We conducted 45 individual interviews with 35 family members of patients being hospitalized and 7 untrained pharmacy attendants and 3 trained pharmacists. Six FGDs were conducted with 30 nurses from 6 community primary healthcare centres within the catchment areas of the hospitals where family members were interviewed. The findings revealed a widespread misuse of antibiotics in the community that was facilitated by antibiotic-seeking behaviours, unrestricted access to antibiotics, and poor knowledge about antibiotics.
Healthcare and antibiotic-seeking behaviour
Participating family members spoke about the severity of illness and the factors that influenced their healthcare and antibiotic-seeking behaviour. Judgement of the severity of symptoms was a common practice used to determine what level of healthcare would be accessed. For a mild illness such as a common cold, mild diarrhoea or general unwell feeling patients would self-prescribe medication purchased and freely available from a nearby pharmacy or village drug outlet.
“When I have a minor headache, sore throat or fever I go to buy medicines from pharmacy.” Family Member # 2-NMCH
“When I’m sick such as from headache, tiny ache, I always buy medicines in the village; 1 dose, 2 doses [something] like that.” Family Member # 2-BT
In local terminology the words Dambao Krapeas (gastric ulcer), Roleak Krapeas (gastritis), Dambao Posvean (intestinal ulcer), or roleak Posvean (intestinitis) all refer to internal inflammation or wound. Because the community uses antibiotics for external wounds, injuries and inflammation the family will seek antibiotics to heal all ‘internal’ pain or illnesses they perceive to be caused by inflammation or internal ‘wound’.
“I usually take one para [paracetamol] and one ampi [ampicillin]. Then I don’t feel any more pain in my stomach.” Family Member #3-NPH
“Phsas (healing) in case we have inflammation, intestinal inflammation, gastric inflammation, other wound we can take ampi [ampicillin].” Family Member #4-KCH
After having taken a cocktail of drugs and when family members perceived that symptoms were unrelenting and severe such unendurable pain, colic or fever they would attend a community primary healthcare centre or hospital. If their finances permitted they would visit a private healthcare provider.
“In case of minor sickness, I go to buy medicines but I go to a healthcare centre if it is a severe illness.” Family Member # 2-KRV
“I go to hospital when I have a sharp pain in my stomach and/or bowel....like when there is an inside pain, which we cannot know what it is. I cannot go to a pharmacy.” Family Member # 7-BT
“We always go to a [private] clinic if we have a severe sickness.” Family Member # 10-MBR
These patients will also consult several healthcare providers when they perceive their treatment has been ineffective including unofficial healthcare providers known in the community as village Petts. The community ‘prescriber-shopper’ would request after-hours private care from physicians, nurses or village Petts.
Interviewer: Did you go to physician H; how many consultations? 5 consultations?
Participant: We visited physician H 3 times. He gave medicines and my husband got better. After he was better, he relapsed.
Interviewer: Then you went to another healthcare provider?
Participant: Yes, after thinking that the hospital was [too] far we went to Pett K.
Interviewer: How many times did you consult Pett K?
Participant: Two times. He injected [my husband] and he gave medicines. When we came the third time he told us that he couldn’t treat [him]; couldn’t continue any more. He told us to come to this hospital.
Healthcare providers are often referred to as Pett and this term includes unofficial “village Pett”. The unofficial village Petts were healthcare providers during the Khmer Rouge genocide period (between 1975 and 1979) or unofficially trained in the Cambodia-Thai border camps during civil unrest after the Khmer Rouge period, and those who have unknown medical training history. These unofficial suppliers have remained practitioners in the community making house calls where they provide their patients with a diagnosis and treatment that includes antibiotics.
Despite perceptions of the severity of an illness that influences healthcare-seeking behaviour, family members described other factors that include:
“I generally go to the healthcare centre near my house. I only pay 1000 riels and I’m given medicines for three days.” Family Member # 3-KTL
Burden of balancing demands of earning an income, taking care of children, the elderly and their properties at home, with providing basic care in the hospital to their family member during their admission;
“I have small grandchildren, their parents go to work. I said to the hospital staff ‘if my husband has typhoid fever please give him IV injections at home’. I don’t want to go to hospital because there’s no one to take care of him in hospital as I’m at home with the grandchildren.” Family Member # 1-KRV
Ability to pay healthcare providers and purchase of medicine.
