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

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.

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.