Factors influencing antibiotic prescribing in China: an exploratory analysis

China has very high rates of antibiotic resistance and a health care system that provides strong incentives for over-prescribing. This paper describes the findings of a qualitative study in a province of southern China that seeks to assess knowledge, attitudes, and practices in relation to the use of antibiotics.

Semi-structured interviews with patients and health workers at provincial, county, township, and village level. Interviews used four probes (common cold, cough, mild diarrhoea and tiredness) where antibiotics were not indicated, supplemented by questions on knowledge, attitudes, and practices. These data were supplemented by two focus groups, with medical students and pharmacists, and discussions with participants at a national conference on antibiotic use.

Coughs and diarrhoea are almost universally treated with antibiotics, while the cold is normally treated with antivirals instead or as well. Many physicians are aware that the cold is usually self-limiting but believe that they can speed recovery and that they are responding to patient expectations. Most physicians and many patients are aware of the phenomenon of antibiotic resistance, although it is often seen as a property acquired by the patient and not the micro-organism. Physicians face financial incentives to prescribe, with profit splitting with pharmaceutical suppliers. Sales profits form a major part of a hospital's income. National guidance on use of antibiotics is fragmentary and incomplete.

The misuse of antibiotics poses considerable risks. Effective action will require a multi-faceted strategy including education, based on an understanding of existing beliefs, the replacement of perverse incentives with those promoting best practice, and investment in improved surveillance. Much of this will require action at national level.