“If I have money I buy medicines, to take two doses. But if I don’t have money I can only buy medicines to take once only.” Family Member # 4-KTL
Trust in the safety of the healthcare provider and effectiveness of the treatment;
“It is safer to come to this hospital than to buy medicines outside. We meet the doctor and he advised us to take this or that [medicine] which is effective.” Family Member # 8-MBR
Nurses from primary healthcare centres and a trained pharmacist at a provincial pharmacy explained how the financial constraints of the patients prevented them from initially consulting a physician and how this drives poor medication behaviour:
“In real practice as I have experienced the patients just let us inject for one or two days. If they are better, they stop because they don’t have the money [to continue treatment].” Nurse #1-SLL5
“For minor cases mostly patients come to buy one or two doses of medicines at the pharmacy because they don’t have much money. They do this because they don’t have money to see a physician.” Pharmacist # 2-SRP
Unrestricted access to antibiotics
Access to antibiotics is unrestricted and facilitated by various community enablers who include trained private pharmacists and untrained pharmacy attendants, drug outlet suppliers, unofficial village Pett suppliers, nurses and trained physicians. The community is so familiar with the antibiotics that are freely available that they know the name of many such as pen [penicillin], amox [amoxicillin], ampi [ampicillin], tetra [tetracycline] and cotrim [co-trimoxazole]. These antibiotics are even freely available in small village grocery shops in remote regions.
“When I have a high temperature or a cold, amox [amoxicillin] and ampi [ampicillin] are given to me mixed together. If I have a runny nose the drug sellers give me ampi, and if this isn’t available it’s replaced with amox.” Family Member #2-NPH
“After I realize that cotrim [cotrimoxazole] can cure diarrhoea I always buy it. I buy only one tablet and I crush and grind it with water for my children to drink.” Family Member #1-SRP
Most drug sellers in pharmacies or drugs outlets were untrained. But training does not always guarantee appropriate antibiotic use. When asked when antibiotics were indicated both trained pharmacists and untrained suppliers believed that antibiotics were indicated when their patients had diarrhoea and respiratory symptoms such as sore throat, fever and cough. Both trained and untrained suppliers drive the antibiotic-seeking behavior by providing a cocktail of drugs based on symptoms and this cocktail includes non-prescription medications plus an antibiotic such as amoxicillin, ampicillin, cephalexin, cefixime or co-amoxyclavulanic acid for upper respiratory infections and co-trimoxazole for diarrhoea.
“For normal colds without high temperature, patients can take amoxicillin. If they cough or have a high temperature, they take augmentin or cefixime. It depends on the seriousness of the sickness.” Untrained pharmacy attendant #1-PP
“It is like what I told you earlier. Antibiotics are mostly used in case of diarrhoea, high temperature, cold and cough.” Untrained pharmacy attendant # 1-NL
“Antibiotics should be prescribed for sicknesses such as respiratory inflammation.” Untrained pharmacy attendant #1-KCH
“As my routine, I listen to their [patient’s] sickness first. If they have a headache, then I give Alaxan [ibuprofen and paracetamol] or Para [paracetamol]; if they have a cold, I give them Decolgen [anti allergic, decongestant and paracetamol] and vitamin. I can use amox or ampi in the case that they have a sore throat or have a fever for many days ago.” Trained pharmacist #2-SRP
Nurses from public hospitals and community primary healthcare centres commonly provide private after-hours services that offer a diagnosis and treatment. When asked “Have you ever invited nurses to your house for treatment?” family members indicated they provide injections and antibiotics:
“Yes. It [occurs] in the case [when] we are very busy at home and don’t have enough time to get treatment at [a] clinic, then we can call the nurse to treat us at our house.” Family Member #9-MBR
“He (nurse) told me that I had gastric inflammation and then he wrote ceftri [ceftriaxone] injection on a piece of paper. He asked me ‘do you want drugs at the healthcare centre or want me to give the injection at home.’ I thought I wanted him to give the injection [at home] because I don’t have time to go to the healthcare centre to take drugs.” Family Member #6-KCH
Nurses who are employed in primary healthcare centres also have a private practice and prescribe fluoroquinolones and 3rd generation cephalosporin and often provide injections.
