Determinants of antibiotic prescribing in primary care in South Africa: studying patient-provider interactions in the private and public sectors

Lead Research Organisation: London School of Economics & Pol Sci
Department Name: LSE Health

Abstract

Because it increases the morbidity and mortality of bacterial infection, as well as the duration and cost of antibacterial treatment, antibiotic resistance constitutes a significant threat to global public health. The problem is even more critical in low- and middle-income countries which have higher infectious disease burdens, often higher rates of antibiotic resistance, less access to diagnostic tools, and fewer financial resources to purchase newer more effective antibiotics. In South Africa, antibiotic resistance is particularly high, despite an effective drug regulatory system and various initiatives to tackle the problem. Antibiotic resistance is accelerated by the overuse and over-prescription of antibiotics, which is the product of complex interactions between providers' decisions and knowledge, and patients' expectations. Yet research on the determinants of prescribing behaviours from LMICs in general, and South Africa in particular, is limited, and has been criticised for being too descriptive and superficial, with limited insight into the relative importance of different behavioural determinants to be able to prioritise interventions. In South Africa, most research efforts have focused on hospitals rather than primary care, despite the fact the majority of antibiotics are prescribed in primary care, mostly for respiratory infections.

This study aims to explore how the interactions between providers and patients influence inappropriate antibiotic prescribing for URTIs in public and private primary care in South Africa.
The study will include three components. First, drawing on medical anthropology, we will explore qualitatively providers' and patients' perceptions an experiences of antibiotic prescribing. This will be done through observations of consultations, interviews with providers and focus group discussions with patients. Second, building on the first part and drawing on methods from marketing research, we will design a survey consisting of a series of hypothetical clinical cases where clinical and patient characteristics will be systematically varied; for each case, the providers taking part will be asked indicate what drugs they would prescribe in a list of proposed drugs. The results will allow us to quantify the relative importance of the factors influencing antibiotic prescribing, with a view to inform policy-makers design future interventions. Finally, drawing on recent economics and medical education research, we will move beyond observational research and design a small randomised field study to test the impact of patients' knowledge and financial incentives on the prescribing practices of public and private primary care providers. This will be achieved with the use of standardised patients, who are healthy subjects trained to portray specific symptoms and disclose a rehearsed medical history. These patients will be sent to visit providers who agreed to take part in the research, at a time and under an identity unknown to them. The standardised patients will only differ in their expectations of antibiotics and the insurance status they will disclose. This will allow us to test the impact of these different characteristics on the likelihood of antibiotic prescription.

We anticipate that the results will provide invaluable insights into our understanding of prescribing decisions in the public and private sector in South Africa, thereby informing the stewardship programmes for antimicrobial resistance in this country. Beyond this setting, these findings will be useful to other middle-income countries with a similar mix of public and private providers. More generally, we aim to produce high-quality research and develop innovative methods that could be replicated in other low-income settings to study antibiotic prescribing.

Planned Impact

We anticipate that this research will benefit six groups.

1.Policy-makers and stakeholders from South Africa and other middle-income countries:
For governments seeking to achieve universal health coverage, encouraging providers to prescribe antibiotics appropriately is a public health and economic imperative. The research findings will therefore be of high interest to them. In South Africa and other similar settings with a large private sector, private insurers who reimburse patients for prescribed medicines will also be interested in understanding the likely impact of different types of purchasing mechanisms on prescribing. The research will set up a Steering Group committee that will include members of the National stewardship programmes as well as representatives of medical insurance schemes. This link, as well as the dissemination workshops organised during the study, will help incorporate study findings into national plans to improve antibiotic prescribing in primary care. In addition, through the team members' networks and collaborations, we will be able to reach other policy-makers in other countries (e.g. Thailand, Senegal).

2.Health care providers
The research will produce robust evidence which should help practitioners reflect on their own practices by showing how their practices is related to a range of factors, including patients' attitudes and characteristics.. To make sure that research participants in South Africa, and in general health workers and managers involved in the delivery of health care in LMICs benefit from findings of this research, we will develop some communication tools designed to question readers' practices and beliefs (leaflets, infographics and a short film). Research participants will also be invited to take part in the final dissemination workshop to discuss the results and potential lessons.

3.Members of the public:
Improving the appropriate prescribing of antibiotics in South Africa has several benefits to the public. First, South African patients and their families would receive medication appropriate to their clinical needs. Second, it is hoped that rational prescribing of antibiotics in South Africa would decrease the risk of antimicrobial resistance, thereby ensuring that South African patients will be able to access effective antibiotics when they need them.

