What is in the drug packet?: access and use of non-prescribed poly-pharmaceutical packs (Yaa Chud) in the community in Thailand

Embedding community and public voices in co-created solutions to mitigate antimicrobial resistance (AMR) in Thailand using the 'Responsive Dialogues' public engagement framework

The use of antimicrobials in Thailand has been reported as one of the highest in the world in human and animal sectors. Our engagement project aimed to improve our understanding of the issue of antimicrobial use and antimicrobial resistance (AMR) among adult Thai communities, and co-create locally relevant solutions to AMR, especially those focusing on raising awareness to improve related policies in Thailand.We conducted a series of online and in-person 'conversations' according to Wellcome's 'Responsive Dialogues' engagement approach, designed to bring together different voices to understand complex AMR problems and find potential solutions. This approach enabled key AMR stakeholders and policy makers to hear directly from communities and members of the public, and vice versa. Conversations events took place between 25 November 2020 and 8 July 2022, and we engaged 179 AMR key stakeholders and members of the public across Thailand.The issues found were: there were quite a lot of misunderstandings around antimicrobials and AMR; participants felt that communications and engagement around antimicrobial resistance had limited reach and impact; asking for and taking antibiotics for self-limiting ailments is a social norm in Thailand; and there appeared to be a wide availability of cheap antimicrobials. To mitigate the spread of AMR, participants suggested that the messages around AMR should be tailored to the target audience, there should be more initiatives to increase general health literacy, there should be increased availability of AMR related information at the local level and there should be increased local leadership of AMR mitigation efforts.Trial registration Thaiclinicaltrials.org registration: TCTR20210528003 (28/05/2021).

A qualitative exploration of purchasing, stockpiling, and use of drugs during the COVID-19 pandemic in an urban city of Bangladesh

Objectives

This research was conducted to explore the patterns and behavior of panic purchasing, stockpiling, and use of drugs during COVID-19 in the Sylhet city, Bangladesh.

Study design

The study adopted qualitative exploratory research design.

Methods

25 in-depth interviews with drug sellers and clients and 7 key informant interviews were conducted with pharmacists and medical representatives of pharmaceutical companies in Sylhet city in Bangladesh from October 2020 to March 2021. Thematic analysis was used to evaluate the primary data.

Results

The findings revealed that individuals sought out, purchased, and stockpiled prescription-only drugs for self-medication purposes during the COVID-19 pandemic. News and rumor spread by social media, television, and everyday interactions concerning the severity of infections and the number of deaths caused an increase in self-medication as a preventive measure. The reason for this panic buying of drugs was identified as a fear of drug shortages, price hikes, the rise of infection, and the availability of medicines and home delivery services during the pandemic.

Conclusion

The purchasing, stockpiling and use of drugs by pharmacies varied based on the person dispensing the drugs, the customer, and the COVID-19 pandemic situation. Furthermore, the role of social media in spreading rumor and (dis) misinformation about drug use, a greater tendency to self-medicate, and poor regulation, influenced the individual's use of drugs. Therefore, the drug regulatory authorities and policymakers need to consider the real level of local drug use in order to encourage more rational use of drugs which will help to ensure that there is reliable access to safe, effective, and high-quality medicines and vaccines for all.

Interventions to address antimicrobial resistance: an ethical analysis of key tensions and how they apply in low- income and middle-income countries

Antimicrobial resistance (AMR) is a global health and one health problem. Efforts to mitigate the problem of AMR are challenging to implement due to unresolved ethical tensions. We present an in-depth ethical analysis of tensions that might hinder efforts to address AMR. First, there is a tension between access and excess in the current population: addressing lack of access requires facilitating use of antimicrobials for some populations, while addressing excessive use for other populations. Second, there is a tension between personal interests and a wider, shared interest in curbing AMR. These personal interests can be viewed from the perspective of individuals seeking care and healthcare providers whose livelihoods depend on using or selling antimicrobials and who profit from the sales and use of antimicrobials. Third, there is a tension between the interests of current populations and the interests of future generations. Last, there is a tension between addressing immediate health threats such as pandemics, and AMR as a 'silent', chronic threat. For each of these tensions, we apply 'descriptive ethics' methods that draw from existing evidence and our experiences living and working in low-income and middle-income countries to highlight how these ethical tensions apply in such settings.

