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

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.

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.

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.