Evidence synthesis summary: social and cultural drivers of antimicrobial use

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This report is for the Chief Public Health Officer of Canada’s 2019 Spotlight Report.



This evidence synthesis identifies social and cultural conditions, including the norms, values, beliefs, historical context, and other sociocultural drivers, that influence unnecessary antimicrobial use in Canada and countries that are part of the Organisation for Economic Co-operation and Development (OECD)


An evidence review was conducted by the Office of the Chief Public Health Officer (OCPHO) in the Public Health Agency of Canada to identify social and cultural drivers of unnecessary antimicrobial use in community and primary care settings in Canada and OECD countries.  

A literature search strategy was developed in conjunction with the Public Health Agency of Canada Health Library based on predefined PICO criteria (Appendix A). Keyword queries were used to identify studies in the following electronic databases: Ovid MEDLINE/PubMed, Embase, PsychINFO, Cochrane and Campbell collaboration databases. Only studies published after January 1, 2009 (past 10 years) were included for initial screening.

A title, abstract, and keywords review was conducted by the OCPHO to determine the relevance of articles regarding sociocultural drivers of antimicrobial use (AMU) in Canada and in OECD countries. The OCPHO screened a total of 113 Canadian articles and 866 OECD articles. Of these, 13 Canadian articles and 203 OECD articles met the search criteria. Following an initial review of 203 OECD articles, 25 systematic reviews and large-scale multi-country studies were retained, in addition to the 13 Canadian articles, for further review. These search results identified gaps in the Canadian literature surrounding behavioural science and sociocultural drivers of AMU. To address these gaps, an additional 11 articles/reports were identified by grey-literature, hand searching and reference checking.

An independent rapid evidence review and synthesis was commissioned from the Michael G. DeGroote Cochrane Canada and GRADE Centres (McMaster University), which identified the sociocultural factors that drive the misuse and overuse of antimicrobials in Canada and OECD countries at all levels of health care. The external review included evidence from systematic reviews retrieved from Ovid MEDLINE, and McMaster University’s evidence databases including ACCESSSS, Health Evidence, and Health Systems Evidence; grey literature from the websites of international and national health organizations; and primary research studies from Canada. The findings were cross-referenced with the OCPHO evidence review results and 12 additional articles/reports were selected and included in the synthesis. This comprised relevant articles published before 2009 that were identified through reference checking and grey literature searching. A total of 61 articles/reports were included in the evidence synthesis summary presented in Table 1.


The searches conducted were not exhaustive and would not have captured literature not indexed in the indicated databases. Only literature published in English and French was reviewed, and some literature may have been excluded on this basis. Risk of bias and study quality was not assessed in this review. Finally, with the exception of a few key articles, the data set presented includes only articles published after January 1, 2009.  


A thematic analysis of the identified drivers was conducted. Results were synthesized and classified as one of the following themes: patient determinants, practitioner determinants, organizational and health systems determinants, and sociocultural determinants of antimicrobial use in Table 1.

Table 1: Research summary on the sociocultural drivers of AMU
Determinants of AMU Description References

Attitudes, knowledge, or beliefs about antibiotics

Well-known cross-national differences in use of antibiotics in OECD countries can only be partially explained by epidemiological differences and differences in health care. Social and cultural factors are also thought to play an important role in the consumption of antibiotics.

One of the most commonly studied determinants of AMU is patient attitude, knowledge, or beliefs about antibiotics, including the perception of the role these classes of drugs may play in the maintenance of good health. Many studies show that misconceptions and uncertainties regarding the role of antibiotics are driven by patient attitudes, knowledge, and beliefs about the causes of antibiotic resistance, such as beliefs and knowledge surrounding the efficacy of antibiotics in treating viral infections as well as general knowledge and beliefs about infectious diseases.

Rennert-May & Conly, 2016; Lucas et al., 2015; Borg, 2012; Pechere, 2001; van Duijn et al., 2003; Grigoriyan et al., 2007; Grigoriyan et al., 2008; Cabral et al., 2016; Tahtinen et al., 2009; Alili-Idrizi et al., 2014; Rzeuwuska et al., 2019; Bosley et al., 2018; Altiner et al., 2007; Cantarero-Arevalo, 2017

At least 1 study found that people believe they are at low risk from antibiotic resistance and attribute its development to the actions of others, and strategies to minimize resistance should be aimed at clinicians.