The unseen use of antimicrobials: Drivers of human antibiotic use in a community in Thailand and implications for surveillance

We investigated sociocultural and economic drivers of human antimicrobial use (AMU) in Thailand through ethnographic research, interviews, focus groups and a cross-sectional survey. This community-based study generated findings clustered around three key themes: treatment-seeking practices, medicine use, and interpretation of biomedical constructs. Participants sought care from public health facilities for chronic conditions, but medicines from the private sector were considered more powerful and were preferred for acute complaints. Many antibiotics were unrecognised as such by consumers due to the practice at private healthcare facilities of dispensing repackaged medicines without identifying labels. This unseen use of antibiotics is probably driven by economic drivers including market competition in the private sector, policy implementation drivers whereby rational drug use policies mainly target the public sector, behavioural drivers relating to treatment seeking-practices, and sociocultural drivers that influenced participants' understanding of medical terms and concepts. Participants regarded antibiotics as reducing inflammation and were uncertain about the distinctions between anti-inflammatories, antibiotics, and pain relievers. Antimicrobial Resistance (AMR) was understood as a form of drug tolerance to be remedied by changing the medicine. Community surveys may not provide accurate estimates of AMU where people are unable to distinguish antibiotics reliably from other medicines.

Is this pill an antibiotic or a painkiller? Improving the identification of oral antibiotics for better use

In this Viewpoint, we discuss how the identification of oral antibiotics and their distinction from other commonly used medicines can be challenging for consumers, suppliers, and health-care professionals. There is a large variation in the names that people use to refer to antibiotics and these often relate to their physical appearance, although antibiotics come in many different physical presentations. We also reflect on how the physical appearance of medicine influences health care and public health by affecting communication between patients and health-care professionals, dispensing , medicine use, and the public understanding of health campaigns. Furthermore, we report expert and stakeholder consultations on improving the identification of oral antibiotics and discuss next steps towards a new identification system for antibiotics. We propose to use the physical appearance as a tool to support and nudge awareness about antibiotics and their responsible use.

Prevalence and impacts of self-medication in a disadvantaged setting: the importance of multi-dimensional health interventions

Background

Self-medication is recognized as an effective form of treatment and is increasingly encouraged to treat minor illnesses. However, misuse of self-medication leaves devastating impacts on human health and causes antimicrobial resistance. Using medication without a prescription among farmers could cause more severe effects on their health than non-farm workers since they suffer from several occupational hazards such as excessive exposure to pesticides.

Methods

A cross-sectional study was conducted in 197 residents living in Moc Chau from August to September. A structured questionnaire and face-to-face were used to collecting data. The multivariate logistic model was applied to indicate associated factors with the self-medication.

Results

The prevalence of self-medication among farmers was 67%. Pain relievers (66.7%) and antibiotics (32.5%) were the types of medicines that were the most commonly purchased and used without a medical prescription. Ethnics and health status also significantly affected the self-medication practice as well as the purchase and use of antibiotics. The distance to travel to a medical center and the dangerous or difficult travel, participants with arthritis or inpatient treatment had significantly associated with buying and using the medicine and antibiotics without the medical prescription of farmers.

Conclusion

Our research highlights a considerably high prevalence of self-medication among farmers residing in the mountainous area of Vietnam. Individual factors such as ethnics, health status, distance to health centers, and dangerous or difficult travel were found to be related to the SM practice as well as the purchase and use of antibiotics. From that, the current study suggests interventions. For instance, official guidelines are needed to raise awareness and minimize the disadvantages of self-medication; and digital health technologies should be applied to reduce the gap in healthcare service between mountainous and other areas of Vietnam.

