Treatment seeking and antibiotic use for urinary tract infection symptoms in the time of COVID-19 in Tanzania and Uganda

Funding: CARE: COVID-19 and Antimicrobial Resistance in East Africa – impact and response is a Global Effort on COVID-19 (GECO) Health Research Award (MR/V036157/1) funded by UK Research and Innovation (Medical Research Council) and the Department of Health and Social Care (National Institute for Health Research).Background There is still little empirical evidence on how the outbreak of coronavirus disease 2019 (COVID-19) and associated regulations may have disrupted care-seeking for non-COVID-19 conditions or affected antibiotic behaviours in low- and middle-income countries (LMICs). We aimed to investigate the differences in treatment-seeking behaviours and antibiotic use for urinary tract infection (UTI)-like symptoms before and during the pandemic at recruitment sites in two East African countries with different COVID-19 control policies: Mbarara, Uganda and Mwanza, Tanzania. Methods In this repeated cross-sectional study, we used data from outpatients (pregnant adolescents aged >14 and adults aged >18) with UTI-like symptoms who visited health facilities in Mwanza, Tanzania and Mbarara, Uganda. We assessed the prevalence of self-reported behaviours (delays in care-seeking, providers visited, antibiotics taken) at three different time points, labelled as ‘pre-COVID-19 phase’ (February 2019 to February 2020), ‘COVID-19 phase 1’ (March 2020 to April 2020), and ‘COVID-19 phase 2’ (July 2021 to February 2022). Results In both study sites, delays in care-seeking were less common during the pandemic than they were in the pre-COVID phase. Patients in Mwanza, Tanzania had shorter care-seeking pathways during the pandemic compared to before it, but this difference was not observed in Mbarara, Uganda. Health centres were the dominant sources of antibiotics in both settings. Over time, reported antibiotic use for UTI-like symptoms became more common in both settings. During the COVID-19 phases, there was a significant increase in self-reported use of antibiotics like metronidazole (<30% in the pre-COVID-19 phase to 40% in COVID phase 2) and doxycycline (30% in the pre-COVID-19 phase to 55% in COVID phase 2) that were not recommended for treating UTI-like symptoms in the National Treatment Guidelines in Mbarara, Uganda. Conclusions There was no clear evidence that patients with UTI-like symptoms attending health care facilities had longer or more complex treatment pathways despite strict government-led interventions related to COVID-19. However, antibiotic use increased over time, including some antibiotics not recommended for treating UTI, which has implications for future antimicrobial resistance.Publisher PDFPeer reviewe

Treatment seeking behaviours, antibiotic use and relationships to multi-drug resistance : a study of urinary tract infection patients in Kenya, Tanzania and Uganda

Antibacterial resistance (ABR) is a major public health threat. An important accelerating factor is treatment-seeking behaviour, including inappropriate antibiotic (AB) use. In many low- and middle-income countries (LMICs) this includes taking ABs with and without prescription sourced from various providers, including health facilities and community drug sellers. However, investigations of complex treatment-seeking, AB use and drug resistance in LMICs are scarce. The Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA) Consortium collected questionnaire and microbiological data from adult outpatients with urinary tract infection (UTI)-like symptoms presenting at healthcare facilities in Kenya, Tanzania and Uganda. Using data from 6,388 patients, we analysed patterns of self-reported treatment seeking behaviours (‘patient pathways’) using process mining and single-channel sequence analysis. Among those with microbiologically confirmed UTI (n = 1,946), we used logistic regression to assess the relationship between treatment seeking behaviour, AB use, and the likelihood of having a multi-drug resistant (MDR) UTI. The most common treatment pathway for UTI-like symptoms in this sample involved attending health facilities, rather than other providers like drug sellers. Patients from sites in Tanzania and Uganda, where over 50% of patients had an MDR UTI, were more likely to report treatment failures, and have repeat visits to providers than those from Kenyan sites, where MDR UTI proportions were lower (33%). There was no strong or consistent relationship between individual AB use and likelihood of MDR UTI, after accounting for country context. The results highlight the hurdles East African patients face in accessing effective UTI care. These challenges are exacerbated by high rates of MDR UTI, suggesting a vicious cycle of failed treatment attempts and sustained selection for drug resistance. Whilst individual AB use may contribute to the risk of MDR UTI, our data show that factors related to context are stronger drivers of variations in ABR.Peer reviewe

