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Brisley A, Lambert H, Rodrigues C. Antibiotics in Catalan Primary Care: Prescription, Use and Remedies for a Crisis of Care. Med Anthropol 2023; 42:682-696. [PMID: 37747451 PMCID: PMC10561602 DOI: 10.1080/01459740.2023.2256451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Antimicrobial resistance is one of the twenty-first century's major health challenges. Linked to the extensive use of antibiotics and other antimicrobials, resistance occurs when microbes stop responding to medications. Rates of antibiotic consumption in Spain are among the highest in Europe. Drawing on research conducted in Catalonia, in this article we present findings from ethnographic fieldwork and semi-structured interviews with general practitioners, residents of Barcelona, and professionals who have worked in antibiotic stewardship. We argue that the circulation of antibiotics should be understood in relation to broader historical processes and the deficient systems of health and social care provision they have produced.
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Affiliation(s)
- Adam Brisley
- Business and Technology Department, La Salle, Universitat Ramon Llull, Barcelona, Spain
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carla Rodrigues
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Sociology, University of Amsterdam, Amsterdam, The Netherlands
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2
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Lambert H, Shen X, Chai J, Cheng J, Feng R, Chen M, Cabral C, Oliver I, Shen J, MacGowan A, Bowker K, Hickman M, Kadetz P, Zhao L, Pan Y, Kwiatkowska R, Hu X, Wang D. Prevalence, drivers and surveillance of antibiotic resistance and antibiotic use in rural China: Interdisciplinary study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001232. [PMID: 37556412 PMCID: PMC10411760 DOI: 10.1371/journal.pgph.0001232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 05/22/2023] [Indexed: 08/11/2023]
Abstract
This study aimed to characterise antibiotic prescribing and dispensing patterns in rural health facilities in China and determine the community prevalence of antibiotic resistance. We investigated patterns and drivers of antibiotic use for common respiratory and urinary tract infections (RTI/UTI) in community settings, examined relationships between presenting symptoms, clinical diagnosis and microbiological results in rural outpatient clinics, and assessed potential for using patient records to monitor antibiotic use. This interdisciplinary mixed methods study included: (i) Observations and exit interviews in eight village clinics and township health centres and 15 retail pharmacies; (ii) Urine, throat swab and sputum samples from patients to identify potential pathogens and test susceptibility; (iii) 103 semi-structured interviews with doctors, patients, pharmacy workers and antibiotic-purchasing customers; (iv) Assessment of completeness and accuracy of electronic patient records through comparison with observational data. 87.9% of 1123 recruited clinic patients were prescribed antibiotics (of which 35.5% contained antibiotic combinations and >40% were for intravenous administration), most of whom had RTIs. Antibiotic prescribing for RTIs was not associated with presence of bacterial pathogens but was correlated with longer duration of infection (OR = 3.33) and presence of sore throat (OR = 1.64). Fever strongly predicted prescription of intravenous antibiotics (OR = 2.87). Resistance rates in bacterial pathogens isolated were low compared with national data. 25.8% of patients reported antibiotics use prior to their clinic visit, but only 56.2% of clinic patients and 53% of pharmacy customers could confirm their prescription or purchase included antibiotics. Diagnostic uncertainty, financial incentives, understanding of antibiotics as anti-inflammatory and limited doctor-patient communication were identified as key drivers of antibiotic use. Completion and accuracy of electronic patient records were highly variable. Prevalence of antibiotic resistance in this rural population is relatively low despite high levels of antibiotic prescribing and self-medication. More systematic use of e-records and in-service training could improve antibiotic surveillance and stewardship in rural facilities. Combining qualitative and observational anthropological methods and concepts with microbiological and epidemiological investigation of antibiotic resistance at both research design and analytic synthesis stages substantially increases the validity of research findings and their utility in informing future intervention development.
