‘You never know when you will need an antibiotic’: A qualitative study of structural barriers and cultural assumptions in antibiotic misuse among immigrants in the United States

Abstract

Objectives

The use of nonprescribed antibiotics increases the risk of antibiotic resistance, which is a primary public health concern of the 21st century. This study explores structural and cultural determinants of antibiotic misuse among immigrants living in the United States who arrived from home countries with easier access to antibiotics.

Methods

Adopting a qualitative approach, we interviewed 34 immigrants living in the United States and who had traveled back to their home countries within 1 year of the interview. We followed the steps of constructive grounded theory to analyze the data.

Results

We found two primary influences of immigrants’ use of nonprescribed antibiotics. The first was structural barriers to health care access in the host country, including insurance coverage, cost of an emergency department visit, cost of missing a paid day of work, complexity of the healthcare system, and communication issues with health care providers. The second was participants’ cultural assumptions, including their experiences of antibiotics use, beliefs about antibiotics, a habit of self-medication, and uncertainty about future medical needs.

Conclusions

This study informs policymakers concerned with combating antibiotic resistance. Promoting antibiotic stewardship among immigrants from countries with lax antibiotic-prescribing practices and improving access to appropriate channels for preventative and same-day care may reduce the inappropriate use of antibiotics.

Keywords

nonprescribed antibiotics antibiotic resistance immigrants qualitative research misuse of antibiotics

Introduction

Antibiotic misuse, overuse, and over-prescription have resulted in the spread of antibiotic resistance to the extent that it has become a primary public health concern of the 21st century.¹ Although the Centers for Disease Control and Prevention have implemented stewardship programs to curb antibiotic misuse in the United States (US), 2.8 million antimicrobial-resistant infections occur each year, resulting in more than 35,000 deaths.² Antibiotic misuse refers to the intake of antibiotics without medical advice or prescription, or the inappropriate use of antibiotics when prescribed (in terms of timing, dosage, and duration.^3,4 While the scholarly literature has defined immigrants in various ways, we define an immigrant to be an individual who moves out of their home country to settle in a host country for an extended period or permanently.⁵

This paper reports the results of our qualitative study exploring the determinants of antibiotic misuse among the immigrant population in the US. The motivation for this study is to address two gaps in public health policy scholarship and the literature on the misuse of antibiotics. First, very few studies have examined immigrants’ experiences of use or misuse of antibiotics (exceptions are a scoping review,^6,7 and a study of Hispanic immigrants in the US).⁸ From the literature, we know that international travelers may use nonprescribed antibiotics because of policies and regulations that control the dispensing of antibiotics in their host countries.⁹ However, the reasons why immigrants misuse antibiotics remain underexplored. To address this gap, we focused on immigrants from countries with weaker regulations for antibiotic dispensing (compared with regulations in the US). This focus enabled us to extend our understanding of people’s decisions to take nonprescribed antibiotics. Second, much of the existing literature examines the perspective of health care providers who are seen as contributing to the spread of antibiotic resistance.^10–12 Our study, by contrast, seeks to unpack the reasons behind the misuse of antibiotics from a community standpoint. We adopted a qualitative design to access to the lived experiences of immigrants, revealing their vulnerabilities regarding access to health care. As recommended by Kilbourne’s (2006) health disparity framework,¹³ which was originally developed to explain differences in health and health care, we focused on understanding the systematic challenges facing immigrants. Our hope is that this work will inform interventions to reduce the current inequalities felt by immigrant communities.

Our qualitative study aims to answer two research questions: ‘What are immigrants’ experiences of antibiotic use in the US?’ and ‘Why do immigrants decide to bring or use nonprescribed antibiotics?’ By answering these questions we seek, firstly, to encourage researchers to account for contextual nuances when examining the use of nonprescribed antibiotics (e.g. identifying structural barriers and cultural assumptions that influence immigrants’ decisions about using antibiotics) and, secondly, to draw attention to vulnerability and uncertainty that drives the immigrants’ decisions to bring nonprescribed antibiotics from their home to the host country.

