Table 7. Reasons mentioned for the excessive use of antibiotics to treat ARIs in 4 private-not-for-profit primary care facilities in Nairobi, Kenya, 2016.
| Main Category | Sub-categories | Verbatim quotes |
|---|---|---|
| 1) Clinician (provider)-related | ||
| 1.1) Clinicians working at the 4 study clinics | ||
| High patient-load with long queues | “Work load. They [clinicians] would just want to clear the long queue of patients [that] are too many, and want to prescribe, prescribe, and prescribe.” [Clinician 6, Clinical Nurse, Female] | |
| To keep patients away from hospital | “I think, we [clinicians] are doing a lot of unnecessary antibiotic prescription…a patient just comes in, and [we] do a review, and found no need to give antibiotics. But, [we] might decide to give just to keep patients away from [the] hospital” [Clinician 6, Clinical Nurse, Female]* | |
| To stock out ‘shortly’ expiring drugs | “[There is] even pushing drugs off because of short expiry” [Clinician 9, Clinical Officer, Female] | |
| Perception that clinicians must always prescribe | “I think, one is a culture that Doctors must prescribe a drug … many [clinicians] just believe that they [should] prescribe Amoxicillin, Paracetamol, or Piriton and Augmentin; that is when they [clinicians feel that they] have treated [the patient]” [Clinician 8, Clinical Officer, Male] | |
| Lack of knowledge | “The truth of the matter is that there is irrational use of antibiotics, which is a fact. I think much of it has got to do with the knowledge on the rational use of antibiotics, yes” [Clinician 1, Clinical Officer, Male] | |
| Not following a treatment guideline | “In some institutions, lack of protocol or failure to follow national guidelines” [Clinician 8, Clinical Officer, Male] | |
| Financial gain | “It’s obvious that we have over-prescription; people want to make profit. But, here at the [study] clinics, we have no such an encounter” [Clinician 5, Clinical Officer, Male] | |
| Clinicians ‘misled’ by parents’ claim that the sick child had previous exposure to antibiotics | “May be, a parent had bought Amoxicillin over-the-counter and had given to the [sick] child for 2 days; but, the parent [might] claim [that s/he] had given [the child] for 5 days, and did not improve. This might influence the clinician to give another antibiotic which may not warrant high potency than the first one” [Clinician 2, Clinical Nurse, F] | |
| Patients put pressure on the clinician | “Patients referred from other facilities say [that] they didn’t improve on the regimen they [had been given], but they cannot remember the drug, may put pressure on the clinician to put the patient on another antibiotic which could be more potent than the previous one”[Clinician 2, Clinical Nurse, Female] | |
| Frequent clinic visit by patients | “At times, it could be that you [the clinician] had seen the client, and it might be that the client come back again and you give an antibiotic which still might not be required” [Clinician 4, Clinical Officer, Male] | |
| Combining two antibiotics together to cover a wide range of micro-organisms | “If you don’t have a broad spectrum antibiotic, maybe you combine 2 antibiotics together you think they can offer the wide coverage, yes.” [Clinician 4, Clinical Officer, Male] | |
| Access to diagnostics | “Depending on whether the clinician has access to diagnostics, s/he may over-prescribe” [Clinician 5, Clinical Officer, Male] | |
| Clinicians’ perception that lab investigation may not always be necessary for ARIs | “Most of them [ARIs] don’t need anything else to be investigated in the laboratory unless its chronic, yeah” [Clinician2, Clinical Nurse, Female] “May not be very necessary; most of the time, i.e. 90%, we use history and physical examination, and 10% laboratory” [Clinician5, Clinical Officer, Male] |
|
| 1.2) Clinicians working outside of the study clinics | ||
| Empirical treatment | “I think, many times it [antibiotics prescribing] is not evidence based. It is based on just empirical thinking.” [Clinician 10, Specialist Doctor, Male] | |
| “Absence” of treatment guideline | “We do not have guidelines for treating many infections, not just respiratory tract infections. . . Even if there are, they are not circulated widely enough.”[Clinician 10, Specialist Doctor, Male] | |
| No antibiotic stewardships in hospitals | “Not have good antibiotic stewardships in many hospitals. . . Some hospitals are trying to introduce stewardship. But, it is not spread wide enough, so people still prescribe the way they feel like” [Clinician 10, Specialist Doctor, Male] | |
| Fear that patient could deteriorate further | “Well, if I am over-prescribing, it is because of what I fear could be the sequel of this infection if it is not treated … I would fear that, may be, the patient could get worse.”[Clinician 10, Specialist Doctor, Male] | |
| Patient influence | “Sometimes, if patients have gone to a hospital, and they have not been given any medication, they feel like they were not treated. So, that could guide some clinicians in to prescribing unnecessarily” [Clinician 10, Specialist Doctor, Male] “[Some] patients say that I have come all this way, and paid all this money just to get some Paracetamol! Give me antibiotics”[Clinician 11, Medical Doctor, Female] |
|
| Patient “safety” | “I think, it is more of better safety kind of thinking that you would rather over-treat than under-treat the patient” [Clinician 11, Medical Doctor, Female] | |
| Money first/To get more profit | “Especially in the private sector, no one is going to prescribe Amoxil. Because it is cheap. So, guys [clinicians] go straight to the Amoxil-Clavulanic combination … they tend to think about money first.”[Clinician 11, Medical Doctor, Female] | |
| Pressure from clinic owners | “When it comes to the private clinics, you also have other goals … you have target revenues. So, you are not going to prescribe drugs worth 100 Shillings, and yet you have the original drug worth 3,000 Shillings. So, you will tend to move towards the more expensive drugs, and keep away from the cheap drugs that are supposed to be used at first.” [Clinician 11, Medical Doctor, Female] | |
