Journal Article > CommentaryFull Text
J Glob Antimicrob Resist. 22 October 2021; Volume 27; 236-238.; DOI:10.1016/j.jgar.2021.10.007
Nair MM, Zeegers MP, Varghese GM, Burza S
J Glob Antimicrob Resist. 22 October 2021; Volume 27; 236-238.; DOI:10.1016/j.jgar.2021.10.007
Antimicrobial resistance (AMR) is widely recognised as a global health threat, which is projected to account for more deaths than cancer by 2050. The Government of India has formulated a National Action Plan to tackle AMR (NAP-AMR), largely modelled on the World Health Organization's Global Action Plan on AMR. While the NAP-AMR successfully mirrors the Global Action Plan and lays out ambitious goals, we find that the lack of financial allocation across states, poor enforcement and inadequate multisectoral co-ordination have hampered progress. A broader focus on improving infrastructure for water and sanitation, linking the issue of AMR to existing vertical health programmes for human immunodeficiency virus (HIV) and tuberculosis (TB), prioritising infection prevention and control, strengthening the frontline healthcare workforce in rural and peri-urban settings to reduce reliance on antibiotics, leveraging point-of-care testing and mobile app-based health interventions for diagnosis and surveillance, and adopting a socioecological approach to health and development would help to create an enabling environment for concrete action on AMR in India.
Conference Material > Abstract
Nair MM, Kumar P, Mahajan R, Harshana A, Richardson K, et al.
MSF Scientific Days International 2020: Research. 20 May 2020
INTRODUCTION
Effective palliative care requires a multidisciplinary and holistic approach based on the provision of comprehensive care with treatment of pain and physical symptoms, management of psychosocial needs, as well as other non-medical needs. Few studies exist about palliative care in India, particularly in the context of people living with HIV/AIDS. MSF supports an advanced HIV inpatient ward in Bihar, where mortality rates are high. We aimed to explore the lived experiences of palliative care among patients, and their families, with advanced HIV, to understand conceptions of illness, death, and end-of-life care in Bihar, India.
METHODS
We carried out an exploratory, qualitative study using 21 semi-structured in-depth interviews and 1 focus group discussion. Participants included patients living with HIV/AIDS (PLHA), caregivers, relatives of deceased patients who had been treated in a government hospital, and key informants from community-based organizations in Patna, Bihar. Interview data were transcribed verbatim, translated from Hindi or other local languages into English by research assistants, and analysed using NVIVO (QSR International, Victoria, Australia). Two researchers then carried out inductive, thematic analysis of the data. Emergent codes and categories were identified and compared to subsequent areas of inquiry.
ETHICS
This study was approved by the ethics committee of the All India Institute of Medical Sciences, Patna, India, and the MSF Ethics Review Board.
RESULTS
Latent thematic analysis revealed poor understanding of palliative care among advanced HIV patients and their caregivers; the term “palliative care” was not known to PLHA. PLHA and relatives expected active treatment, despite poor prognosis, and believed that dying patients should be provided a separate, private inpatient area. However, patients were able to identify the importance of psychosocial counselling, the desire for a separate dedicated space for terminal patients with social and recreational activities to prevent isolation, and a preference for home-based palliative care wherever possible. Our data showed that relatives of patients played a substantial role in influencing doctors and nurses to avoid divulging the nature of the disease and prognosis directly to patients. There was variation in preferences for open disclosure of prognosis amongst critically ill PLHA and relatives of deceased patients.
CONCLUSION
There is a need to improve palliative care provision for advanced HIV patients in Bihar, who do not typically have access to such services. PLHA should have a separate dedicated area, with adequate psychosocial counselling for patients and families, and regular recreational activities to prevent social isolation.
CONFLICTS OF INTEREST
None declared.
Effective palliative care requires a multidisciplinary and holistic approach based on the provision of comprehensive care with treatment of pain and physical symptoms, management of psychosocial needs, as well as other non-medical needs. Few studies exist about palliative care in India, particularly in the context of people living with HIV/AIDS. MSF supports an advanced HIV inpatient ward in Bihar, where mortality rates are high. We aimed to explore the lived experiences of palliative care among patients, and their families, with advanced HIV, to understand conceptions of illness, death, and end-of-life care in Bihar, India.
METHODS
We carried out an exploratory, qualitative study using 21 semi-structured in-depth interviews and 1 focus group discussion. Participants included patients living with HIV/AIDS (PLHA), caregivers, relatives of deceased patients who had been treated in a government hospital, and key informants from community-based organizations in Patna, Bihar. Interview data were transcribed verbatim, translated from Hindi or other local languages into English by research assistants, and analysed using NVIVO (QSR International, Victoria, Australia). Two researchers then carried out inductive, thematic analysis of the data. Emergent codes and categories were identified and compared to subsequent areas of inquiry.
ETHICS
This study was approved by the ethics committee of the All India Institute of Medical Sciences, Patna, India, and the MSF Ethics Review Board.
