhat higher.
Table 1. Self
Table 1. Self
Table 1. Self
Table 1. Self- ---medication, prescribed use of antibiotics in the past 12 m
medication, prescribed use of antibiotics in the past 12 m
medication, prescribed use of antibiotics in the past 12 m
medication, prescribed use of antibiotics in the past 12 months (prevalence rate per 1000 respondents) and indexes of four cultural
onths (prevalence rate per 1000 respondents) and indexes of four cultural
onths (prevalence rate per 1000 respondents) and indexes of four cultural
onths (prevalence rate per 1000 respondents) and indexes of four cultural
dimensions.
dimensions.
dimensions.
dimensions.
Note: PDI (Power Distance Index); ID
V (Individualism
index); MAS (M
asculinity); U
AI (Uncertainty avoidance index)
Countr
y
Response R
ate
(%)
No.
Respon
dents
Self-m
edic
ation
with a
ntib
iotics
Pre
scribed
use
of
antib
iotics
PD
I ID
V
MA
S
UA
I
The N
eth
erl
ands
55
1634
1
152
38
80
14
53
Sw
ed
en
69
704
4
135
31
71
5
29
Denm
ark
63
1881
7
172
18
74
16
23
Luxem
bourg
50
675
9
288
40
60
50
70
Belg
ium
(F
landers
)
54
1734
9
222
61
78
43
97
Malta
54
541
56
422
56
59
47
96
Czech.
Rep
. 59
1169
7
253
57
58
57
74
Slo
vakia
55
546
42
569
104
52
110
51
Rom
ania
43
430
198
307
90
30
42
90
Austr
ia
28
442
9
159
11
55
79
70
United K
ingd
om
23
675
12
221
35
89
66
35
Irela
nd
26
793
14
353
28
70
68
35
Italy
21
213
62
512
50
76
70
75
Slo
ve
nia
38
1143
17
293
71
27
19
88
Cro
atia
31
615
31
439
73
33
40
80
Pola
nd
32
935
33
199
68
60
64
93
Lith
uan
ia
25
747
210
275
42
60
19
65
Chapter 6
84
Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe?
85
Table 2. Correlations between use of antibiotics and cultural dimensionTable 2. Correlations between use of antibiotics and cultural dimensionTable 2. Correlations between use of antibiotics and cultural dimensionTable 2. Correlations between use of antibiotics and cultural dimensionssss
** Correlation is significant at the 0.01 level (2-tailed).
* Correlation is significant at the 0.05 level (2-tailed).
DiscussionDiscussionDiscussionDiscussion
Power distance is positively correlated with self-medication and prescribed use of
antibiotics in all the data sets. Uncertainty Avoidance, at first sight, does not seem to be
relevant but significant positive correlations were found with antibiotic use as reported in
other previous studies (partially based on other European countries). The findings for the
Individualism and Masculinity are not conclusive, since not all data point out to significant
correlations.
Power Distance
In countries with a high Power Distance inequality is expected and preferred.
Subordinates will expect their superior to tell them what to do. In countries with a low Power
Distance, to the contrast, people in less powerful positions will feel less dependent of more
powerful people. They are expected to take initiatives and there is a preference for
consultation. This may have implications for collaboration between doctors and other health
care providers, such as pharmacists and nurses, as well as in the doctor-patient
communication. An example of the former, is the collaboration between physicians and
pharmacists. In countries with high Power Distance, hierarchic differences will be more
manifested and doctors will have a more pronounced (therapeutic) autonomy, in other
countries doctors feel more part of a team. In the Netherlands (a country with a low Power
Power
Distance
Individualism Masculinity Uncertainty
Avoidance
SAR data
Self-medication
Prescribed use
Other data sets
0.54*
0.59*
-0.41*
-0.45
0.31
0.42
0.43
0.32
ESAC (N=24) 0.59** -0.29 0.22 0.59**
Eurobarometer (N=15) 0.62* -0.30 0.31 0.58*
Cars et al. (N=15) 0.78** -0.38 0.16 0.78**
Chapter 6
86
Distance and one of the lowest use of antibiotics) Pharmacotherapy Counselling Groups, in
which GPs and local community pharmacists regularly meet to exchange information about
drug therapy, has been the spearhead of a successful policy for more rational use of antibiotics
and other medicines (10,19,20). Power Distance will also affect the doctor patient- relationship,
besides the relations between professionals. In countries with a high Power Distance patients
look up to their doctor. They expect great expertise of them and feel little need for being
involved in the decision-making. Asking “what do you think yourself of taking an antibiotic?”
would embarrass the ‘modal’ patient. Either so, a physician acknowledging that he is not sure
whether it is a viral or bacterial infection and hence says: “well, let us wait and see” will, in such
a cultural context, not inspire much confidence. Prescribing antibiotics has strong symbolic
connotations and it can be seen as a sign of power and expertise. Hence, antibiotics not only
have a pharmaceutical but also a communicative aspect. The clinician-patient encounter has
been described as ‘one of the most important battlegrounds’ in the struggle with the microbe
(21). Countries with low Power Distance, to the contrast, show a preference for shared decision-
making in which the patient discloses his concerns and point of view, e.g. with regard to pros
and cons of antibiotics. It is true that patients often put pressure on the physician to prescribe
antibiotics but doctors often overestimate patients demand (22). Taking the time to talk about
patients concerns and to make patient expectations explicit has been promoted as a good
strategy to attain a more rational use of antibiotics (23-26). The finding that Power Distance is
relevant with regard to use of antibiotics is in line with other studies (24) that indicate that
doctor-patient relationship and dissatisfaction with the doctor is an important determinant of
antibiotic misuse. Of four types of patients (involved, deferent, ignored and critical types), the
Involved, i.e. patients which ensure they are part of the decision-making process and seeing
themselves as equal to the doctor, have views on and use of antibiotics most in line with the
medical views. Therefore, changing the patient to the more involved type is suggested as a
strategy to limit the use of antibiotics. However this might be more difficult in countries with
high Power Distance.
Uncertainty Avoidance
Uncertainty Avoidance deals with a society's tolerance for uncertainty and ambiguity.
Typically, people in such societies can accept known risks but they try to avoid unclear situation
and want to have control over things. If applied to medical situations, patients and physicians
will have an aversion to diagnostic uncertainty and will prefer a clear labelling of diseases.
However, many symptoms, such as coughing, sore throat, mild fever, etc. are difficult to label
and remarkable cross-cultural variations have been found (14,27). Based on a clinical
examination of the patient, it is often impossible to determine whether the problem is caused
by a (self-limiting) viral infection or a bacterial infection, in which cases antibiotics might be
Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe?
87
warranted (28). Hence, it is usually good practice to ‘wait and see’. However, there is always a
small risk of a dangerous infection. If doctor and patient are not willing to accept risks, they
rather start using antibiotics immediately, likely with a preference to the newest and strongest
broad spectrum antibiotics. When the Uncertainty Avoidance is high, rather than returning
home with the message that ‘the doctor does not know’ neither what disease they have, nor
how to cure it, they accept the known risks of using antibiotics. In the latter case, patients feel
confident that they have a disease with a clear cause that is under control. The above attitude
of avoiding any risk is known as defensive medicine and leads to unnecessary high medical
consumption (29).
Prescribed use versus self-medication
We found little differences between the effects of cultural dimensions on prescribed use
versus self-medication of antibiotics. This suggests that in countries with high incidence of
self-medication with antibiotics, the prescription of antibiotics is also high and that self-
medication and prescribing are practices affected by the same cultural dimensions. This adds
evidence to the hypothesis that notwithstanding the physician is formally the only person to
decide whether or not antibiotics should be used, the final decision is the result of a complex
interaction between patient and physicians in a particular cultural context. There is no
indication in our data that behaviour with regard to use of antibiotics of physicians is less
dependent of the local cultural context than that of the lay people (the patients).
Our study had some limitations. First, the response rate for the SAR data was low in some
countries. We therefore repeated the analysis, limited to countries with response rates of
>40%. We also plotted the results and checked for the effect of possible outliers. These
verifications corroborated our results. Second, culture is certainly a much richer phenomenon
than the presented reduction into 5 dimensions and Hofstede has been criticized for trying ‘to
measure the immeasurable’ (30,31). However, equivalents of Hofstede’s cultural dimensions
were found by several other authors and the cultural dimensions were validated in multiple
other studies (12). An advantage of the use of cultural dimensions is that they enable
quantitative analysis of cultural aspects in relation to other relevant issues such as the use of
antibiotics (11). This is not possible using thicker descriptions of cultures, i.e. anthropological
descriptions based on qualitative data.
In summary, our study indicates that Power Distance is a cultural aspect associated with
antibiotic use, suggesting that the culturally-specific way people deal with authority is an
important factor in explaining cross-national differences in antibiotic use. Uncertainty
Avoidance can lead to defensive medicine which might result in unnecessary use of antibiotics.
