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Antibiotic knowledge, attitudes and practices: new insights from cross-sectional rural health behaviour surveys in low-income and middle-income South-East Asia
  1. Marco J Haenssgen1,2,3,4,
  2. Nutcha Charoenboon5,
  3. Giacomo Zanello6,7,
  4. Mayfong Mayxay8,9,10,
  5. Felix Reed-Tsochas3,4,11,
  6. Yoel Lubell1,5,
  7. Heiman Wertheim12,13,
  8. Jeffrey Lienert3,4,14,
  9. Thipphaphone Xayavong15,16,
  10. Yuzana Khine Zaw17,
  11. Amphayvone Thepkhamkong8,
  12. Nicksan Sithongdeng8,
  13. Nid Khamsoukthavong8,
  14. Chanthasone Phanthavong8,
  15. Somsanith Boualaiseng8,
  16. Souksakhone Vongsavang8,
  17. Kanokporn Wibunjak5,
  18. Poowadon Chai-in5,
  19. Patthanan Thavethanutthanawin5,
  20. Thomas Althaus1,5,
  21. Rachel Claire Greer5,18,
  22. Supalert Nedsuwan19,
  23. Tri Wangrangsimakul18,20,
  24. Direk Limmathurotsakul20,
  25. Elizabeth Elliott21,22,
  26. Proochista Ariana1
  1. 1 Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
  2. 2 School of Cross Faculty Studies, University of Warwick, Coventry, UK
  3. 3 Green Templeton College, Oxford, United Kingdom
  4. 4 Said Business School, University of Oxford, Oxford, UK
  5. 5 Mathematical/Economic Modelling, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
  6. 6 School of Agriculture, Policy and Development, University of Reading, Reading, UK
  7. 7 Leverhulme Centre for Integrative Research on Agriculture and Health, London, London, UK
  8. 8 Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Vientiane, Laos
  9. 9 Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos
  10. 10 Institute of Research and Education Development, University of Health Sciences, Vientiane, Laos
  11. 11 Oxford Martin School, University of Oxford, Oxford, UK
  12. 12 Medical Microbiology Department, Radbuod University, Nijmegen, The Netherlands
  13. 13 Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
  14. 14 National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
  15. 15 Department of Peace and Conflict Studies, University for Peace, Ciudad Colon, Costa Rica
  16. 16 Department of Political Science, Ateneo de Manila University, Quezon City, Philippines
  17. 17 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
  18. 18 Chiangrai Clinical Research Unit, Chiangrai Regional Hospital, Chiang Rai, Thailand
  19. 19 Primary Care Department, Chiangrai Regional Hospital, Chiang Rai, Thailand
  20. 20 Microbiology, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
  21. 21 UCL Anthropology, University College London, London, UK
  22. 22 Institut de recherche pour le développement, Vientiane, Laos
  1. Correspondence to Dr Marco J Haenssgen; marco.haenssgen{at}


Introduction Low-income and middle-income countries (LMICs) are crucial in the global response to antimicrobial resistance (AMR), but diverse health systems, healthcare practices and cultural conceptions of medicine can complicate global education and awareness-raising campaigns. Social research can help understand LMIC contexts but remains under-represented in AMR research.

Objective To (1) Describe antibiotic-related knowledge, attitudes and practices of the general population in two LMICs. (2) Assess the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers.

Design Observational study: cross-sectional rural health behaviour survey, representative of the population level.

Setting General rural population in Chiang Rai (Thailand) and Salavan (Lao PDR), surveyed between November 2017 and May 2018.

Participants 2141 adult members (≥18 years) of the general rural population, representing 712 000 villagers.

Outcome measures Antibiotic-related knowledge, attitudes and practices across sites and healthcare access channels.

Findings Villagers were aware of antibiotics (Chiang Rai: 95.7%; Salavan: 86.4%; p<0.001) and drug resistance (Chiang Rai: 74.8%; Salavan: 62.5%; p<0.001), but the usage of technical concepts for antibiotics was dwarfed by local expressions like ‘anti-inflammatory medicine’ in Chiang Rai (87.6%; 95% CI 84.9% to 90.0%) and ‘ampi’ in Salavan (75.6%; 95% CI 71.4% to 79.4%). Multivariate linear regression suggested that attitudes against over-the-counter antibiotics were linked to 0.12 additional antibiotic use episodes from public healthcare providers in Chiang Rai (95% CI 0.01 to 0.23) and 0.53 in Salavan (95% CI 0.16 to 0.90).

Conclusions Locally specific conceptions and counterintuitive practices around antimicrobials can complicate AMR communication efforts and entail unforeseen consequences. Overcoming ‘knowledge deficits’ alone will therefore be insufficient for global AMR behaviour change. We call for an expansion of behavioural AMR strategies towards ‘AMR-sensitive interventions’ that address context-specific upstream drivers of antimicrobial use (eg, unemployment insurance) and complement education and awareness campaigns.

Trial registration number identifier NCT03241316.

  • antimicrobial resistance
  • antibiotics
  • awareness
  • treatment-seeking behaviour
  • survey
  • social sciences
  • development studies
  • interdisciplinary research
  • Thailand
  • Lao pdr

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  • Contributors Study conceptualisation, design and theoretical framing: MJH. Study design: MJH, NC, GZ, MM, FR-T, YL, HFLW, JL, TX, YKZ, AT, NS, NK, CP, SB, SV, KW, PC-I, PT, TA, RCG, SN, TW, DL, EE, PA. Survey instrument development: MJH, GZ, NC. Study protocol development: MJH, NC. Data cleaning and coding: MJH, NC. Data analysis and manuscript draft: MJH. Manuscript review and approval: MJH, NC, GZ, MM, FR-T, YL, HFLW, JL, TX, YKZ, AT, NS, NK, CP, SB, SV, KW, PC-I, PT, TA, RCG, SN, TW, DL, EE, PA.

  • Funding This project is 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). YKZ was further supported by internal research placement funding by the MSc International Health and Tropical Medicine (University of Oxford).

  • Disclaimer The funders had no involvement in the design and implementation of the project.

  • Map disclaimer The depiction of boundaries on the map(s) in this article do not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The research was reviewed and approved by the University of Oxford Tropical Research Ethics Committee (Ref. OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099), and in Lao PDR from the National Ethics Committee for Health Research (Ref. NEHCR 074). Participation in the survey was voluntary and we obtained informed verbal consent from all participants, which was audio recorded and documented by the survey field investigators with a written record of oral consent for each participant.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository.

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