Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis.

INTRODUCTION: The inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China. METHODS: Searches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only). RESULTS: Intervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies. CONCLUSIONS: Interventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.

Teachers' Perceptions of Student Mental Health in Eastern China: A Qualitative Study.

In China, primary and secondary school teachers, known as ban zhu ren, have pastoral responsibility for the students in their class. The aim of this preliminary study is to identify how ban zhu ren perceive the mental health of their students, and how they have acted on these perceptions. Content analysis was used to organize the data and distinguish categories or themes derived from in-depth semi-structured interviews conducted with 27 ban zhu ren from Zhejiang and Anhui provinces. Frequencies of informant responses were used to identify the areas of agreement and disagreement across identified categories and themes among the informants. The results illustrate that the informants consider issues, such as not paying attention in class (n = 14), not getting along well with classmates (n = 12), and excessive gaming (n = 11) to be indicative of mental illness, although these would commonly be considered normal adolescent behaviors. Fifteen informants admitted that they found it difficult to work with student mental health issues, and 18 felt they had inadequate or non-existent training. However, all informants stated that they had intervened with what they perceived to be students' mental health issues, although only 9 informants had referred students for professional help. The informants reported that they were reluctant to provide referrals, due to the stigmatization they believed students would experience if given a diagnosis of mental illness. We conclude that among our informants there is a lack of agreement on what behavioral and mental health issues are, and that informants may be confusing what are, in actuality, non-conformist or non-compliant (yet often normal), adolescent behaviors with mental illness due to insufficient mental health training.

Factors Impacting Family Planning Use in Mali and Senegal.

The total fertility rate in Mali (6.2) is the third highest in the world. Despite sociocultural similarities, the total fertility rate in neighboring Senegal is 4.2. The aim of this study is to identify factors which may help to explain the differences between the two countries and which may thereby inform family planning policy in Mali. A cross-sectional study was conducted with a convenience sample of 602 married women aged 16-50 from urban and rural sites in southern Mali and Senegal. A total of 298 respondents from Mali and 304 from Senegal completed a structured questionnaire between July and October 2018. In total, 11.1% of the Malian respondents and 30.9% of the Senegalese respondents were currently using family planning, and 34.6% and 40.5%, respectively, had ever used a modern family planning method. Pressure from husbands was cited as a primary influence for having more children (in 50.3% of Malians and 45.4% of Senegalese, p = 0.000). Women's age, education level, and knowledge of different contraceptive methods were associated with ever use of contraceptives. After adjustment for confounders, discussing family planning with one's husband was the strongest predictor of contraceptive use among both Senegalese (OR = 3.4, 95% CI (1.9-6.3), p = 0.000) and Malian respondents (OR = 7.3, (4.1-13.3), p = 0.000).

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

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.

Health service utilization following symptomatic respiratory tract infections and influencing factors among urban and rural residents in Anhui, China.

AIM: This study seeks to identify healthcare utilization patterns following symptomatic respiratory tract infections (RTIs) and the variables that may influence these patterns. BACKGROUND: RTIs are responsible for the bulk of the primary healthcare burden worldwide. Yet, the use of health services for RTIs displays great discrepancies between populations. This research examines the influence of social demographics, economic factors, and accessibility on healthcare utilization following RTIs. METHODS: Structured interviews were administered by trained physicians at the households of informants selected by cluster randomization. Descriptive and multivariate binary logistic regression analysis was performed to assess healthcare utilization and associated independent variables. FINDINGS: A total of 60 678 informants completed the interviews. Of the 2.9% informants exhibiting upper RTIs, 69.5-73.9% sought clinical care. Healthcare utilization rates for common cold, influenza, nine acute upper RTIs, and overall RTIs demonstrate statistically significant associations with the variables of age, type of residence, employment, medical insurance, annual food expenditure, distance to medical facilities, and others. The odds ratios for healthcare utilization rates varied substantially, ranging from 0.026 to 9.364. More than 69% of informants with RTIs sought clinical interventions. These findings signify a marked issue with the large amount of healthcare for self-limited RTIs.