RESULTS
Latent thematic analysis revealed poor understanding of palliative care among advanced HIV patients and their caregivers; the term “palliative care” was not known to PLHA. PLHA and relatives expected active treatment, despite poor prognosis, and believed that dying patients should be provided a separate, private inpatient area. However, patients were able to identify the importance of psychosocial counselling, the desire for a separate dedicated space for terminal patients with social and recreational activities to prevent isolation, and a preference for home-based palliative care wherever possible. Our data showed that relatives of patients played a substantial role in influencing doctors and nurses to avoid divulging the nature of the disease and prognosis directly to patients. There was variation in preferences for open disclosure of prognosis amongst critically ill PLHA and relatives of deceased patients.
CONCLUSION
There is a need to improve palliative care provision for advanced HIV patients in Bihar, who do not typically have access to such services. PLHA should have a separate dedicated area, with adequate psychosocial counselling for patients and families, and regular recreational activities to prevent social isolation.
CONFLICTS OF INTEREST
None declared.
Journal Article > ResearchFull Text
PLOS One. 27 July 2019; Volume 14; DOI:10.1371/journal.pone.0219002
Nair MM, Tripathi S, Mazumdar S, Mahajan R, Harshana A, et al.
PLOS One. 27 July 2019; Volume 14; DOI:10.1371/journal.pone.0219002
Background
Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal.
Materials and methods
We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner.
Results
Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another.
Conclusions
A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.
Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal.
Materials and methods
We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner.
Results
Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another.
Conclusions
A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.
Journal Article > ResearchAbstract Only
J Vector Borne Dis. 1 July 2021; DOI:10.4103/0972-9062.321747
Mahajan R, Nair MM, Saldanha AM, Harshana A, de Lima Pereira A, et al.
J Vector Borne Dis. 1 July 2021; DOI:10.4103/0972-9062.321747
BACKGROUND AND OBJECTIVES
There is limited evidence regarding the accuracy of dengue rapid diagnostic kits despite their extensive use in India. We evaluated the performance of four immunochromatographic Rapid Diagnostic Test (RDTs) kits: Multisure dengue Ab/Ag rapid test (MP biomedicals; MP), Dengucheck combo (Zephyr Biomedicals; ZB), SD bioline dengue duo (Alere; SD) and Dengue day 1 test (J Mitra; JM).
METHODS
This is a laboratory-based diagnostic evaluation study. Rapid tests results were compared to reference non-structural (NS1) antigen or immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) results of 241 dengue-positive samples and 247 dengue-negative samples. Sensitivity and specificity of NS1 and IgM components of each RDT were calculated separately and in combination (either NS1 or IgM positive) against reference standard ELISA.
RESULTS
A total of 238, 226, 208, and 146 reference NS1 ELISA samples were tested with MP, ZB, SD, and JM tests, respectively. In comparison to the NS1 ELISA reference tests, the NS1 component of MP, ZB, SD, and JM RDTs demonstrated a sensitivity of 71.8%, 85.1%, 77.2% and 80.9% respectively and specificity of 90.1%, 92.8%, 96.1 %, and 93.6%, respectively. In comparison to the IgM ELISA reference test, the IgM component of RDTs showed a sensitivity of 40.0%, 50.3%, 47.3% and 20.0% respectively and specificity of 92.4%, 88.6%, 96.5%, and 92.2% respectively. Combining NS1 antigen and IgM antibody results led to sensitivities of 87.5%, 82.9%, 93.8% and 91.7% respectively, and specificities of 75.3%, 73.9%, 76.5%, and 80.0% respectively.
INTERPRETATION & CONCLUSIONS
Though specificities were acceptable, the sensitivities of each test were markedly lower than manufacturers' claims. These results also support the added value of combined antigen-and antibody-based RDTs for the diagnosis of acute dengue.
There is limited evidence regarding the accuracy of dengue rapid diagnostic kits despite their extensive use in India. We evaluated the performance of four immunochromatographic Rapid Diagnostic Test (RDTs) kits: Multisure dengue Ab/Ag rapid test (MP biomedicals; MP), Dengucheck combo (Zephyr Biomedicals; ZB), SD bioline dengue duo (Alere; SD) and Dengue day 1 test (J Mitra; JM).
METHODS
This is a laboratory-based diagnostic evaluation study. Rapid tests results were compared to reference non-structural (NS1) antigen or immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) results of 241 dengue-positive samples and 247 dengue-negative samples. Sensitivity and specificity of NS1 and IgM components of each RDT were calculated separately and in combination (either NS1 or IgM positive) against reference standard ELISA.
RESULTS
A total of 238, 226, 208, and 146 reference NS1 ELISA samples were tested with MP, ZB, SD, and JM tests, respectively. In comparison to the NS1 ELISA reference tests, the NS1 component of MP, ZB, SD, and JM RDTs demonstrated a sensitivity of 71.8%, 85.1%, 77.2% and 80.9% respectively and specificity of 90.1%, 92.8%, 96.1 %, and 93.6%, respectively. In comparison to the IgM ELISA reference test, the IgM component of RDTs showed a sensitivity of 40.0%, 50.3%, 47.3% and 20.0% respectively and specificity of 92.4%, 88.6%, 96.5%, and 92.2% respectively. Combining NS1 antigen and IgM antibody results led to sensitivities of 87.5%, 82.9%, 93.8% and 91.7% respectively, and specificities of 75.3%, 73.9%, 76.5%, and 80.0% respectively.
