Antibiotics and Activity Spaces: An Exploratory Study of Behaviour, Marginalisation, and Knowledge Diffusion

Lead Research Organisation: University of Oxford
Department Name: Tropical Medicine


Antimicrobial resistance (AMR) is a global health threat that endangers the achievement of the Sustainable Development Goals, especially Goal 3 on "Good Health and Well-Being." Leading UK and global strategy papers aiming at improving people's antibiotic usage to fight and prevent AMR thereby focus exclusively on awareness-raising campaigns, but this narrow approach suffers from conceptual, methodological, and empirical weaknesses. In response, our study intends to improve the understanding of patients' antibiotic-related health behaviour to inspire more targeted and unconventional interventions in low- and middle-income countries (LMICs). Speaking to the themes of "awareness and engagement" and "informal markets and access to antibiotics," we will investigate 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 a behavioural health systems intervention 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?
Our interdisciplinary approach frames behaviour within a shared activity space. By drawing on theories and tools from public health, medical anthropology, sociology, and development economics, and by focusing on vulnerable rural dwellers in the DAC countries Thailand and Laos, we will be able to generate innovative and unprecedentedly detailed open-access survey data on antibiotic-related behaviour and its social, economic, and spatial determinants. We aim to maximise complementarities with other ongoing projects in the region that (1) implement biomarker testing and education campaigns in clinical settings, (2) generate mixed-method evidence on cross-cultural patterns of antibiotic use, and (3) engage with the general public to improve global health awareness.
We will apply a rigorous three-stage stratified cluster random sampling design to produce district-level representative survey data of the antibiotic use of 2,400 villagers; and we will carry out social network censuses in four communities with a total of 2,400 villagers. Using satellite imagery and digital data collection tools, we can realise these sample sizes at 75% of the cost of conventional survey approaches. Pursuant to our research questions, we will generate novel insights into the nature and variability of Thai and Lao antibiotic usage and health behaviours using the following methods: We will (1) use event sequence analysis and multilevel regression to investigate the impact of technology and digital media as well as economic, social, and spatial characteristics of patients on adverse antibiotic usage, (2) apply social network analysis to understand how knowledge and practice diffuse from clinical interventions into village communities, and (3) use latent class analysis to detect problematic conditions for antibiotic use through easy-to-collect proxy indicators.
Under the umbrella of the Oxford Tropical Network-an inspiring and enabling research environment-this project will be made possible through collaboration across world-leading researchers and groups in health behaviour research (KEMRI Wellcome Trust Research Programme; Kenya), health economics and public engagement (Mahidol Oxford Tropical Medicine Research Unit in Thailand; LOMWRU in Laos), evidence-based antibiotic policy (Oxford University Clinical Research Unit; Viet Nam), social network analysis (CABDyN Complexity Centre; Oxford), development economics (Technology and Management Centre for Development; Oxford), and global health training (Centre for Tropical Medicine and Global Health; Oxford). ODA relevance follows from our partnerships, capacity building activities, and research interest in vulnerable groups in LMICs. We apply for £249,804 from 1 January 2017 - 31 October 2018 for this pump-priming research.

Planned Impact

We expect our project to have impacts on antimicrobial resistance (AMR) in 3 main ways: (1) We strengthen social research capacity in AMR and public health in our research team and at the Mahidol Oxford Tropical Medicine Research Unit (MORU) in Bangkok and its sub-units across Thailand and Laos. (2) We contribute conceptually to AMR policy and interventions in Thailand, Laos, and low- and middle-income countries (LMICs) more broadly. (3) The general public in rural Thailand and Laos can benefit from our research directly through public engagement and indirectly in medical and economical terms.
1: We will build capacity for social research in AMR and public health through (1) four research internships at MORU; (2) two research assistants (RAs), one of which will be an 18-month position at MORU; and (3) provision of research training courses for RAs and early-career research team members. Through the locally recruited RA and interns, mentoring, and research methods training, we aim to fill a gap in local social research capacity at MORU over the medium term. In addition, we offer valuable learning opportunities for placement students, interns, and the RAs through supervision by the team and through including them into knowledge exchange activities such as conferences, local public engagement, interaction with policy stakeholders, and academic publishing. These activities are also open to early-career researchers in our team in order to support them in developing international collaborative research capacity and an interdisciplinary AMR research profile.
2: We will influence AMR policy and dialogue conceptually by interacting with policy makers and intervention designers, and through four 8-week student placements with the MSc International Health and Tropical Medicine (IHTM; a global health degree at the University of Oxford). Policy workshops and meetings will be held at project beginning and end to discuss existing AMR policies and interventions, gather inputs on priority policy actions, and share our research findings to broaden the presently narrow and awareness-centred approach to antibiotic-related patient behaviour in national and global policies. We aim to involve ministries of public health in Thailand and Laos; aid organisations working in AMR awareness; and representations of the World Health Organization. The placement projects for MSc IHTM students open another route to contributing to global AMR policy by helping to build a new generation of global health leaders. The MSc IHTM offers interdisciplinary global health training primarily for students with a medical background from LMICs; our placement projects will thereby enable students to appreciate the complexity of treatment-seeking behaviour, the relationship between clinical interventions and popular practice, and the trade-offs in AMR health policy making.
3: Our research impact on the general public in Thailand and Laos arises directly from public engagement, and indirectly from our impact on AMR policies. We will address the public directly through infographic summaries of our research and interact with them in local engagement activities such as science cafés in Thailand and Laos. These activities aim to improve the understanding of AMR and the factors that affect people's behaviour, utilising the existing public engagement infrastructure at MORU in Bangkok. Our placement projects and internships can focus specifically on such public engagement activities. Indirect impact will arise from new AMR policies that help to limit problematic antibiotic use and thus one of the factors underlying AMR and its associated disease burden and economic consequences. Novel policy responses based on our research may also address contextual factors that limit people's healthcare decisions, for example cash transfer programmes to improve the well-being of disadvantaged groups with a coinciding reduction of antibiotic overuse.


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Description Educational activity 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact Popular antibiotic use is one dimension under the broader domain of antimicrobial (antibiotic) resistance. In low- and middle-income countries, antibiotics can often be easily accessed through informal providers (those without formal training or supervision) such as convenience stores. Consequently, people commonly resort to self-diagnosis and treatment patterns including the purchase and consumption of antibiotics for medically inappropriate reasons (e.g. taking antibiotics for viral infections). Understanding the drivers of antibiotic acquisition and use would therefore help to provide insights into targeting and reducing medically inappropriate antibiotic use which could contribute towards antibiotic resistance. In order to engage with the public about antimicrobial resistance, particularly in the domain of healthcare seeking (medically inappropriate antibiotic use), we carried out a series of bi-directional one-day educational activities for 25-30 participants in three of our survey villages in Chiang Rai (Thailand) and two villages in Salavan (Laos PDR). By engaging with the general adult village population in our field sites, we were able to share basic information about medicine use and healthcare-seeking behaviour, while also being able to learn about villagers' constraints and how they interpret our messages. As part of the survey, we are able to later understand the impact of our engagement activities, for instance whether and how our messages spread in the village communities. The educational activities involved sessions as varied as trading games, poster making, storytelling and role plays. These activities were developed on the basis of year-long qualitative research in Thailand and Laos by an international team of research interns from Thailand (Yok Penporn Warapikuptanun), Lao PDR (Kee Thipphaphone Xayavong), and Myanmar (Yuzana Khine Zaw) under the supervision of research officer Nutcha Charoenboon and Principal Investigator Marco J Haenssgen.
Year(s) Of Engagement Activity 2017,2018