JAC Advance Access originally published online on February 22, 2008
Journal of Antimicrobial Chemotherapy 2008 61(5):1172-1179; doi:10.1093/jac/dkn054
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Original research |
Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and the healthcare system
1 Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands 2 Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands 3 Department of Medical Microbiology, University Medical Center Groningen, Groningen, The Netherlands 4 Department of Medical Sociology and Health Sciences, Vrije Universiteit Brussel, Brussels, Belgium 5 Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden 6 Nordic School of Public Health and Apoteket AB, Göteborg, Sweden 7 National Center for Antimicrobials and Infection Control, Statens Serum Institut, Copenhagen, Denmark 8 Infection Control Unit, St Luke's Hospital, G'Mangia, Malta 9 Health Protection Agency East Midlands, Nottingham City Hospital, Nottingham, UK
* Corresponding author. Tel: +31-88-7555100; E-mail: l.grigoryan{at}umcutrecht.nl
Received 28 August 2007; returned 16 November 2007; revised 18 January 2008; accepted 21 January 2008
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Abstract |
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Background: Self-medication with antibiotics occurs among the population in Europe, particularly in southern and eastern countries. We studied the impact of predisposing factors (e.g. attitudes and knowledge concerning antibiotic use and self-medication) and enabling factors (country wealth and healthcare system factors) on self-medication with antibiotics in Europe.
Methods: In this follow-up of a previous European survey, we interviewed a subsample of 1101 respondents. A multilevel analysis with two levels (respondent and country) was performed. Variables that were statistically significantly different between users and non-users of self-medication were considered for inclusion into the multilevel regression analyses.
Results: Predisposing factors included individual-level characteristics. High perceived appropriateness of self-medication with antibiotics for bronchitis and an attitude favouring antibiotic use for minor ailments were related to a higher likelihood of self-medication. Enabling factors included individual and country data. At the individual level, perceived availability of antibiotics without a prescription was related to increased probability of self-medication. At the country level, higher gross domestic product (wealth) and exact dispensation of prescribed tablet quantities by pharmacies were independently associated with lower likelihood of self-medication.
Conclusions: Interventions aimed at preventing self-medication should include public education, enforcing regulations regarding the sale of antibiotics, and implementing laws for dispensing exact prescribed tablet quantities in pharmacies. With the included determinants, we explained almost all the variance at the country level, but not at the individual level. Future studies to increase our understanding of determinants of self-medication with antibiotics should focus on individual-level factors such as doctor–patient relationships and patient satisfaction.
Keywords: antibacterial agents , epidemiological factors , drug resistance , bacterial
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Introduction |
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Self-medication with antibiotics occurs among the population in Europe, particularly in southern and eastern countries.1,2 Several studies in the USA have also shown considerable self-medication with antibiotics obtained from leftovers from previous courses, at a local pharmacy or outside the country.3–6 The most common reasons for self-medication were colds and upper respiratory tract symptoms,1,4 which are self-limiting and mostly caused by viruses. This inappropriate use may contribute to antibiotic resistance,7 which is reaching alarming levels in Southern and Eastern Europe.8
Most health behaviours are determined by multiple factors, and interventions that address several key factors are likely to be the most successful.9,10 The PRECEDE model of behaviour change11 is a standardized theoretical framework that has been used to design successful, large-scale health interventions.12,13 According to the PRECEDE model, health behaviour is influenced by predisposing factors (characteristics that lead to or motivate behaviour such as knowledge and beliefs), enabling factors (characteristics that facilitate or are required to perform the particular behaviour, such as resources in the environment), and reinforcing factors (rewards and punishments received from others).
The determinants of self-medication with antibiotics in low-income countries include over-the-counter sale of antibiotics,14 the cost of medical consultation, low satisfaction with medical practitioners,15 and misconceptions regarding the efficacy of antibiotics.16 Studies in the USA showed that recent immigrants from Latin American countries, where antibiotics are available over-the-counter, had the greatest expectations for antibiotics for upper respiratory infections.3,17 The cultural beliefs and a lack of health insurance were other possible determinants of self-medication with antibiotics for these immigrants.3 In Europe, differences in attitudes to antibiotic use have been described,18 but little is known about their effect on self-medication. In the present study, we examined the impact of predisposing (attitudes, beliefs and knowledge) and enabling factors (country wealth and the healthcare system factors) on self-medication with antibiotics in Europe.
