Antibiotic knowledge, attitudes, and practices: new insights from cross-sectional rural health behaviour surveys in low- and middle-income South-East Asia

Introduction: Low- and middle-income countries (LMICs) are crucial in the global response to antimicrobial resistance (AMR), but diverse health systems, healthcare practices, and cultural conceptions of medicine can complicate global education and awareness-raising campaigns. Social research can help understand LMIC contexts but remains underrepresented in AMR research. Objective: To (1) describe antibiotic-related knowledge, attitudes, and practices of the general population in two LMICs and to (2) assess the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers. Design: Observational study: cross-sectional rural health behaviour survey, representative on the population level. Setting: General rural population in Chiang Rai (Thailand) and Salavan (Lao PDR), surveyed between November 2017 and May 2018. Participants: 2141 adult members (≥18 years) of the general rural population, representing 712,000 villagers. Outcome measures: Antibiotic-related knowledge, attitudes, and practices across sites and healthcare access channels. Findings: Villagers were aware of antibiotics (Chiang Rai: 95.7%; Salavan: 86.4%; p<0.001) and drug resistance (Chiang Rai: 74.8%; Salavan: 62.5%; p<0.001), but the usage of technical concepts for antibiotics was dwarfed by local expressions like “anti-inflammatory medicine” in Chiang Rai (87.6%; 95% confidence interval [CI]: 84.9–90.0) and “ampi” in Salavan (75.6%; 95% CI: 71.4–79.4). Multivariate linear regression suggested that attitudes against over-the-counter antibiotics were linked to 0.12 additional antibiotic use episodes from public healthcare providers in Chiang Rai (95% CI: 0.01 – 0.23) and 0.53 in Salavan (95% CI: 0.16 – 0.90). Conclusions: Locally specific conceptions and counter-intuitive practices around antimicrobials can complicate AMR communication efforts and entail unforeseen consequences. Overcoming “knowledge deficits” alone will therefore be insufficient for global AMR behaviour change. We call for an expansion of behavioural AMR strategies towards “AMR-sensitive interventions” that address context-specific upstream drivers of antimicrobial use (e.g. unemployment insurance) and complement education and awareness campaigns

An ethnographic study of medicines, care, and antimicrobial resistance amidst disorder and decline in Yangon, Myanmar

Antimicrobial resistance (AMR) has gained much attention, described by some as a global health emergency. At the 2015 World Health Assembly, countries around the world were asked to create national action plans to address AMR, following a blueprint of the World Health Organization’s Global Action Plan (WHO GAP). This thesis, positioned in a suburban area of Yangon, Myanmar, provides a reflection on the expected state-centric approach to implementation. My ethnographic fieldwork illustrates how efforts under the umbrellas of awareness-raising and changing behaviours to curb antibiotic misuse can reinforce rather than relieve the conditions that lead to reliance on antibiotics through informal routes. Myanmar, with its authoritarian state and ongoing civil wars, is governed by a fragmentary and volatile rule of law. Others have previously shown how the residents of Myanmar have developed everyday coping mechanisms to adapt to a governance structure characterised by caprice and neglect. My ethnographic research explored how coping mechanisms have also developed in the context of medicine regulation and use as I traced medicines from within households, drug shops, private practices, markets, to pharmaceutical companies. I argue that medicine ‘misuse’ behaviours (overuse of medicines, inappropriate use of medicines) in Yangon as characterised from a clinical perspective, are less shaped by individuals and more so by the failures and biopolitical abandonment from the institutions/systems which are, in theory (according to values promoted by the liberal international order /also values promoted by the WHO GAP), supposed to protect individuals.2 Medicines have become a quick fix to care for and support individuals in place of these failures. These findings illuminate universalist assumptions in AMR action plans that expect a particular order and development trajectory of states and citizens. Attempts to regulate or restrict medicines should take the context of disorder and decline – a situation that is not unique to Myanmar in a post covid-19 world – into account, or they risk intensifying pre-existing pressures on those who are already self-governing or coping on their own

It is time to give social research a voice to tackle AMR

We call for more social research to understand and address antimicrobial use and resistance, but this will require a stronger voice for social scientists. Social scientists do not hold a monopoly on social research questions, and the appreciation of social phenomena by medical AMR researchers is laudable indeed. Yet, the continuing absence of social research is a threat to understanding and addressing the social dimensions of AMR more comprehensively and effectively

A comparison of patients’ local conceptions of illness and medicines in the context of C-reactive protein biomarker testing in Chiang Rai and Yangon