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Affiliation(s)
- H. Lambert
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - X. Shen
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - J. Chai
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - J. Cheng
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - R. Feng
- Library Department of Literature Retrieval and Analysis, Anhui Medical University, Hefei, China
| | - M. Chen
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - C. Cabral
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - I. Oliver
- Field Service, National Infection Service, UK Health Security Agency, Bristol, United Kingdom
| | - J. Shen
- Fourth Affiliated Hospital of Anhui Medical University, Hefei, China
| | - A. MacGowan
- Severn Pathology, North Bristol NHS Trust, Bristol, United Kingdom
| | - K. Bowker
- Severn Pathology, North Bristol NHS Trust, Bristol, United Kingdom
| | - M. Hickman
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - P. Kadetz
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - L. Zhao
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Y. Pan
- First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - R. Kwiatkowska
- Field Service, National Infection Service, UK Health Security Agency, Bristol, United Kingdom
| | - X. Hu
- Anhui Provincial Hospital, Hefei, China
| | - D. Wang
- School of Health Services Management, Anhui Medical University, Hefei, China
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Noor MN, Liverani M, Bryant J, Rahman-Shepherd A, Sharif S, Aftab W, Shakoor S, Khan M, Hasan R. The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan. HEALTH SOCIOLOGY REVIEW : THE JOURNAL OF THE HEALTH SECTION OF THE AUSTRALIAN SOCIOLOGICAL ASSOCIATION 2023; 32:198-212. [PMID: 36322797 DOI: 10.1080/14461242.2022.2139628] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 10/10/2022] [Indexed: 05/18/2023]
Abstract
Incentivisation of general practitioners (GPs) by pharmaceutical companies is thought to affect prescribing practices, often not in patients' interest. Using a Bourdieusian lens, we examine the socially structured conditions that underpin exchanges between pharmaceutical companies and GPs in Pakistan. The analysis of qualitative interviews with 28 GPs and 13 pharmaceutical sales representatives (PSRs) shows that GPs, through prescribing medicines, met pharmaceutical sales targets in exchange for various incentives. We argue that these practices can be given meaning through the concept of 'field' - a social space in which GPs, PSRs, and pharmacists were hierarchically positioned, with their unique capacities, to enable healthcare provision. However, structural forces like the intense competition between pharmaceutical companies, the presence of unqualified healthcare providers in the healthcare market, and a lack of regulation by the state institutions produced a context that enabled pharmaceutical companies and GPs to use the healthcare field, also, as space to maximise profits. GPs believed the effort to maximise incomes and meet socially desired standards were two key factors that encouraged profit-led prescribing. We conclude that understanding the healthcare field is an important step toward developing governance practices that can address profit-led prescribing.
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Affiliation(s)
- Muhammad Naveed Noor
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Marco Liverani
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Joanne Bryant
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Afifah Rahman-Shepherd
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Sabeen Sharif
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Wafa Aftab
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sadia Shakoor
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Mishal Khan
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Rumina Hasan
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
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Wang J, Li F, Chen Z, Guo Y, Liu N, Liu B, Xiao S, Yao L, Li J, Zhuo C, He N, Zou G, Zhuo C. Antibiotic Prescription Patterns for Acute Respiratory Infections in Rural Primary Healthcare Settings in Guangdong, China: Analysis of 162,742 Outpatient Prescriptions. Antibiotics (Basel) 2023; 12:antibiotics12020297. [PMID: 36830207 PMCID: PMC9952100 DOI: 10.3390/antibiotics12020297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 02/04/2023] Open
Abstract