4.Future generations of health care providers in South Africa:
Through their links to several nursing schools and the School of Medicine at the University of Witwatersrand (Wits), DB and LM will offer to give guest lectures as a way to reach future generations of medical practitioners and nurses in South Africa. In addition to traditional lectures, the innovative material developed through the project (infographics, short film) will be used in order to create a more lasting impact on students.

5.Future generations of international health policy makers:
Teaching material will be developed for courses taught by grant applicants - medical sociology, health economics and health policy courses taught at LSE, LSHTM, Wits and Brown University. In addition, we will make the material available to other African universities through the Consortium for Health Policy and Systems Analysis in Africa (a partnership of African and European universities, whose purpose is to increase African capacity to use high-quality Health Policy and Systems research by developing teaching material for African educators).

6.International health agencies:
Given current interest in AMR, this research should directly feed into the reflections of policy-makers involved in the antibiotic stewardship programmes, in South Africa, in other LMICs, as well as on the global health scene (DfID, WHO, etc.). Engagement with key stakeholders in LMICs will be facilitated by the various existing networks of the team members, and engagement in the UK will take place at events such as the Roundtable Series on AMR organised by BSAC.

Publications

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Manderson L (2020) Prescribing, care and resistance: antibiotic use in urban South Africa in Humanities and Social Sciences Communications

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Tompson A (2021) Understanding antibiotic use: practices, structures and networks in JAC-Antimicrobial Resistance

 
Description • The rates of unnecessary prescribing of antibiotics in urban South Africa is is high: in total 72% of Standardised patients presenting with a case of Acute Bronchitis received an antibiotic. This proportion is higher in the public sector (78%) than in the private sector (67%).
• These results are driven by lack of knowledge of the guidelines, and of the cause of bronchitis.
• This unnecessary prescription translates into large financial costs to the patient and the healthcare system. The average cost of drugs prescribed in the private sector was 9 times more expensive (R157) than the cost of the recommended symptomatic relief treatment. Although it was only R36 in the public, it was still twice as expensive as the recommended treatment.


Public awareness campaigns are often recommended as a way to change patients' attitudes, in the hope to drastically reduce unnecessary prescription of antibiotics.
We sought out to test what the impact of such campaigns would have if they were successful in changing patients' attitudes. We sent two different mystery standardised patients to each private and public providers enrolled in the audit study adopting different attitudes towards antibiotics. The SPs either adopted a 'normal' attitude (as above - not expressing a particular preference for antibiotics) or were 'reluctant', expressing at the beginning of the consultation that they would prefer not to have antibiotics, unless really necessary.

• We found that the reluctant attitude would lead to a significant reduction of 15 percentage points overall in unnecessary prescribing of antibiotics for a viral RTI, yet the unnecessary rate of AB prescription remains very high at 57%.
• Even though we expected that private GPs in the competitive primary care market would respond more to patients' preferences, we found a similar effect amongst private and public providers.
• While we found no difference in the cost of drugs prescribed by GPs to the normal and reluctant patients, while public providers prescribed more expensive drugs to reluctant patients.

Finally, while there is evidence that remuneration linked to drug sales increases the prescription of unnecessary drugs, there is little evidence about the effects of financial incentives to limit over-prescribing or encourage rational prescribing of drugs, either by using providers' profit concerns. We exploited the fact that most private GPs in South Africa are dispensing drugs: in exchange for an additional fixed fee added to the consultation charge, they have the right to dispense drugs to their patients. This fixed dispensing fee creates a rationing incentive for those GPs, as the more unnecessary and expensive drugs they prescribe, the more their profit will be reduced.
• We found that when patients asked for a prescription and relax the rationing incentive of dispensing GPs, GPs prescribe more expensive drugs but the rate of unnecessary antibiotic prescribing does not change.
Exploitation Route We have been organising various dissemination events to policymakers and the general public. We will continue to do so.
Sectors Healthcare

 
Description Our fundings have been used by regional and national authorities to start a review process of potential interventions to reduce unnecessary prescribing of antibiotics. This is integrated within the broader discussion around the efficiency of service delivery under the current plans to roll out a National Health Insurance scheme at the country level.
First Year Of Impact 2019
Sector Healthcare
Impact Types Policy & public services

