Volume 95, Issue 1
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



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.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Hogerzeil HV, , 1995. Promoting rational prescribing: an international perspective. Br J Clin Pharmacol 39: 16.[Crossref] [Google Scholar]
  2. Holmes A, Moore LSP, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, Guerin P, Piddock LJV, , 2016. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet 387: 176187.[Crossref] [Google Scholar]
  3. Aminov R, , 2010. A brief history of the antibiotic era: lessons learned and challenges for the future. Front Microbiol 1: 134.[Crossref] [Google Scholar]
  4. Lamberti LM, Fischer Walker CL, Black RE, , 2012. Correction: systematic review of diarrhea duration and severity in children and adults in low- and middle-income countries. BMC Public Health 12: 832.[Crossref] [Google Scholar]
  5. Fischer Walker CL, Black RE, , 2010. Diarrhoea morbidity and mortality in older children, adolescents, and adults. Epidemiol Infect 138: 12151226.[Crossref] [Google Scholar]
  6. WHO, 2004. The World Medicines Situation 2004. Geneva, Switzerland: WHO. [Google Scholar]
  7. Pathak A, Mahadik K, Dhaneria SP, Sharma A, Eriksson B, Lundborg CS, , 2011. Antibiotic prescribing in outpatients: hospital and seasonal variations in Ujjain, India. Scand J Infect Dis 43: 479488.[Crossref] [Google Scholar]
  8. Pathak D, Pathak A, Marrone G, Diwan V, Lundborg CS, , 2011. Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India—a cross-sectional prescription analysis. BMC Infect Dis 11: 32.[Crossref] [Google Scholar]
  9. Hafeez A, Kiani AG, ud Din S, Muhammad W, Butt K, Shah Z, Mirza Z, , 2004. Prescription and dispensing practices in public sector health facilities in Pakistan: survey report. J Pak Med Assoc 54: 187191. [Google Scholar]
  10. Nichter M, Vuckovic N, , 1994. Agenda for an anthropology of pharmaceutical practice. Soc Sci Med 39: 15091525.[Crossref] [Google Scholar]
  11. Nichter M, Nichter M, , 1996. Anthropology and International Health: Asian Case Studies. Amsterdam, The Netherlands: Gordon and Breach Publishers. [Google Scholar]
  12. Burtscher D, Al-Kourdi Y, Mahama G, van Overloop C, Leto C, Bajis S, Nasim M, Van den Bergh R, Au S, Sattar A, , 2015. “They Eat It Like Sweets.” Perceptions of Antibiotics and Antibiotic-Use of Patients, Prescribers and Pharmacists in a District Hospital in Kabul, Afghanistan. Médecins Sans Frontières (MSF) Scientific Day 2015. Available at: http://f1000research.com/posters/1000006. [Google Scholar]
  13. Greenhalgh T, , 1987. Drug prescription and self-medication in India: an exploratory survey. Soc Sci Med 25: 307318.[Crossref] [Google Scholar]
  14. Kamat VR, Nichter M, , 1998. Pharmacies, self-medication and pharmaceutical marketing in Bombay, India. Soc Sci Med 47: 779794.[Crossref] [Google Scholar]
  15. Saradamma RD, Higginbotham N, Nichter M, , 2000. Social factors influencing the acquisition of antibiotics without prescription in Kerala State, south India. Soc Sci Med 50: 891903.[Crossref] [Google Scholar]
  16. Chandran A, Hatha AA, Varghese S, Sheeja KM, , 2008. Prevalence of multiple drug resistant Escherichia coli serotypes in a tropical estuary, India. Microbes Environ 23: 153158.[Crossref] [Google Scholar]
  17. Das S, Choudhry S, Saha R, Ramachandran VG, Kaur K, Sarkar BL, , 2011. Emergence of multiple drug resistance Vibrio cholerae O1 in East Delhi. J Infect Dev Ctries 5: 294298.[Crossref] [Google Scholar]
