Socio-cultural influences on antibiotic prescribing in China & England: comparative qualitative study

Problem

Antimicrobial resistance (AMR) is a global health problem, driven largely by over use of antibiotics. China is one of the leading consumers of antibiotics in humans among Low and Middle Income Countries and is seeking to address this issue through antimicrobial stewardship policies. This research was part of a large inter-disciplinary study investigating drivers of antibiotic use for common infections and community prevalence of antimicrobial resistance. This study reports on a comparative analysis of socio-cultural influences on antibiotic prescribing in contrasting global contexts.

Approach

In China, we conducted ethnographic observations and semi-structured interviews in village and township health facilities in four rural counties in central China. We interviewed 18 health care professionals (HCP) and 61 patients about understanding of antibiotics and AMR, treatment-seeking, and antibiotic use. We observed health care encounters and the prescribing and dispensing of antibiotics. These qualitative data were analysed thematically to identify key drivers of antibiotic seeking, prescribing and consumption. A triangulation method was used to compare drivers identified from these data with drivers identified from qualitative work conducted in England. This identified areas of convergence (complementary findings), dissonance (conflicting findings) and silence (drivers that only operated in one context).

Findings

The way in which health care for common infections is delivered in rural China differs from England in many ways. The medical training of HCP in our sample is very diverse; they are a mixture of state employees and private practitioners; the types of tests and treatments offered are different (IV antibiotics for RTI is not uncommon in village clinics); health care is partially paid for via government health insurance; patients can (and do) purchase antibiotics directly from pharmacies or go direct to hospital outpatients in search of care. Given these differences, it is perhaps surprising that there was much commonality. In both contexts, HCP ideas about what being a ‘good doctor’ entailed was a key influence on practice. This included ideas about safety, both for patients and for themselves from medico-legal consequences of not treating; HCP wanted to maintain good relationships with their patients; they believed patients expected antibiotics and felt pressure to provide them. In China, lay understandings of appropriate treatment for infections drew on Traditional Chinese Medicine ideas and ideas about the relative strength of treatments, which contrasted with lay understandings in England.

Consequences

This cross-cultural comparison allows us to see the role of ideas about what it means to be a ‘good doctor’, lay illness models and norms of practice as key influences on antibiotic prescribing rates and important targets for global interventions to reduce AMR.