| Perceived “quality” of drugs | “They [clinicians] are trying to give quality drugs. [If] we do not have quality Amoxil, what we do have is quality Augmentin. So, you end up choosing drugs that you are not supposed to prescribe at first.”[Clinician 11, Medical Doctor, Female] | |
| Drug-company relationship | “Drug [company] representatives, usually come clinic to clinic, at least once or twice a week, and educate you on new drugs that are coming …If you feel that the drug is good for you, we normally just put in a request to the pharmacists to order more of it from the company.”[Clinician 11, Medical Doctor, Female] | |
| Diagnosis of ARIs based on clinical judgment | “You know, many times diagnosis of ARIs is based on the clinical judgment. It is just purely clinical judgment” [Clinician10, Specialist Doctor, Male] | |
| Kick out the disease at once | “You know, at times, the Doctors want to kick out the disease at once. They do not want another time [patient] visits. I think, that is the main cause [for over-prescribing]”[Clinician 12, Clinical Officer, Male] | |
| Fear that patients might not come again | 'Yea, market. If a patient goes out, and tells others that you do not give them drugs, they would not come to you. So, if you give them, may be, an antibiotic for three days, and they take and feel okay, they always come.” [Clinician10, Specialist Doctor, Male] | |
| 2) Patient-related | ||
| 2.1) As perceived by patients | ||
| Patient expectations | “Yes. I had expected drugs so that my baby could recover [soon] … you wouldn’t come to a hospital if you were not given medicines” [Mother of Patient5, <5 years, Male patient] “I would have been shocked [if my son was not prescribed with antibiotics] because my son is ill … [would have] told him [the clinician] to examine him [my son] again”[Mother of Patient2, 1 year, Male patient] |
|
| Patients might go to another clinic if they were not given medicines | “I would have looked for another place to be given drugs because of the way my baby is feeling and reacting.”[Mother of Patient5, <5 years, Male patient] “I would go to another hospital to seek for consultation [if I were not prescribed a medication]” [Patient13, 29 years, Male] |
|
| Patients knew that healthcare was for “free” | “If I was paying, I wouldn’t have come because I don’t have money; however, I thought it was good that I came [here] because medicines are for free” [Patient9, 47 years, Female] | |
| 2.2) As perceived by clinicians | ||
| Patients insist on antibiotics | “Apart from the disappointment, some of them [patients] would insist or become violent, yes, they would insist, especially the old ones, they would insist you to give [them] antibiotics” [Clinician 1, Clinical Officer, Male] | |
| “[Some] patients just say: I have come all this way, and paid all this money just to get some Paracetamol! [Please] give me some antibiotics” [Clinician11, Medical Doctor, Female] | ||
| Fear of patient disappointment | “One is that of disappointment. Yes, patients might feel disappointed and would air out their disappointment” [Clinician 1, Clinical Officer, Male] | |
| Patients’ “self-referral” from one clinic to another | “[patients] moving from one clinic to another and getting the same kind of treatment might end up with antibiotic over-prescription” [Clinician 3, Clinical Nurse, Female] | |
| Patients’ belief/perception | “They [patients] think that taking medication for all [diseases] will make them more healthy” [Clinician 3, Clinical Nurse, Female] | |
| “Most of them [patients] believe once they are sick they should always be given antibiotics”[Clinician4, Clinical Officer, Male] | ||
| Patients influenced by internet technology | “Especially in the private sector, we get a lot of “google patients.” These are patients who already have the symptoms, and they run to google, they look at the symptoms, and they will come to you in a panic, and they will be the most annoyed when you do not give them antibiotics”[Clinician11, Medical Doctor, Female] | |
| Patients’ ‘self-referral’ to different clinics | “They have got one Doctor today, they are given, may be Augmentin, the child does not get better. They go the next day to another one, and they are given Zithromax, and they will go to another one.”[Clinician10, Specialist Doctor, Male] | |
| Patients will buy antibiotics anyway | “Even if you tell them [patients] that they are not supposed to take drugs, they will go to the shop [pharmacy] to buy it anyway” [Clinician12, Clinical Officer, Male] | |
| Patients having insurance | “Many times, it is the patients who have insurance who will demand a prescription because they are not paying for it themselves. The ones who are paying for it themselves do not even bother to go to the Doctor; they go to the pharmacy straight away and buy the medicine from there.”[Clinician10, Specialist Doctor, Male] | |
| 3) Healthcare delivery- or policy-related | ||
| Lack of treatment guideline | “We do not have guidelines for treating many infections, not just respiratory tract infections. . . Even if there are, they are not circulated widely enough.” [Clinician 10, Specialist Doctor, Male] | |
| No antibiotic stewardships in hospitals | “Not have good antibiotic stewardships in many hospitals. . . Some hospitals are trying to introduce stewardship. But, it is not spread wide enough, so people still prescribe the way they feel like” [Clinician 10, Specialist Doctor, Male] | |
| Access to diagnostic facilities | “Depending on whether the clinician has access to laboratory investigations, s/he may over-prescribe” [Clinician 5, Clinical Officer, Male] | |
| Absence of diagnostic facilities | 'No, right now we don’t have any [lab investigations which are readily available to diagnose ARTIs]” [Clinician4, Clinical Officer, Male] “Well I don’t know any lab investigations which are readily available [to diagnose ARIs]” [Clinician2, Clinical Nurse, Female] |
|
* In the study setting, Nurses with a BSc degree qualification are entitled to see patients and to prescribe medications at the primary care/OPD level