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, Thailand2. Food and Drug Administration, Ministry of Public Health, Thailand3. Faculty of Pharmacy, Srinakarintharawiroj University, Thailand4. 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
Shared issues
ที่��มา: ปกหนังสื อกระบวนัที่ศนั�ใหม�ฯ โดย ศ.นัพ.ประเวศ วะสื�
To create societal change on rational use of medicines, we need to find a common area that everybody can work together.
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.
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 9,909Source: Drug Control Division, Food and Drug Administration, Thailand (2007).
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
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.
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
Purposes of ASU1. To reduce unnecessary antibiotic use in three
common diseases:– Upper Respiratory Infection (URI) –cold with sore throat– Acute diarrhea e.g., food poisoning– Simple woundInclusion 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
Goal: To test the effectiveness of interventions in changing antibiotics prescribing behaviorSettings: 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 antibioticsStrategy: 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.
Versiom June 19, 2010 /Nithima Sumpradit
PatientsQuality 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 policyFinancial incentives
Predisposing factors
Cost
Indicator 2: Amount of antibiotics being prescribed
ASU Conceptual framework
Based on:PRECEDE-PROCEED planning modelTheory of Planned BehaviorSocial Cognitive Theory
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 support to LHT.
Tools for prescribers (to educate and increase confidence)
Tools for patients (to lower expectation on antibiotics)
Examples of ASU tools
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
44.242.3
Intervention, N 8,099 Control, N 5,865
Sample: Two community hospitals and 4 primary health centers from an intervention province and the control provinceData 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
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
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 daysSample: 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
Conclusion
• Purpose 1: Reduction of antibiotics use
– Based on a theoretically-guided, multifaceted interventions, ASU is successful in changing antibiotic prescribing behavior.
• 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”
Decentralized ASU networks
Local community leaders
ASU team @ community hospitalTraining session
ASU & partners
Villagers learning about ASU
Home visit
Primary health center
Project’s grand opening
Singing contest
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
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
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