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

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，抗生素耐药性对全球公共卫生构成了重大威胁。这个问题在低收入和中等收入国家更为严重，这些国家的传染病负担更重，抗生素耐药率往往更高，获得诊断工具的机会更少，购买更新更有效的抗生素的财政资源更少。在南非，尽管有有效的药品监管制度和各种解决这一问题的举措，但抗生素耐药性特别高。抗生素的过度使用和过度处方加速了抗生素的耐药性，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LMIC行为处方决定因素的研究总体上是有限的，尤其是南非，有人批评研究过于描述性和肤浅，对不同行为决定因素的相对重要性缺乏洞察力，无法确定干预的优先顺序。在南非，尽管大多数抗生素是在初级保健中开出的，主要是针对呼吸道感染，但大多数研究工作都集中在医院而不是初级保健上。本研究旨在探讨在南非的公立和私立初级保健中，提供者和患者之间的互动如何影响URTIs的不适当抗生素处方。该研究将包括三个部分。首先，我们将借鉴医学人类学，定性地探索提供者和患者对抗生素处方的认知和经验。这将通过观察会诊、与提供者的访谈和与患者的焦点小组讨论来完成。第二，在第一部分的基础上，借鉴市场研究的方法，我们将设计一项调查，由一系列假想的临床病例组成，其中临床和患者特征将有系统地变化；对于每个病例，将询问参与调查的提供者在建议药物清单中说明他们将开哪些药物。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，设计一个小型随机实地研究，以测试患者的知识和经济激励对公共和私营初级保健提供者处方做法的影响。这将通过使用标准化患者来实现，这些患者都是健康的受试者，接受过描绘特定症状并披露排练的病史的培训。这些患者将被送到同意参与研究的提供者那里，时间和身份都不为他们所知。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况方面有所不同。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方案提供信息。除了这一背景，这些发现还将对其他公共和私营部门提供类似服务的中等收入国家有用。更广泛地说，我们的目标是产生高质量的研究，并开发可以在其他低收入环境中复制的创新方法来研究抗生素处方。

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.