Pathways to optimising antibiotic use in rural China: identifying key determinants in community and clinical settings, a mixed methods study protocol.

INTRODUCTION: This study aims to investigate patterns of antibiotic treatment-seeking, describe current levels of and drivers for antibiotic use for common infections (respiratory tract and urinary tract infections) and test the feasibility of determining the prevalence and epidemiology of antimicrobial resistance (AMR) in rural areas of Anhui province, in order to identify potential interventions to promote antibiotic stewardship and reduce the burden of AMR in China. METHODS AND ANALYSIS: We will conduct direct observations, structured and semistructured interviews in retail pharmacies, village clinics and township health centres to investigate treatment-seeking and antibiotic use. Clinical isolates from 1550 sputum, throat swab and urine samples taken from consenting patients at village and township health centres will be analysed to identify bacterial pathogens and ascertain antibiotic susceptibilities. Healthcare records will be surveyed for a subsample of those recruited to the study to assess their completeness and accuracy. ETHICS AND DISSEMINATION: The full research protocol has been reviewed and approved by the Biomedical Ethics Committee of Anhui Medical University (reference number: 20170271). Participation of patients and doctors is voluntary and written informed consent is sought from all participants. Findings from the study will be disseminated through academic routes including peer-reviewed publications and conference presentations, via tailored research summaries for health professionals, health service managers and policymakers and through an end of project impact workshop with local and regional stakeholders to identify key messages and priorities for action.

Pathways of healthcare and antibiotics use following reported gastrointestinal illness: a cross-sectional study in rural Anhui, China.

OBJECTIVE: To document the factors, and their pathways, that influence healthcare and antibiotics use following reported gastrointestinal illnesses in Anhui province, China. STUDY DESIGN: This study uses cross-sectional design, descriptive statistical analysis, pathway mapping and multivariate logistic regression modelling. SETTING: Households in 12 villages in Anhui province, China. PARTICIPANTS: A total of 3659 residents who: (1) held a registered rural residence and were actually living in the sampled villages when this study was conducted; (2) were aged 18 years and older and (3) were willing to participate and able to answer the survey questions. OUTCOME MEASURES: Planned and measured variables included the occurrence of gastrointestinal illness, professional care seeking and antibiotic use due to the illness and factors influencing these measures. RESULTS: Of the 3659 informants, 29.0% reported gastrointestinal illness episodes in the past year. Of these episodes, 50.2% led to professional care seeking and 65.4% of antibiotic use. Multivariate logistic modelling identifies that: (1) reported gastrointestinal illnesses were more frequent in north compared with middle (OR 0.569, 95% CI 0.472 to 0.686) and south (OR 0.588, 95% CI 0.492 to 0.702) Anhui, and were positively associated with age (B=0.123, p<0.05), knowledge concerning (B=0.248, p<0.05) and practice of (B=0.184, p<0.05) prevention; (2) seeking professional care and antibiotic use following the illness was linked to the severity of symptoms and geographical locations, rather than to specific pathogenic features. CONCLUSIONS: Reported gastrointestinal illnesses are quite prevalent in the sample population and a large proportion of these have resulted in professional care and antibiotics use. The factors associated with the reported illnesses and pathways of healthcare and antibiotic use, as identified in this study, should inform future research and intervention efforts.

Psychological factors and demands for breast and cervical cancer screening.

