Development of two community-based interventions targeting inappropriate antibiotic dispensing and use behaviours in rural Vietnam

Between 2000 and 2010, worldwide antibiotic consumption increased by 35%, including large rises in the use of antibiotic drugs used as a last-resort, when other treatments fail. This rise was particularly apparent in middle income countries, with growing populations and increasing access to antibiotics. Rising levels of antibiotic consumption are associated high levels of antibiotic resistance, and increasing numbers of bacterial infections that are difficult or impossible to treat with antibiotics. Reducing inappropriate antibiotic use has been shown to reduce the level of antibiotic resistance at population-level in high income countries, but few population-level interventions aiming to reduce antibiotic use have been evaluated in low and middle income countries with higher burdens of infectious disease and antibiotic resistance.

This development grant will inform the design of two community-based interventions aiming to reduce inappropriate antibiotic use and related antibiotic resistance. One intervention will target the supply of antibiotics through private pharmacies, the major source of treatment for minor illness, and where antibiotics can easily be obtained without a prescription. Introducing a rapid diagnostic test in this setting would help pharmacists to differentiate between people with non-bacterial infections that do not require antibiotics, and those with likely bacterial infections that should be referred to a health professional. The other intervention will tackle the demand for antibiotics in communities by using participatory discussion in groups to improve understanding of the problem of antibiotic resistance, and develop appropriate strategies to address it in their community.

To assist intervention development, we will conduct a review of the literature to learn from other successful approaches using rapid diagnostic tests outside the formal healthcare system, and health behaviour change interventions in communities. We will collect information from providers and consumers of antibiotics in communities, to understand what drives inappropriate use, and we will also explore their views about the introduction of rapid diagnostic tests in pharmacies, and what price would be attractive for both. We will work with community members, using visual media to develop materials and messages that can be used to talk about antibiotic resistance with other communities.

On finalising the design of the interventions, a methodology will be developed to evaluate and understand the effect of these interventions, with input from experts and local partners. Funding sources will be identified to implement the interventions and research the effect of community-based interventions on antibiotic use and resistance in rural Vietnam. We will disseminate our learning from this process through international peer reviewed publications, briefing papers, and discussions with local partners and community participants.

Between 2000 and 2010, worldwide antibiotic consumption increased by 35%, including large rises in use of last-resort antibiotics, and particularly in middle income countries. Reducing inappropriate antibiotic use has been shown to reduce the prevalence of antibiotic resistant bacteria at population-level in high income countries, but few population-level interventions aiming to reduce antibiotic use have been evaluated in low and middle income countries with higher burdens of infectious disease and antibiotic resistance.

This development grant will inform the design of two community-based interventions aiming to reduce inappropriate antibiotic use and resistance. One intervention will target the supply of antibiotics through private pharmacies, the major source of treatment for minor illness, where antibiotics can easily be obtained without a prescription. Introducing rapid diagnostic tests would help pharmacists to differentiate between bacterial and non-bacterial infections, and reduce inappropriate antibiotic dispensing. The other intervention will tackle the demand for antibiotics in communities by using participatory action research to improve understanding of the problem of antibiotic resistance, and develop appropriate strategies to address at community-level.

To inform the design of the interventions, we will conduct a literature review, and qualitative and economic interviews with providers and consumers of antibiotics. We will use a community-led media approach to develop messages and content for the community group intervention. During the development phase we will also develop a probabilistic mathematical model to explore the potential impact of community-based, pharmacy-based, and combined approaches.

The aim of the main study is to test public health interventions with the potential to reduce exposure to antibiotics, carriage of resistant bacteria, and potentially the emergence and spread of untreatable bacterial infections. If successful, these could have population-wide benefits in reducing the burden of antibiotic resistance. These early phase studies will also have the following academic, economic and societal impacts:
1. Academic impacts
a. The ethnographic and social research will add to our understanding of the driving forces for inappropriate antibiotic use in communities, and consequently inform the design of appropriate interventions to reduce this.
b. The mathematical model will provide useful information for policymakers in Vietnam, and could easily be adapted to inform priorities and planning in other countries in the region and low and middle income countries elsewhere in the world.
2. Economic and societal impacts
a. Communities and providers involved in the research will gain increased awareness of antibiotic resistance and ways to reduce it.
b. Through interviews and community discussions, and the use of community-led, participatory visual media approaches, participants may gain an insight into the problem of antibiotic overuse, and consider making changes to their behaviour.