It is often assumed that people use antibiotics inappropriately because they don't understand enough about the spread of drug resistant superbugs.
A new study led by Warwick University Assistant Professor Marco J Haenssgen challenges this view. The study, published in the medical journal BMJ Open, reveals that basic understanding of drug resistance is in fact widespread in Southeast Asia but that higher levels of awareness are actually linked to higher antibiotic use in the general population.
The researchers conducted a large-scale survey among a representative sample of the rural population of 69 villages in northern Thailand and 65 villages in southern Lao PDR.
The survey found that:
- people's awareness of drug resistance was similar to that of many industrialised countries - three in four villagers in Thailand and six in ten in Laos had heard about "drug resistance," although the term was usually interpreted as a change in the human body rather than as the evolution of bacteria to withstand antibiotic medicine.
- people's attitudes in rural Thailand and Laos were often consistent with recommendations from the World Health Organization to not buy antibiotics without prescription. However, such attitudes were linked to disproportionately and potentially problematically high rates of prescribed antibiotics from public clinics and hospitals - up to 0.5 additional antibiotic courses per illness on average when controlling for other drivers of antibiotic use.
- people who obtained antibiotics from informal sources, such as the village shop, were just as aware of drug resistance as people who relied on public healthcare channels.
- patients receiving antibiotics from informal sources had no less wealth or formal education than users of public healthcare. Indeed, wealthier and more educated individuals in Chiang Rai were significantly associated with receiving antibiotics from informal sources, showing that it is not just people on low incomes who obtain antibiotics from informal sources.
Project leader Asst Prof Marco J Haenssgen interprets these results as a sign that the conventional public health model of behaviour change is failing: "Too many arguments in public health behaviour change rest on a model of 'information deficits.' This idea that people behave irrationally because they don't have the right information finds little support in our research."
"Basic awareness about drug resistance and antibiotics is widespread but does not contribute to better behaviour. New information can be empowering in principle, but people themselves decide how they will use this new 'power' in their daily lives. Unnecessary antibiotic use may then rather reflect privilege, resistance to patronising norms, or interference between local and Western ideas of what good care ought to be."
Thailand and Laos were selected for this study because of their traditionally high rates of antibiotic use and busy international travel patterns, which predispose these countries to the development and spread of drug resistance. The survey involved 2,141 adults from more than 130 villages who represent a rural population of 712,000 villagers in Thailand and Laos. Dr Haenssgen argues that the findings have a wider relevance, however.
"Ours is not an isolated case. Colleagues in China found for instance that more educated people were more likely to buy non-prescription medicine from unregistered stores, and the behavioural sciences have long established that information alone only accounts for a fraction of healthcare decisions. Public health has to catch up! To tackle the superbug crisis, we need to shift our attention to human decision-making processes and to people's behavioural responses to local contexts."
The survey was part of the Antibiotics and Activity Spaces project, a study of antibiotic-related health behaviour in rural Thailand and Lao PDR, funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with the Department of Health and Department for Environment Food & Rural Affairs (grant ref. ES/P00511X/1, administered by the UK Economic and Social Research Council).
The research is published in BMJ Open: https:/
Haenssgen, M. J., Charoenboon, N., Zanello, G., Mayxay, M., Reed-Tsochas, F., Lubell, Y., et al. (2019). Antibiotic knowledge, attitudes, and practices: new insights from cross-sectional rural health behaviour surveys in low- and middle-income Southeast Asia. BMJ Open. doi: 10.1136/bmjopen-2018-028224. Available at https:/
The study data is publicly available at the UK Data Service: Haenssgen, M. J., Ariana, P., Wertheim, H. F. L., Greer, R. C., Jones, C., Lubell, Y., et al. (2019). Antibiotics and activity spaces: rural health behaviour survey in Northern Thailand and Southern Laos 2017-2018 [data set]. Colchester: UK Data Service. doi:10.5255/UKDA-SN-853658. Available at http://reshare.
The Department for Global Sustainable Development was founded in 2015 with a remit to deliver a suite of innovative degree courses which take on the challenge of engaging with the UN's Sustainable Development Goals in a multi-disciplinary and intellectually enriching environment. The department has grown to encompass 12 undergraduate degree courses and the Institute for Global Sustainable Development which was established in 2017 to foster research that contributes to the sustainable development agenda across the global north and global south.
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The Centre for Tropical Medicine and Global Health (CTMGH) is a collection of research groups within the Nuffield Department of Medicine, University of Oxford, who are permanently based in Africa, Asia and Oxford. Its research ranges from clinical studies to behavioural sciences, with capacity building integral to all of its activities. The majority of the Centre's research is conducted at three Wellcome Trust Major Overseas Programmes in Kenya, Thailand and Vietnam, as well as at the Oxford Centre for Global Health Research. The Centre for Tropical Medicine and Global Health also brings together a number of sister groups in Cambodia, the Democratic Republic of the Congo, Indonesia, Laos, Myanmar, Nepal, and Uganda, and collaborators around the world. Tackling infectious diseases, which kill many millions of people every year, is one of the greatest challenges of the 21st century. The CTMGH is researching solutions to the increasingly urgent problems these diseases cause.
Dr Marco J Haenssgen
Assistant Professor in Global Sustainable Development
University of Warwick
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University of Warwick