Putting theory into practice: Lessons learned from Antibiotics Smart Use Program

1. Putting theory into practice: Lessons learned from Antibiotics Smart Use Program The 4th National Health Research Forum to Promote the Health Research Systems Strengthening in Lao PDR October 8, 2010 Nithima Sumpradit, Ph.D.1,2Kanyada 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

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

3. Antibiotic resistance & Global warming • 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. Picture source: http://ale1980italy.wordpress.com/

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. Source: Drug Control Division, Food and Drug Administration, Thailand (2007).

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

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

7. We cannot outrun bacteria. So, we must stop creating selective pressure on them. Bacteria/ Microbes STOP unnecessary use of antibiotics 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. • To create the decentralized, collaborative networks between national and local stakeholders. • Well-accepted national policy on antibiotics • Social norms

9. Antibiotics Smart Use Program (5 year) Phase 1: Pilot project (2007 – 2008) • 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 Phase2: Scaling up feasibility (2008 – 2009) 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) Diffusion update: Dec 2009 Phase3: 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 First policy support was from the National Health Security Office (NHSO) in March 2009.

10. Conceptual framework

11. Indicator 1: Knowledge, attitude, self-efficacy, and intention Indicator 3: Percent of targeted patients who were not prescribed with antibiotics Predisposing factors Knowledge, perception & attitude toward disease & antibiotics Indicator4: Patients’ knowledge, perceived health and satisfaction Subjective norm, perception of patients’ expectation Intention Prescribing behavior Patients Quality of life Perceived behavioral control & Self-efficacy Cost Hospital / healthcare setting context Reinforcing factorsDirective policyFinancial incentives Enabling factorsHospital formulary, Medical devices Indicator2: Amount of antibiotics being prescribed Hospital networking context Community context National context ASU Conceptual framework Based on: PRECEDE-PROCEED planning model Theory of Planned Behavior Social Cognitive Theory Versiom June 19, 2010 /Nithima Sumpradit

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 support to LHT.

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

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

17. RESULTS

18. Effects on prescribing behavior Intervention, N 8,099 Control, N 5,865 74.6 45.5 44.2 42.3 Indicator3: Percent of targeted patients who did not receive ABO (Goal: 20% increase) 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) % of patients not receiving antibiotics Source: Kunyada Anuwong & Somying Pumtong

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%) Amount of ABO (Capsules/Tablets) Amount of ABO (Bottles) -23% -18% -46% -39% • Result: antibiotics reduction is accounted for • approximately 34,000 US$/year Source: Kunyada Anuwong & Somying Pumtong

20. Effects on patients’ health and satisfaction Indication 4: Patients’ perception of health status and satisfaction despite no antibiotics prescription (Goal: 70%) • 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. 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) Source: Kunyada Anuwong & Somying Pumtong

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

22. Ayutthaya province team “Excellence Poster Award” Saraburi province team “R2R Outstanding Award” • 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

23. Decentralized ASU networks Villagers learning about ASU ASU & partners Training session Primary health center ASU team @ community hospital Home visit Local community leaders 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