Evaluating antimicrobial stewardship strategies and capacity building through participatory action research and a network approach in Vietnam

In Vietnam, surveillance data showed alarmingly high and increasing drug-resistant proportions of important pathogens in hospitals. Antimicrobial stewardship (AMS) has been an important national strategy to improve antibiotic use, however, implementation has been slow at resource-limited hospitals due to lack of resources, skills and capacity. These include district hospitals, the first-point of hospitalization in the public healthcare system where first intravenous antibiotics are usually given empirically in the absence of microbiology lab services. Connecting with provincial-level hospitals through AMS networks is therefore a potential approach to support district hospitals in accessing external available resources for AMS implementation.
In this proposed four-year research project, Oxford University Clinical Research Unit Vietnam (OUCRU) and National Hospital for Tropical Diseases will work with two hospital networks in a participatory action research approach to 1) to evaluate the effectiveness, costs and implementation outcomes of AMS programmes delivered through the two local networks, 2) to develop staff capacity in provincial and district hospitals in AMS implementation through participatory action research and network involvement, and 3) to explore opportunities for and contextual factors to support effective implementation of AMS programmes in these AMS hospital networks.
Each hospital network will consist of one provincial hospital and five connecting district hospitals identified based on our previous research and the commitment of hospital leadership and AMS staff. Hospital AMS staff (participants) will be involved in an iterative reflective cycle where they will collect and analyse data and determine actions and interventions to implement, observe the process, and reflect and evaluate the outcomes to inform continuing actions. The research team will train hospital staff on AMS related skills and research methods to collect and analyse data, assess and identify interventions, develop and evaluate the implementation. Hospital staff will use evidence and guidance from national guidelines and World Health Organisation's toolkit to identify possible interventions and make hospital-specific action plans contextualized to their local conditions. Results and learning experience will be shared and discussed in regular hospital team meetings and network meetings facilitated by the researchers.
We will use a mixed methods design throughout the research including staff survey, interviews and focus group discussions to understand the process, assess implementation aspects including costs, feasibility, acceptability, sustainability and scalability, and explore opportunities and contextual factors for AMS implementation based on the network approach. Longitudinal routine data will be extracted from hospital information systems to evaluate co-primary outcome measures of antibiotic use and clinical outcomes (in-hospital mortality and length of stay). We will also conduct a survey of 2000 patients in all hospitals at two time points, before and 12 months after implementation started, to investigate the potential impact of AMS on colonization of drug-resistant bacteria.
Evidence generated from this research will be important for policy makers and hospitals in resource-limited settings like Vietnam in developing and implementing locally adapted AMS programmes. This research will also build the capacity and ownership of local hospitals and their staff in assessing, planning, implementing and evaluating their AMS interventions, and increase the capacity of research staff in implementation science and engaging local partners through the participatory action research process. Local AMS networks will be developed and strengthened to increase resource mobilization, motivation and participation of hospitals in the implementation.

Antimicrobial stewardship (AMS) remains a cornerstone in national and global action plans to control drug resistance, however implementation is challenging in resource-limited settings. In Vietnam, as shown in our previous research, main barriers at provincial and district hospitals were lack of resources and evidence on locally effective strategies for empowering AMS staff in improving antibiotic prescribing practices. This study aims to evaluate the impact of AMS implementation in two networks of provincial and district hospitals in Vietnam using participatory action research (PAR) with three main goals: 1) to evaluate its effectiveness, costs and implementation outcomes, 2) to develop capacity of hospital staff in AMS implementation through PAR and network involvement, and 3) to explore opportunities for and contextual factors to support effective AMS implementation in these networks.
Participating in an AMS network will allow district hospitals to build partnerships, engage in opportunities to leverage technical resources from provincial leaders and strengthen local capacity for implementation. The PAR process will involve hospital staff in an iterative reflective cycle to collect data, identify actions, observe and reflect on implementation, and outcome evaluation. We will employ a mixed-methods design to assess the process and outcomes including feasibility, costs, acceptability, sustainability and scalability. A quasi-experimental design will be applied to determine effectiveness on co-primary outcome measures (antibiotic use and clinical outcomes) using time-series data, and investigate the microbiological impact (colonization of drug-resistant bacteria) in patients through before-after surveys.
Our results will contribute practical evidence for contextualized strategies to implement AMS in resource-limited settings and addressing health disparities caused by lack of adequate resources for controlling drug resistance at the district level.