Mapping Developmental Precursors of Cyber-Aggression: Trajectories of Risk Predict Perpetration and Victimization

Technologically mediated contexts are social arenas in which adolescents can be both perpetrators and victims of aggression. Yet, there remains little understanding of the developmental etiology of cyber aggression, itself, as experienced by either perpetrators or victims. The current study examines 3-year latent within-person trajectories of known correlates of cyber-aggression: problem behavior, (low) self-esteem, and depressed mood, in a large and diverse sample of youth (N = 1,364; 54.6 % female; 12–14 years old at T1). Findings demonstrate that developmental increases in problem behavior across grades 8–10 predict both cyber-perpetration and victimization in grade 11. Developmental decreases in self-esteem also predicted both grade 11 perpetration and victimization. Finally, early depressed mood predicted both perpetration and victimization later on, regardless of developmental change in depressed mood in the interim. Our results reveal a clear link between risky developmental trajectories across the early high school years and later cyber-aggression and imply that mitigating trajectories of risk early on may lead to decreases in cyber-aggression at a later date

Treatment seeking and antibiotic use for urinary tract infection symptoms in the time of COVID-19 in Tanzania and Uganda

Background There is still little empirical evidence on how the outbreak of coronavirus disease 2019 (COVID-19) and associated regulations may have disrupted care-seeking for non-COVID-19 conditions or affected antibiotic behaviours in low- and middle-income countries (LMICs). We aimed to investigate the differences in treatment-seeking behaviours and antibiotic use for urinary tract infection (UTI)-like symptoms before and during the pandemic at recruitment sites in two East African countries with different COVID-19 control policies: Mbarara, Uganda and Mwanza, Tanzania. Methods In this repeated cross-sectional study, we used data from outpatients (pregnant adolescents aged &gt;14 and adults aged &gt;18) with UTI-like symptoms who visited health facilities in Mwanza, Tanzania and Mbarara, Uganda. We assessed the prevalence of self-reported behaviours (delays in care-seeking, providers visited, antibiotics taken) at three different time points, labelled as ‘pre-COVID-19 phase’ (February 2019 to February 2020), ‘COVID-19 phase 1’ (March 2020 to April 2020), and ‘COVID-19 phase 2’ (July 2021 to February 2022).Results In both study sites, delays in care-seeking were less common during the pandemic than they were in the pre-COVID phase. Patients in Mwanza, Tanzania had shorter care-seeking pathways during the pandemic compared to before it, but this difference was not observed in Mbarara, Uganda. Health centres were the dominant sources of antibiotics in both settings. Over time, reported antibiotic use for UTI-like symptoms became more common in both settings. During the COVID-19 phases, there was a significant increase in self-reported use of antibiotics like metronidazole (&lt;30% in the pre-COVID-19 phase to 40% in COVID phase 2) and doxycycline (30% in the pre-COVID-19 phase to 55% in COVID phase 2) that were not recommended for treating UTI-like symptoms in the National Treatment Guidelines in Mbarara, Uganda. Conclusions There was no clear evidence that patients with UTI-like symptoms attending health care facilities had longer or more complex treatment pathways despite strict government-led interventions related to COVID-19. However, antibiotic use increased over time, including some antibiotics not recommended for treating UTI, which has implications for future antimicrobial resistance

Evidencing the intersection of environmental, socioeconomic, behavioural and demographic drivers of antibacterial resistance in East Africa