 
Description Behavior Change Meeting: Early messaging and strategies for AMR education for public health students and specialists.
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Consultation with the medical insurance industry
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Membership of a guideline committee
 
Description Preliminary Review of AMR Standardised Patient Results to the Ministerial Advisory Committee on Antimicrobial Resistance and Antimicrobial Stewardship in South Africa
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Participation in a advisory committee
 
Description Presentation to Ministerial Advisory Committee on Antimicrobial Resistance
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Participation in a advisory committee
 
Description Provided input to the design and content of the homepage for the SA National Department of Health Antibiotic Guardian Pledge campaign,
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
URL https://antibioticguardian.com/south-africa/
 
Description Training of data collectors for study on Analysing Behaviour Change in the private hospital group in South Africa: advice on protocol, instrumentation and ethics for antibiotic stewardship
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Health Systems Research Initiative
Amount £765,082 (GBP)
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2020 
End 04/2023
 
Description Small Grant in Humanities and Social Science,
Amount £26,367 (GBP)
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 09/2018 
End 03/2020
 
Description South African collaboration 
Organisation University of the Witwatersrand
Department Centre for Health Policy
Country South Africa 
Sector Academic/University 
PI Contribution We have carried out one main research project in the past (cohort study on within which my PhD was built) - During the course of my fellowship, we have obtained funding for a new project together on health workers' behaviours under different types of incentives. This benefits the South African institution directly (financial support).
Collaborator Contribution This collaboration has mainly consisted in an fruitful intellectual collaboration with one researcher, on two areas of research: analysis and development of Discrete Choice Experiments, and design of experimental economic games. This collaboration also provides facilitated access to sites for primary data collection (that would otherwise be more complex to obtain).
Impact several publications have come out of this: - Cost-effectiveness analysis of human resources policy interventions to address the shortage of nurses in rural South Africa; - Appealing to altruism: an alternative strategy to address the health workforce crisis in developing countries? - Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment. One funded project: - An experimental investigation of the impact of individual payment mechanisms on clinicians' behaviour
Start Year 2008
 
Description AMR Behaviour Research Workshop in Cape Town with experts in Upper Respiratory Tract Infections (URTIs) and the use of Antibiotics 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The workshop was a platform to engage with academic and practicing experts in antibiotic stewardship and respiratory tract infections in South Africa. Feedback from the panel was used to develop the clinical case and checklists that would be tested in the fieldwork using the methodology of standardised patients and to score the providers quality of treatment.
Year(s) Of Engagement Activity 2017
 
Description Advisory group 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The project set up an advisory group comprised of national policy-makers involved in the national AMR stewardship strategy in South Africa, as well as representatives of professional bodies and insurance groups.
Year(s) Of Engagement Activity 2017
 
Description Antimicrobial Resistance Cross Council Initiative Challenges and Opportunities Workshop, 4-5 July 2017, Heathrow 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact TBC
Year(s) Of Engagement Activity 2017
 
Description Discovery meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Industry/Business
Results and Impact Having collaborated with Discovery (the largest private insurance company in the country) on the project, we presented the findings at the Discovery Health Clinical Governance Committee. The meeting was attended by about 15 doctors, specialists and Discovery health managers.
Year(s) Of Engagement Activity 2019
 
Description Discovery podcast 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact The team was approached by a large insurance group to discuss the drivers of unnecessary prescribing of antibiotics in South Africa in a podcast to be widely disseminated, especially to professionals. Dr. Blaauw (member of the team) appears on episode 5, part 1.
Year(s) Of Engagement Activity 2019
URL http://www.discovery.co.za/corporate/podcast-discover-healthier
 
Description Lectures to faculty, students and interested public 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Lecture, Comorbidities, Syndemics, Cascades and Loading: The complex interactions of the social and the biological, Department of Anthropology and Department of Global Health, Yale University, New Haven, CT, 9 November 2017. Estimated attendance: 40 (graduate students and academic staff)
1. Public Lecture, The Unequal Ecologies of Extracorporeal Living, Department of Anthropology, the Critical Disability Studies Program, and the College of Liberal Arts, Purdue University, Lafayette, IN, 13 November 2017. Estimated attendance: 120 (graduate students, academic staff and interested public)
2. Seminar paper, The Unequal Ecologies of Extracorporeal Living, Department of Anthropology, University of the Witwatersrand, 10 May 2018. Estimated attendance: 20 (graduate students and academic staff)
3. Invited Lecture, Preemptive diagnosis, anticipatory prescribing and antimicrobial resistance in urban South Africa, Medical Anthropology Research Seminar Series, LSHTM (London School of Hygiene and Tropical Medicine), London, 5 June 2018. Estimated attendance: 50 (graduate students and academic staff)
Year(s) Of Engagement Activity 2017,2018
 
