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Haenssgen MJ, Charoenboon N, Early A, Althaus T. Community-level incidence and treatment seeking during febrile illness: Insights from health behaviour surveys in rural Thailand and Laos. Trop Med Int Health 2023; 28:806-816. [PMID: 37605295 DOI: 10.1111/tmi.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Critical gaps remain in understanding community perceptions and treatment-seeking behaviours in case of fever. This is especially relevant considering global antimicrobial resistance, where fever is assumed to provoke non-judicious antibiotic use. Our study objective was therefore to document the community-level incidence of fever, the resulting treatment-seeking processes, and their underlying behavioural drivers. METHODS In a cross-sectional observational design, we used descriptive and inferential statistics and multivariable regression analysis to estimate the population-level incidence of fever and individual and socio-economic factors associated with treatment-seeking process characteristics. We utilised a detailed publicly available survey of community-level treatment-seeking behaviour (collected in 2017/2018), comprising a representative sample of 2130 rural adults in Thailand (Chiang Rai Province) and Lao PDR (Salavan Province). RESULTS Fever was reported by 7.1% of the rural adult population in Chiang Rai (95% CI: 5.1%-9.0%) and 7.5% in Salavan (95% CI: 4.5%-10.5%) during a 2-month recall period. Treatment-seeking patterns varied by socio-economic characteristics like precarious employment. 69.3% (95% CI: 60.8%-77.7%) of fever episodes involved access to formal (public/private) healthcare providers, 11.0% (95% CI: 4.5%-17.5%) involved informal providers, and 24.3% (95% CI: 16.6%-32.1%) took place without either formal or informal healthcare access. Febrile patients had on average 0.39 antibiotic use episodes when accessing formal healthcare settings, compared to 0.05 otherwise (p < 0.01). CONCLUSION Treatment-seeking behaviour during fever varies according to population characteristics. Clinical studies would benefit from contextualising quantitative outcomes. Treatment algorithms for non-malarial febrile illnesses should involve outreach to informal healthcare and community settings to support patients in precarious circumstances, and antibiotic resistance interventions should prioritise formal healthcare facilities.
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Affiliation(s)
- Marco J Haenssgen
- Department of Social Science and Development, Chiang Mai University, Chiang Mai, Thailand
| | - Nutcha Charoenboon
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Annabelle Early
- Global Sustainable Development, School of Cross-Faculty Studies, University of Warwick, Coventry, UK
| | - Thomas Althaus
- Centre Scientifique de Monaco, Monaco, Monaco
- Direction de l'Action Sanitaire, Monaco, Monaco
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Haenssgen MJ, Charoenboon N, Xayavong T, Althaus T. Precarity and clinical determinants of healthcare-seeking behaviour and antibiotic use in rural Laos and Thailand. BMJ Glob Health 2020; 5:e003779. [PMID: 33298471 PMCID: PMC7733127 DOI: 10.1136/bmjgh-2020-003779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The social determinants of health are a decisive yet persistently understudied area for tackling global health challenges like antimicrobial resistance (AMR). Precarity is one determinant whose importance is increasingly recognised, which we define here as 'a form of pernicious self-dependence that undermines individuals' control over their own lives and limits their ability to flexibly respond to crises'. We aimed to assess the relationship between precarity, other forms of deprivation and healthcare-seeking behaviour by asking, 'What is the impact of precarity, marginalisation and clinical presentation on healthcare-seeking behaviour?' and 'Do patients experiencing precarious livelihoods have clinically less advisable healthcare-seeking behaviour?' METHODS We used healthcare-seeking behaviour census survey data from rural Thailand and Laos, wherein five rural communities were surveyed two times over a period of 3 months (2-month recall period). Using descriptive statistical and multivariate logistic regression analysis on the illness level, we studied precarity alongside clinical presentation, marginalisation and facilitating solutions during an illness (eg, health-related phone use) as determinants of healthcare-seeking behaviour in the form of healthcare access and antibiotic use. RESULTS The data included 1421 illness episodes from 2066 villagers. Patients in precarious circumstances were up to 44.9 percentage points more likely to misuse antibiotics in the presence of situational facilitators (predicted antibiotic misuse: 6.2% (95% CI: 0.9% to 11.4%) vs 51.1% (95% CI: 16.6% to 85.5%) for precarious circumstances with/without facilitation). Marginalisation was linked to lower antibiotic use, but this did not translate into clinically more advisable behaviour. Clinical presentation played only a minor role in determining healthcare access and antibiotic use. CONCLUSIONS This study underlines the importance of context and local livelihoods in tackling drug resistance. While supporting the growing emphasis on AMR-sensitive development policy, we call for future research to study systematically the healthcare-seeking behaviour impact of precarious livelihoods, social policy and community development initiatives. TRIAL REGISTRATION NUMBER NCT03241316.
