Medical Assistants, Clinical Technicians and Clinical officers are an important group in prescribing antimicrobials in Sub Saharan African countries including Malawi. They are frontline health workers in primary and secondary health facilities in Malawi. They are more likely to prevent inappropriate prescription of antimicrobials and educate patients if they have enough knowledge and are aware of antimicrobial resistance. This study yields important findings regarding factors influencing clinicians to give over their prescribing decision power to patients during consultation. The allocation of more health workers and providing patient education during consultation is crucial and paramount to improve antimicrobial prescription.
The study identifies an important area that needs to be addressed when developing education interventions regarding interactions between clinician and patients. The study has demonstrated that only few clinicians were aware on the definition of antibiotic and antimicrobial resistance.
The majority asserted that some factors influence clinicians to give over their prescribing decision power to patients. Key among the factors are preferences, beliefs and efficacy of antimicrobials, negative attitude of patients towards clinicians, limited time /Clinician being overwhelmed as well as hindrance / obstacle to antimicrobial prescription. However, there is a significant gap on the definition of antibiotic and antimicrobial resistance among Clinicians which needs to be bridged, and that can result into appropriate antimicrobial prescription.
Preference
The present study confirmed that patient preference is a factor that influences clinicians to give over their prescribing decision power to patients and it determines inappropriate antimicrobial prescription in health care settings. These findings are supported by several studies in developed countries [11,26–29].
In the USA, a similar study to the current one found out that parental pressure was influencing clinicians to prescribe antibiotics [12]. This is also reflected in a similar study, in which, one of the reasons for the prescription of antimicrobials is patient demands or attitude [30]. A study done in Egypt also reported that preferences of caregivers and patients were among of the factors that contribute to antibiotics prescriptions [29].
Belief about efficacy
Our study also found out that belief about efficacy among patients in antimicrobials is contributing to inappropriate prescriptions in health care settings. These findings corroborate the findings from other studies.
It is reported that patients have a belief in certain antimicrobials over others when they visit health care settings. Clinicians in this study cited that patients’ demands and preferences for injectable or intravenous antimicrobials over oral ones contribute to inappropriate prescription. Similar findings from developed countries also reported that patients believe in antimicrobials when they visit health care settings, and even when they have a viral infection, they will demand antibiotics to avoid repeated consultations [31–34].
The current findings are also supported by another study which found out that patients come to a hospital with common cold and then demand intravenous antibiotics [35]. The current study findings also corroborate other studies which reported that there is belief that intravascular antibiotics are better than oral antibiotics and that, both doctors and patients encourage prescription of intravenous antibiotics [29,30,34–36].
Negative attitude of patients towards clinicians
Our findings about negative attitude of patients towards clinicians who refuse to prescribe antimicrobials is similar to other study findings which found out that clinicians were prescribing antibiotics in fear of losing patients’ trust [37]. The results also show that patients would change physicians when antibiotics are not prescribed. This is also reflected in similar studies that reported that even when patients do not need medication, doctors prescribe antibiotics to maintain a good patient-doctor relationship [38–40].
A study done in Malaysia found out that a few participants indicated that they would make their expectations explicit and request antibiotics from their physician even when they had viral infections, as they believe the medicine promotes rapid recovery. They also said they would consult another physician if their request was not granted [41].
Educating patients
This study also revealed that clinicians were influenced to prescribe antimicrobials because of patients’ lack of education on medications. In general, the health systems in Malawi are considered inadequate to meet the ever increasing health demanding population in health care settings as health care and clinician-patient ratios still need to improve. Clinicians reported that they do not have enough time to counsel and educate patients during consultations because of demands on their time due to large patient numbers.
In a review conducted by Ayukekbong et al.[42], it was found out that, because of high patient-doctor ratio in most developing countries, doctors are overwhelmed and, as a result, there is often inadequate time for meaningful education and communication with the patient on drug adherence guidelines and consequences of poor or non-adherence to the guidelines.
The current results corroborate a study done in North Carolina that revealed that clinicians should provide information in a manner that is easy for patients to understand as to why an antibiotic is not needed to treat a particular illness as well as how to appropriately use antibiotics in their treatment as and when they are prescribed [43].
Providing education at all levels, that is, community, healthcare setting and individual, is essential to ensuring rational use of antibiotics and suppressing inappropriate use.
Public education campaigns are effective in changing attitudes and knowledge regarding antibiotic use and resistance. Fletcher-Lartey and Machowska [22,40] found out that consumer education, such as discussion and explanation, was the common strategy reported by participants to manage patients’ expectations and demand for antibiotics.