OBJECTIVE: The study aims to investigate relationships between demands for breast and cervical cancer screening (BCS/CCS) and related health beliefs. METHODS: The study used cluster-randomized sampling and collected data about demands for BCS/CCS and constructs of health beliefs model (HBM). It calculated indices of perceived risk and seriousness of the cancers and perceived effectiveness, benefits and difficulties of the screening; and performed descriptive and multivariate regression analysis of the demands and the HBM constructs. RESULTS: Less than 23.7% of respondents (N = 805) had ever undertaken BCS/CCS but 62.7% reported willingness to receive the service. Demands for BCS/CCS illustrated negative associations (Beta = -0.11 and -0.10) with age but positive (Beta = 0.15 and 0.11) links with education. The absolute values of standardized regression coefficients between the demand and the HBM constructs added up to 0.69 for BCS and 0.64 for CCS respectively, being 4-40 times that of age and education. CONCLUSIONS: Models incorporating all HBM constructs have substantially greater power than commonly researched single factors in explaining BCS/CCS demands. PRACTICE IMPLICATIONS: Comprehensive BCS/CCS promotion addressing all HBM constructs in a synergetic way may prove to be more effective.

Manufacturing risk: reframing the discourse of safety of commodified potent substances.

ETHNOPHARMALOGICAL RELEVANCE: The rapid commodification of plant-based medicines has led to the development of regulatory guidelines and standards by the World Health Organization to ensure the safety of these products. However, these standards have been identified to be selectively implemented, if implemented at all, in many contexts. A primary concern for proving the safety of intrinsic factors of plant-based medicines, may result in less attention paid to the often more problematic extrinsic factors of mass production. This article critically examines the normative global discourse of safety concerning plant-based medicines and problematises many of the assumptions identified in this discourse. MATERIALS AND METHODS: This qualitative research was conducted in the Traditional Medicine Unit of the Western Pacific Regional Office of the World Health Organization (WHO) and in field work in the rural Philippines. Data was collected through archival research, analysis of WHO data sets, semi-structured and structured interviews and surveys, participant observation concerning local plant-based medicine use in the Philippines and participant observation in WHO meetings regarding future strategies for traditional Asian medicines. RESULTS: Although informants reported concerns of safety for every aspect of the production, marketing and sales of plant-based medicines, this research has identified that the implementation (WHO guidelines) has been uneven and inconsistent over the past ten years in the Western Pacific Region of the WHO. Differences in local contexts that are not consistent with global guidelines and standards were reported by informants. Issues have also been identified in the inconsistent regulation of plant-based medicines as pharmaceuticals within only certain, rather than all, processes of production. CONCLUSIONS: It is imperative to understand plant-based medicines as the potent substances they are, whose rapid global commodification may affect both their potency and safety. The WHO discourse of the need for safety in the use of plant-based medicines has justified the need for biomedical oversight through processes of commodification. Yet, it is often through these very processes of commodification and mass production that safety may be compromised. This research suggests that the discourse concerning the safety of the plant-based medicines needs to be reframed from a primary focus on the intrinsic factors of plant-based medicines to a greater focus on the extrinsic factors of global commodification.

Excess mortality in the aftermath of Hurricane Katrina: a preliminary report.

BACKGROUND: Reports that death notices in the Times-Picayune, the New Orleans daily newspaper, increased dramatically in 2006 prompted local health officials to determine whether death notice surveillance could serve as a valid alternative means to confirm suspicions of excess mortality requiring immediate preventive actions and intervention. METHODS: Monthly totals of death notices from the Times-Picayune were used to obtain frequency and proportion of deaths from January to June 2006. To validate this methodology the authors compared 2002 to 2003 monthly death frequency and proportions between death notices and top 10 causes of death from state vital statistics. RESULTS: A significant (47%) increase in proportion of deaths was seen compared with the known baseline population. From January to June 2006, there were on average 1317 deaths notices per month for a mortality rate of 91.37 deaths per 100,000 population, compared with a 2002-2004 average of 924 deaths per month for a mortality rate of 62.17 deaths per 100,000 population. Differences between 2002 and 2003 death notices and top 10 causes of death were insignificant and had high correlation. DISCUSSION: Death notices from local daily newspaper sources may serve as an alternative source of mortality information. Problems with delayed reporting, timely analysis, and interoperability between state and local health departments may be solved by the implementation of electronic death registration.