McCullough et al., 2016

Attitudes, knowledge, or beliefs about illness and health behaviours

Many sociocultural factors such as attitudes, knowledge or beliefs about illnesses and health behaviours, including knowledge and beliefs about labeling a diagnosis (i.e. perception of what is considered a problematic symptom), knowledge of the natural course of infectious diseases, perceived thresholds for consulting a physician, coping strategies, and beliefs in the inherent healing power of the human body have been linked to AMU.

van Duijn et al., 2003; Grigoriyan et al., 2008; Rosman et al., 2008; McKay et al., 2016; McIsaac et al., 2011

Canadian studies have demonstrated a strong link between influenza season and the increase in antibiotic use. This illustrates the incorrect belief that antibiotics can be used to combat illnesses caused by viruses. Provinces, such as Ontario, that have implemented a universal influenza immunization program have seen decreases in influenza-associated respiratory antibiotic prescriptions. 

Glass et al., 2010; Kwong et al., 2009

Expectation that a physician visit will lead to a prescription

Patient/caregiver expectations have been identified as one of the main drivers for inappropriate antibiotic prescribing by primary-care physicians. Patient expectations have been shown to vary depending on type, duration and severity of symptoms. Parents/caregivers are also more likely to expect an antibiotic if their child was previously prescribed an antibiotic.

At times, demographic factors have been shown to be associated with patient expectations. For example, studies in the USA showed that recent immigrants from countries where antibiotics are available over the counter had the higher expectations for antibiotics for upper respiratory infections compared with the general population.

Rowan & Thompson, 2016; Cadieux et al., 2007; Cockburn & Pit, 1997; Avorn et al., 2000

Previous experience with antibiotics

At least 1 study showed that patients who received antibiotics were more likely to request these in the future.

Tahtinen et al., 2009

Demographic and social determinants of health

Age (i.e., youngest and oldest patient groups), low socioeconomic status (i.e. poverty, low education levels), being foreign born, living in more urban settings, having co-morbid conditions, and lack of access to a health care system and/or continuous care have been found to be consistently associated with higher or inappropriate antibiotic use.

Kozyrskyj et al., 2004; Marra, Mak and Chong, 2010; PHAC, 2012

Crowding, homelessness, and poverty have all been associated with higher rates of antimicrobial resistance in high-income countries.

Alividza et al., 2018


Perceived patient expectations

Several studies suggest prescribers are influenced by a desire to maintain or establish positive relationships with patients, and prescribe according to their perceptions of patient expectation. Often this is related to their belief or assumption that patients expect antibiotics or that patient satisfaction is related to a prescription, when in fact factors such as time allowed for a consultation tend to be a better predictor of patient satisfaction.

Ternhag, et al., 2014; Teixeira Rodrigues et al., 2013; MacFarlane et al., 1997; Coenen et al., 2013

Knowledge, beliefs, and attitudes towards antibiotics

Many studies show that a better understanding of physician knowledge, beliefs, and attitudes toward antimicrobial prescribing is essential for formulating effective antimicrobial stewardship programs.

Rosman et al., 2008; Deschepper et al., 2008; Cole, 2014; Teixeira Rodrigues et al., 2013

A systematic review conducted in OECD countries demonstrated that although prescribing providers are aware of antimicrobial resistance, they attribute responsibility to patients, other countries, and healthcare settings. They also consider antimicrobial resistance a low priority and distant consequence of antibiotic prescribing.

McCullough et al., 2015

Attitudes, beliefs, or practices related to shared decision making

Shared decision making has long been recognized as an effective strategy for reducing the overuse of treatments and decisional conflict around treatment options. At least 1 good-quality study from Quebec showed that a shared decision-making program in primary care enhanced patient participation and led to fewer patients opting to use antibiotics for acute respiratory infections.

Légaré et al., 2012

Attitudes, beliefs, or practices towards uncertainty avoidance

Uncertainty avoidance or tolerance of an ambiguous situation is thought to result in patient demand and practitioner prescription in situations where the indication of treatment may be unclear. A positive significant correlation was found between the Uncertainty Avoidance Index and use of antibiotics in ecological studies.

Deschepper, 2008; Gaygisiz, Lajunen & Gaygisiz, 2016; Teixeira Rodrigues et al., 2013

Factors that affect the quality of patient-practitioner relationships
(e.g. power distance, trust, and perceived competence)

The patient-practitioner relationship has been described as one of the most important determinants of AMU. Cultural norms, values, beliefs, and attitudes toward health and health care may influence the quality of communication between physicians and their patients. Several studies have explored cross-national differences in medical communication in Europe through Hofstede’s cultural framework and found that factors such as power distance, or the culturally specific way people deal with authority, trust, and perceived competence of the physician by patients are important dimensions that influence antibiotic prescription by affecting communication and shared decision making.