INTERPRETATION & CONCLUSIONS
Though specificities were acceptable, the sensitivities of each test were markedly lower than manufacturers' claims. These results also support the added value of combined antigen-and antibody-based RDTs for the diagnosis of acute dengue.
Journal Article > ResearchFull Text
BMJ Open. 5 October 2020; Volume 10 (Issue 10); e036179.; DOI:10.1136/bmjopen-2019-036179
Nair MM, Kumar P, Mahajan R, Harshana A, Richardson K, et al.
BMJ Open. 5 October 2020; Volume 10 (Issue 10); e036179.; DOI:10.1136/bmjopen-2019-036179
OBJECTIVES
This study aimed to assess the lived experiences of palliative care among critically unwell people living with HIV/AIDS (PLHA), caregivers and relatives of deceased patients. It also aimed to understand the broader palliative care context in Bihar.
DESIGN
This was an exploratory, qualitative study which used thematic analysis of semistructured, in-depth interviews as well as a focus group discussion.
SETTINGS
All interviews took place in a secondary care hospital in Patna, Bihar which provides holistic care to critically unwell PLHA.
PARTICIPANTS
We purposively selected 29 participants: 10 critically unwell PLHA, 5 caregivers of hospitalised patients, 7 relatives of deceased patients who were treated in the secondary care hospital and 7 key informants from community-based organisations.
RESULTS
Critically ill PLHA emphasised the need for psychosocial counselling and opportunities for social interaction in the ward, as well as a preference for components of home-based palliative care, even though they were unfamiliar with actual terms such as 'palliative care' and 'end-of-life care'. Critically unwell PLHA generally expressed preference for separate, private inpatient areas for end-of-life care. Relatives of deceased patients stated that witnessing patients' deaths caused trauma for other PLHA. Caregivers and relatives of deceased patients felt there was inadequate time and space for grieving in the hospital. While both critically ill PLHA and relatives wished that poor prognosis be transparently disclosed to family members, many felt it should not be disclosed to the dying patients themselves.
CONCLUSIONS
Despite expected high inpatient fatality rates, PLHA in Bihar lack access to palliative care services. PLHA receiving end-of-life care in hospitals should have a separate dedicated area, with adequate psychosocial counselling and activities to prevent social isolation. Healthcare providers should make concerted efforts to inquire, understand and adapt their messaging on prognosis and end-of-life care based on patients' preferences.
This study aimed to assess the lived experiences of palliative care among critically unwell people living with HIV/AIDS (PLHA), caregivers and relatives of deceased patients. It also aimed to understand the broader palliative care context in Bihar.
DESIGN
This was an exploratory, qualitative study which used thematic analysis of semistructured, in-depth interviews as well as a focus group discussion.
SETTINGS
All interviews took place in a secondary care hospital in Patna, Bihar which provides holistic care to critically unwell PLHA.
PARTICIPANTS
We purposively selected 29 participants: 10 critically unwell PLHA, 5 caregivers of hospitalised patients, 7 relatives of deceased patients who were treated in the secondary care hospital and 7 key informants from community-based organisations.
RESULTS
Critically ill PLHA emphasised the need for psychosocial counselling and opportunities for social interaction in the ward, as well as a preference for components of home-based palliative care, even though they were unfamiliar with actual terms such as 'palliative care' and 'end-of-life care'. Critically unwell PLHA generally expressed preference for separate, private inpatient areas for end-of-life care. Relatives of deceased patients stated that witnessing patients' deaths caused trauma for other PLHA. Caregivers and relatives of deceased patients felt there was inadequate time and space for grieving in the hospital. While both critically ill PLHA and relatives wished that poor prognosis be transparently disclosed to family members, many felt it should not be disclosed to the dying patients themselves.
CONCLUSIONS
Despite expected high inpatient fatality rates, PLHA in Bihar lack access to palliative care services. PLHA receiving end-of-life care in hospitals should have a separate dedicated area, with adequate psychosocial counselling and activities to prevent social isolation. Healthcare providers should make concerted efforts to inquire, understand and adapt their messaging on prognosis and end-of-life care based on patients' preferences.
Journal Article > ReviewFull Text
Trop Med Int Health. 16 January 2021; Volume 26 (Issue 5); 504-517.; DOI:10.1111/tmi.13550
Nair MM, Mahajan R, Burza S, Zeegers MP
Trop Med Int Health. 16 January 2021; Volume 26 (Issue 5); 504-517.; DOI:10.1111/tmi.13550
OBJECTIVES
To explore the current evidence on interventions to influence antibiotic prescribing behaviour of health professionals in outpatient settings in low‐income and lower‐middle‐income countries, an underrepresented area in the literature.
METHODS
The systematic review protocol for this study was registered in PROSPERO (CRD42020170504). We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies relating to antibiotic prescribing of health professionals in outpatient settings in low‐income and lower‐middle‐income countries. Behavioural interventions were classified as persuasive, enabling, restrictive, structural or bundle (mix of different interventions). In total, 3,514 abstracts were screened and 42 studies were selected for full‐text review, with 13 studies included in the final narrative synthesis.
