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Murray JL, Leung DT, Hanson OR, Ahmed SM, Pavia AT, Khan AI, Szymczak JE, Vaughn VM, Patel PK, Biswas D, Watt MH. Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002507. [PMID: 38573955 PMCID: PMC10994369 DOI: 10.1371/journal.pgph.0002507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n = 173); after removing duplicates and preprints (n = 12) and excluding those that did not meet eligibility criteria (n = 115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). This study is the first to succinctly identify a range of norms, behaviors, and policy contexts driving inappropriate use of antimicrobials in South Asia, emphasizing the importance of working across multiple sectors to design and implement approaches specific to the region.
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Affiliation(s)
- Jennifer L. Murray
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
- School of Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Daniel T. Leung
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Olivia R. Hanson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Sharia M. Ahmed
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Andrew T. Pavia
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Ashraful I. Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Julia E. Szymczak
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Valerie M. Vaughn
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Payal K. Patel
- Department of Internal Medicine, Intermountain Health, Murray, Utah, United States of America
| | - Debashish Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Melissa H. Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
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Murray JL, Leung DT, Hanson OR, Ahmed SM, Pavia AT, Khan AI, Szymczak JE, Vaughn VM, Patel PK, Biswas D, Watt MH. Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296313. [PMID: 37808732 PMCID: PMC10557824 DOI: 10.1101/2023.09.28.23296313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n=173); after removing duplicates and preprints (n=12) and excluding those that did not meet eligibility criteria (n=115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). The findings highlight the importance of working across multiple sectors to design and implement approaches to antimicrobial stewardship in South Asia.
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Affiliation(s)
- Jennifer L. Murray
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT USA
- School of Medicine, University of Utah, Salt Lake City, UT USA
| | - Daniel T. Leung
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Olivia R. Hanson
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Sharia M. Ahmed
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Andrew T. Pavia
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Ashraful I. Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Julia E. Szymczak
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Valerie M. Vaughn
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Payal K. Patel
- Department of Internal Medicine, Intermountain Health, Murray, UT
| | - Debashish Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Melissa H. Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT USA
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Saleem Z, Godman B, Azhar F, Kalungia AC, Fadare J, Opanga S, Markovic-Pekovic V, Hoxha I, Saeed A, Al-Gethamy M, Haseeb A, Salman M, Khan AA, Nadeem MU, Rehman IU, Qamar MU, Amir A, Ikram A, Hassali MA. Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications. Expert Rev Anti Infect Ther 2021; 20:71-93. [PMID: 34038294 DOI: 10.1080/14787210.2021.1935238] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: The emergence of antimicrobial resistance (AMR) is a threat to public health. In 2015, the World Health Organization (WHO) introduced a global action plan to tackle AMR in the World Health Assembly. Pakistan's national action plan (NAP) for AMR was released in May 2017 by the Ministry of National Health Services. Based on the NAP, strategies have been initiated on a national and provincial scale in Pakistan.Areas covered: This narrative review of the five components of the Pakistan NAP has been undertaken to discuss some of the challenges in implementation of the NAP for AMR in Pakistan including different opinions and views of key stakeholders, combined with suggestions on potential ways to reduce the burden of the AMR.Expert opinion: Going forward, healthcare authorities should focus on screening and monitoring of all the objectives of the NAP by establishing proper policies as well as promoting antimicrobial stewardship interventions and Infection prevention and control (IPC) practices. Overall, the comprehensive strengthening of the healthcare system is required to adequately implement the NAP, tackle continued inappropriate antimicrobial use and high AMR rates in Pakistan.
