Antimicrobial resistance is a ‘wicked problem’, globally recognised as an important and growing threat to health in clinical settings. Still, community knowledge, attitudes and behaviours related to antibiotic use, and the social and cultural drivers of inappropriate use are less known. This situation is especially the case in Vietnam, where levels of antimicrobial resistance are among the world’s highest. Between 2000 and 2010, worldwide antibiotic consumption for human use increased by 35%, including large rises in the use of last-resort antibiotic drugs, particularly in middle-income countries.
Reducing inappropriate antibiotic use reduces the prevalence of antibiotic-resistant bacteria at the population level in high-income countries. Still, few population-level interventions aiming to reduce antibiotic use have been evaluated in low and middle-income countries (LMICs) with higher burdens of infectious disease and antibiotic resistance.
This study will be conducted in rural communities in Vietnam, where two-thirds of the population lives and where levels of antibiotic resistance are amongst the highest in the world. There is a high demand for human and animal antibiotic use, the majority of which is supplied through private pharmacies without a prescription.
Interventions aiming to sustainably reduce antibiotic consumption at the population level will need to target both supply and demand for antibiotics through the formal and informal markets.
On the supply side, rapid, low-cost diagnostics have been shown to reduce unnecessary dispensing of antibiotics. In Vietnam, rapid diagnostic tests (RDT) in a primary health care setting, using the biomarker C-reactive protein (CRP) to differentiate between bacterial and non-bacterial illness, have been shown to reduce the unnecessary use of antibiotics for acute respiratory infections by around 20%. However, reducing supply through the formal healthcare system could have limited population impact, as many patients that were not prescribed antibiotics in primary health centres in this CRP study went on to obtain them elsewhere, and in general, the first point-of-care for non-severe illnesses for many people is a nearby private pharmacy, where distance and waiting times are shorter.
There is currently no precedent for blood testing at pharmacies, and little is known about how such tests might be perceived and used, nor how much users would be willing to pay for them or at what price sellers would find them a profitable alternative to selling antibiotics. Understanding how community members use drug shops, as well as potential challenges to introducing CRP-RDTs through them, is essential to inform intervention design.
On the demand side, perceived customer desire for antibiotics is often cited as a reason for prescribing or dispensing them, although most research around inappropriate antimicrobial use focuses on prescribers and dispensers of antibiotics. Self-medication is also common in Vietnam, but community beliefs and understanding about the treatment of illness and the role of antibiotics have not been well documented. The drivers of inappropriate antibiotic use are likely multifactorial, and a problem with complex social drivers could be comprehensively tackled with a complex social intervention.
Most studies that have engaged users of antibiotics have used passive health education approaches through mass media campaigns, posters, leaflets and websites. However, active engagement of communities in solving problems may provide a more powerful way of stimulating action and changing norms than simply increasing knowledge, especially where there is a complex interplay of social, cultural and economic factors.
Community participation is a major component of people-centred health systems, and interventions that mobilise communities through participatory action approaches have been used to successfully change behaviours and improve health outcomes for maternal and child health and other health domains.
Intervention development phase
In order to implement trials of the interventions at scale, we need to develop replicable interventions based on a theory of change and logic models. Understanding current community knowledge and practice related to antibiotics and resistance in the context of the wider research literature will inform this theory and study design. We also need interventions that are acceptable to participants and feasible to deliver. This phase will develop and pilot potential interventions at three levels – communities, private drug stores and schools.
a) Communities: We will explore modes of engagement and content of health messages, with communities taking a key role, and we will explore social and logistical factors that might hinder or facilitate the interventions. We will use a community-led visual media approach, as well as develop a short educational film. These materials will be used to stimulate group discussion in the main study in the implementation phase.
b) Private drug stores: We will pilot CRP testing in pharmacies and qualitatively review user and provider experiences to inform the development of a scaled-up intervention. We will also explore the market for CRP-RDTs, considering the economic dimensions for users and sellers, to position them as useful and affordable products. We will also engage with policymakers and other stakeholders to explore potential challenges and barriers to introducing point-of-care testing in pharmacies in Vietnam.
c) Schools: we will develop and pilot test visual-media materials targeting parents of nursery school children as well as secondary school students.