Protocol for a randomized controlled trial on community education and surveillance on antibiotics use among young children in Nepal

BACKGROUND: Antimicrobial resistance (AMR) is one of the top ten threats to global health. There exists limited empirical evidence on effective approaches to address this threat. In low- and middle-income countries (LMICs), one of the primary drivers of AMR is easy access to antibiotics without prescriptions, in particular from community pharmacies. Interventions to reduce non-prescribed use of antibiotics and surveillance systems to track such usage are critically needed. This protocol describes a study that aims to test the effect of an educational intervention targeted to parents of young children on non-prescribed antibiotics consumption in Nepal and to track such consumption using a phone-based application. METHODS: The study is a clustered randomized controlled trial, in which we randomly assign 40 urban wards of Kathmandu Valley to either treatment group or control group, and randomly select 24 households in each ward. Households in the treatment group will receive an education intervention consisting of an AMR pitch (an in-person interaction that lasts up to an hour) by community nurses, videos and text messages on AMR every two weeks, and a brochure. We will conduct a survey at baseline with the parents of children ages 6 months to 10 years and track consumption of antibiotics and health care use among these children for a period of 6 months using a phone-based application. CONCLUSION: While the study will primarily inform future policy and programmatic efforts to reduce AMR in Nepal, the study-both the education intervention and the surveillance system-can serve as a prototype for tackling AMR in other similar settings

Economic and social drivers of antibiotic dispensing practices among community pharmacies in Nepal

OBJECTIVE: To assess economic and social drivers of dispensing antibiotics without prescription by community pharmacies in Nepal. METHOD: A survey was conducted among 111 pharmacy owners and managers in five districts. Information on demographic and economic characteristics of the pharmacies (e.g. revenue and profits from antibiotics) and their inclination to sell antibiotics without a physician\u27s prescription under various scenarios (e.g. diarrhoea in a child) was collected. Univariate analysis was conducted to assess the demographic and economic characteristics. Bivariate analysis was conducted to examine the relationship between dispensing antibiotics without prescription and economic and social factors. RESULTS: Azithromycin and amoxicillin were the most commonly dispensed antibiotics. The proportions of pharmacies reporting that they would \u27most likely\u27 or \u27likely\u27 dispense antibiotics without prescription to adult patients ranged from 36.9% (sore throat) to 67.6% (cough). The proportions for paediatric patients ranged from 62.2% (sore throat) to 80.2% (cough or diarrhoea). There was no consistent relationship between the likelihood of dispensing antibiotics and revenues, profits or the number of patients. Instead, dispensing behaviour was influenced by the pressure from the patient; the respondents were more likely to dispense antibiotics when the patient specifically asked for \u27an antibiotic\u27 rather than for \u27a medicine\u27, and 68.5% respondents ranked \u27customer satisfaction\u27 as the most important factor motivating their work. CONCLUSIONS: In Nepal, inappropriate sale of antibiotics by community pharmacists is high, particularly for paediatric patients. Additional research is needed to establish key drivers of this behaviour and to help design effective approaches to reducing AMR

Protocol for a randomized controlled trial on community education and surveillance on antibiotics use among young children in Nepal

Background: Antimicrobial resistance (AMR) is one of the top ten threats to global health. There exists limited empirical evidence on effective approaches to address this threat. In low- and middle-income countries (LMICs), one of the primary drivers of AMR is easy access to antibiotics without prescriptions, in particular from community pharmacies. Interventions to reduce non-prescribed use of antibiotics and surveillance systems to track such usage are critically needed. This protocol describes a study that aims to test the effect of an educational intervention targeted to parents of young children on non-prescribed antibiotics consumption in Nepal and to track such consumption using a phone-based application. Methods: The study is a clustered randomized controlled trial, in which we randomly assign 40 urban wards of Kathmandu Valley to either treatment group or control group, and randomly select 24 households in each ward. Households in the treatment group will receive an education intervention consisting of an “AMR pitch” (an in-person interaction that lasts up to an hour) by community nurses, videos and text messages on AMR every two weeks, and a brochure. We will conduct a survey at baseline with the parents of children ages 6 months to 10 years and track consumption of antibiotics and health care use among these children for a period of 6 months using a phone-based application. Conclusion: While the study will primarily inform future policy and programmatic efforts to reduce AMR in Nepal, the study—both the education intervention and the surveillance system—can serve as a prototype for tackling AMR in other similar settings

Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal.

Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets