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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 11-15

Outpatient antibiotic prescribing behavior and their psychosocial predictors among early-career clinicians in Delhi, India

1 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
2 Department of Office of the Medical Superitendent, Maulana Azad Medical College, New Delhi, India

Date of Submission18-Nov-2020
Date of Acceptance14-Jan-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Saurav Basu
Room No. 358, Department of Community Medicine, Maulana Azad Medical College, 2 Bahadur Shah Zafar Marg, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_156_20

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Introduction: Psychosocial factors are significant drivers of inappropriate antibiotic prescription leading to antibiotic resistance. We ascertained the psychosocial predictors of outpatient antibiotic prescribing (OAP) behavior among early-career clinicians in India.
Materials and Methods: We enrolled 200 early-career clinicians, including 100 medical interns and 100 junior residents (postgraduate student doctors) in six clinical departments, and collected data using a self-administered questionnaire. Response options were coded on five-item Likert scales.
Results: Antimicrobial resistance was viewed as a significant public health problem by most (95%) participants. Presumptive antibiotic prescribing was reported by 84% of participants, although the participant attitude indicated a slight disinclination against the presumptive use of antibiotics (mean = 2.8, standard deviation = 0.72). The majority (52.5%) of the participant's perceived social pressure frequently influenced their decision to prescribe antibiotics to the outpatients. Furthermore, the maximum social pressure was perceived as driven by patient expectation for antibiotics and the existing antibiotic prescribing behavior of their peers and colleagues. The perception of increased social pressure stipulating antibiotic prescribing negatively correlated with the participant's intention to reduce antibiotic use in outpatients (r= −0.124, P < 0.001). Social pressure was reported to be higher when treating adult patients reporting diarrheal symptoms and children having cough.
Conclusions: OAP practices among early-career clinicians working in the government health sector in India are mediated by considerable social pressure despite behavioral intention for reducing antibiotic use.
The following core competencies are addressed in this article: Practice-based learning and improvement, Professionalism.

Keywords: Antibiotic prescribing behavior, antibiotic resistance, antibiotic stewardship, dysbiosis

How to cite this article:
Basu S, Santra S, Bhatnagar N, Laul A. Outpatient antibiotic prescribing behavior and their psychosocial predictors among early-career clinicians in Delhi, India. Int J Acad Med 2022;8:11-5

How to cite this URL:
Basu S, Santra S, Bhatnagar N, Laul A. Outpatient antibiotic prescribing behavior and their psychosocial predictors among early-career clinicians in Delhi, India. Int J Acad Med [serial online] 2022 [cited 2022 Oct 5];8:11-5. Available from: https://www.ijam-web.org/text.asp?2022/8/1/11/341184

  Introduction Top

The emergence of antibiotic resistance (ABR) as a major global public health challenge is an outcome of the increasing use and misuse of antibiotics, which reduces the effectiveness of these lifesaving drugs against disease-causing microbes.[1] Inappropriate antibiotic prescription by clinicians, especially in outpatient settings which constitute the most common sites of antibiotic dispensing, contributes enormously to the problem of ABR.[2],[3] The failure to prevent ABR results in millions of avoidable deaths each year, which, in the absence of effective intervention, could scale 10 million deaths by 2050.[4] There is also growing recognition of the negative impact of antibiotic exposure, especially during infancy and early life on the microbiome in the human body, which predisposes to chronic diseases in adolescence and adulthood.[5]

Unwarranted antibiotic prescriptions in outpatient settings can account for nearly one in two inappropriate prescriptions, even in developed countries like the USA.[6] In resource-constrained environments, the risk of unnecessary antibiotic prescription is further accentuated due to the widespread practice of presumptive or empirical therapy, when antibiotics, especially of broad-spectrum type, are prescribed without considering results of appropriate laboratory investigations.[7] Furthermore, the antibiotic prescribing behavior of physicians in resource-constrained settings is also susceptible to antibiotic overuse due to clinicosocial challenges compelling empirical use, especially when combined with a lack of effective regulation and oversight.[8],[9] The identification of psychosocial determinants of clinicians' outpatient antibiotic prescribing (OAP) practices in India is pivotal due to its applicability in the formulation of appropriate public health interventions for combating ABR.