RESULTS
Of the 13 included studies, five were conducted in Vietnam, two in Sudan, two in Tanzania, two in India and two in Kenya. All studies were conducted in the outpatient or ambulatory setting: eight took place in primary health centres, two in private clinics and three in pharmacies. Our review found that enabling or educational interventions alone may not be sufficient to overcome the ingrained incentives to link revenue generation to sales of antibiotics, and hence, their inappropriate prescription or misuse. Bundle interventions appear to be very effective at changing prescription behaviour among healthcare providers, including drug sellers and pharmacists.
CONCLUSIONS
Multi‐faceted bundle interventions that combine regulation enforcement with face‐to‐face education and peer influence may be more effective than educational interventions alone at curbing inappropriate antibiotic use.
To explore the current evidence on interventions to influence antibiotic prescribing behaviour of health professionals in outpatient settings in low‐income and lower‐middle‐income countries, an underrepresented area in the literature.
METHODS
The systematic review protocol for this study was registered in PROSPERO (CRD42020170504). We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies relating to antibiotic prescribing of health professionals in outpatient settings in low‐income and lower‐middle‐income countries. Behavioural interventions were classified as persuasive, enabling, restrictive, structural or bundle (mix of different interventions). In total, 3,514 abstracts were screened and 42 studies were selected for full‐text review, with 13 studies included in the final narrative synthesis.
RESULTS
Of the 13 included studies, five were conducted in Vietnam, two in Sudan, two in Tanzania, two in India and two in Kenya. All studies were conducted in the outpatient or ambulatory setting: eight took place in primary health centres, two in private clinics and three in pharmacies. Our review found that enabling or educational interventions alone may not be sufficient to overcome the ingrained incentives to link revenue generation to sales of antibiotics, and hence, their inappropriate prescription or misuse. Bundle interventions appear to be very effective at changing prescription behaviour among healthcare providers, including drug sellers and pharmacists.
CONCLUSIONS
Multi‐faceted bundle interventions that combine regulation enforcement with face‐to‐face education and peer influence may be more effective than educational interventions alone at curbing inappropriate antibiotic use.
Conference Material > Abstract
Nair MM, Tripathi S, Mazumdar S, Mahajan R, Harshana A, et al.
MSF Scientific Days UK 2019: Research. 9 May 2019
INTRODUCTION
Inappropriate antibiotic use is thought to be widespread, particularly in less well-regulated healthcare systems, and contributes to antimicrobial resistance. Patients may interact with both formal and informal healthcare providers in accessing primary healthcare, but the level of knowledge, attitudes, and practices (KAP) of both providers and patients in relation to appropriateness of prescribing has not been well documented in India.
METHODS
We aimed to use a mixed methods approach to explore the prescribing patterns of informal and formal healthcare providers in West Bardhaman district of West Bengal, India. We surveyed 384 participants using convenience sampling (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) using a validated KAP questionnaire, adapted to the local context. In order to triangulate data, we also conducted 28, semi-structured, in-depth interviews with providers and community members. Qualitative data was analysed using the framework method in an inductive and deductive manner, while quantitative data was collated in Excel and analysed using SPSS. Questions used 5-point Likert scales, with maximum possible scores of 32, 45, and 20 in the knowledge, attitudes, and practice sections respectively, and a maximum total composite score of 97. We calculated a percent composite score across all categories by dividing the mean score with the maximum possible score, and used multivariate logistic regression analysis to estimate the odds of having a low composite score (<60) based on occupation by comparing allopathic doctors (referent category) with all other study participants, adjusted for age and gender.
ETHICS
This study was approved by the Ethics Committee of the Calcutta School of Tropical Medicine, Kolkata, India, and the MSF Ethics Review Board.
RESULTS
We found substantial dissonance between knowledge and practice amongst allopathic doctors, who scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed worst regarding practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n=82) reported prescribing them in this situation.
19 (6.6%) non-doctors (including eight informal health providers, 8.3%), three nurses (3.1%), and eight pharmacy workers (8.3%) received low overall composite scores for KAP, as compared to doctors (n=1; 1%; OR 10.4, 95% CI 5.4-20.0, p<0.01). Over 95% of informal health providers, nursing staff and pharmacy shopkeepers stated knowledge of antibiotics was important, even though none were legally permitted to prescribe. Only 42 (43.8%) doctors and 17 (17.7%) pharmacy shopkeepers correctly identified gentamicin as an antibiotic contraindicated in pregnancy. 30.8% (118) of all providers and 56 out of 96 (58%) of all informal providers described pharmaceutical company representatives as a major source of information about antibiotics. Healthcare providers described company representatives as having extensive networks, with informal providers reporting that attendance at antibiotic marketing conferences was common. Community members reported actively seeking “potent” medicines from providers, and frequent switching of providers if they perceived medications to be inadequate.
CONCLUSION
Current initiatives aimed at tackling antimicrobial resistance in Asia focus on surveillance systems, regulation of antibiotic sales, and on national guidelines for use, but fail to take into account patient perceptions and the relationships between different providers and the role of pharmaceutical company representatives. We highlight ways in which pharmaceutical company representatives play roles in networking with informal providers.
CONFLICTS OF INTEREST: None declared.
Mohit Nair is a qualitative research manager with MSF, India, and holds a Master’s in Public Health from Harvard T.H. Chan School of Public Health. Previous work has focused on perceptions of care amongst advanced HIV patients in Bihar, drivers of antibiotic use in West Bengal, and quality of life for HIV-kala-azar patients in Bihar. Prior to joining MSF, Mohit was a consultant for Save the Children, in Laos, assessing gaps in primary healthcare and developing action plans for children with disabilities.