“If it’s typhoid fever we prescribe oflocet [fluoroquinolones] for 5 days. If they [patients] don’t recover we prescribe ceftri [cetriaxone].” Nurse #3-NL
“If the sickness becomes more severe, we have to use IV injection and ceftri [cetriaxone]. If the sickness is just a simple fever, which is not serious, we continue using oflocet [fluoroquinolone] for 3-5 days.” Nurse #2-NL
Unofficial village Petts are unregistered or have undefined training and supply medications and antibiotics including broad-spectrum antibiotics in the community.
“Village Pett are Pett from Pol Pot regime [Khmer Rouge] who have experience (providing health care during that time). They sell medicines and if we need ampi [ampicillin] or amox [amoxicillin], they will sell them to us. They provide injections too.” Family Member #3-BT
“It is the same for both treatment at the healthcare centre and treatment from door to door. Some people use Amox as Thnam Psas (antibiotic). Village Petts providing treatment from door to door mostly prescribe Ceftri [ceftriaxone]. They prescribe the high ones. Ceftri is generally used.” Nurse #2-NL
Official healthcare providers were concerned about these village Petts providing care and antibiotics but did not recognise their own professions’ role in misusing antibiotics.
“Yes, there are [unofficial Petts] but far from here in the remote rural area. There are also some Petts who just learn from each other and never went to school. Now we still cannot stop this problem.” Nurse # 1-SLL5
Poor knowledge about antibiotics
Family members were asked about the benefit of antibiotics with the interviewer who used the local term Thnam Phsas or the antibiotics by name such as amoxicillin, ampicillin or penicillin. They described how Thnam Phsas could heal minor wounds (‘dambao’), injuries (‘robuos’) or cuts (‘mout’) and inflammation (‘roleak’) such as throat inflammation (‘roleak bampongkor’).
“If there is a wound [dambao], mostly people take Thnam Phsas. It can heal both inside and outside of the body.” Family Member #8-MBR
“We take ampi [ampicillin] when we have cuts [mout] on arms or legs or when we have a motorbike accident or other small accident. When we take it [ampicillin], it helps to heal the injury [robuos].” Family Member # 2-NMCH
“If we have cough and we’re afraid that it will cause throat inflammation we take Thnam Phsas. When I tell drug sellers that I have a cough, cold or sore throat, then they will cocktail it [Thnam Phsas] for me.” Family Member #13-SRP
“Based on my understanding, Thnam Phsas [antibiotic] is for throat inflammation.” Family Member #4-NL
Trained pharmacists, untrained pharmacy attendants and nurses from community primary healthcare centers upheld the community’s belief about the benefits of antibiotics that they use to treat inflammation.
“Generally drug cocktail is for common cold, cough or mild sore throat. For common cold and cough I don’t give antibiotic in the cocktail. I only give antibiotics for throat inflammation.” Trained pharmacist #001_A_007 PP
“Antibiotics should be prescribed for sicknesses such as respiratory inflammation.” Untrained pharmacy Attendant #3-KCH
“For those who have minor sicknesses, sometimes I do not prescribe antibiotics for them, never. Mostly I prescribe them as long as they have throat inflammation. It is like this.” Untrained pharmacy attendant #3-NL
“If we see that they have upper breathing inflammation or bronchitis, we prescribe antibiotics for them [patients].” Nurse #5-KRV
“We think that the disease could be something related to inflammation, and then we use antibiotics.” Nurse #3-SLL5
Besides a belief that antibiotics were beneficial for injuries, wounds and inflammation, family members described further misconceptions that antibiotics could be beneficial for the common cold, high temperature, pain and even malaria.
“Ampi [ampicillin] and amox [amoxicillin] help us, for example, when I have a stuffy nose, it helps to reduce the clogging and I can breathe more easily, feel better, reduces the temperature and so on.” Family Member #2-NPH
“When I have pain, we take it [amoxicillin]. It helps to reduce pain.” Family Member #2-KRV
“Yes. Ampi [ampicillin] for less severe disease has less phsas (healing) substance but it has cooling substance inside. For malaria, we can take it [ampicillin] in a mixture as well. For ampi [ampicillin], if there is amox [amoxicillin], we still use ampi [ampicillin] because it has cooling substance. I use [it] like this.” Family Member #4-KCH