Further cross-national comparative research is needed to better understand the correlations
between the cultural dimensions and the use of antibiotics and the reasons for this so that our
Chapter 6
88
hypothetical explanations can be corroborated or falsified. These findings and the deduced
explanations suggest that countries are likely to react differently on campaigns aiming at a
more rational use of antibiotics. It should be taken into account that cultural dimensions can
be obstacles or facilitators which, by their nature, are hard to change (26,32). The
understanding of the effect of cultural dimensions might explain why campaigns are less
successful in some countries than in others (21, 26, 33-35). A better understanding of cultural
dimensions can be used to anticipate reactions to a campaign in a particular country. For
example, our results suggest that in countries with low Power Distance, campaigns for more
appropriate use of antibiotics should involve both professionals and the general public, while
in countries with high Power Distance campaigns to improve antibiotic use should focus
primarily at the physicians.
AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements
The overall study was funded by the European Commission Public Health Directorate DG
SANCO (SPC2002333). In addition, funding was also provided from funds of the participating
institutions. The researchers of this study have been independent of funding source.
The SARThe SARThe SARThe SAR----consoconsoconsoconsortium rtium rtium rtium
Antonella Di Matteo (Consorzio Mario Negri Sud, Santa Maria Imbaro, Chieti, Italy);
Arjana Tambic-Andrasevic (University Hospital for Infectious Diseases, Zagreb, Croatia);
Retnosari Andrajati (Faculty of Pharmacy, Charles University, Prague, Czech Republic); Hana
Edelstein (Ha'Emek Medical Center, Afula, Israel); Rolanda Valinteliene (Institute of Hygiene,
Vilnius, Lithuania); Reli Mechtler (University of Linz, Linz, Austria).
Transparency Transparency Transparency Transparency ddddeclarationeclarationeclarationeclaration
None to declare.
Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe?
89
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General discussion
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General discussionGeneral discussionGeneral discussionGeneral discussion
This thesis addresses the problem of self-medication with antibiotics in Europe. It is
well recognised that unnecessary and inappropriate use of antibiotics is the major determinant
of antibiotic resistance. Most studies have focused on prescribed use and little attention has
been given to self-medication. We estimated the prevalence of self-medication with antibiotics
in 19 European countries and explored its determinants. Because cultural factors play an
important role in the consumption of antibiotics we also studied the influence of cultural
differences on international differences in antibiotic consumption in Europe.
The studies in this thesis were based on two European surveys. The first one was a
postal survey including 1000-3000 randomly selected persons in each of the 19 participating
countries. The second follow-up survey was face-to-face interviews limited to respondents in 12
countries willing to be interviewed.
In this general discussion, an overview of the main findings in this thesis will be given.
In addition, some methodological issues will be discussed. Finally, implications for the
strategies to prevent inappropriate use of antibiotics and recommendations for future research
will be given.
Main findingsMain findingsMain findingsMain findings
Self-medication with antibiotics in Europe
Self-medication with systemic antibiotics occurred in each of the 19 participating
countries. The prevalence of actual self-medication varied widely, with the highest rates in
eastern and southern countries, and the lowest in northern and western. A throat symptom
(e.g. inflamed, red or sore throat), teeth or gum symptoms and bronchitis were the most
common reasons for self-medicating. In general, respondents’ self-diagnosed disorders were
self-limiting and antibiotics would not have been indicated. In eastern countries, the major
source of self-medication was the pharmacy without prescription, followed by leftover
antibiotics from previous prescribed courses. By contrast, in southern, northern, and western
countries use of leftover antibiotics was more prevalent, followed by antibiotics obtained
directly from the pharmacy. The rates of at-risk self-medication (those who indicated the
intention to self-medicate or store antibiotics at home) also tended to be higher in southern
and eastern Europe than in northern and western Europe. Intended self-medication with
antibiotics had a much higher prevalence than actual self-medication, indicating that
population at-risk is much larger than those who have actually self-medicated in the previous
12 months. Persons who were more prone to self-medicate with antibiotics were younger
persons, more educated and had chronic diseases.
General discussion
95
The relationship between prescribed use of antibiotics and self-medication
In chapter 3 the relationship between prescribed use and self-medication was studied.
The association between prescribed use and self-medication in general implies that antibiotics
prescribed for one symptom/disease may be used both as self-medication for (repeated)
episodes of the same symptom/disease and for another symptom/disease. The association for
URTIs implies that prescribed use for URTIs increases the probability of self-medication for
URTIs. We found an association between prescribed use and self-medication with antibiotics in
general from a leftover source in Northern/Western and Eastern Europe. In both regions the
effect of prescribed use was larger in lower educated respondents. One could hypothesize that
respondents with low education are less aware about the consequences of repeating
prescriptions of the doctors for the same symptom/disease or for another symptom/disease.
This effect of education disappeared when looking at the relation between prescribed use and
self-medication for URTIs. The effect of prescribed use on self-medication for URTIs with
leftover antibiotics in all European regions was the same for both educational levels. For self-
medication from sources other than leftovers the associations did not reach statistical
significance. This might be due to a lack of statistical power to detect a smaller effect.
Determinants of self-medication with antibiotics in Europe
Using the PRECEDE model of behaviour change we examined the impact of
predisposing and enabling factors on self-medication with antibiotic in Europe in chapter 4. We
considered both country and individual level factors. Predisposing factors included in the
analyses were attitudes, beliefs and knowledge concerning antibiotic use and self-medication.
Enabling factors were country wealth and health care system factors. Positive attitude towards
appropriateness of self-medication with antibiotics and incorrect beliefs about antibiotics for
minor ailments, i.e. sore throat and common cold, were predisposing factors for use of self-
medication. The perceived availability of antibiotics from pharmacies without a prescription
was the main enabling factor at the individual level. Other enabling factors included country
characteristics, i.e. country wealth (GDP per capita) and dispensing regulations for prescribed
antibiotics in pharmacies. Country wealth and dispensing exact number of prescribed tablets in
pharmacies were independently associated with lower self-medication.
Cultural differences between countries influencing antibiotic use in Europe
We compared public attitudes, beliefs and knowledge concerning antibiotic use and
self-medication between 11 European countries in chapter 5. Respondents were interviewed on
their attitudes towards appropriateness of self-medication with antibiotics and situational use
of antibiotics, beliefs about antibiotics for minor ailments, i.e. sore throat and common cold,
Chapter 7
96
knowledge about the effectiveness of antibiotics on viruses and bacteria and awareness about
antibiotic resistance and adverse effects of antibiotics. Respondents from all participating
southern (Malta, Israel and Italy) and eastern (Czech Republic, Croatia and Lithuania) countries
had less appropriate attitudes, beliefs or knowledge compared with Swedish respondents at
least for one of the dimensions. With the exception of the UK, respondents from northern and
western countries did not differ from respondents in Sweden for any of the dimensions.
Awareness about antibiotic resistance was the lowest in countries reporting high prevalence of
antibiotic resistance.
Cultural dimensions and antibiotic use
In Chapter 6, data on both prescribed use of antibiotics and self-medication were
correlated with country-specific scores on cultural dimensions (1). Results were verified by
correlating the data on antibiotic use from three other studies (2-4) and scores on cultural
dimensions. Power distance index (PDI) was positively correlated with both prescribed use and
self-medication in all the datasets. This suggests that the culturally-specific way people deal
with authority is an important factor in explaining cross-national differences in antibiotic use.
In countries with a high PDI, hierarchic differences will be more manifested and doctors will
have a more pronounced (therapeutic) autonomy, while in countries with a low PDI doctors
feel more part of a team. Power distance will also affect the doctor-patient relationship,
besides the relations between professionals. In countries with a high PDI patients feel little
need for being involved in the decision-making and a physician acknowledging that he is not
sure whether it is a viral or bacterial infection will in such a cultural context not inspire
confidence. Therefore, antibiotics not only have a pharmaceutical but also a communicative
aspect in this culture. We did not find consistent significant correlations between antibiotic use
in all four datasets and other cultural dimensions (IDV, MAS and UAI).
Methodological considerationsMethodological considerationsMethodological considerationsMethodological considerations
The prevalence of self-medication with antibiotics from various sources among the
population can be investigated in a survey only. It is possible to estimate over-the-counter use
by subtracting the difference between sales and reimbursement data. However, the data on
self-medication with antibiotics from leftovers from previous prescribed courses or obtained
from relatives or friends are not registered in any database. Therefore, we chose a
comprehensive approach i.e. the population survey. Low response rates are a continuing
problem for surveys and may lead to biased estimates of prevalence rates. Low response rates
were observed in several countries in our postal survey. To deal with this problem we
calculated the prevalence rates adjusted for non-response based on the assumption that
General discussion
97
respondents who replied after the reminder most resemble non-respondents. It might be that
this assumption is not strictly true. However, we included the data from countries with low
response rates because in most of theses countries (except Spain) no other information is
available about self-medication. Moreover, low response rate is a general problem of surveys in
these countries (5;6) and if we want to obtain information about these countries we will
always face the problem of non-response. In addition, debate is growing that low response is
less problematic in affecting survey estimates than previously assumed (7). Nevertheless, the
prevalence rates of self-medication in countries with low response rates should be considered
as a rough estimate and interpreted as an indication that the problem exists.