Antibiotic resistance is not solely a medical but also a social problem, influenced partly by patients’ treatment-seeking behavior and their conceptions of illness and medicines. Situated within the context of a clinical trial of C-reactive protein (CRP) biomarker testing to reduce antibiotic over-prescription at the primary care level, our study explores and compares the narratives of 58 fever patients in Chiang Rai (Thailand) and Yangon (Myanmar). Our objectives are to (1) compare local conceptions of illness and medicines in relation to healthcare seeking and antibiotic demand; and to (2) understand how these conceptions could influence CRP point-of-care testing (POCT) at the primary care level in low- and middle-income country settings. We thereby go beyond the current knowledge about antimicrobial resistance (AMR) and CRP POCT, which consists primarily of clinical research and quantitative data. We find that CRP POCT in Chiang Rai and Yangon interacted with fever patients’ pre-existing conceptions of illness and medicine, their treatment-seeking behavior, and their healthcare experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients’ self-assessed illness severity, and an increase in the status of the formal healthcare facilities that provide the test. While we expected that local conceptions of illness diverge from in-built assumptions of clinical interventions, we conclude that this mismatch can undermine the intervention and potentially reproduce problematic equity patterns among CRP POCT users and non-users. As a partial solution, implementers may consider applying the test after clinical examination to validate rather than direct prescription processes

A comparison of patients’ local conceptions of illness and medicines in the context of C-reactive protein biomarker testing in Chiang Rai and Yangon

Antibiotic resistance is not solely a medical but also a social problem, influenced partly by patients’ treatment-seeking behavior and their conceptions of illness and medicines. Situated within the context of a clinical trial of C-reactive protein (CRP) biomarker testing to reduce antibiotic over-prescription at the primary care level, our study explores and compares the narratives of 58 fever patients in Chiang Rai (Thailand) and Yangon (Myanmar). Our objectives are to (1) compare local conceptions of illness and medicines in relation to healthcare seeking and antibiotic demand; and to (2) understand how these conceptions could influence CRP point-of-care testing (POCT) at the primary care level in low- and middle-income country settings. We thereby go beyond the current knowledge about antimicrobial resistance (AMR) and CRP POCT, which consists primarily of clinical research and quantitative data. We find that CRP POCT in Chiang Rai and Yangon interacted with fever patients’ pre-existing conceptions of illness and medicine, their treatment-seeking behavior, and their healthcare experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients’ self-assessed illness severity, and an increase in the status of the formal healthcare facilities that provide the test. While we expected that local conceptions of illness diverge from in-built assumptions of clinical interventions, we conclude that this mismatch can undermine the intervention and potentially reproduce problematic equity patterns among CRP POCT users and non-users. As a partial solution, implementers may consider applying the test after clinical examination to validate rather than direct prescription processes

How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions

Background: Context matters for the successful implementation of medical interventions, but its role remains surprisingly understudied. Against the backdrop of antimicrobial resistance, a global health priority, we investigated the introduction of a rapid diagnostic biomarker test (C-reactive protein, or CRP) to guide antibiotic prescriptions in outpatient settings and asked, “Which factors account for cross-country variations in the effectiveness of CRP biomarker test interventions?”Methods: We conducted a cross-case comparison of CRP point-of-care test trials across Yangon (Myanmar), Chiang Rai (Thailand), and Hanoi (Vietnam). Cross-sectional qualitative data were originally collected as part of each clinical trial to broaden their evidence base and help explain their respective results. We synthesised these data and developed a large qualitative data set comprising 130 interview and focus group participants (healthcare workers and patients) and nearly one million words worth of transcripts and interview notes. Inductive thematic analysis was used to identify contextual factors and compare them across the three case studies. As clinical trial outcomes, we considered patients’ and healthcare workers’ adherence to the biomarker test results, and patient exclusion to gauge the potential “impact” of CRP point-of-care testing on the population level.Results: We identified three principal domains of contextual influences on intervention effectiveness. First, perceived risks from infectious diseases influenced the adherence of the clinical users (nurses, doctors). Second, the health system context related to all three intervention outcomes (via the health policy and antibiotic policy environment, and via health system structures and the ensuing utilisation patterns). Third, the demand-side context influenced the patient adherence to CRP point-of-care tests and exclusion from the intervention through variations in local healthcare-seeking behaviours, popular conceptions of illness and medicine, and the resulting utilisation of the health system.Conclusions: Our study underscored the importance of contextual variation for the interpretation of clinical trial findings. Further research should investigate the range and magnitude of contextual effects on trial outcomes through meta-analyses of large sets of clinical trials. For this to be possible, clinical trials should collect qualitative and quantitative contextual information for instance on their disease, health system, and demand-side environment