Overuse and inappropriate use of antibiotics are important contributors to bacterial antimicrobial resistance (AMR), especially in ambulatory primary healthcare (PHC) settings in low- and middle-income countries. This study aimed to investigate antibiotic prescription patterns among patients with acute respiratory infections (ARIs) in rural PHC facilities in the Guangdong Province, China. A total of 444,979 outpatient prescriptions were extracted from the electronic medical record system of 35 township health centers (THCs) and 2 community health centers (CHCs) between November 2017 and October 2018. We used the chi-square test to analyze the antibiotic prescription patterns and binary logistic regression to explore patient-related factors associated with antibiotic prescriptions. Of the 162,742 ARI prescriptions, 85.57% (n = 139,259) included at least one antibiotic. Among the 139,259 prescriptions with antibiotics, 37.82% (n = 52,666) included two or more antibiotics, 55.29% (n = 76,993) included parenteral antibiotics, and 56.62% (n = 78,852) included Watch group antibiotics. The binary logistic regression indicated that (1) female patients were slightly less likely to be prescribed antibiotics than males (adjusted odds ratio (OR) = 0.954, 95% confidence interval [CI] [0.928-0.981]; p = 0.001); and (2) compared to patients aged ≤5 years, those who were 6-15 years old (adjusted OR = 1.907, 95% CI [1.840-1.978]; p < 0.001), 16-60 years old (adjusted OR = 1.849, 95% CI [1.785-1.916]; p < 0.001), and >60 years old (adjusted OR = 1.915, 95% CI [1.810-2.026]; p < 0.001) were more likely to be prescribed antibiotics. The overuse and irrational use of antibiotics in PHC settings remain major healthcare challenges in rural Guangdong. Thus, it is imperative to implement targeted antimicrobial stewardship (AMS) policies to address this problem.
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Affiliation(s)
- Jiong Wang
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Feifeng Li
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Zhixu Chen
- Department of Respiratory and Critical Care Medicine, Meizhou People’s Hospital, Meizhou 514000, China
| | - Yingyi Guo
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Ningjing Liu
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Baomo Liu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510000, China
| | - Shunian Xiao
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Likang Yao
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Jiahui Li
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Chuyue Zhuo
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Nanhao He
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Guanyang Zou
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
- Correspondence: (G.Z.); (C.Z.)
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
- Correspondence: (G.Z.); (C.Z.)
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Antibiotic Prescribing in Outpatient Settings: Rural Patients Are More Likely to Receive Fluoroquinolones and Longer Antibiotic Courses. Antibiotics (Basel) 2023; 12:antibiotics12020224. [PMID: 36830137 PMCID: PMC9952143 DOI: 10.3390/antibiotics12020224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Suboptimal antibiotic prescribing may be more common in patients living in rural versus urban areas due to various factors such as decreased access to care and diagnostic testing equipment. Prior work demonstrated a rural health disparity of overprescribing antibiotics and longer durations of antibiotic therapy in the United States; however, large-scale evaluations are limited. We evaluated the association of rural residence with suboptimal outpatient antibiotic use in the national Veterans Affairs (VA) system. Outpatient antibiotic dispensing was assessed for the veterans diagnosed with an upper respiratory tract infection (URI), pneumonia (PNA), urinary tract infection (UTI), or skin and soft tissue infection (SSTI) in 2010-2020. Rural-urban status was determined using rural-urban commuting area codes. Suboptimal antibiotic use was defined as (1) outpatient fluoroquinolone dispensing and (2) longer antibiotic courses (>ten days). Geographic variation in suboptimal antibiotic use was mapped. Time trends in suboptimal antibiotic use were assessed with Joinpoint regression. While controlling for confounding, the association of rurality and suboptimal antibiotic use was assessed with generalized linear mixed models with a binary distribution and logit link, accounting for clustering by region and year. Of the 1,405,642 veterans diagnosed with a URI, PNA, UTI, or SSTI and dispensed an outpatient antibiotic, 22.8% were rural-residing. In 2010-2020, in the rural- and urban-residing veterans, the proportion of dispensed fluoroquinolones declined by 9.9% and 10.6% per year, respectively. The rural-residing veterans were more likely to be prescribed fluoroquinolones (19.0% vs. 17.5%; adjusted odds ratio (aOR), 1.03; 95% confidence interval (CI), 1.02-1.04) and longer antibiotic courses (53.8% vs. 48.5%; aOR, 1.19, 95% CI, 1.18-1.20) than the urban-residing veterans. Among a large national cohort of veterans diagnosed with URIs, PNA, UTIs, and SSTIs, fluoroquinolone use and longer antibiotic courses were disproportionally more common among rural- as compared to urban-residing veterans. Outpatient antibiotic prescribing must be improved, particularly for rural-residing patients. There are many possible solutions, of which antibiotic stewardship interventions are but one.