As with all self-reported data, results of this survey have the potential for recall bias,
underreporting, or overreporting. We attached the list of the most commonly used antibiotics
in each country to the questionnaires to reduce recall problems. To discourage underreporting
of self-medication, the questions about antibiotic use were formulated in a neutral way in
which the source of the drug could be chosen from 6 predefined sources or “other sources”.
In our second follow-up survey we conducted face-to-face interviews with the
respondents of the postal survey. We recruited a limited number of respondents in each
country. The samples were not selected randomly and therefore may not be representative of
the general population in the studied countries. They differed in the proportion of both users of
self-medication and respondents with high education. To compare public attitudes, beliefs and
knowledge concerning antibiotic use and self-medication with antibiotics between the
countries we had to take into account these differences between the samples. We performed
stratified analyses, i.e. separate analysis for users and non-users of self-medication, and for
respondents with high and low education. We used a conservative approach considering as
relevant only those differences which were significant in all stratum-specific analyses. As a
consequence, we might have underestimated differences between countries.
A lesson learnt from our international survey is that the choice of data collection
technique depends on the country. Different data collection techniques (postal self-
administered questionnaires or interviewer administered etc.) are appropriate in different
countries. For example, in Romania a higher response rate can be expected when
questionnaires are administered by the interviewer because many respondents in rural areas
have difficulties in understanding some questions. In other countries interviews at home are
not accepted by people and may lead to low response rates. Therefore, before choosing a data
collection technique in a particular country it is important to conduct a pilot study.
Chapter 7
98
ImplicationsImplicationsImplicationsImplications
Self-medication with systemic antibiotics occurred in all 19 countries that participated
in our survey. Antibiotics obtained directly from pharmacies and leftovers from previous
prescribed courses were the main sources of self-medication. In Eastern and Southern
European countries self-medication obtained directly from pharmacies was the highest though
over the counter sale is illegal in these countries. Investigation of the reasons for such
permissive policy is very important. The number of pharmacies per inhabitant may be related
to over-the-counter sale of antibiotics. For example the number of pharmacies is 10 times
greater in Spain than in Denmark (8), which may lead to a higher level of competition between
pharmacies in Spain. This may trigger pharmacists to sell antibiotics without prescription. Our
multilevel analysis revealed that perceived possibility of obtaining antibiotics directly from
pharmacies was one of the determinants of self-medication. Enforcing pharmacy regulations is
an effective way of combating self-medication. This will be possible when the advantages of
obeying to the laws will outweigh the advantages of disobeying in these countries. The
European Commission and the World Health Organization can have an important role in
drawing the attention of the governments of these countries to this issue.
Leftovers from previous prescribed courses was another common source of self-
medication in Europe. Antibiotics could be left over because extra tablets were dispensed or
because of patient non-compliance. Dispensing antibiotics per package size was an important,
potentially modifiable enabling factor facilitating self-medication in our study. Dispensing
exact number of antibiotic tablets in pharmacies as implemented in the UK, The Netherlands,
The Czech Republic and Israel, as well as in the United States, could be promoted in other
countries.
Actions to prevent self-medication with leftovers should also include physician
education. Doctors should be aware that prescribing for minor respiratory tract infections may
increase the risk of self-medication for such ailments. It is well known that not all upper and
lower respiratory tract infections need antimicrobial therapy (9), because many of these
illnesses are of viral origin and self-limiting. Promising results for changing the practice in
managing community-acquired lower respiratory tract infections (LRTIs) are expected from
GRACE (Genomics to Combat Resistance against Antibiotics in Community-acquired LRTI in
Europe), a recently launched new scientific network. LRTIs account for a major part of the
community burden of antibiotic use and contribute dramatically to the rising prevalence of
resistance. In particular, GRACE aims to provide doctors with algorithms that can help to
distinguish viral from bacterial infections and discern patients with community acquired LRTI
at risk for complications from patients with self-limiting diseases with low risk for poor
outcome (10).
General discussion
99
Another issue in combating inappropriate antibiotic use includes widespread
misconceptions about antibiotic use among the general public in southern and eastern
countries. Continuous and intensive efforts (such as involving the mass media) are needed to
reduce these misconceptions. A better understanding of cultural dimensions can be used to
anticipate reactions to a campaign in a particular country. For example, in countries with lower
Power Distance, campaigns for more appropriate use of antibiotics should involve both
professionals and the general public, while in countries with high Power Distance campaigns to
improve antibiotic use should focus primarily at the physicians.
Future researchFuture researchFuture researchFuture research
We were able to explain almost all variance at the country level in our multilevel
analysis. However, much remains to be explained at the individual level. Further research
should be focused on other determinants of self-medication such as accessibility to health care,
patient satisfaction and doctor-patient relationship. Another area of research should focus on
assessing the effectiveness of different interventions, as described in the previous section,
aiming to prevent self-medication.
ConclusionsConclusionsConclusionsConclusions
Self-medication with systemic antibiotics is a reason for concern in Europe. A high
prevalence of self-medication was observed in southern and eastern countries reporting high
prevalence of antibiotic resistance. It is extremely difficult to demonstrate a proven causal link
between self-medication with antibiotics and resistance because of the large number of
confounding factors which are not possible to control. However, self-medication usually
involves frequent intake of antibiotics in small doses which definitely contributes to the
resistance (11). The European agenda addressing inappropriate use of antibiotics should be
expanded to address the issue of self-medication. An integral approach involving policy
makers, pharmacists, prescribers, and general public is needed. Because resistant
microorganisms do not recognize geographical borders the problem acquires a global
importance. In the words of Lao Tzu, “the biggest problem in the world could have been solved
when it was small."
Chapter 7
100
ReferencesReferencesReferencesReferences
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2. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and
association with resistance: a cross-national database study. Lancet 2005 February
12;365(9459):579-87.
3. Cars O, Molstad S, Melander A. Variation in antibiotic use in the European Union. The Lancet
2001 June 9;357(9271):1851-3.
4. The health of adults in the European Union. Available from
//europa.eu.int/comm/public_opinion/archives/ebs/ebs_183.7_en.pdf , last accessed February 11,
2007. Special Eurobarometer 183-7/wqve 58.2- European Opinion Research Group, December
2003.
5. O'Neill TW, Marsden D, Matthis C et al. Survey response rates: national and regional differences
in a European multicentre study of vertebral osteoporosis. J Epidemiol Community Health 1995
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6. Community Trade Mark Survey 2002, Final report, Office for Harmonisation in the Internal
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7. Keeter S, Miller C, Kohut A et al. Consequences of reducing nonresponse in a national telephone
survey. Public Opin Q 2000;64(2):125-48.
8. Llor C, Bjerrum L. Background for different use of antibiotics in different countries. Clin Infect Dis
2005 January 15;40(2):333.
9. Revised SWAB guidelines for antimicrobial therapy of Community-acquired pneumonia, Dutch
Working Party on Antibiotic Policy (SWAB), April. Available from
http://www.swab.nl/swab/swabcms.nsf/, last accessed February 11, 2007.
10. Genomics to Combat resistance against Antibiotics in Community-acquired LRTI in Europe
(GRACE). Available from: http://www.grace-lrti.org/portal/en-GB/Publications/Presentations/,
last accessed February 11, 2007.
11. Guillemot D, Carbon C, Balkau B et al. Low dosage and long treatment duration of beta-lactam:
risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA 1998 March
4;279(5):365-70.
SummarySummarySummarySummary
Summary
102
At the beginning of 21 century antimicrobial resistance has developed against every class of
antimicrobial drugs and has become a rapidly increasing global problem, with widely varying
prevalences among countries. An important international issue is to avoid further increase in
resistance by reducing unnecessary and inappropriate use of antibiotics. Most studies in
Europe have focused on prescribed use of antibiotics. However, consumption of antibiotics may
also include self-medication, i.e. using antibiotics obtained without prescription, leftover
antibiotics from treatment courses prescribed earlier, antibiotics obtained from relatives,
friends or other sources. Use of antibiotics without medical guidance may lead to a wrong
choice of antibiotics, use of insufficient dosages or unnecessary treatment. Such inappropriate
use increases the risk of selection of resistant bacteria and may contribute to antibiotic
resistance.
This thesis describes the prevalence of self-medication with antibiotics in 19 European
countries and determinants of self-medication with a focus on 1) prescribed use of antibiotics,
2) predisposing and enabling factors. In addition, differences in attitudes, beliefs and
knowledge concerning antibiotic use and self-medication between countries and the influence
of cultural dimensions on antibiotic use in Europe are studied.