How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions

BACKGROUND: Context matters for the successful implementation of medical interventions, but its role remains surprisingly understudied. Against the backdrop of antimicrobial resistance, a global health priority, we investigated the introduction of a rapid diagnostic biomarker test (C-reactive protein, or CRP) to guide antibiotic prescriptions in outpatient settings and asked, "Which factors account for cross-country variations in the effectiveness of CRP biomarker test interventions?" METHODS: We conducted a cross-case comparison of CRP point-of-care test trials across Yangon (Myanmar), Chiang Rai (Thailand), and Hanoi (Vietnam). Cross-sectional qualitative data were originally collected as part of each clinical trial to broaden their evidence base and help explain their respective results. We synthesised these data and developed a large qualitative data set comprising 130 interview and focus group participants (healthcare workers and patients) and nearly one million words worth of transcripts and interview notes. Inductive thematic analysis was used to identify contextual factors and compare them across the three case studies. As clinical trial outcomes, we considered patients' and healthcare workers' adherence to the biomarker test results, and patient exclusion to gauge the potential "impact" of CRP point-of-care testing on the population level. RESULTS: We identified three principal domains of contextual influences on intervention effectiveness. First, perceived risks from infectious diseases influenced the adherence of the clinical users (nurses, doctors). Second, the health system context related to all three intervention outcomes (via the health policy and antibiotic policy environment, and via health system structures and the ensuing utilisation patterns). Third, the demand-side context influenced the patient adherence to CRP point-of-care tests and exclusion from the intervention through variations in local healthcare-seeking behaviours, popular conceptions of illness and medicine, and the resulting utilisation of the health system. CONCLUSIONS: Our study underscored the importance of contextual variation for the interpretation of clinical trial findings. Further research should investigate the range and magnitude of contextual effects on trial outcomes through meta-analyses of large sets of clinical trials. For this to be possible, clinical trials should collect qualitative and quantitative contextual information for instance on their disease, health system, and demand-side environment. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02758821 registered on 3 May 2016 and NCT01918579 registered on 7 August 2013

Antibiotic knowledge, attitudes and practices: new insights from cross-sectional rural health behaviour surveys in low-income and middle-income South-East Asia

Introduction: Low-income and middle-income countries (LMICs) are crucial in the global response to antimicrobial resistance (AMR), but diverse health systems, healthcare practices and cultural conceptions of medicine can complicate global education and awareness-raising campaigns. Social research can help understand LMIC contexts but remains under-represented in AMR research. Objective: To (1) Describe antibiotic-related knowledge, attitudes and practices of the general population in two LMICs. (2) Assess the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers. Design: Observational study: cross-sectional rural health behaviour survey, representative of the population level. Setting: General rural population in Chiang Rai (Thailand) and Salavan (Lao PDR), surveyed between November 2017 and May 2018. Participants: 2141 adult members (≥18 years) of the general rural population, representing 712,000 villagers. Outcome measures: Antibiotic-related knowledge, attitudes and practices across sites and healthcare access channels. Findings: Villagers were aware of antibiotics (Chiang Rai: 95.7%; Salavan: 86.4%; p&lt;0.001) and drug resistance (Chiang Rai: 74.8%; Salavan: 62.5%; p&lt;0.001), but the usage of technical concepts for antibiotics was dwarfed by local expressions like ‘anti-inflammatory medicine’ in Chiang Rai (87.6%; 95% CI 84.9% to 90.0%) and ‘ampi’ in Salavan (75.6%; 95% CI 71.4% to 79.4%). Multivariate linear regression suggested that attitudes against over-the-counter antibiotics were linked to 0.12 additional antibiotic use episodes from public healthcare providers in Chiang Rai (95% CI 0.01 to 0.23) and 0.53 in Salavan (95% CI 0.16 to 0.90). Conclusions: Locally specific conceptions and counterintuitive practices around antimicrobials can complicate AMR communication efforts and entail unforeseen consequences. Overcoming ‘knowledge deficits’ alone will therefore be insufficient for global AMR behaviour change. We call for an expansion of behavioural AMR strategies towards ‘AMR-sensitive interventions’ that address context-specific upstream drivers of antimicrobial use (eg, unemployment insurance) and complement education and awareness campaigns. Trial Registration Number: clinicaltrials.gov identifier NCT03241316.</p