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The General Public's Perceptions and Use of Antimicrobials in Trinidad

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The General Public's Perceptions and Use of Antimicrobials in Trinidad The general public’s perceptions and use of antimicrobials in Trinidad and Tobago Neeta Parimi,1 Lexley M. Pinto Pereira,2 and Parimi Prabhakar 3 ABSTRACT Objective. To determine the general public’s perceptions and use of antibiotics in Trinidad and Tobago, a two-island republic in the Caribbean. Methods. This prospective study surveyed 824 randomly selected households listed in the telephone directory, from November 1998 to January 1999. Through telephone interviews we determined knowledge about antibiotics and beliefs concerning their safety and efficacy. We studied the influence of age, gender, education, and having private health insurance on know- ledge, self-medication, storing medication at home for emergency use (“hoarding”), and asking a private doctor to prescribe antibiotics (“demand prescribing”). Results. For the 824 telephone calls that the interviewers completed, 753 of the households agreed to participate (91.4% response rate). Of those 753 participants, 699 of them (93%) knew the term “antibiotic,” 29% (206/699) said it was a drug for bacterial infections, and 25% (170/690) had asked a doctor for an antibiotic prescription. Penicillin was correctly identified as an antibiotic across age, gender, and education categories, but 36% of respondents inco- rrectly said Benadryl (diphenhydramine), a common over-the-counter cough and cold formu- lation, was an antibiotic. Gender was not significantly associated with knowledge of antibiotic safety, with self-medication, or with hoarding antibiotics. On the other hand, completion of ter- tiary (university) education was significantly associated with correct knowledge of the safety of antibiotics and whether or not they could cure all infections. Of the various antimicrobials, beta-lactams were the ones that survey respondents had used most frequently in the preceding year, and 20% of antibiotics users had used multiple antibiotics in that period. In comparison to persons with private health insurance, more individuals without private health insurance said that antibiotics are safe and do not have side effects, and more of them also incorrectly ca- lled aspirin and Benadryl antibiotics. Conclusions. In Trinidad and Tobago, inappropriate use of antimicrobials results from self-medication, over-the-counter availability at the community pharmacy, prescribing on de- mand, and lack of regulatory control. In order to contain antibiotic abuse, both the Drug Ins- pectorate of the Ministry of Health and the Pharmacy Board should exert stricter control on the dispensing of antibiotics at private pharmacies. Further, education of the general public and of health care professionals on antibiotic misuse and appropriate use must be instituted, along with community-based surveillance of antimicrobial resistance trends. Key words Antimicrobials, health education, professional education, self-medication, Carib- bean. 1 Bishop Anstey High School, Port-of-Spain, Tri- cal Sciences, University of the West Indies, St. Au- Bacterial resistance to multiple anti- nidad and Tobago. gustine, Trinidad, West Indies; e-mail: lexleyp@ 2 University of the West Indies, Faculty of Medical hotmail.com biotics is a growing global problem, Sciences, Department of Paraclinical Sciences, St. 3 Caribbean Epidemiology Center (Pan American due in large measure to extensive and Augustine, Trinidad and Tobago. Send correspon- Health Organization/World Health Organiza- inappropriate usage of antibiotics (1, dence to: Lexley M. Pinto Pereira, Faculty of Medi- tion), Port-of-Spain, Trinidad and Tobago. 2). That resistance occurs in hospitals Rev Panam Salud Publica/Pan Am J Public Health 12(1), 2002 11 and their intensive care units and in- This study was undertaken to exa- these drugs as over-the-counter medi- creasingly in the community setting mine how the public at large in Trini- cations in response to requests from as well. dad and Tobago perceives and uses customers. Antibiotic resistance may be more antibiotics. Trinidad and Tobago is a Prior to this study, no data had been widespread in lesser-developed coun- two-island Caribbean republic of 1.3 available on the general public’s per- tries, where there are fewer controls on million people. It is located just off the ceptions and use of antibiotics in the the use of antimicrobial drugs (3) and coast of Venezuela, and it is the se- English-speaking Caribbean. where the higher incidence of infec- cond-largest country in the English- tious disease in the population fuels speaking Caribbean. Divided into 8 the demands for the drugs (4). In counties, Trinidad has some 96% of METHODS developing countries such major com- the country’s population, with 