Tag: Primary Health

Increases in drug-resistant infections have been blamed on “uncontrolled access” to antibiotics. But, what antibiotics do community members recognise and use in Malawi? In this pre-print, myself and researchers from the Malawi-Liverpool-Wellcome Research Programme, Liverpool School of Tropical Medicine and London School of Hygiene and Tropical Medicine, present findings from a cross-sectional survey on antibiotic use practices in Malawi.

In Malawi, there is no Chichewa word for an antibiotic as a group and this poses a significant challenge for asking survey questions, particularly when trying to measure the different types of antibiotics used. During our earlier ethnographic studies, we worked with partners to develop the drug-bag method. Sourcing as many antibiotics from formal and informal sources and placing the drugs in a pile allowed participants to identify which medicines they regularly used.

In this study, we used this method to ask about household use, including current and recent (the past 6 months). The number of antibiotics recognised was significantly lower among people with poorer formal healthcare access and amongst men, who are less likely to support healthcare-seeking for family members. Reported antibiotic use was mostly limited to a small number of antibiotics (amoxicillin, erythromycin and cotrimoxazole), with current antibiotic use reported by 67/1051 (6.4%) and recent use (last 6 months) by 440/1051 (41.9%). Our study seeks to the need for improved access to quality healthcare in urban and peri-urban African settings to promote appropriate antibiotic use and limit the development and spread of AMR

Globally, antimicrobial resistance has often been framed as either a problem of access or excess, with stewardship interventions and overall reductions the dominant intervention to ‘rationalise’ use. Insufficient attention has been paid to care relations beyond the binary of ‘too many’ or ‘too few’ – particularly in low-income contexts – and how these relations shape, and are shaped by, antibiotic prescribing. Addressing this gap, our ethnographic work provides an in-depth examination of the practices that comprise care in rural Chikwawa. In this context, we found that care was centred around provision of an antimicrobial. Amid chronic lack of essential medicines and other resources, clinic interactions were tightly scripted, providing patients little time to question or negotiate their treatment. Based on our empirical work we developed the concept of ‘antibiotic vulnerabilities’ to reveal multiple ways in which provision of antimicrobials in rural Malawi impacts care in conditions of extreme scarcity.

Implications of our work
Ensuring a stable drug supply is vital, but must be accompanied by wider changes that enable quality care to be performed and received beyond antibiotic-oriented case management. We propose programmes be designed not only to protect vulnerable antibiotics, and patients vulnerable to antibiotic resistance but also to protect patients from systems that have come to be organised around antibiotics which leave patients with insufficient care.