Monica Holiday-Goodman, RPh, PhD. Toledo ... States. As a category of drugs, antibiotics comprised ... able affecting antibiotic use (and drug use in general).
KNOWLEDGE, BELIEFS, AND USE OF PRESCRIBED ANTIBIOTIC MEDICATIONS AMONG LOWSOCIOECONOMIC AFRICAN AMERICANS Tina L. Kandakai, MEd, James H. Price, PhD, MPH, Susan K. Telljohann, HSD, CHES, and Monica Holiday-Goodman, RPh, PhD Toledo, Ohio
This study examined knowledge, beliefs, and use of prescribed oral antibiotics of 163 lowsocioeconomic African-American adults in a large midwestern city. The effects of age, education, and gender on knowledge and use of antibiotics were examined. Slightly more than 65% of the subjects in this study preferred using brand-name antibiotics. Females were more likely to report using all of their prescribed antibiotics, while males and those in the older age category were more likely to report using antibiotics only until the problem stopped. Twenty-three percent of the males and 18% of the females reported sharing their antibiotics with someone. Less than half of the respondents reported using physicians (and other health professionals) as a major source of information on prescribed antibiotics. Respondents often incorrectly identified painkillers and other medications as antibiotics. Based on these results, it appears that more education is needed to improve patients' understanding of antibiotic regimens. (J Nati Med Assoc. 1996;88:289-294.)
From the Departments of Health Promotion and Pharmacy Administration, The University of Toledo, Toledo, Ohio. Requests for reprints should be addressed to Tina L. Kandakai, Dept of Health Promotion, The University of Toledo, Toledo, OH 43606. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 5
Key words * antibiotic usage * African Americans To date, amoxicillin is the most frequently prescribed medication in office practices in the United States. As a category of drugs, antibiotics comprised 22% of all medications used in ambulatory settings in 1990.1 Because of the occurrence of antibiotic-resistant strains of bacteria, in part due to inappropriate use of antibiotics, pharmaceutical manufacturers have been prompted to develop a greater variety and more potent forms of antibiotic medications. The effectiveness of antibiotic treatments can be maximized with appropriate use by patients. However, to improve appropriate antibiotic use, it is necessary to attain an understanding of the beliefs, knowledge, attitudes, and previous use of antibiotic medications among specific populations so that health professionals can render effective treatment for targeted groups. In the recent past, controversy has risen over the effectiveness of name-brand versus generic antibiotic medications. It is believed that individuals who are more skeptical about the effectiveness of generic products may be less likely to use them.2 Consequently, individuals who are less able to afford name-brand antibiotics (those of low-socioeconomic status) and those who are apprehensive about taking generic antibiotics may be less likely to use the medication in a manner that would result in costeffective treatment. There is a dearth of research on the effect of race, gender, age, education, and socioeconomic status on use and knowledge of prescribed antibiotic medica289
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TABLE 1. DEMOGRAPHICS OF LOWSOCIOECONOMIC AFRICAN-AMERICAN
RESPONDENTS*
Characteristic Gender Male Female Age (years) 18 to 29 30 to 49 50 to 78 Meant age (years) Educational level < high school High school graduate 1 year of college Meant education (years) *N=1 63. _
No. (%) 78 (48) 85 (52) 55 (34) 75 (46) 32 (20) 38 ± 14.2
45 (28) 57 (35) 60 (37)
12±+41.9
t±standard deviation.
tions. A lack of knowledge about any medication, including antibiotics, can increase the probability of misuse. Because low-socioeconomic status AfricanAmerican males are known to use health-care services less than their female counterparts,3 one may question the effects of less use and experience with health-care services on males' knowledge of health-related issues, including knowledge of various medications. Several factors that seem to play a role in the improper use of antibiotic prescriptions have been identified by researchers. One study found that modifiable factors such as the context and manner in which information is communicated to patients, the level of satisfaction with physician consultation, and patients' health beliefs all affect adherence to proper antibiotic use. Nonmodifiable factors associated with proper antibiotic use included age, socioeconomic status, and severity of the illness.4 Other factors found to affect patients' antibiotic use included lack of knowledge and recall of the antibiotic regime5 and increased marketing efforts of the pharmaceutical industry by pressuring physicians and pharmacists to use certain types and brands of antibiotics.6'7 Other studies indicate that the primary variable affecting antibiotic use (and drug use in general) is patient demand.6"8 One study interviewed 141 physicians to asses their motivations for nonscientific prescribing. Patient demand was the single most commonly cited motivation for prescribing drugs. Inappropriate prescribing due to patient demand occurred regardless of pharmacological effectiveness.8 290
METHODS Participants A sample population of 32 randomly selected lowsocioeconomic African Americans from a large midwestem city was selected for an open-ended elicitation questionnaire. Areas from which subjects were selected were from the 1980 census tract data on geographical and socioeconomic status. A tract was chosen from those areas that incorporated the highest percentage of lowsocioeconomic African-American households, the subjects targeted for this study. Subjects were approached at three center city shopping mall areas and asked to complete the questionnaire. The subjects were given the option of having the questions read to them and their responses recorded by the researcher or they could read and answer the survey on their own. Providing both options was to prevent any discomfort in subjects who may have had literacy difficulties as well as to increase the participation rate.
