Non-biomedical factors affecting antibiotic use in the community: a mixed-methods systematic review and meta-analysis

In the past two decades, human antibiotic consumption has increased globally, contributing to the emergence and spread of antimicrobial resistance and needing urgent effective actions. Our objectives were to systematically identify and collate studies exploring non-biomedical factors influencing healthcare consumers' antibiotic use globally, in order to inform future interventions to improve practices in antibiotic use.

Data sources were PubMed, EMBASE, PsycINFO, and Cochrane. Study eligibility criteria were original and empirical studies that identified factors for healthcare consumers' antibiotic use. Participants were healthcare consumers. Assessment of risk of bias used adapted BMJ survey appraisal tools, the Critical Appraisal Skills Programme checklist, and the Mixed Methods Appraisal Tool for quality assessment. Methods of data synthesis employed the Social Ecological Framework and Health Belief Model for data synthesis. We did random-effects meta-analyses to pool the odds ratios of risk factors for antibiotic use.

We included 71 articles for systematic review and analysis; 54 were quantitative, nine were qualitative, and eight were mixed-methods studies. Prevalent non-prescription antibiotic use and irresponsible prescriptions were reported globally, especially in low-to-middle-income countries. Barriers to healthcare-wait time, transportation, stigmatization-influenced people's practices in antibiotic use. Further, lack of oversight and regulation in the drug manufacturing and a weak supply chain have led to the use of substandard or falsified antibiotics. Knowledge had mixed effects on antibiotic use behaviours. Meta-analyses identified pro-attitudes towards self-medication with antibiotics, relatives having medical backgrounds, older age, living in rural areas, and storing antibiotics at home to be risk factors for self-medication with antibiotics.

Non-prescription antibiotic use and irresponsible prescriptions in the community are prevalent in all WHO regions and are driven largely by a mixed collection of non-biomedical factors specific to the respective setting. Future antimicrobial resistance strategies should incorporate an implementation science approach for community-based complex interventions that address drivers of the target behaviours tailored to local contexts.