Table 2.

Non-biomedical factors influencing outpatient and community antibiotic use for common community-acquired infections

Non-biomedical factors	Application/examples	Inappropriate antibiotic use (including prevention use)
		Antibiotic use behaviour outcomes	References
Knowledge
General knowledge about antibiotics/AMR	Combined knowledge score Inadequate diagnostic knowledge of doctors Misconceptions (eg, antibiotic is an anti-inflammatory drug)	Asking/pressuring doctors for antibiotics Self-medication with antibiotics Storing antibiotics at home Taking antibiotics as prophylaxis Healthcare seeking behaviour The likelihood to be prescribed with antibiotics by doctors Combined behaviour score	14 17 25 36 46 63
Literacy	Being able to recognise antibiotics Knowing when/how to use antibiotics	No evidence available to date	–
Knowledge about the infection	The participant’s knowledge about the specific infection (eg, URTI symptoms will dissipate naturally)	No evidence available to date	–
AMR awareness	The participant’s awareness of AMR as a health threat on individual or on the society as a whole	No evidence available to date	–
Attitudes
Attitudes towards antibiotic misuse behaviours	The participant’s accepting attitudes towards storing/self-medicating with antibiotics	Self-medication with antibiotics Storing antibiotics at home	28 52
Self-efficacy	The participant’s perception of his/her or others’ competence in engaging in caring for the infection or in antibiotic use	No evidence available to date	–
Medical background	The participants or their family members having some level of medical education	Asking/pressuring doctors for antibiotics Self-medication with antibiotics Over-the-counter purchases Storing antibiotics at home Taking antibiotics as prophylaxis The likelihood to be prescribed with antibiotics by doctors Combined behaviour score	13 19 20 28 34 40 41 43 44 47–51
Prior experience	Participants use of antibiotics on previous occasions	Over-the-counter purchase	76
Perceptions
Perceived susceptibility	Self-rated health status	Self-medication with antibiotics Combined behaviour score	28 46 63
Perceived severity	The participant’s assessment/perception of the severity of the situation regarding the infection (eg, self-diagnosed symptoms experienced) The participant’s perception of potential harm of over-the-counter purchase	Over-the-counter purchase	32
Perceived benefits and disbenefits	The participant’s mistaken understanding of antibiotics (eg, considering antibiotics as Xiaoyanyao, anti-inflammatory drugs) (misconceptions)	Asking/pressuring doctors for antibiotics Self-medication with antibiotics Taking antibiotics as prophylaxis	36
Perceived barriers	The participant’s assessment/perception of barriers to engaging in antibiotic use (health insurance and knowledge of current policy)	Self-medication with antibiotics Healthcare seeking behaviour	14 28
Family dynamics	Family members who might influence the healthcare decisions of caregiver or the patients	Self-medication with antibiotics	28 45
Doctor–patient relationships	Having a regular doctor Following all the advice from physicians	Asking/pressuring doctors for antibiotics Self-medication with antibiotics	18 30
Access to antibiotics	Access to antibiotics, with or without prescription
Access to non-prescription antibiotics	Over-the-counter purchase Antibiotics stored at home Leftover prescriptions	Self-medication with antibiotics Taking antibiotics as prophylaxis	17 18 28 31 41 42 46 50 51
Access to antibiotic prescriptions	Asking/pressuring doctors for antibiotics The education level, training, specialty or seniority of the doctors	The likelihood to be prescribed with antibiotics by doctors	22–24
Cues to action	External trigger mechanisms to prompt engagement in antibiotic use behaviour
Symptoms	Presence of fever	No evidence available to date	–
Information sources and seeking for therapeutic purposes decisions	Expectation for antibiotic use knowledge	Combined behaviour score	63
Socio-contextual factors
Age	The age of the participant or caregiver	Asking/pressuring doctors for antibiotics Self-medication with antibiotics Over-the-counter purchase Storing antibiotics at home Taking antibiotics as prophylaxis Healthcare seeking behaviour The likelihood to be prescribed with antibiotics by doctors (oral, intravenous or both) Combined behaviour score	13 14 18–20 32 40 41 45 47 48 50 51 76
Gender	The gender of the participant or caregiver	Self-medication with antibiotics Storing antibiotics at home Taking antibiotics as prophylaxis Healthcare seeking behaviour Combined behaviour score	13–15 19 20 28 35 45 48–51
Education	The education level of the participant, his/her parent or the caregiver	Asking/pressuring doctors for antibiotics Self-medication with antibiotics Storing antibiotics at home Over-the-counter purchases Taking antibiotics as prophylaxis Healthcare seeking behaviour Combined behaviour score	13 14 18–20 28 29 38 42 45 49–51 63 76
Income	The household income or monthly allowance of the participant or caregiver	Self-medication with antibiotics Storing antibiotics at home Taking antibiotics as prophylaxis	20 29 32 40 45 50 51
Location	The rural/urban of residence of the participant or caregiver	Asking/pressuring doctors for antibiotics Self-medication with antibiotics Over-the-counter purchases Storing antibiotics at home Taking antibiotics as prophylaxis The likelihood to be prescribed with antibiotics by doctors Combined behaviour score	13 18–20 24 29 43–45 47 49 50
Region	Region of residence of the participant or caregiver—geographic area or economic development stage	Asking/pressuring doctors for antibiotics Self-medication with antibiotics Over-the-counter purchases Storing antibiotics at home Taking antibiotics as prophylaxis The likelihood to be prescribed with antibiotics by doctors	13 20 28 50 51
Policy	Health policy or AMR programme that might affect prescribing or access to antibiotics (eg, measures to de-incentivise over-prescription in public health facilities, including decoupling the link between facility income and the sale of medicines and policy that bans over-the-counter purchases) Financial incentives for antibiotic prescribing of doctors	Self-medication with antibiotics Over-the-counter purchases* The likelihood to be prescribed with antibiotics by doctors	23 24 28
Norm	Participants’ view of how others treat illnesses and/or use antibiotics (non-China and non-predictor)* Healthcare providers reviewing others’ prescriptions (non-predictor)*	The likelihood to be prescribed with antibiotics by doctors*	59 75 77–79
Point-of-care	Prescribing habits/capacity might vary at different levels of health facilities: tertiary hospital, secondary/county hospital, community health centres/township hospital or private clinics/village clinics	No evidence available to date	–

*Non-predictor: effect is implied.

AMR, antimicrobial resistance; URTI, upper respiratory tract infections.