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Affiliation(s)
- Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK.,School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa.,School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town Malaysia
| | - Faiza Azhar
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | | | - Joseph Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University, Ado-Ekiti, Nigeria
| | - Sylvia Opanga
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Vanda Markovic-Pekovic
- Department of Social Pharmacy, Faculty of Medicine, University of Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Iris Hoxha
- Department of Pharmacy, Faculty of Medicine, University of Medicine Tirana, Albania
| | - Amna Saeed
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Manal Al-Gethamy
- Alnoor Specialist Hospital Makkah, Department of Infection Prevention & Control Program, Makkah, Kingdom of Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al Qura University, Makkah, Kingdom of Saudi Arabia
| | - Muhammad Salman
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Ayaz Ali Khan
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Muhammad Umer Nadeem
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Inaam Ur Rehman
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Muhammad Usman Qamar
- Department of Microbiology, Faculty of Life Sciences, Government College University Faisalabad, Faisalabad, Pakistan
| | - Afreenish Amir
- Department of Microbiology, National Institute of Health Islamabad, Pakistan
| | - Aamer Ikram
- Department of Microbiology, National Institute of Health Islamabad, Pakistan
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Chatterjee S, Hazra A, Chakraverty R, Shafiq N, Pathak A, Trivedi N, Sadasivam B, Kakkar AK, Jhaj R, Kaul R, Kshirsagar N. A multicentric knowledge-attitude-practice survey in the community about antimicrobial use and resistance in India. Trans R Soc Trop Med Hyg 2021; 115:785-791. [PMID: 33216125 DOI: 10.1093/trstmh/traa124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/09/2020] [Accepted: 10/20/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To address the reasons for inappropriate use of antimicrobials, it is important to understand the knowledge, attitude and practices (KAP) of all pertinent stakeholders. This multicentric survey is aimed at understanding the KAP quotients of the community regarding antimicrobial use and antimicrobial resistance (AMR), as such information is lacking in India. METHODS A cross-sectional survey was conducted by face-to-face interviews across five centers in India using a validated, field-tested questionnaire incorporating KAP domain questions. Scores were appropriately assigned to the questions. RESULTS The mean (SD) age of the respondents was 35.2 (12.61) y and 62% had a graduate or higher level of education. The median (IQR) KAP scores were 10 (8-12), 5 (3-5) and 2 (2-3) out of a maximum of 18, 5 and 6, respectively. Higher educational and socioeconomic levels were associated with better attitude scores, but knowledge levels were comparable. Correlations between KAP scores were poor. CONCLUSIONS This study reveals that laypeople have appropriate knowledge and attitude regarding antibiotic use and AMR to some degree but there are important lacunae and practices are often wanting. These issues need to be addressed in sustained public awareness and motivation campaigns to improve the rational use of antibiotics in India.
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Affiliation(s)
- Suparna Chatterjee
- Department of Pharmacology, Institute of Postgraduate Medical Education & Research, Kolkata, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Postgraduate Medical Education & Research, Kolkata, India
| | - Raja Chakraverty
- Department of Pharmacology, Institute of Postgraduate Medical Education & Research, Kolkata, India
| | - Nusrat Shafiq
- Department of Pharmacology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashish Pathak
- Department of Pediatrics, R. D. Gardi Medical College, Ujjain, India
| | - Niyati Trivedi
- Department of Pharmacology, Government Medical College, Baroda, India
| | | | - Ashish Kumar Kakkar
- Department of Pharmacology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ratinder Jhaj
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, India
| | - Rajni Kaul
- Indian Council of Medical Research, New Delhi, India
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Kotwani A, Joshi J, Lamkang AS, Sharma A, Kaloni D. Knowledge and behavior of consumers towards the non-prescription purchase of antibiotics: An insight from a qualitative study from New Delhi, India. Pharm Pract (Granada) 2021; 19:2206. [PMID: 33828621 PMCID: PMC8005328 DOI: 10.18549/pharmpract.2021.1.2206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/21/2021] [Indexed: 01/11/2023] Open
Abstract
Background: In Low-and Middle-Income Countries, including India, consumers often purchase
antibiotics over-the-counter (OTC) from retail pharmacies. This practice
leads to the inappropriate use of antibiotics in the community which is an
important driver for the development of antimicrobial resistance. A better
understanding of consumers’ views towards this grave public health
concern is critical to developing evidence-based intervention programs for
awareness among the general population. Objective: To explore knowledge, practice and, behavior of consumers towards
antibiotics, antibiotic use, antimicrobial resistance, purchasing behavior
of consumers for antibiotics, and to gain insight which will help in
developing evidence-based policy interventions. Methods: 72 in-depth consumer interviews were conducted in all 11 districts of the
National Capital Territory of Delhi. The qualitative data were analyzed
using thematic analysis. Results: Our study found that retail pharmacies were the first point of consultation
for common ailments for patients/consumers once home remedies failed; they
were largely unaware of the threat of antimicrobial resistance.
