Develop an interventional study on reducing antibiotic over-prescribing among children with URIs in rural Guangxi, China

Lead Research Organisation: Shandong University
Department Name: Centre for Health Management and Policy

Abstract

Irrational use of antibiotics is a serious issue globally. It is also very common among children with acute upper respiratory tract infection (URTI). It left many children suffering from the bacterial resistance due to irrational use of antibiotics, especially in less developed rural area. Antibiotic widely abused in China, more severe in rural areas. However, few studies focused on this area in developing countries including China. We intend to carry out a feasibility study rural Guangxi, China to explore an effective approach of reducing irrational antibiotic prescription for upper respiratory infections (URTIs) among children.
To define the facilitators and barriers that influence antibiotic prescribing for childhood URIs in rural Guangxi, questionnaire will be used to interview policy makers from provincial, county Bureau of Health and leaders from township hospital. We will also interview these policy-makers, clinicians and caregivers to obtain their perspective opinions regarding rational antibiotic use. Then the theory based intervention package, which had been developed in Bangladesh and tested in Zhejiang province, will be evaluated in rural Guangxi once adapted further to be sensitive to the local context. Finally the intervention package will then be tested in 6 townships within one county. Six township hospitals will be divided into three groups. The arm A will be only targeted clinicians, with: operational guidelines and training on rational antibiotic use, mobile message reminder from pharmacist). Group B will be involving both clinicians and caregivers , which will include: the leaflet material and video information on rational antibiotic use, workshops between parents/caregivers and the trained kindergarten volunteers. The usual-care control group C will manage patients according to the clinicians' normal procedures without any intervention.
We will carry out the intervention for 6 months and collect inpatient and outpatient prescriptions for 6 months before and after interventions. A questionnaire survey will be conducted to see the changes among clinicians, caregivers and kindergarten teachers' knowledge, attitude and practice (KAP) before and after intervention at each group. Interview and group discussion will be used to see if this study is feasible and acceptable with the intervention package. Also positive and negative factors for the intervention implementation will be carried out. We will assess effectiveness though the difference in the antibiotic prescriptions rate among all the prescriptions between before and after intervention and between intervention and control groups. Those preliminary data will help us to aid in planning a larger effectiveness study in whole Guangxi province.

Technical Summary

We plan to conduct a pilot study to test the feasibility of a multidimensional intervention on inappropriate antibiotic use for childhood URTIs. Six townships will be randomly selected to test the intervention package. They will be divided into three groups with two townships in each group: Intervention A target clinicians, Intervention B target both clinicians and caregivers, and control group (usual care).The research outcomes will provide evidence to design a cluster randomized control trial.
Objective 1: To define the facilitators and barriers that influence antibiotic prescribing for childhood URTIs and shape the intervention package. In depth interview and focus group discussion will be conducted with health care managers, clinicians and caregivers.
Objective 2: To refine the specific interventions based on a integrated theory model. A questionnaire will be used to test the knowledge, attitude and practice (KAP) before and after intervention from both provider and consumer perspectives. (as will be also for the KAP assessment in the objective 3).
Objective 3: To measure the feasibility of the interventions through their acceptability, demand, implementation, effectiveness and also KAP of clinicians and caregivers. The KAP will be assessed as above. Adherence to the guidelines and how knowledge is put into practice will be assessed through prescription review and assess patient flows (to inform enrollment) and ICC to inform sample size estimations. Questionnaires will be used for the acceptability, demand and implementation outcomes. In patient and out patients' prescriptions will be reviewed for changes in antibiotic prescription rate before and after intervention.

Planned Impact

Antibiotic resistance is related to overuse antibiotic prescribing, changing the antibiotic prescribing behavior will reduce the resistance, as the travel and frequent migrant in population in Modern society, the resistance bacterial is easy to spread, control and reduce the antibiotic resistance in developing country as large population country like China will be benefit not only in China but also diseases burden globally. As the UK prime minister said: "If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine where treatable infections and injuries will kill once again."
This study will contribute to 1) building the capacity of the rational prescription of antibiotics among primary care doctors in rural China; 2) enhancing the knowledge, attitude and practice of the antibiotic use among the policy makers, primary care workers and residents/community in the study areas. Based on this study, a large scale trial will be developed and research results will be transferred into policy and practice. It will thus potentially benefit the 46.8 million people in Guangxi, and contribute to less spread of antibiotics drug resistance in China. This study will also have international implications as antibiotic misuse is prevalent in Asian countries, such as India, Bangladesh, Nepal, Vietnam and Indonesia. The study results will be made available to those countries through existing Comdis HSD network and south-south collaboration.
Specifically, at the institutional level, the study will reinforce the policy of rational use of antibiotics; build the compelling and supportive climate for rational use of antibiotics; develop collaboration network among different departments in the health system. At the social level, the study will contribute to increasing the social norms on rational use of antibiotics and common recognition of acute URIs. At the health system level, the study will contribute to reducing the antibiotic resistance and the burden of antibiotic resistant infections, and provide evidence for policy makers to reform the current antibiotic regulations.
Public health links all countries together. Controlling and reducing the antibiotic resistance in China, the largest developing country with the largest population will not only benefit the health of the Chinese people, but also relieve bacterial related disease burden globally, thus reduce the spread of antibiotic strains to other countries.