We, therefore, conducted this study to ascertain the psychosocial predictors of OAP behavior among early career clinicians in India.

  Methods Top

Study site, participants, and setting

We conducted a cross-sectional study at a government medical college and affiliated tertiary care hospital in Delhi, India, and enrolled early-career clinicians, including medical interns and junior resident (postgraduate student) doctors from the clinical departments. We selected only those interns who had already completed internship training both in the medicine (hospital outpatient) and the community medicine department (outreach primary care settings), which ensured adequate experience in the dispensing of antibiotics. Data were collected from September–December 2019.

No formal outpatient antibiotic stewardship training program as part of continuing medication education or training was available for the interns and postgraduate students of the institute. Diagnostics were available free of cost at the hospital laboratory, but there were long waiting queues due to high patient load. Furthermore, outpatients of low socioeconomic status were unwilling to spend out of pocket for routine diagnostics. Under these circumstances, considering the effective high laboratory turnabout time in obtaining outpatient reports, presumptive antibiotic prescribing is a ubiquitous practice in the study settings.

Study outcomes

Proportion of participants that considered social pressure influencing their antibiotic prescribing practices.

Sample size and sampling

A study in China reported that 48.7% of primary care physicians considered their decision to prescribe antibiotics being mediated by social pressure.[10] The sample size of this study was thereby calculated as 200 participants as per the prevalence estimate of 48.7%, 95% confidence levels, and 20% relative precision.

The study participants were enrolled through the consecutive sampling method in six clinical departments and were contacted after their morning or afternoon outpatient clinic hours. Four departments were selected by the simple random sampling method, while two departments, pediatrics and community medicine, were selected purposively as they were considered more susceptible to the problem. The number of participants selected from each department was allocated proportional to size, based on the number of eligible individuals working in the specific department.

Study instruments

We used a self-administered questionnaire for data collection, which included questions adapted from the previously validated instrument by Liu et al. after obtaining permission from the authors.[10] The questionnaire measured attitudes, subjective norms, behavioral control, behavioral intentions, and awareness, and perspectives on dysbiosis in the prescribers. All the responses were recorded on a five-item Likert scale.

  1. Attitudes (5 items) were defined as the perceived attitude of the clinicians' toward the practice of presumptive antibiotic therapy in terms of the usefulness, appropriateness, and responsibleness, with higher scores indicating a more favorable view
  2. Subjective norms (13 items) assessed social pressure perceived by the physician in clinical situations that required antibiotic prescribing related decision-making. The participants rated the extent of perceived pressure arising from patient expectations, peer prescribing behavior, peer expectations, social and familial obligation, and as per the patient clinicodemographic profile
  3. Perceived behavioral control (5 items): It measured the confidence and ease of the physician in deciding whether to prescribe antibiotics to their patients or not
  4. Behavioral intentions (7 items): It measured if the physician desired to change their frequency of antibiotic use, either by increasing or reducing prescription by adhering to the recommended local antibiotic stewardship guidelines.

Statistical analysis

We analyzed the data with IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. Likert item responses were reverse coded before scoring for questions relating to perceived behavioral control and behavioral intention. Results were expressed in frequency and proportions for categorical variables, and the median and mean value was reported for the Likert scale items. Continuous outcomes were expressed as mean and standard deviation (SD). P < 0.05 was considered statistically significant.

  Results Top

We enrolled a total of 114 (57%) men and 86 (43%) women, comprising 100 medical interns and 100 resident doctors undergoing postgraduate training.

The Cronbach's alpha of the subscales including attitude, subjective norms, perceived behavioral control, and behavioral intention was 0.78, 0.82, 0.63, and 0.61, respectively, suggestive of acceptable reliability.