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Methods |
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Face-to-face structured interviews were conducted in 12 countries. Countries were selected to represent Northern/Western (Austria, The Netherlands, Sweden, the UK and Belgium), Southern (Italy, Malta, Israel and Spain) and Eastern (the Czech Republic, Lithuania and Croatia) European regions. Because of data collection problems, Spain was excluded from the analyses. Data were collected between October 2003 and May 2004, after approval of the appropriate Institutional Review Boards. This study is a follow-up study from a European survey estimating prevalence of both self-medication and prescribed use of antibiotics.1 In the previous survey, we used a multistage sampling design. Within each country, a region with average prescribed antibiotic consumption was chosen, and in each chosen region, a middle-sized city and rural area were selected. Questionnaires were mailed to 1000–3000 randomly selected adults in each country. These were equally divided between urban and rural areas. The mean response rate of all countries was 40%. The characteristics of the respondents in each country and the prevalence rates of self-medication and prescribed use in each country are described elsewhere.1
This follow-up study was limited to respondents in 12 countries willing to be interviewed. Interviewers called the respondents to set a time and place for the interview. Several attempts were made to reach each respondent. Respondents could choose to be interviewed at home or in a neutral place such as a library. Interviews were conducted mainly at home. Because of a feasibility issue, we limited inclusion to 100 respondents in each country: 50 users of self-medication with antibiotics and 50 non-users, both equally distributed in urban and rural areas. The total sample size of users and non-users of self-medication from all participating countries provides sufficient statistical power to identify the determinants of self-medication with antibiotics in Europe. If the number of self-medication users willing to be interviewed was less than 50 in a country, non-users of self-medication were added to achieve 100 respondents. In Lithuania, the number of non-users willing to be interviewed did not reach 50; therefore, self-medication users were added. Respondents who failed to identify antibiotics correctly (for example, confusing antibiotics with painkillers) were excluded from the study.
The questionnaire for interviews was developed in English, translated into national languages, and back-translated to English to ensure consistency. Pre-testing of the questions took place in each country. Interviewers from all countries were trained in a collaborative workshop. The first two interviews with respondents were ‘training interviews’ and were immediately followed by an in-depth discussion between the trainer and the interviewer. These first two interviews were excluded from the analysis.
In this study, we have included individual characteristics of the interviewees, as well as characteristics of the country of residence. Predisposing factors included individual data on attitudes and knowledge concerning antibiotic use and self-medication (Table 1). Enabling factors included both individual and country data. Individual data comprised perceived availability of antibiotics without a prescription and reimbursement of prescribed antibiotics. Country data included the gross domestic product (GDP) per capita and dispensing regulations.
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Interviewees were asked about their attitudes and knowledge concerning antibiotic use and self-medication in a series of statements rated on a Likert scale. We aimed to include statements assessing both respondents' attitudes towards self-medication and antibiotic use in general. We developed 10 statements assessing perceived appropriateness of self-medication with antibiotics, as no standardized questionnaire exists about this subject. These statements concerned perceived appropriateness of self-medication with antibiotics for bronchitis in various situations of daily life. Bronchitis was chosen as it is considered as a serious illness by lay people,19 and we anticipated that lay people in many countries may consider using antibiotics for bronchitis. Statements assessing respondents' attitudes and knowledge concerning antibiotic use in general were derived from other studies.6,20,21 We added two statements assessing perceived appropriateness of antibiotic use in various situations of daily life. We assessed dimensionality of the data by performing two factor analyses. First, factor analysis was performed for the statements about perceived appropriateness of self-medication. Secondly, factor analysis was performed for statements about antibiotic use in general. Items were included in a factor when the factor loading was
0.40. A varimax rotation identified one factor for perceived appropriateness of self-medication and three factors for attitudes and knowledge about antibiotic use in general (Table 1). The three factors related to attitudes and knowledge about antibiotic use in general were: (i) attitudes towards antibiotic use for minor ailments; (ii) perceived appropriateness of antibiotic use in different situations; and (iii) knowledge about the effectiveness of antibiotics on bacteria and viruses. As shown in Table 1, all four factors showed satisfactory reliability (Cronbach's alpha and mean inter-item correlation). We used these four factors as indices in this study. Statements were grouped in four factors and the mean scores were computed for each factor. We used unweighted summated scoring as a high correlation (0.98) was reported between weighted and unweighted scoring previously.22 Higher scores for each factor represented higher perceived appropriateness of self-medication and antibiotic use in different situations, an attitude favouring antibiotic use for minor ailments or less knowledge about the effectiveness of antibiotics on bacteria and viruses. The respondents' knowledge about health dangers associated with taking antibiotics was assessed with an open-ended question, ‘Are you aware of any dangers to your health or the health of other people associated with taking antibiotics?’ derived from another study.6 We classified the answers into two categories: knowledge of antibiotic resistance and knowledge of adverse effects of antibiotics (including allergies/reactions, antibiotics may kill ‘friendly’/good flora, diarrhoea, vomiting etc.).