Consumers’ knowledge of antibiotic use and about antimicrobial
resistance was low, they used old prescriptions, and bought antibiotics OTC
to save time and money. Despite the presence of regulations constituted to
regulate the sale of antibiotics by the Government and the implementation of
national campaigns, the practice of self-medication and behaviors such as
OTC purchase, non-adherence to prescribed antibiotics was prevalent.
Consumers perceive that antibiotics provide quick relief and accelerate the
curing process and retail pharmacy shops try to protect their retail
business interests by honoring old prescriptions and self-medication for
antibiotics. Conclusions: The lack of awareness and insufficient knowledge about what antibiotics are
and issues such as antimicrobial resistance or antibiotic resistance
resulted in misuse of antibiotics by consumers. Limited access to public
healthcare and affordability of private healthcare are factors that
contribute towards the self-medication/OTC purchase of antibiotics. The
regular misuse of antibiotics through irrational use reinforces the need for
strong enactment of strategies like continuous community awareness
campaigns. Mitigation efforts should focus upon educating consumers
continuously and sustainably for the understanding of antibiotic misuse,
antimicrobial resistance, and promote better compliance with
regulations.
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Affiliation(s)
- Anita Kotwani
- PhD (Pharmacol). Professor & Head of Pharmacology Department, Vallabhbhai Patel Chest Institute (VPCI), University of Delhi. Delhi (India).
| | - Jyoti Joshi
- MD, MBBS (Commun Med). Adjunct Professor. Amity Institute of Public Health, Center for Disease Dynamics, Economics and Policy (CDDEP), Amity University and Head-South Asia. New Delhi (India).
| | - Anjana S Lamkang
- PhD (Anthropol). Fellow. Center for Disease Dynamics, Economics and Policy (CDDEP). New Delhi (India).
| | - Ayushi Sharma
- MSc (Anthropol). Senior Research Fellow. Pharmacology Department, Vallabhbhai Patel Chest Institute (VPCI), University of Delhi. Delhi (India).
| | - Deeksha Kaloni
- MTech. (Biotechnol). Junior Research Fellow. Pharmacology Department, Vallabhbhai Patel Chest Institute (VPCI), University of Delhi. Delhi (India).
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Broom J, Broom A, Kenny K, Chittem M. Antimicrobial overuse in India: A symptom of broader societal issues including resource limitations and financial pressures. Glob Public Health 2020; 16:1079-1087. [PMID: 33161832 DOI: 10.1080/17441692.2020.1839930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
India and the global community are facing a critical crisis of antimicrobial resistance (AMR), significantly contributed to by on-going and increasing antimicrobial misuse. Information as to what drives misuse of antimicrobials within India is essential to inform strategies to address the crisis. This papers aims to identify perceived influences on antimicrobial use in Hyderabad, India. We conducted semi-structured qualitative interviews conducted with thirty participants (15 doctors, 15 pharmacists) around their experiences of antimicrobials in Hyderabad, India. Thematic analysis was performed and four themes identified around (1) Perceptions of the problem of resistance and antimicrobial use; (2) Social pressures to prescribe/dispense; (3) Financial pressures driving antimicrobial over-use; and (4) Lack of regulation around training and qualifications. We conclude that antimicrobial use within India is embedded with, and occurs as a result of, complex social and economic factors including issues of resource limitation, structural/governance limitations and social relationships. Strategies to address misuse without acknowledging and addressing the critical driving forces of use will be unlikely to induce significant change.
