Pain, infection, and colds and flu: Samoan people's views about antibiotics

Article Outline

• Abstract
• Introduction
  • Samoans and Samoan health beliefs
  • Antibiotic resistance and lay knowledge
• Methods
  • Semi-structured interviews
  • Structured interview questionnaire
• Results
  • What do antibiotics do?
    • Semi-structured interviews
    • Structured interviews
  • Antibiotics as pain killers
    • Semi-structured interviews
  • Which medicines are antibiotics?
    • Semi-structured interviews
    • Structured interviews
  • Colds and flu
    • Semi-structured interviews
    • Structured interviews
  • Antibiotics for colds and flu
    • Semi-structured interviews
    • Structured interviews
• Discussion
• Conclusion
• Acknowledgments
• Appendix 1. Semi-structured interview guide
• Appendix 2. Structured interview schedule
• References
• Copyright

Abstract 

Background

Samoan people have access to and use both Western and traditional forms of healing. Little is known about their perceptions and use of healing agents.

Objectives

To explore Samoan people's interpretation and use of a subset of Western medicines, namely, antibiotics, in Samoa and in New Zealand.

Methods

Semi-structured interviews were held with a purposeful sample of 31 Samoans, recruited through informal networks. Thematic analysis focused on understanding participants' perspectives on antibiotics using a phenomenological approach. Results from these interviews were used to develop a questionnaire administered to 232 Samoans recruited in health care facilities in Samoa and New Zealand.

Results

Participants were mostly females (57% of structured interview participants), and most (88%) were born in Samoa. Nearly half the sample had tertiary education. In Western terms, confusion about what antibiotics do and lack of clarity about which medicines are antibiotics were very common among the Samoan population. Antibiotics are commonly believed to be useful for colds and flu (75% of respondents) and were frequently used for these conditions. The distinctive features of the responses were the belief that antibiotics are pain killers (50%) and confusion between infection and pain. The confusion between antibiotics and pain killers may reflect a conflict between Samoan and Western concepts of illness. In the Samoan view, the lived experience of illness appears to be conflated with the illness itself; that is, pain is seen as an illness.

Conclusions

The findings have implications for attempts to promote rational use of antibiotics either with individuals or as a part of public education campaigns. Such efforts may fail in some communities if they are based on the assumption that people share Western beliefs about what antibiotics are; what they do; and which illness have microbial, bacterial, or viral causes.

Keywords: Antibiotics, Culture, Lay people's understandings, Samoa, New Zealand

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Introduction 

Samoan people have access to and use both Western and traditional forms of healing.¹ Many studies have explored how people make decisions between Western and traditional health care,², ³, ⁴, ⁵, ⁶ but rather less attention has been focused on pharmaceuticals and, in particular, how people in non-Western cultures adopt and interpret Western medicines.⁷

Studies of how people understand and use Western medicines vary in their assumptions and orientation to the topic. Studies of understanding of concepts⁸, ⁹, ¹⁰, ¹¹ assume Western scientific medical ideas to be correct and measure lay knowledge against these. For example, Arroll and Everts⁹ assessed lay people's knowledge about colds and found that only 41% understood that antibiotics work against bacteria but not against viruses. Others (eg, Kinloch¹²) follow an ethnographic tradition, where the focus is on understanding the complexity of lay beliefs about health and illness and their relationship with the social structure. Ethnographic studies in Pacific health have, for example, explored the belief that family disharmony leads to ill health.¹³ The qualitative tradition of privileging lay beliefs about health and illness also produces studies where lay beliefs are described rather than evaluated or judged.¹⁴ The study described here attempts to follow Whyte et al.⁷ and Nichter and Nichter¹⁵ in integrating these 2 approaches. Whyte et al argue that it is important to compare lay people's knowledge and use of drugs with biomedical orthodoxy but not to focus only on the “shortcomings” of lay people vis-à-vis biomedical ideals of rational drug use. For example, Nichter¹⁵ explores and describes various cultural ideas about the time when women are most fertile. He compares these with Western scientific views and is clear that, although the cultural beliefs are understandable, they are erroneous, and he discusses the implications of these erroneous beliefs for family planning. In our study, we assumed that Western medical ideas about antibiotics, their action, and the development of resistance are correct. We were interested in how much Samoan people share this understanding of antibiotics, because we believe that the inappropriate use of antibiotics has real consequences on health and the provision of health care. However, rather than evaluating or judging traditional Samoan beliefs about health and illness, we attempt to understand some of these beliefs and their impact on the way Samoan people interpret and use Western medicines, such as antibiotics.

Samoans and Samoan health beliefs 

Samoa is an island nation in the Pacific Ocean, with a population of about 220,000.¹⁶ There are substantial Samoan communities in New Zealand,¹⁷ Australia,¹⁸ and the United States,¹⁹ and there is considerable movement of people between these countries.

Kinloch¹² suggests that, in Samoan culture, illness is seen as a disruption to social order. She also mentions the way in which traditional beliefs affect the use of Western medicine and suggests that Samoan people use Western medicines and traditional healing methods concurrently, intermittently, and erratically. Kinloch argues that, for Samoan people, sickness is identified on the basis of symptoms, and when symptoms cease, they see this as a cure. McPherson and McPherson²⁰ focus on traditional Samoan beliefs about health and healing. They stress variation in beliefs among both the lay population and the traditional healers. Their work describes a repertoire of beliefs that fofo (traditional healers) draw on in their practice. McPherson and McPherson's work suggests that there is no monolithic “Samoan view” on many health care issues. Capstick et al.¹³ also note that individual Polynesian people may vary considerably in the extent to which they adhere to traditional beliefs about health. Their review draws attention to the differences between traditional health beliefs and biomedical beliefs, the role of the relational self (that is the self as interconnected with others and the environment), and the place of spirituality and religion in health and illness causation in Pacific views.

Antibiotic resistance and lay knowledge 

Resistance to antibiotics is common throughout the world, and the rates are growing rapidly. The World Health Organization has described resistance as one of the top 3 global health issues.²¹ Resistance, to a large extent, is because of overuse and suboptimal use of antibiotics, including use in agriculture and in humans, including indiscriminate use for nonbacterial infections (particular colds and flu) for which they are not useful.²²

It is widely acknowledged that patient expectations are a major factor in unnecessary antibiotic prescribing.²³ Lay peoples' knowledge and understanding of antibiotics can create pressure on doctors and other health care providers to prescribe inappropriately. Lay knowledge and understanding also affect how antibiotics are used, such as whether appropriate doses are taken and whether full courses are taken. Patients may not understand what antibiotics do and do not do, the concept of resistance, or the importance of adhering to dosage instructions.⁸, ⁹, ²⁴, ²⁵

Lay people's knowledge and understanding are particularly important when antibiotics are available over the counter, as seen in many countries, including Samoa.²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹ Research on lay people's understandings of medicines is crucial to tackle inappropriate use of antibiotics and, therefore, resistance.

The aim of this study was to explore the extent of Samoan people's knowledge and to describe their understanding of antibiotics, a particular aspect of Western medicine. Antibiotics are widely used³² and are available over the counter in Samoa but are available only on prescription in New Zealand. Because the use of antibiotics for viral colds and flu is an important component of inappropriate antibiotic use, the researchers also sought to explore Samoan people's understandings of colds and flu and whether they understood that antibiotics are not appropriate for treating these.

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Methods 

The study used 31 semi-structured interviews (18 in Samoa and 13 in New Zealand) followed by structured interviews (by means of questionnaire) with 232 Samoan people (120 in Samoa and 112 in New Zealand). All interviews were carried out by Samoan researchers (3 of the authors and a research assistant) and were either in English or Samoan, depending on the preferences of the respondents. Ethical approval for the study was obtained from the Auckland and Wellington ethics committees in New Zealand and the Health Research Committee in Samoa.

Semi-structured interviews 

Purposeful sampling was used,³³ and respondents were recruited through informal networks. Although attempts were made to obtain a sample of people from different social strata, the sample was biased toward those with some form of tertiary education. In-depth interviews explored participants' knowledge and use of antibiotics, in the context of their understandings of health and illness (Appendix 1). Interviews in English were transcribed and those in Samoan translated and transcribed, with Samoan-speaking team members assisting each other in this process.