Background: Risk factors for antibiotic-resistant infections are multi-scalar and interdependent, but few studies investigate them in an integrated way. We investigated how location, the environment, socioeconomics, behaviours, attitudes, and demographics are jointly associated with multi-drug resistant urinary tract infection (MDR UTI). Methods: Between 2018-2020, the Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium recruited outpatients with UTI symptoms in healthcare facilities in Kenya, Tanzania, and Uganda. We collected urine samples and questionnaires from patients and households. Our primary outcome was MDR UTI, defined as resistance to 3 or more categories of antibiotics. We used linked individual-level data on 67 variables capturing geographic, environmental, socioeconomic, demographic, attitudinal, and behavioural characteristics. We employed bivariate analyses and Bayesian profile regression to investigate the joint association of risk factors with MDR UTI. Findings: Out of 2332 patients with microbiologically-confirmed UTI, we analysed 1610 with linked microbiological, social, and environmental data. Most were female (1369 [85·0%]), younger than 45 years (1206 [74·9%]), and nearly half had MDR UTI (766 [47.6%]). Profile regression generated 10 high-risk and 7 low-risk MDR UTI clusters. High-risk MDR clusters contained patients that were on average older, with lower education, more chronic illness, and lived in resource-deprived households. They were also more likely to have contact with animals, and human/animal waste. Interpretation: Risk factors for antibiotic resistance are interrelated through multidimensional poverty. We need studies which explore how these factors interact longitudinally to shape inequalities, and to design appropriate interventions

Evidencing the intersection of environmental, socioeconomic, behavioural and demographic drivers of antibacterial resistance in East Africa

Background: Risk factors for antibiotic-resistant infections are multi-scalar and interdependent, but few studies investigate them in an integrated way. We investigated how location, the environment, socioeconomics, behaviours, attitudes, and demographics are jointly associated with multi-drug resistant urinary tract infection (MDR UTI). Methods: Between 2018-2020, the Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium recruited outpatients with UTI symptoms in healthcare facilities in Kenya, Tanzania, and Uganda. We collected urine samples and questionnaires from patients and households. Our primary outcome was MDR UTI, defined as resistance to 3 or more categories of antibiotics. We used linked individual-level data on 67 variables capturing geographic, environmental, socioeconomic, demographic, attitudinal, and behavioural characteristics. We employed bivariate analyses and Bayesian profile regression to investigate the joint association of risk factors with MDR UTI. Findings: Out of 2332 patients with microbiologically-confirmed UTI, we analysed 1610 with linked microbiological, social, and environmental data. Most were female (1369 [85·0%]), younger than 45 years (1206 [74·9%]), and nearly half had MDR UTI (766 [47.6%]). Profile regression generated 10 high-risk and 7 low-risk MDR UTI clusters. High-risk MDR clusters contained patients that were on average older, with lower education, more chronic illness, and lived in resource-deprived households. They were also more likely to have contact with animals, and human/animal waste. Interpretation: Risk factors for antibiotic resistance are interrelated through multidimensional poverty. We need studies which explore how these factors interact longitudinally to shape inequalities, and to design appropriate interventions

Treatment seeking behaviours, antibiotic use and relationships to multi-drug resistance: A study of urinary tract infection patients in Kenya, Tanzania and Uganda.

Antibacterial resistance (ABR) is a major public health threat. An important accelerating factor is treatment-seeking behaviour, including inappropriate antibiotic (AB) use. In many low- and middle-income countries (LMICs) this includes taking ABs with and without prescription sourced from various providers, including health facilities and community drug sellers. However, investigations of complex treatment-seeking, AB use and drug resistance in LMICs are scarce. The Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA) Consortium collected questionnaire and microbiological data from adult outpatients with urinary tract infection (UTI)-like symptoms presenting at healthcare facilities in Kenya, Tanzania and Uganda. Using data from 6,388 patients, we analysed patterns of self-reported treatment seeking behaviours ('patient pathways') using process mining and single-channel sequence analysis. Among those with microbiologically confirmed UTI (n = 1,946), we used logistic regression to assess the relationship between treatment seeking behaviour, AB use, and the likelihood of having a multi-drug resistant (MDR) UTI. The most common treatment pathway for UTI-like symptoms in this sample involved attending health facilities, rather than other providers like drug sellers. Patients from sites in Tanzania and Uganda, where over 50% of patients had an MDR UTI, were more likely to report treatment failures, and have repeat visits to providers than those from Kenyan sites, where MDR UTI proportions were lower (33%). There was no strong or consistent relationship between individual AB use and likelihood of MDR UTI, after accounting for country context. The results highlight the hurdles East African patients face in accessing effective UTI care. These challenges are exacerbated by high rates of MDR UTI, suggesting a vicious cycle of failed treatment attempts and sustained selection for drug resistance. Whilst individual AB use may contribute to the risk of MDR UTI, our data show that factors related to context are stronger drivers of variations in ABR

