This article was submitted to Pharmacoepidemiology, a section of the journal Frontiers in Pharmacology
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Irrational use of antibiotics and the antibiotic resistance it has caused pose a serious threat to globe health (
With the development of electronic commerce, online sales of antibiotics have increased public access to these medicines, which is an enormous challenge for antibiotic stewardship (
China is one of the countries with a serious problem of irrational use of antibiotics (
A nationally cross-sectional study on the online antibiotic purchase behavior was designed and conducted among Chinese residents. The data was collected as a part of the community survey module of the undergraduate students of Hainan Medical College using a web-based questionnaire. From January 20 and February 28, 2019, participants were recruited from these student’s native place communities, using the convenience sampling method. The inclusion criteria for the subjects were: 1) 18 years and older 2) those who could read Chinese and 3) able to use smartphone. We also excluded those with severe mental/cognitive problems.
The minimum number of residents required to estimate the prevalence of antibiotic purchase online was calculated. We used the formula for calculating the sample size of the cross-sectional study:
With the help of local community workers, these students who received unified training, identified the eligible residents and sent the questionnaire link to them through social networks. After clicking the link, respondents will first access the informed consent page, which includes the purpose of the investigation, the institution conducting the investigation, assurance of anonymity, and a question: “Do you agree to participate in this survey (Yes/No).” Only respondents who chose “Yes” were directed to the questionnaire page. Considering that some respondents are not familiar with antibiotics, we set a screening item at the beginning of the questionnaire: “Do you know the term of “antibiotic” or drugs like penicillin, amoxicillin, cephalosporin, and roxithromycin? (Yes/No).” If the screening item was answered with “No,” the survey ended, and if the screening item was answered with “Yes,” the survey continued. In addition, we set up three quality control questions at different places in the questionnaire to identify the respondents who filled the questionnaire at random. The three questions were “Where is the capital of China?”, “What is 7 minus 2?”, and “What is 1 plus 3?”. Each question had 4 alternative answers, of which only one was correct, and the correct alternatives for the 3 questions were inconsistent. After answering all the questions, respondents were directed to submit the questionnaire. The questionnaire system would mark the questionnaire as invalid if any of the three answers of the quality control questions was incorrect. Additionally, to prevent multiple submissions, each mobile phone or computer was eligible to answer only once. The answers to all respondent’s questionnaires were automatically entered into a data file and checked by two independent researchers. Respondent’s information was completely confidential and recorded anonymously. This study is a joint research project of Tongji Medical College, Huazhong University of Science and Technology and Hainan Medical College. The former institution was responsible for the study design and the latter was responsible for the data collection. The Medical Research Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology approved the study [no. IEC (S175)] on March 1, 2018.
Our primary outcome variable was the purchase of antibiotics online. Respondents were asked whether they bought any antibiotics online in the past 3 months. We defined respondents as purchasers of antibiotics online if they answered yes to the question.
These variables included age (18–44, 45–64, or ≥65 years of age), gender (male or female), ethnicity (Han or minority), geographic location (east, central, or west), residence (urban or rural), education level (high school or below, associate or bachelor degree, or graduate degree or higher), marital status (never married, married and living with a partner, or divorced or widowed), employment status (employed or not employed), self-reported economic status (excellent, good, fair, poor, or terrible), health insurance status (insured or uninsured), whether suffering from physician-diagnosed chronic diseases (yes or no), and whether searching for health information online in the past 3 months (yes or no).
To account for the oversampling and the nonresponse, we used post-stratification weights, which corrected the distribution of respondents to match the known distribution of the Chinese population on age group, gender, residence, and geographic location (
During the study period, we distributed 171,335 questionnaire links, and 107,650 participants from 31 Chinese mainland provinces (municipalities, autonomous regions) completed the online questionnaire, with a response rate of 62.83%. Of them, 6530 who failed to pass the quality control questions were excluded. Finally, 101,120 respondents were included in the analysis. The mean age of the respondents was 30.43 (standard deviation: 13.12) years. Over half were female (58%), unmarried (63%), and living in urban area (60%). As for geographic location, 55, 22, and 23% lived in the eastern, central, and western China, respectively. Furthermore, 68% had an associate or bachelor degree, 91% had health insurance, 50% was employed, as well as 59% reported that their economic status was fair. Nearly one seventh of them (14%) suffered from physician-diagnosed chronic diseases, and 42% had searched for health information online in the past 3 months. Respondent’s characteristics are detailed in
Resident’s characteristics and their associations with antibiotic purchase online in the past 3 months.