In chapter 2 In chapter 2 In chapter 2 In chapter 2 we present the results of the postal survey estimating the prevalence of self-
medication with antibiotics and prescribed use in the previous 12 months among the general
population of 19 European countries (Austria, The Netherlands, Sweden, United Kingdom,
Ireland, Denmark, Italy, Malta, Luxembourg, Belgium, Spain, Israel, Romania, Czech Republic,
Slovakia, Lithuania, Slovenia, Croatia and Poland). A multistage sampling design was used for
sample selections in each country. Within each country, a region with average prescribed
antibiotic consumption was chosen. In those countries where this information was not
available, a region was selected that was representative of the country’s population in terms of
age and sex. In each region, a city (75000-750000 inhabitants) and a rural area (5000-10000)
were selected. By using population registries, including lists of persons in the identified cities
and rural areas, persons >18 years of age were selected by simple random sampling. Self-
administered questionnaires were mailed between March and July 2003, and reminders with a
new questionnaire attached were sent 2-4 weeks later. A total of 15548 respondents completed
the questionnaires. The mean response rate of the countries was 40%. Self-medication with
systemic antibiotics occurred in each of the participating countries. The prevalence of actual
self-medication in the previous 12 months varied from 1 (The Netherlands) to 210 (Lithuania)
per 1000. The highest rates were observed in eastern countries (in particular Lithuania and
Romania), followed by southern countries (Malta, Spain and Italy). The lowest rates were found
in northern and western countries (The Netherlands and Sweden). The most common reasons
of self-medication were throat symptoms (e.g. red or sore throat). The main medication
sources were pharmacies and leftovers from previous prescriptions. The rates of at risk self-
medication (those who indicated the intention to self-medicate or store antibiotics at home)
Summary
103
also tended to be higher in southern and eastern Europe than in northern and western Europe.
Younger age, higher education and presence of a chronic disease were associated with higher
rates of self-medication.
IIIIn Chapter 3n Chapter 3n Chapter 3n Chapter 3 we studied the relationship between prescribed use of antibiotics and self-
medication to gain insight into determinants of self-medication. We used multinomial logistic
regression analyses to study the association between previous prescribed use and self-
medication for all symptoms/diseases and for upper respiratory tract infections (URTIs). We
examined separately self-medication with leftover antibiotics and self-medication with
antibiotics obtained from other sources as a stronger relation must be expected between
prescribed use and self-medication with leftovers. The association between prescribed use and
self-medication was modified by source of self-medication, region in Europe and education.
This association was consistently stronger for self-medication with leftovers than from other
sources, primarily directly from a pharmacy. It was stronger also for respondents from
Northern/Western Europe than respondents from Eastern and Southern Europe and those
with low education. For URTIs, a significant association was found between prescribed use and
self-medication with leftover antibiotics. A significant interaction was found between
prescribed use and region in Europe (P<0.001). In Northern/Western Europe, respondents who
had used prescribed antibiotics for URTIs had a 37.45 (95% CI 9.89-141.75) higher odds of self-
medication for URTIs. The effects were smaller in Southern Europe (OR 3.64, 1.60-8.25) and
Eastern Europe (3.64, 1.96-6.74). These associations were not significant for self-medication
from sources other than leftovers (1.96, 0.45–8.67 in Northern/Western Europe, 1.58, 0.51–4.87
in Southern Europe and 1.06, 0.59–1.93 in Eastern Europe). We showed consistent associations
between prescribed use and self-medication with leftover antibiotics, but were not able to
support the hypothesis that self-medication from other sources than leftovers is triggered by
earlier prescribed use. The association between prescribed use and self-medication in general
implies that antibiotics prescribed for one symptom/disease may be used both as self-
medication for (repeated) episodes of the same symptom/disease and for another
symptom/disease. The association for URTIs implies that prescribed use for URTIs increases the
probability of self-medication for URTIs. In both cases there is reason for concern. URTIs are
usually not an appropriate indication for the use of antibiotics, so in these cases antibiotics
should not be used either prescribed or as self-medication. The use of leftovers for a variety of
indications without professional advice is just as inappropriate. In both cases action should be
undertaken to prevent the use of leftovers.
Continuing with our investigation of determinants of self-medication, in Chapter 4, in Chapter 4, in Chapter 4, in Chapter 4 we studied
the impact of predisposing and enabling factors on self-medication with antibiotics in Europe
using the PRECEDE model of behaviour change. According to the PRECEDE theoretical model,
health behaviour is influenced by predisposing factors (characteristics that lead to or motivate
behaviour such as knowledge and beliefs), enabling factors (characteristics that facilitate or
Summary
104
are needed to perform the particular behaviour, such as resources in the environment ) and
reinforcing factors (rewards and punishments received from others). We conducted a follow-
up study with the respondents of our previous survey willing to be interviewed. In total, 1101
respondents in 11 countries representing Northern/Western (Austria, The Netherlands,
Sweden, United Kindom and Belgium), Southern (Italy, Malta and Israel) and Eastern (Czech
Republic, Lithuania and Croatia) European regions were interviewed. We aimed to recruit at
least 100 respondents in each country, 50 users of self-medication and 50 non-users, both
equally distributed in urban and rural areas. If the number of self-medication users willing to
be interviewed was less than 50 in a country, non-users of self-medication were added to
achieve 100 respondents. In Lithuania, the number of non-users willing to be interviewed did
not reach 50, therefore, self-medication users were added. A multilevel analysis with two levels
(country and respondent) was performed. Among the five predisposing factors, only two were
statistically significant in the final multilevel logistic regression analysis. As expected,
respondents who had more inappropriate attitudes towards self-medication with antibiotics
for bronchitis had a higher likelihood of actual self-medication (OR 2.13, 1.70-2.66). Having
incorrect beliefs about antibiotics for minor ailments was also independently associated with
higher likelihood of self-medication (1.76, 1.32-2.34). Inappropriate attitudes towards situational
use of antibiotics and non-awareness about antibiotic resistance and adverse effects of
antibiotics were not associated with use of self-medication in the final model. Among the four
enabling factors, three were significant determinants of self-medication. Country wealth
(higher GDP per capita) was related to a lower likelihood of self-medication. Dispensing the
exact number of antibiotics was associated with a decreased risk of self-medication (0.51, 0.27-
0.98). Respondents who perceived antibiotics as easily or sometimes available directly from
pharmacies, had a higher risk of self-medication whereas those who answered “do not know”
had a lower risk compared to respondents perceiving that antibiotics are not available.
Reimbursement of prescribed antibiotics was not independently associated with use of self-
medication in the multilevel regression analysis. We conclude that interventions aimed at
preventing self-medication with antibiotics should include public education, stricter control
over the laws influencing sale of antibiotics and dispensing exact number of tablets of
prescribed antibiotics in pharmacies.
In chapterchapterchapterchapterssss 5 5 5 5 and 6 and 6 and 6 and 6 we move beyond use of self-medication and study the influence of cultural
factors on antibiotic use in general in Europe. In chapter 5In chapter 5In chapter 5In chapter 5 we compare public attitudes, beliefs
and knowledge concerning antibiotic use in general and self-medication between 11 European
countries. We used data from our follow-up study where 1101 respondents were interviewed
on their attitudes towards appropriateness of self-medication with antibiotics and situational
use of antibiotics, beliefs about antibiotics for minor ailments, knowledge about the
effectiveness of antibiotics on viruses and bacteria and awareness about antibiotic resistance
and adverse effects of antibiotics. Each of these domains was assessed with a series of items,
Summary
105
partly derived from other studies. An exploratory factor analysis revealed four underlying
constructs consistent with the conceptual basis for the scales. The first scale was attitudes
towards appropriateness of self-medication with antibiotics for bronchitis. The other scales
were beliefs about antibiotics for minor ailments, attitudes towards situational use of
antibiotics and knowledge about the effectiveness of antibiotics on bacteria and viruses.
To analyse the differences between countries, regression analyses were used with the outcome
variable being each of dimensions of attitudes, beliefs and knowledge. Multiple linear
regression analysis was used for continuous variables (the four aforementioned scales) and
logistic regression for binary variables (knowledge of antibiotic resistance and adverse effects
of antibiotics). The number of users and non-users of self-medication as well as those with low
and high education willing to be interviewed differed between countries. To deal with the
possible confounding effect of both use of self-medication and education, we performed
stratified analyses, i.e. studying the differences between the countries separately for users and
non-users of self-medication, and for respondents with high and low education. The
differences between countries were considered relevant when regression coefficients were
significant in all stratum-specific analyses. The effects of other possible confounding variables
(presence of a chronic disease, sex, age and place of residence) were considered in all analyses.
Differences significant in all stratum-specific analysis were found for the UK, Malta, Italy, Czech
Republic, Croatia, Israel and Lithuania. Respondents from these countries had less appropriate
attitudes, beliefs or knowledge compared with Swedish respondents at least for one of the
dimensions. The Dutch, Austrian and Belgian respondents were not significantly different from
Swedish for any of the dimensions. The most pronounced differences were for awareness
about resistance followed by attitudes towards situational use of antibiotics. Awareness about
antibiotic resistance was the lowest in countries with higher prevalence of resistance.
