What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India.
What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India.
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DOI：
10.1016/j.socscimed.2021.113813
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发表时间：
2021-04
期刊：
影响因子：
--
通讯作者：
Goodman C
中科院分区：
文献类型：
--
作者：
Gautham M;Spicer N;Chatterjee S;Goodman C
在许多低收入和中等收入国家，未经正规培训的提供者是抗生素的重要来源，但可能提供不当，导致耐药感染负担不断增加。从事对抗疗法的非正式医疗服务提供者 (IP) 是印度多元化卫生系统遗产的一部分。它们的数量超过了正规提供者，但在合法性不明确的政策环境中运作，给抗生素管理带来了独特的挑战。我们使用系统方法分析了西孟加拉邦农村地区知识产权机构提供抗生素的多重内在（特定于提供商）和外在（社区、卫生和监管系统以及制药行业）驱动因素，为社区管理干预措施的设计提供信息。我们在两个对比区随机抽取的村庄群中的 291 个居民点进行了调查，并对 30 个居民点和 17 名关键知情人（包括药品销售代表、管理人员和批发商/零售商）进行了深入访谈；具有医学资格的私人和公立医生以及卫生和监管官员。与社区成员进行了八次焦点小组讨论。我们发现，知识产权、合格的医生和行业利益相关者所进行的非正式实践马赛克或拼凑，维持了私营企业并补充了薄弱的公共卫生部门。 IP 的内在驱动因素包括对抗生素治疗必要性的误解，以及直接和间接的经济效益，尽管抗生素并不是最赚钱的药品销售类别。私人医生是 IP 学习的主要来源，通常是为了换取转介。知识产权对当地和全球制药公司来说是一个重要的市场，这些公司采取积极的商业策略来开拓饱和度较低的农村市场。矛盾的是，监管的自上而下的性质造成了监管僵局，监管机构不愿对非法销售实施严厉制裁，担心对农村医疗保健产生不利影响，但由于法律障碍而无法实施改善抗生素供应的有利战略。我们讨论了在这种情况下多利益相关者抗生素管理策略的影响。 IP 是印度农村地区医疗保健和抗生素的主要来源。非正式抗生素实践涉及知识产权、医生和制药行业。多种内在和外在驱动因素影响知识产权的抗生素实践。法规难以执行，但却为管理解决方案设置了障碍。加强抗生素管理的努力必须针对多个利益相关者。
In many low- and middle-income countries, providers without formal training are an important source of antibiotics, but may provide these inappropriately, contributing to the rising burden of drug resistant infections. Informal providers (IPs) who practise allopathic medicine are part of India's pluralistic health system legacy. They outnumber formal providers but operate in a policy environment of unclear legitimacy, creating unique challenges for antibiotic stewardship. Using a systems approach we analysed the multiple intrinsic (provider specific) and extrinsic (community, health and regulatory system and pharmaceutical industry) drivers of antibiotic provision by IPs in rural West Bengal, to inform the design of community stewardship interventions. We surveyed 291 IPs in randomly selected village clusters in two contrasting districts and conducted in-depth interviews with 30 IPs and 17 key informants including pharmaceutical sales representatives, managers and wholesalers/retailers; medically qualified private and public doctors and health and regulatory officials. Eight focus group discussions were conducted with community members. We found a mosaic or bricolage of informal practices conducted by IPs, qualified doctors and industry stakeholders that sustained private enterprise and supplemented the weak public health sector. IPs' intrinsic drivers included misconceptions about the therapeutic necessity of antibiotics, and direct and indirect economic benefits, though antibiotics were not the most profitable category of drug sales. Private doctors were a key source of IPs' learning, often in exchange for referrals. IPs constituted a substantial market for local and global pharmaceutical companies that adopted aggressive business strategies to exploit less-saturated rural markets. Paradoxically, the top-down nature of regulations produced a regulatory impasse wherein regulators were reluctant to enforce heavy sanctions for illegal sales, fearing an adverse impact on rural healthcare, but could not implement enabling strategies to improve antibiotic provision due to legal barriers. We discuss the implications for a multi-stakeholder antibiotic stewardship strategy in this setting. IPs are a key source of healthcare and antibiotics in rural India. Informal antibiotic practices cut across IPs, doctors and pharmaceutical industry. Multiple intrinsic and extrinsic drivers influence IPs' antibiotic practices. Regulations are difficult to enforce but create barriers for stewardship solutions. Efforts to strengthen antibiotic stewardship must target multiple stakeholders.
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DOI：
10.1093/cid/cit212
发表时间：
2013-07
期刊：
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
影响因子：
--
作者：
Charani E;Castro-Sanchez E;Sevdalis N;Kyratsis Y;Drumright L;Shah N;Holmes A
通讯作者：
Holmes A
影响因子：
4.8
作者：
Edwards, Suzanne E.;Morel, Chantal M.;Harbarth, Stephan
通讯作者：
Harbarth, Stephan
越南北部农村和城市药房的抗生素销售：一项观察性研究。
影响因子：
2.9
作者：
Nga do TT;Chuc NT;Hoa NP;Hoa NQ;Nguyen NT;Loan HT;Toan TK;Phuc HD;Horby P;Van Yen N;Van Kinh N;Wertheim HF
通讯作者：
Wertheim HF
影响因子：
5.4
作者：
Das, Jishnu;Daniels, Benjamin;Ashok, Monisha;Shim, Eun-Young;Muralidharan, Karthik
通讯作者：
Muralidharan, Karthik
影响因子：
56.9
作者：
Das, Jishnu;Chowdhury, Abhijit;Banerjee, Abhijit V.
通讯作者：
Banerjee, Abhijit V.