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Affiliation(s)
- Marco J Haenssgen
- Global Sustainable Development, University of Warwick, Coventry, West Midlands, UK
- Institute of Advanced Study, University of Warwick, Coventry, West Midlands, UK
| | - Nutcha Charoenboon
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Thipphaphone Xayavong
- Jacobs, Cordova & Associates, Vientiane, Vientiane Capital, Lao People's Democratic Republic
| | - Thomas Althaus
- Centre for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
- Mathematical and Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
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Evaluation of the forum theatre approach for public engagement around antibiotic use in Myanmar. PLoS One 2020; 15:e0235625. [PMID: 32645036 PMCID: PMC7347174 DOI: 10.1371/journal.pone.0235625] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/18/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The risk of emergence and spread of antibiotic resistance is high in Southeast Asian countries and various strategies are being used to raise awareness about appropriate antibiotic use and antibiotic resistance within communities. Public engagement in science has not been widely practised in Myanmar. We describe the use of a forum theatre to engage with the community about antibiotic use. METHODS The engagement activities took place in a peri-urban township in Yangon, Myanmar. Five preliminary story gathering workshops with the community were carried out to develop scripts and songs for the forum theatre. After that, we organised forum theatre plays between September and October 2018. Following each play we provided four simple key messages based on WHO's world antibiotic awareness week advocacy materials; 1) Antibiotics are medicines used to treat bacterial infections 2) Antibiotics are not useful for coughs and colds 3) Never use leftover antibiotics or share antibiotics with others 4) Prevent infections by regularly washing hands, preparing food hygienically, avoiding close contact with sick people, and keeping vaccinations up to date. We evaluated the engagement activities by conducting focus group discussions (FGD) with audience members. RESULTS Ten forum theatre plays were performed on two topics; "Fever and antibiotics" and "Mixed medicines", reaching 1175 community members. Four themes emerged from our thematic analysis: 1) Knowledge dissemination, 2) Enjoyment and fun, 3) Willingness to support and recommendations for future engagement activities and 4) Preference over traditional methods of health education. We found improvement of antibiotic related knowledge and enjoyment among audience who were also willing to support future engagement activities and preferred forum theatre approach over formal health talks. CONCLUSIONS We conclude that forum theatre is an effective innovative approach to engage and disseminate knowledge on appropriate use of antibiotics with the community in a participatory way.
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van Hecke O, Butler C, Mendelson M, Tonkin-Crine S. Introducing new point-of-care tests for common infections in publicly funded clinics in South Africa: a qualitative study with primary care clinicians. BMJ Open 2019; 9:e029260. [PMID: 31772084 PMCID: PMC6887073 DOI: 10.1136/bmjopen-2019-029260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
UNLABELLED Broad-spectrum antibiotics are routinely prescribed empirically in the resource-poor settings for suspected acute common infections, which drive antimicrobial resistance. Point-of-care testing (POCT) might increase the appropriateness of decisions about whether and which antibiotic to prescribe, but implementation will be most effective if clinician's perspectives are taken into account. OBJECTIVES To explore the perceptions of South African primary care clinicians working in publicly funded clinics about: making antibiotic prescribing decisions for two common infection syndromes (acute cough, urinary tract infection); their experiences of existing POCTs; their perceptions of the barriers and opportunities for introducing (hypothetical) new POCTs. DESIGN, METHOD, PARTICIPANTS, SETTING Qualitative semistructured interviews with 23 primary care clinicians (nurses and doctors) at publicly funded clinics in the Western Cape Metro district, South Africa. Data were analysed using thematic analysis. RESULTS Clinicians reported that their antibiotic prescribing decisions were influenced by their clinical assessment, patient comorbidities, social factors (eg, access to care) and perceived patient expectations. Their experiences with currently available POCTs were largely positive, and they were optimistic about the potential for new POCTs to: support evidence-based prescribing decisions that might reduce unnecessary antibiotic prescriptions; reduce the need for further investigations; support effective communication with patients, especially when antibiotics were unlikely to be of benefit. Resources and workflow disruption were seen as the main barriers to uptake into routine care. CONCLUSIONS Clinicians working in publicly funded clinics in the Western Cape Metro of South Africa saw POCTs as potentially useful for positively addressing both clinical and social drivers of the overprescribing of broad-spectrum antibiotics, but were concerned about the resource implications and disruption of existing patient workflows.