| Characteristic | Total No. (%) | Antibiotic purchase online |
|
|
|---|---|---|---|---|
| Unweighted frequency and percent No. (%) | Weighted percent |
|||
| Overall | 101120 | 3318 (3.28) | 3.71 (3.53–3.88) | NA |
| Age (years) | <0.0001 | |||
| 18–44 | 82394 (81.48) | 2654 (3.22) | 3.34 (3.20–3.47) | |
| 45–64 | 16914 (16.73) | 539 (3.19) | 3.29 (2.99–3.58) | |
| ≥65 | 1812 (1.79) | 125 (6.90) | 6.93 (5.73–8.14) | |
| Gender | <0.0001 | |||
| Male | 42930 (42.45) | 1710 (3.98) | 4.31 (4.04–4.57) | |
| Female | 58190 (57.55) | 1608 (2.76) | 3.09 (2.86–3.32) | |
| Ethnicity | 0.0201 | |||
| Han | 90876 (89.87) | 2954 (3.25) | 3.63 (3.45–3.81) | |
| Minority | 10244 (10.13) | 364 (3.55) | 4.44 (3.78–5.09) | |
| Geographic location | 0.3213 | |||
| East | 55797 (55.18) | 1903 (3.41) | 3.82 (3.59–4.06) | |
| Central | 21812 (21.57) | 669 (3.07) | 3.50 (3.15–3.85) | |
| West | 23511 (23.25) | 746 (3.17) | 3.77 (3.41–4.12) | |
| Residence | 0.0008 | |||
| Urban | 61036 (60.36) | 1951 (3.20) | 3.41 (3.21–3.61) | |
| Rural | 40084 (39.64) | 1367 (3.41) | 4.02 (3.73–4.32) | |
| Education level | <0.0001 | |||
| High school or below | 27908 (27.60) | 682 (2.44) | 2.66 (2.38–2.93) | |
| Associate or bachelor degree | 69035 (68.27) | 2364 (3.42) | 4.01 (3.79–4.23) | |
| Graduate degree or higher | 4177 (4.13) | 272 (6.51) | 8.07 (6.72–9.41) | |
| Marital status | 0.1394 | |||
| Never married | 63645 (62.94) | 2034 (3.20) | 3.61 (3.41–3.81) | |
| Married and living with a partner | 35628 (35.23) | 1193 (3.35) | 3.71 (3.42–3.99) | |
| Divorced or widowed | 1847 (1.83) | 91 (4.93) | 5.09 (3.62–6.55) | |
| Employment | <0.0001 | |||
| Not employed | 50926 (50.36) | 1578 (3.10) | 3.32 (3.10–3.54) | |
| Employed | 50194 (49.64) | 1740 (3.47) | 4.05 (3.78–4.31) | |
| Self-reported economic status | <0.0001 | |||
| Excellent | 5626 (5.56) | 417 (7.41) | 7.70 (6.68–8.72) | |
| Good | 11207 (11.08) | 526 (4.69) | 5.45 (4.79–6.11) | |
| Fair | 60064 (59.40) | 1592 (2.65) | 2.85 (2.66–3.03) | |
| Poor | 16233 (16.05) | 468 (2.88) | 3.00 (2.65–3.36) | |
| Terrible | 7990 (7.90) | 315 (3.94) | 5.10 (4.28–5.91) | |
| Health insurance | 0.5833 | |||
| Uninsured | 8749 (8.65) | 283 (3.23) | 3.88 (3.24–4.52) | |
| Insured | 92371 (91.35) | 3035 (3.29) | 3.69 (3.51–3.88) | |
| Chronic disease | <0.0001 | |||
| No | 86834 (85.87) | 2610 (3.01) | 3.25 (3.08–3.41) | |
| Yes | 14286 (14.13) | 708 (4.96) | 5.62 (5.03–6.22) | |
| Searching for health information online | <0.0001 | |||
| No | 58650 (58.00) | 998 (1.70) | 2.22 (2.02–2.43) | |
| Yes | 42470 (42.00) | 2320 (5.46) | 6.09 (5.77–6.41) | |
CI, confidence interval; NA, not applicable.
Estimates are weighted to be nationally representative.
The overall weighted prevalence of antibiotic purchase online in the past 3 months was 3.71% (95% confidence interval [95% CI], 3.53–3.88%). Additionally, the weighted prevalence was more than 6% (1.5 times of the overall weighted prevalence) among those who were aged 65 years or older, and who had a graduate degree or higher education level, reported an excellent economic status, or searched for health information online. Whereas, there was no difference in the prevalence among residents with different marital or insurance status, as well as among those who lived in different regions of China.