Perceived availability of antibiotics from pharmacies without a prescription was assessed by the question, ‘Could you tell me if it is possible for you to get an antibiotic directly from the pharmacy without prescription?’ The responses for this item were ‘yes, easily’, ‘yes, sometimes’, ‘no’ and ‘do not know’. We asked about perceived availability of antibiotics directly from pharmacies because illegal acquisition of antibiotics without prescription from pharmacies occurs frequently in some countries.1
For the question about the reimbursement of antibiotics, we classified the answers in three categories ‘complete reimbursement’, ‘patient co-payment’ and ‘no reimbursement’. Reimbursement was measured at the individual level, because within a country, different reimbursement schemes are available for individuals.
Socio-demographic information included age, educational level, and presence of a chronic disease. Education was categorized as low (incomplete primary education, completed primary education and lower vocational or general education) or high (intermediate or higher vocational or general education, college or university).
Data on GDP per capita were retrieved from the 2004 World Health Organization's core health indicators,23 and information on regulations regarding the dispensing of exact numbers of tablets or per package size was provided by country co-investigators of this study (Table 2).
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Respondents were asked whether they had ever taken an antibiotic without a prescription. They were classified as users of self-medication if they reported that they had ever taken any antibiotic without a prescription. Self-medication included use of antibiotics obtained directly from a pharmacy, leftovers from treatment courses prescribed earlier and antibiotics obtained from relatives or friends or other sources.
2 tests were used to compare users and non-users of self-medication for differences in categorical variables (sex, education, presence of a chronic disease, location, predisposing and enabling factors), and a t-test was used for differences in age. SPSS (version 12) for Windows (SPSS, Inc., Chicago, IL, USA) was used. Variables that were statistically significantly different between users and non-users of self-medication (P < 0.05) were considered for inclusion into the multilevel regression analyses. Due to the hierarchical nature of the data, multilevel logistic regression analysis was applied. In the present analysis, the levels were respondents (level 1) and countries (level 2). Multilevel analysis allows us to split total variance of self-medication and to attribute it to each level. We used the partitioning of the variance based on the threshold representation, as suggested by Snijders and Bosker.24 The analysis was performed in three steps. First, an ‘intercept-only’ model was created, which included only countries (level 2) and did not include any explanatory variables. This model revealed each level's contribution to variation. Secondly, explanatory variables at the individual level, which were significantly different between users and non-users of self-medication, were included. In the multilevel regression analysis, we used the mean scores of the factors measuring perceived appropriateness of self-medication and antibiotic use, attitudes towards antibiotic use for minor ailments and knowledge about the effectiveness of antibiotics on bacteria and viruses. Finally, variables at the country level were added. The contribution of each determinant in the multilevel analysis was expressed as odds ratio (OR) and a 95% confidence interval (CI). Interaction terms were examined for the significant determinants. MLwiN version 2.00 was used to test multilevel logistic regression models.
