Abstract
New and affordable point-of-care testing (POCT) solutions are hoped to guide antibiotic prescription and to help limit antimicrobial resistance (AMR)—especially in low- and middle-income countries where resource constraints often prevent extensive diagnostic testing. Anthropological and sociological research has illuminated the role and impact of rapid point-of-care malaria testing. This paper expands our knowledge about the social implications of non-malarial POCT, using the case study of a C-reactive-protein point-of-care testing (CRP POCT) clinical trial with febrile patients at primary-care-level health centres in Chiang Rai province, northern Thailand. We investigate the social role of CRP POCT through its interactions with (a) the healthcare workers who use it, (b) the patients whose routine care is affected by the test, and (c) the existing patient-health system linkages that might resonate or interfere with CRP POCT. We conduct a thematic analysis of data from 58 purposively sampled pre- and post-intervention patients and healthcare workers in August 2016 and May 2017.We find widespread positive attitudes towards the test among patients and healthcare workers. Patients’ views are influenced by an understanding of CRP POCT as a comprehensive blood test that provides specific diagnosis and that corresponds to notions of good care. Healthcare workers use the test to support their negotiations with patients but also to legitimise ethical decisions in an increasingly restrictive antibiotic policy environment. We hypothesise that CRP POCT could entail greater patient adherence to recommended antibiotic treatment, but it could also encourage riskier health behaviour and entail potentially adverse equity implications for patients across generations and socioeconomic strata. Our empirical findings inform the clinical literature on increasingly propagated point-of-care biomarker tests to guide antibiotic prescriptions, and we contribute to the anthropological and sociological literature through a novel conceptualisation of the patient-health system interface as an activity space into which biomarker testing is introduced.
Highlights
Antibiotics procured through formal and informal channels are popularly over- and misused across high, middle, and low-income countries, which contributes to the development of antimicrobial resistance (AMR) and potentially to the spread of resistant bacteria across the world (Butler et al, 2009; Kumarasamy et al, 2010; Morgan et al, 2011)
This study examines the case of Chiang Rai in northern Thailand, where we collected qualitative data from 58 fever patients and healthcare workers alongside a clinical trial of C-reactive protein (CRP) point-of-care testing (POCT) to reduce antibiotic prescriptions
This reassurance led a wide range of our respondents to trust that a low CRP level indicated good health
Summary
Antibiotics procured through formal and informal channels are popularly over- and misused across high-, middle-, and low-income countries, which contributes to the development of antimicrobial resistance (AMR) and potentially to the spread of resistant bacteria across the world (Butler et al, 2009; Kumarasamy et al, 2010; Morgan et al, 2011). A review by Aabenhus et al (2014, 6) lists a range of potential disadvantages of such point-of-care tests, including “suboptimal use of time, costs, handling errors, patient dissatisfaction and false negative values that can lead to lack of necessary antibiotic treatments or false positive values that may increase inappropriate antibiotic use.”. The rationale behind their introduction is not that they are perfect diagnostic devices, but that they can aid and support clinical diagnosis in a resource-poor environment of high or ill-targeted antibiotic use until superior and affordable pathogen-specific tests become available (Lubell and Althaus, 2017) A review by Aabenhus et al (2014, 6) lists a range of potential disadvantages of such point-of-care tests, including “suboptimal use of time, costs, handling errors, patient dissatisfaction and false negative values that can lead to lack of necessary antibiotic treatments or false positive values that may increase inappropriate antibiotic use.” The rationale behind their introduction is not that they are perfect diagnostic devices, but that they can aid and support clinical diagnosis in a resource-poor environment of high or ill-targeted antibiotic use until superior and affordable pathogen-specific tests become available (Lubell and Althaus, 2017)
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