The crude and adjusted OR (aOR) for factors associated with antibiotic purchase online are shown in
Univariable and multivariable logistic regression of factors associated with antibiotic purchase online in the past 3 months.
| Characteristic | Crude OR (95% CI) |
|
Adjusted OR (95% CI) |
|
|---|---|---|---|---|
| Age (years) | ||||
| 18–44 | 1.00 | 1.00 | ||
| 45–64 | 0.98 (0.89–1.09) | 0.7630 | 1.09 (0.95–1.25) | 0.2067 |
| ≥65 | 2.16 (1.78–2.61) | <0.0001 | 2.18 (1.74–2.74) | <0.0001 |
| Gender | ||||
| Male | 1.00 | 1.00 | ||
| Female | 0.71 (0.64–0.78) | <0.0001 | 0.69 (0.62–0.77) | <0.0001 |
| Ethnicity | ||||
| Han | 1.00 | 1.00 | ||
| Minority | 1.23 (1.05–1.45) | 0.0117 | 1.15 (0.97–1.37) | 0.1023 |
| Geographic location | ||||
| East | 1.00 | 1.00 | ||
| Central | 0.91 (0.81–1.03) | 0.1425 | 0.93 (0.83–1.06) | 0.2712 |
| West | 0.98 (0.88–1.11) | 0.7909 | 0.96 (0.85–1.08) | 0.4653 |
| Residence | ||||
| Urban | 1.00 | 1.00 | ||
| Rural | 1.19 (1.08–1.31) | 0.0006 | 1.43 (1.29–1.58) | <0.0001 |
| Education level | ||||
| High school or below | 1.00 | 1.00 | ||
| Associate or bachelor degree | 1.53 (1.36–1.73) | <0.0001 | 1.51 (1.31–1.74) | <0.0001 |
| Graduate degree or higher | 3.22 (2.61–3.97) | <0.0001 | 2.11 (1.66–2.67) | <0.0001 |
| Marital status | ||||
| Never married | 1.00 | 1.00 | ||
| Married and living with a partner | 1.03 (0.93–1.14) | 0.5922 | 0.91 (0.77–1.06) | 0.2277 |
| Divorced or widowed | 1.43 (1.05–1.95) | 0.0233 | 0.97 (0.67–1.40) | 0.8763 |
| Employment | ||||
| Not employed | 1.00 | 1.00 | ||
| Employed | 1.23 (1.11–1.35) | <0.0001 | 1.06 (0.94–1.20) | 0.3554 |
| Self-reported economic status | ||||
| Excellent | 1.00 | 1.00 | ||
| Good | 0.69 (0.57–0.84) | 0.0002 | 0.76 (0.62–0.93) | 0.0084 |
| Fair | 0.35 (0.30–0.41) | <0.0001 | 0.45 (0.37–0.53) | <0.0001 |
| Poor | 0.37 (0.31–0.45) | <0.0001 | 0.44 (0.36–0.54) | <0.0001 |
| Terrible | 0.64 (0.52–0.80) | <0.0001 | 0.70 (0.55–0.90) | 0.0057 |
| Health insurance | ||||
| Uninsured | 1.00 | 1.00 | ||
| Insured | 0.95 (0.79–1.14) | 0.5756 | 0.90 (0.75–1.10) | 0.2997 |
| Chronic disease | ||||
| No | 1.00 | 1.00 | ||
| Yes | 1.77 (1.57–2.01) | <0.0001 | 1.44 (1.27–1.63) | <0.0001 |
| Searching for health information online | ||||
| No | 1.00 | 1.00 | ||
| Yes | 2.85 (2.56–3.18) | <0.0001 | 3.10 (2.79–3.46) | <0.0001 |
CI, confidence interval; OR, odds ratio.
Adjusted for the other eleven variables.
Additionally, residents who lived in rural areas (aOR, 1.43; 95% CI, 1.29–1.58), or suffered from chronic diseases (aOR, 1.44; 95% CI, 1.27–1.63) had higher odds of purchasing antibiotics online. Compared with those having a high school or lower degree, residents who had an associate or bachelor degree (aOR, 1.51; 95% CI, 1.31–1.74) as well as a graduate or higher degree (aOR, 2.11; 95% CI, 1.66–2.67) were more likely to purchase antibiotics from online pharmacies. In the past 3 months, those had searched for health information on the internet were more than three times (aOR, 3.10; 95% CI, 2.79–3.46) more likely to purchase antibiotics online.