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Results |
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In total, 1101 respondents were interviewed. Eleven respondents who failed to identify what was an antibiotic were excluded from the analyses. The number of subjects approached and included for both surveys and the general characteristics of the respondents in the follow-up survey are shown in Table 3. In comparison with the respondents in the source population of the previous survey,1 interviewees in the follow-up study more often had a high education, but were similar with regard to age, sex, presence of a chronic disease and place of residence (urban/rural). Table 4 summarizes the difference between users and non-users of self-medication with regard to demographic characteristics and predisposing and enabling factors. General characteristics (age, sex, education, presence of a chronic disease and location) were not significantly different between users and non-users of self-medication (Table 4). Perceived appropriateness of self-medication with antibiotics for bronchitis was significantly higher among users of self-medication than non-users. The same trend was observed for attitudes towards antibiotic use for minor ailments and perceived appropriateness of antibiotic use in various situations (Table 4). Incorrect knowledge about the effectiveness of antibiotics on bacteria and viruses was slightly higher among non-users of self-medication, although the difference was not statistically significant. Non-awareness about antibiotic resistance was significantly higher among users of self-medication. In contrast, non-awareness about adverse effects was significantly higher among non-users of self-medication.
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As shown in Table 4, significant differences between users and non-users of self-medication were also observed with respect to enabling factors, i.e. perceived availability of antibiotics directly from pharmacies and reimbursement of prescribed antibiotics. Users of self-medication were more likely to perceive that antibiotics are available directly from pharmacies without prescription. Users of self-medication were less likely to receive complete reimbursement for prescribed antibiotics and more likely to get no reimbursement at all.
The ‘intercept-only’ model showed that variation at the country level contributed considerably to the model (18%), although most variation was explained by the individual characteristics of respondents (82%). The total variance explained by the second model including factors at the individual level was 32%. The residual variance at the country level decreased (7%), indicating that a part of the differences between countries had been explained by the information at the individual level. After adding variables at the country level, the proportion of total variance explained by the third model was 38%. The between-country residual variance was 2%, and the residual variance at the individual level was 60%.
The results of the multilevel logistic regression analysis including those variables that were significantly different between users and non-users of self-medication in the univariate analysis are presented in Table 5. Among the five predisposing factors, only two were statistically significant in the final multilevel logistic regression. As expected, respondents who expressed higher perceived appropriateness of self-medication with antibiotics for bronchitis had a higher likelihood of actual self-medication (OR 2.13, 95% CI 1.70–2.66). Having attitudes favouring antibiotic use for minor ailments was also independently associated with higher likelihood of self-medication. Higher perceived appropriateness of antibiotic use in different situations and non-awareness about antibiotic resistance and adverse effects of antibiotics were no longer associated with the use of self-medication in the multilevel analysis.
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Among the four enabling factors, three were significant determinants of self-medication (Table 5). Country wealth (higher GDP per capita) was related to a lower likelihood of self-medication. Dispensing the exact number of antibiotic tablets was associated with a decreased risk of self-medication (OR 0.51, 95% CI 0.27–0.98). Respondents who perceived antibiotics as easily or sometimes available directly from pharmacies had a higher risk of self-medication, whereas those who answered ‘do not know’ had a lower risk when compared with respondents perceiving that antibiotics are not available (Table 5). Reimbursement of prescribed antibiotics was not independently associated with the use of self-medication in the multilevel regression analysis. No statistical interaction was found between the determinants of self-medication in the multilevel logistic regression analysis.