Inappropriate antibiotic use is thought to be widespread, particularly in less well-regulated healthcare systems, and contributes to antimicrobial resistance. Patients may interact with both formal and informal healthcare providers in accessing primary healthcare, but the level of knowledge, attitudes, and practices (KAP) of both providers and patients in relation to appropriateness of prescribing has not been well documented in India.
METHODS
We aimed to use a mixed methods approach to explore the prescribing patterns of informal and formal healthcare providers in West Bardhaman district of West Bengal, India. We surveyed 384 participants using convenience sampling (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) using a validated KAP questionnaire, adapted to the local context. In order to triangulate data, we also conducted 28, semi-structured, in-depth interviews with providers and community members. Qualitative data was analysed using the framework method in an inductive and deductive manner, while quantitative data was collated in Excel and analysed using SPSS. Questions used 5-point Likert scales, with maximum possible scores of 32, 45, and 20 in the knowledge, attitudes, and practice sections respectively, and a maximum total composite score of 97. We calculated a percent composite score across all categories by dividing the mean score with the maximum possible score, and used multivariate logistic regression analysis to estimate the odds of having a low composite score (<60) based on occupation by comparing allopathic doctors (referent category) with all other study participants, adjusted for age and gender.
ETHICS
This study was approved by the Ethics Committee of the Calcutta School of Tropical Medicine, Kolkata, India, and the MSF Ethics Review Board.
RESULTS
We found substantial dissonance between knowledge and practice amongst allopathic doctors, who scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed worst regarding practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n=82) reported prescribing them in this situation.
19 (6.6%) non-doctors (including eight informal health providers, 8.3%), three nurses (3.1%), and eight pharmacy workers (8.3%) received low overall composite scores for KAP, as compared to doctors (n=1; 1%; OR 10.4, 95% CI 5.4-20.0, p<0.01). Over 95% of informal health providers, nursing staff and pharmacy shopkeepers stated knowledge of antibiotics was important, even though none were legally permitted to prescribe. Only 42 (43.8%) doctors and 17 (17.7%) pharmacy shopkeepers correctly identified gentamicin as an antibiotic contraindicated in pregnancy. 30.8% (118) of all providers and 56 out of 96 (58%) of all informal providers described pharmaceutical company representatives as a major source of information about antibiotics. Healthcare providers described company representatives as having extensive networks, with informal providers reporting that attendance at antibiotic marketing conferences was common. Community members reported actively seeking “potent” medicines from providers, and frequent switching of providers if they perceived medications to be inadequate.
CONCLUSION
Current initiatives aimed at tackling antimicrobial resistance in Asia focus on surveillance systems, regulation of antibiotic sales, and on national guidelines for use, but fail to take into account patient perceptions and the relationships between different providers and the role of pharmaceutical company representatives. We highlight ways in which pharmaceutical company representatives play roles in networking with informal providers.
CONFLICTS OF INTEREST: None declared.
Mohit Nair is a qualitative research manager with MSF, India, and holds a Master’s in Public Health from Harvard T.H. Chan School of Public Health. Previous work has focused on perceptions of care amongst advanced HIV patients in Bihar, drivers of antibiotic use in West Bengal, and quality of life for HIV-kala-azar patients in Bihar. Prior to joining MSF, Mohit was a consultant for Save the Children, in Laos, assessing gaps in primary healthcare and developing action plans for children with disabilities.
Conference Material > Abstract
de Lima Pereira A, Saldanha E, Nair MM, Potter L, Bryson LHM
MSF Scientific Days International 2021: Innovation. 20 May 2021
WHAT CHALLENGES OR OPPORTUNITY DID YOU TRY TO ADDRESS? WERE EXISTING SOLUTIONS NOT AVAILABLE OR NOT GOOD ENOUGH?
An estimated 1.5 million children die each year from vaccine-preventable diseases. Besides vaccines, other life-saving drugs such as oxytocin, rectal artesunate, snake antivenom, insulin, and diazepam are unavailable at peripheral health centres due to a lack of cold chain facilities. Existing solutions are inadequate as they rely heavily on passive cold chain especially for the last mile, necessitating centralised models of healthcare delivery and leading to increased patient costs and limited access.
WHY DOES THIS CHALLENGE OR OPPORTUNITY MATTER--WHY SHOULD MSF ADDRESS IT?
Desk research has shown that there is no single product that can address this gap. A solution would have a positive impact at scale in most complex medical emergencies and could be a ubiquitous tool for decreasing mortality in neglected populations.
DESCRIBE YOUR INNOVATION AND WHAT MAKES IT INNOVATIVE
We are rethinking the passive vaccine day carrier by developing FriGO, a long-term, portable, active cool box that uses off-grid sources of energy. FriGo utilises solar power, thermoelectric cooling, phase-change material, battery back-up and a unique construction to provide continuous portable off-grid cooling for prolonged periods of time. FriGo benefits from accurate condition logging and monitoring and preventive action warning system. The technology that is utilised in FriGo has been individually proven in several other industries from international food shipping to outdoor camping. However, resource-limited healthcare settings require appropriately customised solutions. Although a handful of organisations are looking at this problem, a successful scalable solution is yet to be reached. The Covid-19 pandemic has brought a renewed focus on the vaccine cold chain industry and could act as a catalyst in bringing about this much needed change.
