Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

The influence of attributes on community preferences regarding antibiotic treatment: evidence from a discrete choice model

Antibiotic resistance (AR) rates in Vietnam are among the highest in Asia, and recent infections due to multi-drug resistance in the country have caused thousands of deaths each year. This study investigated a Vietnamese community's preferences for antibiotic treatment and its knowledge and attitudes regarding antibiotics. A discrete choice experiment-based survey was developed and administered to the population of interest. The respondents were given sociodemographic-, knowledge- and attitude-related items and 17 pairs of choice tasks. Two hypothetical options were included in each choice task. Latent class analysis was conducted to determine the differences among the respondents' preferences. Among 1,014 respondents, 805 (79.4%) gave valid questionnaires. A three-latent-class model with four covariates (age, healthcare-related education or career, occupation, and attitude classifications) was used in the analysis. All five attributes significantly influenced the respondents' decisions. The majority, including young employed respondents with non-healthcare-related work or education, found treatment failure more important. Older respondents who had healthcare-related education/careers and/or appropriate antibiotic use- and antibiotics resistance-related attitudes, regarded contribution to antibiotic resistance as an important attribute in selecting antibiotic treatments. Unemployed individuals with correct knowledge identified the cost of antibiotic treatment as the most essential decision-making factor. Findings suggest minimal antibiotic impact on resistance; only 7.83% view it as amajor concern. The respondents exhibited substantial preference heterogeneity, and the general Vietnamese public had poor knowledge of and attitudes toward antibiotic use and antibiotic resistance. This study emphasizes the need for individual responsibility for antibiotic resistance and appropriate antibiotic use.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

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.

Innovation, advertising, personal selling, and sustainability in the industries massively benefited from major public health emergencies: paradoxical evidence from China

Background

While major public health emergencies have severe socio-economic impacts, they may also present many opportunities for certain industries. For these industries that have benefited significantly (e.g., China' s healthcare industry), the traditional emphasis on improving business performance through increased investment in innovation, marketing and sustainability may face contextual applicability challenges.

Methods

We used the data of healthcare industry in China during Covid-19 and the methods of hierarchical regression, moderating effect test to analyze the impact of innovation, advertising, personal selling, and sustainability on healthcare firms' profitability. Three kinds of robust test including increasing the measurement range of variables, changing the data source and parameter estimation method, and Quantile regression are used.

Results

This paper finds that innovation, advertising, and environmental sustainability have significant negative impacts on profitability, while personal selling, social sustainability, and governance sustainability have significant positive impacts on profitability in the industries massively benefited from major public health emergencies. Besides, social sustainability can significantly moderate the relationship between innovation and profitability.

Conclusion

On one hand, for companies in industries that have benefited greatly from major public health emergencies, a shift in resource allocation from innovation, advertising, and environmental sustainability to personal selling, social sustainability, and governance sustainability may be more conducive to improving their profitability. On the other hand, for public health regulatory authorities, it is necessary to strengthen the supervision of sales representatives of health care enterprises, hospitals, public health organizations, etc., and appropriately subsidize the innovation of enterprises to enhance their innovation motivation.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

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.

"If You Do Not Take the Medicine and Complete the Dose…It Could Cause You More Trouble": Bringing Awareness, Local Knowledge and Experience into Antimicrobial Stewardship in Tanzania

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action.

