blog 03 May 2018
– Marco Haenssgen – University of Oxford

Northern Thailand (Chiang Rai), 19 March 2018, 7am: The steep mountain road winds through rice fields, small streams, and coffee and tea plantations. The road surface is still damp from the morning dew, mist is just dispersing at the mountain tops. People come our way walking and on motorcycles to work as farmers and daily labourers; the few who travel with their pickup trucks own the farms, work in town, or are village officials. After a 45-minute ride from the district town, we reach the village.

This route is new, it was only constructed a year ago. In the past, it was not possible to reach the village by car. We heard that food and medical services would only reach the village with great difficulty, and often people would die here as they could not get to a doctor. Since the road was built, access to medical care has improved, but it is still far from easy – the journey to town is tedious, especially if you are ill, or need to travel in the rainy season. Unlike other villages, there is no village health volunteer (a kind of community health worker). Instead villagers only receive half-yearly visits from a neighbouring volunteer. All the medical care in and around the village consists of traditional healers (herbalists and spiritual healers referred to as “ghost doctors”) and two sundry shops that sell things like eggs, soy sauce, soda, detergent, and medicine, including antibiotics. Occasionally, non-governmental organisations (NGOs) come to the village and provide supplies and medicine as well.

Photo credit: Nutcha Charoenboon
Approach road to survey village through mountainous areas and rice, tea, and coffee farms.

Approach road to survey village through mountainous areas and rice, tea, and coffee farms.

We visited this village as part of a rural survey in Thailand and Laos to understand the link between rural health behaviours and antibiotic use, marginalisation, and knowledge diffusion. During our survey interviews, we asked people about these sources of healthcare (Haenssgen et al., 2018b). Part of the information is captured in our questionnaire, quantitatively. But the discussions around these questions were richer (we collected additional qualitative data as well), with people telling us for example that they appreciate the work of the NGOs, but they could not quite remember the NGOs’ names, or even what kind of medicine it was that they brought to the village. For these villagers, the medicine matters insofar as it helps them to continue working. And while some villagers can afford a trip to the nearest town for medical treatment at the hospital or a private clinic, those who do not have a vehicle, or enough money for transit, might choose to buy medicines in the village shops first. As our research intern Penporn (Yok) Warapikuptanun summarised in her conversations, “[the villagers] have to work, to bring food back to their family. That means they cannot get sick. And if they are sick, they better get well quick so they can go back to work because they don’t want to waste time or money to hire a ride [to go see a doctor].” Our survey investigator and research intern Kanokporn (Joobjang) Wibunjak reported similar tendencies: “What’s more important for the villagers isn’t long-term wellness, but not having food to eat and a job to do tomorrow.” People are concerned with their own and their families’ subsistence and survival – antibiotic resistance or side-effects of medicines take a subordinate role in this environment.

We carried out educational activities in this setting, both for us to learn about villagers’ lives and their conceptions of medicine, but also to share some of the ideas about antibiotic resistance with the villagers (our purpose was not to change their behaviour actively towards any particular ideal). We were conscious that villagers do not necessarily think in terms of antibiotics, bacteria, or even infectious diseases. We therefore drew on insights from our previous qualitative research and benefitted from the ideas and viewpoints of three research local interns to develop activities that built on language and conceptions of rural Thai dwellers (Haenssgen et al., 2018a; Khine Zaw et al., 2018). The half-day activity was attended by 30 out of the 400 villagers.

Did it work? Take the example of a teacher who participated in the village and who also lived in the village and maintained strong social ties in the community. Although he discussed the activity on social media with his friends outside of the village, he did not talk to anyone else in the village about it.

“Language and concepts did not seem to be the problem, but rather it seems that ideas about antibiotic resistance, the side-effects of medicine, and consultation from medical doctors did not resonate with his experiences of hardship and poverty in the village.”

Villagers draw maps of village and health providers during public engagement activity.

Globally, policies and interventions to change people’s antibiotic use remain firmly locked into education and awareness raising campaigns (Haenssgen et al., 2018b). Education and awareness campaigns operate on the logic that the population has a knowledge deficit, and that the rectification of this will improve behaviour (which may indeed be the case for a subset of the population). Considered from a conventional (neoclassical economics) market perspective, this approach would make sense insofar as new information would influence people’s preferences and therefore the demand for goods, like antibiotics. Telling people to not take antibiotics would help to deflate demand and might make them use herbal medicine instead.