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Affiliation(s)
- Jennifer Broom
- Sunshine Coast Health Institute, Birtinya, Australia.,University of Queensland, Brisbane, Australia
| | - Alex Broom
- School of Social and Political Sciences, The University of Sydney, Sydney, Australia
| | - Katherine Kenny
- School of Social and Political Sciences, The University of Sydney, Sydney, Australia
| | - Mahati Chittem
- Department of Liberal Arts, Indian Institute of Technology (IIT), Hyderabad, India
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Tackling antimicrobial resistance in Bangladesh: A scoping review of policy and practice in human, animal and environment sectors. PLoS One 2020; 15:e0227947. [PMID: 31986167 PMCID: PMC6984725 DOI: 10.1371/journal.pone.0227947] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 01/04/2020] [Indexed: 11/29/2022] Open
Abstract
Background Antimicrobial resistance (AMR) has become an emerging issue in the developing countries as well as in Bangladesh. AMR is aggravated by irrational use of antimicrobials in a largely unregulated pluralistic health system. This review presents a ‘snap shot’ of the current situation including existing policies and practices to address AMR, and the challenges and barriers associated with their implementation. Methods A systematic approach was adopted for identifying, screening, and selecting relevant literature on AMR situation in Bangladesh. We used Google Scholar, Pubmed, and Biomed Central databases for searching peer-reviewed literature in human, animal and environment sectors during January 2010-August 2019, and Google for grey materials from the institutional and journal websites. Two members of the study team independently reviewed these documents for inclusion in the analysis. We used a ‘mixed studies review’ method for synthesizing evidences from different studies. Result Of the final 47 articles, 35 were primary research, nine laboratory-based research, two review papers and one situation analysis report. Nineteen articles on human health dealt with prescribing and/or use of antimicrobials, five on self-medication, two on non-compliance of dosage, and 10 on the sensitivity and resistance patterns of antibiotics. Four papers focused on the use of antimicrobials in food animals and seven on environmental contamination. Findings reveal widespread availability of antimicrobials without prescription in the country including rise in its irrational use across sectors and consequent contamination of environment and spread of resistance. The development and transmission of AMR is deep-rooted in various supply and demand side factors. Implementation of existing policies and strategies remains a challenge due to poor awareness, inadequate resources and absence of national surveillance. Conclusion AMR is a multi-dimensional problem involving different sectors, disciplines and stakeholders requiring a One Health comprehensive approach for containment.
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Nair M, Tripathi S, Mazumdar S, Mahajan R, Harshana A, Pereira A, Jimenez C, Halder D, Burza S. "Without antibiotics, I cannot treat": A qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India. PLoS One 2019; 14:e0219002. [PMID: 31247028 PMCID: PMC6597109 DOI: 10.1371/journal.pone.0219002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/13/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal. MATERIALS AND METHODS We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner. RESULTS Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another. CONCLUSIONS A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.
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Affiliation(s)
- Mohit Nair
- Medecins Sans Frontieres, New Delhi, India
| | | | - Sumit Mazumdar
- Centre for Health Economics, University of York, York, United Kingdom
| | | | | | | | | | | | - Sakib Burza
- Medecins Sans Frontieres, New Delhi, India
- * E-mail:
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Knowledge, attitudes, and practices related to antibiotic use in Paschim Bardhaman District: A survey of healthcare providers in West Bengal, India. PLoS One 2019; 14:e0217818. [PMID: 31150515 PMCID: PMC6544287 DOI: 10.1371/journal.pone.0217818] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 05/20/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India. Although informal providers are involved with substantial segments of primary healthcare, their level of knowledge, attitudes, and practices is not well documented in the literature. Objectives This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use. Methods We surveyed a convenience sample of 384 participants (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Our team created an equivalent, composite KAP score for each respondent in the survey, which was subsequently compared between providers. We then performed a multivariate logistic regression analysis to estimate the odds of having a low composite score (<80) based on occupation by comparing allopathic doctors (referent category) with all other study participants. The model was adjusted for age (included as a continuous variable) and gender. Results Doctors scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed poorly in practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n = 82) reported prescribing them in this situation. Nurses, pharmacy shopkeepers, and informal providers were more likely to perform poorly on the survey compared to allopathic doctors (OR: 10.4, 95% CI 5.4, 20.0, p<0.01). 30.8% (n = 118) of all providers relied on pharmaceutical company representatives as a major source of information about antibiotics. Conclusions Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors. The nexus between allopathic doctors, pharmaceutical company representatives, and informal health providers present promising avenues for future research and intervention.