In Chapter 6Chapter 6Chapter 6Chapter 6 we investigate whether broad and general cultural characteristics of countries
are correlated with cross-national differences in use of antibiotics. Country-specific scores on
cultural dimensions obtained from Hofstede are correlated with country-level data on
antibiotic use. Cultural dimensions included Power Distance, Individualism, Masculinity and
Uncertainty Avoidance. We used data on antibiotic use from our postal survey and verified
results by using data from three other studies on antibiotic use. Spearman’s correlation
coefficient rho was used to calculate correlations between country-aggregated use of
antibiotics and country-specific scores of cultural dimensions. Power distance index (PDI) was
positively correlated with both prescribed use and self-medication in all datasets. This suggests
that the culturally-specific way people deal with authority is an important factor in explaining
cross-national differences in antibiotic use. In countries with a high PDI, hierarchic differences
will be more manifested and doctors will have a more pronounced (therapeutic) autonomy,
while in countries with a low PDI doctors feel more part of a team. Power distance will also
affect doctor-patient relationship. In countries with a high PDI patients feel little need for
Summary
106
being involved in the decision-making and a physician acknowledging that he is not sure
whether it is a viral or bacterial infection will in such a cultural context not inspire confidence.
Therefore, antibiotics not only have a pharmaceutical but also a communicative aspect in this
culture. We did not find consistent significant correlations between antibiotic use in all four
datasets and other cultural dimensions (Individualism, Masculinity and Uncertainty
Avoidance).
Finally, in chapter 7chapter 7chapter 7chapter 7 we discuss the main implications from all the studies presented in this
thesis for the strategies to prevent unnecessary and inappropriate use of antibiotics. We
conclude that self-medication with systemic antibiotics is a reason for concern in Europe. A
high prevalence of self-medication was observed in southern and eastern countries reporting
high prevalence of antibiotic resistance. Antibiotics obtained directly from pharmacies was
one of the main sources of self-medication in these countries. Moreover, perceived possibility
of obtaining antibiotics directly from pharmacies was one of the determinants of self-
medication. Investigation of the reasons for such permissive policy is very important. The
European Commission and the World Health Organization can have an important role in
drawing the attention of the governments of these countries to this issue. Leftovers from
previous prescribed courses was another common source of self-medication in Europe.
Dispensing antibiotics per package size was an important potentially modifiable enabling
factor facilitating self-medication. Dispensing exact number of tablets in pharmacies as
implemented in the UK, The Netherlands, The Czech Republic and Israel, as well as in the
United States, could be promoted in other countries. Actions to prevent self-medication with
leftovers should also include physician education. Doctors should be aware that prescribing for
minor respiratory tract infections may increase the risk of self-medication for such ailments.
Another issue in combating inappropriate antibiotic use includes widespread misconceptions
about antibiotic use among the general public of southern and eastern countries. Continuous
and intensive efforts (such as involving the mass media) are needed to reduce these
misconceptions. A better understanding of cultural dimensions can be used to anticipate
reactions to a campaign in a particular country.
In conclusion, self-medication with antibiotics occurs in all European countries that
participated in this study. The European agenda addressing inappropriate use of antibiotics
should be expanded to address the issue of self-medication. An integral approach involving
policy makers, pharmacists, prescribers and general public is needed using both educational
and regulatory measures.
SamenvattingSamenvattingSamenvattingSamenvatting
Samenvatting
108
Antimicrobiële resistentie heeft zich vanaf het begin van de introductie van antimicrobiële
middelen en tot op heden tegen elke nieuwe klasse antimicrobiële middelen ontwikkeld. Het
is een snel stijgend globaal probleem geworden, met sterk wisselende prevalenties in
verschillende Europese landen. Een belangrijke internationaal aandachtspunt is het voorkomen
van verdere ontwikkeling van resistentie door het verminderen van onnodig en onjuist
antibioticagebruik. De meeste studies in Europa hebben zich geconcentreerd op het
voorgeschreven antibioticagebruik. Antibioticagebruik kan ook zelfmedicatie omvatten, d.w.z.
antibioticagebruik zonder doktersvoorschrift door het gebruik van ‘restanten’ van antibiotica
uit eerdere niet afgemaakte antibioticakuren of antibioticagebruik verkregen van familie,
vrienden of andere bronnen. Antibioticagebruik zonder medische begeleiding kan tot een
verkeerde keus, een ontoereikende dosering, ongewilde bijwerkingen of onnodige behandeling
met antibiotica leiden. Dergelijk onjuist gebruik kan door verhoging van de selectiedruk een
bijdrage leveren aan de kans op resistentie.
Dit proefschrift beschrijft de prevalentie van zelfmedicatie met antibiotica in 19 Europese
landen en determinanten van zelfmedicatie met een nadruk op 1) voorgeschreven
antibioticagebruik, 2) predisposing (predisponerende) factoren (kennis, opvattingen en
waarden) en enabling (faciliterende) factoren (vaardigheden, reguleringen, toegankelijkheid
van voorzieningen). Bovendien worden de verschillen in houding, opvatting en kennis
betreffende antibioticagebruik en zelfmedicatie tussen landen en de invloed van culturele
aspecten op antibioticagebruik in Europa bestudeerd.
In hoofdstuk 2hoofdstuk 2hoofdstuk 2hoofdstuk 2 presenteren we de resultaten van een schriftelijk vragenlijstonderzoek naar het
vaststellen van de prevalentie van zelfmedicatie met antibiotica en voorgeschreven
antibioticagebruik in de afgelopen twaalf maanden in de algemene bevolking van 19 Europese
landen (Oostenrijk, Nederland, Zweden, Verenigd Koninkrijk, Ierland, Denemarken, Italië,
Malta, Luxemburg, België, Spanje, Israël, Roemenië, Tsjechië, Slowakije, Litouwen, Slovenië,
Kroatië en Polen). Een getrapte steekproefopzet werd gebruikt voor steekproefselecties in elk
land. Binnen elk land werd een gebied met een gemiddelde antibioticaconsumptie gekozen. In
die landen waar deze informatie niet beschikbaar was, werd een gebied geselecteerd dat
representatief was voor de bevolking van het land in termen van leeftijd en geslacht. In elk
gebied werd een stad (75000-750000 inwoners) en een plattelandsgebied (5000-10000
inwoners) geselecteerd. Bevolkingsregistraties werden gebruikt om lijsten met personen van 18
jaar en ouder in de geselecteerde steden en de plattelandsgebieden te genereren. Uit deze
lijsten werden steekproefsgewijs personen geselecteerd die in de periode van maart tot juli
2003 een vragenlijst kregen toegestuurd. Twee tot vier weken later werd een herinneringsbrief
met een nieuwe vragenlijst verzonden. In totaal deden 15548 ondervraagden mee aan het
vragenlijstonderzoek. De gemiddelde respons over alle deelnemende landen was 40%.
Zelfmedicatie met systemische antibiotica kwam voor in alle deelnemende landen. De
prevalentie van zelfmedicatie in de afgelopen twaalf maanden varieerde van 1 (Nederland) tot
Samenvatting
109
aan 210 (Litouwen) per 1000 personen. De hoogste cijfers werden waargenomen in oostelijke
landen (in het bijzonder Litouwen en Roemenië), gevolgd door de zuidelijke landen (Malta,
Spanje en Italië). De laagste cijfers werden gevonden in noordelijke en westelijke landen
(Nederland en Zweden). De meest voorkomende redenen van zelfmedicatie waren
keelproblemen (bijvoorbeeld keelpijn). De belangrijkste bronnen waren apotheken en
restanten van eerdere kuren. Het risico van zelfmedicatie (personen die te kennen geven op
eigen initiatief antibiotica te nemen of thuis antibiotica op voorraad te hebben) neigde ook
hoger te zijn in zuidelijk en oostelijk Europa dan in noordelijk en westelijk Europa. Jongere
leeftijd, hoger opleidingsniveau en de aanwezigheid van een chronische ziekte waren
geassocieerd met hogere kans op zelfmedicatie.
Om inzicht te krijgen in determinanten van zelfmedicatie bestudeerden we in hoofdstuk 3hoofdstuk 3hoofdstuk 3hoofdstuk 3 het
verband tussen voorgeschreven antibioticagebruik en zelfmedicatie. We gebruikten
multinomiale logistische regressieanalyse om de associatie tussen voorgeschreven
antibioticagebruik en zelfmedicatie voor alle symptomen/ziekten alsmede voor bovenste
luchtweginfecties apart te bestuderen. We onderzochten afzonderlijk zelfmedicatie met
restanten van antibiotica uit eerdere niet afgemaakte antibioticakuren en zelfmedicatie met
antibiotica die uit andere bronnen werd verkregen, aangezien een sterkere relatie tussen
voorgeschreven antibioticagebruik en zelfmedicatie met restanten van antibiotica werd
verwacht. De associatie tussen voorgeschreven antibioticagebruik en zelfmedicatie veranderde
na correctie voor bron van zelfmedicatie, gebied in Europa en opleidingsniveau. Deze
associaties waren steeds sterker voor zelfmedicatie met restanten van antibiotica dan voor
zelfmedicatie uit andere bronnen, voornamelijk antibiotica direct verkregen bij de apotheek.