Methods

We adopted an interpretive qualitative approach¹⁴ informed by social constructivism, which assumes that different individuals build multiple realities as a result of their interactions with the same experience.¹⁵ In contrast to hypothesis-driven research, this approach aims to provide a nuanced understanding of nonprescribed antibiotic use among immigrants within their social context.¹⁶

Participants

Interview flyers were distributed through online channels, including Facebook and Telegram groups serving diverse communities including the Iranian community in Atlanta, San Antonio, Houston, Philadelphia. Interested participants responded to the first author, who screened details provided to confirm they fulfilled the inclusion criteria (detailed below). Those who met the requirements were subsequently invited by the first author to participate in the study. We employed purposive,¹⁷ criterion sampling¹⁶ for participant selection. Thirty-four adults over 18 years old participated in our study. We included participants who (1) immigrated to the US as refugees, asylum seekers, students, family members sponsorship, or workers, and (2) had traveled back to their home countries within 1 year prior to the interview. The criterion for recent travel to the home country facilitated recall and allowed interviewees to share recent experiences. English fluency was not a requirement and this allowed us to encompass participants from diverse backgrounds. Twenty-nine interviews were conducted in English, and five interviews were in other languages #2 (Spanish), #6 (Spanish), #8 (Spanish), #16 (Arabic), and #26 (Nepali), where we utilized an interpreter. We only interviewed people from countries where antibiotics are available for purchase without a doctor’s prescription and where the public generally has easy access to antibiotics. Table 1 presents interviewees’ demographic characteristics. Each participant received a $20 e-gift card.

Table 1.

Demographic characteristics of participants (n = 34).

Participant #	Gender	Age range	Home country	Highest educational achievement	Health insurance	Has used nonprescribed antibiotics	Has brought antibiotics into the US	Years of residency in the US	Occupation
1	M	50-60	Bangladesh	Diploma	Yes	Yes	Yes	10	Cook
2	F	60-70	Venezuela	High school	No	Yes	Yes	2	Nanny
3	F	50-60	Iran	Three years of college	No	No	Yes	3	Housekeeping services and part-time student
4	F	40-50	Nigeria	College degree	No	No	Yes	1	Medical field
5	F	30-40	Iran	PhD	Yes	Yes	Yes	10	Faculty at a university
6	M	30-40	Mexico	High school	No	Yes	Yes	4	Lawn mowing
7	M	40-50	Iran	PhD	Yes	No	No	12	Faculty at a community college
8	Not specified	20-30	Honduras	High school	No	Yes	Yes	5	Boat cleaner
9	F	20-30	Bangladesh	One year of college	Yes	Yes	No	6	Assistant cook in a hotel
10	F	40-50	Iran	PhD	Yes	Yes	Yes	15	Data analyst
11	F	60-70	Ghana	High school	Yes	No	No	2	Construction
12	F	50-60	China	College degree	Yes	No	No	4	Translator
13	F	50-60	Nepal	Three years of college	Yes	Yes	No	8	Home health care
14	F	40-50	Pakistan	High school	Yes	Yes	Yes	2	Not specified
15	F	30-40	China	College degree	Yes	Yes	Yes	6	Housewife
16	F	50-60	Saudi Arabia	High school	Yes	Yes	No	5	Housewife
17	M	30-40	Mexico	High school	Yes	Yes	Yes	9	Lawn mowing
18	M	40-50	Mexico	College degree	Yes	No	No	10	Teacher
19	F	40-50	India	College degree	Yes	Yes	Yes	7	Engineer
20	F	60-70	Mexico	High school	Yes	No	No	6	Cashier
21	F	20-30	Saudi Arabia	PhD	Yes	No	No	5	University faculty
22	M	60-70	Central America (country unspecified)	High school	Yes	Yes	No	8	Farming
23	F	50-60	Honduras	Three years of college	No	Yes	Yes	9	Not specified
24	F	30-40	Vietnam	College degree	Yes	No	No	10	Educator
25	M	50-60	Pakistan	College degree	Yes	Yes	Yes	15	Store manager
26	F	30-40	Nepal	High school	Yes	No	Yes	6	Cleaning services
27	F	30-40	India	College degree	Yes	No	No	6	Student
28	F	60-70	Nepal	High school	Yes	No	No	9	Waitress
29	F	60-70	Nepal	High school	No	Yes	Yes	10	Social worker
30	F	30-40	Iran	College degree	Yes	No	No	9	Engineer
31	F	50-60	Iran	High school	Yes	No	No	1	Not specified
32	F	30-40	Iran	College degree	Yes	No	No	4	Cashier
33	F	30-40	Malaysia	College degree	Yes	No	Yes	2	Data analyst
34	F	30-40	Iran	College degree	Yes	Yes	Yes	7	Finance manager