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Public Awareness about Antibiotic Use and Resistance among Residents in Highland Areas of Vietnam. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9398536. [PMID: 31223624 PMCID: PMC6541961 DOI: 10.1155/2019/9398536] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/31/2019] [Accepted: 04/22/2019] [Indexed: 11/18/2022]
Abstract
Background Antibiotic resistance (AR) remains a global crisis. However, the literature on public awareness about antibiotic use and AR in the highland provinces of Vietnam has been constrained. This study explores the awareness of antibiotic use and resistance among general people in highland provinces in Vietnam and detects associated factors. Methods A cross-sectional study was performed in five highland provinces with 1000 households. Information about socioeconomic status and awareness regarding prescription medicine use, antibiotic use, and AR was surveyed. Multivariate logistic regression was used to identify associated factors with awareness. Results 64.2% of people were aware of prescription drugs. More than two-thirds (67.4%) of participants were aware of antibiotic use, of whom only 55.8% were aware of AR. Higher age, education, and family income were positively associated with being aware of prescription medicine, antibiotic, and AR. Females had a lower likelihood of being aware of prescription medicine (OR=0.64; 95%CI=0.45-0.90) compared to male counterparts. Those being freelancers were more likely to be aware of antibiotic resistance (OR=2.30; 95%CI=1.13-4.67) compared to those working in agriculture/fishery/forestry sector. Compared to Kinh ethnic, most ethnic minorities were less likely to be aware of prescription medicine, antibiotic, and AR. Conclusions This study showed a low awareness regarding prescription medicine, antibiotic use, and AR among public people in the highland provinces of Vietnam. Further systemic and didactic educational interventions targeting females, low education, low income, ethnic minorities, and those working in agriculture/fishery/forestry sector in this setting should be performed and evaluated to improve the awareness about antibiotic use and resistance.
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Fernandes R, Naik S, Bhat AG, Shetty R, Hande MH, Ghafur A, Rao M, Kunhikatta V, Pathiraj JPK. Knowledge Assessment of E-Bug Assisted Antimicrobial Resistance Education Module in Class VII School Students of South Indian Coastal Town of Manipal. J Clin Med 2019; 8:jcm8010084. [PMID: 30642058 PMCID: PMC6351948 DOI: 10.3390/jcm8010084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/17/2018] [Accepted: 01/02/2019] [Indexed: 12/03/2022] Open
Abstract
Antimicrobial resistance (AMR) is a recognized public health threat today globally. Although many active and passive stewardship strategies are advocated to counter AMR clinically, educating school going children on AMR could be a cost-effective measure to minimize AMR development in the future. We implemented NICE’s e-bug as a module to educate class VII school students on AMR determinants. A prospective quasi-experimental study on 327 students from nine different schools of class VII around Manipal town, Udupi district, Karnataka state, India were included in the study. Ten questions on AMR determinants from the e-bug program were used in written pre-test. After an education intervention, a post-test was conducted. Descriptive statistics to estimate epidemiological characteristics, Wilcoxon Signed Ranks and Kruskal–Wallis tests were applied to analyze statistical significance of pre/post-test performance scores and between schools. Students had inadequate knowledge on seven AMR determinants (antimicrobial indication, its course, hand hygiene, fermentation, spread of infection, microbial multiplication and characteristics of microbe) as analyzed from the post-test performance (p < 0.05). Comparison of post-test performance between schools showed significant improvement in scores (p < 0.05) for three questions (definition on antimicrobial, cover while cough/sneezing and microbial characteristics). Although students exhibited sub-optimal knowledge on some AMR determinants, they showed keenness to learn, which was evident by their post-test performance. Our findings and previous similar studies from Europe are suggestive of early pedagogic interventions on AMR through inclusion of such education modules in the regular school curriculum could be a potential tool for AMR prevention.
