Determinants of household safe drinking water practices in Kabul, Afghanistan: New insights from behavioural survey data

More than 2 billion people worldwide lack access to safe drinking water. Household water treatment (HWT) is an interim option for reducing the risk of water born disease. Understanding the factors that influence HWT behaviour is crucial for delivering successful interventions aimed at scaling relevant technologies, but the literature tends to emphasise psychological determinants with little consideration of socioeconomic and contextual factors. This article responds to this literature by using the COM-B model to examine the determinants of HWT practices through a comprehensive and context-sensitive behaviour definition. We informed this model through a cross-sectional survey design in which we collected data from 913 households in two peri‑urban neighbourhoods of Kabul, Afghanistan. Our findings from descriptive statistical and regression analysis highlight the importance of not only psychological but also socio-economic and contextual determinants of HWT behaviour: Especially the COM-B dimensions of reflective and automatic motivation, and physical opportunity - which are heavily influenced by local context and economic circumstances - had statistically significant associations with performing HWT. The practical significance of these dimensions was similarly pronounced. For example, an increase in the physical opportunity index by 0.1 units from an average value of 0.7 to 0.8 would be associated with a 7.7 percentage-point higher likelihood of HWT performance. These results suggest that the COM-B model can be utilised to systematically design interventions aimed at promoting HWT practices, while highlighting the need to broaden behavioural analyses of HWT and consider contextual factors to develop interventions that are tailored to the specific needs and obstacles of different communities.

Community-level incidence and treatment seeking during febrile illness: Insights from health behaviour surveys in rural Thailand and Laos

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.

Tales of treatment and new perspectives for global health research on antimicrobial resistance

Global health champions modernism and biomedical knowledge but tends to neglect knowledge, beliefs and identities of rural communities in low-income and middle-income countries. The topic of antimicrobial resistance represents these common challenges, wherein the growing emphasis on public engagement offers a yet underdeveloped opportunity to generate perspectives and forms of knowledge that are not typically incorporated into research and policy. The medical humanities as an interdisciplinary approach to illness and health behaviour play a central role in cultivating this potential-in particular, through the field's emphasis on phenomenological and intersubjective approaches to knowledge generation and its interest in dialogue between medicine, the humanities and the broader public.We present a case study of public engagement that incorporates three medical humanities methods: participatory co-production, photographic storytelling and dialogue between researchers and the public. Situated in the context of northern Thailand, we explore subcases on co-production workshops with villagers, tales of treatment shared by traditional healers and dialogue surrounding artistic display in an international photo exhibition. Our starting assumption for the case study analysis was that co-produced local inputs can (and should) broaden the understanding of the sociocultural context of antimicrobial resistance.Our case study illustrates the potential of medical humanities methods in public engagement to foreground cultural knowledge, personal experience and 'lay' sensemaking surrounding health systems and healing (including medicine use). Among others, the engagement activities enabled us to formulate and test locally grounded hypotheses, gain new insights into the social configuration of treatment seeking and reflect on the relationship between traditional healing and modern medicine in the context of antimicrobial resistance. We conclude that medical-humanities-informed forms of public engagement should become a standard component of global health research, but they require extensive evaluation to assess benefits and risks comprehensively.

Impact and effect mechanisms of mass campaigns in resource-constrained health systems: quasi-experimental evidence from polio eradication in Nigeria

Background

Mass campaigns are a key strategy for delivering life-saving interventions under Global Health Initiatives, especially in weak health system contexts. They are frequently designed parallel to the health system to rapidly achieve programme targets such as vaccination coverage, but we lack quantitative evidence demonstrating their impact and effect mechanisms on health system performance at sub-/national level. This longitudinal study responds to this gap through an analysis of polio eradication campaigns in Nigeria.

Methods

Using four rounds of Demographic and Health Surveys in Nigeria between October 2000 and December 2017, we created a longitudinal dataset containing 88 881 under-5 children/pregnancies. We estimated the relationships between individuals’ campaign exposure and health system performance indices (full RI schedule attainment, maternal healthcare services utilisation and child survival) using multilevel, mixed-effects regression models applied nationally and stratified by the six geopolitical zones in Nigeria.

Results

Nationally, high-frequency mass campaigns had detrimental health systems effects that potentially left 3.6 million children deprived of full immunisation. The frequency of campaigns was most concentrated in regions with weak health systems, where the operations of RI were disrupted, alongside negative effects on child survival and institutional delivery. In contrast, regions with relatively strong health systems and few campaigns experienced beneficial effects on maternal healthcare service utilisation.

Conclusions

As we provide evidence that well-functioning health systems can benefit from mass campaigns under Global Health Initiatives, our work also challenges the established wisdom to intensify mass campaigns in weaker health systems to bypass service provision bottlenecks. Mass campaigns do not inherently benefit or damage a health system, but frequent campaigns in weak health system contexts can impede service provision. We call for an additional burden of proof and active efforts to integrate mass campaigns into routine health services by harmonising implementation plans and service delivery in weak health system contexts.