Publications

10 25 50
 
Description The intervention strategy in this study can significantly reduce inappropriate use of antibiotics among children aged 2-14 with upper respiratory tract infections. The intervention effect can remain at an acceptable level for a relatively long time after the intervention ended. The interventions include comprehensive training, prescription review meeting, an operational guide for doctors and health education materials for patients.
Exploitation Route The intervention strategies and training materials can be learnt and shared with policymakers and primary care physicians in other provinces of China and other LMICs.
Sectors Healthcare

 
Description The positive findings brought encouragement and confidence for local policymakers and primary healthcare physicians on reducing inappropriate use of antibiotics among patients with upper respiratory tract infections. The local doctors are willing to continue the practice learnt from the study. In addition, some other provinces such as Guangdong province would like to learn from the interventions.
Sector Healthcare
Impact Types Policy & public services

 
Description Influence on regional clinical practice of prescribing antibiotics
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact Based on our preliminary qualitative analysis, we found positive feedbacks from both our target doctors and patients/caregivers. Doctors were more confident on their clinical practice in treatment of upper respiratory infections without antibiotics. Patients/caregivers understood more about antibiotics and realized the long-term impact of inappropriate use of antibiotics.
 
Description COMDIS-HSD
Amount £50,000 (GBP)
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 04/2014 
End 12/2016
 
Title Guidelines and training modules 
Description All the doctors in the township hospitals are trained on rational use of antibiotics especially for childhood URI, using participatory and interactive lectures, case discussion and questions and answers sections; 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact Doctors in the township hospitals had a better understanding of the use of antibiotics (when and why). 
 
Title Health education materials 
Description Health education materials to caregivers and operational guideline to health providers 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact Improved the understanding of rational use of antibiotics among caregivers and health providers. 
 
Title In-depth interviews 
Description In-depth interviews with leaders from provincial, prefectural Bureau of Health and hospitals, clinicians from county, township hospitals and village clinics, caregivers. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact Had a better understanding of the context and policies that may influence the implementation of the study. 
 
Title medical records review 
Description Review medical records of children with URIs. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact By conducting medical records review, we got much information about patients' condition so as to judge whether the patient had received unnecessary antibiotics therapy. 
 
Title monthly peer review forms 
Description Monthly peer review of rational use of antibiotics 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact Each intervention township hospital was required to report antibiotics prescription rate monthly for peer review, which encouraged township hospitals to improve the rational use of antibiotics. 
 
Title Nvivo for interview data 
Description In-depth interview transcription data, saved in Nvivo 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact From those in-depth interviews, we understood the context and policies of antibiotics use in a more comprehensive way, which helped to improve the intervention strategies. 
 
Title SPSS for prescription data 
Description out-patient prescription data 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact With the out-patient prescription data, we can analyse the situation of antibiotics use of URIs, which helped us to have a close monitoring on the progress. 
 
Title Educational for caregivers 
Description 1) Printed educational material/leaflets (with simple words and pictures), which are distributed to the caregivers whose children have URIs during the clinical consultation. They mainly cover definition of antibiotic, impact of antibiotic resistance, rational use of antibiotics for childhood URIs. 2) Educational videos, which are played on a loop in the waiting areas of township hospitals (5-8 minutes). The content mainly includes definition of antibiotic, situation of irrational use antibiotics in China, impact of antibiotics resistance (using local TV show). 
Type Support Tool - For Medical Intervention
Current Stage Of Development Small-scale adoption
Year Development Stage Completed 2015
Development Status Under active development/distribution
Impact These tools improved caregivers' understanding of antibiotics 
 
Title Monthly peer review 
Description Monthly peer review of rational use of antibiotics within all the intervention sites. 
Type Support Tool - For Medical Intervention
Current Stage Of Development Small-scale adoption
Year Development Stage Completed 2015
Development Status Under active development/distribution
Impact Each intervention township hospital was required to report antibiotics prescription rate monthly for peer review, which encouraged township hospitals to improve the rational use of antibiotics. 
 
Title Operational guideline 
Description Operational guideline, which is distributed to township hospital doctors. The guideline is based on Chinese antibiotics use guidelines, Integrated Management of Childhood Illness (IMCI), and the National Institute for Health and Care Excellence (NICE) guideline, focus on but not limit to URIs. 
Type Support Tool - For Medical Intervention
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2015
Development Status Under active development/distribution
Impact The guideline covers the work flow of URI management, methods of diagnosis URI and other common diseases among children, communication skills between doctors and patients, which helped to improve the accurate diagnosis of URIs and reinforced the management of the patients with URIs. 
 
Title Training workshop 
Description All the doctors in the township hospitals are trained on rational use of antibiotics especially for childhood URI, using participatory and interactive lectures, case discussion and questions and answers sections; 
Type Support Tool - For Medical Intervention
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2015
Development Status Under active development/distribution
Impact Doctors in the township hospitals had a better understanding of the use of antibiotics (when and why). 
 
Description The 4th Global Symposium on Health System Research 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact Zhitong Zhang had delivered a presentation on 'Reducing irrational antibiotic prescribing among children with upper respiratory infections in rural China: a pragmatic cluster randomized controlled trial' in The 4th Global Symposium on Health System Research, Vancouver, Canada. This symposium took place over a packed 5 days of formal sessions, oral presentations, skill building events and social media sharing. Zhitong Zhang set the scene by informing delegates that antibiotic consumption per capita is 10 times higher in China than the United States. He went on to describe how our multi-faceted intervention package - including evidence-based guidelines, peer review of prescriptions and health education materials - has been effective in reducing antibiotic prescribing for childhood URTIs in China's rural primary care facilities.
Year(s) Of Engagement Activity 2016
URL http://healthsystemsresearch.org/hsr2016/
 
Description Workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact We invited 17 directors/experts/coordinators, who are long-term partners with China team, from China CDC, China National Health Development Research Centre, China Anti-tuberculosis Association, Zhejiang Provincial and County CDC, Guangxi Provincial and County CDC, and Shandong University. We gave the presentation regarding this project and shared our experience with these participants. Meanwhile, they also left comments and provided practical suggestions.
Year(s) Of Engagement Activity 2016