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Affiliation(s)
- Reona Fernandes
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India.
| | - Swathi Naik
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India.
| | - Archana-Gururaj Bhat
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India.
| | - Rashmi Shetty
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India.
| | - Manjunatha-H Hande
- Department of Medicine, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal 576104, India.
| | - Abdul Ghafur
- Infectious Diseases Department, Apollo Cancer Institute, 320 Anna Salai, Chennai 600035, India.
| | - Mahadev Rao
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India.
| | - Vijayanarayana Kunhikatta
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India.
| | - John-Preshanth-Kumar Pathiraj
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, India.
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12
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Ranjalkar J, Chandy SJ. India's National Action Plan for antimicrobial resistance - An overview of the context, status, and way ahead. J Family Med Prim Care 2019; 8:1828-1834. [PMID: 31334140 PMCID: PMC6618210 DOI: 10.4103/jfmpc.jfmpc_275_19] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Antimicrobial resistance (AMR) is a multifaceted complex problem with momentous consequences for individuals as well as health-care systems. Understanding the gravity of the problem, the World Health Assembly has adopted the Global Action Plan on AMR in the year 2015 as a part of the tripartite collaboration with World Health Organization, Food and Agricultural Organization, and World Organization for Animal Health. India's National Action Plan (NAP) for AMR was released in April 2017 by the Union Ministry of Health and Family Welfare. The objectives of the NAP include improving awareness, enhancing surveillance measures, strengthening infection prevention and control, research and development, promoting investments, and collaborative activities to control AMR. On the basis of the NAP, various states have begun the process of initiating their State Action Plans. The aim of this article is to highlight some of the main components of the NAP and to make family physicians, general practitioners, and other stakeholders aware of the issue of AMR and its factors and what can be done. The article also discusses some of the challenges in implementation of NAP such as varied perceptions about antibiotic use and AMR among key stakeholders, inappropriate antibiotic use owing to a number of reasons, lack of diagnostic facilities, widespread use of antibiotics in various sectors, environmental contamination because of pharmaceutical industry, agricultural and hospital waste, gaps in infection prevention and control, and difficulty in enforcing regulations. Similar to other low-middle income countries (LMICs), lack of sufficient finances remains a major challenge in NAP implementation in India as well. Overall, a strong political will, inter-sectoral co-ordination between public and private sectors and comprehensive strengthening of the healthcare systems are necessary to achieve the desired forward momentum.
