A Comparison of Patients' Local Conceptions of Illness and Medicines in the Context of C-Reactive Protein Biomarker Testing in Chiang Rai and Yangon.

Yuzana Khine Zaw,Nutcha Charoenboon,Marco J. Haenssgen,Yoel Lubell

doi:10.4269/ajtmh.17-0906

Abstract

.Antibiotic resistance is not solely a medical but also a social problem, influenced partly by patients’ treatment-seeking behavior and their conceptions of illness and medicines. Situated within the context of a clinical trial of C-reactive protein (CRP) biomarker testing to reduce antibiotic over-prescription at the primary care level, our study explores and compares the narratives of 58 fever patients in Chiang Rai (Thailand) and Yangon (Myanmar). Our objectives are to 1) compare local conceptions of illness and medicines in relation to health-care seeking and antibiotic demand; and to 2) understand how these conceptions could influence CRP point-of-care testing (POCT) at the primary care level in low- and middle-income country settings. We thereby go beyond the current knowledge about antimicrobial resistance and CRP POCT, which consists primarily of clinical research and quantitative data. We find that CRP POCT in Chiang Rai and Yangon interacted with fever patients’ preexisting conceptions of illness and medicines, their treatment-seeking behavior, and their health-care experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients’ self-assessed illness severity, and an increase in the status of the formal health-care facilities that provide the test. Although we expected that local conceptions of illness diverge from inbuilt assumptions of clinical interventions, we conclude that this mismatch can undermine the intervention and potentially reproduce problematic equity patterns among CRP POCT users and nonusers. As a partial solution, implementers may consider applying the test after clinical examination to validate rather than direct prescription processes.

Highlights

Antimicrobials have been considered the basis of modern medicine and are one of the most frequently purchased drug types globally, but their effectiveness is challenged by growing antimicrobial resistance (AMR).[1,2,3] high-income and low- and middle-income countries (LMICs) are affected by AMR because it can compromise the management of leading causes of death such as gastrointestinal, respiratory, sexually transmitted, and nosocomial infections.[4]
We find that C-reactive protein (CRP) point-of-care testing (POCT) in Chiang Rai and Yangon interacted with fever patients’ preexisting conceptions of illness and medicines, their treatment-seeking behavior, and their health-care experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients’ self-assessed illness severity, and an increase in the status of the formal health-care facilities that provide the test
This article aimed to expand our understanding of the social context of CRP POCT testing in LMICs

Summary

Introduction

Antimicrobials have been considered the basis of modern medicine and are one of the most frequently purchased drug types globally, but their effectiveness is challenged by growing antimicrobial resistance (AMR).[1,2,3] high-income and low- and middle-income countries (LMICs) are affected by AMR because it can compromise the management of leading causes of death such as gastrointestinal, respiratory, sexually transmitted, and nosocomial infections.[4]. This article addresses AMR from a social perspective, focusing on patients’ antibiotic use against the backdrop of antibiotic resistance (ABR; a subset of AMR). Our understanding of the social dimensions of ABR remains surprisingly narrow— indicated by the persistent narrow focus of national and global AMR policies on awareness raising (rather than e.g., socioeconomic drivers of resistance such as poverty), by repeated calls for more social research into AMR in general[5,6,7] and by a social science share of only 0.53% out of 17,675 documents with the key words “AMR” according to the Scopus database (as of July 31, 2017).[8] The social research gap is problematic because it affects how we think about the increasing global efforts to curb AMR

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