Good example from Thailand --The theoretical framework for antibiotic use intervention

1. Putting theory into practice: Lessons learned from
Antibiotics Smart Use Program
Nithima Sumpradit, Ph.D.1,2
Kanyada Anuwong, Ph.D.3
Pisonthi Chongtrakul, MD.4
Somying Pumthong, Ph.D.3
1. International Health Policy Program, Ministry of Public Health, Thailand
2. Food and Drug Administration, Ministry of Public Health, Thailand
3. Faculty of Pharmacy, Srinakarintharawiroj University, Thailand
4. Faculty of Medicine, Chulalongkorn University, Thailand
The 4th
National Health Research Forum
to Promote the Health Research Systems Strengthening in Lao PDR
October 8, 2010

2. Shared
issues
ที่มา: ปกหนังสือกระบวนทัศน์ใหม่ฯ
โดย ศ.นพ.ประเวศ วะสี
To create societal change on rational use of
medicines, we need to find a common area
that everybody can work together.

3. Antibiotic resistance & Global warming
Picture source: http://ale1980italy.wordpress.com/
Similarities:
• Burning issue but well-
tolerated (no sense of
urgency)
• Everybody’s matters
• Effects on mankind
Difference:
Unlike the global warming,
antibiotic resistance is not
well-recognized among
outsiders.

4. Antibiotics profile, Thailand
• Anti-infective drugs (including antibiotics) are the top
value for being imported and manufactured since 2000.
– In 2007, this drug group was accounted for approximately
20,000 m. baht (625 m. US$) or 20% of all medicine values.
Drug group Values (million baht)
Anti-infective drugs 20,094
Alimentary tract and metabolism 15,747
Central nervous system 13,719
Cardiovascular system 9,909
Source: Drug Control Division, Food and Drug Administration, Thailand (2007).

5. Adverse Drug Reactions
Source: The 2009 Annual report of Food and Drug Administration, Thailand
Antibiotics are the
top of ADR reports.
-In 2007, antibiotics are
accounted for 54% of ADR
reports from all medicines.
Top ten of medicines
reported with ADR (2009)
Reports

6. Antibiotic resistance crisis
Source: http://www.weizmann.ac.il/molgen/Sorek/antimicrobials.html
In Thailand, Acinetobacter baumannii –
resistance to Cabapenam increases from 2.1% in 1998 to 61% in 2010.

7. We cannot outrun bacteria.
So, we must stop creating
selective pressure on them.
unnecessary
use of antibiotics
STOP
Bacteria/
Microbes
Picture source: http://www.geology.wisc.edu/homepages/g100s2/public_html/Geologic_Time/Time_Clock.gif

8. Purposes of ASU
1. To reduce unnecessary antibiotic use in three
common diseases:
– Upper Respiratory Infection (URI) –cold with sore throat
– Acute diarrhea e.g., food poisoning
– Simple wound
Inclusion criteria: OPD patients, 2 years and older with overall good
health.
Exclusion criteria: IPD patients, patients who are seriously ill or
diabetic, or people with low or compromised immune system.
2. To create the decentralized, collaborative
networks between national and local stakeholders.
- Well-accepted national policy on antibiotics
- Social norms

9. Goal: To test the effectiveness of interventions in
changing antibiotics prescribing behavior
Settings: 1 province (Saraburi) involving all 10
community hospitals and 87 primary health centers
Phase 1: Pilot project (2007 – 2008)
Goal: To test feasibility of program expansion and
develop decentralized, collaborative networks.
Settings: 3 provinces (large, medium & small
provinces) and 2 hospital networks (public & private
hospitals)
Phase 2: Scaling up feasibility (2008 – 2009)
Phase 3: Program sustainability (2009 – 2012)
Goal: To integrate ASU into national agenda on
antibiotics and create social norms on proper use of
antibiotics
Strategy: Policy advocacy, Network strengthening &
empowerment, Public communication & campaign
Diffusion update:
Dec 2009
Antibiotics Smart Use Program (5 year)
First policy support was from the National Health Security
Office (NHSO) in March 2009.

10. Conceptual framework

11. Versiom June 19, 2010 /Nithima Sumpradit
Patients
Quality
of life
Prescribing
behavior
Hospital /
healthcare
setting context
Intention
Knowledge, perception
& attitude toward
disease & antibiotics
Subjective norm,
perception of patients’
expectation
Enabling factors
Hospital formulary,
Medical devices
Perceived behavioral
control & Self-efficacy
Hospital networking
context
Community context
National context
Indicator 1: Knowledge, attitude, self-
efficacy, and intention
Indicator 3: Percent of targeted
patients who were not prescribed with
antibiotics
Indicator 4:
Patients’ knowledge,
perceived health and
satisfaction
Reinforcing factors
Directive policy
Financial incentives
Predisposing factors
Cost
Indicator 2:
Amount of
antibiotics being
prescribed
ASU Conceptual framework
Based on:
PRECEDE-PROCEED planning model
Theory of Planned Behavior
Social Cognitive Theory