The approach taken was phenomenological in the sense that the investigators attempted to understand participants' experiences and worldviews from their own perspectives.³⁴ All team members read the transcripts, and a meeting was held to identify and discuss the themes in the data. These themes were then used as the basis of coding by the first author. Interview transcripts were coded using nVivo 7.0 (QSR International Pty Ltd, Doncaster, Victoria, Australia), and the material coded to each concept or theme was printed and sent to team members. This allowed them to check the first author's decisions and draw attention to any aspects of writing from the project that they did not agree with or found problematic. No discrepancies were identified. This is likely because of the extensive discussion of the interview material at the team meeting, which had led to a common understanding of the interview material.

Structured interview questionnaire 

The basis of a questionnaire was developed at a team meeting. This drew on reviews of literature on lay people's knowledge and use of antibiotics, alongside the material from the semi-structured interviews. This questionnaire was developed in consultation between team members, pretested with Samoan people, adapted, translated into Samoan, and pretested again.

The questionnaire consisted of 18 questions, including 6 demographic questions (Appendix 2). Apart from questions about occupation and recent medicine use, all questions were close ended, and respondents were asked to pick responses from a list. Every attempt was made to avoid the assumption that people knew what antibiotics were; as such, no explanations of the term were given in the first half of the questionnaire. Respondents were asked 2 basic questions about antibiotics: what do antibiotics do, and which medicines are antibiotics (participants were given a list to identify these from). Two general questions were then asked about colds and flu (what causes these, and what participants would do if they had one for 3 days). The Samoan language version of the questionnaire had fewer response options for the causes of colds and flu. In the English language version of the questionnaire, bacteria were distinguished from viruses. In the Samoan language version of the questionnaire, only 1 option for “germs” (siama) was presented. Participants were also asked what medicines they had used in the previous month.

In the second half of the questionnaire, participants were given a list of a few commonly used antibiotics, and they were asked to think of these while we asked 7 questions about the use of antibiotics. These explored participants' previous use of the specified antibiotics; whether they thought antibiotics were useful for colds and flu, and why; 3 questions about how participants would take a course of antibiotics (when they would stop, whether they would swallow or crush tablets and use them topically, whether they would follow instructions); what they would do with leftover antibiotics; and whether antibiotics can have any bad effects.

The questionnaire was administered to 232 people attending health care facilities in Samoa and in New Zealand. Most interviews (n=223) were held in Samoan language. Questionnaire interviews were carried out by the 3 Samoan authors (M.C., F.F., and C.V.). Results were analyzed using Microsoft Excel.

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Results 

Demographic characteristics of participants are presented in Table 1. Most of the participants were women (77% of those in semi-structured interviews and 58% of those in structured interviews). Approximately half of each sample lived in Samoa, and most of both samples (87% and 88%) were born in Samoa. A wide range of ages was represented. Nearly half the sample had tertiary education, that is, optional education in another institution beyond secondary school, such as a technical institute, a university, or a teachers' college.

Table 1. Demographic characteristics of the study participants

All participants had contact with Western medicines in some way, and all but one had personally used Western medicine. All were familiar to at least some extent with traditional Samoan health care, and only 1 young respondent in New Zealand reported not knowing any traditional Samoan healers. The way participants mixed and selected from Western and traditional healing traditions has been described elsewhere.¹

What do antibiotics do? 

Although some respondents correctly reported that antibiotics kill bacteria or treat infections, there were many other contradictory views. These were sometimes expressed by the same respondent and sometimes in the same sentence. Understandings seemed to be confused and, sometimes, fleeting and transitory.

Some respondents reported many different ideas at the same time. For example:

They're a very strong medicine, which immediately attacks the inflammation or the disease through direct ingestion into the bloodstream …. [if you stop before the course is completed] your body may immunize itself against the antibiotic in future if you don't take the medicine for the full length of its course where it can kill the disease or the bacteria (interview 12).

Those participants who understood that antibiotics treat infection were often confused about bacterial and viral infections. For example, the following respondent gives a very good definition of what antibiotics do, but then uses a viral illness as an example.

It's those medicines that kill bacteria. Like when you have a flu, you get the bacteria that causes it (interview 11).

Antibiotics were specifically reported to be useful for viral infections by some respondents. There was also confusion about whether antibiotics strengthened the immune system or killed bacteria.

I don't know what they do technically but you know, they help your immune system fight diseases or something (interview 13).

The results from the structured interviews suggest that the prevalence of misunderstandings in the Samoan community may be high (Table 2). When asked “what do antibiotics do?” and presented with a list of 5 answers, 50% said that antibiotics relieve pain, 51% said that they kill viruses, 48% said that they heal illness, and 36% said that they strengthen the immune system. The correct answer “kill bacteria” was the least commonly chosen answer (32%).

Table 2. Results from structured interviews

Questions and responses	N	%
What do antibiotics do?
Relieve pain	116	50
Kill viruses	119	51
Heal illness	112	48
Strengthen the immune system	84	36
Kill bacteria	75	32
Which medicines are antibiotics?
Panadol/paracetamol (acetaminophen)	30	13
Coldrex/Codrala (in Samoa: Fualaaufulū or green cold and flu tablets)	19	8
Amoxylb/amoxycillin	197	85
Allopurinol for gout	32	14
Asthma inhalers	7	3
Metformin for diabetes	35	15
Augmentin	121	52
Causes of colds and flu
Change in weather	155	67
Getting cold	106	46
Dust	106	46
Microbes (germs, bacteria, viruses)	92	40
Are antibiotics useful for colds and flu
Yes	175	75
No	40	17
Don't know	15	7
If yes, why?c
Prevent more serious illnesses developing	69	39
Prevent the cold/flu getting worse	128	73
Relieve symptoms	82	47
Make you get better sooner	91	52
Other	1	1

Antibiotics as pain killers 

The notion of antibiotics as pain killers was very common among respondents. Definitions of antibiotics frequently included comments like:

It's the drug that they used to ease the pain (interview 1).

As far as I know the antibiotics are quite different from other tablets for pain. For example, when pain-killers are taken it takes a while before any result is noticed but the antibiotics bring quick results when pain is felt (interview 25).

When asked if antibiotics would be useful for bone, joint, or muscle pain, a large minority of respondents said that they were or might be useful in some situations.

Respondents sometimes reported having been told that prescribed antibiotics were for pain:

The people at the National Hospital pulled my tooth, one of my teeth out, and they left a little bit in there. And they told me to drink it for the pain (interview 14).

Antibiotics were frequently confused with other medicines that the respondents had used for pain.

Are Panadols (paracetamol/acetaminophen) antibiotics? Pandeine? (paracetamol/acetaminophen with codeine) (interview 11).

Well I'm not sure if Indocid (indomethacin) is an antibiotic, but definitely Indocid is very useful for gout just from my husband's experience (interview 12).

Penicillin's like Panadol, isn't it? (interview 13).

There were some suggestions from participants that intensity of pain is linked with seriousness of illness.

I think pneumonia was more serious to me than my ear infection; well, at least the pain was not the same (interview 2).

Believing that antibiotics were pain killers did not seem to be incompatible with believing that they were for treating infection.

They cure and relieve pain, an immediate treatment of bacterial infections (interview 26).

They heal you, get rid of the pain and kill bacteria (interview 28).

Which medicines are antibiotics? 

Throughout the interviews, a wide range of medicines were referred to as antibiotics. This included medicines for epilepsy, gout, asthma, and flu. Specific products mentioned included paracetamol (acetaminophen), topical anti-inflammatories advertised on television, asthma atomizers, cold and flu tablets (decongestants), magnesia, diclofenac, fluoxetine, and urinary alkalinizers. In the following quotes, antibiotics are confused with medication for epilepsy and gout:

My grandson who had epilepsy … was definitely on some sort of antibiotics but I have no idea what they were; I will have to ask my sister. I think it was two lots of different ones (interview 1).

I know a lot of older people in my family that take antibiotics for their gout. It's quite painful (interview 27).

The responses in the structured interviews also confirmed a high level of confusion about which medicines are antibiotics. This was exhibited even by those taking the medicines in question. Of the 30 people (13%) who thought that paracetamol (acetaminophen) was an antibiotic, 12 later reported that they had taken it for headaches, flu, and others. Of the 35 people who thought “metformin for diabetes” was an antibiotic, 8 reported later in the structured interview that they took metformin for diabetes, and 5 reported that they took an unknown diabetes medication. Of the 32 people who thought “allopurinol for gout” was an antibiotic, 1 reported taking allopurinol for gout, and 4 reported taking an unknown gout medication.

Colds and flu 

The semi-structured interviews contain many references to flu and colds as being common conditions, which, largely speaking, do not indicate ill health.

My husband and I have kept reasonably healthy, except for the odd cold and flu (interview 12).

Two kinds of accounts were given about the causes of colds and flu. One stressed environmental causes: changes in weather, dust, or wearing inappropriate clothing.

Interviewer: And how do you think people get the flu or what causes it?

Participant: Um, I would say it's the dust, or when it's cold and raining (interview 11).

My Mum says that when I finish training I stay in my wet shirt, and that's how I get the flu. Um, I know I get the flu from doing that (interview 14).

The other account stressed the contagiousness of colds and suggested that they were caused by microbes (ie, bacteria or viruses).

I don't have a great understanding, but it's like a virus or something and you catch it from other people who are sick with it (interview 13).

Some participants included both in their answers, suggesting that these are not mutually exclusive views.

People get the flu by contacting it from other people who have it. It is caused by a germ that they have and coughing spreads it. It can also result from being over exposed to the cold (interview 18).

In the structured interview, participants were asked to choose 1 or more of several options as causes of colds and flu. Nonmicrobial causes were more commonly chosen than microbial causes. The most common option was changes in the weather (67%), followed by getting cold (46%) and dust (45%). Of the 9 respondents with whom the English language version of the questionnaire was used, 7 thought that colds and flu were caused by bacteria, and 5 thought they were caused by viruses. In the Samoan language version of the questionnaire, only 1 option for “germs” was presented, and 38% of respondents chose this. About a third of all participants (29%) chose both microbial and nonmicrobial causes.

Antibiotics for colds and flu 

Many participants reported regular use of antibiotics for colds and flu.

Interviewer: So what have you or your children used antibiotics for?

Participant: Just for the common flu, colds and flu (interview 11).

Little distinction was made between antibiotics and other medicines that one would take for colds and flu (particularly paracetamol or acetaminophen)

I guess things like the pamol (paracetamol/acetaminophen formulated for children), augmentin are the common ones. I think my nieces and nephews take those for colds and flus (interview 1).

In Samoa, use of antibiotics for colds and flu seemed to be regarded as normal and unproblematic. Antibiotics were regularly prescribed for colds and flu, and participants had come to expect this.

Normally I'd feel more achy all over, in my joints, and I wouldn't be getting any better with Panadols (paracetamol/acetaminophen) and a lot of lime juice, plus sometimes I'd develop a very phlegmy cough. At that stage, if it had been 3 or 4 days, I'd be going to see my doctor and he'd prescribe usually some antibiotics and I'd get better pretty quickly after taking those (interview 12).

Sometimes congestion gets quite … worrying and then going to the doctor, almost every time I go I get put on antibiotics (interview 15).

In addition, antibiotics were sometimes purchased from pharmacies, without a prescription.

My throat was sore and not getting any better. Then my wife suggested that I take it. Yes, she was the one who went and got them from the pharmacy (interview 16).

Antibiotic use for colds and flu seemed to be regarded as a responsible thing to do.

Once I feel that I am getting the flu I quickly take antibiotics (interview 19).

In Samoa, this may be done because flu is seen as possibly developing into pneumonia.

Illnesses like a blocked nose and the flu that people are careless about and suffer the consequences later. People do not go and see the doctor, and the flu and blocked nose result in pneumonia and become complicated later. As the saying goes, protection is better than cure (interview 23).

Only 1 participant in Samoa reported encountering a doctor who was reluctant to prescribe antibiotics. Prescriber reluctance was more commonly described by participants in New Zealand, and although taking antibiotics for flu was commonly reported, it was regarded as somewhat more problematic.

We have this one doctor who gives out antibiotics for the flu or a cold but you are not supposed to, but the doctors that we actually PHO with [i.e. the doctor the family is registered with], they won't prescribe any antibiotics or anything for the flu or cold. They just say just have teas and lemon drinks. But we know this one doctor so we go there when we want antibiotics. Is that bad? I heard it does not work for the flu but I don't know, it makes you feel better I guess (interview 2).

Participant: My family usually suggests antibiotics when they see a GP.

Interviewer: And do they get it straight away if they suggested?

Participant: No, it depends on the doctor and their diagnosis (interview 26).

In the structured interview, respondents were asked about their responses to a simple cold: “If you had a cold/flu for three days, with coughing, heavy nose, and headache, what would you do?” Several options were presented. A very large proportion of participants reported that they would seek health care advice. Other options (much less frequently reported) were taking medicines, hot drinks, rest, and traditional healing. By far, the most common medicines reported were paracetamol or acetaminophen (58 out of 75) medicines mentioned. Other medicines included cough mixtures (7), cold and flu tablets or lozenges (4), and antibiotics (2).

Participants were also asked whether antibiotics were useful for colds and flu. Overall, 75% said they were. Contrary to the impression gained from the qualitative interviews, this view was more common among New Zealand respondents (81%) than among Samoan respondents (70%). When asked about why antibiotics might be useful, the most common answer given was that antibiotics prevent the cold or flu from getting worse (73% of those who thought antibiotics were useful for colds and flu). Making colds and flu get better sooner (52%), relieving symptoms (47%), and preventing serious illness (39%) were also common answers.

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Discussion 

This study showed that, in Western terms, Samoan people tended to lack knowledge of antibiotics, were confused about what antibiotics do, and lacked understanding about which medicines are antibiotics. It also showed widespread belief that antibiotics are useful for colds and flu, and that antibiotics may be used commonly for these conditions.

Some of the misunderstandings respondents had may be common in the general population. For example, other studies have shown that people often think antibiotics are useful for colds and flu,²⁵ and the idea that antibiotics work on the immune system has been previously noted.³⁵ However, to our knowledge, only 1 other study has found confusion between antibiotics and pain killers, and this was also carried out in a Pacific population.⁸ This confusion and the belief that antibiotics relieve pain was a distinctive feature of the study reported here. Initial analysis of the interviews led us to the conclusion that Samoans simply confuse pain killers with antibiotics. Throughout the interviews, people switched seemingly randomly between a view of antibiotics as pain relievers and killers of microbes, sometimes revealing both views within the same sentence. Further discussions and re-reading have led us to think that this confusion reveals a deeper conflict between Samoan and Western concepts of illness. Samoans seem to equate illness and pain in a different way from Western scientific medicine. Western medicine conceives of a cause of an illness (such as a microbe, injury, blockage) and a range of symptoms caused by the illness. These symptoms may or may not include pain. This model makes the lived experience of illness (the symptoms) less central than the, possibly invisible, processes allegedly causing the experience. In this model, pain might be indicative of nothing (eg, phantom pain), or illness may exist without causing any pain at all (eg, hypertension). In Samoan ways of thinking, perhaps, the lived experience and 1 particular type of lived experience, pain, is central to conceptions of illness. Illness is seen as the presence of pain, and pain is illness. This makes much better sense of our findings, including the respondents who seemed to see greater pain as indicating a more serious illness.

The idea of pain as the central feature of illness and the conflation of pain and infection should, perhaps, be explored further among Western cultures. A recent study found that Belgians who want antibiotics for sore throat may, in fact, be wanting relief from pain.³⁶

Rogers et al³⁷ argue that previous health service use influences future use, either directly (ie, patients learn what is expected, reasonable treatment for symptoms) or indirectly (through talking to others about this). In this study, participants reported that taking antibiotics for flu was common in their community and that health professionals in Samoa routinely prescribed antibiotics for flu. This suggests that the community has learned from health professionals that antibiotics are the appropriate and responsible ways to treat flu. Similarly Little et al³⁸ found that, although receiving antibiotics for sore throats did not alleviate symptoms, it enhanced patients' beliefs in the efficacy of antibiotics. In contrast, in the New Zealand setting, it seemed that doctors were trying to reeducate the community and refusing to prescribe antibiotics. Some participants reported that health professionals had told them that the antibiotics they were prescribed were for pain. Participants may have misunderstood what the health professionals were trying to say because of their existing beliefs about the purpose of antibiotics, or health professionals may have learnt to say things that encourage the patient to take antibiotics. However, 1 risk associated with this approach is that patients may stop taking antibiotics when their pain ceases.

The investigators examined views regarding colds and flu specifically, because, in many countries, inappropriate use of antibiotics for these conditions is a significant cause of antibiotic resistance. Public education campaigns about antibiotics frequently involve arguments that colds and flu are caused by viruses, and therefore, cannot be treated by antibiotics. This relies on some basic knowledge and shared understandings; that is, colds and flu are caused by some kind of microbes, antibiotics kill microbes, and different types of microbes cause different illnesses. These assumptions were not shared by many study participants, who in addition to being unaware of the microbe-killing role of antibiotics, frequently cited beliefs in nonmicrobial causes of colds and flu. Those who mentioned microbial causes of colds and flu often believed that bacteria caused them.

Public education that emphasizes appropriate responses to minor health problems, such as the Australian “common colds need common sense”³⁹ campaign, may be more appropriate for Samoan people rather than campaigns that directly address antibiotic use as a separate issue. The latter run the risk of either assuming knowledge and beliefs that Samoan people often do not share or of having to include long and complex explanations (eg, about the difference between viruses and bacteria and the viral origin of colds and flu). Campaigns that emphasize appropriate responses to minor and self-limiting health problems could be made culturally appropriate by drawing on and reinforcing traditional cultural ways of dealing with these problems.

There are several limitations of the study, including the possibility that some groups were underrepresented in the sample. Interviewing people in health care facilities is likely to lead to overrepresentation of frequent care seekers. Participants may, sometimes, have been less focused on the interview, because they were concerned about their health problems. The semi-structured interviews varied considerably in length and depth. Two interviewers were health professionals who were not experienced qualitative interviewers. These interviews were shorter, and participants seemed to try to emphasize their compliance with Western treatment, whereas participants interviewed by the 2 non-health professionals who were experienced qualitative interviewers did not seem to do this. However, the fact that nonoptimal use of antibiotics was reported by participants interviewed by health professionals and non-health professionals alike strengthens the argument that there is widespread lack of understanding of antibiotics among Samoans.

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Conclusion 

The distinctive features of Samoan participants' views were the identification of antibiotics as pain killers and confusion between infection and pain. This may reflect Samoan views of illness, which do not distinguish illnesses from symptoms. Widespread use of antibiotics for inappropriate conditions is also likely to have been influenced by previous encounters with health services.

It cannot be assumed that non-Western people share Western understanding of health problems and treatments. Participants' lack of clarity about which medicines are antibiotics has consequences on attempts to promote the rational use of antibiotics through public education campaigns or though individual counseling. Direct exhortations to reduce antibiotic use should probably be avoided, because Samoan people may respond by reducing the use of other essential medicines, thinking these are antibiotics.

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Acknowledgments 

This study was funded by the Health Research Council of New Zealand. The authors would like to thank the participants; the health facilities in New Zealand and Samoa, who allowed us to conduct interviews on their premises; P'ai Reupuna for conducting the semi-structured interviews in Savai'i; Anh Nguyen for making the photo prompts in New Zealand; Lynn Cheong for help with questionnaire; the Health Research Council for funding the study; and Dr Asiata Saleimoa Va'ai for help with translation.

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Appendix 1. Semi-structured interview guide 

General introductory discussion about the participant, their family situation, employment etc.Beliefs about and responses to illness

Encourage the participant to tell the whole story of the illness: what the first symptoms were, what they thought about it at this point, what they did, whether this worked, how long they tried it for, how the symptoms developed, what they thought about it, etc.Access to health services

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Appendix 2. Structured interview schedule 

Samoan People's Antibiotic Knowledge And Use

If born in NZ, how much time spent in Samoa?

For the following questions, you may choose more than one answer.

What did you take these for?

For the following questions, you may choose more than one answer.

The antibiotics we want to know about are Penicillin, Amoxyl, Amoxicillin, Augmentin

For the following questions, you may choose more than one answer.

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