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Affiliation(s)
- Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Haenssgen MJ, Charoenboon N, Zanello G, Mayxay M, Reed-Tsochas F, Lubell Y, Wertheim H, Lienert J, Xayavong T, Khine Zaw Y, Thepkhamkong A, Sithongdeng N, Khamsoukthavong N, Phanthavong C, Boualaiseng S, Vongsavang S, Wibunjak K, Chai-In P, Thavethanutthanawin P, Althaus T, Greer RC, Nedsuwan S, Wangrangsimakul T, Limmathurotsakul D, Elliott E, Ariana P. Antibiotic knowledge, attitudes and practices: new insights from cross-sectional rural health behaviour surveys in low-income and middle-income South-East Asia. BMJ Open 2019; 9:e028224. [PMID: 31434769 PMCID: PMC6707701 DOI: 10.1136/bmjopen-2018-028224] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/20/2019] [Accepted: 07/22/2019] [Indexed: 12/12/2022] Open
Abstract
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<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% 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.
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Affiliation(s)
- Marco J Haenssgen
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
- School of Cross Faculty Studies, University of Warwick, Coventry, UK
- Green Templeton College, Oxford, United Kingdom
- Said Business School, University of Oxford, Oxford, UK
| | - Nutcha Charoenboon
- Mathematical/Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Giacomo Zanello
- School of Agriculture, Policy and Development, University of Reading, Reading, UK
- Leverhulme Centre for Integrative Research on Agriculture and Health, London, London, UK
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Vientiane, Laos
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos
- Institute of Research and Education Development, University of Health Sciences, Vientiane, Laos
| | - Felix Reed-Tsochas
- Green Templeton College, Oxford, United Kingdom
- Said Business School, University of Oxford, Oxford, UK
- Oxford Martin School, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
- Mathematical/Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Heiman Wertheim
- Medical Microbiology Department, Radbuod University, Nijmegen, The Netherlands
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Jeffrey Lienert
- Green Templeton College, Oxford, United Kingdom
- Said Business School, University of Oxford, Oxford, UK
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Thipphaphone Xayavong
- Department of Peace and Conflict Studies, University for Peace, Ciudad Colon, Costa Rica
- Department of Political Science, Ateneo de Manila University, Quezon City, Philippines
| | - Yuzana Khine Zaw
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Amphayvone Thepkhamkong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Vientiane, Laos
| | - Nicksan Sithongdeng
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Vientiane, Laos
| | - Nid Khamsoukthavong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Vientiane, Laos
| | - Chanthasone Phanthavong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Vientiane, Laos
| | - Somsanith Boualaiseng
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Vientiane, Laos
| | - Souksakhone Vongsavang
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Vientiane, Laos
| | - Kanokporn Wibunjak
- Mathematical/Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Poowadon Chai-In
- Mathematical/Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Thomas Althaus
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
- Mathematical/Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Rachel Claire Greer
- Mathematical/Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Chiangrai Clinical Research Unit, Chiangrai Regional Hospital, Chiang Rai, Thailand
| | - Supalert Nedsuwan
- Primary Care Department, Chiangrai Regional Hospital, Chiang Rai, Thailand
| | - Tri Wangrangsimakul
- Chiangrai Clinical Research Unit, Chiangrai Regional Hospital, Chiang Rai, Thailand
- Microbiology, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Elizabeth Elliott
- UCL Anthropology, University College London, London, UK
- Institut de recherche pour le développement, Vientiane, Laos
| | - Proochista Ariana
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
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Haenssgen MJ, Charoenboon N, Do NTT, Althaus T, Khine Zaw Y, Wertheim HFL, Lubell Y. How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions. Trials 2019; 20:111. [PMID: 30736818 PMCID: PMC6368827 DOI: 10.1186/s13063-019-3215-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 01/19/2019] [Indexed: 11/10/2022] Open
Abstract
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. Electronic supplementary material The online version of this article (10.1186/s13063-019-3215-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco J Haenssgen
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK. .,CABDyN Complexity Centre, Saïd Business School, University of Oxford, Park End Street, Oxford, OX1 1HP, UK. .,Global Sustainable Development, University of Warwick, Ramphal Building, Coventry, CV4 7AM, UK. .,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.
