Unravelling patient pathways in the context of antibacterial resistance in East Africa

HATUA Consortium; Katherine Keenan; Kathryn J Fredricks; Mary Abed Al Ahad; Stella Neema; Joseph R Mwanga; Mike Kesby; Martha F Mushi; Annette Aduda; Dominique L Green; Andy G Lynch; Sarah I Huque; Blandina T Mmbaga; Hannah Worthington; Catherine Kansiime; Emmanuel Olamijuwon; Nyanda E Ntinginya; Olga Loza; Joel Bazira; Antonio Maldonado-Barragán; VAnne Smith; Arun Gonzales Decano; John Mwaniki Njeru; Alison Sandeman; John Stelling; Alison Elliott; David Aanensen; Stephen H Gillespie; Gibson Kibiki; Wilber Sabiiti; Derek J Sloan; Benon B Asiimwe; John Kiiru; Stephen E Mshana; Matthew T G Holden

doi:10.21203/rs.3.rs-1933132/v1

Unravelling patient pathways in the context of antibacterial resistance in East Africa

HATUA Consortium, Katherine Keenan^*, Kathryn J Fredricks, Mary Abed Al Ahad, Stella Neema, Joseph R Mwanga, Mike Kesby, Martha F Mushi, Annette Aduda, Dominique L Green, Andy G Lynch, Sarah I Huque, Blandina T Mmbaga, Hannah Worthington, Catherine Kansiime, Emmanuel Olamijuwon, Nyanda E Ntinginya, Olga Loza, Joel Bazira, Antonio Maldonado-BarragánVAnne Smith, Arun Gonzales Decano, John Mwaniki Njeru, Alison Sandeman, John Stelling, Alison Elliott, David Aanensen, Stephen H Gillespie, Gibson Kibiki, Wilber Sabiiti, Derek J Sloan, Benon B Asiimwe, John Kiiru, Stephen E Mshana, Matthew T G Holden

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

Abstract

BACKGROUND

A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals' use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high.

METHODS

The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs.

RESULTS

Although most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability.

CONCLUSION

There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).

Original language	English
Article number	414
Number of pages	12
Journal	BMC Infectious Diseases
Volume	23
Issue number	1
DOIs	https://doi.org/10.21203/rs.3.rs-1933132/v1 https://doi.org/10.1186/s12879-023-08392-9
Publication status	Published - 19 Jun 2023

Keywords

Adult
Humans
Qualitative Research
Bayes Theorem
Delivery of Health Care
Uganda
Anti-Bacterial Agents/pharmacology

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Katherine Keenan - SFC GCRF 19/20: Maximising analytical and translational capability for social science data on antimicrobial resistance (AMR) in East Africa
Keenan, K. L. (PI) & Kesby, M. (CoI)
Scottish Funding Council
1/12/19 → 31/12/20
Project: Standard
Kesby/Keenan HATUA: Holistic Approach to Unravel Antibacterial resistance in East Africa (HATUA)
Kesby, M. (PI) & Keenan, K. L. (CoI)
Medical Research Council
1/05/18 → 31/03/22
Project: Standard

Cite this

HATUA Consortium, Keenan, K., Fredricks, K. J., Al Ahad, M. A., Neema, S., Mwanga, J. R., Kesby, M., Mushi, M. F., Aduda, A., Green, D. L., Lynch, A. G., Huque, S. I., Mmbaga, B. T., Worthington, H., Kansiime, C., Olamijuwon, E., Ntinginya, N. E., Loza, O., Bazira, J., ... Holden, M. T. G. (2023). Unravelling patient pathways in the context of antibacterial resistance in East Africa. BMC Infectious Diseases, 23(1), Article 414. https://doi.org/10.21203/rs.3.rs-1933132/v1, https://doi.org/10.1186/s12879-023-08392-9

@article{793c2a74b865423bae19473454f29d58,

title = "Unravelling patient pathways in the context of antibacterial resistance in East Africa",

abstract = "BACKGROUND A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals' use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high.METHODS The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs.RESULTSAlthough most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability.CONCLUSION There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).",

keywords = "Adult, Humans, Qualitative Research, Bayes Theorem, Delivery of Health Care, Uganda, Anti-Bacterial Agents/pharmacology",

author = "{HATUA Consortium} and Katherine Keenan and Fredricks, {Kathryn J} and {Al Ahad}, {Mary Abed} and Stella Neema and Mwanga, {Joseph R} and Mike Kesby and Mushi, {Martha F} and Annette Aduda and Green, {Dominique L} and Lynch, {Andy G} and Huque, {Sarah I} and Mmbaga, {Blandina T} and Hannah Worthington and Catherine Kansiime and Emmanuel Olamijuwon and Ntinginya, {Nyanda E} and Olga Loza and Joel Bazira and Antonio Maldonado-Barrag{\'a}n and VAnne Smith and Decano, {Arun Gonzales} and Njeru, {John Mwaniki} and Alison Sandeman and John Stelling and Alison Elliott and David Aanensen and Gillespie, {Stephen H} and Gibson Kibiki and Wilber Sabiiti and Sloan, {Derek J} and Asiimwe, {Benon B} and John Kiiru and Mshana, {Stephen E} and Holden, {Matthew T G}",

note = "Funding: The Holistic Approach to Unravel Antibacterial Resistance in East Africa is a Global Context Consortia Award (MR/S004785/1) funded by the National Institute for Health Research, Medical Research Council, and the Department of Health and Social Care. The award is also part of the EDCTP2 programme supported by the European Union. This work is supported in part by the Makerere University-Uganda Virus Research Institute Centre of Excellence for Infection and Immunity Research and Training (MUII). MUII is supported through the DELTAS Africa Initiative (grant number 107743). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences and Alliance for Accelerating Excellence in Science in Africa and is supported by the New Partnership for Africa{\textquoteright}s Development Planning and Coordinating Agency with funding from the Wellcome Trust (grant number 107743) and the UK Government. This paper was funded in part by a grant from the National Institutes of Health (grant number U01CA207167), and a Scottish Funding Council GCRF Consolidator Award.",

year = "2023",

month = jun,

day = "19",

doi = "10.21203/rs.3.rs-1933132/v1",

language = "English",

volume = "23",

journal = "BMC Infectious Diseases",

issn = "1471-2334",

publisher = "BioMed Central",

number = "1",

}

HATUA Consortium, Keenan, K , Fredricks, KJ , Al Ahad, MA, Neema, S, Mwanga, JR, Kesby, M, Mushi, MF, Aduda, A, Green, DL, Lynch, AG, Huque, SI, Mmbaga, BT, Worthington, H, Kansiime, C, Olamijuwon, E, Ntinginya, NE, Loza, O, Bazira, J, Maldonado-Barragán, A, Smith, VA, Decano, AG, Njeru, JM, Sandeman, A, Stelling, J, Elliott, A, Aanensen, D, Gillespie, SH, Kibiki, G, Sabiiti, W , Sloan, DJ, Asiimwe, BB, Kiiru, J, Mshana, SE & Holden, MTG 2023, 'Unravelling patient pathways in the context of antibacterial resistance in East Africa', BMC Infectious Diseases, vol. 23, no. 1, 414. https://doi.org/10.21203/rs.3.rs-1933132/v1, https://doi.org/10.1186/s12879-023-08392-9

TY - JOUR

T1 - Unravelling patient pathways in the context of antibacterial resistance in East Africa

AU - HATUA Consortium

AU - Keenan, Katherine

AU - Fredricks, Kathryn J

AU - Al Ahad, Mary Abed

AU - Neema, Stella

AU - Mwanga, Joseph R

AU - Kesby, Mike

AU - Mushi, Martha F

AU - Aduda, Annette

AU - Green, Dominique L

AU - Lynch, Andy G

AU - Huque, Sarah I

AU - Mmbaga, Blandina T

AU - Worthington, Hannah

AU - Kansiime, Catherine

AU - Olamijuwon, Emmanuel

AU - Ntinginya, Nyanda E

AU - Loza, Olga

AU - Bazira, Joel

AU - Maldonado-Barragán, Antonio

AU - Smith, VAnne

AU - Decano, Arun Gonzales

AU - Njeru, John Mwaniki

AU - Sandeman, Alison

AU - Stelling, John

AU - Elliott, Alison

AU - Aanensen, David

AU - Gillespie, Stephen H

AU - Kibiki, Gibson

AU - Sabiiti, Wilber

AU - Sloan, Derek J

AU - Asiimwe, Benon B

AU - Kiiru, John

AU - Mshana, Stephen E

AU - Holden, Matthew T G

N1 - Funding: The Holistic Approach to Unravel Antibacterial Resistance in East Africa is a Global Context Consortia Award (MR/S004785/1) funded by the National Institute for Health Research, Medical Research Council, and the Department of Health and Social Care. The award is also part of the EDCTP2 programme supported by the European Union. This work is supported in part by the Makerere University-Uganda Virus Research Institute Centre of Excellence for Infection and Immunity Research and Training (MUII). MUII is supported through the DELTAS Africa Initiative (grant number 107743). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences and Alliance for Accelerating Excellence in Science in Africa and is supported by the New Partnership for Africa’s Development Planning and Coordinating Agency with funding from the Wellcome Trust (grant number 107743) and the UK Government. This paper was funded in part by a grant from the National Institutes of Health (grant number U01CA207167), and a Scottish Funding Council GCRF Consolidator Award.

PY - 2023/6/19

Y1 - 2023/6/19

N2 - BACKGROUND A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals' use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high.METHODS The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs.RESULTSAlthough most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability.CONCLUSION There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).

AB - BACKGROUND A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals' use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high.METHODS The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs.RESULTSAlthough most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability.CONCLUSION There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).

KW - Adult

KW - Humans

KW - Qualitative Research

KW - Bayes Theorem

KW - Delivery of Health Care

KW - Uganda

KW - Anti-Bacterial Agents/pharmacology

U2 - 10.21203/rs.3.rs-1933132/v1

DO - 10.21203/rs.3.rs-1933132/v1

M3 - Article

C2 - 37337134

SN - 1471-2334

VL - 23

JO - BMC Infectious Diseases

JF - BMC Infectious Diseases

IS - 1

M1 - 414

ER -

Unravelling patient pathways in the context of antibacterial resistance in East Africa

Abstract

Keywords

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Katherine Keenan - SFC GCRF 19/20: Maximising analytical and translational capability for social science data on antimicrobial resistance (AMR) in East Africa

Kesby/Keenan HATUA: Holistic Approach to Unravel Antibacterial resistance in East Africa (HATUA)

Cite this