Antibiotic use in rural China: a cross-sectional survey of knowledge, attitudes and self-reported practices among caregivers in Shandong province

We have surveyed over 700 adults living in villages in a province in eastern China about their knowledge, attitudes and practices concerning antibiotics in children. Each participant is the primary caregiver for a child under the age of 7, a demographic commonly associated with high use of antibiotics. Despite limiting our investigation to this single specific demographic, our results indicate that multifaceted and multi-target interventions are vital to improve antibiotic use in rural China. To the best of our knowledge, this is only the second ever study of this type conducted among caregivers in China, a country in which a fifth of the world’s population resides. Several of the results from our study are similar to those of Yu et al., conducted among rural caregivers attending vaccination clinics in central China [16]. This similarity indicates that interventions aimed at improving antibiotic practices need to be applied over a wide population base and geographical area; these interventions must take into account the growing socio-demographic heterogeneity in the rural population, as young parents more frequently travel to nearby towns for work during the weekdays, and children are left in the care of grandparents.

The village doctor plays a central role in determining antibiotic use: 70 % of antibiotics that participants admitted to having stored in their homes were obtained from village clinics, and the village doctor was, by a wide margin, the most frequently mentioned source of information about antibiotic use, as was also found among rural caregivers in central China [16]. Almost all participants (93 %) knew they should follow the doctor’s advice about taking antibiotics. All of these results indicate the need for a well-trained base of village doctors, capable not only of determining when antibiotics are needed, but also describing how to use them once they have been prescribed; as Yu et al. reported, village doctors frequently do not explain a condition or treatment to caregivers, but those who had received explanations were more likely to follow them [16]. This need becomes more important, and also more influential, in the context of policies aimed at reducing illegal over the counter dispensing of antibiotics [22, 23]. It is encouraging to see that in a recent study in another part of Shandong province over 90 % of village clinic doctors had accessed training on antibiotic use, and most had done this in the previous three years [24]; however, even though only 5 % of these village doctors said they would use antibiotics for a patient with common cold, a prescription analysis at the same village clinics found that over half of common cold prescriptions included at least one antibiotic. In a qualitative study in another rural province, Reynolds et al. found that doctors used antibiotics to speed recovery and respond to patient expectations, even if they did not believe antibiotics were needed to treat an infection [8].

Although participants view the doctor’s advice on use of antibiotics as important, only 83 % of participants reported that they always follow this advice. On further questioning, many participants admitted that they had made adjustments in antibiotic use, such as choosing to lower a dose for efficacy, and almost half said that they had on a previous occasion given their children an antibiotic intermittently rather than regularly as prescribed. In addition, close to a half of participants reported always or sometimes stopping antibiotics once symptoms started to improve, as did 63 % of rural caregivers in central China [16]. All of these behaviours can easily lead to under-dosing, with risks of treatment failure and selection of resistant bacteria [25]. Participants that were older and that had lower levels of education were less likely to report deviating from a doctor’s advice; however, it is possible that these individuals were expressing a greater degree of reliance on doctor’s advice, rather than purposeful adherence.

Nearly two-thirds of participants knew that a prescription was needed to obtain antibiotics. At the same time, a third of participants admitted that they stored antibiotics at home for their children, and almost all had used these antibiotics on a second occasion for their child. It appears that the need for a prescription for antibiotics is not a strong enough signal that such drugs should only be used with input from a trained healthcare professional – indeed, participants who knew that a prescription was needed to get antibiotics were actually more likely to store leftover antibiotics at home. In the study by Yu et al., rural caregivers who did not know that a prescription was needed to get antibiotics were more likely to have purchased antibiotics at a drugstore without a prescription [16]; here we have found that awareness of the need for a prescription alone may change behaviour, but it may not improve how antibiotics are actually used. Fixed pack dispensing, which is not currently widely practiced in China, may be a complementary method to help reduce the availability of leftover antibiotics in homes [26].

We found gaps in participant’s knowledge about antibiotic use, and community focused interventions may have an important role to play in addressing these [27]. Firstly, some participants are probably not aware what an antibiotic is. Using a list of the fifteen most commonly used antibiotics in the area, 4.4 % of people were still unable to identify a single medication as being an antibiotic. Secondly, there was very little awareness about how often antibiotics are truly needed for a variety of common childhood symptoms and illnesses. Between 23.5 % and 55 % of participants responded that they did not know whether antibiotics were needed for each complaint; and close to a half of all participants suggested that a fever or a dry cough should always or usually be treated with antibiotics; similarly, 34 % of rural caregivers in central China reported that antibiotics should always be used when a child has a fever [16]. Meanwhile, some participants thought that antibiotics were never necessary for a fever (13.4 %) or a sore throat (18.6 %). Over-expectation, under-expectation and a lack of knowledge all co-exist among caregivers in this setting. We have not investigated to what extent these expectations direct health-seeking behaviours, but they have the potential to lead to both problems of inappropriate overuse and underuse of antibiotics [1, 16]. The only socio-demographic factor associated with high levels of over-expectation was having a child over the age of three; a possible explanation for this is that the participants’ expectations are driven by experience, rather than knowledge, with caregivers of older children having had more exposure to antibiotics being used for their children, and so they become more likely to think this is normal. Thirdly, just over a half of respondents knew that inappropriate antibiotic usage adds to the risk of antibiotic resistance. This is the same proportion as reported in rural caregivers in central China concerning excessive antibiotic use (57 %) [16], and slightly lower than the median 70 % reported in a recent global systematic review of the general public’s knowledge and attitudes towards antibiotic resistance [28]. Furthermore, only 38 % of participants agreed that antibiotics were overused in China, and most participants did not think that it was dangerous for their children to be infected with antibiotic-resistant bacteria. This lack of awareness may contribute to the widespread behaviours of participants storing and deciding to use antibiotics by themselves, and to adjusting antibiotic dosing without asking the doctor for advice. A three year national campaign on antibiotic resistance was launched by the Ministry of Health in 2011, but focussed mainly on improving antibiotic use in secondary and tertiary care hospitals in China [29]. Although there were no major public education elements to the campaign, there have recently been accounts of the problems of antibiotic resistance on mass media, which will likely have promoted public awareness of the issue.

Our study has several strengths, including a high response rate with a randomized selection of a large population of caregivers from twelve different villages, and the use of trained interviewers to conduct the questionnaires. We also have important limitations: first, we were only able to select villages with at least 60 households with children aged 0–7, in order to include a sufficient number of participants for the planned educational intervention; this means that the selected villages were sampled from the largest 40 % of villages in the township, but are similar in other respects to all villages in the study setting. Secondly, a convenience sample was used to select the final participants; however, a large proportion of eligible households within each village were included (39-73 %), and we have no reason to suspect that it led to the introduction of any major biases. Thirdly, participants were primary caregivers for their children, but this does not mean that they take full responsibility for decision-making when children under their care are ill. Fourthly, our study investigated reported rather than observed practices, and we did not gather any data on actual frequency of antibiotic use in children. Overall, the consistency of several of our findings with those of Yu et al. in central China [16] suggest that many of our conclusions may be generalizable to caregivers living in villages in other parts of rural China.