title: What Happens When "Germs Don't Get Killed and They Attack Again and Again": Perceptions of Antimicrobial Resistance in the Context of Diarrheal Disease Treatment Among Laypersons and Health-Care Providers in Karachi, Pakistan.
abstract: In south Asia, where diarrhea is common and antibiotics are accessible without prescription, antimicrobial resistance is an emerging and serious problem. However, beliefs and behaviors related to antimicrobial resistance are poorly understood. We explored laypersons' and health-care providers' (HCP) awareness and perceptions of antimicrobial resistance in the context of treatment of adult diarrheal disease in Karachi, Pakistan. In-depth, open-ended interviews were conducted with 40 laypersons and 45 HCPs in a lower-middle-class urban neighborhood. Interviews conducted in Urdu were audiotaped, transcribed, translated, and coded using applied thematic analysis. Slightly over half of laypersons and two-thirds of HCPs were aware that antimicrobial medication could lose effectiveness, but misperceptions were common. Laypersons and HCPs often believed that "the body becomes immune" or "bacteria attack more strongly" if medications are taken "improperly." Another prevalent theme was that causes and effects of antimicrobial resistance are limited to the individual taking the antimicrobial medication and to the specific diarrheal episode. Participants often attributed antimicrobial resistance to patient behaviors; HCP behavior was rarely discussed. Less than half of the HCPs were aware of treatment guidelines. To combat antimicrobial resistance in urban Pakistan, a health systems strategy and community-supported outreach campaigns on appropriate antimicrobial use are needed.
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia. hjoseph1@cdc.gov.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Joseph
authors.affiliation: Health-Oriented Preventive Education, Karachi, Pakistan.
authors.forename: Mubina
authors.initials: M
authors.lastname: Agboatwalla
authors.affiliation: Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Hurd
authors.affiliation: Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia. Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Kara
authors.initials: K
authors.lastname: Jacobs-Slifka
authors.affiliation: Procter and Gamble, Cincinnati, Ohio.
authors.forename: Adam
authors.initials: A
authors.lastname: Pitz
authors.affiliation: Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Anna
authors.initials: A
authors.lastname: Bowen
mesh_terms: D000293:Adolescent; D000328:Adult; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D003967:Diarrhea / Q000188:drug therapy* / Q000382:microbiology; D024901:Drug Resistance, Multiple, Bacterial; D005069:Evaluation Studies as Topic; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010154:Pakistan; D012959:Socioeconomic Factors; D055815:Young Adult
chemical_list: D000890:Anti-Infective Agents