Mystifying medicines and maximising profit: Antibiotic distribution in community pharmacies in Thailand

Thailand's antimicrobial stewardship strategy has focussed on promoting 'rational drug use' in the public sector, to reduce the threat of drug resistance and control healthcare expenditure. The strategy's next ambition is to attend to the private sector, where antibiotics are widely available over the counter without prescription. Using ethnographic and survey data, this paper follows antibiotics through community pharmacies, to explore drug distribution and access, and identify potential challenges for stewardship. We extend the analytical frame beyond 'irrational' dispenser-customer transactions, to explore the logics of practice of a multiplicity of actors in the context of a highly competitive pharmaceutical market. Highlighting the role of the pharmaceutical industry in mystifying medicines, we show how antibiotics are collapsed into a category of 'strong medicines' and requested by customers using 'prescriptions by proxy'. We further examine how Thailand's drug regulation and classificatory systems, historically orientated around access to medicines, enable the proliferation of antibiotics in the context of contemporary efforts to control distribution. Recognising the negotiations involved in dispensing antibiotics in a pluralistic health system, we attempt to reconfigure allocations of responsibility, advocating for stewardship approaches that take into account local ecologies of care, as well as implications for access, equity, and accountability.

Community Health Nurses' Perspective on the Introduced Rational Drug Use Policy in Primary Care Settings in Thailand: A Descriptive Qualitative Study

BACKGROUND

To address the problems related to drug resistance and medication safety, the rational drug use (RDU) policy has been implemented in Thailand since 2014. Theoretically, the policy was supposed to bring drastic changes to the way clinicians prescribe medications and its impacts on clinical practice, however, it has not yet been investigated. The study aimed to describe the experience of community health nurses with regard to the impact of RDU policy implementation on their practices.

METHODS

Focus group interviews and in-depth interviews with community nurses were conducted. Thematic analysis was performed.

RESULTS

Five themes emerged from the analysis, namely, (1) a welcome opportunity, (2) RDU as the quality of healthcare, (3) multidisciplinary collaboration, (4) reinventing productive interactions between nurses and patients, and (5) challenges over control of medications prescribed or purchased elsewhere.

CONCLUSIONS

Implementing RDU in primary care provides opportunities for protecting individual patients and public health as well as safeguarding against professional prescription error. This can be made possible by adopting a systemic approach to changes. Additional educational and organizational support will optimize health professionals' contribution to the implementation and hence optimal outcomes of this important policy.

"Ya Luk Ka Tan Yoo": An Ethnography of Filial Piety Culture, Medication Usage, and Health Perceptions of the Elderly in Rural Southern Thailand

Filial piety is a Buddhist virtue, and its meaning varies across cultures. In Thailand, filial piety refers to an appreciation of one's indebtedness to others. Previous studies showed that filial piety is deeply grounded in longstanding culture values and related to the health of the elderly. Information from some literature revealed that medicinal products given to the elderly by their children, called "Ya-Luk-Ka-Tan-Yoo", were apparent in the communities of rural southern Thailand. This study aims to explore in depth how "Ya-Luk-Ka-Tan-Yoo" is perceived, valued, and functions in southern Thailand's socio-cultural contexts. Ethnography methodology is used, and a researcher was embedded in the field for six months, gathering data through participant observation and ethno-graphic interviews with fifty-two respondents. The findings reveal that filial piety medication is related to the local meanings of medicine, children, and gratitude. "Ya-Luk-Ka-Tan-Yoo," in the eyes of both the elderly and their children, encompasses more than just health. Implicit herein are the concepts of a means of care and gratitude and a symbol of life. Filial piety medication is thus a carrier/medium of physical, financial, and emotional support. This research reveals how the ill health of the elderly is transformed to a commodity. Nonetheless, the negative impact of the efficacy of filial piety medication remains an issue of concern among professionals. The findings indicate that people are aware of the risks associated with self-medication. However, they insisted that their use was still necessary and justifiable.

