High proportions of self-medication were similar in both pharmacies, despite the differences in monthly income and educational level. This differs with findings in other studies. One comparative study in Brazil documented a higher prevalence of self-medication in higher socio-economic classes versus lower socio-economic classes; higher socio-economic patients paid out of pocket for their medications and lower socio-economic patients had free access to medication. In this Brazilian study, paying for medications was a positive factor associated to self-medication [26]. Another study in Mexico showed that low socio-economic status and lower educational level were positively associated to self-medication [11]. Practices in self-medication and their relation to socio-economic status have been defined in these settings, but to our knowledge this has not been previously established in Guatemala. Our findings suggest that self-medication with antibiotics in this urban Guatemala City setting is high despite differences in monthly income and educational level.

More women came to pharmacies to self-medicate with antibiotics than men in both settings. This is similar to a recent study carried out in Chile whose findings indicated that 73% of those who self-medicated were female [10]. The high proportion of females who self-medicate has also been reported in several LMIC, OECD and European countries [3] with the exception of Nepal, Syria and the United Arab Emirates [8,18,27]. In Mexico women have been reported to self-medicate themselves or their children more often than men, in this context, authors agreed that women should be targeted in health-education campaigns [7]. One study in rural Peru interviewed heads of the household in order to understand characteristics surrounding those who self-medicate. The head of the household was predominately male and responded more frequently to the questionnaire, however, there was no significant association found between gender and self-medicating practices [14]. The patterns of women who self-medicate are unknown in rural areas of Guatemala, in other urban areas outside of Guatemala City, and in areas with high proportions of indigenous people who do not use Spanish as their first language. These factors may affect the proportion of men and women who obtain medications from the pharmacy in order to self-medicate. Further investigation regarding gender and self-medication is warranted in Guatemala given that the gender of those who self-medicate may vary based on pharmacy and socio-cultural practices of each region.

We found that participants of a lower socio-economic status go to family or friends for advice when self-medicating, whereas those of a higher socio-economic status more frequently talk to a pharmacy technician although they also rely on family. In a recent review of 70 studies looking at self-medication, 8 studies cited family as the major source of information for those who self-medicate. Seven studies cited friends and only 6 studies recorded pharmacists as the primary source of drug-information [3]. A recent study in older Mexican participants showed that respondents seek out advice first from family (30%), followed by a pharmacist (27%) [11]. In Guatemala we see a significant difference in whom participants are willing to approach for advice based on their socio-economic status. These findings would likely be important when designing educational programs aiding participants in the selection of self-medication.

The majority of respondents in both pharmacies indicated that self-medication has a positive effect on their health. Previous studies have emphasized the dangers in self-medicating with antibiotics. Side effects, incorrect drugs or dosages and antibiotic resistances are all factors that make the practice problematic [1,7,28]. Patient awareness surrounding the “how”, “why” and “when” to use antibiotics as well as the risks involved in self-medication with antibiotics may be created through educational initiatives. One study reviewed LMIC pharmacy interventions and placed an emphasis on the educational services pharmacists may provide in order to improve outcomes [9]. These types of services must go beyond classifying medication use as “good or bad” [29]. If educational services are to be implemented, they must be all-inclusive resulting in a comprehensive educational plan for those who self-medicate [6,9,13]. There must be support within the local health-system giving incentive to form sustainable educational programs in the community. The gender of those who self medicate, how the socio-economic status influences self-medication, with whom respondents are willing to go to for advice, and techniques by which participants receive information about self-medicating all contribute to developing educational and political movements to ensure the safety and efficacy of antibiotic use.

Participants in this study did not read the antibiotic information handout associated with the medications they purchased, regardless of their socio-economic status and educational level. Educational level plays an important role when deciding how to effectively design drug information for participants [9]. Informing patients about a medication’s indications, posology and side effects using means other than patient handouts that accompany medications is an important challenge if antibiotic use is to be addressed. Although all participants had some level of schooling, patient handouts accompanying medications may be inadequate in Guatemala given that the majority of self-medicators did not have a secondary school education. Combining the risks of self-medication with the demographic data we have gathered, we provide a basis for initiating educational policies surrounding medication use in the urban setting of Guatemala.

The majority of respondents purchased antibiotics from pharmacies where antibiotics are sold in the absence of any medical regulation, contributing to irrational use and antimicrobial resistance. In most LMIC, the debate of antibiotic regulation skews towards authorization of unregulated vendors selling antibiotics in order to maintain reasonable access to medications [30,31]. Additionally, competing interests of the pharmaceutical industry and pharmacy chains promote unregulated use of antibiotics [30]. Nevertheless, restricted and regulated use of antibiotics is of public health concern both locally and for many globally recognized organizations [2,28].

There is currently no law in Guatemala requiring the continual presence of a pharmacist in the pharmacy. Trained health care professionals do not monitor the sale and dispensing of antibiotics in Guatemala in community pharmacies, and there is no law requiring a prescription for antibiotic use; prescriptions are only required for controlled substances. Both factors -absence of health care professionals in the pharmacy and lack of regulations- lead to irrational use of antibiotics and antimicrobial resistance. This presents an opportunity for developing the role of the pharmacist in guiding the rational use of antibiotics in Guatemala where we have shown that a proportion of respondents seek advice from pharmacists. Fundamental to the policy development surrounding the role of a pharmacist is the establishment of associated laws regulating the dispensing of medications [14]. Relationships with other health care professionals, social pressures and conflicts of business and professional roles must be taken into account in this type of policy development [9]. Restructuring and eventual development of the role of the pharmacist may improve safe and rational use, affordability and accessibility of antibiotics in Guatemala [9,12].

Limitations of this study include those inherent to the cross-sectional research design, as well as the use of purposeful sampling for selecting the pharmacies. The study is not population-based and therefore its results cannot be assumed to be generalizable to all pharmacies in Guatemala City or to Guatemala City. The study did not ask qualitative questions that allowed participants to provide their own explanations and meanings around self-medication.

The results of our study contribute to a better understanding of why people self-medicate, the characteristics of those who self-medicate and how people self-medicate in Guatemala and should be complemented with further investigations that include pharmacies located in other urban and rural settings. It is also important to determine which, if any, side effects participants may experience as a result of self-medicating with antibiotics and if their perceived risk of self-medication changes across rural versus urban settings. Also, it may be important to know if participants perceive self-medication as “curative” or, if as a result of their practice, they have to see a physician to improve health outcomes. Additionally, further studies may focus on health literacy and the health systems dimensions of this problem.