Deze associaties waren ook sterker voor ondervraagden uit noordelijk en westelijk Europa dan
voor ondervraagden uit oostelijk en zuidelijk Europa en ondervraagden met een laag
opleidingsniveau. Voor bovenste luchtweginfecties werd een significante associatie gevonden
tussen voorgeschreven antibioticagebruik en zelfmedicatie met restanten van antibiotica. Een
significante interactie werd gevonden tussen voorgeschreven antibioticagebruik en gebied in
Europa (p<0.001). Ondervraagden in noordelijk/westelijk Europa die voorgeschreven
antibiotica voor bovenste luchtweginfecties hadden gebruikt, hadden een 37 maal hogere kans
(95% betrouwbaarheidsinterval 10-142) op zelfmedicatie voor bovenste luchtweginfecties. Het
effect was kleiner in zuidelijk Europa (odds ratio [OR] 3.64, 1.60-8.25) en oostelijk Europa (OR
3.64, 1.96-6.74). Deze associaties waren niet significant voor zelfmedicatie uit bronnen anders
dan restanten van antibiotica (OR 1.96, 0.45-8.67 in noordelijk/westelijk Europa, OR 1.58, 0.51-
4.87 in zuidelijk Europa en OR 1.06, 0.59-1.93 in oostelijk Europa). We toonden consistente
associaties aan tussen voorgeschreven antibioticagebruik en zelfmedicatie met restanten van
antibiotica, maar konden niet de hypothese onderbouwen dat zelfmedicatie uit andere
bronnen dan restanten van antibiotica wordt teweeggebracht door eerder voorgeschreven
antibioticagebruik. De associatie tussen voorgeschreven antibioticagebruik en zelfmedicatie
Samenvatting
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impliceert dat de antibiotica die voor één symptoom/ziekte wordt voorgeschreven in het
algemeen zowel als zelfmedicatie voor (herhaalde) episoden van hetzelfde symptoom/ziekte
als voor een ander symptoom/ziekte kunnen worden gebruikt. De associatie voor bovenste
luchtweginfecties impliceert dat het voorgeschreven antibioticagebruik voor bovenste
luchtweginfecties de kans op zelfmedicatie voor bovenste luchtweginfecties verhoogt. In beide
gevallen is er reden voor zorg. Bovenste luchtweginfecties zijn gewoonlijk geen indicatie voor
antibiotica. Dit betekent dat antibiotica in deze gevallen in het algemeen niet moet worden
voorgeschreven noch moet worden gebruikt als zelfmedicatie. Het gebruik van restanten van
antibiotica voor een verscheidenheid van indicaties zonder professioneel advies is ook
verkeerd. In beide gevallen zou de actie moeten worden ondernomen om het gebruik van
restanten van antibiotica uit eerdere niet afgemaakte antibioticakuren te verhinderen.
In hoofdstuk hoofdstuk hoofdstuk hoofdstuk 4444 gaan we nader in op het vaststellen van determinanten van zelfmedicatie en
bestuderen we het effect van predisposing en enabling factoren op zelfmedicatie met
antibiotica in Europa met behulp van het PRECEDE model van gedragsverandering. Volgens het
PRECEDE model wordt het gezondheidsgedrag beïnvloed door predisposing factoren
(kenmerken die leiden tot gedrag of gedrag motiveren zoals kennis en opvattingen), enabling
factoren (kenmerken die nodig zijn om bepaald gedrag uit te voeren, zoals omgevingsfactoren)
en reinforcing factoren (beloningen en straffen van anderen). We deden een vervolgstudie
onder de ondervraagden uit ons vragenlijstonderzoek die bereid waren om te worden
geïnterviewd. In totaal werden 1101 ondervraagden geïnterviewd in landen in
noordelijk/westelijk (Oostenrijk, Nederland, Zweden, Verenigde Koninkrijk en België), zuidelijk
(Italië, Malta en Israël) en oostelijk Europa (Tsjechië, Litouwen en Kroatië). We probeerden
minstens 100 ondervraagden in elk land te werven, 50 gebruikers van zelfmedicatie en 50 niet-
gebruikers, waaronder evenveel ondervraagden uit stedelijke en plattelandsgebieden. Als het
aantal zelfmedicatie gebruikers dat bereid gevonden werd om te worden geïnterviewd minder
dan 50 ondervraagden was, werden de niet-gebruikers van zelfmedicatie toegevoegd om 100
geïnterviewden per land te bereiken. In Litouwen vonden we minder dan 50 niet-gebruikers
van zelfmedicatie bereid om te worden geïnterviewd en daarom werden meer gebruikers van
zelfmedicatie toegevoegd. Een multilevel analyse met twee niveaus (land en ondervraagde)
werd uitgevoerd. Onder de vijf predisposing factoren waren slechts twee statistisch significant
in het uiteindelijke logistische multilevel regressiemodel. Zoals verwacht hadden de
ondervraagden met een verkeerde houding ten opzichte van zelfmedicatie met antibiotica
voor bronchitis een hogere kans op zelfmedicatie (OR 2.13, 1.70-2.66). Het hebben van onjuiste
opvattingen over antibiotica voor zelflimiterende aandoeningen was ook geassocieerd met
hogere kans op zelfmedicatie (1.76, 1.32-2.34). In het uiteindelijke regressiemodel bleken een
verkeerde houding ten opzichte van antibioticagebruik in specifieke gevallen, het niet bewust
zijn van antimicrobiële resistentie en de bijwerkingen van antibiotica niet geassocieerd te zijn
met gebruik van zelfmedicatie. Onder de vier enabling factoren, waren drie significante
Samenvatting
111
determinanten van zelfmedicatie. Rijkdom van het land (hoger bruto binnenlands product per
hoofd van de bevolking) was geassocieerd met een lagere kans op zelfmedicatie. Het
verstrekken van een nauwkeurig aantal antibiotica tabletten was ook geassocieerd met een
lagere kans op zelfmedicatie (OR 0.51, 0.27-0.98). Ondervraagden die aangaven gemakkelijk
aan antibiotica te kunnen komen, waaronder het verkrijgen van antibiotica in de apotheek
zonder recept, hadden een hogere kans op zelfmedicatie. Ondervraagden die aangaven niet te
weten of zij aan antibiotica konden komen, hadden een lager risico op zelfmedicatie in
vergelijking met ondervraagden die aangaven dat antibiotica niet beschikbaar waren. In het
multilevel regressiemodel was vergoeding van voorgeschreven antibiotica niet onafhankelijk
geassocieerd met gebruik van zelfmedicatie. We concluderen dat interventies gericht op het
verhinderen van zelfmedicatie met antibiotica moeten bestaan uit openbare voorlichting,
striktere controle over de wetgevingdie de verkoop van antibiotica beïnvloedt en het
verstrekken van het exacte aantal voorgeschreven tabletten antibiotica in apotheken.
In hoofdstukken 5 en 6hoofdstukken 5 en 6hoofdstukken 5 en 6hoofdstukken 5 en 6 bestuderen we de invloed van culturele factoren op antibioticagebruik
in Europa. In hoofdstuk 5hoofdstuk 5hoofdstuk 5hoofdstuk 5 vergelijken we algemene houdingen, opvattingen en kennis
betreffende voorgeschreven antibioticagebruik en zelfmedicatie tussen 11 Europese landen. We
gebruikten gegevens van onze vervolgstudie waarin 1101 ondervraagden werden geïnterviewd
over 1) hun houdingen ten opzichte van geschiktheid van zelfmedicatie met antibiotica en
antibioticagebruik in specifieke situaties, 2) over hun opvattingen betreffende antibiotica voor
zelflimiterende aandoeningen, 3) over kennis van het al of niet werkzaam zijn van antibiotica
tegen bacteriën en virussen, en 4) over hun bewustzijn van antimicrobiële resistentie en
bijwerkingen van antibiotica. Elk van deze domeinen werd gemeten met een reeks stellingen,
die gedeeltelijk uit andere studies werden afgeleid. Een oriënterende factoranalyse leverde vier
onderliggende concepten op die overeenkwamen met de conceptuele basis voor de schalen. De
eerste schaal was houdingen ten opzichte van de geschiktheid van zelfmedicatie met
antibiotica voor bronchitis. De andere schalen waren opvattingen over antibiotica voor
zelflimiterende aandoeningen, houdingen ten opzichte van antibioticagebruik in specifieke
situaties en kennis over het al of niet werkzaam zijn van antibiotica tegen bacteriën en
virussen.
Om de verschillen tussen landen te analyseren, werden regressieanalyses gebruikt met als
afhankelijke variabele elk van de dimensies van houdingen, opvattingen en kennis. Multipele
lineaire regressieanalyse werd gebruikt voor continue variabelen (de vier eerdergenoemde
schalen) en logistische regressie voor binaire variabelen (kennis van antimicrobiële resistentie
en bijwerkingen van antibiotica). Het aantal gebruikers en niet-gebruikers van zelfmedicatie
evenals het aantal personen met een laag en hoog opleidingsniveau dat bereid was om
geïnterviewd te worden, verschilde tussen de landen. Om rekening te houden met het
mogelijke verstorende effect van zowel het aantal gebruikers van zelfmedicatie als het
opleidingsniveau, voerden we gestratificeerde analyses uit, d.w.z. het afzonderlijk bestuderen
Samenvatting
112
van de verschillen tussen de landen voor gebruikers en niet-gebruikers van zelfmedicatie, en
voor ondervraagden met een hoog en laag opleidingsniveau. De verschillen tussen landen
werden als relevant beschouwd wanneer de regressiecoëfficiënten in alle gestratificeerde
analyses significant waren. Voor het verstorende effect van andere potentiële confounders
(aanwezigheid van een chronische ziekte, geslacht, leeftijd en woonplaats) werd gecorrigeerd
in alle analyses. Significante verschillen in alle gestratificeerde analyses werden gevonden voor
het Verenigd Koninkrijk, Malta, Italië, Tsjechië, Kroatië, Israël en Litouwen. De ondervraagden
van deze landen hadden verkeerde houdingen, opvattingen of kennis in vergelijking met de
Zweedse ondervraagden op tenminste één van de dimensies. De Nederlandse, Oostenrijkse en
Belgische ondervraagden waren niet beduidend verschillend van de Zweedse ondervraagden
op deze dimensies. De meest uitgesproken verschillen werden gevonden voor kennis van
resistentie gevolgd door houdingen ten opzichte van antibioticagebruik in specifieke situaties.