Chitosan Nanoparticle Encapsulation of Antibacterial Essential Oils

Chitosan is the most suitable encapsulation polymer because of its natural abundance, biodegradability, and surface functional groups in the form of free NH₂ groups. The presence of NH₂ groups allows for the facile grafting of functionalized molecules onto the chitosan surface, resulting in multifunctional materialistic applications. Quaternization of chitosan's free amino is one of the typical chemical modifications commonly achieved under acidic conditions. This quaternization improves its ionic character, making it ready for ionic-ionic surface modification. Although the cationic nature of chitosan alone exhibits antibacterial activity because of its interaction with negatively-charged bacterial membranes, the nanoscale size of chitosan further amplifies its antibiofilm activity. Additionally, the researcher used chitosan nanoparticles as polymeric materials to encapsulate antibiofilm agents (such as antibiotics and natural phytochemicals), serving as an excellent strategy to combat biofilm-based secondary infections. This paper provided a summary of available carbohydrate-based biopolymers as antibiofilm materials. Furthermore, the paper focuses on chitosan nanoparticle-based encapsulation of basil essential oil (Ocimum basilicum), mandarin essential oil (Citrus reticulata), Carum copticum essential oil ("Ajwain"), dill plant seed essential oil (Anethum graveolens), peppermint oil (Mentha piperita), green tea oil (Camellia sinensis), cardamom essential oil, clove essential oil (Eugenia caryophyllata), cumin seed essential oil (Cuminum cyminum), lemongrass essential oil (Cymbopogon commutatus), summer savory essential oil (Satureja hortensis), thyme essential oil, cinnamomum essential oil (Cinnamomum zeylanicum), and nettle essential oil (Urtica dioica). Additionally, chitosan nanoparticles are used for the encapsulation of the major essential components carvacrol and cinnamaldehyde, the encapsulation of an oil-in-water nanoemulsion of eucalyptus oil (Eucalyptus globulus), the encapsulation of a mandarin essential oil nanoemulsion, and the electrospinning nanofiber of collagen hydrolysate-chitosan with lemon balm (Melissa officinalis) and dill (Anethum graveolens) essential oil.

Antimicrobial Resistance Research Collaborations in Asia: Challenges and Opportunities to Equitable Partnerships

Antimicrobial Resistance is recognized as a major threat to global health security. The WHO Southeast Asia region is dubbed a “global hub for AMR emergence”, as it runs the highest risk for AMR emergence among all WHO regions in Asia. Hence, there is a need for Asia-centric, collaborative AMR research aligned with the true needs and priorities of the region. This study aimed to identify and understand the challenges and opportunities for such collaborative endeavors to enhance equitable partnerships. This qualitative study adopted an interpretative approach involving a thematic analysis of 15 semi-structured interviews with AMR experts conducting research in the region. The study identified several factors influencing research collaborations, such as the multi-dimensional nature of AMR, limited or lack of funds, different AMR research priorities in Asian countries, absence of Asia-centric AMR leadership, lack of trust and, unequal power relationships between researchers, and the negative impact of the COVID-19 pandemic in research collaborations. It also identified some opportunities, such as the willingness of researchers to collaborate, the formation of a few networks, and the prioritization by many academics of the One Health paradigm for framing AMR research. Participants reported that the initiation of stronger cross-discipline and cross-country networks, the development of Asia-centric AMR leadership, flexible research agendas with shared priorities, transparent and transferable funds, and support to enhance research capacity in LMICs could assist in developing more equitable collaborative research in Asia.

How conflicts of interest hinder effective regulation of healthcare: an analysis of antimicrobial use regulation in Cambodia, Indonesia and Pakistan

Background

There has been insufficient attention to a fundamental force shaping healthcare policies—conflicts of interest (COI). We investigated COI, which results in the professional judgement of a policymaker or healthcare provider being compromised by a secondary interest, in relation to antimicrobial use, thereby illuminating challenges to the regulation of medicines use more broadly. Our objectives were to characterise connections between three groups—policymakers, healthcare providers and pharmaceutical companies—that can create COI, and elucidate the impacts of COI on stages of the policy process.

Methods

Using an interpretive approach, we systematically analysed qualitative data from 136 in-depth interviews and five focus group discussions in three Asian countries with dominant private healthcare sectors: Cambodia, Indonesia and Pakistan.

Findings

We characterised four types of connections that were pervasive between the three groups: financial, political, social and familial. These connections created strong COI that could impact all stages of the policy process by: preventing issues related to medicines sales from featuring prominently on the agenda; influencing policy formulation towards softer regulatory measures; determining resource availability for, and opposition to, policy implementation; and shaping how accurately the success of contested policies is reported.