Well-meaning educational campaigns, however, can miss their target if they assume that people take antibiotics because they believe them to be a magic pill that will cure all their ailments. Rather, people here tended to take any available medicine to help them cope with precarious situations. For many, it didn’t matter – nor did they know – if what they took was an antibiotic or not.

One of the main limitations of the conventional market logic that corresponds to this reductionist perspective is the focus on a single product or family of products. Although it is abundantly common, it is not necessarily intrinsic to definitions of “the market.” An alternative conception can be found in the field of strategic management (Abell, 1980), which suggests that a market does not just comprise products, but more general functions that a consumer aims to fulfil, and different types of solutions or technologies can fulfil these functions. Accordingly, a product (e.g. antibiotics) may compete with an altogether different industry (e.g. crop insurance) in fulfilling a consumer function (e.g. economic security). (Consider for instance Skype as it competes with airline companies for communication in transnational business and long-distance relationships.)

Antibiotic prescription and use, even if they are deemed “inappropriate” by outsiders, are part of a network of solutions to meet health-related and broader functions among the general population (Haenssgen et al., 2018b). This network constitutes potential competition for new interventions to reduce antibiotic use, and education and awareness-raising campaigns are by no means the intuitive or only response from a strategic management perspective. Anthropological and sociological research can help uncover what functions people fulfil by using antibiotics and what therefore constitutes the relevant “market,” but it also raises critical questions as to who articulates the problems of a population and who defines the corresponding solutions and interventions.

References

– Abell, D. F. (1980). Defining the business: the starting point of strategic planning. Englewood Cliffs, NJ: Prentice-Hall.
– Haenssgen, M. J., Charoenboon, N., Althaus, T., Greer, R. C., Intralawan, D., & Lubell, Y. (2018a). The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in Northern Thailand. Social Science & Medicine, 202, 1-12. doi: 10.1016/j.socscimed.2018.02.018
– Haenssgen, M. J., Charoenboon, N., Zanello, G., Mayxay, M., Reed-Tsochas, F., Jones, C. O. H., et al. (2018b). Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation, and knowledge diffusion. BMJ Global Health, 3(e000621). doi: 10.1136/bmjgh-2017-000621
– Khine Zaw, Y., Charoenboon, N., Haenssgen, M. J., & Lubell, Y. (2018). A comparison of patients’ local conceptions of illness and medicines in the context of C-reactive protein biomarker testing in Chiang Rai and Yangon [epub ahead of print]. American Journal of Tropical Medicine and Hygiene. doi: 10.4269/ajtmh.17-0906

Notes

This blog entry derives from a presentation at the Oxford Tropical Network 2018 Conference, it is a description of a forthcoming paper on the use of the strategic market definition in AMR, and it has benefitted from comments from Giacomo Zanello. We explore the implications of our educational activities in Thailand in another forthcoming paper on “Translating AMR: A Case Study of Three Thai Villages.” The current portfolio of publications related to this conceptual work includes:

– Haenssgen, M. J., Charoenboon, N., Zanello, G., Mayxay, M., Reed-Tsochas, F., Jones, C. O. H., et al. (2018). Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation, and knowledge diffusion. BMJ Global Health, 3(e000621). doi: 10.1136/bmjgh-2017-000621
– Khine Zaw, Y., Charoenboon, N., Haenssgen, M. J., & Lubell, Y. (2018). A comparison of patients’ local conceptions of illness and medicines in the context of C-reactive protein biomarker testing in Chiang Rai and Yangon [epub ahead of print]. American Journal of Tropical Medicine and Hygiene. doi: 10.4269/ajtmh.17-0906
– Haenssgen, M. J., Charoenboon, N., Althaus, T., Greer, R. C., Intralawan, D., & Lubell, Y. (2018). The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in northern Thailand. Social Science & Medicine, 202, 1-12. doi: 10.1016/j.socscimed.2018.02.018
– Haenssgen, M. J., Charoenboon, N., & Khine Zaw, Y. (2018). It is time to give social research a voice to tackle AMR. Journal of Antimicrobial Chemotherapy, 73(4), 1112-1113. doi: 10.1093/jac/dkx533
– Haenssgen, M. J., & Ariana, P. (2017). The social implications of technology diffusion: uncovering the unintended consequences of people’s health-related mobile phone use in rural India and China. World Development, 94, 286-304. doi: 10.1016/j.worlddev.2017.01.014