| | - Nutcha Charoenboon
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Nga T T Do
- Oxford University Clinical Research Unit (OUCRU), National Hospital for Tropical Diseases, 78 Giai Phong Street, Hanoi, Vietnam
| | - Thomas Althaus
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Yuzana Khine Zaw
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Heiman F L Wertheim
- Oxford University Clinical Research Unit (OUCRU), National Hospital for Tropical Diseases, 78 Giai Phong Street, Hanoi, Vietnam.,Medical Microbiology Department, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, 6525, Netherlands
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
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Althaus T, Greer RC, Swe MMM, Cohen J, Tun NN, Heaton J, Nedsuwan S, Intralawan D, Sumpradit N, Dittrich S, Doran Z, Waithira N, Thu HM, Win H, Thaipadungpanit J, Srilohasin P, Mukaka M, Smit PW, Charoenboon EN, Haenssgen MJ, Wangrangsimakul T, Blacksell S, Limmathurotsakul D, Day N, Smithuis F, Lubell Y. Effect of point-of-care C-reactive protein testing on antibiotic prescription in febrile patients attending primary care in Thailand and Myanmar: an open-label, randomised, controlled trial. Lancet Glob Health 2019; 7:e119-e131. [PMID: 30554748 PMCID: PMC6293968 DOI: 10.1016/s2214-109x(18)30444-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/27/2018] [Accepted: 09/15/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In southeast Asia, antibiotic prescription in febrile patients attending primary care is common, and a probable contributor to the high burden of antimicrobial resistance. The objective of this trial was to explore whether C-reactive protein (CRP) testing at point of care could rationalise antibiotic prescription in primary care, comparing two proposed thresholds to classify CRP concentrations as low or high to guide antibiotic treatment. METHODS We did a multicentre, open-label, randomised, controlled trial in participants aged at least 1 year with a documented fever or a chief complaint of fever (regardless of previous antibiotic intake and comorbidities other than malignancies) recruited from six public primary care units in Thailand and three primary care clinics and one outpatient department in Myanmar. Individuals were randomly assigned using a computer-based randomisation system at a ratio of 1:1:1 to either the control group or one of two CRP testing groups, which used thresholds of 20 mg/L (group A) or 40 mg/L CRP (group B) to guide antibiotic prescription. Health-care providers were masked to allocation between the two intervention groups but not to the control group. The primary outcome was the prescription of any antibiotic from day 0 to day 5 and the proportion of patients who were prescribed an antibiotic when CRP concentrations were above and below the 20 mg/L or 40 mg/L thresholds. The primary outcome was analysed in the intention-to-treat and per-protocol populations. The trial is registered with ClinicalTrials.gov, number NCT02758821, and is now completed. FINDINGS Between June 8, 2016, and Aug 25, 2017, we recruited 2410 patients, of whom 803 patients were randomly assigned to CRP group A, 800 to CRP group B, and 807 to the control group. 598 patients in CRP group A, 593 in CRP group B, and 767 in the control group had follow-up data for both day 5 and day 14 and had been prescribed antibiotics (or not) in accordance with test results (per-protocol population). During the trial, 318 (39%) of 807 patients in the control group were prescribed an antibiotic by day 5, compared with 290 (36%) of 803 patients in CRP group A and 275 (34%) of 800 in CRP group B. The adjusted odds ratio (aOR) of 0·80 (95% CI 0·65-0·98) and risk difference of -5·0 percentage points (95% CI -9·7 to -0·3) between group B and the control group were significant, although lower than anticipated, whereas the reduction in prescribing in group A compared with the control group was not significant (aOR 0·86 [0·70-1·06]; risk difference -3·3 percentage points [-8·0 to 1·4]). Patients with high CRP concentrations in both intervention groups were more likely to be prescribed an antibiotic than in the control group (CRP ≥20 mg/L: group A vs control group, p<0·0001; CRP ≥40 mg/L: group B vs control group, p<0·0001), and those with low CRP concentrations were more likely to have an antibiotic withheld (CRP <20 mg/L: group A vs control group, p<0·0001; CRP <40 mg/L: group B vs control group, p<0·0001). 24 serious adverse events were recorded, consisting of 23 hospital admissions and one death, which occurred in CRP group A. Only one serious adverse event was thought to be possibly related to the study (a hospital admission in CRP group A). INTERPRETATION In febrile patients attending primary care, testing for CRP at point of care with a threshold of 40 mg/L resulted in a modest but significant reduction in antibiotic prescribing, with patients with high CRP being more likely to be prescribed an antibiotic, and no evidence of a difference in clinical outcomes. This study extends the evidence base from lower-income settings supporting the use of CRP tests to rationalise antibiotic use in primary care patients with an acute febrile illness. A key limitation of this study is the individual rather than cluster randomised study design which might have resulted in contamination between the study groups, reducing the effect size of the intervention. FUNDING Wellcome Trust Institutional Strategic Support Fund grant (105605/Z/14/Z) and Foundation for Innovative New Diagnostics (FIND) funding from the Australian Government.
