Social, economic, and access to services factors influencing non-prescription antibiotic use in island communities: A Qualitative study

Abstract

Background: The use of antibiotics without a prescription remains a public health problem because it can increase inappropriate drug use and accelerate antimicrobial resistance. In island communities, this behavior is not only influenced by knowledge, but also by treatment experience, family norms, economic capacity, distance between islands, sea transportation, weather, and service availability. This study aims to explore social, economic, and service access factors that underlie the use of antibiotics without a prescription in the community. Methods: The study used an exploratory qualitative case study design with a constructivist-interpretive paradigm. Informants were selected purposively with maximum variation, consisting of 20 community members who had obtained or used antibiotics without a prescription and seven key informants, including health workers, drug managers, cadres, village officials, and drug sellers. Data were collected through in-depth interviews, non-participant observation, and document review. The analysis was conducted through data condensation, inductive-deductive coding, matrix presentation, thematic analysis, source triangulation, and conclusion verification. Findings: Five main themes were identified, antibiotics are perceived as a powerful medicine based on recovery experiences; family and social networks shape usage decisions; direct and indirect costs influence treatment choices; geographic and operational barriers limit access to community health centers; and the use of antibiotics without a prescription becomes a pragmatic strategy when services are difficult to access. These findings indicate that positive attitudes toward previous experiences, social norms, and perceived ease of access to antibiotics reinforce the use of antibiotics without a prescription. Conversely, transportation costs, loss of income, ship schedules, weather, travel time, and service uncertainty reduce the community's ability to reach health facilities. The integration of the theory of planned behavior and the service access framework explains the relationship between individual decisions and structural barriers in local island communities. Conclusions: The use of antibiotics without a prescription in island communities is shaped by the interaction of individual experiences, social norms, economic burdens, and limited access. Novelty/Originality of this article: The study provides a community-based framework for addressing non-prescription antibiotic use by integrating educational interventions, mobile services, pharmaceutical service strengthening, and strategies to reduce transportation barriers and indirect costs.