About the Authors

Dr Marco J Haenssgen is a social scientist with a background in management and international development and experience in aid evaluation, intergovernmental policy making, and management consulting. His research emphasises marginalization and health behaviour in the context of health policy implementation, technology diffusion, and antimicrobial resistance (AMR). His AMR-related research in Southeast Asia focuses on population behaviour, how people understand antibiotics and illness, their constraints in accessing healthcare, and the intended and unintended consequences of AMR interventions. His research also involves antibiotic-related public engagement activities with villagers in northern Thailand and southern Lao PDR. He is the Principal Investigator of “Antibiotics and Activity Spaces,” a Theme-4 project funded by the UK Research Council’s AMR Initiative.

Nutcha (Ern) Charoenboon is based at the Mahidol-Oxford Tropical Medicine Research Unit in Bangkok. She is a biologist with extensive volunteering and public engagement experience, and currently works as research officer on the project “Antibiotics and Activity Spaces,” where she manages qualitative and quantitative data collection and AMR-based educational activities among teams of 20 field investigators and research interns. Her research interests relate to the drivers of people’s medicine use and treatment choices, and the unintended consequences of public engagement.

The Antibiotics and Activity Spaces project is a study of antibiotic-related health behaviour in rural Thailand and Lao PDR, funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with the Department of Health and Department for Environment Food & Rural Affairs (grant ref. ES/P00511X/1, administered by the UK Economic and Social Research Council). The Economic and Social Research Council (ESRC) is the UK’s largest funder of research on the social and economic questions facing us today. It supports the development and training of the UK’s future social scientists and also funds major studies that provide the infrastructure for research. ESRC-funded research informs policymakers and practitioners and helps make businesses, voluntary bodies and other organisations more effective. The ESRC also works collaboratively with six other UK research councils and Innovate UK to fund cross-disciplinary research and innovation addressing major societal challenges. The ESRC is an independent organisation, established by Royal Charter in 1965, and funded mainly by the Government.

The CABDyN Complexity Centre at the Saïd Business School engages in research on complex systems and networks, with a particular focus on the social, economic, financial, communication and infrastructural networks that underpin most of modern life. The acronym CABDyN stands for Complex Agent-Based Dynamics Networks, and reflects some of the techniques such as complex network analysis and agent-based modelling that the Centre’s researchers typically use to understand these systems. The activities at the Saïd Business School form part of a larger research network that applies shared methods and techniques to a broad range of problems and domains. CABDyN was established in July 2003 as a research cluster spanning the University with the seed funding under the EPSRC Novel Computation Initiative, and currently brings together a truly multi-disciplinary group of researchers across Oxford, ranging from the physical, biological and computational sciences to the social, economic and political sciences.

The Centre for Tropical Medicine and Global Health (CTMGH) is a collection of research groups within the Nuffield Department of Medicine, University of Oxford, who are permanently based in Africa, Asia and Oxford. Its research ranges from clinical studies to behavioural sciences, with capacity building integral to all of its activities. The majority of the Centre’s research is conducted at three Wellcome Trust Major Overseas Programmes in Kenya, Thailand and Vietnam, as well as at the Oxford Centre for Global Health Research. The Centre for Tropical Medicine and Global Health also brings together a number of sister groups in Cambodia, the Democratic Republic of the Congo, Indonesia, Laos, Myanmar, Nepal, and Uganda, and collaborators around the world. Tackling infectious diseases, which kill many millions of people every year, is one of the greatest challenges of the 21st century. The CTMGH is researching solutions to the increasingly urgent problems these diseases cause.

The Mahidol Oxford Tropical Medicine Research Unit (MORU) develops effective and practical means of diagnosing and treating malaria and other neglected diseases such as melioidosis, typhus, TB and leptospirosis. MORU was established in 1979 as a research collaboration between Mahidol University (Thailand), Oxford University (UK) and the UK’s Wellcome Trust. MORU’s main office and laboratories are located within the Faculty of Tropical Medicine at Mahidol University in Bangkok, Thailand, with MORU study sites and collaborations across Thailand, Asia and Africa.