Data collection

We conducted semi-structured interviews using online platforms (Zoom or FaceTime). Interviews were video- and audio-recorded with the permission of the participants and were kept in a password-protected, non-public desktop computer at our university. The topic guide focused on (1) participants’ experiences of antibiotic use, including nonprescribed antibiotics in their home country and in the US; (2) experiences of bringing or using nonprescribed antibiotics to the US; and (3) the reasons for such actions and behaviors. We also asked participants’ opinions on nonprescribed antibiotic use. The interview questions are available in the online supplement.

In total, we interviewed 34 participants. We reached saturation—a point where we found no new information in the setting¹⁸ —after conducting 29 interviews. and interviewed five more people to ensure that no new categories emerged. We transcribed the interviews, which yielded 485 pages of data per 1650 min of recording.

Data analysis

To code the data we followed key steps outlined in constructive grounded theory.¹⁹ Each interview transcript was read and divided into units of meaning, and each unit was assigned an open code (using the exact words of the participants)^14,16 following Charmaz’s (2006)¹⁹ definition of open coding. For example, ‘Cost of emergency department visit’ was given to the following quote from a participant: ‘It is freaking expensive in here. One ER visit costs us above $6000; that is my entire freaking salary for a month.’ Similarly, ‘insurance coverage’ was given to this quote: ‘I have no insurance, meaning no doctor, meaning no sickness for me.’ From here, we developed subcategories and categories by grouping codes, and these were later used to construct our interpretations. Our analysis led to 854 initial open codes, which we later combined into 10 subcategories and two main categories. Axial coding was then used to examine the relationships and links between categories and subcategories¹⁹ and selective coding was used to re-examine the data to ensure we had captured all the links between codes. We then organized our subcategories and categories into themes that help explain the decisions to bring and use nonprescribed antibiotics from a home country into the US.

Trustworthiness

We used different strategies to ensure the trustworthiness of the analysis.¹⁶ One strategy was writing reflective journal memos to record our thoughts throughout the data collection and analysis. We shared the journals with team members. We also asked four participants to read our interpretations to check that these represented their experience of nonprescribed antibiotic use.

Results

The participants had an average of 6.7 years of residence in the US and had various professions, including university professor, engineer, data analyst, cashier, assistant cook, and nanny. Twenty-six of the participants were women. The average age of the interviewees was 42.2 years, ranging from 22 to 68 years. Four of the participants had a PhD degree as their highest educational qualification, 12 a college degree. The majority of participants (79%) were insured.

We organized our findings in Figure 1 under two themes. The first described the structural barriers to health care access in the host country, and the second described cultural assumptions in the home country that help explain participants’ accounts for misusing antibiotics. Below, we present each subcategory under the two main themes using representative quotations from our participants.

Structural barriers to health care access in the host country

Our participants referred to five structural barriers limiting their access to health care in the US. Several participants explicitly mentioned that they brought antibiotics from their home countries to the US to use if needed. Others indicated that they had recently brought antibiotics from their home to host country were uninsured or underinsured. Those with insurance mentioned that they brought antibiotics for their personal use because they wanted to avoid emergency department (ED.) visits with high and unpredictable costs. Participants with temporary jobs or precarious employment were concerned about the cost of missing days of paid work. In contrast, participants who had full-time jobs or secure work were confused by the complexity of the health care system. Almost all participants needed clarification about whether they could clearly communicate their health care needs with the health care providers, especially if the providers were not from a similar cultural or immigrant background.