Het bewustzijn over antimicrobiële resistentie was het laagst in landen met een hoge
prevalentie van resistentie.
In hoofdstuk 6hoofdstuk 6hoofdstuk 6hoofdstuk 6 onderzoeken we of de brede en algemene culturele kenmerken van landen
gecorreleerd zijn met verschillen in antibioticagebruik. De landspecifieke scores op culturele
dimensies volgens Hofstede zijn gecorreleerd met gegevens over antibioticagebruik. De
culturele dimensies omvatten machtsafstand, individualisme / collectivisme, masculiniteit /
femininiteit en onzekerheidsvermijding. We gebruikten gegevens over antibioticagebruik uit
ons vragenlijstonderzoek en verifieerden de resultaten door gegevens te gebruiken uit drie
andere studies over antibioticagebruik. Spearman’s correlatiecoëfficiënt werd gebruikt om
correlaties tussen antibioticagebruik per land en landspecifieke scores van culturele dimensies
te berekenen. De machtafstandsindex was positief gecorreleerd met zowel voorgeschreven
antibioticagebruik als zelfmedicatie in alle datasets. Dit suggereert dat de cultuurspecifieke
manier waarop mensen omgaan met gezag een belangrijke factor is in het verklaren van
verschillen in antibioticagebruik tussen landen. In landen met een hoge machtafstandsindex
zullen de hiërarchische verschillen zich meer manifesteren en zullen artsen een meer
uitgesproken (therapeutische) autonomie hebben, terwijl in landen met een lage
machtafstandsindex artsen zich meer deel van een team zullen voelen. De machtsafstand zal
ook de arts-patiënt verhouding beïnvloeden. In landen met een hoge machtafstandsindex
voelen patiënten weinig behoefte om in de besluitvorming te worden betrokken en een arts
die erkent dat hij niet zeker is of het een virale of bacteriële besmetting betreft zal in een
dergelijke culturele context geen vertrouwen wekken. Daarom hebben antibiotica niet alleen
een farmaceutisch maar ook een communicatief aspect in deze cultuur. We vonden geen
consistente significante correlaties tussen antibioticagebruik in alle vier datasets en andere
culturele dimensies (individualisme, masculiniteit en onzekerheidsvermijding).
Tenslotte bespreken we in hoofdstuk 7hoofdstuk 7hoofdstuk 7hoofdstuk 7 de belangrijkste implicaties van alle onderzoeken in dit
proefschrift over de strategieën om onnodig en onjuist antibioticagebruik tegen te gaan. We
Samenvatting
113
concluderen dat zelfmedicatie met antibiotica voor systemisch gebruik in Europa een reden tot
zorg is. Een hoge prevalentie van zelfmedicatie werd in zuidelijke en oostelijke landen
waargenomen, landen die tevens een hoge prevalentie van antimicrobiële resistentie melden.
De antibiotica die direct uit de apotheek worden verkregen waren één van de belangrijkste
bronnen van zelfmedicatie in deze landen. Wanneer ondervraagden denken dat antibiotica
direct bij de apotheek verkregen kunnen worden, wordt de kans op zelfmedicatie groter.
Onderzoek naar de redenen voor dergelijk tolerant beleid is zeer belangrijk. De Europese
Commissie en de Wereldgezondheidsorganisatie kunnen een belangrijke rol spelen in het
vestigen van de aandacht van de overheden van deze landen op deze kwestie.
De restanten van eerdere voorgeschreven kuren waren een andere belangrijke bron van
zelfmedicatie in Europa. Het afleveren van antibiotica per doosje was een belangrijke enabling
factor die zelfmedicatie vergemakkelijkt. Het verstrekken van het exacte aantal benodigde
tabletten zoals dat wordt gedaan in apotheken in het Verenigd Koninkrijk, Nederland, Tsjechië
en Israël, evenals in de Verenigde Staten, zou in andere landen kunnen worden bevorderd.
Activiteiten om zelfmedicatie met restanten te verhinderen zouden ook onderwijs aan artsen
moeten omvatten. Artsen zouden zich ervan bewust moeten zijn dat het voorschrijven van
antibiotica voor zelflimiterende aandoeningen, zoals bovenste luchtweginfecties en bronchitis
het risico van zelfmedicatie voor dergelijke kwalen kan verhogen. Een ander aandachtspunt is
de bestrijding van misvattingen over antibioticagebruik onder het grote publiek van zuidelijke
en oostelijke landen. Ononderbroken en intensieve inspanningen (zoals het erbij betrekken van
de massamedia) zijn nodig om deze misvattingen te verminderen. Een beter inzicht in culturele
dimensies kan worden gebruikt om te anticiperen op reacties op een campagne in een bepaald
land. Concluderend kan gezegd worden dat zelfmedicatie met antibiotica voorkomt in alle
Europese landen die onderdeel waren van deze studie. De Europese agenda waarop het onjuist
antibioticagebruik staat, zal uitgebreid moeten worden met het probleem van zelfmedicatie
met antibiotica. Een integrale benadering is nodig waarbij zowel beleidsmakers, apothekers,
voorschrijvers en de bevolking worden betrokken en waarbij gebruik gemaakt wordt van zowel
onderwijs als regelgevende maatregelen.
AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements
Acknowledgements
116
I would like to thank the many people whose various contributions over the past four and a half
years have made the writing of this thesis possible. One of the most exciting parts of this project
has been working with an international team of co-investigators.
Firstly, I would like to thank my first promotor, Prof. Flora Haaijer-Ruskamp. Dear Flora, thank you
for the time and efforts you have spent guiding, advising and motivating me over the past four
and a half years. Your ideas, insight and connections made it possible to realize this project. I am
also very grateful to you for your encouragement in my difficult times. I admire your interest in
different cultures and it was extremely nice for me to hear that your trip to Armenia was among
the five top holidays that you ever had. I want to thank also Prof. John Degener, my second
promotor. John, it was always a pleasure to work with you and to learn from you. Thank you for
our always interesting discussions and your constructive feedback. I extend my special gratitude
to Johannes Burgerhof for his professionalism, dedication, assistance, big contribution and
admirable patience! Dear Hans, I could not have made it without you. Thanks a lot for everything.
The realization of this project was only possible through efforts and input of our co-investigators
from other European countries. I would like to thank each of you for your input, time, patience and
sincere support. I am very grateful to Dominique Monnet. Dear Dominique, your strong interest in
our research and valuable suggestions improved greatly the quality of the studies. Our phone and
e-mail discussions and meetings at the conferences were always inspiring. I also thank you for
your belief in me and willingness to help with my future career. I express my special gratitude to
Reginald Deschepper, Luc Delians, Greta van der Kelen and Joachim Cohen. Thanks for your big
contribution, efforts and support. Many thanks go to Cecilia Stålsby Lundborg. Dear Cecilia, thank
you for your committed efforts to help me. I have always admired your ability to work on so many
projects in different parts of the world and your always on-time feedback to my articles and
questions. I want to thank Reli Mechtler, Arjana Tambic-Andrasevic, Retnosari Andrajati, Robert
Cunney, Antonella Di Matteo, Hana Edelstein, Rolanda Valinteliene, Alaa Alkerwi, Elizabeth
Scicluna, Pawel Grzesiowski, Ana-Claudia Bara, Thomas Tesar, Milan Cisman, Jose Campos and
Joan Birkin for their continuous sincere support, valuable suggestions, dedication, big contribution
and patiently answering my many questions. It was a great pleasure to work with you and I thank
you all for your good collaboration!
I am very grateful to Monique Elseviers for her contribution and willingness to help to set up the
“SAR” project. Many thanks go to Eric Van Sonderen and Willem Lok from the Northern Center for
Healthcare Research (NCH) for their contribution to the “SAR” project. Many thanks also go to the
colleagues from the Social Pharmacy and Pharmacoepidemiology for their valuable input during
the dRUGS meetings. I want to thank also the entire department of Medical Microbiology for our
interesting discussions and their valuable comments.
Acknowledgements
117
I would like to thank the members of the reading committee, Prof. dr. H. Grundmann, Prof. dr.
M.J.M. Bonten and Prof. dr. T.J.M. Verheij for assessing this thesis. My special thanks go to Prof.