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Poompruek P, Perris A, Whanpuch P, Chandler CIR, Sringernyuang L. Mystifying medicines and maximising profit: Antibiotic distribution in community pharmacies in Thailand. Glob Public Health 2022; 17:3931-3943. [PMID: 35282798 DOI: 10.1080/17441692.2022.2049843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Thailand's antimicrobial stewardship strategy has focussed on promoting 'rational drug use' in the public sector, to reduce the threat of drug resistance and control healthcare expenditure. The strategy's next ambition is to attend to the private sector, where antibiotics are widely available over the counter without prescription. Using ethnographic and survey data, this paper follows antibiotics through community pharmacies, to explore drug distribution and access, and identify potential challenges for stewardship. We extend the analytical frame beyond 'irrational' dispenser-customer transactions, to explore the logics of practice of a multiplicity of actors in the context of a highly competitive pharmaceutical market. Highlighting the role of the pharmaceutical industry in mystifying medicines, we show how antibiotics are collapsed into a category of 'strong medicines' and requested by customers using 'prescriptions by proxy'. We further examine how Thailand's drug regulation and classificatory systems, historically orientated around access to medicines, enable the proliferation of antibiotics in the context of contemporary efforts to control distribution. Recognising the negotiations involved in dispensing antibiotics in a pluralistic health system, we attempt to reconfigure allocations of responsibility, advocating for stewardship approaches that take into account local ecologies of care, as well as implications for access, equity, and accountability.
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Affiliation(s)
- Panoopat Poompruek
- Department of Community Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Anna Perris
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Phakha Whanpuch
- Department of Society and Health, Mahidol University, Nakhon Pathom, Thailand
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Cai S, Wang N, Xu L, Yan F, Jiang Q, Zhao X, Wang W, Wang H, Jiang L, Cong W, Sheppard SK, Weeks J, Kasprzyk-Hordern B, Fu C, Lambert H. Impacts of Antibiotic Residues in the Environment on Bacterial Resistance and Human Health in Eastern China: An Interdisciplinary Mixed-Methods Study Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19138145. [PMID: 35805804 PMCID: PMC9266211 DOI: 10.3390/ijerph19138145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023]
Abstract
Antibiotic resistance is a global health challenge that threatens human and animal lives, especially among low-income and vulnerable populations in less-developed countries. Its multi-factorial nature requires integrated studies on antibiotics and resistant bacteria in humans, animals, and the environment. To achieve a comprehensive understanding of the situation and management of antibiotic use and environmental transmission, this paper describes a study protocol to document human exposure to antibiotics from major direct and indirect sources, and its potential health outcomes. Our mixed-methods approach addresses both microbiological and pathogen genomics, and epidemiological, geospatial, anthropological, and sociological aspects. Implemented in two rural residential areas in two provinces in Eastern China, linked sub-studies assess antibiotic exposure in population cohorts through household surveys, medicine diaries, and biological sampling; identify the types and frequencies of antibiotic resistance genes in humans and food-stock animals; quantify the presence of antibiotic residues and antibiotic resistance genes in the aquatic environment, including wastewater; investigate the drivers and behaviours associated with human and livestock antibiotic use; and analyse the national and local policy context, to propose strategies and systematic measurements for optimising and monitoring antibiotic use. As a multidisciplinary collaboration between institutions in the UK and China, this study will provide an in-depth understanding of the influencing factors and allow comprehensive awareness of the complexity of AMR and antibiotic use in rural Eastern China.