  18. Raju B, Ballal M, , 2009. Multidrug resistant enteroaggregative Escherichia coli diarrhoea in rural southern Indian population. Scand J Infect Dis 41: 105108.[Crossref] [Google Scholar]
  19. Zafar A, Hasan R, Nizami SQ, von Seidlein L, Soofi S, Ahsan T, Chandio S, Habib A, Bhutto N, Siddiqui FJ, Rizvi A, Clemens JD, Bhutta ZA, , 2009. Frequency of isolation of various subtypes and antimicrobial resistance of Shigella from urban slums of Karachi, Pakistan. Int J Infect Dis 13: 668672.[Crossref] [Google Scholar]
  20. Dellit TH, Owens RC, McGowan JE, Jr Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM, , 2007. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 44: 159177.[Crossref] [Google Scholar]
  21. WHO, 2001. Interventions and Strategies to Improve the Use of Antimicrobials in Developing Countries. Geneva, Switzerland: WHO. [Google Scholar]
  22. Luby S, Agboatwalla M, Raza A, Sobel J, Mintz E, Baier K, Rahbar M, Qureshi S, Hassan R, Ghouri F, Hoekstra RM, Gangarosa E, , 2001. A low-cost intervention for cleaner drinking water in Karachi, Pakistan. Int J Infect Dis 5: 144150.[Crossref] [Google Scholar]
  23. Guest G, Bunce A, Johnson L, , 2006. How many interviews are enough? An experiment with data saturation and variability. Field Methods 18: 5982.[Crossref] [Google Scholar]
  24. Guest G, MacQueen K, Namey EE, , 2012. Applied Thematic Analysis. New York, NY: Sage.[Crossref] [Google Scholar]
  25. Mangione-Smith R, Elliott MN, Stivers T, McDonald L, Heritage J, McGlynn EA, , 2004. Racial/ethnic variation in parent expectations for antibiotics: implications for public health campaigns. Pediatrics 113: e385e394.[Crossref] [Google Scholar]
  26. Arnold SR, Straus SE, , 2005. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev CD003539. [Google Scholar]
  27. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, Jha P, Mills A, Musgrove P, , eds., 2006. Disease Control Priorities in Developing Countries, 2nd edition, Vol. 2. New York, NY: Oxford University Press and The World Bank. [Google Scholar]
  28. Hawkings NJ, Wood F, Butler CC, , 2007. Public attitudes towards bacterial resistance: a qualitative study. J Antimicrob Chemother 59: 11551160.[Crossref] [Google Scholar]
  29. Bandura A, , 1977. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 84: 191215.[Crossref] [Google Scholar]
  30. Janz NK, Becker MH, , 1984. The health belief model: a decade later. Health Educ Q 11: 147.[Crossref] [Google Scholar]
  31. Ajzen I, , 1991. The theory of planned behaviour. Organ Behav Hum Decis Process 50: 179211.[Crossref] [Google Scholar]
  32. Denis M, , 1998. Improving compliance with quinine + tetracycline for treatment of malaria: evaluation of health education interventions in Cambodian villages. Bull World Health Organ 76 (Suppl 1): 4349. [Google Scholar]
  33. Fuangchan A, Dhippayom T, Kongkaew C, , 2014. Intervention to promote patients' adherence to antimalarial medication: a systematic review. Am J Trop Med Hyg 90: 1119.[Crossref] [Google Scholar]
  34. Gradel KO, Dethlefsen C, Ejlertsen T, Schønheyder HC, Nielsen H, , 2008. Increased prescription rate of antibiotics prior to non-typhoid Salmonella infections: a one-year nested case-control study. Scand J Infect Dis 40: 635641.[Crossref] [Google Scholar]
  35. Koningstein M, Simonsen J, Helms M, Hald T, Mølbak K, , 2011. Antimicrobial use: a risk factor or a protective factor for acquiring campylobacteriosis? Clin Infect Dis 53: 644650.[Crossref] [Google Scholar]
