The effect of continuity of care on antibiotics prescription for Palestinian refugees in UNRWA health centres: a cross-sectional study

Abstract

BackgroundAntimicrobial resistance is a growing public health threat worldwide, with over-prescription of antibiotics for upper respiratory tract infections (URTI) in children being very common although at least half of URTIs have a viral aetiology. A Family Health Team (FHT) model was gradually implemented at United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) health centres to provide continuity of care and patient-centred care. These types of care are associated with lower antibiotic prescription rates for URTI in several European countries, but their effect in a refugee setting is unknown. The aim of this study was to assess the differences in medical officers' knowledge and beliefs about antibiotics and to investigate the association between sociobehavioural factors and high antibiotic prescription for URTI in children in FHT and non-FHT health centres. MethodsThis cross-sectional study included medical officers working at UNRWA health centres in Jordan, Gaza Strip, West Bank, and Lebanon in 2014. We used a self-administered, standardised multiple-choice questionnaire that covered demographics, beliefs, knowledge, and antibiotic use and included five case-vignettes on URTI in children. Case-vignette 1 described a child aged 9 months that was previously healthy but presented with fever of 38·5°C and rhinorrhoea. The child had been pulling at his right ear since the beginning of the day; the tympanic membrane was slightly pink, retracted, and had decreased mobility; and no air-fluid level was seen. A self-reported antibiotic prescription rate of more than 25% for URTI was considered high prescription. This cut-off was chosen to match an internal UNRWA target to not prescribe antibiotics for more than 25% of URTI cases and on the basis that more than 50% of URTI cases are viral and do not need an antibiotic treatment. We did χ2 tests to compare knowledge and beliefs about antibiotics, and we did multiple logistic regression to analyse the association between sociobehavioural factors and high antibiotic prescription in FHT and non-FHT health centres. Ethical approval was not considered necessary since questionnaires were obtained anonymously. Verbal consent was obtained from participants. Findings362 medical officers were asked to complete the questionnaire, and 335 (93%) medical officers completed the questionnaire (227 officers in the FHT group, 108 in the non-FHT-group). Medical officers in the two groups had similar demographics, including their self-reported prescription rate. Antimicrobial resistance was described as a problem in the community by more participants in the FHT group than in the non-FHT group (p=0·048), and the correct answer to case-vignette 1 was given more often in the FHT group than in the non-FHT group (p=0·001). No demographic determinant was associated with high prescription. In the non-FHT group, high antibiotic prescription was associated with previous clinical experience (odds ratio 0·14, 95% CI 0·03–0·74) and the educational level of patients' parents (11·6, 2·33–58·10). In the FHT group, high antibiotic prescription was associated with wanting to be on the safe side (2·49, 1·07–5·79). InterpretationThe FHT group had a better knowledge of antibiotics use and antimicrobial resistance as a community problem. The factors associated with high prescription differed between the FHT and non-FHT groups. Further research is needed to assess whether the working environment determines actual antibiotic prescribing in a refugee setting. FundingNone.