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Affiliation(s)
- Shenghan Cai
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Na Wang
- Key Laboratory of Public Health Safety of Ministry of Education, NHC Key Laboratory of Health Technology Assessment, Shanghai 200032, China
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China
| | - Like Xu
- Department of Chemistry, University of Bath, Bath BA2 7AY, UK
| | - Fei Yan
- Key Laboratory of Public Health Safety of Ministry of Education, NHC Key Laboratory of Health Technology Assessment, Shanghai 200032, China
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai 200032, China
| | - Qingwu Jiang
- Key Laboratory of Public Health Safety of Ministry of Education, NHC Key Laboratory of Health Technology Assessment, Shanghai 200032, China
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China
| | - Xinping Zhao
- Key Laboratory of Public Health Safety of Ministry of Education, NHC Key Laboratory of Health Technology Assessment, Shanghai 200032, China
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai 200032, China
| | - Wei Wang
- Key Laboratory of Public Health Safety of Ministry of Education, NHC Key Laboratory of Health Technology Assessment, Shanghai 200032, China
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai 200032, China
| | - Hexing Wang
- Key Laboratory of Public Health Safety of Ministry of Education, NHC Key Laboratory of Health Technology Assessment, Shanghai 200032, China
| | - Lufang Jiang
- Key Laboratory of Public Health Safety of Ministry of Education, NHC Key Laboratory of Health Technology Assessment, Shanghai 200032, China
| | - Wenjuan Cong
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Samuel K Sheppard
- The Milner Centre for Evolution, Department of Biology and Biochemistry, University of Bath, Bath BA2 7AY, UK
- Department of Zoology, University of Oxford, Oxford OX1 2JD, UK
| | | | | | - Chaowei Fu
- Key Laboratory of Public Health Safety of Ministry of Education, NHC Key Laboratory of Health Technology Assessment, Shanghai 200032, China
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai 200032, China
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
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MacPherson EE, Reynolds J, Sanudi E, Nkaombe A, Mankhomwa J, Dixon J, Chandler CIR. Understanding antimicrobial use in subsistence farmers in Chikwawa District Malawi, implications for public awareness campaigns. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000314. [PMID: 36962375 PMCID: PMC10021458 DOI: 10.1371/journal.pgph.0000314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/09/2022] [Indexed: 05/30/2023]
Abstract
Drug resistant infections are increasing across the world and urgent action is required to preserve current classes of antibiotics. Antibiotic use practices in low-and-middle-income countries have gained international attention, especially as antibiotics are often accessed beyond the formal health system. Public awareness campaigns have gained popularity, often conceptualising antimicrobial resistance (AMR) as a problem of excess, precipitated by irrational behaviour. Insufficient attention has been paid to people's lived experiences of accessing medicines in low-income contexts. In Chikwawa District, Malawi, a place of extreme scarcity, our study aimed to understand the care and medicine use practices of households dependent on subsistence farming. Adopting an anthropological approach, we undertook medicine interviews (100), ethnographic fieldwork (six-month period) and key informant interviews (33) with a range of participants in two villages in rural Chikwawa. The most frequently used drugs were cotrimoxazole and amoxicillin, not considered to be of critical importance to human health. Participants recognised that keeping, sharing, and buying medicines informally was not the "right thing." However, they described using antibiotics and other medicines in these ways due to conditions of extreme precarity, the costs and limitations of seeking formal care in the public sector, and the inevitability of future illness. Our findings emphasise the need in contexts of extreme scarcity to equip policy actors with interventions to address AMR through strengthening health systems, rather than public awareness campaigns that foreground overuse and the dangers of using antibiotics beyond the formal sector.