  36. Rabbani F, Cheema FH, Talati N, Siddiqui S, Syed S, Bashir S, Zuberi LZ, Shamim A, Mumtaz Q, , 2001. Behind the counter: pharmacies and dispensing patterns of pharmacy attendants in Karachi. J Pak Med Assoc 51: 149153. [Google Scholar]
  37. Bexell A, Lwando E, von Hofsten B, Tembo S, Eriksson B, Diwan VK, , 1996. Improving drug use through continuing education: a randomized controlled trial in Zambia. J Clin Epidemiol 49: 355357.[Crossref] [Google Scholar]
  38. Hadiyono JE, Suryawati S, Danu SS, Sunartono Santoso B, , 1996. Interactional group discussion: results of a controlled trial using a behavioral intervention to reduce the use of injections in public health facilities. Soc Sci Med 42: 11771183.[Crossref] [Google Scholar]
  39. Thamlikitkul V, Danchaivijitr S, Kongpattanakul S, Ckokloikaew S, , 1998. Impact of an educational program on antibiotic use in a tertiary care hospital in a developing country. J Clin Epidemiol 51: 773778.[Crossref] [Google Scholar]
  40. Gutiérrez G, Guiscafré H, Bronfman M, Walsh J, Martínez H, Muñoz O, , 1994. Changing physician prescribing patterns: evaluation of an educational strategy for acute diarrhea in Mexico City. Med Care 32: 436446.[Crossref] [Google Scholar]
  41. Mangione-Smith R, Zhou C, Robinson JD, Taylor JA, Elliott MN, Heritage J, , 2015. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med 13: 221227.[Crossref] [Google Scholar]
  42. Gonzalez Ochoa E, Armas Perez L, Bravo Gonzalez JR, Cabrales Escobar J, Rosales Corrales R, Abreu Suarez G, , 1996. Prescription of antibiotics for mild acute respiratory infections in children. Bull Pan Am Health Organ 30: 106117. [Google Scholar]
  43. le Grand A, Hogerzeil HV, Haaijer-Ruskamp FM, , 1999. Intervention research in rational use of drugs: a review. Health Policy Plan 14: 89102.[Crossref] [Google Scholar]
  44. Huttner B, Goossens H, Verheij T, Harbarth S, , 2010. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis 10: 1731.[Crossref] [Google Scholar]
  45. Zahid AB, Gilani AH, Nanan D, Sheikh AL, White F, , 2005. Quality of pharmacies in Pakistan: a cross-sectional survey. Int J Qual Health Care 17: 307313.[Crossref] [Google Scholar]
  46. Okeke IN, Klugman KP, Bhutta ZA, Duse AG, Jenkins P, O'Brien TF, Pablos-Mendez A, Laxminarayan R, , 2005. Antimicrobial resistance in developing countries. Part II: strategies for containment. Lancet Infect Dis 5: 568580.[Crossref] [Google Scholar]
  47. Bowen A, Hurd J, Hoover C, Khachadourian Y, Traphagen E, Harvey E, Libby T, Ehlers S, Ongpin M, Norton JC, Bicknese A, Kimura A, Centers for Disease Control and Prevention (CDC), , 2015. Importation and domestic transmission of Shigella sonnei resistant to ciprofloxacin—United States, May 2014–February 2015. MMWR 64: 318320. [Google Scholar]
  48. Ruppé E, Armand-Lefèvre L, Estellat C, Consigny PH, El Mniai A, Boussadia Y, Goujon C, Ralaimazava P, Campa P, Girard PM, Wyplosz B, Vittecoq D, Bouchaud O, Le Loup G, Pialoux G, Perrier M, Wieder I, Moussa N, Esposito-Farèse M, Hoffmann I, Coignard B, Lucet JC, Andremont A, Matheron S, , 2015. High rate of acquisition but short duration of carriage of multidrug-resistant enterobacteriaceae after travel to the tropics. Clin Infect Dis 61: 593600.[Crossref] [Google Scholar]

Data & Media loading...

  • Received : 10 Sep 2015
  • Accepted : 20 Mar 2016
  • Published online : 06 Jul 2016

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error