Findings in this study are all consistent with other studies done in Belgium, England and France which reported that mass media interventions such as national TV campaigns and campaigns through other forms of mass media have been shown to reduce antibiotic prescribing for Acute Respiratory Tract Infection but argued that this strategy works best when targeting both healthcare professionals and the public [44]. It is recommended that care providers, dispensers and patients need to be educated on how the use and misuse of antimicrobials may contribute to the development of resistance [42]. It is cited that lack of communication skills is a factor that promotes unnecessary antimicrobial prescription [45].
Limited -Time /Clinician being overwhelmed
The findings also reveal that limited time act as a barrier to proper antimicrobial prescriptions. Clinicians reported that they prescribe antimicrobials in order to handle long queues in the outpatient department. Several studies support the fact that clinicians spend less time with patients because of work overload.
It is reported that clinicians prescribe medications in order to end the consultation and the clinicians themselves also reported that they prescribe under pressure when factors other than clinical presentation pushed them into prescribing even when they believe antibiotics are not needed [33].
In a study conducted in Karnataka state in South India, physicians agreed that they have too much work because of staff shortages and nearly half of them said that their patients ask them to prescribe antibiotics [46].
In this current study, clinicians do not perceive that limited time and inadequate number of clinicians is a facilitator for inappropriate prescription of antimicrobials.
Hindrance / Obstacle to antimicrobial prescription
Several factors exist such as unavailability of antimicrobials or their shortage, as well as antibiotics being sold on the open markets all of which are barriers to proper antimicrobial prescriptions since people can go and buy antimicrobials from pharmacies and open markets without a prescription from a clinician. One of the barriers to appropriate antibiotic prescriptions is inappropriate antibiotic use which has resulted from lack of access to and affordability of antibiotics due to inadequate government funding in developing countries [47].
In another study, it is also reported that those who were on medical aid were more likely to receive an antibiotic than those not on medical aid [48].
A study done by Baubie, et al. [49] also reported that high physician workload and high antibiotic use in the community were major barriers to antimicrobial stewardship implementation and lack of patient or client understanding of antibiotics, and difficulty in making diagnoses were barriers to proper antimicrobial prescription [50].
The current study is also supported by another study done in India which shows that selection of particular antibiotics also depends on their availability at the public health center and this is a barrier to prescribers [46]. The above study findings also corroborate other results, which report that clinicians felt that some antibiotics available in their hospital are of poor quality and less effective or that the required ones are not available and the patient gets antibiotics directly from shopkeepers without prescriptions [24]. Similarly, a study done in South Asia reveal that common challenges to proper antimicrobials prescription were poor dispensing, poor quality antibiotics, less effective ones in hospital, insufficient history taking and sale of antibiotics that have no proper dosage or are clinically inappropriate [51].
In fact, a study done in India found out that one of the obstacles to the appropriate use of antibiotics is poor quality of antibiotics and less effective ones in hospitals [24].
Clinician Lack of Knowledge on antibiotic and antimicrobial resistance
Furthermore, we need to educate clinicians on antibiotic and antimicrobial resistance. Overall, participants had minimal understanding of antibiotics and antimicrobials resistance. In this study, clinicians pointed out that overuse, poor adherence, and self-medication were causes of antibiotic resistance. In a study done in France and Scotland, the clinicians had knowledge of antibiotics resistance [52].
But, overall, in the current study, clinicians knew the causes of antimicrobial resistance and had knowledge which is similar to the findings of a study done in Saud Arabia on rural and urban physicians which pointed out that inadequate prescription, use of antimicrobials without prescription and noncompliance of patients are the most important factors contributing to the development of bacterial resistance to antibiotics [52,53]. Studies done in Sudan and Ghana also found out that a number of factors were mostly perceived by the majority of physicians as very important causes of antibiotic resistance such as overuse in the population and hospitals, self-medication, uncompleted antibiotics therapy, inappropriate empiric choice and low antibiotics dosage use in animals as well [54,55].
Nicholson et al. [56] similarly reported that factors contributing to antibiotic resistance are: wide spread use of antibiotics, overuse of a broad-spectrum of antibiotics, inappropriate use, inadequate hand washing and use of antibiotics in animals.
In a similar study done in Ghana among prescribers, causes of antibiotics resistance identified include antibiotics over-prescription, irrational prescription of antibiotics and patients’ noncompliance to medications [57].
Strength and Limitation of the study
This is the first study done in Malawi among clinical officers on antimicrobial prescription. The study managed to capture a wide range of determinants of inappropriate antimicrobial prescription. Sample size in qualitative research is determined by data saturation and it is a gold standard in a qualitative study however (n=30) were all interviewed. The study had high levels of participation which might show that research participants were interested in antimicrobial resistance and they were willing to participate in the study. This study was only done in one district, Mulanje, Southern Malawi, so it is a snapshot of Mulanje district as such the result cannot be generalized. Another limitation is non-random sampling. Finally, private clinicians were not interviewed which is also one of the limitations of the study.