Social, behavioural and economic drivers of inappropriate antibiotic use by informal private healthcare providers in rural India.

抗生素在降低结核病、伤寒、肺炎和肠胃炎等传染病的死亡率和发病率方面发挥着挽救生命的作用。然而，在人群中过度使用抗生素可能导致疾病，导致细菌随着时间的推移变得耐药。例如，在印度和南非的5个地点发现胃肠炎引起的细菌对氨苄西林（52.3% - 84.6%）、复方新诺明（45.5% - 65%）和头孢氨苄（15.9% - 59.7%）等抗生素具有高度耐药性。这种抗菌素耐药性是一种全球威胁，因为它可以逆转在防治危及生命的感染方面取得的进展，并增加患者的治疗和住院费用，使最贫穷和最脆弱的人更难以获得更新的抗生素。人类过度使用抗生素的一个主要原因是卫生保健提供者过度分配抗生素和过度开处方。这在低收入和中等收入国家是一个巨大的挑战，因为这些国家的卫生系统薄弱，卫生工作者和制药业的监管框架要么不存在，要么执行不力，而且大多数贫困人口和农村人口依赖未经正规培训和无执照的提供者，这些提供者在治疗中过度和不当地使用抗生素。在包括印度在内的中低收入国家，这些非正式提供者或专业人员可能占所有提供者的50%至96%，但对影响他们不适当使用抗生素的因素以及哪些干预措施可以切实有效地制止这种不适当使用的深入了解甚少。来自正规部门的证据表明，抗生素的使用受到社会文化、行为和经济因素的影响。然而，这些因素的确切性质以及它们如何相互作用还没有在ip的案例中得到探讨。在这项实地研究中，我们建议研究印度西孟加拉邦IPs的横截面及其抗生素使用的驱动因素。由于自主知识产权缺乏明确的法律地位，很少有政府项目愿意与他们合作，但西孟加拉邦政府已决定从2016年初开始培训和利用10万多名自主知识产权作为乡村卫生工作者。因此，我们在西孟加拉邦进行了这项及时的研究。我们将探讨与供应商相关的因素，以及社区和各种政府利益相关者的看法。为此，将在两个社会经济不同的地区（birbham和South24 Parganas）进行200次结构化访谈和30次深入访谈，并对知识产权做法进行观察，同时与社区成员进行焦点小组讨论，并与政府、制药和正规医疗部门利益攸关方进行关键信息提供者访谈。我们将利用这些发现概念化干预措施，以减少IPs中抗生素的使用，并寻求研究参与者对这些干预措施的可行性和有效性的反馈。这项研究将由伦敦卫生和热带医学学院与肝脏基金会合作实施。肝脏基金会是西孟加拉邦的一个非政府组织，自2007年以来一直与知识产权合作，并与邦政府一起倡导利用知识产权。我们将利用最终的研究结果与州政府一起制定一项提案，以便在未来实施和评估这些干预措施，可能从2017年年中到年底开始。

Antibiotics play a life-saving role in reducing mortality and morbidity due to communicable diseases like tuberculosis, typhoid, pneumonia and gastroenteritis. However, the overuse of antibiotics in populations can lead to the disease causing bacteria becoming drug resistant over time. For example, high levels of resistance have been found in gastroenteritis causing bacteria to antibiotics like ampicillin (52.3% - 84.6%), cotrimoxazole (45.5% - 65%), and cephalexin (15.9% - 59.7%) across five sites in India and South Africa. This antimicrobial resistance (AMR) is a global threat because it can reverse the advances made in combating life threatening infections and increase the costs of treatment and hospital stays for the sick, making newer antibiotics even more inaccessible to the poorest and most vulnerable. One major reason for the overuse of antibiotics in humans is antibiotic over-dispensing and over-prescribing by health care providers. This is a big challenge in low and middle income countries where health systems are weak, regulatory frameworks for health workers and the pharmaceutical industry either do not exist or are weakly enforced, and the majority of poor and rural populations rely on informally trained and unlicenced providers who use antibiotics excessively and inappropriately in their treatments. These informal providers or IPs may constitute from 50% to 96% of all providers in LMICs, including in India, but there is very little in-depth knowledge of the factors that influence their inappropriate antibiotic use and what interventions can feasibly and effectively arrest this inappropriate use. Evidence from the formal sector suggests that antibiotic use is influenced by socio-cultural, behavioural and economic factors. However the precise nature of these factors and how they interact has not been explored in the case of IPs.In this field study we propose to study a cross section of IPs, and the drivers of their antibiotic use in the state of West Bengal in India. Since IPs lack a clear legal status, few government programmes are willing to engage with them, but the West Bengal government has decided to train and harness more than 100,000 IPs as village health workers, from early 2016. We are therefore locating this timely study in West Bengal. We will explore provider related factors and also the perceptions of communities and various government stakeholders. This will be done through 200 structured and 30 in-depth interviews and observations of IP practices in two socio-economically different districts (Birbhum and South24 Parganas), accompanied by focus groups discussions with community members and key informant interviews with government, pharmaceutical and formal medical sector stakeholders. We will use these findings to conceptualise interventions to reduce antibiotic use among IPs and seek feedback from study participants on the feasibility and effectiveness of these interventions. The study will be implemented by the London School of Hygiene and Tropical Medicine in collaboration with the Liver Foundation, a non-governmental organisation in West Bengal that has worked with IPs since 2007 and has championed the harnessing of IPs with the state government. We will use the final study outcomes to develop a proposal with the state government to implement and evaluate these interventions in the future, possibly starting in mid to late 2017.