Determinants of antibiotic prescribing behaviors of primary care physicians in Hubei of China: a structural equation model based on the theory of planned behavior

Abstract

BackgroundOver-prescription of antibiotics is prevalent all over the world, contributing to the development of antibiotic resistance. The importance of understanding how physicians prescribe antibiotics is increasingly highlighted for the purpose of promoting good practice. This study aimed to identify factors that shape the antibiotic prescribing behaviors of physicians in primary care based on the theory of planned behavior (TPB).MethodsData were collected from 503 prescribers within 65 primary care facilities in Hubei, tapping into four behavioral aspects leading to antibiotic prescribing based on TPB, namely, attitudes (the degree to which a prescriber is in favor of the use of antibiotics), subjective norms (perceived social pressure to which a prescriber is subject in relation to antibiotic prescriptions), perceived control of behaviors (how easy a prescriber feels in making a rational decision on antibiotic prescriptions) and intentions (the degree to which a prescriber is willing to prescribe antibiotics). A total of 440,268 prescriptions were audited to assess physician antibiotic prescribing practices. The four behavioral constructs were further linked with physician’s actual use of antibiotics using structural equation modelling (SEM) based on TPB.ResultsOn average, 40.54% (SD = 20.82%) of the outpatient encounters resulted in a prescription for an antibiotic given by the participants and 9.81% (SD = 10.18%) of the patients were given two or more antibiotics. The participants showing a more favorable attitude toward antibiotics had a higher intention to prescribe antibiotics (β = 0.226, p < 0.001) and a lower intention to reduce antibiotic use (β = − 0.211, p < 0.001). Those who perceived lower social pressure (β = 0.113, p = 0.030) and higher control over prescribing behaviors (β = 0.113, p = 0.037) reported a higher intention to reduce the use of antibiotics. However, such intention did not translate into prescribing practice (p > 0.05), although stronger perceived behavioral control was directly linked with lower antibiotic prescriptions (β = − 0.110, p = 0.019). Weaker perceived behavioral control was evident in the participants who showed a less favorable attitude toward antibiotics (β = 0.128, p = 0.001).ConclusionAntibiotic prescribing practice is not under the volitional control of prescribers in primary care in China. Their rational prescribing practice is likely to be jeopardized by perceived weak control over prescribing behaviors.Electronic supplementary materialThe online version of this article (10.1186/s13756-019-0478-6) contains supplementary material, which is available to authorized users.

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“…Consistent with previous research [42][43][44], attitude and perceived behavioral control are the important in uencing factors of health professionals' intention to use a certain service or product. TPB suggests that an individual's intention and usage behavior are the results of internal factors, the consistency of behavior with attitude and motivation is the requirement of performing a speci c behavior [45].…”

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“…Secondly, we observed the changes in the percentage of patients receiving antibiotics. The PRA and PRCA indices, which are used by the Chinese government to evaluate the effects of clinical application management of antibacterial therapeutics (National Health Commission of the People's Republic of China, 2015b), were also used by scholars to analyze prescribing practice (Yang et al, 2014;Liu et al, 2019). In this study, the PRA and PRCA presented a decreasing trend and reduced levels after intervention.…”

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“… 10–15 For example, Liu et al noted that rational prescribing practices are prone to weak control over prescribing behaviours, and 40% of prescriptions in a primary care setting in Hubei, China, contained an antibiotic, with 10% containing two or more antibiotics. 14 Where antibiotic stewardship efforts have worked, they have relied on dedicated committees overseeing antibiotic use, prompt laboratory investigations, established guidelines for empiric prescribing and an easily accessible antibiogram. 16 However, none of these components of an antibiotic stewardship strategy were in place in the four countries included in this study.…”

“…[6][7][8][9] Previous studies from low-and-middle-income countries (LMICs) have reported that patient demands often play a salient role in inconsistent prescription practices. [10][11][12][13][14][15] For example, Liu et al noted that rational prescribing practices are prone to weak control over prescribing behaviours, and 40% of prescriptions in a primary care setting in Hubei, China, contained an antibiotic, with 10% containing two or more antibiotics. 14 Where antibiotic stewardship efforts have worked, they have relied on dedicated committees overseeing antibiotic use, prompt laboratory investigations, established guidelines for empiric prescribing and an easily accessible antibiogram.…”