Perspectives on antimicrobial resistance (AMR) and OAP: AMR was perceived as a significant public health problem by most (95%) participants, and the mean (SD) score of the ABR threat rated on a 5-point continuous rating scale was 3.89 (0.88). The role of OAP contributing to the problem of ABR was viewed as “somewhat likely” by 14 (7%), “likely” by96 (48%), and “very likely” by 83 (41.5%) participants. The presumptive use of antibiotics in outpatients was practiced “sometimes” by 119 (59.6%), “often” by 46 (23%), “always” by 3 (1.5%), and “rarely/never” by 32 (16%) participants. Most (80.5%) participants also perceived that their antibiotic prescribing behavior was consistent with autonomous decision-making and expressed their intention to further reduce antibiotic use (91.5%) in their outpatients [Table 1].
Table 1: Attitudes, perceptions, and practices related to outpatient antibiotic prescribing among clinicians in Delhi (n=200)

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Attitude and practices toward presumptive antibiotic prescribing in outpatients: The attitude of the participated indicated a slight disinclination against the presumptive use of antibiotics (mean = 2.8, SD = 0.72). The majority (52.5%) of the participants agreed that social pressure could influence their decision to prescribe antibiotics for their outpatients. The maximum social pressure was attributed to patient expectations for antibiotics and observing antibiotic prescribing behavior in their peers and colleagues [Table 2]. When considering the clinicodemographic profile of patients, social pressure was reported to be maximum when treating adult patients reporting symptoms of diarrhea and children having cough [Table 3]. However, the participants were also positively inclined toward reducing their antibiotic use in outpatients (mean = 4.2, SD = 0.68), when adhering to the recommended antibiotic prescribing guidelines (mean = 4.2, SD = 0.72). Increasing social pressure negatively correlated with the participant's intention to reduce antibiotic prescription for outpatients (r = −0.124, P < 0.001).
Table 2: Perceived social pressure in prescribing antibiotics to outpatients among clinicians in Delhi (n=200)

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Table 3: Perceived social pressure in prescribing antibiotics to outpatients influenced by the patient clinicodemographic profile (n=200)

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  Discussion Top

Psychosocial factors are major drivers of inappropriate antibiotic prescription.[2] The present study observed significant self-reported social pressures and social obligations influencing OAP practices among early career clinicians in Delhi, India. However, nearly four in five participants perceived themselves having adequate behavioral control needed for adhering to rational antibiotic prescription guidelines and in reducing undesirable antibiotic use. The results of our study, in comparison with findings from a large cross-sectional study among primary care providers in China, show similar levels of social pressure but a comparatively stronger perception of self-control in regulating antibiotic prescription in their outpatients.[10] Nevertheless, it is well established that physician intention is a weak predictor of antibiotic prescribing behavior in scenarios where the physician is unable to generate a reliable diagnosis as during presumptive prescribing.[11] Concern over the development of disease complications in patients, especially if socioeconomically vulnerable, can also decisively influence antibiotic prescribing decisions.[8],[12]

We found social pressure in prescribing antibiotics varied with the presenting symptoms and the age profile of the patient. Clinicians perceived higher social pressure when treating diarrheal conditions in adults, similar to the finding from a previous study conducted among primary care physicians in Delhi.[13] A study among Flemish general practitioners (GPs) also observed that perceived patient demand was independently associated with the decision for antibiotic prescribing in acute cough with negative lung auscultation findings.[14]

In this study, higher social pressure on clinicians was associated with limited self-efficacy for reducing the antibiotic usage in outpatients, a result in agreement with a Chinese study.[10] A survey in the United Kingdom also revealed that 9 in 10 GPs felt their patients pressured them into prescribing antibiotics.[15] However, a pragmatic randomized controlled trial observed no significant change in the rate of antibiotic item prescribing by GPs after a clinic based patient focused intervention targeted to reduce the patient driven demand for antibiotics.Instead, direct written feedback to those GPs who were identified as high prescribers of antibiotics significantly reduced their antibiotic dispensing practices.[16]


First, the study was conducted in a government hospital setting, which may attenuate social and financial obligations involved in antibiotic prescription to patients, compared to the private medical sector that caters to a large segment of the population.[17] Second, the participants were enrolled from a single site in Delhi, and the findings cannot be extrapolated to varied regional settings. Third, we did not corroborate the subjective measure of physician self-reported antibiotic prescribing behavior by linking it with their prescription data. Fourth, the correct knowledge of antibiotic stewardship may influence the clinician's prescribing decision, but this was not assessed in this study.[18] Fifth, behavioral intention to reduce antibiotic prescription can be overreported by the participants due to the social desirability bias.