WHO WILL BENEFIT (WHOSE LIFE / WORK WILL IT IMPROVE?) AND WERE THEY INVOLVED IN THE DESIGN?
FriGo has the potential to decrease mortality and morbidity in most contexts where MSF works by increasing our reach and decreasing wastage.
WHAT OBJECTIVES DID YOU SET FOR THE PROJECT--WHAT DID YOU WANT TO ACHIEVE AND HOW DID YOU DEFINE AND MEASURE SUCCESS (IMPROVED SERVICE, LOWER COST, BETTER EFFICIENCY, BETTER USER EXPERIENCE, ETC.)?
In October 2019, we conducted a user preference study involving field workers and technical specialists to define and design the project. The primary objective and measure of success was to prove that a portable chamber could maintain a temperature of 2-8°C for a minimum of 28 days without an external energy source.
WHAT DATA DID YOU COLLECT TO MEASURE THE INNOVATION AGAINST THESE INDICATORS AND HOW DID YOU COLLECT IT? INCLUDE IF YOU DECIDED TO CHANGE THE INDICATORS AND WHY
Three assessments (desk research, technical study, and user preference study) were conducted to assess available products, feasibility, minimum requirements, cost comparison, and unmet needs. A proof-of-concept is underway.
HOW DID YOU ANALYSE THIS DATA TO UNDERSTAND TO WHAT EXTENT THE INNOVATION ACHIEVED ITS OBJECTIVES? DID THIS INCLUDE A COMPARISON TO THE STATUS QUO OR AN EXISTING SOLUTION?
Phase 1 aimed at validating the use-cases and reviewing the available products in the market. The data was collected through interviews and correspondence with experts and analysed by the team. The objectives for phase 2 were to validate the specific design and features, through an in-depth interview-based user preference study and a desk research technology analysis. Phase 3 objectives focus on validating the feasibility of the concept by building a proof-of-concept to demonstrate the proposed features of the product. The experimentation and testing are ongoing and will be assessed based on milestones established at the outset of the phase. The final milestone will be the ability to maintain a cold-life of 2-8°C for seven days with the possibility of continuous repeatability, without user-intervention or grid resources.
WERE THERE ANY LIMITATIONS TO THE DATA YOU COLLECTED, HOW YOU COLLECTED IT OR HOW YOU ANALYSED IT, OR WERE THERE ANY UNFORESEEN FACTORS THAT MAY HAVE INTERFERED WITH YOUR RESULTS?
Data collection was comprehensive, but non-exhaustive. Prototype data collection is underway but will need to be done in a range of field locations to ensure it works under various field conditions.
WHAT RESULTS DID YOU GET?
Phase 1 revealed that existing solutions, while some of them innovative, did not address all the current problems highlighted by some of the use-cases, and did not greatly change the current possibilities. The outcome of the user-preference study and technology analysis (phase 2) highlighted specific requirements such as being durable, easily carried on the back, suitable for all modes of transport, plug and play operation, and preferably around 2.5L in capacity. From a service perspective, the product needs to have prolonged cold life, minimal expertise and intervention, no grid dependency, non-circular route possibilities, fail-safe responses and decentralised operation. FriGo is being designed, prototyped and tested based on these findings. Some of the results achieved include the ability to cool a 1L payload chamber to 2-8°C, with an ambient temperature of +30°C, in under 4 hours solely using solar power, a thermoelectric heat pump, and a phase-change material thermal battery; with a current cold-life retention of 28h through an insulating structure.
COMPARING THE RESULTS FROM YOUR DATA ANALYSIS TO YOUR OBJECTIVES, EXPLAIN WHY YOU CONSIDER YOUR INNOVATION A SUCCESS OR FAILURE?
These conclusions can only be drawn after field testing is completed.
TO WHAT EXTENT DID THE INNOVATION BENEFIT PEOPLE’S LIVES / WORK?
This will be determined during the next phase of development, when FriGo is scaled-up and piloted.
IS THERE ANYTHING THAT YOU WOULD DO DIFFERENTLY IF YOU WERE TO DO THE WORK AGAIN?
Framing the product lifecycle to anticipate partnerships and legal processes, and consider alternative pathways, would reduce negative impacts on progress and timeline.
WHAT ARE THE NEXT STEPS FOR THE INNOVATION ITSELF (SCALE UP, IMPLEMENTATION, FURTHER DEVELOPMENT, DISCONTINUED)?
Following a successful proof-of-concept, we will build and distribute prototypes for field testing, ideally in collaboration with a commercialisation partner.
IS THE INNOVATION TRANSFERABLE OR ADAPTABLE TO OTHER SETTINGS OR DOMAINS?
Besides humanitarian settings, FriGo can be used in other medical contexts (including developed countries), farming and other cold chain dependent industries, and in end-consumer applications such as food and beverage storage.
WHAT BROADER IMPLICATIONS ARE THERE FROM THE INNOVATION FOR MSF AND / OR OTHERS (CHANGE IN PRACTICE, CHANGE IN POLICY, CHANGE IN GUIDELINES, PARADIGM SHIFT)?