Instrument An open-ended elicitation questionnaire was developed and administered to randomly selected individuals. A final closed-ended questionnaire was developed based on responses made by 10% or more of the respondents on the open-ended questionnaire. The information gathered was to assess the salient perceptions of low-socioeconomic African Americans regard-
ing antibiotics. Based on the aforementioned salient responses and a comprehensive literature review to establish content validity, an 18-item, closed-ended questionnaire was developed to assess knowledge, use, and beliefs about prescribed antibiotic medications. The final question-
naire consisted of three knowledge items examining ability to identify antibiotic medications, conditions treated with antibiotics, and signs of an allergic reaction; six items examining previous use of antibiotics; and one item each on examining preference for generic versus name-brand antibiotics, beliefs about taking generic or name-brand antibiotics, negative beliefs about taking antibiotics, and sources used for information on antibiotics. Five items examined demographic variables (eg, age, race, gender, education level, and socioeconomic status). A statistical correlation (Pearson) was conducted between 21 subjects' responses to the instrument on two occasions to determine stability reliability of the instrument. The test-retest stability correlation was .62. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 5
ANTIBIOTIC USE
RESULTS Demographics A total of 237 individuals were approached, and 12 refused to participate. Sixty-two surveys were not representative of low-socioeconomic African Americans and were removed from the final analysis. Analysis was conducted on 163 surveys (72% response rate) completed by 85 females and 78 males ranging in age from 18 to 78 years (Table 1). Chi-square analyses were used to determine homogeneity in the distribution of subjects' demographics. The results indicated that young adults and middle-aged adults were significantly (X2=lO.2; P-.0l) more likely to have more than a high school education while older subjects were more likely to have less than a high school education. Chi-square analysis also indicated a significant difference in subjects by gender and age. There were significantly (X2=lO.8; P-.0l) more males representing the middle-aged (30 to 49 years) category while females were more concentrated in the young adult (18 to 29 years) category. No significant gender differences existed by levels of education (X2=0.25; P=.89).
Sources of Antibiotic Information Respondents were asked to identify which sources of information on antibiotics were used and the degree of antibiotic information obtained. A seven-point Likert-type scale (ranging from "no information" [one point] to "a great deal of information" [seven points]) was used to assess the degree of information obtained. The 12 information sources listed included family member, physician, books, nurse, booklets, friends, pharmacist, minister, television, magazine, newspaper, and radio. Frequency analysis indicated that family members (50%), physicians (46%), books (42%), and nurses (32%) were the four most frequently used sources of information. Of the three health professionals mentioned, pharmacists (23%) were the least used source of information. Three-way analysis of variance (ANOVA) was used to assess the effects of age, gender, and education on subjects' use of sources of information on antibiotics. The three-way ANOVA indicated that young adults were significantly more likely (F=5.177; dft2, 138; P=.01) than older subjects to use family members as sources of information on antibiotics. Young adult subjects were also significantly more likely (F=6.060; df=2, 140; P=.003) than middle-aged adults to use nurses as a source of information on antibiotics. The ANOVA also indicated that high school graduates were significantly more likely (F=5.144; dfr-2, 138; P=.007) to use books as a source of information on JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 5
TABLE 2. RESPONDENTS' OVERALL KNOWLEDGE OF ANTIBIOTICS* Item (Correct Response) No. (%)
Identification of Antibiotics Penicillin (yes) 144 (89) Acetaminophen (no) 112 (71) Amoxicillin (yes) 100 (63) Darvon (no) 86 (57) Tetracycline (yes) 67 (43) Muscle relaxer (no) 63 (41) Tylenol (no) 52 (34) Aspirin (no) 43 (28) Identification of Signs of an Allergic Reaction to an Antibiotic Dizziness (no) 128 (81) Nausea (yes) 122 (75) Shakes (no) 119 (75) Pain (no) 109 (69) Rash (yes) 103 (65) Swelling (yes) 99 (63) Fever (yes) 89 (56) Diarrhea (yes) 80 (50) Identification of Conditions Commonly Treated With Antibiotics Viral infections (no) 146 (92) Sexually transmitted diseases (yes) 134 (83) Bacterial infections (yes) 129 (82) Flu (no) 129 (81) Common cold (no) 122 (77) Pain (no) 85 (57) Heart problems (no) 65 (43) *N=163; percentages only reflect those responding to the question.
antibiotics than were subjects with less than a high school education. Male subjects were significantly more likely (F=7.921, df=l, 140; P=.006) to use television as a source of information on antibiotics. The use of medical professionals steadily increased with increased level of education.
Knowledge and Perceptions of Antibiotics Respondents were asked to identify medications thought to be antibiotics, conditions commonly treated with antibiotics, and signs of an allergic reaction to antibiotics. These three questions were combined to assess overall knowledge of antibiotics (Table 2). Three-way analysis of variance (ANOVA) was calculated to assess the effects of age, gender, and education on subjects' overall knowledge of antibiotics. No significant differences were found based on age (F=1.553; df=2, 143; P=.215), educational level 291
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TABLE 3. PREFERENCE FOR AND REASONS WHY RESPONDENTS DESIRE A PARTICULAR ANTIBIOTIC BY AGE AND EDUCATIONAL LEVEL* Education Aget No. (%) Young
No. (%) Middle
No. (%) Old
No. (%) No. (%) High No. (%) High School (n=60) (n=45) (n=57) 40 (70) 38 (63) 29 (64) 14 (23) 13 (27) 13 (25) 8 (13) 4 (9) 3 (5)
(n=32) (n=55) (n=75) Categories 21 (70) 51 (69) 36 (61) Prefer brand 5 (17) 22 (37) 13 (18) No preference 4 (13) 1 (2) 10 (14) Generic Reason for brand preference 22 (79) 15 (40) 23 (48) 16 (70)t 9 (29) Safer drug 2 (7) 9 (24) 4 (17) 11 (23) 6 (19) Doctor prefers it 10 (27) 11 (23) 3 (11) 3 (13) 13 (42) Works better 1 (4) 3 (8) 0 (0) 3 (10) 3 (6) Cost less *Percentages only reflect those responding to the question. tYoung=18 to 29 years old, middle=30 to 49 years old, and old=50 to 78 years old. tKruskal-Wallis one-way analysis of variance; P
