title: Pervasive antibiotic misuse in the Cambodian community: antibiotic-seeking behaviour with unrestricted access.
abstract: BACKGROUND
  Antibiotic misuse is widespread in resource-limited countries such as Cambodia where the burden of infectious diseases is high and access to antibiotics is unrestricted. We explored healthcare seeking behaviour related to obtaining antibiotics and drivers of antibiotic misuse in the Cambodian community.
  
  
  METHODS
  In-depth interviews were held with family members of patients being admitted in hospitals and private pharmacies termed pharmacy attendants in the catchment areas of the hospitals. Nurses who run community primary healthcare centres located within the hospital catchment areas were invited to attend focus group discussions. Nvivo version 10 was used to code and manage thematic data analysis.
  
  
  RESULTS
  We conducted individual interviews with 35 family members, 7 untrained pharmacy attendants and 3 trained pharmacists and 6 focus group discussions with 30 nurses. Self-medication with a drug-cocktail was widespread and included broad-spectrum antibiotics for mild illness. Unrestricted access to antibiotics was facilitated by various community enablers including pharmacies or drug outlets, nurse suppliers and unofficial village medical providers referred to as "village Pett" whose healthcare training has historically been in the field and not at university. These enablers supplied the community with various types of antibiotics including broad spectrum fluoroquinolones and cephalosporins. When treatment was perceived to be ineffective patients would prescriber-shop various suppliers who would unfailingly provide them with antibiotics. The main driver of the community's demand for antibiotics was a mistaken belief in the benefits of antibiotics for a common cold, high temperature, pain, malaria and 'Roleak' which includes a broad catch-all for perceived inflammatory conditions. For severe illnesses, patients would attend a community healthcare centre, hospital, or when their finances permitted, a private prescriber.
  
  
  CONCLUSIONS
  Pervasive antibiotic misuse was driven by a habitual supplier-seeking behaviour that was enabled by unrestricted access and misconceptions about antibiotics for mild illnesses. Unofficial suppliers must be stopped by supporting existing regulations with tough new laws aimed at outlawing supplies outside registered pharmacies and fining registered pharmacist/owners of these pharmacies for supplying antibiotics without a prescription. Community primary healthcare centres must be strengthened to become the frontline antibiotic prescribers in the community thereby enabling the community's access to inexpensive and appropriate healthcare. Community-based education program should target appropriate health-seeking pathways and the serious consequences of antibiotic misuse.
authors.affiliation: School of Public Health and Community Medicine, UNSW Medicine, UNSW, Level 3 Samuels Building, Sydney, 2052 NSW Australia.
authors.forename: Chhorvoin
authors.identifier: 0000-0002-2987-4460
authors.initials: C
authors.lastname: Om
authors.affiliation: Diagnostic Microbiology Development Program, # 23 (First Floor), Street 310, BKK 1, Khan Chamcar Morn, Phnom Penh, Cambodia.
authors.forename: Frances
authors.initials: F
authors.lastname: Daily
authors.affiliation: Department of Clinical Sciences, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium.
authors.forename: Erika
authors.initials: E
authors.lastname: Vlieghe
authors.affiliation: Diagnostic Microbiology Development Program, # 23 (First Floor), Street 310, BKK 1, Khan Chamcar Morn, Phnom Penh, Cambodia.
authors.forename: James C
authors.initials: JC
authors.lastname: McLaughlin
authors.affiliation: School of Public Health and Community Medicine, UNSW Medicine, UNSW, Level 3 Samuels Building, Sydney, 2052 NSW Australia.
authors.forename: Mary-Louise
authors.identifier: 0000-0003-0453-8425
authors.initials: ML
authors.lastname: McLaws
keywords: Antibiotic resistance; Behaviour; Drug outlet; Nurse prescriber; Pharmacy; Self-medication; Unofficial prescriber