If successful and cost efficient, FriGo could change the way MSF works by expanding reach for vaccination campaigns, allowing for decentralised healthcare delivery, and enabling home-based care in remote or conflict settings.
WHAT OTHER LEARNINGS FROM YOUR WORK ARE IMPORTANT TO SHARE?
MSF would benefit from an innovation culture backed by standard operating procedures for product development aspects such as partnerships, intellectual property, commercialisation, and mentorship.
ETHICS
This innovation project did not involve human participants or their data; the MSF Ethics Framework for Innovation was used to help identify and mitigate potential harms.
An estimated 1.5 million children die each year from vaccine-preventable diseases. Besides vaccines, other life-saving drugs such as oxytocin, rectal artesunate, snake antivenom, insulin, and diazepam are unavailable at peripheral health centres due to a lack of cold chain facilities. Existing solutions are inadequate as they rely heavily on passive cold chain especially for the last mile, necessitating centralised models of healthcare delivery and leading to increased patient costs and limited access.
WHY DOES THIS CHALLENGE OR OPPORTUNITY MATTER--WHY SHOULD MSF ADDRESS IT?
Desk research has shown that there is no single product that can address this gap. A solution would have a positive impact at scale in most complex medical emergencies and could be a ubiquitous tool for decreasing mortality in neglected populations.
DESCRIBE YOUR INNOVATION AND WHAT MAKES IT INNOVATIVE
We are rethinking the passive vaccine day carrier by developing FriGO, a long-term, portable, active cool box that uses off-grid sources of energy. FriGo utilises solar power, thermoelectric cooling, phase-change material, battery back-up and a unique construction to provide continuous portable off-grid cooling for prolonged periods of time. FriGo benefits from accurate condition logging and monitoring and preventive action warning system. The technology that is utilised in FriGo has been individually proven in several other industries from international food shipping to outdoor camping. However, resource-limited healthcare settings require appropriately customised solutions. Although a handful of organisations are looking at this problem, a successful scalable solution is yet to be reached. The Covid-19 pandemic has brought a renewed focus on the vaccine cold chain industry and could act as a catalyst in bringing about this much needed change.
WHO WILL BENEFIT (WHOSE LIFE / WORK WILL IT IMPROVE?) AND WERE THEY INVOLVED IN THE DESIGN?
FriGo has the potential to decrease mortality and morbidity in most contexts where MSF works by increasing our reach and decreasing wastage.
WHAT OBJECTIVES DID YOU SET FOR THE PROJECT--WHAT DID YOU WANT TO ACHIEVE AND HOW DID YOU DEFINE AND MEASURE SUCCESS (IMPROVED SERVICE, LOWER COST, BETTER EFFICIENCY, BETTER USER EXPERIENCE, ETC.)?
In October 2019, we conducted a user preference study involving field workers and technical specialists to define and design the project. The primary objective and measure of success was to prove that a portable chamber could maintain a temperature of 2-8°C for a minimum of 28 days without an external energy source.
WHAT DATA DID YOU COLLECT TO MEASURE THE INNOVATION AGAINST THESE INDICATORS AND HOW DID YOU COLLECT IT? INCLUDE IF YOU DECIDED TO CHANGE THE INDICATORS AND WHY
Three assessments (desk research, technical study, and user preference study) were conducted to assess available products, feasibility, minimum requirements, cost comparison, and unmet needs. A proof-of-concept is underway.
HOW DID YOU ANALYSE THIS DATA TO UNDERSTAND TO WHAT EXTENT THE INNOVATION ACHIEVED ITS OBJECTIVES? DID THIS INCLUDE A COMPARISON TO THE STATUS QUO OR AN EXISTING SOLUTION?
Phase 1 aimed at validating the use-cases and reviewing the available products in the market. The data was collected through interviews and correspondence with experts and analysed by the team. The objectives for phase 2 were to validate the specific design and features, through an in-depth interview-based user preference study and a desk research technology analysis. Phase 3 objectives focus on validating the feasibility of the concept by building a proof-of-concept to demonstrate the proposed features of the product. The experimentation and testing are ongoing and will be assessed based on milestones established at the outset of the phase. The final milestone will be the ability to maintain a cold-life of 2-8°C for seven days with the possibility of continuous repeatability, without user-intervention or grid resources.
WERE THERE ANY LIMITATIONS TO THE DATA YOU COLLECTED, HOW YOU COLLECTED IT OR HOW YOU ANALYSED IT, OR WERE THERE ANY UNFORESEEN FACTORS THAT MAY HAVE INTERFERED WITH YOUR RESULTS?
Data collection was comprehensive, but non-exhaustive. Prototype data collection is underway but will need to be done in a range of field locations to ensure it works under various field conditions.
WHAT RESULTS DID YOU GET?
Phase 1 revealed that existing solutions, while some of them innovative, did not address all the current problems highlighted by some of the use-cases, and did not greatly change the current possibilities. The outcome of the user-preference study and technology analysis (phase 2) highlighted specific requirements such as being durable, easily carried on the back, suitable for all modes of transport, plug and play operation, and preferably around 2.5L in capacity. From a service perspective, the product needs to have prolonged cold life, minimal expertise and intervention, no grid dependency, non-circular route possibilities, fail-safe responses and decentralised operation. FriGo is being designed, prototyped and tested based on these findings. Some of the results achieved include the ability to cool a 1L payload chamber to 2-8°C, with an ambient temperature of +30°C, in under 4 hours solely using solar power, a thermoelectric heat pump, and a phase-change material thermal battery; with a current cold-life retention of 28h through an insulating structure.