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Affiliation(s)
- Jaya Ranjalkar
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sujith J Chandy
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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13
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Kotwani A, Joshi PC, Jhamb U, Holloway K. Prescriber and dispenser perceptions about antibiotic use in acute uncomplicated childhood diarrhea and upper respiratory tract infection in New Delhi: Qualitative study. Indian J Pharmacol 2018; 49:419-431. [PMID: 29674796 PMCID: PMC5892023 DOI: 10.4103/ijp.ijp_508_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE: The objective of the study was to explore the prescribing practices, knowledge, and attitudes of primary care doctors and community pharmacists, regarding antibiotic use in acute upper respiratory tract infections (URTI) and diarrhea in children to better understand causes of misuse and identify provider suggestions to change such behavior. MATERIALS AND METHODS: Two focus group discussions (FGDs) each were conducted with primary care government doctors (GDs), private general practitioners (GPs), pediatricians, and community pharmacists in Delhi. Each FGD had 8–12 participants and lasted 2 h. Furthermore, 22 individual face-to-face semi-structured interviews were conducted with providers of varying type and experience at their workplaces. Thematic and summative qualitative content analysis was done. RESULTS: All groups admitted to overusing antibiotics, GPs appearing to use more antibiotics than GDs and pediatricians for URTI and diarrhea in children. Pharmacists copy the prescribing of neighborhood doctors. Antimicrobial resistance (AMR) knowledge was poor for all stakeholders except pediatricians. Causes for prescribing antibiotics were patient pressure, profit motive, lack of follow-up and in addition for GDs, workload, no diagnostic facility, and pressure to use near-expiry medicines. Knowledge was gained through self-experience, copying others, information from pharmaceutical companies, and for some, training, continuous medical education/conferences. All groups blamed other professional groups/quacks for antibiotic overuse. Interventions suggested were sensitizing and empowering prescribers through training of providers and the public about the appropriate antibiotic use and AMR and implementing stricter regulations. CONCLUSIONS: A package of interventions targeting providers and consumers is urgently needed for awareness and change in behavior to reduce inappropriate community antibiotic use.
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Affiliation(s)
- Anita Kotwani
- Department of Pharmacology, V. P. Chest Institute, University of Delhi, New Delhi, India
| | - P C Joshi
- Department of Anthropology, University of Delhi, New Delhi, India
| | - Urmila Jhamb
- Department of Paediatrics, L. N. Hospital, New Delhi, India
| | - Kathleen Holloway
- Indian Institute of Health Management Research (IIHMR) University, Jaipur, Rajasthan, India.,Department of Health and Nutrition, Institute of Development Studies, University of Sussex, Brighton, UK
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14
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Yusef D, Babaa AI, Bashaireh AZ, Al-Bawayeh HH, Al-Rijjal K, Nedal M, Kailani S. Knowledge, practices & attitude toward antibiotics use and bacterial resistance in Jordan: A cross-sectional study. Infect Dis Health 2017; 23:33-40. [PMID: 30479302 DOI: 10.1016/j.idh.2017.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/04/2017] [Accepted: 11/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Antimicrobial resistance represents a significant public health problem worldwide. Irrational use of antibiotics is the main driving factor for the evolution of antimicrobials-resistant organisms. The aim of this study is to evaluate the areas of defects in the knowledge and practices of the community about antibiotic use. METHODS A cross-sectional study on a sample of 1060 randomly-selected adults residing in the North of Jordan using a pre-validated questionnaire to evaluate knowledge, practices and attitude toward antimicrobial use and misuse, as well as to assess knowledge about antimicrobial resistance. RESULTS Of all respondents, 41% (n = 437) stated that they have received oral antibiotics in the past two months, of which 38% acquired the antibiotics without a prescription. 32% of those who received antibiotics did not complete the recommended course of treatment. 39-54% of the sample population believe in common misconceptions/malpractices of antibiotics use. The majority (70%) of the respondents have not known about the term "antimicrobials resistance". Although people with higher education and higher income were generally more knowledgeable about appropriate antibiotics use and antimicrobial resistance, responses to some of the most important aspects in the assessment of knowledge showed no statistical difference between the different groups. CONCLUSIONS Our data revealed major defects in the public knowledge about appropriate antibiotics use, as well as lack of awareness on "antimicrobial resistance" problem. Awareness about appropriate antibiotic use and the serious consequences of antibiotic misuse should reach everyone in the community regardless of their educational or economic status.
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Affiliation(s)
- Dawood Yusef
- Pediatric Infectious Diseases, Jordan University of Science and Technology, King Abdullah University Hospital, Irbid, Jordan.
| | - Ahmad I Babaa
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Alaa Z Bashaireh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Kenan Al-Rijjal
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Maisa Nedal
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sajeda Kailani
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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