Implementing multi-component intervention to reduce antibiotic prescribing in primary care of rural China: a qualitative process evaluation of the trial
Implementing multi-component intervention to reduce antibiotic prescribing in primary care of rural China: a qualitative process evaluation of the trial
OBJECTIVES: The overuse of antibiotics for respiratory tract infections in primary healthcare in rural China is a particular challenge and is highly related to antibiotic resistance. Our research team designed a multi-component intervention focusing predominantly on health practitioners to reduce antibiotic prescriptions in rural communities of China. The effects of the intervention were evaluated through a randomised controlled trial. This study was conducted alongside the trial to develop a contextualised understanding of the implementation of the intervention and related influencing factors.
DESIGN: Qualitative process study nested in a randomised controlled trial, including observation and semi-structured interviews.
SETTING: Primary healthcare in rural China.
PARTICIPANTS: 27 health practitioners from township health centres assigned to the intervention arm.
INTERVENTION: A complex intervention to reduce antibiotic prescriptions in rural communities of China, which includes the following components: training for health practitioners, a public letter of commitment, patient leaflets, a decision support system and a peer support group.
PRIMARY AND SECONDARY OUTCOME MEASURES: Not applicable.
ANALYSIS: Data were analysed using thematic analysis.
RESULTS: The overall multi-component intervention was described as useful in reducing antibiotic prescribing, with a particularly high acceptance and use of patient leaflets and the public letter of commitment among health practitioners. There were mixed views on the decision support system and peer support group. Practitioners reported usability-related barriers to using the decision support system during consultations. Practitioners did not understand the role or benefits of the peer support group and found it difficult to initiate group discussions, due to the lack of any existing clinical team at the primary care level.
CONCLUSIONS: The multi-component intervention appears to be acceptable and useful in primary healthcare in rural China. Successful implementation requires a comprehensive understanding of the contextual characteristics of the setting. Interventions to reduce antibiotic prescribing in China in the future could consider wider stakeholders including patients, retail pharmacies and health authorities.
TRIAL REGISTRATION NUMBER: ISRCTN30652037 (01/12/2020).
Anti-Bacterial Agents/therapeutic use, China, Female, Humans, Inappropriate Prescribing/prevention & control, Male, Practice Patterns, Physicians'/statistics & numerical data, Primary Health Care, Qualitative Research, Respiratory Tract Infections/drug therapy, Rural Health Services, Rural Population
Zhang, Tingting
dc40ceb4-ffc0-4457-a688-98177d239ba4
Shen, Xingrong
537d225f-5c97-49f2-8233-d88eadce498d
Chai, Jing
fe49eaf3-1e1c-412e-a3dc-082f37964865
Liu, Rong
c30d45dd-68bc-4410-9e9a-7dc5598eb89e
Wang, Debin
55d3645e-f668-4109-8c53-d42af21e1007
Yardley, Lucy
64be42c4-511d-484d-abaa-f8813452a22e
Lambert, Helen
84f72d77-d159-4a46-94d3-539c68ecf0cd
Cabral, Christie
e45df99c-4e9a-4d55-b9f0-923ee4b2a506
16 January 2026
Zhang, Tingting
dc40ceb4-ffc0-4457-a688-98177d239ba4
Shen, Xingrong
537d225f-5c97-49f2-8233-d88eadce498d
Chai, Jing
fe49eaf3-1e1c-412e-a3dc-082f37964865
Liu, Rong
c30d45dd-68bc-4410-9e9a-7dc5598eb89e
Wang, Debin
55d3645e-f668-4109-8c53-d42af21e1007
Yardley, Lucy
64be42c4-511d-484d-abaa-f8813452a22e
Lambert, Helen
84f72d77-d159-4a46-94d3-539c68ecf0cd
Cabral, Christie
e45df99c-4e9a-4d55-b9f0-923ee4b2a506
Zhang, Tingting, Shen, Xingrong, Chai, Jing, Liu, Rong, Wang, Debin, Yardley, Lucy, Lambert, Helen and Cabral, Christie
(2026)
Implementing multi-component intervention to reduce antibiotic prescribing in primary care of rural China: a qualitative process evaluation of the trial.
BMJ Open, 16 (1), [e108618].
(doi:10.1136/bmjopen-2025-108618).
Abstract
OBJECTIVES: The overuse of antibiotics for respiratory tract infections in primary healthcare in rural China is a particular challenge and is highly related to antibiotic resistance. Our research team designed a multi-component intervention focusing predominantly on health practitioners to reduce antibiotic prescriptions in rural communities of China. The effects of the intervention were evaluated through a randomised controlled trial. This study was conducted alongside the trial to develop a contextualised understanding of the implementation of the intervention and related influencing factors.
DESIGN: Qualitative process study nested in a randomised controlled trial, including observation and semi-structured interviews.
SETTING: Primary healthcare in rural China.
PARTICIPANTS: 27 health practitioners from township health centres assigned to the intervention arm.
INTERVENTION: A complex intervention to reduce antibiotic prescriptions in rural communities of China, which includes the following components: training for health practitioners, a public letter of commitment, patient leaflets, a decision support system and a peer support group.
PRIMARY AND SECONDARY OUTCOME MEASURES: Not applicable.
ANALYSIS: Data were analysed using thematic analysis.
RESULTS: The overall multi-component intervention was described as useful in reducing antibiotic prescribing, with a particularly high acceptance and use of patient leaflets and the public letter of commitment among health practitioners. There were mixed views on the decision support system and peer support group. Practitioners reported usability-related barriers to using the decision support system during consultations. Practitioners did not understand the role or benefits of the peer support group and found it difficult to initiate group discussions, due to the lack of any existing clinical team at the primary care level.
CONCLUSIONS: The multi-component intervention appears to be acceptable and useful in primary healthcare in rural China. Successful implementation requires a comprehensive understanding of the contextual characteristics of the setting. Interventions to reduce antibiotic prescribing in China in the future could consider wider stakeholders including patients, retail pharmacies and health authorities.
TRIAL REGISTRATION NUMBER: ISRCTN30652037 (01/12/2020).
Text
e108618.full
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More information
Accepted/In Press date: 25 December 2025
Published date: 16 January 2026
Additional Information:
© Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY. Published by BMJ Group.
Keywords:
Anti-Bacterial Agents/therapeutic use, China, Female, Humans, Inappropriate Prescribing/prevention & control, Male, Practice Patterns, Physicians'/statistics & numerical data, Primary Health Care, Qualitative Research, Respiratory Tract Infections/drug therapy, Rural Health Services, Rural Population
Identifiers
Local EPrints ID: 509380
URI: http://eprints.soton.ac.uk/id/eprint/509380
ISSN: 2044-6055
PURE UUID: f563d264-a367-49c2-a14e-87959fa83433
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Date deposited: 19 Feb 2026 17:50
Last modified: 20 Feb 2026 02:36
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Contributors
Author:
Tingting Zhang
Author:
Xingrong Shen
Author:
Jing Chai
Author:
Rong Liu
Author:
Debin Wang
Author:
Helen Lambert
Author:
Christie Cabral
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