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Alhusein N, Charoenboon N, Wichuwaranan K, Poonsawad K, Montrivade V, Avison MB, Sringernyuang L, Lambert H. The unseen use of antimicrobials: Drivers of human antibiotic use in a community in Thailand and implications for surveillance. Glob Public Health 2024; 19:2298940. [PMID: 38190612 DOI: 10.1080/17441692.2023.2298940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024]
Abstract
We investigated sociocultural and economic drivers of human antimicrobial use (AMU) in Thailand through ethnographic research, interviews, focus groups and a cross-sectional survey. This community-based study generated findings clustered around three key themes: treatment-seeking practices, medicine use, and interpretation of biomedical constructs. Participants sought care from public health facilities for chronic conditions, but medicines from the private sector were considered more powerful and were preferred for acute complaints. Many antibiotics were unrecognised as such by consumers due to the practice at private healthcare facilities of dispensing repackaged medicines without identifying labels. This unseen use of antibiotics is probably driven by economic drivers including market competition in the private sector, policy implementation drivers whereby rational drug use policies mainly target the public sector, behavioural drivers relating to treatment seeking-practices, and sociocultural drivers that influenced participants' understanding of medical terms and concepts. Participants regarded antibiotics as reducing inflammation and were uncertain about the distinctions between anti-inflammatories, antibiotics, and pain relievers. Antimicrobial Resistance (AMR) was understood as a form of drug tolerance to be remedied by changing the medicine. Community surveys may not provide accurate estimates of AMU where people are unable to distinguish antibiotics reliably from other medicines.
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Affiliation(s)
- Nour Alhusein
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nutcha Charoenboon
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kantima Wichuwaranan
- Faculty of Social Science and Humanities, Mahidol University, Nakhon Pathom, Thailand
| | - Kornrawan Poonsawad
- Faculty of Social Science and Humanities, Mahidol University, Nakhon Pathom, Thailand
| | - Varapon Montrivade
- Faculty of Social Science and Humanities, Mahidol University, Nakhon Pathom, Thailand
| | - Matthew B Avison
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Luechai Sringernyuang
- Faculty of Social Science and Humanities, Mahidol University, Nakhon Pathom, Thailand
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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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] [What about the content of this article? (0)] [Affiliation(s)] [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, Thavethanutthanawin P, Wibunjak K. Tales of treatment and new perspectives for global health research on antimicrobial resistance. Med Humanit 2021; 47:e10. [PMID: 32948667 PMCID: PMC8639946 DOI: 10.1136/medhum-2020-011894] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 05/06/2023]
Abstract
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.
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Affiliation(s)
- Marco J Haenssgen
- Global Sustainable Development, University of Warwick, Coventry, UK
- Institute of Advanced Study, University of Warwick, Coventry, West Midlands, UK
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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, Khine Zaw Y. It is time to give social research a voice to tackle antimicrobial resistance? J Antimicrob Chemother 2019; 73:1112-1113. [PMID: 29361004 DOI: 10.1093/jac/dkx533] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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.,Green Templeton College, 43 Woodstock Road, Oxford OX2 6HG, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 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, 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, Thailand.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Khine Zaw Y, Charoenboon N, Haenssgen MJ, Lubell Y. A Comparison of Patients' Local Conceptions of Illness and Medicines in the Context of C-Reactive Protein Biomarker Testing in Chiang Rai and Yangon. Am J Trop Med Hyg 2018; 98:1661-1670. [PMID: 29633689 PMCID: PMC6086164 DOI: 10.4269/ajtmh.17-0906] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
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.
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Affiliation(s)
- Yuzana Khine Zaw
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nutcha Charoenboon
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marco J Haenssgen
- CABDyN Complexity Centre, Saïd Business School, University of Oxford, Oxford, United Kingdom.,Green Templeton College, United Kingdom.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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Haenssgen MJ, Charoenboon N, Zanello G, Mayxay M, Reed-Tsochas F, Jones COH, Kosaikanont R, Praphattong P, Manohan P, Lubell Y, Newton PN, Keomany S, Wertheim HFL, Lienert J, Xayavong T, Warapikuptanun P, Khine Zaw Y, U-Thong P, Benjaroon P, Sangkham N, Wibunjak K, Chai-In P, Chailert S, Thavethanutthanawin P, Promsutt K, Thepkhamkong A, Sithongdeng N, Keovilayvanh M, Khamsoukthavong N, Phanthasomchit P, Phanthavong C, Boualaiseng S, Vongsavang S, Greer RC, Althaus T, Nedsuwan S, Intralawan D, Wangrangsimakul T, Limmathurotsakul D, Ariana P. Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion. BMJ Glob Health 2018; 3:e000621. [PMID: 29629190 PMCID: PMC5884330 DOI: 10.1136/bmjgh-2017-000621] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 02/01/2018] [Accepted: 02/14/2018] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Marco J Haenssgen
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- CABDyN Complexity Centre, Saïd Business School, University of Oxford, Oxford, UK
- Green Templeton College, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nutcha Charoenboon
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Giacomo Zanello
- School of Agriculture, Policy and Development, University of Reading, Reading, UK
| | - Mayfong Mayxay
- Lao Oxford Mahosot Wellcome Trust Research Unit (LOMWRU), Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos
| | - Felix Reed-Tsochas
- CABDyN Complexity Centre, Saïd Business School, University of Oxford, Oxford, UK
- Institute for New Economic Thinking, Oxford Martin School, University of Oxford, Oxford, UK
- Department of Sociology, University of Oxford, Oxford, UK
| | - Caroline O H Jones
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Department of Health System and Research Ethics, KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | - Romyen Kosaikanont
- School of Social Innovation, Mae Fah Luang University, Chiang Rai, Thailand
| | | | - Pathompong Manohan
- School of Social Innovation, Mae Fah Luang University, Chiang Rai, Thailand
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul N Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao Oxford Mahosot Wellcome Trust Research Unit (LOMWRU), Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Heiman F L Wertheim
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Medical Microbiology Department, Radboudumc, Nijmegen, The Netherlands
| | - Jeffrey Lienert
- CABDyN Complexity Centre, Saïd Business School, University of Oxford, Oxford, UK
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Thipphaphone Xayavong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Penporn Warapikuptanun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Yuzana Khine Zaw
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Patchapoom U-Thong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Patipat Benjaroon
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Narinnira Sangkham
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kanokporn Wibunjak
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Poowadon Chai-In
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sirirat Chailert
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Krittanon Promsutt
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Amphayvone Thepkhamkong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicksan Sithongdeng
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Maipheth Keovilayvanh
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nid Khamsoukthavong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Phaengnitta Phanthasomchit
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chanthasone Phanthavong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Somsanith Boualaiseng
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Souksakhone Vongsavang
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Rachel C Greer
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thomas Althaus
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Supalert Nedsuwan
- Primary Care Department, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
| | - Daranee Intralawan
- Primary Care Department, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
| | - Tri Wangrangsimakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Proochista Ariana
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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