Understanding Internal and External Drivers Influencing the Prescribing Behaviour of Informal Healthcare Providers with Emphasis on Antibiotics in Rural India: A Qualitative Study

Abstract

Globally, Antibiotic resistance is a major public health concern, with antibiotic use contributing significantly. Targeting informal healthcare providers (IHCPs) is important to achieve universal health coverage and effective antibiotic stewardship in resource-constrained settings. We, therefore, aimed to analyse the internal and external drivers that influence IHCPs’ prescribing behaviour for common illnesses in children under five, with an emphasis on antibiotic use in rural areas of India. A total of 48 IHCPs participated in focus group discussions. Thematic framework analysis with an inductive approach was used, and findings were collated in the theoretical framework based on knowledge, attitude, and practice model which depicted that the decisions made by IHCPs while prescribing antibiotics are complex and influenced by a variety of external and internal drivers. IHCPs’ internal drivers included the misconception that it is impossible to treat a patient without antibiotics and that antibiotics increase the effectiveness of other drugs and cure patients faster in order to retain them. Formal healthcare providers were the IHCPs’ sources of information, which influences their antibiotic prescribing. We found when it comes to seeking healthcare in rural areas, the factors that influence their choice include ‘rapid cure’, ‘cost of treatment’, ‘distance’ and ‘24 h availability’, instead of qualification, which may create pressure for IHCPs to provide a quick fix. Targeted and coordinated efforts at all levels will be needed to change the antibiotic prescribing practices of IHCPs with a focus on behaviour change and to help resolve misconceptions about antibiotics.

Exploring Barriers to One Health Antimicrobial Stewardship in Sri Lanka: A Qualitative Study among Healthcare Professionals

“…Both the human and veterinary healthcare participants in our study were under pressure from their clients to over-prescribe antibiotics. Antibiotic-demanding behaviour among clients has been reported in other studies [34][35][36]. Similar to our findings, antibiotics may be over-prescribed in order to secure and expand the client base of healthcare professionals [37,38].…”

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

“…These informal drug vendors report being commercially driven to sell medications and reach sales targets, often resulting in an over prescription of antimicrobials, inaccurate dosing, and the distribution of “half” antimicrobials which may be mixed with other materials (e.g., caffeine, routine pain medications) [ 28 , 74 , 85 ]. In a study of informal healthcare providers in rural India, Khare et al explained how informal drug vendors are an essential resource for rural and medically underserved communities, where antimicrobials are often handed out in response to a verbal description of symptoms or patient demand based on prior treatment success [ 91 ]. The authors noted that without informal drug vendors, these patients would likely forego healthcare entirely.…”

“…The high value placed on antimicrobials and belief in their power leads patients to expect and even demand antimicrobials when seeking medical care [87][88][89]. Patients will "doctor shop" or seek care only from providers who are known to readily provide antimicrobials or pharmacies that are liberal with their distribution [65,[90][91][92].…”

Instant Gratification and Overtreating to Be Safe: Perceptions of U.S. Intensive Care Unit Pharmacists and Residents on Antimicrobial Stewardship

“…Instant gratification as a theme draws on literature that frames antimicrobials as technological solutions to medical problems [ 23 ]. Namely, antimicrobials as quick-fix solutions [ 24 ] reflect pervasive ideas about what antimicrobials are and what they can be used for [ 25 , 26 ]. While overtreating to be safe depicts the pressures of safeguarding patients and avoiding medical mistakes, instant gratification as a theme can also refer to the feeling a physician gets when they solve a patient case.…”