Prescribing Antibiotics in Rural China: The Influence of Capital on Clinical Realities

Abstract

Primary care clinicians in rural China are required to balance their immediate duty of care to their patients with patient expectations for antibiotics, financial pressures, and their wider responsibilities to public health. The clinicians in our sample appear to make greater efforts in managing immediate clinical risks and personal reputation than in considering the long-term consequences of their actions as potentially contributing to antimicrobial resistance. This paper employs Bourdieu's theory of capital to examine the perspectives and practices of Chinese primary care clinicians prescribing antibiotics at low-level health facilities in rural Anhui province, China. We examine the institutional context and clinical realities of these rural health facilities and identify how these influence the way clinicians utilize antibiotics in the management of common upper respiratory tract infections. Confronted with various official regulations and institutional pressures to generate revenues, informants' desire to maintain good relations with patients coupled with their concerns for patient safety result in tensions between their professional knowledge of "rational" antibiotic use and their actual prescribing practices. Informants often deferred responsibility for antimicrobial stewardship to the government or upper echelons of the healthcare system and drew on the powerful public discourse of "suzhi" (human quality) to legitimize their liberal prescribing of antibiotics in an imagined socioeconomic hierarchy. The demands of both practitioners' and patients' social, cultural, and economic forms of capital help to explain patterns of antibiotic prescribing in rural Chinese health facilities.

Antimicrobial stewardship in rural and remote primary health care: a narrative review

“…Compared with other Australian settings, narrow spectrum antimicrobials were more commonly prescribed with high appropriateness of use (WA: 91%; NT: 82%; QLD: 65%). The dominant treatment indications were skin and soft tissue infections (WA: 35%; NT: 29%; QLD: 40%) [ 54 ] Chen 2020 Cross-sectional qualitative study Cross Sectional Study (5/8) China Village doctors and township level physicians The dissonance between physicians' knowledge and their prescribing behaviour were due to various official regulations, institutional pressures to generate revenues, their desire to maintain good patient relationships and concerns for patient safety. Physicians often leave the responsibility for antimicrobial stewardship to the government or higher bodies in the health care system [ 38 ] Xue 2019 Quasi-experimental Quasi-experimental Study (9/9) China Rural village clinics and township health centres Primary care providers in rural China frequently prescribed antibiotics inappropriately, predominantly due to deficits in diagnostic knowledge but also to financial incentives linked to drug sales and perceived patient demand [ 52 ] Zhang 2016 Cross-sectional qualitative study Cross Sectional Study (7/8) China Village doctors, primary caregivers, directors from the local county-level CDC, Health Bureaus or CFDA offices, and township hospital staff Unnecessary prescribing for children with upper respiratory tract infections was common in village clinics in rural China, where doctors often had inadequate knowledge and misconceptions of antibiotic use.…”

“…Doctors cited apprehension of medical complications from undertreatment, perceived patient expectations and intentions to preserve good relations, and the notion that selected prescribed antibiotics would not contribute to resistance as grounds for discrepancy in personal knowledge and clinical practice [38,51,52,[54][55][56][57]. Concurrently, external pressures including financial considerations in line with incentivising drug sales and patient retention may compel physicians into prescribing inappropriately [38,52,54]. System factors such as insufficient accessibility to follow-up as well as the fear of litigation or related medico-legal issues were also strong drivers of excessive antibiotic prescribing [51,54].…”

“…In rural and remote health care settings, financial considerations of patient retention play a particularly important part during clinical interactions. Compounded by institutional pressures to generate revenue for health facilities and financial incentives from the sale of certain drugs, physicians may be compelled to prescribe unnecessary antimicrobials to patients who demand them [38,52,54] Providing incentives for lower rates of prescribing has been proven to reduce antibiotic use Equitable access to affordable medicine, potentially through subsidised medicines or insurance Sources of guidance Absence or limited depth of rural-specific clinical guidelines on which PHC providers can base prescribing practices [80] Develop clear and concise clinical guidelines in consultation with relevant stakeholders including those with AMS expertise that take into account the unique cultural and socioeconomical aspects of specific remote communities of the region. If the problem lies in their implementation, CDSS may be beneficial in translating written guidelines to clinical practice…”

The Impact of COVID-19 on Primary Health Care and Antibiotic Prescribing in Rural China: Qualitative Study

“…Most VCs are independent entities that are non-government owned and nancially semi-autonomous, charging fees that are either paid by patients or reclaimed from insurance [9,11]. The THCs deliver technical guidance and have oversight of the public health work conducted by VCs [12], but VCs can diagnose and treat patients attending for general illness such as infections. Notably, China's 'primary health care' system differs in important ways from that in high-income settings; VCs offer only outpatient care and are staffed by 'village doctors', most of whom do not hold a medical degree but have some medical training, whereas THCs have inpatient wards and a range of outpatient clinics staffed by fully quali ed physicians.…”

The impact of COVID-19 on primary health care and antibiotic prescribing in rural China: qualitative study

“…[10] Most VCs are independent entities that are non-government owned and financially semi-autonomous, charging fees that are either paid by patients or reclaimed from insurance. [9, 11] The THCs deliver technical guidance and have oversight of the public health work conducted by VCs,[12] but VCs can diagnose and treat patients attending for general illness such as infections. Notably, China’s ‘primary health care’ system differs in important ways from that in high-income settings; VCs offer only outpatient care and are staffed by ‘village doctors’, most of whom do not hold a medical degree but have some medical training, whereas THCs have inpatient wards and a range of outpatient clinics staffed by fully qualified physicians.…”