Study says patient perceptions drive frivolous antibiotic use in India

Antimicrobial resistance is one of the most pressing global health threats of the 21st century, already causing around 5 million deaths a year. A major driver is the overuse of antibiotics, particularly for conditions that don’t benefit from them.

This problem is acute in low- and middle-income countries. India in particular issues more than half a billion antibiotic prescriptions annually in the private sector alone. Although most cases of childhood diarrhoea are viral and should be treated with ORS and zinc, for example, studies have shown that about 70% of cases are still treated with antibiotics.

One possible explanation for why providers overprescribe antibiotics despite knowing better is lack of knowledge. However, earlier evidence has suggested another force at work, called the know-do gap, i.e. the gap between what providers know and what prevents them from following it. Understanding which of these gaps matters more is crucial to determine what the appropriate solution is: training programmes or different interventions.

In a new study in Science Advances, an international team of researchers, including from IIM-Bangalore and an NGO named NEERMAN in New Delhi, studied 2,282 private providers in Karnataka and Bihar. First, they assessed knowledge through hypothetical cases of viral diarrhoea. Then they used “standardised patients” — trained actors posing as caretakers — to observe real prescribing behaviour. Randomised experiments tested the effects of patient preferences, financial incentives, and drug availability.

Half the providers displayed poor knowledge but even among those who knew antibiotics were unnecessary, 62% still prescribed them. Closing the knowledge gap would reduce inappropriate prescribing by only about 6 percentage points while closing the know-do gap could reduce it by 30, the study reported.

The team also showed the main driver was providers’ belief that patients wanted antibiotics. When actors expressed a preference for ORS, antibiotic use fell sharply. Financial incentives and drug supply played little role. These findings suggest that simply educating providers may not suffice to curb antibiotic misuse. Many already understand correct practice but act differently, fearing they will disappoint patients or lose them to competitors if they don’t offer “strong medicines”.

In reality, patients cared more about kindness, trust, and overall treatment quality than about receiving antibiotics. This mismatch between perception and reality fuels the know-do gap, per the study. The study also highlighted the importance of targeting less-trained providers, such as pharmacists and rural medical practitioners, who showed the widest gaps.