A Systematic Scoping Review on Migrant Health Coverage in Thailand

(1) Background: Thailand is a major migrant receiving country and pioneer of migrant health policy in the ASEAN region. However, on the ground, coverage of migrants is faced with multiple barriers. (2) Objectives: We aim to scope and analyse the types of available evidence on migrant health coverage in Thailand and identify knowledge gaps. Specifically, we characterise the literature along year of publication, migrant subpopulation, health domain, scope of coverage, methods, study design, objectives and results. (3) Methods: We searched PubMed, Web of Science, Google Scholar, Cochrane Database, Worldwide Science and the Asian Citation Index for peer-reviewed and grey literature in October 2021 for studies analysing original data on health coverage of migrants in Thailand. To conceptualise health coverage, we used the three dimensions availability, accessibility and acceptability. (4) Results: 101 articles were included in the final analysis. Sixty-three were published after 2016, 39 focused on migrant workers and 18 on migrants in general. Forty-two concentrated on health in broader terms, followed by reproductive and maternal health (n = 31). Thirty-eight assessed coverage of specific services and 36 health coverage in general. Migrants themselves and key informants were the main data sources in 80 and 43 of the articles, respectively. Forty publications were qualitative, while 38 applied quantitative methods (22% descriptive; 7% analytical). Among the health coverage components, 79 articles included aspects of accessibility, followed by acceptability (n = 59) and availability (n = 30). (5) Conclusions: While there is a high number and broad range of studies on migrant health coverage in Thailand, we found that research on migrant subgroups, such as victims of trafficking and migrant children, as well as on the health domains, non-communicable diseases and occupational and mental health is neglected.

Community-based antibiotic access and use in six low-income and middle-income countries: a mixed-method approach

BACKGROUND

Antimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices.

METHODS

We did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016-Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions.

FINDINGS

Vietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through health-care facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia.

INTERPRETATION

Contextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance.

FUNDING

Wellcome Trust and Volkswagen Foundation.

Precarity and clinical determinants of healthcare-seeking behaviour and antibiotic use in rural Laos and Thailand

BACKGROUND

The social determinants of health are a decisive yet persistently understudied area for tackling global health challenges like antimicrobial resistance (AMR). Precarity is one determinant whose importance is increasingly recognised, which we define here as 'a form of pernicious self-dependence that undermines individuals' control over their own lives and limits their ability to flexibly respond to crises'. We aimed to assess the relationship between precarity, other forms of deprivation and healthcare-seeking behaviour by asking, 'What is the impact of precarity, marginalisation and clinical presentation on healthcare-seeking behaviour?' and 'Do patients experiencing precarious livelihoods have clinically less advisable healthcare-seeking behaviour?'

METHODS

We used healthcare-seeking behaviour census survey data from rural Thailand and Laos, wherein five rural communities were surveyed two times over a period of 3 months (2-month recall period). Using descriptive statistical and multivariate logistic regression analysis on the illness level, we studied precarity alongside clinical presentation, marginalisation and facilitating solutions during an illness (eg, health-related phone use) as determinants of healthcare-seeking behaviour in the form of healthcare access and antibiotic use.

RESULTS

The data included 1421 illness episodes from 2066 villagers. Patients in precarious circumstances were up to 44.9 percentage points more likely to misuse antibiotics in the presence of situational facilitators (predicted antibiotic misuse: 6.2% (95% CI: 0.9% to 11.4%) vs 51.1% (95% CI: 16.6% to 85.5%) for precarious circumstances with/without facilitation). Marginalisation was linked to lower antibiotic use, but this did not translate into clinically more advisable behaviour. Clinical presentation played only a minor role in determining healthcare access and antibiotic use.

CONCLUSIONS

This study underlines the importance of context and local livelihoods in tackling drug resistance. While supporting the growing emphasis on AMR-sensitive development policy, we call for future research to study systematically the healthcare-seeking behaviour impact of precarious livelihoods, social policy and community development initiatives.

TRIAL REGISTRATION NUMBER

NCT03241316.

US Immigration Is Associated With Rapid and Persistent Acquisition of Antibiotic Resistance Genes in the Gut

Little is known about the effect of human migration on gut microbiome antibiotic resistance gene (ARG) carriage. Using deep shotgun stool metagenomics analysis, we found a rapid increase in gut microbiome ARG richness and abundance in women from 2 independent ethnic groups relocating from Thailand to the United States.