Precarity and clinical determinants of healthcare-seeking behaviour and antibiotic use in rural Laos and Thailand

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.

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

INTRODUCTION

Low-income and middle-income countries (LMICs) are crucial in the global response to antimicrobial resistance (AMR), but diverse health systems, healthcare practices and cultural conceptions of medicine can complicate global education and awareness-raising campaigns. Social research can help understand LMIC contexts but remains under-represented in AMR research.

OBJECTIVE

To (1) Describe antibiotic-related knowledge, attitudes and practices of the general population in two LMICs. (2) Assess the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers.

DESIGN

Observational study: cross-sectional rural health behaviour survey, representative of the population level.

SETTING

General rural population in Chiang Rai (Thailand) and Salavan (Lao PDR), surveyed between November 2017 and May 2018.

PARTICIPANTS

2141 adult members (≥18 years) of the general rural population, representing 712 000 villagers.

OUTCOME MEASURES

Antibiotic-related knowledge, attitudes and practices across sites and healthcare access channels.

FINDINGS

Villagers were aware of antibiotics (Chiang Rai: 95.7%; Salavan: 86.4%; p<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.

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

Background

Context matters for the successful implementation of medical interventions, but its role remains surprisingly understudied. Against the backdrop of antimicrobial resistance, a global health priority, we investigated the introduction of a rapid diagnostic biomarker test (C-reactive protein, or CRP) to guide antibiotic prescriptions in outpatient settings and asked, “Which factors account for cross-country variations in the effectiveness of CRP biomarker test interventions?”

Methods

We conducted a cross-case comparison of CRP point-of-care test trials across Yangon (Myanmar), Chiang Rai (Thailand), and Hanoi (Vietnam). Cross-sectional qualitative data were originally collected as part of each clinical trial to broaden their evidence base and help explain their respective results. We synthesised these data and developed a large qualitative data set comprising 130 interview and focus group participants (healthcare workers and patients) and nearly one million words worth of transcripts and interview notes. Inductive thematic analysis was used to identify contextual factors and compare them across the three case studies. As clinical trial outcomes, we considered patients’ and healthcare workers’ adherence to the biomarker test results, and patient exclusion to gauge the potential “impact” of CRP point-of-care testing on the population level.

Results

We identified three principal domains of contextual influences on intervention effectiveness. First, perceived risks from infectious diseases influenced the adherence of the clinical users (nurses, doctors). Second, the health system context related to all three intervention outcomes (via the health policy and antibiotic policy environment, and via health system structures and the ensuing utilisation patterns). Third, the demand-side context influenced the patient adherence to CRP point-of-care tests and exclusion from the intervention through variations in local healthcare-seeking behaviours, popular conceptions of illness and medicine, and the resulting utilisation of the health system.

Conclusions

Our study underscored the importance of contextual variation for the interpretation of clinical trial findings. Further research should investigate the range and magnitude of contextual effects on trial outcomes through meta-analyses of large sets of clinical trials. For this to be possible, clinical trials should collect qualitative and quantitative contextual information for instance on their disease, health system, and demand-side environment.

Trial registration

ClinicalTrials.gov, NCT02758821 registered on 3 May 2016 and NCT01918579 registered on 7 August 2013.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3215-9) contains supplementary material, which is available to authorized users.

New impulses from international development for more comprehensive and balanced public engagement evaluation

Public engagement in health research has gained popularity because of its potential to co-create knowledge, generate dialogue, and ground research in the priorities and realities of the target groups. However, public engagement that achieves these objectives could still entail unforeseen negative consequences or a wasteful use of resources. Although the evaluation of public engagement has evolved in recent years, we lack consistent evaluation criteria for systematic and transparent assessments of success and failure. This article introduces standard evaluation criteria from the field of development aid evaluation (effectiveness, efficiency, impact, relevance, sustainability) to promote more systematic and comprehensive evaluation practice. I apply these criteria to the public engagement component of a recent research project into antimicrobial resistance, antibiotic use, and health behaviour in Thailand and Laos. Considering village-level engagement workshops, international exhibitions of photo narratives of traditional healing in northern Thailand, and social media communication, I demonstrate that activities that seem to achieve their objectives can still have problematic characteristics in other dimensions. I conclude that these five generic evaluation criteria can broaden our understanding of public engagement. Their more widespread use in evaluations can help build a more comprehensive and balanced evidence base, even if only a sample of public engagement projects and programmes can be evaluated systematically.

A Comparison of Patients' Local Conceptions of Illness and Medicines in the Context of C-Reactive Protein Biomarker Testing in Chiang Rai and Yangon

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

Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion

BACKGROUND

Antimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people's antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients' healthcare-seeking pathways?RQ2: Will people's exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities?

