“Miss, I want itchy medicine”: Understanding what, why, and how antibiotics are used in Central Java province, Indonesia through the drug bag method

Abstract

Antibiotic use is shaped by access, knowledge, norms, and practices, yet remains poorly understood in many community settings worldwide. To address these gaps, we investigated community antibiotic use in six villages across Sukoharjo, Karanganyar, and Klaten districts of Central Java province in Indonesia. This study focused on three key questions: (i) which antibiotics are accessible in community settings; (ii) how do community members recognize and understand these antibiotics; and (iii) what social, economic, cultural, and contextual factors drive antibiotic use. Between April and May 2024, 36 drug bag interviews, in which locally available antibiotics were purchased, compiled, and used in household pile-sorting activities, were conducted with community members. Complementary ethnographic fieldwork included simulated patient visits, informal conversations, and participant observations in community settings and at local pharmacies and shops (Warungs). This study found that knowledge of antibiotics and Indonesian medicine labels was generally low, while access to antibiotics without prescription, particularly from pharmacies and Warungs, was high. Access antibiotics, such as amoxicillin and tetracycline, were the most commonly used and recognized, while Watch antibiotics, including aminoglycosides, were also popular for self-medication, especially in topical forms. Common reasons for self-medication included convenience, ease of access, and lower cost. Practices such as stopping treatment early, repurposing antibiotics, and sharing them among family members were commonly adopted. This study identified multiple intersecting factors influencing antibiotic use in community settings. The findings highlight that effective antibiotic stewardship requires not only policies to restrict non-prescription sales but also interventions that address the social, economic, and cultural drivers of self-medication.