Determinants of antibiotic prescribing in primary care in South Africa: studying patient-provider interactions in the private and public sectors

南非初级保健中抗生素处方的决定因素：研究私营和公共部门的患者与提供者之间的互动

• 批准号: ES/P004059/1
• 负责人: Mylene Lagarde
• 金额: $ 28.66万
• 依托单位: London School of Economics and Political Science
• 依托单位国家: 英国
• 项目类别: Research Grant
• 财政年份: 2017
• 资助国家: 英国
• 起止时间: 2017 至 无数据
• 项目状态: 已结题
• 来源: https://gtr.ukri.org/projects?ref=ES%2FP004059%2F1
• 关键词: Determinants; antibiotic; prescribing; primary; care

Because it increases the morbidity and mortality of bacterial infection, as well as the duration and cost of antibacterial treatment, antibiotic resistance constitutes a significant threat to global public health. The problem is even more critical in low- and middle-income countries which have higher infectious disease burdens, often higher rates of antibiotic resistance, less access to diagnostic tools, and fewer financial resources to purchase newer more effective antibiotics. In South Africa, antibiotic resistance is particularly high, despite an effective drug regulatory system and various initiatives to tackle the problem. Antibiotic resistance is accelerated by the overuse and over-prescription of antibiotics, which is the product of complex interactions between providers' decisions and knowledge, and patients' expectations. Yet research on the determinants of prescribing behaviours from LMICs in general, and South Africa in particular, is limited, and has been criticised for being too descriptive and superficial, with limited insight into the relative importance of different behavioural determinants to be able to prioritise interventions. In South Africa, most research efforts have focused on hospitals rather than primary care, despite the fact the majority of antibiotics are prescribed in primary care, mostly for respiratory infections.This study aims to explore how the interactions between providers and patients influence inappropriate antibiotic prescribing for URTIs in public and private primary care in South Africa. The study will include three components. First, drawing on medical anthropology, we will explore qualitatively providers' and patients' perceptions an experiences of antibiotic prescribing. This will be done through observations of consultations, interviews with providers and focus group discussions with patients. Second, building on the first part and drawing on methods from marketing research, we will design a survey consisting of a series of hypothetical clinical cases where clinical and patient characteristics will be systematically varied; for each case, the providers taking part will be asked indicate what drugs they would prescribe in a list of proposed drugs. The results will allow us to quantify the relative importance of the factors influencing antibiotic prescribing, with a view to inform policy-makers design future interventions. Finally, drawing on recent economics and medical education research, we will move beyond observational research and design a small randomised field study to test the impact of patients' knowledge and financial incentives on the prescribing practices of public and private primary care providers. This will be achieved with the use of standardised patients, who are healthy subjects trained to portray specific symptoms and disclose a rehearsed medical history. These patients will be sent to visit providers who agreed to take part in the research, at a time and under an identity unknown to them. The standardised patients will only differ in their expectations of antibiotics and the insurance status they will disclose. This will allow us to test the impact of these different characteristics on the likelihood of antibiotic prescription. We anticipate that the results will provide invaluable insights into our understanding of prescribing decisions in the public and private sector in South Africa, thereby informing the stewardship programmes for antimicrobial resistance in this country. Beyond this setting, these findings will be useful to other middle-income countries with a similar mix of public and private providers. More generally, we aim to produce high-quality research and develop innovative methods that could be replicated in other low-income settings to study antibiotic prescribing.

由于它增加了细菌感染的发病率和死亡率，以及抗菌治疗的持续时间和成本，抗生素耐药性构成了对全球公共卫生的重大威胁。在低收入和中等收入国家，这个问题更加严重，这些国家的传染病负担更高，抗生素耐药性往往更高，获得诊断工具的机会更少，用于购买更新更有效抗生素的财政资源也更少。在南非，抗生素耐药性特别高，尽管有有效的药物监管制度和各种解决问题的举措。抗生素的过度使用和过度处方加速了抗生素耐药性，这是提供者的决定和知识与患者的期望之间复杂相互作用的产物。然而，对一般中低收入国家（特别是南非）处方行为决定因素的研究有限，并被批评为过于描述性和肤浅，对不同行为决定因素的相对重要性了解有限，无法优先考虑干预措施。在南非，大多数研究工作都集中在医院，而不是初级保健，尽管事实上，大多数抗生素的处方在初级保健，主要是呼吸道infections.This study旨在探讨如何供应商和患者之间的相互作用影响不适当的抗生素处方URTI在公共和私人的初级保健在南非。这项研究将包括三个组成部分。首先，利用医学人类学，我们将定性探讨供应商和患者的看法和经验的抗生素处方。这将通过对咨询的观察、与提供者的访谈以及与患者的焦点小组讨论来完成。第二，在第一部分的基础上，利用市场研究的方法，我们将设计一个调查，其中包括一系列假设的临床病例，这些病例的临床和患者特征将系统地变化;对于每个病例，将要求参与的提供者说明他们将在拟议药物清单中开出哪些药物。研究结果将使我们能够量化影响抗生素处方的因素的相对重要性，以期为政策制定者设计未来的干预措施提供信息。最后，借鉴最近的经济学和医学教育研究，我们将超越观察性研究，设计一个小型的随机实地研究，以测试患者的知识和经济激励对公共和私人初级保健提供者的处方实践的影响。这将通过使用标准化患者来实现，标准化患者是经过培训的健康受试者，可以描述特定症状并披露排练的病史。这些患者将被送往同意参加研究的访问提供者，时间和身份未知。标准化的患者只会在他们对抗生素的期望和他们将披露的保险状态方面有所不同。这将使我们能够测试这些不同特征对抗生素处方可能性的影响。我们预计，这些结果将为我们理解南非公共和私营部门的处方决策提供宝贵的见解，从而为该国的抗菌素耐药性管理计划提供信息。除此之外，这些发现对其他拥有类似公共和私人提供者组合的中等收入国家也很有用。更广泛地说，我们的目标是进行高质量的研究，并开发可在其他低收入环境中复制的创新方法，以研究抗生素处方。

项目成果

Understanding antibiotic use: practices, structures and networks.

• DOI: 10.1093/jacamr/dlab150
• 发表时间: 2021-12
• 期刊: JAC-antimicrobial resistance
• 影响因子: 3.4
• 作者: Tompson AC;Manderson L;Chandler CIR
• 通讯作者: Chandler CIR

Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa.

• DOI: 10.1136/bmjgh-2023-012374
• 发表时间: 2023-07
• 期刊: BMJ GLOBAL HEALTH
• 影响因子: 8.1
• 作者: Lagarde, Mylene;Blaauw, Duane
• 通讯作者: Blaauw, Duane

Prescribing, care and resistance: antibiotic use in urban South Africa

• DOI: 10.1057/s41599-020-00564-1
• 发表时间: 2020-09-01
• 期刊: HUMANITIES & SOCIAL SCIENCES COMMUNICATIONS
• 作者: Manderson, Lenore

Overtreatment and benevolent provider moral hazard: Evidence from South African doctors

• DOI: 10.1016/j.jdeveco.2022.102917
• 发表时间: 2022-09-01
• 期刊: JOURNAL OF DEVELOPMENT ECONOMICS
• 影响因子: 5
• 作者: Lagarde, Mylene;Blaauw, Duane
• 通讯作者: Blaauw, Duane