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Affiliation(s)
- Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Rachel C Greer
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Myo Maung Maung Swe
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Medical Action Myanmar, Yangon, Myanmar
| | - Joshua Cohen
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Medical Action Myanmar, Yangon, Myanmar
| | - Ni Ni Tun
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Medical Action Myanmar, Yangon, Myanmar
| | - James Heaton
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Medical Action Myanmar, Yangon, Myanmar
| | - Supalert Nedsuwan
- Primary Care Department, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | - Daranee Intralawan
- Primary Care Department, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | - Nithima Sumpradit
- Thai Food and Drug Administration, Ministry of Public Health, Bangkok, Thailand
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Zoë Doran
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Naomi Waithira
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Han Win
- Department of Medical Research, Yangon, Myanmar
| | - Janjira Thaipadungpanit
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prapaporn Srilohasin
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mavuto Mukaka
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Pieter W Smit
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ern Nutcha Charoenboon
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marco Johannes Haenssgen
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Tri Wangrangsimakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Stuart Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Frank Smithuis
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in Northern Thailand. Soc Sci Med 2018; 202:1-12. [PMID: 29499522 PMCID: PMC5910303 DOI: 10.1016/j.socscimed.2018.02.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 02/17/2018] [Accepted: 02/20/2018] [Indexed: 11/24/2022]
Abstract
New and affordable point-of-care testing (POCT) solutions are hoped to guide antibiotic prescription and to help limit antimicrobial resistance (AMR)—especially in low- and middle-income countries where resource constraints often prevent extensive diagnostic testing. Anthropological and sociological research has illuminated the role and impact of rapid point-of-care malaria testing. This paper expands our knowledge about the social implications of non-malarial POCT, using the case study of a C-reactive-protein point-of-care testing (CRP POCT) clinical trial with febrile patients at primary-care-level health centres in Chiang Rai province, northern Thailand. We investigate the social role of CRP POCT through its interactions with (a) the healthcare workers who use it, (b) the patients whose routine care is affected by the test, and (c) the existing patient-health system linkages that might resonate or interfere with CRP POCT. We conduct a thematic analysis of data from 58 purposively sampled pre- and post-intervention patients and healthcare workers in August 2016 and May 2017. We find widespread positive attitudes towards the test among patients and healthcare workers. Patients’ views are influenced by an understanding of CRP POCT as a comprehensive blood test that provides specific diagnosis and that corresponds to notions of good care. Healthcare workers use the test to support their negotiations with patients but also to legitimise ethical decisions in an increasingly restrictive antibiotic policy environment. We hypothesise that CRP POCT could entail greater patient adherence to recommended antibiotic treatment, but it could also encourage riskier health behaviour and entail potentially adverse equity implications for patients across generations and socioeconomic strata. Our empirical findings inform the clinical literature on increasingly propagated point-of-care biomarker tests to guide antibiotic prescriptions, and we contribute to the anthropological and sociological literature through a novel conceptualisation of the patient-health system interface as an activity space into which biomarker testing is introduced. Novel social research contribution to the study of antimicrobial resistance. Examines increasingly popular diagnostic point-of-care testing (POCT). Analyses POCT introduction at the patient – health system interface. Reveals interferences of test with patient and health worker behaviour. Provides evidence of un-/intended behavioural effects of point-of-care tests.
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