The main findings of this detailed cross-sectional survey of community antibiotic use practices in Blantyre Malawi were that current antibiotic use was (67/1051, 6.4%) and recent use (last 6 months) was (440/1051, 41.9%). Both current and recent antibiotic use were limited to a small number of antibiotic formualtions, with amoxicillin and cotrimoxazole being the most frequently recognised and used. Both antibiotics are classified as “access” on the WHO’s Access, Watch, Reserve (AWaRe) list, meaning they are commonly used to treat infections and should be clinically available at all times ²³. In contexts such as Malawi, cotrimoxazole is commonly used for chemoprophylaxis for people living with HIV, and with HIV prevalence in the study populations being high, it is not surprising that this was one of the most commonly used and recognised antibiotic. In contrast, the number of antibiotics recognised was significantly lower among people less likely to access formal health services (such as people with unknown HIV status, a strong indicator of delayed healthcare seeking and poor access where testing is widely available), and men, who frequently do not participate in care-seeking activities for families.

Taken together, these findings suggest that, contrary to popular narratives, use of a wide range of antibiotics and antibiotics on the watch or reserve lists was not widespread in these urban and periurban African settings; rather access to a wide range of antibiotics is likely to be limited for the majority of the population, and potentially not a major contributor to so-called “antibiotic overuse”. Nevertheless, antibiotics such as cotrimoxazole, amoxicillin, and erythromycin have broad spectrum action, and dependence on these antibiotics for community management of illness is associated with generation of resistance. Therefore, ABU and AMR guidance must recognise the healthcare and sociological context within which recommendations are made; improvements in universal healthcare access (including treatment of infection) should be accompanied by high quality surveillance and antibiotic use data, supported by interrogation of social narratives around the determinants of antibiotic use.

In Malawi and similar settings in Southern and Eastern African countries, primary health care facilities are an important source of community care, with services provided free, ²⁴ but delivered under severe resource constraints with high rates of stockouts of many essential medicines.^25,26 International donor programmes play a significant role in funding services, and infectious diseases have received comparably more resources.²⁷ The provision of cotrimoxazole by the HIV programme at primary care clinics may explain why it is well recognised and used within households.²⁵ A multi-site study exploring household antibiotic use in Zimbabwe, Malawi and Uganda identified differences in the profile of ABU, with cotrimoxazole being the most frequently used in rural Malawi, amoxicillin in Harare, Zimbabwe, and metronidazole within informal settlements in Uganda.²⁸ Most differences in use reflected differences in the configuration of the health system and antibiotic supplies.

In Malawi, gender power relations shape household care seeking practices, with men often presenting at health care facilities critically ill, and having delayed diagnosis of diseases of major public health importance, particularly HIV and tuberculosis.²⁹ Women spend considerably more time than men seeking care and supporting household members to seek care.³⁰ These factors are likely to explain why women had better recognition and use of antibiotics. While government health care facilities provide care without user fees, care seeking incurs costs for transportation and loss of time from other livelihood activities.³¹ Improving access and removing economic barriers to care seeking, are likely to be important interventions to improve the community management of febrile illness, both to improve recognition of severe illness requiring antibiotics with referral to hospital where required, and to restrict unnecessary ABU.

Global public engagement campaigns to improve awareness of antimicrobial resistance have focused predominantly on communicating the need to stop people from indiscriminately using antibiotics with insufficient attention paid to the issues of access.³² Our findings demonstrate frequent use of a very limited number of antibiotic formulations in the preceding six months, however in a context where febrile illness is common and presentation to health care facilities is late, and diagnostics are few, this may represent appropriate prescribing. Indeed, this may instead speak to the need to improve access to and quality of health care services, not limit access, particularly for the most economically disadvantaged groups.

The limitations of this study include the potential for social desirability bias, whereby household respondents may state that they recognised or used antibiotics to meet interviewer’s expectations. We mitigated against this by using our innovative and previously validated “drug bag” methodology and experienced field interviewers. The drug bag uses a wide range of antibiotics available in the community; however it is possible that we did not include some important formulations, or that packaging designs have changed, limiting recognition. The concept of an “antibiotic” is not well understood in Malawi and has no specific Chichewa word, potentially hindering accurate recall of use and recognition. We randomly sampled households from a community sampling frame to minimise sampling bias; nevertheless, women were over-represented, perhaps because men may not have been available for interview, or at work. We may therefore have underestimated antibiotic use and recognition.

In conclusion, we found patterns of current and recent antibiotic use and recognition among randomly-sampled household members in Blantyre, Malawi to be limited to a small number of broads-spectrum antibiotic formulations. People known to have poorer access to healthcare reported recognising fewer antibiotics. So-called “antibiotic overuse” – specifically of antibiotics on the watch list – is unlikely to be a major driver of antimicrobial resistance and drug resistance infections in this and similar settings. Rapidly reducing generation of antibiotic resistance and drug resistant infection in low-income settings in Africa will require a shift of focus, away from narratives that blame people in precarious living conditions for “antibiotic overuse” and instead towards holistic approaches that address the underlying systemic drivers of AMR, whilst recognising and supporting antibiotic access within well-functioning health systems.