46% of munity pathogens as Neisseria gonorr- those persons living in urban areas Study design hoea, Streptococcus pneumoniae, Salmo- (Tobago is classified as a ward). Trini- nella typhi, and Shigella spp. have dad and Tobago has a literacy rate We conducted a cross-sectional already demonstrated their resistance above 90%, and at least 75% of the population-based study in Trinidad to the first-line, less-expensive broad- country’s adult population has com- and Tobago by interviewing study spectrum antimicrobials (5–8). Gram- pleted secondary school. subjects over the telephone. We calcu- negative pathogens that cause hospi- Medical care in Trinidad and To- lated a sample size of 800 households tal-acquired infections have developed bago is available free through public with a working telephone, based on resistance to extended-spectrum beta- sector health care facilities. At these 80% power to detect a difference of at lactam antimicrobials, which until re- centers, patients can consult specialist least 3% in perception and use of anti- cently demonstrated high cure rates physicians, undergo recommended in- biotics, given an alpha of 0.05. As we for these infections (9, 10). vestigations and procedures, and re- did not know in advance what the te- In the English-speaking Caribbean, ceive prescribed medication from the lephone-survey participation rate infections due to resistant pathogens country’s restricted drug list, all at no would be for answered calls nor the are frequent in hospitals and also occur cost. Other than these centers, there number of busy or unanswered calls, in the family practice setting. The re- are no free pharmacies. At these public we selected 1 600 households at ran- ported rates of penicillin-resistant centers, however, patients often en- dom from the listed 167 272 house- pneumococci and chloramphenicol- counter long waiting periods and find holds in the telephone directory of the resistant Haemophilus influenzae in the that drugs are available erratically or Telecommunication Services of Trin- English- and Dutch-speaking Carib- not at all. To receive expeditious ad- idad and Tobago. It is estimated that bean are low, but high rates of resis- vice and treatment, many patients con- about 90% of households in the tance to ampicillin, co-trimoxazole, and sult a private doctor at their own ex- country have telephones and that gentamicin by common gram-negative pense, and that cost may be covered about 15% of those customers have an pathogens that cause urinary tract in- by private health insurance. Patients unlisted telephone number. fections have been reported (11). can also go to a private pharmacy and Various factors contribute to this re- directly approach the pharmacist for sistance problem in developing coun- advice and treatment. Talking to the Interview tries around the world (3). These in- pharmacist has the advantage of avoi- clude indiscriminate and widespread ding doctor consultation fees, and Six interviewers were trained to use of antimicrobials for community- much of the population utilizes this conduct structured interviews over the acquired infections, self-medication, approach. telephone. Prior to interviewing mem- incomplete treatment courses, and the The country’s Food and Drugs Act bers of the general public, the intervie- unregulated use of antibacterial drugs. classifies antibiotics as controlled wers practiced administering the Antibiotic use without physician con- drugs, to be dispensed only with a questionnaire, to be certain that they sultation occurs not only in develo- prescription. An anomaly in the law is were conveying identical meanings for ping nations but also in the United Sta- its strict application only to those the questions. The interviewers rehe- tes of America (12). In the United drugs defined by the term “antibio- arsed with each other and also with Kingdom, concerns have been raised tics” per se and not to all antimicro- some adult friends and relatives, both regarding deregulation and shifting bials; therefore, agents such as co-tri- face-to-face and on the telephone. antimicrobials for topical or oral use moxazole and the quinolones, which Based on that pilot-testing experience, from the “prescription-only medicine” do not fall under this regulation, are the survey instrument was modified. status (to be dispensed only on a phy- available without prescription. Ne- With the general public, the ques- sician’s prescription) to the “pharmacy vertheless, it is widely known that an- tionnaire was administered to a res- medicine” category (pharmacists can timicrobial agents can be obtained at ponsible adult household member dispense without a prescription) (13). pharmacies without a prescription, who was at least 18 years old and who and pharmacists simply dispense had to take care of family members 12 Parimi et al. • The general public’s perceptions
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