Non-Biomedical Factors Affecting Inappropriate Antibiotic Use in the Community: A Global Mixed-Methods Systematic Review and Meta-Analysis

Background: Inappropriate antibiotic use behaviours have been widely reported across the world, exacerbating the development of antimicrobial resistance (AMR). In this study, we aimed to systematically identify and collate studies exploring factors influencing healthcare consumers’ antibiotic misuse globally, in order to inform future interventions to improve antibiotic use practices. Methods: We systematically searched PubMed, EMBASE, PsycINFO, Cochrane, and reference lists for potentially relevant studies published before June 2020. Original and empirical studies that identified factors for healthcare consumers’ antibiotic misuse were eligible for inclusion. The Social Ecological Framework and Health Belief Model were employed for data extraction and synthesis. We did random-effects meta-analyses to pool the odds ratios of risk factors for antibiotic misuse. Findings: We included 68 articles for systematic review and analysis: 51 quantitative, nine qualitative, and eight mixed-methods studies. Prevalent antibiotic misuses were reported globally, especially in low-to-middle income countries. Knowledge had mixed effects on antibiotic use behaviours. Barriers to healthcare – wait time, transportation, stigmatization – influenced people’s antibiotic use practices. Meta-analyses identified pro-attitudes towards self-medication with antibiotics (SMA), relatives having medical backgrounds, older age, living in rural areas, and storing antibiotics at home to be risk factors for SMA; relatives having a medical background and prior experience of antibiotic use were risk factors for storing antibiotics at home. Interpretation: Antibiotic misuse in the community is alarmingly prevalent, and is identified to be affected by non-biomedical factors. Future AMR strategies should incorporate a multifaceted community-based design that addresses drivers of antibiotic misuse tailored to local contexts. Funding Statement: This work was supported by the UK Foreign, Commonwealth and Development Office and Wellcome [215373/A/19/Z]. Declaration of Interests: The authors declare that there is no conflict of interest