Interpretation

Our multicountry study fills a gap in empirical evidence on how COI can impede effective policies to improve the quality of healthcare. It shows that COI can be pervasive, rather than sporadic, in influencing regulation of medicine use, and highlights that, in addition to financial connections, other types of connections should be examined as important drivers of COI.

An overview of health workforce education and accreditation in Africa: implications for scaling-up capacity and quality

BACKGROUND

For countries to achieve universal health coverage, they need to have well-functioning and resilient health systems. Achieving this requires a sufficient number of qualified health workers and this necessitates the importance of investments in producing and regulating health workers. It is projected that by 2030, Africa would need additional 6.1 million doctors, nurses, and midwives. However, based on the current trajectory, only 3.1 million would be trained and ready for service delivery. To reduce current shortages of the health workforce, Africa needs to educate and train 3.0 million additional health workers by 2030. This study was conducted to describe the distribution and ownership of the health training institutions, production of health workers, and the availability of accreditation mechanisms for training programmes in the WHO African Region.

METHODS

A cross-sectional study was conducted using a standardized questionnaire from January 2018 to April 2019. All the 47 countries in the Region were invited to complete a structured questionnaire based on available secondary information from health sector reports, annual HRH reports, country health workforce profiles, and HRH observatories and registries.

RESULTS

Data from 43 countries in the World Health Organization African Region in 2018 show that there were 4001 health training institutions with 410, 1469 and 2122 being medical, health sciences, and nursing and midwifery schools, respectively, and 2221, 1359 and 421 institutions owned by the public, private for-profit and private not-for-profit sectors, respectively. A total of 148 357 health workers were produced in Region with 40% (59, 829) being nurses and midwives, 19% (28, 604) other health workers, and 14% (20 470) physicians. Overall, 31 countries (79%) in the Region have an accreditation framework for the health training institutions and seven countries do not have any accreditation mechanism.

CONCLUSION

To achieve universal health coverage, matching of competencies with population needs, as well as increasing capacities for health worker production to align with demand (numbers and skill-mix) for improved service delivery should be prioritized, as this would improve the availability of skilled health workforce in the Region.

Challenges and Innovations Brought about by the COVID-19 Pandemic Regarding Medical and Pharmacy Education Especially in Africa and Implications for the Future

BACKGROUND

Multiple measures introduced early to restrict COVID-19 have dramatically impacted the teaching of medical and pharmacy students, exacerbated by the lack of infrastructure and experience with e-learning at the start of the pandemic. In addition, the costs and reliability of the Internet across Africa pose challenges alongside undertaking clinical teaching and practical programmes. Consequently, there is a need to understand the many challenges and how these were addressed, given increasingly complex patients, to provide future direction.

METHOD

An exploratory study was conducted among senior-level medical and pharmacy educators across Africa, addressing four key questions, including the challenges resulting from the pandemic and how these were dealt with.

RESULTS

Staff and student members faced multiple challenges initially, including adapting to online learning. In addition, concerns with the lack of equipment (especially among disadvantaged students), the costs of Internet bundles, and how to conduct practicals and clinical teaching. Multiple activities were undertaken to address these challenges. These included training sessions, developing innovative approaches to teaching, and seeking ways to reduce Internet costs. Robust approaches to practicals, clinical teaching, and assessments have been developed.

CONCLUSIONS

Appreciable difficulties to teaching arising from the pandemic are being addressed across Africa. Research is ongoing to improve education and assessments.

Community pharmacies, drug stores, and antibiotic dispensing in Indonesia: a qualitative study

BACKGROUND

Inappropriate dispensing of antibiotics at community pharmacies is an important driver of antimicrobial resistance (AMR), particularly in low- and middle-income countries. Thus, a better understanding of dispensing practices is crucial to inform national, regional, and global responses to AMR. This requires careful examination of the interactions between vendors and clients, sensitive to the context in which these interactions take place.