  Conclusions Top

OAP practices in early-career clinicians working in the government health sector can be mediated by considerable social pressure despite recognition of the threat of ABR and strong behavioral intentions toward reducing outpatient antibiotic use. Future studies need to identify the effect of behavioral interventions among clinicians for overcoming social pressures and strengthening outpatient antibiotic stewardship for the promotion of rational prescribing practices.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The study was approved with exemption from full review by the Institutional Ethics Committee, Maulana Azad Medical College and Associated Hospitals, New Delhi (F.1/IEC/MAMC/(68/03/2019/No/68) dated 4th September' 2019. The authors have utilized the STROBE statement which was applicable as per the EQUATOR (https://www.Equator-network.Org/) reporting guidelines. Written and informed consent was obtained from all the study participants.

  References Top

WHO. Global action plan on antimicrobial resistance. Geneva: World Health Organization; 2015.  Back to cited text no. 1
King LM, Fleming-Dutra KE, Hicks LA. Advances in optimizing the prescription of antibiotics in outpatient settings. BMJ 2018;363:k3047.  Back to cited text no. 2
Laxminarayan R, Duse A, Wattal C, Zaidi AK, Wertheim HF, Sumpradit N, et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis 2013;13:1057-98.  Back to cited text no. 3
O ' Neil J. Review on antimicrobial resistance antimicrobial resistance: Tackling a crisis for the health and wealth of nations. London: Review on Antimicrobial Resistance; 2014.  Back to cited text no. 4
Carding S, Verbeke K, Vipond DT, Corfe BM, Owen LJ. Dysbiosis of the gut microbiota in disease. Microb Ecol Health Dis 2015;26:26191.  Back to cited text no. 5
Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother 2014;69:234-40.  Back to cited text no. 6
Leekha S, Terrell CL, Edson RS. General principles of antimicrobial therapy. Mayo Clin Proc 2011;86:156-67.  Back to cited text no. 7
Basu S, Garg S. Antibiotic prescribing behavior among physicians: Ethical challenges in resource-poor settings. J Med Ethics Hist Med 2018;11:5.  Back to cited text no. 8
Mao W, Vu H, Xie Z, Chen W, Tang S. Systematic review on irrational use of medicines in China and Vietnam. PLoS One 2015;10:e0117710.  Back to cited text no. 9
Liu C, Liu C, Wang D, Deng Z, Tang Y, Zhang X. Determinants of antibiotic prescribing behaviors of primary care physicians in Hubei of China: A structural equation model based on the theory of planned behavior. Antimicrob Resist Infect Control 2019;8:23.  Back to cited text no. 10
Lambert BL, Salmon JW, Stubbings J, Gilomen-Study G, Valuck RJ, Kezlarian K. Factors associated with antibiotic prescribing in a managed care setting: An exploratory investigation. Soc Sci Med 1997;45:1767-79.  Back to cited text no. 11
Sanchez GV, Roberts RM, Albert AP, Johnson DD, Hicks LA. Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States. Emerg Infect Dis 2014;20:2041-7.  Back to cited text no. 12
Kotwani A, Wattal C, Katewa S, Joshi PC, Holloway K. Factors influencing primary care physicians to prescribe antibiotics in Delhi India. Fam Pract 2010;27:684-90.  Back to cited text no. 13
Coenen S, Michiels B, Renard D, Denekens J, Van Royen P. Antibiotic prescribing for acute cough: The effect of perceived patient demand. Br J Gen Pract 2006;56:183-90.  Back to cited text no. 14
Leonard R. In the balance: GPS, patient care and antibiotics. Available from: https://longitudeprize. org/blog-post/balance-gps-patient-care-and-antibiotics. [Last accessed on 2020 Jan 12].  Back to cited text no. 15
Hallsworth M, Chadborn T, Sallis A, Sanders M, Berry D, Greaves F, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: A pragmatic national randomised controlled trial. Lancet 2016;387:1743-52.  Back to cited text no. 16
Farooqui HH, Mehta A, Selvaraj S. Outpatient antibiotic prescription rate and pattern in the private sector in India: Evidence from medical audit data. PLoS One 2019;14:e0224848.  Back to cited text no. 17
Garcell HG, Arias AV, Sandoval CP, Valle Gamboa ME, Sado AB, Alfonso Serrano RN. Impact of a focused antimicrobial stewardship program in adherence to antibiotic prophylaxis and antimicrobial consumption in appendectomies. J Infect Public Health 2017;10:415-20.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]


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