METHODS

We apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1-3), social network analysis (RQ2) and latent class analysis (RQ3).

DISCUSSION

Social research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour.

TRIAL REGISTRATION NUMBER

NCT03241316; Pre-results.

Impact of high-intensity polio eradication activities on children's routine immunization status in Northern India

The objective of this article is to analyse and quantify the side effects of the Polio Eradication Initiative on routine immunization performance in India. Past studies have faced methodological challenges in assessing these side effects. This article offers a methodological alternative for health policy analysts. The research uses secondary household survey data from the Indian District-Level Household and Facility Survey (DLHS), focusing on children aged 10-30 months in the Northern Indian states of Uttar Pradesh (n = 34 327) and Bihar (n = 20 525). Covering the years 2002-08, this is the latest large-scale data from India that enables the matching technique used in this article. District-level programme intensity data of the Polio Eradication Initiative in India were reconstructed using publicly available resources. The methodological innovation compared with previous studies consists of matching each child in the DLHS data set with a child-specific value of programme exposure depending on its district of residence, its birth date, and the date of the survey interview. Average and age-specific associations between polio programme exposure and children's full immunization status were assessed using logistic regression, controlling for other determinants of immunization. The regression results show that the link is negative in Uttar Pradesh and positive in Bihar. Age-specific analysis shows that the positive association diminishes for older children in Bihar and that a negative association emerges and becomes increasingly pronounced for older children in Uttar Pradesh. This indicates that heterogeneous results emerge across two neighbouring states with similar programme intensity and suggests that the catch-up of unvaccinated older children may be a channel through which negative effects accrue. The method described in this article, based on an analytical focus on individual-level programme exposure, can therefore help health policy implementers and evaluators to illuminate positive or negative interactions between a health intervention and a health system.

Healthcare access: A sequence-sensitive approach

It is widely accepted that healthcare-seeking behaviour is neither limited to nor terminated by access to one single healthcare provider. Yet the sequential conceptualisation of healthcare-seeking processes has not diffused into quantitative research, which continues to analyse healthcare access as a "one-off" event. The ensuing lack of understanding healthcare behaviour is problematic in light of the immense burden of premature death especially in low- and middle-income countries. This paper presents an alternative approach. Based on a novel survey instrument, we analyse original survey data from rural India and China that contain 119 unique healthcare pathways among 637 respondents. We offer three applications of how such sequential data can be analysed to enhance our understanding of people's health behaviour. First, descriptive analysis of sequential data enables more a comprehensive representation of people's health behaviours, for example the time spent in various healthcare activities, common healthcare pathways across different groups, or shifts in healthcare provider access during a typical illness. Second, by analysing the effect of mobile technology on healthcare-seeking process characteristics, we demonstrate that conventional, sequence-insensitive indicators are potentially inconsistent and misleading approximations when compared to a more precise, sequence-sensitive measure. Third, we describe how sequential data enable transparent and flexible evaluations of people's healthcare behaviour. The example of a sequence-insensitive evaluation suggests that household wealth has no statistical link to an illustrative "ideal" form of public healthcare utilisation. In contrast, sequence-sensitive evaluations demonstrate that household wealth is associated with an increased likelihood of bypassing referral processes and approaching unregulated and costly informal and private practitioners before accessing a public clinic. Sequential data therefore do not only reveal otherwise neglected locational idiosyncrasies, but they also yield deeper insights into the drivers of people's health behaviours compared to a conventional approach to "access to healthcare."

Satellite-aided survey sampling and implementation in low- and middle-income contexts: a low-cost/low-tech alternative

Background

The increasing availability of online maps, satellite imagery, and digital technology can ease common constraints of survey sampling in low- and middle-income countries. However, existing approaches require specialised software and user skills, professional GPS equipment, and/or commercial data sources; they tend to neglect spatial sampling considerations when using satellite maps; and they continue to face implementation challenges analogous to conventional survey implementation methods. This paper presents an alternative way of utilising satellite maps and digital aides that aims to address these challenges.

Results

The case studies of two rural household surveys in Rajasthan (India) and Gansu (China) compare conventional survey sampling and implementation techniques with the use of online map services such as Google, Bing, and HERE maps. Modern yet basic digital technology can be integrated into the processes of preparing, implementing, and monitoring a rural household survey. Satellite-aided systematic random sampling enhanced the spatial representativeness of the village samples and entailed savings of approximately £4000 compared to conventional household listing, while reducing the duration of the main survey by at least 25 %.

Conclusion

This low-cost/low-tech satellite-aided survey sampling approach can be useful for student researchers and resource-constrained research projects operating in low- and middle-income contexts with high survey implementation costs. While achieving transparent and efficient survey implementation at low costs, researchers aiming to adopt a similar process should be aware of the locational, technical, and logistical requirements as well as the methodological challenges of this strategy.