12. Intervention Implementation

13. Intervention implementation
• ASU is a voluntary program with an incentive policy support
from NHSO.
– 10 good reasons to join ASU
• Local healthcare team (LHT) in each province or setting
plans their own ASU project and can name their own project
(sense of ownership).
• LHT can request support from the ASU program e.g.,
materials, speakers and technical support. Example of
materials to be shown.
• LHT implements the program. Activities are for example:
– Training or group discussion
– Herbal medicine substitution
– Local/Provincial policy
– Positive competition / Campaign
– Reminder (e.g., salary pay slip)
– etc.
• The ASU program monitor progress from LHT and provide

14. Tools for prescribers (to educate and increase confidence)
Tools for patients (to lower expectation on antibiotics)
Examples of ASU tools

16. All supportive materials can be download from
http://newsser.fda.moph.go.th/rumthai/

17. RESULTS

18. Indicator 3: Percent of targeted patients who did not receive ABO
(Goal: 20% increase)
0
10
20
30
40
50
60
70
80
Before After
Saraburi
Ayuthaya (control)
45.5
74.6
44.2
42.3
Intervention, N 8,099
Control, N 5,865
Sample: Two community hospitals and 4 primary health centers from an
intervention province and the control province
Data analysis: Chi-square (before - after) (May–Oct 07 vs. Dec 07–May 08)
Source: Kunyada Anuwong & Somying Pumtong
Effects on prescribing behavior
% of patients
not receiving
antibiotics

19. Indicator 2: Change in antibiotics use (Goal: 10%
reduction)
Data collection: Before (Dec 06–Oct 07) vs. After (Dec 07–Oct 08)
Sample: All 10 community hospitals and 87 primary health
centers in Saraburi (RR = 50%)
Source: Kunyada Anuwong & Somying Pumtong
0
1
2
3
4
5
6
7
Before After
Amount of ABO (Capsules/Tablets)
0
2
4
6
8
10
12
Before After
Primary health centers
Community hospitals
-39%
-18%
-46%
-23%
Amount of ABO (Bottles)
• Result: antibiotics reduction is accounted for
approximately 34,000 US$/year

20. Indication 4: Patients’ perception of health status and
satisfaction despite no antibiotics prescription (Goal: 70%)
Source: Kunyada Anuwong & Somying Pumtong
Data collection: Telephone interviews targeted patients after their hospital
visit for 7-10 days
Sample: 3 settings (N = 2,286): Sarabuti province (n=1,200),
Samutsongkarn province (n = 151), Srivichai private hospital (n = 917)
• Almost all patients (97.1%, 96% and 99.3%,
respectively) were fully recovered or felt better.
• Over 80-90% were satisfied with medical services
and treatment outcome and intended to return to
this healthcare setting for the next medical visit.
Effects on patients’ health
and satisfaction

21. Conclusion
• Purpose 1: Reduction of antibiotics use
– Based on a theoretically-guided, multifaceted
interventions, ASU is successful in changing
antibiotic prescribing behavior.

22. • Purpose 2: Developing decentralized, collaborative
network between national and local stakeholders
• At the end of 2nd
year, more than 10,000 people/ health
professionals was trained and involved in this program
• Some local teams start to apply the ASU framework to
irrational use of other medicines e.g., NSAIDs
• Local materials and media were initiated.
• Strengthening research capacity of local teams via their
own ASU program (22 local projects on ASU in 2010)
• International collaboration opportunity e.g., exchange
program and joined project
Saraburi province team
“R2R Outstanding Award”
Ayutthaya province team
“Excellence Poster Award”

23. Decentralized ASU networks
Local community leaders
ASU team @ community hospital
Training session
ASU & partners
Villagers learning
about ASU
Home visit
Primary health
center
Project’s
grand opening
Singing
contest

24. Strengths and limitations
• Strengths:
– Characteristics of the program
• ASU concept is not complex and it is part of their routine work
• Relatively advantage e.g., cost saving
• Compatible with health professionals’ values e.g., patient safety
• Observable outcomes e.g., patients’ recovery
– Multisectoral partners
– Supportive mechanism for local healthcare teams
– Autonomy “decentralization – sense of ownership”
• Limitations:
– Limited resources
– Resistance to change
– Application to big hospitals or private healthcare setting

25. Thank you for your attention.
Thank you for ASU partners and network.
• Thai Food and Drug Administration
• World Health Organization
• Health Systems Research Institution
• National Health Security Office
• Drug System Monitoring and Development Center
• Faculty of Medicine at Chulalongkorn University, Konkean
University and Thammasart University
• Faculty of Pharmacy at Srinakarintharawiroj University,
Chulalongkorn University, Maha Sarakram University
• Health professionals and participants in
• Saraburi, Ayutthaya, Samutsongkhram and Ubonratchathani
• Kantang community hospital network
• Srivichai private hospital network
• many other provinces and settings
• International Health Policy Program, Thailand