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Discussion |
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To the best of our knowledge, the present study is the first study that includes an analysis of predisposing and enabling factors to evaluate the determinants of self-medication with antibiotics in Europe. High perceived appropriateness of self-medication with antibiotics and attitudes favouring antibiotic use for minor ailments, i.e. sore throat and common cold, were predisposing factors for use of self-medication. The perceived availability of antibiotics from pharmacies without a prescription was the main enabling factor at the individual level. Other enabling factors included country characteristics, i.e. country wealth (GDP per capita) and dispensing regulations for prescribed antibiotics in pharmacies. Country wealth and dispensing exact number of prescribed tablets in pharmacies were independently associated with lower self-medication. Dispensing antibiotics per package size can produce leftovers, which, in a previous study, have been shown to substantially contribute to self-medication, with 36% of those who self-medicated using leftovers.25
In general, determinants of self-medication must be sought primarily at the individual level and much less as a characteristic of a country, although the latter may be relevant as well. In the present study, we were able to explain almost all variance at the country level with the included determinants. However, the 60% residual variance at the individual level indicates that much remains to be explained. It is not clear why the wealth of a nation is an important determinant of self-medication with antibiotics. One might hypothesize that wealth could indicate a more structured healthcare system, with adequate accessibility to healthcare. Perceived appropriateness of antibiotic use in different situations, awareness about antibiotic resistance and adverse effects, and reimbursement of prescribed antibiotics were associated with self-medication in the univariate analyses, but became non-significant in the multilevel analysis. This might be because of the correlations between these factors and the determinants of self-medication that remained significant in the multilevel model. In particular, awareness about antibiotic resistance was correlated with attitudes towards antibiotic use for minor ailments, and awareness about adverse effects was correlated with the attitude towards self-medication with antibiotics. Perceived appropriateness of antibiotic use in different situations was correlated with both the determinants. Reimbursement of prescribed antibiotics was correlated with the perceived availability of antibiotics directly from pharmacies.
We did not find significant associations between age, education and presence of chronic diseases and use of self-medication as in our previous study.1 However, the sample size in our previous study was larger. In this study, statistical power was not sufficient to detect smaller effects of age and education. There was a trend towards statistical significance for the presence of chronic diseases.
Our findings are consistent with the results of other studies, indicating that availability of antibiotics without prescription and misconceptions about the efficacy of antibiotics influence self-medication with antibiotics.3,14–16 Studies in low-income countries showed that the cost of medical consultation and low satisfaction with medical practitioners were also related to self-medication with antibiotics.15 In our study, the factor measuring perceived appropriateness of self-medication with antibiotics consisted to a large extent of items indicating practical barriers for consulting a doctor, such as time constraints and expense, as appropriate reasons for self-medication. Despite the fact that we do not know to what extent such difficulties in accessing healthcare actually exist in the countries included in this study, this attitude was clearly relevant as a determinant of self-medication. Further research in actual accessibility may clarify the issue further. Satisfaction with medical practitioners may also influence use of self-medication. The effect of satisfaction with medical practitioners on the appropriate use of antibiotics for mild respiratory tract infections was investigated in another European study.26 Low patient satisfaction was correlated with less compliant behaviour, whereas involving the patient more fully in the management of their illness was related to a lower probability of antibiotic misuse. Another area where additional studies are required is the relevance of reinforcing factors for use of self-medication, which were not included in this study. Attitudes and behaviour of health personnel may reinforce use of self-medication with antibiotics. In our earlier study,25 we found that previous prescribed use of antibiotics for upper respiratory tract infections (URTIs) increased the likelihood of self-medication with leftover antibiotics from previous courses for these symptoms/diseases. This factor was not included in the current study, because we had no information about prescribed use prior to self-medication.
Additional information on individual-level factors, such as doctor–patient relationships, patient satisfaction and perceived accessibility of healthcare, will increase our understanding of determinants of self-medication with antibiotics in Europe. Our study focused on determinants of self-medication for adults. Future studies may investigate self-medication in children as they experience more URTIs than adults.
A limitation of our study is its reliance on self-reported data about self-medication with antibiotics. In our earlier study, the outcome variable only focused on self-medication over the previous 12 month period. In the current study, it refers to any previous use of self-medication with antibiotics, because we did not want to misclassify users of self-medication. However, in some cases, the use of self-medication may have occurred a long time ago. Another limitation is that our population sample may not be representative of the general population in the studied countries. Nevertheless, our findings have implications for understanding the relative importance of various determinants for use of self-medication, the need for additional information and the interventions needed to prevent self-medication with antibiotics.