Bosley et al., 2018; Brooks-Howell et al., 2013; Lucas et al., 2015; Deschepper, 2008

Practice volume

At least 3 studies showed that physicians practicing in a high practice volume were more likely than those in a low practice volume to prescribe antibiotics inappropriately or excessively.

Cadieux et al., 2007; Daneman et al., 2017; Fleming-Dutra et al., 2018

Socio-demographic factors of practitioners

Of physicians’ socio-demographic factors, older age, medical speciality, and higher number of years in practice were associated with inappropriate prescribing. For instance, 1 study from Manitoba, which examined prescribing among children, showed higher prescribing rates among older clinicians, than those trained outside North America and non-specialists.

Lopez-Vazquez et al., 2012; Kozyrskyj et al., 2004

Medical training and education

Better physician clinical skills and education are associated with reduced antibiotic prescribing for viral respiratory infections. A systematic review of OECD countries demonstrated that the lack of previous clinical experience and continuous medical education was associated with inappropriate prescribing.

Cadieux et al., 2011; Teixeira Rodrigues et al., 2013

A study conducted in British Columbia, examining the prevalence of antibiotic prescribing among providers, found that dentists were the second highest prescribers of antibiotics after physicians. Factors that drove dentists to prescribe include differences in training and slow uptake of new guidelines.

Marra et al., 2016

Organization and health system-related

Availability and access to diagnostic tools

Diagnostic uncertainty can play a role in inappropriate antibiotic use. Diagnostic tools often can help identify the organism causing the infection and provide insight into the patient’s immune response, thereby enabling healthcare providers to distinguish between infections requiring antimicrobial treatment and those that do not.

Laxminarayan et al., 2013; Drekonja et al., 2015

Availability of guidelines tailored to local context


Diagnostic uncertainty and the wish to avoid complications can be important drivers of inappropriate antimicrobial prescribing. Where available, tailored clinical practice guidelines are important drivers of behaviour to reduce inappropriate antimicrobial prescribing.

Grossman et al., 2012; Doyon et al., 2009; Ness et al., 2016; Dickson et al., 2017

Peer influence and the availability of systems for self-monitoring

Social norms can influence human behaviour. A few studies show that shared values within a clinical practice can define the local antibiotic-prescribing culture. Characteristics of cultures where this may be more prevalent include practices where antibiotic overuse is generally accepted, where the potential adverse effects of antibiotics have a limited influence on clinical decision making, and where there may be limited peer-to-peer feedback.

Doyon et al., 2009 ; Daneman et al., 2017; Livorsi et al., 2015

Over-the-counter prescription of antibiotics

Antimicrobial use may be affected by reimbursement policies, financial incentives, and healthcare regulation. Ways in which health care is funded or reimbursed can affect antibiotic prescriptions. At least 1 study reported a decrease in antibiotic use following regulatory restrictions on over-the-counter prescription of antibiotics.

Harbarth & Monnet, 2007

Economic incentives or pressures from pharmaceutical industries

Economic incentives or the pressure of pharmaceutical industries can affect antibiotic prescription by clinicians. A few studies showed that pharmaceutical industries sometimes strive aggressively to influence physician prescribing habits. For example, Harbarth et al. (2002) describe how low drug prices in 1 European country motivated the pharmaceutical industry to compensate with extremely offensive marketing.  Frequent physician meetings with pharmaceutical representatives have also been associated with high rates of antibiotic prescriptions (Harbarth, 2007).

Hulscher et al., 2010; Harbarth & Monnet, 2007; Harbarth et al., 2002; Teixeira Rodrigues et al., 2013

Malpractice laws

In certain jurisdictions, physicians may be more likely to prescribe to avoid legal complaints.

Rosman, 2009; Harbarth & Monnet, 2007

Sick leave policies

One study reported the influence of parents under sick leave policies on antibiotic demand by illustrating the need of parents to return to work as a common driver of antibiotic demand.

Harbarth & Monnet, 2007

Daycare practices and policies

At least 1 study reported that attendance at a child-care centre has been associated with an increased risk of ear infections in children and excessive antibiotic use.