Insurance coverage

Lack of insurance was given as the main reason for bringing antibiotics to the US among all uninsured and underinsured participants. Most of the participants with temporary and precarious employment, such as seasonal and part-time jobs, did not benefit from employer-based insurance, making health care relatively unaffordable. e.g., Participant #3, who was working a precarious job, said: ‘It is too expensive to go and see a doctor here. You know, if I can treat myself, why should I go and pay too much to see a nurse.’ Some had partial coverage through their employers (e.g. medical coverage without dental insurance) or self-funded their insurance with high deductibles and co-payments. As a result of such concerns, uninsured and underinsured participants tried to avoid using health care services as much as possible and potentially chose to self-medicate using antibiotics they brought from their home country. The following quotation from Participant #8 describes this situation:

You know, I got injuries at work last year and could not go to the doctor, you know, I don’t have insurance … I do not have the documents yet, I took some antibiotics that I had brought with me, which was good and helped.

Cost of emergency department visit

Participants who had insurance coverage referred to the high and unpredictable costs associated with ED visits as a reason for bringing antibiotics and self-medicating, instead of making unnecessary ED visits. These participants had heard about the high cost of ED visits, or they had visited the ED (for themselves or their family members or friends) and encountered these costs. The fear of being unable to afford ED treatment influenced decisions to bring antibiotics to the US. Participant #5, who was working as an engineer in a company in Atlanta and was covered by private insurance, said:

I can save tons of money by not going to ER [ED] and taking the antibiotics at home … The other day, my husband had a toothache. It was the weekend, and there was no dentist, so I told him to take the antibiotics we brought but not go to the ER. We literally saved thousands of dollars by not going to the ER. So, the next day, he went to the dentist, and [laugh] the dentist gave him the same antibiotics he had been taking for a week.

Cost of missing a paid day of work

Of the participants who said they had brought antibiotics to the US, some referred to the cost of missing paid work as the reason they decided to bring antibiotics from their home country for personal use. The lack of employer-based insurance coverage for temporary jobs such as cashier, photographer, and assistant chef was mentioned, as was the fact that some participants were not aware of how to request a sick day or could not communicate with supervisors about their health concerns. Most of these participants were also afraid to lose their jobs if they asked for a sick day or missed a day of work, especially if they needed to provide for themselves and their families. Participant #6 said:

As soon as I get a runny nose, I start taking antibiotics. It will make my body strong, and I can’t afford to miss a day at work. They will easily replace me with someone else. I am the breadwinner for my family and cannot afford a sick day.

Complexity of health care system

Our participants described difficulties in navigating their path through the host country’s complex health system. This was partially due to the US’s multifaceted health care system, and their confusion about where to start and how to find a first point of contact. Participant #10, who has a graduate degree, described this as follows:

Honestly, I don’t know where to start, who to contact and how to get referrals. It is so complicated here [in the US]. I called the specialist and wanted to make an appointment, and the person who answered the call told me that I can’t just make an appointment; I had to get a referral. Then, she said you could look for in-network providers … that was a moment for me to realize that this system is so difficult to navigate.

Communication issues with health care providers

Our participants, regardless of their educational level or background, wanted to consult health care providers from their own cultural backgrounds. They felt that it was hard to communicate with providers in the health care system and sought providers competent in understanding them. Participant #25, who immigrated from Pakistan and uses the term ‘desi’ to refer to those of the same background, explained:

I choose desi doctors, otherwise the other doctors don’t understand my needs … my parents who live in New York also have a desi doctor … the other doctors are not bad, but it is just hard for me to describe my pain, and how I feel to doctors who is not desi.

Cultural assumptions about medication in the home country

Our participants’ accounts revealed four cultural assumptions rooted in their experiences with medication, especially antibiotics, in their home countries. These assumptions were identified when participants described everyday experiences of taking antibiotics, beliefs about using antibiotics, and a culture that normalizes self-medication.

Experiences of antibiotics use

Nearly all the participants had experience of taking nonprescribed antibiotics back in their home countries and recalled taking nonprescribed antibiotics as a child or giving nonprescribed antibiotics to their children. Participant #16 described her experience as: ‘My mom used to give me antibiotics even when I was healthy [laugh], when I used to get some runny nose, she used to give me amoxicillin for sure.’