Our results suggest that interventions aimed at reducing and preventing self-medication with antibiotics in Europe should focus on both predisposing and enabling factors. Public education aimed at predisposing factors should emphasize the potential risks of using self-medication and the inappropriateness of antibiotic therapy for URTIs. Education will be effective only when coupled with strategies aimed at modifying enabling factors. One of the potentially modifiable enabling factors facilitating self-medication is the absence of enforcement of the laws regulating the sale of antibiotics. Over-the-counter sale of antibiotics was illegal in all participating countries during the study period, and enforcing the law could reduce self-medication to some extent. However, given the increasing opportunities of purchasing antibiotics via the Internet and the widening options of obtaining antibiotics from pharmacies, it may be hard to limit direct access of patients to antibiotics.27 A large number of sources supply medicines by mail order. Control of these suppliers would be difficult as most of them operate from countries with less restrictive regulations.27 Also, there are government policies for providing alternative access to treatment—including nurse and pharmacist prescribing—and encouraging self-care for minor illnesses.27 Specific regulations are then required to prevent patients from receiving antibiotics without the appropriate counselling and advice.
Dispensing regulation is another enabling factor. To reduce self-medication with leftovers, prescribed antibiotics should not be dispensed according to the package size. Dispensing exact numbers of antibiotic tablets in pharmacies as implemented in the UK, the Netherlands, the Czech Republic and Israel, as well as in the USA, could be promoted in other countries. Our study shows that predisposing and enabling factors are relevant for self-medication, which can be viewed as practical targets for designing interventions aimed at combating self-medication in Europe. In future, qualitative studies may contribute information for better understanding of underlying human and societal constraints.
In conclusion, our study identified several determinants of self-medication with antibiotics, both at the individual level and at the country level. Interventions aimed at preventing self-medication with antibiotics should be directed primarily at diminishing the availability of antibiotics without professional advice and counselling, at facilitating the dispensation of the exact numbers of antibiotic tablets, and at educating the general public to reduce misconceptions about the use of antibiotics for minor ailments.
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This project was supported by a grant from Directorate-General Health and Consumer Protection (SANCO) of the European Commission (SPC2002333).
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None to declare.
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Footnotes |
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Present address. Scientific Advice Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden. 
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Acknowledgements |
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The SAR Consortium: Antonella Di Matteo (Consorzio Mario Negri Sud, Santa Maria Imbaro, Chieti, Italy); Arjana Tambic-Andrasevic (University Hospital for Infectious Diseases, Zagreb, Croatia); Retnosari Andrajati (Faculty of Pharmacy, Charles University, Prague, the Czech Republic); Hana Edelstein (Ha'Emek Medical Center, Afula, Israel); Rolanda Valinteliene (Institute of Hygiene, Vilnius, Lithuania); Reli Mechtler (University of Linz, Linz, Austria); Luc Deliens (Vrije Universiteit Brussel, Brussels, Belgium); and Greta Van der Kelen (Vrije Universiteit Brussel, Brussels, Belgium).
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1 Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JGM, et al. Self-medication with antimicrobial drugs in Europe. Emerg Infect Dis (2006) 12:452–9.[Web of Science][Medline]
2 Mitsi G, Jelastopulu E, Basiaris H, et al. Patterns of antibiotic use among adults and parents in the community: a questionnaire-based survey in a Greek urban population. Int J Antimicrob Agents (2005) 25:439–43.[CrossRef][Web of Science][Medline]
3 Mainous AG III, Cheng AY, Garr RC, et al. Nonprescribed antimicrobial drugs in Latino community, South Carolina. Emerg Infect Dis (2005) 11:883–8.[Web of Science][Medline]
4 Richman PB, Garra G, Eskin B, et al. Oral antibiotic use without consulting a physician: a survey of ED patients. Am J Emerg Med (2001) 19:57–60.[CrossRef][Web of Science][Medline]
5 McKee MD, Mills L, Mainous AG III. Antibiotic use for the treatment of upper respiratory infections in a diverse community. J Fam Pract (1999) 48:993–6.[Web of Science][Medline]
6 Vanden Eng J, Marcus R, Hadler JL, et al. Consumer attitudes and use of antibiotics. Emerg Infect Dis (2003) 9:1128–35.[Web of Science][Medline]
7
Guillemot D, Carbon C, Balkau B, et al. Low dosage and long treatment duration of β-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA (1998) 279:365–70.