The role of multidimensional poverty in antibiotic misuse:a study of self-medication and non-adherence in Kenya, Tanzania, and Uganda

Background: Poverty is a proposed driver of antimicrobial resistance (AMR), influencing inappropriate antibiotic (AB) use in low and middle-income countries (LMICs). However, at sub-national levels, studies investigating poverty and AB use are sparse and the results inconsistent.Methods: The Holistic Approach to Unravelling Antimicrobial Resistance (HATUA) Consortium collected data from 6,827 patients presenting with urinary tract infection (UTI) symptoms in Kenya, Uganda, and Tanzania. Using Bayesian hierarchical modelling, we investigated the association between multidimensional poverty and self-reported AB self-medication and treatment non-adherence (skipping a dose and not completing the course). We also analysed linked qualitative in-depth patient interviews (IDIs) (n = 82) and unlinked focus group discussions (FGDs) with community members (n = 44 groups).Findings: AB self-medication and non-adherence to treatment courses was significantly more common in the least deprived group compared with those in severe poverty. Adjustment for AB ‘knowledge’, attitudes and socio-demographics diminished the association with self-medication, but not non-adherence. IDIs and FGDs suggested that self-medication and non-adherence are driven by perceived inconvenience of the healthcare system, financial barriers, and ease of unregulated AB access.Interpretation: Structural barriers to optimal AB use exist at all levels of the socioeconomic hierarchy. Inefficiencies in public healthcare may be fuelling alternative antibiotic access points, for those who can afford it. In designing interventions to tackle AMR and reduce AB misuse, the behaviours and needs of wealthier population groups should not be neglected.Funding Information: UK National Institute for Health Research, Medical Research Council and the Department of Health and Social Care

Treatment seeking behaviours, antibiotic use and relationships to multi-drug resistance:a study of urinary tract infection patients in Kenya, Tanzania and Uganda

Antibacterial resistance (ABR) is a major public health threat. An important accelerating factor is treatment-seeking behaviour, including inappropriate antibiotic (AB) use. In many low- and middle-income countries (LMICs) this includes taking ABs with and without prescription sourced from various providers, including health facilities and community drug sellers. However, investigations of complex treatment-seeking, AB use and drug resistance in LMICs are scarce. The Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA) Consortium collected questionnaire and microbiological data from adult outpatients with urinary tract infection (UTI)-like symptoms presenting at healthcare facilities in Kenya, Tanzania and Uganda. Using data from 6,388 patients, we analysed patterns of self-reported treatment seeking behaviours (‘patient pathways’) using process mining and single-channel sequence analysis. Among those with microbiologically confirmed UTI (n = 1,946), we used logistic regression to assess the relationship between treatment seeking behaviour, AB use, and the likelihood of having a multi-drug resistant (MDR) UTI. The most common treatment pathway for UTI-like symptoms in this sample involved attending health facilities, rather than other providers like drug sellers. Patients from sites in Tanzania and Uganda, where over 50% of patients had an MDR UTI, were more likely to report treatment failures, and have repeat visits to providers than those from Kenyan sites, where MDR UTI proportions were lower (33%). There was no strong or consistent relationship between individual AB use and likelihood of MDR UTI, after accounting for country context. The results highlight the hurdles East African patients face in accessing effective UTI care. These challenges are exacerbated by high rates of MDR UTI, suggesting a vicious cycle of failed treatment attempts and sustained selection for drug resistance. Whilst individual AB use may contribute to the risk of MDR UTI, our data show that factors related to context are stronger drivers of variations in ABR