METHODS

In 2019, we conducted a qualitative study to examine antibiotic dispensing practices and associated drivers in Indonesia, where self-medication with antibiotics purchased at community pharmacies and drug stores is widespread. Data collection involved 59 in-depth interviews with staff at pharmacies and drug stores (n = 31) and their clients (n = 28), conducted in an urban (Bekasi) and a semi-rural location (Tabalong) to capture different markets and different contexts of access to medicines. Interview transcripts were analysed using thematic content analysis.

RESULTS

A common dispensing pattern was the direct request of antibiotics by clients, who walked into pharmacies or drug stores and asked for antibiotics without prescription, either by their generic/brand name or by showing an empty package or sample. A less common pattern was recommendation to use antibiotics by the vendor after the patient presented with symptoms. Drivers of inappropriate antibiotic dispensing included poor knowledge of antibiotics and AMR, financial incentives to maximise medicine sales in an increasingly competitive market, the unintended effects of health policy reforms to make antibiotics and other essential medicines freely available to all, and weak regulatory enforcement.

CONCLUSIONS

Inappropriate dispensing of antibiotics in community pharmacies and drug stores is the outcome of complex interactions between vendors and clients, shaped by wider and changing socio-economic processes. In Indonesia, as in many other LMICs with large and informal private sectors, concerted action should be taken to engage such providers in plans to reduce AMR. This would help avert unintended effects of market competition and adverse policy outcomes, as observed in this study.

Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications

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.

Variations in regulations to control standards for training and licensing of physicians: a multi-country comparison

BACKGROUND

To strengthen health systems, the shortage of physicians globally needs to be addressed. However, efforts to increase the numbers of physicians must be balanced with controls on medical education imparted and the professionalism of doctors licensed to practise medicine.

METHODS

We conducted a multi-country comparison of mandatory regulations and voluntary guidelines to control standards for medical education, clinical training, licensing and re-licensing of doctors. We purposively selected seven case-study countries with differing health systems and income levels: Canada, China, India, Iran, Pakistan, UK and USA. Using an analytical framework to assess regulations at four sequential stages of the medical education to relicensing pathway, we extracted information from: systematically collected scientific and grey literature and online news articles, websites of regulatory bodies in study countries, and standardised input from researchers and medical professionals familiar with rules in the study countries.

RESULTS

The strictest controls we identified to reduce variations in medical training, licensing and re-licensing of doctors between different medical colleges, and across different regions within a country, include: medical education delivery restricted to public sector institutions; uniform, national examinations for medical college admission and licensing; and standardised national requirements for relicensing linked to demonstration of competence. However, countries analysed used different combinations of controls, balancing the strictness of controls across the four stages.

CONCLUSIONS

While there is no gold standard model for medical education and practise regulation, examining the combinations of controls used in different countries enables identification of innovations and regulatory approaches to address specific contextual challenges, such as decentralisation of regulations to sub-national bodies or privatisation of medical education. Looking at the full continuum from medical education to licensing is valuable to understand how countries balance the strictness of controls at different stages. Further research is needed to understand how regulating authorities, policy-makers and medical associations can find the right balance of standardisation and context-based flexibility to produce well-rounded physicians.

Antimicrobial resistance in low- and middle-income countries: current status and future directions

Introduction: Rising rates of antimicrobial resistance (AMR) globally continue to pose agrave threat to human health. Low- and middle-income countries (LMICs) are disproportionately affected, partly due to the high burden of communicable diseases.Areas covered: We reviewed current trends in AMR in LMICs and examined the forces driving AMR in those regions. The state of interventions being undertaken to curb AMR across the developing world are discussed, and the impact of the current COVID-19 pandemic on those efforts is explored.Expert opinion: The dynamics that drive AMR in LMICs are inseparable from the political, economic, socio-cultural, and environmental forces that shape these nations. The COVID-19 pandemic has further exacerbated underlying factors that increase AMR. Some progress is being made in implementing surveillance measures in LMICs, but implementation of concrete measures to meaningfully impact AMR rates must address the underlying structural issues that generate and promote AMR. This, in turn, will require large infrastructural investments and significant political will.