Beliefs about antibiotics

Participants who decided to bring antibiotics with them from their home countries strongly believed that antibiotics could treat the symptoms of viral diseases, such as respiratory infections or the common cold. Like many people, our respondents did not seem to be aware of the distinctions between viruses and bacteria. Many participants mentioned that they took antibiotics for cold symptoms while growing up, or observed others taking them for symptoms such as fever, cough, and runny nose over the years. Because they experienced an improvement in symptoms, they came to believe that taking antibiotics is necessary or practical for such conditions. Participant #2, originally from South America who grew up in an underserved area of her country, said: ‘When I got a runny nose, I would start taking antibiotics, and my runny nose would stop in a day or so … [the antibiotic] works like magic.’

Habit of self-medication

Self-medication may include the use of over-the-counter medications or unused or shared prescription drugs.²⁰ Participants referred to the practice of self-medication with antibiotics in their home countries as a common practice. Participant #26 said:

My grandfather used to take penicillin or amoxicillin every month just to make sure he would not catch a cold or flu, and the same applies to my mother. She takes antibiotics now and then and forced us as kids to take antibiotics when we had coughs or fever, or even red eyes [i.e. pink eye].

Uncertainty about future medical needs

Self-medication practices and decisions to bring antibiotics from a home country were prompted by uncertainty about future medical needs. Participant #3, who came to the US as a student, explained:

When I was packing my suitcase to come here, my mother told me to take some medicines with you, and I immediately remembered to take amoxicillin because I always have problems with my teeth ... you don’t know where you’re going or what will happen there [in the US].

Participant #10, who travels once or twice a year to his home country, said ‘you never know when you will need an antibiotic. If I have flu and my doctor is not willing to prescribe me antibiotics, then I need to have some handy.’ Likewise, Participant #5, who visits her home country at least three times a year, said: ‘Every time I go back to Iran, I make sure to do a thorough check-up of my teeth and bring some antibiotics [back to the US] for when I would need them.’

Discussion

Our study examined the misuse of antibiotics among an understudied population. By studying immigrants from home countries with easier access to antibiotics, we provide insights into vulnerability in the context of immigration and how this determines immigrants’ decisions to use nonprescribed antibiotics. This qualitative work enabled us to find underexplored factors in the host and home country that contributed to immigrants’ vulnerability and decision-making regarding self-medicating with antibiotics. Our findings highlight how structural barriers to health care access in the host country (i.e. insurance coverage, cost of ED. visits, cost of missing a paid day of work, complexity of the health care system, and communication issues with health care providers) interact with participants’ cultural assumptions (i.e. experiences of antibiotics use, beliefs about antibiotics, a habit of self-medication, and uncertainty about future medical needs) and together influence immigrants’ use of nonprescribed antibiotics. These findings show how the decision to use non-prescribed antibiotics is socially and culturally grounded.

These findings cannot be directly generalized to other contexts in the way that findings from statistical analyses are.¹⁴ However, our findings show important structural and cultural reasons for the misuse of restricted medications, such as antibiotics. These findings may apply to other medication misuse where individuals travel from a country with easier access to a destination country with restricted access. We have shown that when structural barriers limit access to health care and cultural assumptions motivate medication use, individuals seem more likely to decide to self-medicate while in their host country. Given that more people are now moving between countries (the PEW Research Center in 2020 suggested that 3.6% of the global population resided in a country different from their country of birth),²¹ paying close attention to the culture, beliefs, experience, and barriers to health care access, of these migrant populations will assist policymakers in creating targeted campaigns to curb antibiotic resistance. Recent research suggests there is a link between the cultural context, personal-psychological attributes and the use of antibiotics.²² Further research into these connections will inform antibiotic stewardship programs worldwide.

Our study adds to the literature on immigrants that highlights the difficulties immigrants face accessing health care in developed countries,²³ and the communication barriers they experience when seeking health services.⁸ Our results suggest that structural barriers and cultural assumptions intersect with vulnerability to drive immigrants in the US to bring and use nonprescribed antibiotics from countries in which antibiotics are available without a prescription. We found that structural barriers functioned as constraining forces, which could be described as the capacity of the US healthcare context to impose boundaries and influence the behavior of immigrants.²⁴ For example, the lack of access to insurance could explain the motivation for immigrants to bring and use nonprescribed antibiotics. Similarly, cultural assumptions functioned as driving forces where cultural beliefs and values motivated or facilitated the decisions of immigrants in our study.²⁴ These structural barriers and cultural assumptions may influence decisions to use nonprescribed antibiotics and conflict with health promotion efforts to reduce inappropriate use of antibiotics in the US.

