E-drug: Determinants of antibiotic use in developing countries
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Dear E-druggers,
Quite some time ago we asked you to help us to identify literature
on determinants of antimicrobials use by community members and
health care providers in developing countries; an activity that was
funded by the ARCH project of Boston University, and sponsored
by USAID, Bureau of Global Health, The Child Health Research
Project.
Many people (too many to name individually) sent us extremely
useful information and we are pleased to inform you that the final
report is now available as:
Determinants of Antimicrobial Use in the Developing World
Aryanti Radyowijati and Hilbrand Haak
Child Health Research Project
Special Report Volume 4, Number 1
Below you will find the Executive Summary and the Table of
Contents.
Richard Laing of Boston University School of Public Health was
so kind to publish it on his website (thanks Richard!), from where
it can be downloaded as a pdf file (please repair the link, as it is
too long for one line and wraps):
http://dcc2.bumc.bu.edu/richardl/ih820/Resource_materials/amr_vol
4.pdf
Cheers to the E-drug family for the help provided!
Aryanti Radyowijati and Hilbrand Haak
Consultants for Health and Development
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Sleedoorntuin 7 tel: +31-71-523.2052
2317 MV Leiden fax: +31-71-523.3592
The Netherlands e-mail: haakh@chd-consultants.nl
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Executive Summary
Antibiotics play a key role in treating diseases of bacterial origin, a
major cause of morbidity and mortality in the developing world.
High levels of consumption, often clinically unnecessary, have led
to a steady increase in drug resistance, particularly to antibiotics
used in treating high prevalence diseases. The effectiveness of
many antibiotics is lost almost as quickly as scientists discover
them.
This review provides information from well-designed scientific
studies on the factors that influence the use of antibiotics by health
providers, dispensers and community members in non-industrialized
countries. These practices tend to be determined by a complex and
multi-layered mix of medical, psychosocial, cultural, economic, and
political factors. Understanding these factors can lead to the
development of more effective policies and programs to address
inappropriate antibiotic use.
Determinants of antibiotic use by community members
Drug use is strongly influenced by cultural preferences and beliefs.
Prescribers, dispensers, and consumers share similar perceptions on
health, illness, and antibiotics. Antibiotics are often perceived as
"strong", almost magical medicines, capable of curing nearly any
kind of disease. Many cultures believe that antibiotics also have the
ability to prevent disease. Local cultural traditions have also
developed related to the use of specific antibiotics, e.g., based on
color or imitating methods used in traditional medicine. People are
willing to pay high prices for antibiotics, and if they cannot afford a
full course, will purchase them in smaller quantities.
Self-medication is often seen as an important determinant of
improper antibiotic use. However, a patient's decisions about
whether and how to use antibiotics are themselves influenced by
more fundamental factors, e.g. lack of access to appropriate health
care, poverty, or the stigma associated with having certain
illnesses. Interventions should address these underlying
determinants of self-medication, rather than focusing exclusively on
the phenomenon itself.
The decision to self-medicate or to seek care from other sources is
determined by perceived symptoms, knowledge about treatment
options, and their availability and accessibility. Advice may be
sought from physicians, pharmacists, pharmacy clerks, paramedics,
traditional healers, family, or friends at any time during an illness.
Each group of advisers has its own specific characteristics,
advantages, and disadvantages.
Physicians influence antibiotic use in three ways: by giving verbal
recommendations to buy antibiotics, by writing prescriptions, or by
prescribing and directly dispensing drugs. Doctors' practices can
legitimize popular choices of antibiotics, and their previous
prescribing can be an important factor in determining
self-medication. Despite their importance, there is evidence that
some people prefer not to consult physicians for day-to-day health
problems, because of the high cost and time investment, lack of
trust, or the easier availability of pharmacies.
In most legal systems, qualified pharmacists must manage
pharmacies, and dispensing should be restricted to drugs prescribed
by a qualified physician. In practice, drugs are frequently sold
without prescription, and many pharmacies conduct physical
examinations or make treatment recommendations.
Traditional practitioners often lack access to sophisticated medical
technology, but some have started to include western medicine,
including antibiotics, in their daily practice. They rarely receive
training in antibiotic prescribing, and their information about drugs
comes mostly from informal, non-medical sources, or from
pharmaceutical representatives.
Economic considerations are also important determinants of
community antibiotic use. The decision to buy medicines, and the
amount of it, is often influenced by factors such as a drug's price
and a consumer's ability to pay. Poverty, lack of access to
appropriate health care, and drug company marketing are also often
believed to cause improper use of antibiotics, but these factors
have not been well examined in research studies.
Determinants of antibiotic prescribing
It is commonly believed that physicians' practices are largely
determined by what they know about illness and about correct
prescribing, but there is little evidence to support this assumption.
There are frequent discrepancies between biomedical knowledge
and prescribing practices. Knowledge may be necessary for good
practice, but improving knowledge may not improve prescribing.
Peer norms and the local medical culture are other important
influences on antibiotic prescribing.
Prescribers in industrialized countries may fear legal action for not
practicing evidence-based medicine, but their colleagues in
non-industrialized countries may be more concerned about losing
clients if they do not deliver a fast cure. Many doctors report that
patient demand influences their prescribing decisions. Giving a
prescription is perceived as the easiest way to end a consultation,
but little is known about whether patients can be satisfied by less
harmful drugs than antibiotics.
Financial incentives are an important factor to prescribers, and fear
of losing business or the higher profit margins of expensive drugs
may result in inappropriate practices. Some physicians believe their
reputations would suffer if they do not prescribe desired antibiotics.
This economic rationale is especially strong in private settings
where patients pay for services.
The ability to provide appropriate therapy may be limited by the lack
of functioning laboratories, although physicians do not always use
laboratory facilities when they are available. Consistency of drug
supply can also affect prescribing. Prescribers in health facilities
may adjust prescribing practices to whatever drugs are in stock.
The pharmaceutical industry has a strong financial incentive to
market drugs to doctors and pharmacists in non-industrialized
countries. Despite many reports on commercial pressures in drug
prescribing, most of this literature is anecdotal. Little is known
about how this influence works, and how it is able to encourage
health care providers to use specific products.
Determinants of antibiotic dispensing and sales
Dispensers of antibiotics in non-industrialized countries range from
public sector facilities, to dispensing physicians, commercial
pharmacies and retail shops, and traditional healers. Each system
can contain formal, informal, illegal, and clandestine aspects of
antibiotic distribution. Pharmacy clerks with a wide range of
backgrounds commonly handle day-to-day activities in pharmacies.
Many customers do not differentiate between untrained street
vendors and pharmacists, and all are regarded as knowledgeable.
This variety of settings and people makes studying
dispenser-related determinants of antibiotic use a challenge.
Drug dispensers have considerable influence on community drug
use. The dispenser is not only expected to be knowledgeable on
biomedical concepts, but also to be acquainted with popular and
folk traditions. Many people prefer to purchase drugs directly from
pharmacies instead of from physicians because of easier
accessibility, lower cost, and closer social and cultural ties.
Although quantitative aspects of dispensing have been studied, little
is known about the characteristics of dispensers and the role they
actually see for themselves.
The level of knowledge of dispensers about illness and correct use
of antibiotics has not been well researched. Dispensers are usually
prepared to negotiate the type and quantity of drugs with
customers, and clients' purchasing power is often the ultimate
deciding factor. Dispensers frequently defer to clients' ideas on
appropriate care and necessary medicines. It is often difficult to
differentiate whether pharmacy attendants or customers determine
the medicines to be purchased.
Pharmacists' dispensing is also influenced by pressure and sales
incentives from their suppliers. Despite reports on marketing
methods from a few countries, little is actually known about
industry practices in promoting antibiotic sales through pharmacies.
Program priorities
The rapid growth in antimicrobial resistance demands concerted
action. Governments, public and private institutions, and medical
leaders need to implement policies and programs that encourage
changes in the way antibiotics are used. To achieve lasting change,
interventions will need to be multifaceted, long-term, and based on
solid understanding of the behaviors involved. Strategies that lean
too heavily on professional education are not likely to result in
large-scale or long-lasting improvement.
Based on the findings of this review, some priorities for action
would include the following:
- Governments should create appropriate regulations and programs
to address antibiotic use and resistance, especially among private
medical providers and dispensers.
- Health delivery systems should routinely assess appropriateness of
antibiotic use, and adopt policies and ongoing quality improvement
programs that encourage more appropriate use.
- Health training institutions should incorporate an explicit
component in their curriculum on appropriate use of antibiotics and
the problem of antibiotic resistance.
- Professional societies should offer modern, evidence-based
continuing education programs about antibiotic use that address the
behavioral aspects of prescribing and dispensing.
- Pharmaceutical companies should voluntarily control promotional
messages about antibiotics, and should work together with other
stakeholders to deliver information about prudent and correct use of
antibiotics.
- Consumer organizations should be encouraged to take up
antibiotic use and resistance as consumer issues, and should be
subsidized to provide simple, targeted information to consumers.
- International organizations involved in pharmaceutical assistance
programs should 'add value to access' by integrating support for
activities that encourage appropriate use of the drugs they provide,
or are procured with their funding.