Marc Bonten who gave me the opportunity after completing the “SAR “ project to continue with
the “MOSAR” project.
I am very grateful to my former colleagues from the Department of Clinical Pharmacology. Many
thanks go to Jacoba and Heidrun. It was a very nice and extremely quiet experience to be sharing
an office with both of you. Dear Jacoba, thanks for the nice time spent both in- and outside the
office, your help with research problems and your support in difficult times. Special thanks for
translating my summary into Dutch. Dear Heidrun, thanks for sharing your knowledge and your
continuous support. I am grateful to Petra Denig. Petra, I have very much appreciated your
comments and input whenever they were needed, thanks a lot. Many thanks go to Ruth, Peter,
Jasperien, Amany, Daniela, Frank, Anuschka and Jaco for all their support and chats and laughs on
so many occasions. Dear Jasperien, thank you for standing beside me on this special day. Frank,
thanks a lot for helping with the cover. Many thanks go to Wessel Sloof and Adriaan van Doorn for
solving my computer problems and sincere support. I am grateful to Ellen, Ardy and Alexandra for
their willingness to help in all occasions. Dear Ellen, thanks for your help and nice time spent
outside the office.
I would like to thank my friends in Groningen. Dear Lena and Simon, thanks a lot for your
friendship, all your support and incredible trust in me. Dear Berty and Ruben, thanks for so many
nice moments and helping me feel at home in Groningen. I would like to thank Jean-Pierre
Macquart for the nice time spent together. Special thanks also go to Tom Breur who gave me
important tips to work with my data and helped me to solve many problems with my database.
Many thanks go to Liana and Sascha for the very nice time spent together. Dear Liana, my best
friend, former colleague and paranymph, I can’t begin to tell you how much your friendship and
support means to me. You have been always there for me whether we lived in the same city or far
away and shared all the ups and downs both in Armenia and The Netherlands. Thanks a lot for
being such a great friend.
I would like to thank my lecturers from the American University of Armenia and Erasmus Medical
Center Rotterdam who taught me how to do good research.
Many thanks go to the respondents of the “SAR” project for completing the questionnaires and
participating in the interviews without whom this thesis would not have been possible.
Finally, I would like to thank my parents, my brother and my sister-in-law for their love, support
and encouragement of everything I do.
About the authorAbout the authorAbout the authorAbout the author
About the author
120
Larissa Grigoryan was born on 2 November 1976 in Yerevan, Armenia. She passed her secondary
school exams at the “Russian secondary school# 83 after V. Tereshkova” in Yerevan, Armenia in
1993. She was admitted to the Yerevan State Medical University and obtained her medical
degree in 1999. In 2000, she completed her residency in Epidemiology at the Armenian
National Institute of Health. Afterwards, she entered the Master Program in Public Health at
the American University of Armenia, affiliated with Johns Hopkins Bloomberg School of Public
Health (supervisors: Prof. Haroutune Armenian and Dr. George Jakab). During these years she
worked at the Centre for Health Services Research of the American University of Armenia. In
July 2001 she moved to Rotterdam to follow a Master Programme In Epidemiology at the
Netherlands Institute for Health Sciences (Erasmus University). Here she studied the relation
between statin use and dementia using the Rotterdam Study database (supervisors: Dr.
Monique Breteler and Prof. dr. Bruno Stricker).
In July 2002, she started the project described in this thesis at the Department of Clinical
Pharmacology of the University Medical Center Groningen (supervisors Prof. dr. Flora Haaijer-
Ruskamp and Prof. dr. John Degener). She was a member of the Evidence Based Medicine
research group of the Northern Center for Healthcare Research (NCH).
Currently she is working as a post-doc on the European project “Mastering hospital
Antimicrobial Resistance and its spread into the Community” at the Julius Center for Health
Sciences and Primary Care, University Medical Center Utrecht.
List of pList of pList of pList of publicationsublicationsublicationsublications
List of publications
122
1. Grigoryan L Grigoryan L Grigoryan L Grigoryan L , Haaijer-Ruskamp FM, Burgerhof JGM et al. Self-medication with
antimicrobial drugs in Europe. Emerging Infectious Diseases 2006; 12: 452-9.
2. Grigoryan L Grigoryan L Grigoryan L Grigoryan L , Burgerhof JGM, Haaijer-Ruskamp FM, Degener JE et al. Is self-medication
with antibiotics in Europe driven by prescribed use? Journal of Antimicrobial
Chemotherapy; 2007; 59(1):152-156
3. Grigoryan LGrigoryan LGrigoryan LGrigoryan L, Burgerhof JGM, Degener JE, et al. Attitudes, beliefs and knowledge
concerning antibiotic use and self-medication: a comparative European study. Submitted
4. Grigoryan LGrigoryan LGrigoryan LGrigoryan L, Burgerhof JGM, et al. Determinants of self-medication with antibiotics in
Europe: the impact of beliefs, country wealth and health care system. Submitted
5. Deschepper R, Grigoryan LGrigoryan LGrigoryan LGrigoryan L, et al. Are cultural dimensions relevant for cross-national
differences in antibiotic use? Submitted
6. Muscat M, Monnet DL, Klemmensen T, Grigoryan LGrigoryan LGrigoryan LGrigoryan L, Jensen MH, Andersen M, Haaijer-
Ruskamp FM. Patterns of antibiotic use in the community in Denmark. Scand J Infect Dis.
2006; 38: 597-603
7. Raz R, Edelstein H, Grigoryan LGrigoryan LGrigoryan LGrigoryan L, Haaijer-Ruskamp FM. Self-medication with antibiotics by
a population in northern Israel. Israel Medical Association Journal 2005; 7777: 722-5.
8. Berzanskyte A, Valinteliene R, Haaijer-Ruskamp FM, Gurevicius and Grigoryan L. Grigoryan L. Grigoryan L. Grigoryan L. Self-
medication with antibiotics in Lithuania. . . . International Journal of Occupational Medicine
and Environmental Health. 2006;19(4):246-53
NorthernNorthernNorthernNorthern Center for Healthcare Research (NCH) Center for Healthcare Research (NCH) Center for Healthcare Research (NCH) Center for Healthcare Research (NCH) and and and and
previous dissertationsprevious dissertationsprevious dissertationsprevious dissertations
Northern Center for Healthcare Research (NCH) and previous dissertations
124
This thesis is published within the research program Evidence Based Medicine in PracticeEvidence Based Medicine in PracticeEvidence Based Medicine in PracticeEvidence Based Medicine in Practice of the
Northern Center for Healthcare Research. More information regarding the institute and its
research can be obtained from our internet site: www.med.rug.nl/nch.
Previous dissertations from the program Evidence Based MedicineEvidence Based MedicineEvidence Based MedicineEvidence Based Medicine in Practice in Practice in Practice in Practice:
Sturm HBSturm HBSturm HBSturm HB (2007) Influencing physician prescribing in an international context: the role
of systems, policies and patients.
Supervisors: prof dr FM Haaijer-Ruskamp, prof dr WH van Gilst
Greving JGreving JGreving JGreving J (2007) Trends in cardiovascular drug prescribing in Dutch general practice:
role of patient and physician related characteristics.
Supervisors: prof dr FM Haaijer-Ruskamp, prof dr D de Zeeuw
Co-supervisor: dr P Denig
Dobre DDobre DDobre DDobre D (2006) Treatment of heart failure and patient outcomes in real life.
Supervisors: prof dr FM Haaijer-Ruskamp, prof dr R Sanderman,
prof dr DJ van Veldhuisen
Co-supervisors: dr AV Ranchor, dr MLJ de Jongste
Houweling STHouweling STHouweling STHouweling ST (2005) Taakdelegatie in de eerste en tweedelijns diabeteszorg;
resultaten van de DISCOURSE studies.
Supervisor: prof dr B Meyboom-de Jong
Co-supervisor: dr HJ Bilo
Mol PGMMol PGMMol PGMMol PGM (2005) The quest for optimal antimicrobial therapy.
Supervisors: prof dr FM Haaijer-Ruskamp, prof dr ROB Gans, prof dr JE Degener
Bergman GJDBergman GJDBergman GJDBergman GJD (2005) Manipulative therapy for shoulder complaints in general practice.
Supervisors: prof dr B Meyboom-de Jong, prof dr K Postema
Co-supervisors: dr JS Winters, dr GJMG van der Heijden
Baarveld FBaarveld FBaarveld FBaarveld F (2004) Sportgerelateerde problemen in de huisartspraktijk.
Supervisor: prof dr B Meyboom-de Jong
Co-supervisors: dr J Schuling, dr GC van Enst
UbinkUbinkUbinkUbink----Veltmaat LJVeltmaat LJVeltmaat LJVeltmaat LJ (2004) Type 2 diabetes mellitus in a dutch region; epedemiology and
shared care.
Supervisor: prof dr B Meyboom-de Jong
Co-supervisor: dr HJG Bilo
Kasje WNKasje WNKasje WNKasje WN (2004) Implementing joint treatment guidelines to improve prescribing in
general practice.
Supervisors: prof dr FM Haaijer-Ruskamp, prof dr PA de Graeff
Co-supervisor: dr P Denig