Vietnam has levels of antibiotic resistance amongst the highest in the world, driven by a combination of high burden of infectious diseases and ineffective regulation and antibiotic stewardship. Antibiotic use in the community accounts for the largest volume of antibiotics used for human health, the majority for respiratory infections. Most respiratory infections are self-limiting and can be treated at home, without antibiotics or contact with formal health services. But reliable information about when to seek care and how to manage illnesses at home is difficult to access in the community, and over-the counter antibiotic use without prescription is common, as access and opening hours for private pharmacies and drug sellers are more convenient. Gaps in access to and availability of quality healthcare drive over-the-counter antibiotic use, which is often inappropriate. Primary care services are poorly resourced, and physicians lack technical and communication skills, confidence, and diagnostics to guide their clinical decision-making, especially in rural areas.

Antibiotics used for livestock production accounts for two-thirds of all antibiotics consumed in Vietnam, but less is known about antimicrobial use in crop production. Residues of antimicrobials used in agriculture remain in soils and water and drive emergence and spread of antibiotic resistance in the environment.

Interventions aiming to sustainably reduce antibiotic consumption at population level will need to target both supply and demand for antibiotics through the formal and informal markets, as well as infection prevention and measures to reduce bacterial transmission.

Involving communities in co-design of solutions may provide a powerful way to stimulate action and accelerate behaviour change. Community participation is a major component of people-centred health systems, and participatory action research methods have been widely and successfully used to tackle health problems and change behaviours in communities and in hospitals. The World Health Organisation recommends community mobilisation through participatory group-based learning for promotion of maternal and newborn health, but this approach has not been used to tackle unnecessary antibiotic use. Participatory learning and action (PLA) can be used to empower communities to generate locally appropriate solutions using a bottom-up approach. Generating local data for what is working or not working provides a powerful feedback loop, engenders a strong sense of ownership, and fosters an appreciation for the importance of evidence to inform decision-making.

This study will evaluate the impact of One Health interventions across the healthcare system, communities, and farms to reduce inappropriate antibiotic consumption and prescription through a cluster randomised controlled trial. These intervention approaches will seek to increase awareness and understanding of antibiotics, reduce the inappropriate prescribing, dispensing, and use of antibiotics, improve hygiene and sanitation in communities, and ultimately reduce the carriage of drug resistant, potentially disease-causing bacteria in the population.

OUTPUTS TO DATE

Publications

1. Nguyen NV, Do NTT, Vu DTV, Greer RC, Dittrich S, Vandendorpe M, Pham TN, Ta NTD, Pham TQ, Khuong VT, Le TTB, Anh LT, Cao TH, Trinh TS, Nguyen HT, Ngo LN, Vu TT, van Doorn HR, Lubell Y, Lewycka SO. Outpatient antibiotic prescribing for acute respiratory infections in Vietnamese primary care settings by the WHO AWaRe (Access, Watch and Reserve) classification: An analysis using routinely collected electronic prescription data. Lancet Reg Health West Pac. 2022 Oct 11;30:100611. doi: 10.1016/j.lanwpc.2022.100611. eCollection 2023 Jan.

This paper explored antibiotic prescribing in primary healthcare, finding that 97% of patients with acute respiratory infections were prescribed antibiotics. Children under 5-yars were more likely to be prescribed ‘watch-antibiotics’ with higher potential for contributing to development of antibiotic resistance. Interventions are needed to address overprescribing in primary healthcare.

 

2. Minh D, Nguyen Thi Hong Y, Nagraj S, Do Thi Thuy N, Vu Thi Lan H, Nguyen Vinh N, Nguyen Thi Cam T, Nguyen Hai Y, Cai Ngoc Thien H, Tran Thi H, Nguyen Yen N, Alban H, Khuong Thanh V, Duong Thi Thanh H, Tran Huy H; CoAct investigators; Van Nuil J, Lewycka S. Determinants of antibiotic prescribing in primary care in Vietnam: a qualitative study using the Theoretical Domains Framework. Antimicrob Resist Infect Control. 2024 Sep 30;13(1):115. doi: 10.1186/s13756-024-01471-9.

This paper used qualitative methods and a behavioural framework to identify behavioural factors driving unnecessary prescription of antibiotics in primary healthcare. Themes included low awareness of antimicrobial resistance (AMR), diagnostic uncertainty, a prescription-based reimbursement policy, inadequate medication supplies, insufficient

This paper used qualitative methods and a behavioural framework to identify behavioural factors driving unnecessary prescription of antibiotics in primary healthcare. Themes included low awareness of antimicrobial resistance (AMR), diagnostic uncertainty, a prescription-based reimbursement policy, inadequate medication supplies, insufficient financing, patients’ perception of health insurance medication as an entitlement, and maintaining doctor-patient relationships. Identifying behavioural determinants using a theoretical framework offers a structured foundation for designing impactful antimicrobial stewardship interventions in primary care. The findings underscore the importance of not only enhancing knowledge and skills but also addressing structural barriers, guidelines and regulations, inter-personal relationships, and promoting enabling social environments for change.

Fig.1 Themes were identified and mapped onto behavioural domains using the Theoretical Domains Framework and COM-B model. The behaviour of interest—antibiotic prescription in primary care, is surrounded by three COM-B pillars: capability, opportunity, and motivation. Surrounding each pillar are the TDF domains linked to the behaviour. The outermost layer represents the specific themes identified through interviews and focus groups, aligned with each respective domain.

3. Nguyen YHT, van Doorn R, Van Nuil JI, Lewycka S. Dilemmas of care: Healthcare seeking behaviours and antibiotic use among women in rural communities in Nam Dinh Province, Vietnam. Soc Sci Med. 2024 Dec;363:117483. doi: 10.1016/j.socscimed.2024.117483. Epub 2024 Nov 10.

This paper used ethnographic methods to explore ‘dilemmas of care’ among rural women in Nam Dinh Province, finding that women in rural communities use antibiotics to mitigate social and structural challenges. Unequal distribution of quality healthcare drives self-medication with antibiotics, while medical pluralism may contribute to use of antibiotics in inappropriate ways. Communications on antibiotic resistance can be confusing and misleading, and antibiotics can be prescribed inappropriately by medical doctors in primary healthcare. Thus, responses need to improve access to quality healthcare and be appropriate to local contexts.

Fig. 2. A medicine sorting activity highlighted misunderstandings about antibiotics. This participant could not recognise antibiotics and grouped them together with other medicines often prescribed for flu symptoms including antihistamine, vitamin C, cough lozenges (in circle).

Workshops

In February and July 2020 we held Introductory study meetings with partners and local authorities in Nam Dinh Province.

On 22 June 2022 we held a stakeholder workshop with participants from health, agriculture, environment, education, community, and other sectors. Participants were engaged in exercises to develop action plans and inform the theory of change for interventions to address overuse of antibiotics and antibiotic resistance.

On 19 January 2024 we held a second stakeholder workshop to identify facilitators and barriers to implementation of antimicrobial stewardship in healthcare, farms, and communities. This helped to further refine develop action plans and build multisectoral collaboration.