Our study showed that 3.71% of Chinese residents had purchased antibiotics on the internet in the past 3 months. Currently, few study on online antibiotic purchase behavior of residents has been conducted in other countries, but studies on prescription medicine purchase online have been carried out. Relevant studies showed that 0.45 and 5.00% of residents have purchased prescription medicines on the internet in Malta and the United States in the past year, respectively (
The current study found that the female was less likely to buy antibiotics on the internet, which may be due to that they were more cautious about medicine purchase online. A study on the online medicine purchase behavior of Chinese residents reported that women were less inclined to buy medicines in online pharmacies due to their cautiousness (
In our study, residents with higher education level were more prone to purchase antibiotics online. This is consistent with the result of studies on factors related to self-medication with antibiotics, which found that higher education level was associated with irrational use of antibiotics (
In the past 3 months, nearly half of the residents had searched for health information on the internet, and they were more likely to purchase antibiotics online. This may be due to that they usually chose to seek information online to self-diagnose and self-medication when they suffered from illness. Information obtained online and internet usage habits may encourage them to purchase medicines online. It is very important to ensure that the internet provides correct health information and medication knowledge in the information age.
To our knowledge, this is the first study to explore the prevalence of antibiotic purchase online among residents and identify its associated factors. We considered that this study will help the researchers and policymakers worldwide understand the online antibiotic purchase behavior of residents, as well as provide evidence for antibiotic stewardship. This study has several limitations. First, this study was conducted by using a convenience sampling method and web-based survey. These may affect the sample’s representativeness. However, the survey was conducted by trained investigators in urban and rural communities all over the country, the sample size was large, and post-stratification weights were used to correct the distribution of the respondents, which can make the results more nationally representative. Second, we investigated the online antibiotic purchase behavior in the past 3 months, and therefore, recall bias may exist. Third, we did not collect the information on types of antibiotics purchased online, medical conditions that required antibiotics, whether residents purchased antibiotics with a prescription or not, and other possible factors influencing the purchase behavior, which limited our more comprehensive understanding of the online antibiotic purchase behavior of residents.
Our study investigated the online antibiotic purchase behavior of residents, which could provide evidence for researchers and policymakers worldwide to understand this behavior. Additionally, the study results showed that the prevalence of antibiotic purchase online was relatively high among Chinese residents. This implied that, on the one hand, the regulation of antibiotic sales online should be strengthened; on the other hand, there is a need to improve public education on antibiotic purchase online, so as to promote purchases of antibiotics with a prescription and rational use of antibiotics.
As a new channel to obtain antibiotics, online antibiotic purchase has rarely been studied. Therefore, it is necessary to pay attention to this purchase behavior, and carry out more relevant researches. For the future studies, more detailed information of antibiotic purchase online should be collected, such as types of antibiotics purchased and whether residents purchased antibiotics with a prescription or not, so as to provide a more comprehensive reference for antibiotic stewardship. In addition, antibiotic is an important kind of medicines for the treatment of acute bacterial diseases. Online sales of antibiotics have improved the accessibility of these medicines among residents. However, considering that antibiotics should be used accurately and timely for patients when needed, whether online purchases of antibiotics will result in delay in treatment is a matter of concern. Extensive researches and discussions should be conducted to reveal the advantages and disadvantages of online sales of antibiotics.
Our study found that numerous Chinese residents had purchased antibiotics on the internet. Age, gender, residence, education level, economic status, suffering from chronic diseases, and searching for health information on the internet were all significantly associated with the purchase behavior. Therefore, it is necessary to strengthen the regulation of antibiotic sales on the internet, and improve public education on antibiotic purchase online. In the future studies, more comprehensive information on antibiotic purchase online should be collected, as well as the advantages and disadvantages of online sales of antibiotics should be investigated.
The raw data supporting the conclusions of this article will be made available from the corresponding author on reasonable request.
The studies involving human participants were reviewed and approved by Medical Research Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology. The participants provided their electronic informed consent to participate in this study.
NS, YG, and XY conceived the study. JL, JW, KM, and GZ commented on the research question and design. NS, RA, YD, and YZ participated in the data analysis. NS wrote the draft of the paper. All authors contributed to writing, reviewing or revising the paper and read and approved the final manuscript.
This work was supported by National Natural Science Foundation of China (grant number 71874060). The funder had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
We greatly appreciate community residents for their time and efforts in participating in this study. We also thank all community workers for collaborating with us on this project.
The Supplementary Material for this article can be found online at: