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Journal of Immigrant and Minority Health

, Volume 17, Issue 4, pp 1177–1184 | Cite as

Are There Differences in Antibiotic Use Between the Recent-Immigrants from Mainland China and the Local-Born in Hong Kong?

  • Yuk Tsan Wun
  • Tai Pong LamEmail author
  • Kwok Fai Lam
  • Pak Leung Ho
  • Wai Hung Raymond Yung
Original Paper

Abstract

Immigrants, especially the first-generation, were thought to have different knowledge, attitudes and practice (KAP) with antibiotics. Doctors often perceived extra pressure from them to prescribe antibiotics. To test these perceptions, we studied the difference in KAP with antibiotics between the recent-immigrants from mainland China and the local-born of Hong Kong—places with significantly different healthcare and socio-economic systems. Focus groups (including one specific group of recent-immigrants) with 56 participants and territory-wide telephone questionnaire survey with 2,471 randomly selected respondents. Recent-immigrants shared similar KAP with the local-born. After adjustment for age, sex and education, the main significant difference was the new-immigrants’ behaviour of acquiring antibiotics without prescription and keeping the leftover. They, like the local-born, preferred doctors who prescribed antibiotics cautiously. Immigration status could be the surrogate for age, sex and education in the KAP with antibiotics. For antibiotic use, health education and patient care could be similar between the recent-immigrants and the local-born.

Keywords

Antibiotics Knowledge Attitudes Behaviour Immigrant 

Introduction

People from different countries vary markedly in their knowledge, attitudes and practice (KAP) with antibiotics due to different cultures, economies and healthcare systems [1, 2, 3, 4, 5, 6]. Accordingly, strategies to promote proper use of antibiotics and hence prevent antibiotic resistance need to be consistent with people’s socio-cultural background [2]. These might not be simple tasks for countries which regularly accept immigrants from diverse cultures (like North America) or accommodate influx of people from allied countries (like European Union). Self medication, with antibiotics in particular, is common in many countries and immigrants have been shown to continue with such practice after immigration. For example, the Latino immigrants in the US took antibiotics acquired from their friends or small drug stores in their community [7]. The immigrants in Spain were more likely to self medicate than the native population, with the trend of higher antibiotic use [8].

Physicians unfamiliar with the new immigrants’ expectations might feel more pressure to prescribe, e.g. “immigrants always crave antibiotics” [7]. In a study of the Dutch primary care, the non-western immigrants were more likely than the natives to receive antibiotics [9], and the difference was found only in the first-generation immigrants, not in the second-generation. The postulation was that the second-generation had integrated into the local society. However, if acculturation is the determinant for better use of antibiotics among the immigrants, would this be confined to just the second-generation? This issue of antibiotic use and immigration has not been widely studied.

Hong Kong has been and still is an immigrant city. The population was four millions in 1970 and reached seven millions in 2010. But the birth rate is among the lowest in the world, declining from 16.8 live births per 1,000 population in 1981 to 9.6 in 2006. The origin of most of its immigrants, with fixed annual quota, is mainland China, people of the same ethnicity [10]. Despite Hong Kong has returned from being a British colony to be a Special Administrative Region of China, under the principle of “one country, two systems”, Hong Kong has maintained her British-styled political, judicial and healthcare systems which are distinctly different from mainland China [11, 12]. Furthermore, similar to the colonial days, residents of mainland China are still required to obtain entry-visas to visit or live in Hong Kong. The significant differences in social, political, education and healthcare systems as well as the language difference between mainland China (where Mandarin is used) and Hong Kong (where Cantonese is the principal dialect) have continued to make mainland Chinese substantially different from the local-born of Hong Kong (who often identify themselves as ‘Hongkongers’) in many distinct ways.

Over-prescription and over-use of antibiotics were reported to be common in mainland China [13, 14, 15]. In a southern province, cough and diarrhea were said to be almost universally treated with antibiotics [16]. In Hong Kong the prescription rate of antibiotics for patients with upper respiratory tract infection (URTI) was reported to be 23.7 %, and 26.0 % of patients with URTI expected antibiotics—similar to those reported from western countries [17]. With this background, we aimed to study whether recent-immigrants from mainland China to Hong Kong would have KAP with antibiotics different from the local-born after moving to live in a community with many differences in daily life.

Methods

We define the “recent-immigrants” as people who have immigrated for not more than 10 years. They were all the first-generation immigrants and would have adequate time to familiarize with the host community. The study consisted of qualitative and quantitative parts. Ethics approval was obtained from the local Institutional Review Board.

Qualitative Part

We wrote to 236 community centres in Hong Kong to invite their members for focus-groups. Eight focus-groups (6–8 participants each) were finally conducted with participants of different ages (aged 18 years or over), education levels, and socio-economic strata. One of them consisted of eight recent-immigrants who had stayed in Hong Kong for about 5 years. A recent female immigrant aged 36 was also invited for an in-depth individual interview.

The discussions were conducted in Cantonese, audio-taped and transcribed verbatim. An experienced facilitator conducted the discussions with another investigator experienced in qualitative research in charge. Two independent investigators read and coded all the transcripts separately. They then jointly abstracted themes from the coded texts. The quotations were translated into English for the purpose of this paper.

Quantitative Part

A questionnaire was developed based on the information collected from the focus groups. The face- and content-validity were tested with academic tutors in family medicine and a group of laypeople. It was then pilot-tested on 50 successfully completed telephone interviews and refined. The data from the pilot-test were discarded in the final analysis.

The Social Sciences Research Centre of the University of Hong Kong conducted the survey between 6 pm and 10 pm on weekdays from November to December 2010. All interviewers were trained on the questionnaire and completed a practice interview before making phone calls. A computer software randomly selected household telephone numbers. The target population was Cantonese-speaking residents in Hong Kong. When contact was successfully established, it was first screened for persons aged 18 or over. Out of the adults present, the one with the nearest next birthday was selected, excluding persons with communication difficulties. A maximum of five attempts were made for unanswered lines.

The questionnaire contained, among others, 16 questions on knowledge about antibiotics. To quantify the knowledge level, a score of +1 was given for the correct response to each question, −1 for the incorrect response and 0 for the “don’t know” or refusal. The “knowledge-score” was the sum of these scores. The negative score was used to offset the effect by the respondent’s possibly guessing the answer.

Statistical Analysis

The outcomes of the questionnaire survey would be in terms of some proportions of the respondents. We assumed a “half–half” proportion from the respondents. To ensure that the error would be at most 0.02 with 95 % confidence, a sample size of 2,401 was required.

To minimize refusals to reveal the age, the questionnaire asked which age subgroups (18–19, 20–24, 25–29, …, 65–69, 70–74, ≥75 years) the respondents belonged to. We used the Wilcoxon (Mann–Whitney U) Test to compare the age-subgroups between the local-born and the recent-immigrants. The Pearson Chi squared test and the Student’s t test were used to compare the responses between the recent-immigrants and the local-born. For binary or multinomial responses, multinomial logistic regression analysis was carried out to identify the risk factors associated with the respondent’s choice. A p value <0.05 was considered statistically significant.

Results

Participants Recruited

Focus Groups

A total of 56 participants, 21 males and 35 females aged 20–73 years, took part in the eight focus groups. Of these, 28.8 % had completed tertiary education, 46.2 % secondary, and 25.0 % primary or below. The immigrant group consisted of seven housewives and one male, aged between 27 and 42 years.

Telephone Survey

Of 3,996 successful calls to households, there were 157 calls with language problems and 219 not qualified e.g., no adults. Of the remaining 3,620 calls, 813 refused to be interviewed and 336 did not complete the interview, leaving 2,471 completed interviews (response rate 68.3 %) for analysis.

There were 864 (35.0 %) males and 1,607 (65.0 %) females. As for the birthplace, 1,634 (66.1 %) were born in Hong Kong, 729 (29.5 %) in mainland China, and 88 (3.6 %) elsewhere, with 20 (0.8 %) refusals. Of all the immigrants from mainland China, 134 arrived within the past 10 years and therefore classified as recent-immigrants. Their mean year in Hong Kong was 7.4 ± 2.74 years. Relative to the local-born, the respondents in the recent-immigrant group were significantly younger (Wilcoxon V = 325, p < 0.001, Table 1), with a significantly higher proportion of females (χ2 = 26.460, p < 0.001), and a significantly higher proportion of respondents with secondary education (χ2 = 27.223, p < 0.001).
Table 1

Frequency of questionnaire recruits under age-group, education level and sex

 

Local-born n = 1,634

Recent-immigrants n = 134

Mean age (years)

45–49

35–39

Male/female

584/1,050 (1:1.8)

18/116 (1:6.4)

Education (%)a

 Primary education or below

214 (13.2)

7 (5.3)

 Secondary education

827 (51.1)

99 (74.4)

 Tertiary education

577 (35.7)

27 (20.3)

aSome data in the categories were missing due to the respondents’ refusals

Knowledge

While the focus-group participants knew that antibiotics killed bacteria, they were uncertain about terms like drug resistance, anti-inflammatory drugs, (in)effectiveness against viral infections like URTI, and the side-effects. The recent-immigrants were not different from the local-born. Some exemplary quotes were:

[Antibiotics were for] killing bacteria and anti-inflammation. (FG4.P1.p1, local; and FG7.P2.p6, immigrant)

I am quite confused with antibiotics and anti-inflammatory drugs. Are they of the same kind? (FG6.P6.p2, local, secondary school teacher)

In the telephone survey, 223 (9.0 %) did not know the term antibiotic-resistance. Apart from being significantly more likely to agree to the effectiveness of antibiotics for urinary tract infection, the local-born were not different from the recent-immigrants in other knowledge questions (Table 2). The mean total knowledge-score was 3.8 ± 3.92 (range −9 to 16) for the local-born and 3.4 ± 3.65 (range −7 to 14) for the recent-immigrants (t = 1.38, p = 0.17). If no negative scores were given, the mean knowledge-scores for the local-born and recent-immigrants were just 8.1 ± 3.02 and 7.7 ± 2.78 respectively out of the possible maximum of 16.
Table 2

Responses to questions on knowledge

Question

Local-born

Recent-immigrants

Know why anti-biotics prescribed (χ2 = 4.403, p = 0.036)

(Excluding 173 respondents who had not been prescribed antibiotics)

 Yes

997 (64.4a)

67 (54.9)

 No

551 (35.6)

55 (45.1)

Different antibiotics for different infections (χ2 = 1.442, p = 0.486)

 Yes

1,380 (84.5)

118 (88.1)

 No

80 (4.9)

6 (4.5)

 DN

174 (10.6)

10 (7.5)

Effective for bacteria (χ2 = 4.514, p = 0.105)

 Yes

1,208 (73.9)

101 (75.4)

 No

126 (7.7)

4 (3.0)

 DN

300 (18.4)

29 (21.6)

Effective for virus (χ2 = 3.339, p = 0.188)

 Yes

926 (56.7)

81 (60.4)

 No

269 (16.5)

14 (10.4)

 DN

439 (26.9)

39 (29.1)

Effective for common cold (χ2 = 1.188, p = 0.552)

 Yes

774 (47.4)

58 (43.3)

 No

560 (34.3)

52 (38.8)

 DN

300 (18.4)

24 (17.9)

Effective for inflamed throat (χ2 = 1.507, p = 0.471)

 Yes

888 (54.3)

79 (59.0)

 No

456 (27.9)

31 (23.1)

 DN

290 (17.7)

24 (17.9)

Effective for urinary tract infection (χ2 = 18.278, p < 0.001)

 Yes

949 (58.1)

54 (40.3)

 No

146 (8.9)

12 (9.0)

 DN

539 (33.0)

68 (50.7)

Undesirable to stop early when symptom-free (χ2 = 1.770, p = 0.413)

 Yes

1,136 (69.5)

86 (64.2)

 No

343 (21.0)

32 (23.9)

 DN

155 (9.5)

16 (11.9)

Undesirable to purchase over the counter (χ2 = 1.487, p = 0.476)

 Yes

1,141 (69.6)

87 (64.9)

 No

314 (19.2)

29 (21.6)

 DN

179 (11.0)

18 (13.4)

Antibiotics have possible side-effects (χ2 = 2.192, p = 0.334)

 Yes

1,197 (73.3)

106 (79.1)

 No

238 (14.6)

15 (11.2)

 DN

199 (12.2)

13 (9.7)

Drowsy as a side-effectb2 = 4.252, p = 0.119)

 Yes

494 (41.3)

45 (42.5)

 No

591 (49.4)

45 (42.5)

 DN

112 (9.4)

16 (15.1)

Loss of appetite as a side-effectb2 = 2.559, p = 0.278)

 Yes

507 (42.4)

48 (45.3)

 No

557 (46.5)

42 (39.6)

 DN

133 (11.1)

16 (15.1)

Sweating as a side-effectb2 = 4.604, p = 0.100)

 Yes

382 (31.9)

40 (37.7)

 No

592 (49.5)

41 (38.7)

 DN

223 (18.6)

25 (23.6)

Only full course to be effectivec2 = 0.046, p = 0.977)

 Yes

913 (85.2)

61 (84.7)

 No

111 (10.4)

8 (11.1)

 DN

47 (4.4)

3 (4.2)

May be ineffective next time if not full coursec2 = 2.164, p = 0.339)

 Yes

652 (60.9)

44 (61.1)

 No

272 (25.4)

22 (30.6)

 DN

147 (13.7)

6 (8.3)

Duration of common cold (χ2 = 7.048, p = 0.133)

 1–3 days

381 (23.3)

22 (16.4)

 4–6 days

419 (25.6)

31 (23.1)

 1–2 weeks

756 (46.3)

77 (57.5)

 >2 weeks

37 (2.3)

2 (1.5)

 DN

41 (2.5)

2 (1.5)

DN don’t know

aPercentage within the birthplace group

bAnalyzed only respondents who agreed with possible side-effects from antibiotics

cAnalyzed only respondents who always finished the full course of antibiotics

Though the local-born were marginally more likely to know why antibiotics were prescribed to them, this difference was not significant after adjustment for age, sex, and education (p = 0.061) with a logistic regression analysis. However, the local-born were still more likely to be correct with urinary tract infection even after the same adjustment (odds ratio (OR) of giving a correct response for the local-born relative to the recent-immigrants was 2.401, 95 % CI 1.624, 3.548).

Attitudes

Many focus-group participants accepted the doctor’s authority and trusted his/her decision on antibiotics. The recent-immigrants encountered treatment different from what they had before immigration, and had mixed feelings on this.

To almost every child and adult in the mainland, when they get sick, they always receive this kind of treatment [intravenous infusion]. However, in Hong Kong, doctors tend to prescribe ordinary drugs, not to mention antibiotics. It took longer to recover from the ailments. And so the kid had to suffer a longer period. (In-depth interview, immigrant)

I trust doctors in Hong Kong. … [In the mainland,] intravenous infusion is for every condition. Doctors in Hong Kong prescribe lesser drugs. Doctors in the mainland prescribe a large pack of drugs after the infusion. (FG7.P1.p3&p27, immigrant)

In the telephone survey, the local-born and the recent-immigrants shared similar attitudes (Table 3) except that the recent-immigrants were more likely to prefer physicians who would prescribe antibiotics on request (χ2 = 10.793, p = 0.013). After adjustment for age, sex and education, there was no significant association between the immigration status and the preferred physicians [multinomial logistic regression likelihood ratio test statistic for: immigration status was 6.728 (p = 0.151), age 45.911 (p < 0.001), education 30.606 (p < 0.001), sex 7.111 (p = 0.130)].
Table 3

Responses to questions on attitudes

Question

Local-born

Recent-immigrants

Taking more courses of antibiotics would weaken immunity (χ2 = 0.006, p = 0.940)

 Agree

1,267 (85.4a)

103 (85.1)

 Disagree

217 (14.6)

18 (14.9)

Fewer courses of antibiotics taken would lead to less drug resistanceb2 = 2.687, p = 0.101)

 Agree

1,214 (88.6)

90 (83.3)

 Disagree

156 (11.4)

18 (16.7)

Fewer prescriptions by doctors would lead to less drug resistanceb2 = 0.519, p = 0.471)

 Agree

1,139 (85.4)

87 (82.9)

 Disagree

194 (14.6)

18 (17.1)

Antibiotic resistance was a serious problem in Hong Kongb2 = 0.184, p = 0.668)

 Agree

887 (72.9)

63 (70.8)

 Disagree

330 (27.1)

26 (29.2)

Interviewee could help in reducing antibiotics resistanceb2 = 0.286, p = 0.593)

 Agree

543 (41.7)

39 (39.0)

 Disagree

758 (58.3)

61 (61.0)

Type of doctor’s antibiotics-prescribing behaviour preferred (χ2 = 10.793, p = 0.013)

 Rarely

631 (41.7)

58 (46.0)

 Readily

25 (1.7)

5 (4.0)

 On request

69 (4.6)

11 (8.7)

 Indifferent

790 (52.1)

52 (41.3)

aPercentage within the birthplace group

b223 respondents did not know what drug resistance was and were excluded from analysis

Practice

Few participants in the focus groups had ever asked the doctors for antibiotics. The main reason was their trust in the doctors. One immigrant had even refused the doctor’s prescription.

…. Usually during consultation, the doctor would ask me whether I would like to take [those medicines]. In fact, I had no idea and would let the doctor make the decision. It’s because even though I paid for the consultation, to a certain degree, I surrendered my health and my life to him [for his care]. … (FG3.P8.p10, local)

My son just started having a fever of 100 °C and the doctor wanted to prescribe antibiotics. The government always says ‘Don’t abuse antibiotics’. So I did not accept it. (FG7.P8.p10, immigrant)

It was common among all the focus groups that the full course of antibiotics was often not completed. The main reasons included symptomatic recovery before the end of full course, worry about and/or troubled by the side-effects. The unused antibiotics were often kept for future use.

And most of the time, it would only take 2 days for the illness and pain to be gone. After that, we kept the rest [of the drugs] in the refrigerator for recycle [later use]. (FG6.P5.p2, local)

He [husband] often stopped taking the drugs when feeling well. He said he was worried about the side-effects. (FG7.P3.p13, immigrant)

Another frequent practice among the focus groups was acquiring drugs without prescriptions over the counter. But antibiotics were not easily available. (It is illegal to dispense antibiotics without a prescription.)

Those drugs were bought for prevention. …. My home always had some kinds of drugs. (FG1.P4.p5, local)

[After a few episodes], I bought antibiotics [from drug stores] for my gastro-enteritis. (FG1.P8.p10, a participant who lived in mainland China before but not in the immigrant group)

No, antibiotics are not on sale in the drug stores [here]. (FG7.P2.p20, immigrant)

Of all the telephone respondents, 216 (8.7 %) had ever asked their doctors for antibiotics, 150 (6.1 %) had kept left-over antibiotics for future use, and 191 (7.7 %) had bought antibiotics over the counter. The recent-immigrants were less likely than the local-born to finish the full course (Table 4). They were also more likely to buy antibiotics over the counter and keep the left-over. After the adjustment for age, sex and education, the recent-immigrants were still significantly more likely to keep left-over (OR 2.37, 95 % CI 1.29, 4.15) and to acquire antibiotics without prescriptions (OR 2.37, 95 % CI 1.28, 4.15). Age, sex and education were the significant determinants for completing the full course of antibiotics; the immigration status was not (the recent-immigrants relative to the local-born OR 0.71. 95 % CI 0.46, 1.06).
Table 4

Responses to questions on practice

Question

Local-born

Recent-immigrants

Ever asked doctor for antibiotics (χ2 = 1.347, p = 0.246)

 Yes

136 (8.3a)

15 (11.3)

 No

1,493 (91.7)

118 (88.7)

Expected but did not ask (χ2 = 0.444, p = 0.505)

 Yes

311 (21.4)

27 (24.1)

 No

1,141 (78.6)

85 (75.9)

Treated with antibiotics during last common cold (χ2 = 2.749 p = 0.097)

 Yes

204 (13.6)

24 (18.9)

 No

1,298 (86.4)

103 (81.1)

Accepted doctor’s offer of antibiotics (χ2 = 0.698, p = 0.403)

 Yes

464 (62.5)

46 (67.6)

 No

278 (37.5)

22 (32.4)

Finish the full course (χ2 = 6.101, p = 0.014)

 Always

1,071 (70.7)

72 (60.0)

 Not always

443 (29.3)

48 (40.0)

Kept left-over for future use (χ2 = 11.568, p < 0.001)

 Yes

93 (6.1)

17 (14.0)

 No

1,443 (93.9)

104 (86.0)

Bought antibiotics over the counter (χ2 = 4.996, p = 0.025)

 Yes

112 (6.9)

16 (12.1)

 No

1,518 (93.1)

116 (87.9)

aPercentage within the birthplace group

The respondents who acquired non-prescription antibiotics over the counter were significantly more likely than their counterparts to keep the leftovers (for the local-born, OR 6.03, 95 % CI 3.46, 10.27; for the recent-immigrants, OR 5.51, 95 % CI 1.35, 21.65).

Discussion

This study compared the local-born with recent-immigrants of the same ethnicity but from different sociopolitical backgrounds, life-styles, education, and healthcare systems and with very different antibiotic use in particular. In the focus groups, some immigrants commented their experience in mainland China before immigration and most of them preferred doctors in Hong Kong who were more cautious in prescribing antibiotics. The telephone survey showed that the essential difference between the recent-immigrants and the local-born was self medication (acquiring antibiotics without prescriptions and keeping the left-over) after the adjustment for age, sex and education.

The notable observation in this study is the close similarity between the local-born and the recent-immigrants in their knowledge of antibiotics. It could be due to the low and very inadequate knowledge in both groups. It is also notable that only the recent-immigrants in the focus groups had cited the Government’s promotion of the proper use of antibiotics suggesting their awareness of health policy in the host community. This suggested that the same education program on the use of antibiotics would reach the immigrants as well as the locals.

The focus-group participants had mixed opinions towards the doctors’ prescribing antibiotics in Hong Kong and mainland China. But the telephone survey showed that the recent-immigrants, like the local-born, preferred doctors with cautious prescribing of antibiotics; even the expectation of antibiotics did not differ between the two groups (Table 4). Doctors had reported to feel under strong pressure to prescribe antibiotics in consultations with immigrants [7]. This study however shows that it is not true in general. As a group, the immigrants would be the same as the locals in the expectation of antibiotics. Doctors could be assured of no extra pressure from the immigrants.

The recent-immigrants differed from the local-born mainly in continuing their old practice of acquiring antibiotics without prescriptions over the counter and keeping the left-over for future use. Both practices were self-medication though only <15 % of the immigrants did so. The association between acquiring non-prescription antibiotics and keeping the leftovers in this study suggests that these two practices came mainly from the same subgroup. Such practice of self medication was also observed in the immigrants in Spain [8] and the Latino immigrants in USA [18]. This practice seems to be common in countries where the control of dispensing prescribed drugs is not stringent. The participants of our focus-groups gave some explanations, including experience of past therapeutic success and convenience. The tight enforcement of dispensing with prescription would prevent this behaviour but their past experience should be addressed in educating them on the proper use of antibiotics.

The probable explanation for the similarity of KAP between the two populations in this study could be partly due to the predominance of young age (below 40 years) in the recent-immigrants. Young immigrants had been shown to be more likely to integrate into the host population. Wilkinson et al. [19] showed that young Mexican immigrants were more likely than the older ones to be ever smokers like the American-born. Likewise, female Latino immigrants who arrived in US when younger than 25 years of age were more likely than the others to be physically active as the American peers [20]. Our recruited immigrants might have integrated with the local-born and shared similar KAP with antibiotics. Irrespective of the probable explanation, this study showed that the first-generation immigrants should not be presumed to be very different.

Limitations

The immigrants in this study were unique in being of the same ethnically with the host community, different from the inter-ethnic immigrants in other countries. However, at the time of the study, there were great differences in social, education and healthcare systems between the host and the original communities; the immigrants were shown to be socially disadvantaged and excluded from the host community as other inter-ethnic immigrants [21]. Language was shown to be the most significant predictor of the immigrants’ adaptation to the host community [22], and language barrier was postulated to explain the more healthcare use [23] or antibiotic use in the first-generation immigrants [9]. The local dialect in Hong Kong is very different from the rest of mainland China except places in close proximity with Guangzhou (Canton city), and the written language is Traditional instead of Simplified Chinese characters. The immigrants have to re-learn a language though perhaps with lesser difficulties than the inter-ethnic immigrants. On the other hand, by recruiting respondents who spoke the local dialect, this study might have included a biased population who had successfully acculturated into the host community. But this potential bias does not contradict the conclusion that the recent-immigrants could share closely similar KAP with the local natives.

This was a cross-sectional study. The immigrants’ previous KAP and hence whether any change after immigration were unknown although the focus-group participants confirmed the differences of antibiotic use in the communities before and after immigration. This study could only show whether there were differences and what they were. We used the cutoff point of 10 years to define our immigrant group and the mean years after immigration was close to seven—the legal requirement of residency for citizenship. Five to 10 years after immigration were shown to be the time when socio-cultural adaptation was most substantial [22, 24]. This study however was not designed to demonstrate the role of acculturation. This study recruited only 134 recent-immigrants. They constituted 5.4 % of the total recruits of 2,471 respondents, but were consistent with the proportion of new immigrants in the local population. According to the Sub-census in 2006, 3.5 % of the population were immigrants who had arrived <7 years [25].

This study analyzed the respondents’ self-reported practices that were not validated. What the respondents reported might not be same as what they did. But we believe that such discrepancy, if present, would be small. We covered the respondents’ practice with antibiotics with non-judgmental statements or questions, in both the focus groups and the questionnaire survey. There was no indication as to what was right or wrong, and the respondents were asked to report what they did rather than what they would do. People in the focus group commented that they were unable to buy non-prescribed antibiotics over the counter, but not that such buying was right or wrong. The respondents apparently had no cause to cover their practice and, hence, what they reported was likely to be what they did.

Conclusions

Immigrants who have lived in the host community up to 10 years could have similar KAP with antibiotics as the local-born. The only significant differences were the practice of keeping the left-over and acquiring antibiotics without prescriptions over the counter, taken from their past experience. The notion that immigrants exert extra pressure for the prescription of antibiotics and that the first-generation immigrants were very different from the native community in the preference of antibiotics may be misconceptions caused by individuals rather than the population in general. Strategies for the proper use of antibiotics should aim at the diversities in age, education and sex, rather than the immigration status.

Notes

Acknowledgments

The work described in this paper was fully supported by a grant from the Research Fund for the Control of Infectious Diseases of the Hong Kong Special Administrative Region, China (Project No. 09080852). We would like to thank all those individuals who participated in the focus groups, individual interviews and telephone surveys.

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Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Yuk Tsan Wun
    • 1
  • Tai Pong Lam
    • 1
    Email author
  • Kwok Fai Lam
    • 2
  • Pak Leung Ho
    • 3
  • Wai Hung Raymond Yung
    • 4
  1. 1.Department of Family Medicine and Primary CareThe University of Hong KongAp Lei ChauHong Kong
  2. 2.Department of Statistics and Actuarial ScienceThe University of Hong KongPokfulamHong Kong
  3. 3.Carol Yu Centre for Infection, Department of MicrobiologyThe University of Hong KongPokfulamHong Kong
  4. 4.Hong Kong Sanatorium and HospitalHappy ValleyHong Kong

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