8
Mayor S. Antibiotic resistance is highest in south and east Europe. BMJ (2005) 330:383.
9 Oxman AD, Thomson MA, Davis DA, et al. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ (1995) 153:1423–31.[Abstract]
10 Mullen PD, Hersey JC, Iverson DC. Health behavior models compared. Soc Sci Med (1987) 24:973–81.[CrossRef][Web of Science][Medline]
11 Green LW, Kreuter MW. Health Promotion Planning: An Educational and Environmental Approach (1991) 2nd edn. Mountain View, CA: Mayfield Publishing Co.
12 Gans KM, Jack B, Lasater TM, et al. Changing physicians' attitudes, knowledge, and self-efficacy regarding cholesterol screening and management. Am J Prev Med (1993) 9:101–6.[Web of Science][Medline]
13 Murray DM, Kurth CL, Finnegan JR, et al. Direct mail as a prompt for follow-up care among persons at risk for hypertension. Am J Prev Med (1988) 4:331–5.[Web of Science][Medline]
14 Lansang MA, Lucas-Aquino R, Tupasi TE, et al. Purchase of antibiotics without prescription in Manila, the Philippines. Inappropriate choices and doses. J Clin Epidemiol (1990) 43:61–7.[CrossRef][Web of Science][Medline]
15 Saradamma RD, Higginbotham N, Nichter M. Social factors influencing the acquisition of antibiotics without prescription in Kerala State, south India. Soc Sci Med (2000) 50:891–903.[CrossRef][Web of Science][Medline]
16 Radyowijati A, Haak H. Improving antibiotic use in low-income countries: an overview of evidence on determinants. Soc Sci Med (2003) 57:733–44.[CrossRef][Web of Science][Medline]
17 Corbett KK, Gonzales R, Leeman-Castillo BA, et al. Appropriate antibiotic use: variation in knowledge and awareness by Hispanic ethnicity and language. Prev Med (2005) 40:162–9.[CrossRef][Web of Science][Medline]
18 Pechere JC. Patients' interviews and misuse of antibiotics. Clin Infect Dis (2001) 33(Suppl_3):S170–3.[CrossRef][Web of Science][Medline]
19 Deschepper R, Vander Stichele RH, Haaijer-Ruskamp FM. Cross-cultural differences in lay attitudes and utilisation of antibiotics in a Belgian and a Dutch city. Patient Educ Couns (2002) 48:161–9.[CrossRef][Web of Science][Medline]
20 Belongia EA, Naimi TS, Gale CM, et al. Antibiotic use and upper respiratory infections: a survey of knowledge, attitudes, and experience in Wisconsin and Minnesota. Prev Med (2002) 34:346–52.[CrossRef][Web of Science][Medline]
21 Collett CA, Pappas DE, Evans BA, et al. Parental knowledge about common respiratory infections and antibiotic therapy in children. South Med J (1999) 92:971–6.[Web of Science][Medline]
22 Jenkinson C. Why are we weighting? A critical examination of the use of item weights in a health status measure. Soc Sci Med (1991) 32:1413–6.[CrossRef][Web of Science][Medline]
23 GDP per Capita, Core Health Indicators, World Health Organization. http://www.who.int/countries/srb/en/index.html (7 August 2007, date last accessed).
24 Snijders T, Bosker R. An Introduction to Basic and Advanced Multilevel Modelling (1999) London: Sage Publications.
25
Grigoryan L, Burgerhof JG, Haaijer-Ruskamp FM, et al. Is self-medication with antibiotics in Europe driven by prescribed use? J Antimicrob Chemother (2007) 59:152–6.
26 Pechere JC, Cenedese C, Muller O, et al. Attitudinal classification of patients receiving antibiotic treatment for mild respiratory tract infections. Int J Antimicrob Agents (2002) 20:399–406.[CrossRef][Web of Science][Medline]
27
Reeves DS. The 2005 Garrod Lecture: the changing access of patients to antibiotics—for better or worse? J Antimicrob Chemother (2007) 59:333–41.
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