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Affiliation(s)
- Eleanor E. MacPherson
- Blantyre Malawi and Department of Clinical Sciences, Malawi-Liverpool-Wellcome Trust, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Joanna Reynolds
- Sheffield Hallam University and Capacity Q, Sheffield, United Kingdom
| | | | | | | | - Justin Dixon
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clare I. R. Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Xu X, Zhang K, Ma H, Shen X, Chai J, Tang M, Du Y, Xue Q, Guan X, Li G, Wang D. Differences in service and antibiotics use following symptomatic respiratory tract infections between 2016 and 2021 in rural Anhui, China. Epidemiol Infect 2022; 150:e117. [PMID: 35610736 PMCID: PMC9254148 DOI: 10.1017/s0950268822000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In the past 10-15 years, the government of China has made various efforts in tackling excessive antibiotics use. Yet, little is known about their effects at rural primary care settings. This study aimed to determine the impact of government policies and the COVID-19 pandemic on antibiotic prescribing practices at such settings utilizing data from separate studies carried out pre- and during the pandemic, in 2016 and 2021 in Anhui province, China, using identical sampling and survey approaches. Data on antibiotics prescribed, diagnosis, socio-demographic, etc., were obtained through non-participative observation and a structured exit survey. Data analysis comprised mainly descriptive comparisons of 1153 and 762 patients with respiratory infections recruited in 2016 and 2021, respectively. The overall antibiotics prescription rate decreased from 89.6% in 2016 to 69.1% in 2021, and the proportion of prescriptions for two or more classes of antibiotics was estimated as 35.9% in 2016 and 11.0% in 2021. There was a statistically significant decrease in the number of days from symptom onset to clinic visits between the year groups. In conclusion, measures to constrain excessive prescription of antibiotics have led to some improvements at the rural primary care level, and the COVID-19 pandemic has had varying effects on antibiotic use.
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Affiliation(s)
- Xiuze Xu
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Kexin Zhang
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Huan Ma
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Xingrong Shen
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Jing Chai
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Mengsha Tang
- School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Yanan Du
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Qun Xue
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Xiaoqin Guan
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Guocheng Li
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Debin Wang
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
- Author for correspondence: Debin Wang, E-mail:
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10
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Coope C, Schneider A, Zhang T, Kadetz P, Feng R, Lambert H, Wang D, Oliver I, Michie S, Cabral C. Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis. BMJ Open 2022; 12:e056348. [PMID: 35338063 PMCID: PMC8961142 DOI: 10.1136/bmjopen-2021-056348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/15/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China. METHODS Searches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only). RESULTS Intervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies. CONCLUSIONS Interventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.
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Affiliation(s)
- Caroline Coope
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Annegret Schneider
- Population Health Sciences, University of Bristol, Bristol, UK
- Centre for Behaviour Change, University College London, London, UK
| | - Tingting Zhang
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Paul Kadetz
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, UK
| | - Rui Feng
- Library, Anhui Medical University, Hefei, Anhui, China
| | - Helen Lambert
- Population Health Sciences, University of Bristol, Bristol, UK
| | - DeBin Wang
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
| | - Isabel Oliver
- Field Service, National Infection Service, Public Health England National Infection Service, Salisbury, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, London, UK
| | - Christie Cabral
- Population Health Sciences, University of Bristol, Bristol, UK
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11
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Tompson AC, Manderson L, Chandler CIR. Understanding antibiotic use: practices, structures and networks. JAC Antimicrob Resist 2021; 3:dlab150. [PMID: 34617017 PMCID: PMC8488471 DOI: 10.1093/jacamr/dlab150] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In this article, we consider how social sciences can help us to understand the rising use of antibiotics globally. Drawing on ethnography as a way to research how we are in the world, we explore scholarship that situates antibiotic use in relation to interactions of pathogens, humans, animals and the environment in the context of globalization, changes in agriculture and urbanization. We group this research into three areas: practices, structures and networks. Much of the public health and related social research concerning antimicrobial resistance has focused on antibiotic use as a practice, with research characterizing how antibiotics are used by patients, farmers, fishermen, drug sellers, clinicians and others. Researchers have also positioned antibiotic use as emergent of political-economic structures, shedding light on how working and living conditions, quality of care, hygiene and sanitation foster reliance on antibiotics. A growing body of research sees antibiotics as embedded in networks that, in addition to social and institutional networks, comprise physical, technical and historical connections such as guidelines, supply chains and reporting systems. Taken together, this research emphasizes the multiple ways that antibiotics have become built into daily life. Wider issues, which may be invisible without explication through ethnographic approaches, need to be considered when addressing antibiotic use. Adopting the complementary vantage points of practices, networks and structures can support the diversification of our responses to AMR.