Public knowledge, attitudes and practices surrounding antibiotic use and resistance in Cambodia

Background

WHO's Global Action Plan on Antimicrobial Resistance includes as a priority to increase public education surrounding antibiotic use and resistance. Monitoring population-level antibiotic behaviours is crucial for informing intervention strategies, but data from a broad range of settings, particularly lower-resourced countries, are lacking.

Objectives

We measured public knowledge, attitudes and practices regarding antibiotics and antibiotic resistance in Cambodia, providing baseline information against which to monitor the progress of future interventions.

Methods

Between September and October 2018, we conducted a household survey of knowledge, attitudes and practices related to antibiotic use in urban and rural populations of three Cambodian provinces: Phnom Penh, Siem Reap and Prey Veng. Response rates were respectively 79%, 86% and 86%.

Results

Among the 2005 participants, we found high levels of awareness of terms relating to antibiotics (86.5%) and antibiotic resistance; most participants also recognized that antibiotic resistance is a problem (58.4%). However, few understood that antibiotics are effective only against bacterial infections (1.2%). We also found province-specific differences in participants' sources of antibiotics and their sources of AMR-related information. In regression analyses, more favourable antibiotic practice scores were associated with higher knowledge (β = 0.18; 95% CI: 0.14-0.22) and attitude (β = 0.16; 95% CI: 0.11-0.22) scores, as well as trust in healthcare sources to obtain antibiotics and antibiotic information.

Conclusions

This study highlights the importance of interventions and public communication on antibiotic use and resistance that is effectively targeted to the local context through trusted healthcare providers.

Response to the Novel Corona Virus (COVID-19) Pandemic Across Africa: Successes, Challenges, and Implications for the Future

BACKGROUND

The COVID-19 pandemic has already claimed considerable lives. There are major concerns in Africa due to existing high prevalence rates for both infectious and non-infectious diseases and limited resources in terms of personnel, beds and equipment. Alongside this, concerns that lockdown and other measures will have on prevention and management of other infectious diseases and non-communicable diseases (NCDs). NCDs are an increasing issue with rising morbidity and mortality rates. The World Health Organization (WHO) warns that a lack of nets and treatment could result in up to 18 million additional cases of malaria and up to 30,000 additional deaths in sub-Saharan Africa.

OBJECTIVE

Document current prevalence and mortality rates from COVID-19 alongside economic and other measures to reduce its spread and impact across Africa. In addition, suggested ways forward among all key stakeholder groups.

OUR APPROACH

Contextualise the findings from a wide range of publications including internet-based publications coupled with input from senior-level personnel.

ONGOING ACTIVITIES

Prevalence and mortality rates are currently lower in Africa than among several Western countries and the USA. This could be due to a number of factors including early instigation of lockdown and border closures, the younger age of the population, lack of robust reporting systems and as yet unidentified genetic and other factors. Innovation is accelerating to address concerns with available equipment. There are ongoing steps to address the level of misinformation and its consequences including fines. There are also ongoing initiatives across Africa to start addressing the unintended consequences of COVID-19 activities including lockdown measures and their impact on NCDs including the likely rise in mental health disorders, exacerbated by increasing stigma associated with COVID-19. Strategies include extending prescription lengths, telemedicine and encouraging vaccination. However, these need to be accelerated to prevent increased morbidity and mortality.

CONCLUSION

There are multiple activities across Africa to reduce the spread of COVID-19 and address misinformation, which can have catastrophic consequences, assisted by the WHO and others, which appear to be working in a number of countries. Research is ongoing to clarify the unintended consequences given ongoing concerns to guide future activities. Countries are learning from each other.