Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis

Caroline Coope, Annegret Schneider, Tingting Zhang, Paul Kadetz, Rui Feng, Helen Lambert, De Bin Wang, Isabel Oliver, Susan Michie, Christie Cabral

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INTRODUCTION: The inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China. 

METHODS: Searches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only). 

RESULTS: Intervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies. 

CONCLUSIONS: Interventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.

Original languageEnglish
Pages (from-to)e056348
JournalBMJ Open
Issue number3
Publication statusPublished - 25 Mar 2022

Bibliographical note

Funding Information: Newton Fund (UKRI and NSFC) the National Natural Science Foundation of China (NSFC) supported this study under the UK-China AMR Partnership Initiative, grant number MR/P00756/1 and 81661138001. The funding source had no role in study design, analysis or in the decision to submit the manuscript for publication. CLC and IO and CMC acknowledge support from the NIHR Health Protection Research Unit in Evaluation of Interventions at the University of Bristol.

Open Access: This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Publisher Copyright: © Author(s) (or their employer(s)) 2022. Published by BMJ.

Citation: Coope C, Schneider A, Zhang T, et al. Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis. BMJ Open 2022;12:e056348.

DOI: 10.1136/bmjopen-2021-056348


  • health policy
  • international health services
  • public health


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