Description Main study dissemination 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The event was organised at the School of Public Health, in Johannesburg. About 40 people attended and were given a series of 5 short presentations summarising the different findings of the study. This led to many questions and discussions, including further individual interactions afterward. The policy-makers who were present agreed to further collaborate with the team to identify solutions to reduce unnecessary prescribing of AB.
Year(s) Of Engagement Activity 2019
 
Description Meetings with experts in the antibiotic resistance societies and researchers 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact 1. Paper presentation, Stewardship and the everyday ethics of care in Johannesburg, Panel 6-9245 on Care as Critical Frame - Part Two, Epistemologies of Care, 117th AAA Annual Meeting, San Jose, 18 November 2018. Estimated attendance: 30 medical anthropologists

2. Meetings with Clare Chandler, Co-ordinator of the Antimicrobials in Society (AMIS) Hub, LSHTM, 28 September 2017; 5 June 2018.

3. Participation in Antimicrobials in Society (AMIS) Hub (https://www.antimicrobialsinsociety.org/about/)

4. AMR Public Awareness Campaign, Discussion of video production, Vanessa Carter and Lenore Manderson, Cityvarsity, Braamfontein, 27 September 2018
Year(s) Of Engagement Activity 2018
 
Description Sharing of Preliminary Review of AMR Standardised Patient Results with experts in pulmonology at Wits University South Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Preliminary study results were presented to 2 pulmonology experts based at Wits University, South Africa. The experts provided insight into the package of drugs that primary care providers had prescribed, specifically, the prescribing of steroids/cortisols was deemed unnecessary for an acute bronchitis case. This was, therefore, concerning in the prescribing behaviours of not only unnecessary antibiotics but also this new trend of prescribing steroids.
Year(s) Of Engagement Activity 2019
 
Description Sharing of Preliminary Review of AMR Standardised Patient Results with practitioners and study members in public and private primary care in South Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Multiple talks were held in December 2018 with various stakeholders. These stakeholders represented views from the private, public and educational sectors involved in primary care in South Africa such as pharmacy, primary care providers in the private sector, primary care providers in the public sector, medical insurance firms and teachers of undergraduate medical students.
Feedback from these sessions highlighted specific questions that specific stakeholders were interested in resulting in refining the analysis and making further investigations into specific areas to better understand the antibiotic prescribing behaviours in the public vs the private sector separately.
The outcomes of the sessions also initiated future research areas, collaborations and interventions that could be piloted/tested to target private and public sector providers.
Year(s) Of Engagement Activity 2018
 
Description South African Universal Health Coverage National Dialogue 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The meeting was attended by most of the health system researchers in the country. Also attended by many of the senior NDoH officials (although not for the whole time of course) including the Minister of Health (Dr Zweli Mkhize), Acting DG (Dr Anban Pillay), Dr Yogan Pillay (DDG Health Programmes), Dr Nicholas Crips (NHI Manager) etc etc. Also number of senior MRC people including the President Dr Glenda Gray
Year(s) Of Engagement Activity 2019
URL https://www.samrc.ac.za/media-release/two-day-national-dialogue-focus-universal-health-coverage
 
Description Symposiums and workshops at Brown (USA) and Monash (AUS) University 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact 1. Organiser, chair and paper presentation at Symposium: After Illness, Under Diagnosis Symposium held at Brown University, Providence on 2-4 April 2018. Paper title: Preemptive Diagnosis and Anticipatory Prescribing in Urban South Africa. Attendance: 20 (closed workshop, by invitation only) (medical anthropologists, including senior and emerging academic staff and completing PhD students, from US, South Africa, Norway, Denmark and Australia.
2. Invited paper to The unequal ecologies of extracorporeal living Workshop: Making Biofutures: Anticipating the futures of Biomedicine, Healthcare and Life Itself held at Monash University Prato Centre, Prato, Italy, 11-12 June 2018. Estimated attendance: 20 academic staff from UK, Italy, South Africa and Australia (closed workshop, by invitation only)
Year(s) Of Engagement Activity 2018