Harbarth & Monnet, 2007

Vaccination campaigns and vaccine development

Investment in development of new vaccines and implementation of vaccination strategies are likely to contribute to decreased transmission and impact of antimicrobial-resistant bacteria by decreasing susceptibility to various infectious diseases.

Kwong et al., 2009; Harbarth & Monnet, 2007; Harbarth & Samore, 2005

Sociocultural factors

Power distance

Power distance refers to the strength of real or perceived social hierarchies. Prescribing antibiotics can hold symbolic connotations and be seen as a sign of power and expertise. Several studies indicate that high power distance between prescriber and patient may result in poor communication and less shared decision making.

On the other hand, low power distance between prescriber and patient is thought to result in better communication and higher patient satisfaction, as well as more shared decision making. While the pathways between AMU and power distance have been tested in ecological studies, thereby limiting causal inferences, it is thought that low power distance between patients and practitioners can reduce inappropriate AMU by supporting shared decision making around patient preferences on the pros and cons of antibiotic treatment. Shared decision making may also lead to clarifying patient expectations, which has been identified as a key driver of AMU.

Harbarth & Monnet, 2007; Deschepper et al., 2008; Pechere et al., 2001; Rosman 2010

Uncertainty avoidance

Many studies show that use of antibiotics is associated with unwillingness of both practitioners and patients to accept uncertainty. High uncertainty avoidance is likely to result in patient demand for or physician prescription of antibiotics in situations where indication for treatment maybe unclear. Cultural analyses of this phenomenon describe the association of lower antibiotic use in countries where “watchful waiting” strategies are more common among practitioners prescribing antibiotics.

Harbarth & Monnet, 2007; Deschepper et al., 2008; Pechere et al., 2001; van Duijn et al., 2003; Deschepper, Vander & Stichele, 2001

Cultural perceptions of health and illnesses

Cultural factors that may influence antibiotic use include cultural conceptions of health and illnesses, including beliefs about health, causes of disease, labelling of illnesses, and coping strategies. These factors may determine which signs and symptoms require medical attention and drive health-seeking behaviours.

WHO, 2019; OECD, 2017; Harbarth & Monnet, 2007; Hulscher et al., 2010

Income inequality

One ecological study observed a moderate correlation between antimicrobial resistance and income inequality in 15 European countries. Although the mechanisms that might link income inequality and antimicrobial resistance remain poorly understood, they may be influenced by factors related to income inequality, such as access to and investment in health care.

Kirby & Herbert, 2013;

One Canadian study found an increase in demand for antibiotics in populations with high percentages of low-income individuals, high unemployment levels and low percentages of individuals with a bachelor’s degree.

Glass et al., 2010


Appendix A: PICO criteria

Criteria Inclusion Exclusion


Patients and  prescribers (i.e. physicians, pharmacists, dentists, nurse practitioners, specialists)

Animal studies, veterinary studies

Healthcare system

Social and cultural systems and institutions


Patient factors – Norms, beliefs, attitudes and values that may lead patients to have misconceptions about the effectiveness of antibiotics and create expectations around problematic use.

Practitioner factors – Factors that lead healthcare providers to prescribe antibiotics unnecessarily. This may include beliefs, practice patterns (pressure from patients to prescribe, prescribing “just in case”), lack of knowledge and training (medical school curricula, practice guidelines), as well as structural barriers such as not having sufficient time to have conversations with patients about appropriate antibiotics use and treatment alternatives.

Health system factors - Health system factors that perpetuate antibiotics overuse and misuse (e.g. lack of system supports, such as rapid diagnostic tools and antimicrobial resistance research and development funding, lack of time in a fee-for-service environment).

Cultural factors – Societal norms, values, and beliefs of various groups that may lead groups of individuals to misuse antimicrobial agents.



Appropriate use of antimicrobials



Primary: misuse or overuse of antimicrobials



Patient outcomes (i.e. symptom severity, symptom resolution, disease duration and complication or adverse effects)

Antibiotic resistance, patient and/or provider knowledge, attitudes, or beliefs about antibiotic use

Patient participation in shared decision making about antibiotic use

Patient satisfaction with care

Quality of patient-healthcare provider communication

Changes to regulatory practices


Study designs

Systematic reviews

Conference reports



Case series reports

Case-control studies

Cohort/longitudinal studies

Cross–sectional studies

Randomized controlled trials and/or cluster RCTs

Economic evaluations


Canada and OECD countries


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