Project details: Antibiotics and Activity Spaces

Overarching objective:

To improve the understanding of patients’ antibiotic-related behaviour to support creative thinking about targeted and unconventional antimicrobial resistance (AMR) interventions in low- and middle-income countries (LMICs).

Primary goals (in order of priority):

P1 Generate novel insights on AMR “Awareness and Engagement” and “Informal Markets and Access to Antibiotics” from a patient behaviour perspective by answering 3 research questions: (1) what are the nature and determinants of problematic antibiotic use, (2) how does new knowledge diffuse in a system of existing practices, and (3) can we detect problematic conditions and behaviours using simple proxy indicators?

P2 Publish a unique open-access data set of antibiotic-related health behaviour from rural Thailand & Laos

P3 Inform behaviour-focused antibiotic policies and AMR interventions in Southeast Asia and beyond

P4 Develop local social science research capacity in public health at our partner institutions in Thailand & Laos

P5 Inspire academic interest in novel methodological (sequence analysis) and theoretical approaches (activity spaces) to behavioural AMR research.

The research was implemented by 10-member survey teams in each country between November 2017 and April 2018. It comprised three main elements:

1) Provincial-level representative survey: Three-stage stratified cluster random sampling design. The first stage involved the random selection of 30 primary sampling units (PSUs) across five purposively selected districts in each site, stratified by their distance to the nearest urban centre (using data from the National Geospatial-Intelligence Agency, 2017). The second stage enumerated all residential buildings within the selected villages using satellite imagery from Google Maps and Bing Maps, of which we sampled 5% of the buildings (but at least 30 houses) in a stratified interval sampling approach to ensure spatial representativeness. During the survey implementation, the third sampling stage involved selecting randomly one respondent for every five adults in each chosen house. The resulting data are representative for the general adult population of rural Chiang Rai and Salavan (522,000 in Chiang Rai and 190,000 in Salavan as per census data).

2) Two-round village census: Community-level social network census surveys in five purposively selected villages across the two field sites (3 in Chiang Rai, 2 in Salavan). The villages were selected in consultation with local stakeholders; guiding criteria were (1) village size and structure, (2) remoteness and road accessibility, (3) economic status as approximated by village-level infrastructure and facilities, (4) ethnic composition and (5) number and location of health facilities within a 2 km radius. The villages had between 300 and 1,500 residents. Within the selected communities, all households were approached, their adult members enumerated and invited to participate. Between the two rounds of the census surveys, the survey team conducted half-day workshops for 25-35 participants to share knowledge and learn from villagers about their medicine use.

3) Qualitative component: Cognitive interviews were conducted for questionnaire testing and development, but also to contextualise survey data and help interpret them. The questionnaire itself involved components on the respondents’ socio-economic and demographic background, their knowledge and attitudes with respect to antibiotics and drug resistance, and their behaviour during recent episodes of acute illnesses. Previous mixed-methods research on health behaviour and mobile phone use in India and China and on antibiotic use and primary healthcare in Thailand and Myanmar informed the study.

In addition to the half-day workshops, the project-related public engagement activities also involved an international photo exhibition on traditional healing practices in Northern Thailand entitled “Tales of Treatment”.