These antimicrobial stewardship programs are critical public health and health promotion efforts designed to reduce the overuse of antibiotics and prevent the rise of antibiotic-resistant bacterial infections. However, these programs typically assume decision-making occurs in the context of relatively high levels of health literacy and equitable access to health care. A holistic strategy aligning antimicrobial stewardship programs with targeted educational initiatives could improve health outcomes while reducing the risks associated with antibiotic resistance. In this context, the development of comprehensive educational initiatives on antimicrobial stewardship targeting immigrant communities and health care professionals is warranted. Such initiatives should inform immigrant communities about the proper use of antibiotics, train health care providers on the provision of culturally appropriate care, and emphasize the compounding adverse effects of improper use of antibiotics and lack of culturally appropriate care on individual and population health outcomes. These efforts can extend beyond education and provide support to immigrants navigating the complexities of the US healthcare system. This comprehensive approach stands to not only reduce inappropriate use of antibiotics among immigrant communities but also improve health outcomes by facilitating access to culturally appropriate health care.

While we examined antibiotic misuse among immigrants in the US, some of our findings map onto existing studies on immigrants’ experiences with the health care systems in the US. Our work describes lack of access to health care, vulnerability, cost of care, lack of cultural competence of health care providers, and complexity as health care challenges that immigrants face in the US. These are features that have been uncovered elsewhere.²⁵ Similarly, previous studies have shown how experiences,²⁶ beliefs,^27,26 and the exposure to self-medication²⁸ play an important role in misuse of medication. Our study adds details about how lack of insurance coverage, related to the cost of ED. visits, and/or the cost of missing a paid day of work form structural barriers to antibiotic stewardship in these vulnerable communities.

Limitations

Our study has three main limitations. First, we only conducted interviews with immigrants who traveled back to their home countries within the prior year. Interviews with immigrants who last visited their home countries a long time ago might yield different results.

Second, we focused on the explicit experience of bringing nonprescribed antibiotics from the home country. However, many immigrants will bring antibiotics that their physicians in their home countries prescribed, or, to comply with the regulations in their host countries, refrain from bringing antibiotics at all. Researchers may want to explore how medicines regulations impact on different communities’ decisions to consume or bring restricted medications.

Third, even though proficiency in English was not a specific criterion for our study, the majority of our participants possessed sufficient fluency in English to conduct the interviews in this language. Future research could explore the cultural and structural barriers faced by those with limited English proficiency that influence their use of non-prescribed antibiotics.

Conclusions

Limitations in access to health care due to insurance coverage, cost of emergency care, fear of missing a paid day of work, a complicated health care system, and difficulty in communicating with providers contribute to immigrants’ vulnerability in the US health care context. Such vulnerable situations steer immigrants toward bringing antibiotics from their home countries and self-medicating with nonprescribed antibiotics. Policymakers must consider these structural challenges when implementing stewardship programs in health care settings. The structural drivers of this use of antibiotics combine with cultural assumptions – immigrants’ experiences with antibiotics, self-medication, lay beliefs about antibiotics – to reinforce the misuse of antibiotics among these vulnerable populations. Educational interventions will thus need to address cultural assumptions to support behavior change.

Supplemental Material

Supplemental Material - ‘You never know when you will need an antibiotic’: A qualitative study of structural barriers and cultural assumptions in antibiotic misuse among immigrants in the United States

Supplemental Material for ‘You never know when you will need an antibiotic’: A qualitative study of structural barriers and cultural assumptions in antibiotic misuse among immigrants in the United States by Sara Imanpour, and Darcy Jones McMaughan in Journal of Health Services Research and Policy

Footnotes

Acknowledgements

The authors would like to thank Dr Melika Shirmohammadi who provided constructive feedback contributing to the development of this manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical statement

ORCID iD

Sara Imanpour

Supplemental Material

Supplemental material for this article is available online

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