Globally coordinated governance needed

Promoting rational use of antibiotics – the Thailand example

The Antibiotics Smart Use program was started in 2007 in Thailand as an innovative way to promote the rational use of antibiotics. The program aimed to strengthening human resources, improving health facility infrastructure and empowering communities. This in a setting with limited resources and difficulty translating rational use of medicines from theory into practice.

Dr. Nithima Sumpradi from the Thai Food and Drug Administration was one of the key researchers responsible for the evolution of the Antibiotics Smart Use project. Here she answers a few questions about the details and outcome of the program.

The program targeted three conditions not requiring antibiotic treatment: upper respiratory infections (especially the common cold with sore throat), acute diarrhea and simple wounds. For these conditions the Antibiotics Smart Use Program attempted to reduce unnecessary use of antibiotics.

Nithima Sumpradit
Dr. Nithima Sumpradit.

What has been the impact of the Antibiotics Smart Use Program at the level of the community hospital?

– The National Health Security Office (NHSO) data shows overall reduction of antibiotic prescriptions although it varies from hospital to hospital. In some hospitals health professionals transfer their knowledge to health volunteers and people in the community and some of them initiate community-based outreach program. This may be because they realize that prescribing behavior is not solely influenced by the knowledge of the prescriber but is also influenced by expectations and pressure from the patients to receive antibiotics.

– While designing the Antibiotics Smart Use program we thought of all the factors that may influence prescribing behavior. We categorize factors in terms of predisposing factors like knowledge, attitude, confidence; enabling factors like environment or availability of antibiotics or alternative drugs for non-antibiotic therapy and then the reinforcing factors, for example, pressure from patients or from other prescribers. Then we prioritized these factors and designed the intervention to address them.

You had to understand the social, economic and cultural factors to design the Antibiotics Smart Use Program.

Have your assumptions proved right or did you have to make modifications?

– Understanding the social, economic and cultural factors is important but still these factors could vary across settings or areas. Thus, interventions needed modification to fit contexts. Especially when we are to expand the program from community hospitals to other settings such as big hospitals, pharmacies and communities.

Can you give some examples?

– For example, in big hospitals health professionals usually argue that the Antibiotics Smart Use Program is not applicable to their Outpatient Department (OPD) visits because their patients are sicker compared to community hospitals, and therefore the rate of antibiotic use should be higher. To convince prescribers in big hospitals, international literature is important but it alone is not enough to trigger changes. A common justification is that the context in Thailand differs from that described in international studies, mostly conducted in Western countries. For example, they assume that a simple wound in Thailand may be more vulnerable to get infected because Thailand’s weather is hot and humid; patients who work in agriculture fields may be exposed to dirt and so on.

– To convince them relevant evidence of Thailand’s context or their own local contexts is essential. For the community pharmacists the aspect is different from public hospitals because they are from the private sector and need to balance between professional practice and profit. So we can help them minimize the pressure from the patients by making the patients take a more active role or involvement in the decision to take antibiotics.

A training program for community health workers as part of the Antibiotics Smart Use campaign in progress.

– My favorite example is from my experience of working with communities. One community member mentioned that since antibiotic resistance is a very serious issue how come we (the Antibiotics Smart Use central team) use cartoon characters in educational materials. Only real people and real things should be depicted! Later on, people from this community created their own posters that were so meaningful. The posters are personalized to individual families and this simple device transforms them into presenters/ambassadors promoting rational use of antibiotics. There are so many creative ideas like this among the many communities we work with.

What has been the experience of nationwide scaling up?

– I think scaling up is perhaps the hardest part for the Antibiotics Smart Use Program because the scale is big – a nationwide level, types of settings are many, contexts are varied. And most important point of all – input-output relationships are not always linear as you might expect and there are a number of uncontrollable factors that may influence this scaling up process.

– To manage this complexity, we use two strategies. One is the vertical scaling up which involves policy and regulations but another is the horizontal scaling up which is the network management, building trust, local ownership, and relationship and getting a buy-in from the community to accept Antibiotics Smart Use program as their own concept. We use the framework developed by World Health Organization while scaling up.

What is the impact of the Antibiotics Smart Use program in terms of antibiotic use beyond the three diseases you have targeted?

– We anticipate that the Antibiotics Smart Use Program may reduce the number of Outpatient Department (OPD) visits, especially in tertiary care hospitals. This is because the targeted diseases in the program are self-limiting. Patients have learned about the types and duration of symptoms associated with their diseases so that they may not feel so worried. They can conduct a basic assessment of their condition if they need to see a doctor.

– Once the patients have direct experience of how to assess their condition and take care of themselves, this could reduce the number of OPD visits. Decreased number of OPD visits of common diseases can reduce workload for health professionals, especially those in big hospitals and health professionals may have more time for sicker patients. I think the Antibiotics Smart Use Program is a platform for learning and for capacity building for people engaged with OPD including myself. Some of the networks have said they will use the knowledge and experience from the Antibiotics Smart Use program planning and implementation to apply in solving irrational use of other medicines. A final contribution is about the network development.

The Antibiotics Smart Use program is a starting point that facilitates stakeholders at the national, provincial and local levels to gather and work together.

Can you explain the use of traditional medicine as part of the Antibiotics Smart Use program approach?

– We use a couple of traditional medicines in the project which are from the national list of essential herbal preparations. These are prescribed to the very concerned patients only. Normally we will not prescribe anything for viral infections but sometimes patients are still very worried about their symptoms and would like to get some medicine. So the doctor or nurse will have the choice to prescribe traditional medicine. These traditional medicines are used for the short term period only because the disease is a self-limiting one and will not last long anyway. In addition, some prescribers find that prescribing traditional medicines could preserve the patient’s confidence while avoiding prescribing antibiotics.

Could you tell us how the interaction with ReAct was useful for the Antibiotics Smart Use program project?

– We first interacted with ReAct around 2008 or 2009 when ReAct came to visit and Dr. Niyada arranged a small meeting with to discuss the situation on antibiotic resistance in Thailand, what Thai colleagues and ReAct had done so far and what would be next steps.

– We appreciate ReAct for being such a good catalyst at connecting ‘antibiotic fellows’ from different countries to share experiences. Interactions among like-minded people are important when you need to create a momentum on something. Involving, having or supporting representatives from the Antibiotics Smart Use Program in joining international forums has been another key contribution from ReAct that has helped in disseminating the concept and building networks.

– Lastly, I think a study visit from ReAct and its affiliates to local networks of the program in May 2011 was very meaningful. It is not just for exchanging information and experiences – it was also a real recognition of the local networks including health professionals, community leaders and villagers who are the real change makers.

Read more about the Antibiotics Smart Use Program in Thailand in the ReAct Toolbox.