Research objects

From August 2018 to March 2019, five counties (cities) were randomly selected according to the level of urban development and geographical distribution in Sichuan Province, China. Each county and city randomly selected 1 first-level hospital, 3 community hospitals, 3 township hospitals, and 5 village clinics and private enterprises. Each level 1 hospital had 10 to 20 doctors, covering all departments; each community hospital and township hospital investigated about 10 doctors; each village clinic and private clinic investigated 1 or 2 doctors. We sent out a questionnaire to each doctor. A total of 430 valid questionnaires were collected, including 88 first-class hospitals, 129 community hospitals, 130 township health centers, 41 village clinics, and 42 private clinics.

Questionnaire investigation

We design the status quo of antibiotic use and cognitive questionnaires of the doctors at the grassroots level. In the questionnaire description, it was clarified that the research was only used for academic research and was filled in anonymously. All the respondents in this study signed the informed consent form. The researcher collected the audit and summarized the analysis. According to the contents of the doctor’s questionnaire, we used Excel 2016 to organize the database. The survey included basic information (Table 1), antibiotic-related cognition, current status, and some relevant views on current antibiotic abuse. The questionnaire involves several common topics in clinical treatment (Table 2), and there are 7 knowledge questions and 1 attitude question in the cognitive part of the questionnaire (Table 3), with 3 options ‘Yes’, ‘No’ and ‘Unclear’, with a score of 1 point if the answer was correct (correct answers to these topics come from representative literature^6-9), and 0 points for incorrect answers or ‘not known’.

Statistical analysis

SPSS 25.0 was used to describe and analyze the data. The comparison between doctors in various types of primary medical institutions was performed by a χ²-test. The differences in antibiotic-related cognitive scores of different groups under different demographic characteristics were tested by Wilcoxon rank-sum test. Inspection standards were based on α= 0.05.

Definitions

The ‘drug use authority’ is the State Drug Administration, China. The ‘preventive use of antibiotics’ is ‘the use of antibiotics before the onset of a disease to prevent possible infection in a specific population’. The ‘combined antibiotics’ is using two or more types of antibiotics. The ‘empirical medication’ is the practice of using antibiotics based on the clinical experience of a doctor before identifying which pathogens cause the infection. The ‘relevant compliance’ is the Guidelines for Clinical Application of Antimicrobial Drugs issued by the Chinese government in 2018. The ‘relevant institutional impacts’ refer to National Health Commission of the People’s Republic of China (NHC), subordinate units of NHC and hospitals where doctors work.

Basic information of the respondents

Among the 430 doctors, 218 were males with an average age of 43.3 years and 212 females with an average age of 35.8 years. With regard to the educational level, secondary school (high school) and below accounted for 33.3%, college graduates were 32.8%, and undergraduate and above were 34.0%. Those who entered the profession after the ‘new medical reform’, i.e. whose work experience was less than 10 years accounted for 37.2%; those who entered the profession before the ‘new medical reform’, i.e. whose work experience was 10–20 years accounted for 35.4% ; those in the top 10 of the ‘new medical reform’, i.e. more than 20 years of work experience accounted for 27.4%. A total of 359 people (83.5%) had relevant learning and training experience, with the highest level in the first-level hospitals, reaching 95.5%; the lowest in private clinics, being only 42.9% (Table 1). The training organization mainly includes county and city health offices, county and city hospitals, disease control centers and medical schools.

Comparison of current status of antibiotic use among doctors in different primary medical institutions

There was no significant difference in the level of understanding of antibiotic use among village clinics and private clinic doctors (p=0.95), but they were both lower than those of county, township and community hospitals; a small number of doctors preferred broad-spectrum antibiotics, mostly those from private clinics, 14 (33.3%); while 26.7% of doctors preferred preventive use of antibiotics; 34.0% had combined use of different types of antibiotics (mainly for inpatients), the difference was not statistically significant (p=0.60), but for the village clinics this was higher (43.9%).

Empirical medication was quite common (90.5%), and the difference was statistically significant (p<0.05). It is worth mentioning that empirical medication was mostly in township hospitals, village clinics and private clinics, the difference was not statistically significant (p=0.36). When faced with the pressure of patients to use antibiotics, first-level hospitals and private clinic doctors were persuaded the highest (22.7% and 31.0%, respectively); only 56.7% of the doctors were able to comply with guidance on the use of antibiotics; but generally, the compliance rate of doctors in all levels of hospitals was low, the difference was not statistically significant (p=0.07); only 76.5% of doctors indicated that the implementation of the relevant drug system has affected the use of antibiotics, private clinic doctors had the least impact (35.7%) while the first-level hospital doctors had a relatively large impact (86.4%).

Comparison of antibiotic use among doctors in primary health care institutions

Statistics show that the overuse of antibiotics led to the highest awareness of bacterial resistance, the correct rate was 96.3%; the antibiotics were the worst for most acute sensations, and only 69.3% of the respondents answered correctly. Doctors that realized their knowledge of antibiotics needed to be improved had the lowest rate in first-level hospitals (38.6%) and highest in private clinics (95.2%), shown in Table 3. The median number of antibiotic-related cognitive scores was 6, and the IQR was 5–6, indicating that doctors have better knowledge of antibiotics. Because the knowledge scores were skewed, we used Wilcoxon rank-sum test to analyze whether the scores of the different groups are different for different demographic characteristics. The rank sum-test shows that the cognitive differences of doctors with or without relevant training experience are statistically significant (p=0.018), those with the relevant training were better than the untrained doctors; the cognitive differences of doctors with different working years were statistically significant (p=0.038), and the doctors working under 10 years were better than those with 10–20 working years. There was no significant difference in the correct rate of antibiotic use among doctors with different academic qualifications (p=0.077). There was no significant difference in knowing the correct rate of antibiotic use among doctors of different genders (p=0.076).

Analysis of the reasons for the non-standard use of antibiotics by doctors at the grassroots level

Through open-ended questionnaire investigation, we learned that there were three basic sources for unreasonable use of antibiotics by grassroots doctors. First, limited by laboratory technology and diagnostic techniques, primary hospitals often use antibiotics prophylactically and empirically; their understanding of antibiotic application is not comprehensive; their wages are low, especially in private clinics, which are vulnerable to economic interests; doctors and patients are nervous, want to quickly achieve the desired therapeutic effect resulting in antibiotic abuse. Second, patients have high expectations for treatment, often judge the doctor’s level by the patient’s disease condition, driving them to abuse antibiotics; the patient’s awareness of the rational use of antibiotics was not strong, and the risks were not well understood. Often the patients blindly asked the doctor to prescribe antibiotics, and when they could not obtain a prescription they would buy antibiotics themselves. Third, the relevant institutions are not strict with the regulation of supply and marketing channels for antibiotics. Many patients have purchased antibiotics through e-commerce platforms. The convenience of people purchasing antibiotics is as simple as buying ordinary items online; the relevant health system departments insufficiently inform medical staff in village clinics, private clinics and pharmacies about antibiotics.