Research priorities
If programs are to be effective, future research must explore, in
more depth, the sociocultural rationality in antibiotic usage. The
most productive approach would be to combine quantitative studies
of the patterns of antibiotic use with the rich variety of qualitative
methods like case simulations, focus group discussions, in-depth
interviews, informal interviews, or illness diaries to explore
determinants. There is a need for such studies from all regions in
the world, but especially from NIS countries, China, francophone
Africa, Middle Eastern countries, and the Pacific region. More
information is needed on the economic motivations and perceptions
of prescribers, dispensers, and consumers. Few studies have
explored whether appropriate antibiotic use can be compatible with
adequate profits. Research is needed on the role of price in
determining perceptions of quality in the decision to purchase
expensive antibiotics.
Antibiotic use is influenced by decisions made throughout the
course of the illness process. There is a need to summarize what is
known from the literature about disease recognition, care seeking,
and antibiotic treatment for specific priority health problems (ARI,
diarrhea, STDs, and TB). It would also be revealing to conduct a
comparative review of the determinants of antimalarial use to see if
common approaches to behavior change are justified for both
classes of drugs.
Specific topics of interest in research on community use of
antibiotics include how private sector physicians' prescribing
shapes the practices of dispensers and community members, and
how knowledge about antibiotics enters and is exchanged among
members of the community. Research is also needed on the
discordance between knowledge and prescribing among prescribers,
and on low use of diagnostic services. It is also not known whether
improving communication between prescribers and patients could
reduce unnecessary antibiotic therapy. It is not clear how
dispensers' knowledge and cultural notions about antibiotics reflect
the prevailing opinions of their communities, or the extent to which
counter attendants model physicians' prescribing or contribute to
purchasing decisions by customers.
The pharmaceutical industry is felt to be an important force in
determining antibiotic use. Little is known about how drug
promotion affects consumers, or whether interactions with
pharmaceutical representatives are the primary sources of antibiotic
information for prescribers and dispensers. Experiences are needed
to determine if companies can participate in promoting better
clinical practice without distorting the messages about appropriate
therapy or compromising their marketing.
Table of Contents
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESEARCH PRIORITIES . . . . . . . . . . . . . . . . . . . . . . . . .7
INTRODUCTION . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .
.8
DETERMINANTS OF USE BY COMMUNITY MEMBERS . .. 9
Cultural aspects of pharmaceutical use . . . . . . . . . . . . . ..9
Self-medication . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 11
Sources of advice . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .12
Economics, gender, and other factors . . . . . . . . . . . . . ..14
DETERMINANTS OF ANTIBIOTIC PRESCRIBING . . . . . . .15
Lack of knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . .
.15
Fear of bad outcomes . . . . . . . . . . . . . . . . . . . . . . . .
..16
Perceived patient demand . . . . . . . . . . . . . . . . . . . . . ..16
Economic factors . . . . . . . . . . . . . . . . . . . . . . . . . . .
..17
Peer norms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .18
Timely laboratory results . . . . . . . . . . . . . . . . . . . . . .
.18
Unstable antibiotic supply . . . . . . . . . . . . . . . . . . . . .
.18
Pressure of pharmaceutical promotion . . . . . . . . . . . . .18
DETERMINANTS OF ANTIBIOTIC DISPENSING. . . . . . . .19
Economic incentives . . . . . . . . . . . . . . . . . . . . . . . . .
.20
Client demand . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .
.20
Lack of knowledge . . . . . . . . . . . . . . . . . . . . . . . . . .
.21
Influence of the pharmaceutical industry . . . . . . . . . . .. .22
Lack of regulation and enforcement . . . . . . . . . . . . . . . .22
PROGRAM PRIORITIES . . . . . . . . . . . . . . . . . . . . . . . . .23
Governments and delivery systems . . . . . . . . . . . . . . . .23
Health professions . . . . . . . . . . . . . . . . . . . . . . . . . ..
.24
Companies, consumers, and donors . . . . . . . . . . . . . . .24
RESEARCH PRIORITIES . . . . . . . . . . . . . . . . . . . . . . . .26
General research themes . . . . . . . . . . . . . . . . . . . . . . 26
Example of best practice research . . . . . . . . . . . . . . . . 27
Research on target groups . . . . . . . . . . . . . . . . . . . . . 28
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . 30
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
APPENDX 1. OVERVIEW OF STUDIES INCLUDED . . . . .34
Key characteristics . . . . . . . . . . . . . . . . . . . . . . . . . .
34
Community studies . . . . . . . . . . . . . . . . . . . . . . . . . .
35
Prescriber studies . . . . . . . . . . . . . . . . . . . . . . . . . . .
35
Dispenser studies . . . . . . . . . . . . . . . . . . . . . . . . . . .
35
Studies that targeted more than one group . . . . . . . . . 35
APPENDX 2. POTENTIAL DETERMINANTS OF AB USE . 36
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