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Affiliation(s)
- A C Tompson
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK
| | - L Manderson
- School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
| | - C I R Chandler
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK
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12
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Zhang T, Shen X, Liu R, Zhao L, Wang D, Lambert H, Cabral C. The impact of COVID-19 on primary health care and antibiotic prescribing in rural China: qualitative study. BMC Health Serv Res 2021; 21:1048. [PMID: 34610843 PMCID: PMC8490966 DOI: 10.1186/s12913-021-07082-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/21/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In China, the primary health care (PHC) system has been designated responsible for control and prevention of COVID-19, but not treatment. Suspected COVID-19 cases presenting to PHC facilities must be transferred to specialist fever clinics. This study aims to understand the impact of COVID-19 on PHC delivery and on antibiotic prescribing at a community level in rural areas of central China. METHODS Qualitative semi-structured interviews were conducted with 18 PHC practitioners and seven patients recruited from two township health centres and nine village clinics in two rural residential areas of Anhui province. Interviews were transcribed verbatim and analysed thematically. RESULTS PHC practitioners reported a major shift in their work away from seeing and treating patients (due to government-mandated referral to specialist Covid clinics) to focus on the key public health roles of tracing, screening and educating in rural areas. The additional work, risk, and financial pressure that PHC practitioners faced, placed considerable strain on them, particularly those working in village clinics. Face to face PHC provision was reduced and there was no substitution with consultations by phone or app, which practitioners attributed to the fact that most of their patients were elderly and not willing or able to switch. Practitioners saw COVID-19 as outside of their area of expertise and very different to the non-COVID-19 respiratory tract infections that they frequently treated pre-pandemic. They reported that antibiotic prescribing was reduced overall because far fewer patients were attending rural PHC facilities, but otherwise their antibiotic prescribing practices remained unchanged. CONCLUSIONS The COVID-19 pandemic had considerable impact on PHC in rural China. Practitioners took on substantial additional workload as part of epidemic control and fewer patients were seen in PHC. The reduction in patients seen and treated in PHC led to a reduction in antibiotic prescribing, although clinical practice remains unchanged. Since COVID-19 epidemic control work has been designated as a long-term task in China, rural PHC clinics now face the challenge of how to balance their principal clinical and increased public health roles and, in the case of the village clinics, remain financially viable.
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Affiliation(s)
- Tingting Zhang
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Xingrong Shen
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Rong Liu
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Linhai Zhao
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Debin Wang
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christie Cabral
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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13
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Yau JW, Thor SM, Tsai D, Speare T, Rissel C. Antimicrobial stewardship in rural and remote primary health care: a narrative review. Antimicrob Resist Infect Control 2021; 10:105. [PMID: 34256853 PMCID: PMC8278763 DOI: 10.1186/s13756-021-00964-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies. METHODS The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools. RESULTS Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing. CONCLUSIONS Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.
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Affiliation(s)
- Jun Wern Yau
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Malaysia
| | - Sze Mun Thor
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Malaysia
| | - Danny Tsai
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.,Alice Springs Hospital, Central Australian Health Service, Alice Springs, NT, 0870, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Tobias Speare
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.,Alice Springs Hospital, Central Australian Health Service, Alice Springs, NT, 0870, Australia
| | - Chris Rissel
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.
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