COMPARING THE RESULTS FROM YOUR DATA ANALYSIS TO YOUR OBJECTIVES, EXPLAIN WHY YOU CONSIDER YOUR INNOVATION A SUCCESS OR FAILURE?
These conclusions can only be drawn after field testing is completed.
TO WHAT EXTENT DID THE INNOVATION BENEFIT PEOPLE’S LIVES / WORK?
This will be determined during the next phase of development, when FriGo is scaled-up and piloted.
IS THERE ANYTHING THAT YOU WOULD DO DIFFERENTLY IF YOU WERE TO DO THE WORK AGAIN?
Framing the product lifecycle to anticipate partnerships and legal processes, and consider alternative pathways, would reduce negative impacts on progress and timeline.
WHAT ARE THE NEXT STEPS FOR THE INNOVATION ITSELF (SCALE UP, IMPLEMENTATION, FURTHER DEVELOPMENT, DISCONTINUED)?
Following a successful proof-of-concept, we will build and distribute prototypes for field testing, ideally in collaboration with a commercialisation partner.
IS THE INNOVATION TRANSFERABLE OR ADAPTABLE TO OTHER SETTINGS OR DOMAINS?
Besides humanitarian settings, FriGo can be used in other medical contexts (including developed countries), farming and other cold chain dependent industries, and in end-consumer applications such as food and beverage storage.
WHAT BROADER IMPLICATIONS ARE THERE FROM THE INNOVATION FOR MSF AND / OR OTHERS (CHANGE IN PRACTICE, CHANGE IN POLICY, CHANGE IN GUIDELINES, PARADIGM SHIFT)?
If successful and cost efficient, FriGo could change the way MSF works by expanding reach for vaccination campaigns, allowing for decentralised healthcare delivery, and enabling home-based care in remote or conflict settings.
WHAT OTHER LEARNINGS FROM YOUR WORK ARE IMPORTANT TO SHARE?
MSF would benefit from an innovation culture backed by standard operating procedures for product development aspects such as partnerships, intellectual property, commercialisation, and mentorship.
ETHICS
This innovation project did not involve human participants or their data; the MSF Ethics Framework for Innovation was used to help identify and mitigate potential harms.
Journal Article > ResearchFull Text
PLOS One. 31 May 2019; Volume 14 (Issue 5); DOI:10.1371/journal.pone.0217818
Nair MM, Tripathi S, Mazumdar S, Mahajan R, Harshana A, et al.
PLOS One. 31 May 2019; Volume 14 (Issue 5); DOI:10.1371/journal.pone.0217818
INTRODUCTION:
Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India. Although informal providers are involved with substantial segments of primary healthcare, their level of knowledge, attitudes, and practices is not well documented in the literature.
OBJECTIVES:
This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use.
METHODS:
We surveyed a convenience sample of 384 participants (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Our team created an equivalent, composite KAP score for each respondent in the survey, which was subsequently compared between providers. We then performed a multivariate logistic regression analysis to estimate the odds of having a low composite score (<80) based on occupation by comparing allopathic doctors (referent category) with all other study participants. The model was adjusted for age (included as a continuous variable) and gender.
RESULTS:
Doctors scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed poorly in practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n = 82) reported prescribing them in this situation. Nurses, pharmacy shopkeepers, and informal providers were more likely to perform poorly on the survey compared to allopathic doctors (OR: 10.4, 95% CI 5.4, 20.0, p<0.01). 30.8% (n = 118) of all providers relied on pharmaceutical company representatives as a major source of information about antibiotics.
CONCLUSIONS:
Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors. The nexus between allopathic doctors, pharmaceutical company representatives, and informal health providers present promising avenues for future research and intervention.
Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India. Although informal providers are involved with substantial segments of primary healthcare, their level of knowledge, attitudes, and practices is not well documented in the literature.
OBJECTIVES:
This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use.
METHODS:
We surveyed a convenience sample of 384 participants (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Our team created an equivalent, composite KAP score for each respondent in the survey, which was subsequently compared between providers. We then performed a multivariate logistic regression analysis to estimate the odds of having a low composite score (<80) based on occupation by comparing allopathic doctors (referent category) with all other study participants. The model was adjusted for age (included as a continuous variable) and gender.
RESULTS:
Doctors scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed poorly in practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n = 82) reported prescribing them in this situation. Nurses, pharmacy shopkeepers, and informal providers were more likely to perform poorly on the survey compared to allopathic doctors (OR: 10.4, 95% CI 5.4, 20.0, p<0.01). 30.8% (n = 118) of all providers relied on pharmaceutical company representatives as a major source of information about antibiotics.
CONCLUSIONS:
Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors. The nexus between allopathic doctors, pharmaceutical company representatives, and informal health providers present promising avenues for future research and intervention.
Conference Material > Video
Nair MM
MSF Scientific Days International 2020: Research. 13 May 2020