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Care Seeking and Treatment for Adults with URIs
in Congested Communities in Bangkok: Where Problems Occur
Suttajit Sa, Tantipidoke Ra, Sitthi-amorn Ca, Wagner Ab, Ross-Degnan Db.
aChulalongkorn
University, Bangkok; bHarvard Medical School, USA
Problem Statement: Understanding where in the care process patients receive antibiotics may help in
designing interventions to decrease antibiotic use and drug resistance in community.
Objectives: To measure patterns of antibiotic use in adults with URIs and to identify where
inappropriate use of antibiotics occurs in the community.
Study Population: Interviewers visited 3,973 households in 2 congested communities in Bangkok and
interviewed 779 adult patients with URIs.
Methods: Interviews of adults age >18 who had URIs within 2 prior weeks in a systematic random
sample of households.
Outcome Measures: Patterns of care seeking, % antibiotics use, and treatment costs.
Results: About 81% of URI cases were likely of viral origin. Patients with viral and bacterial URIs
exhibited the same pattern of care seeking: patients first took care of themselves at home, some then
went to drugstores and then to clinical settings. During their URI episode, 44% of viral URIs and 54%
of bacterial URIs patients had used an antibiotic; antibiotic use was significantly higher among those
who sought care outside their home. Among patients who only self-treated, 10% used antibiotics. Half
of all patients sought treatment in drugstores, 65% received an antibiotic regardless of the infection
type. In clinical settings, 61% of viral URIs and 71% of bacterial URIs patients received antibiotics.
Self-medication with inappropriate antibiotics for viral URI cost 23 baht/patient and unnecessary
visits to clinical settings for symptomatic treatment cost 89 baht/patient.
Conclusions: Antibiotics are misused for viral URIs by self-medication at home but more frequently
misused when patients visit drug stores and clinical settings. Interventions should be implemented to
promote symptomatic self-treatment and appropriate antibiotic use by health providers as well.
Introduction
Most upper respiratory tract infections (URIs) are
caused by viruses, and antibiotics are not
recommended in their treatment. However, antibiotics
are frequently used to treat URIs.
Understanding where in the care process patients
receive antibiotics may help in designing interventions
to decrease antibiotic use and help reduce the rate of
development of drug resistance in low-income and
high-risk communities.
Objectives
In order to understand the problem of drug use in
community well and be able to design effective
interventions to improve antibiotic use, the aims of
this study are:
1. To measure patterns of antibiotic use in adults
with URIs, and
2. To identify where inappropriate
antibiotics occurs in the community
use
of
Methods
Design
Cross-sectional study
Setting and Study Population
In October 2002, interviewers visited 3,973
households in two congested communities in
Bangkok and interviewed 779 adult patients with
URIs.
Methods
Interviews of adults over 18 years old who had
URIs within two prior weeks in a systematic
random sample of households. Interviewers asked
about URIs symptoms, health seeking behavior,
drugs taken and cost, and self care.
Methods
Analysis
Based on patient’s reported symptoms, we adapted
GAS score1 and signs for sinusitis2 to identify
probability of Group A strep throat and sinusitis,
and whether or not antibiotic should be taken in
each case.
Data were managed and analyzed using SPSS for
Windows 12.0. Chi-square and Student’s t-test
were applied where appropriate. A P-value <0.05
was considered statistically significant.
McIsaac WJ, White D, Tannenbaum D, Low DE. 1998. A clinical score to reduce unnecessary antibiotic use
in patients with sore throat. Canadian Medical Association Journal 158: 75-83.
1
William JW Jr, Simel DL. 1993. Does this patient have sinusitis?: Diagnosing acute sinusitis by history and
physical examination. Journal of the American Medical Association 270(10):1242-1246.
2
Results
1
URI Cases in Community
Total household visited was 3,973, 1,138 (28.6%)
reported recently URIs within 2 weeks and 779 adult
URIs cases were interviewed. About 82% were likely of
viral origin.
Table1. Characteristics of Patients (n=779)
Female
Age 18-40
41-60
> 60
Education < high school
Income < 10000 baht
Health insurance
None
National health plan
Others
Likely to be:
Viral URIs
Bacterial URIs
Sick day, mean+SD
81.8 %
44.7 %
40.1 %
15.3 %
82.8 %
85.6 %
11.8 %
55.5 %
32.7 %
81.6 %
18.4 %
6.21+3.97
Results
2
Pattern of Health Seeking Behavior
Viral and bacterial URIs cases usually first took care of
themselves at home, but bacterial URIs were more likely
have visited a clinical setting at the end of their illness.
Table 2. Choice of Treatment
Choice of Treatment
and setting
1st choice
Viral (634)
Non-pharmacological tx.
No treatment
6.0 %
Non-drug treatment
52.7 %
Pharmacological tx.
Self-prescribing
23.0 %
At home
4.7 %
At drug store
Tx. recommended by others
At drug store
6.3 %
In clinical settings1
6.2 %
Others
1.1 %
1 private
clinic, hospital, health center
During the illness
Bact. (145)
Viral (634) Bact. (145)
4.1 %
49.7 %
6.0 %
53.2 %
4.1 %
50.3 %
28.3 %
5.5 %
23.8 %
21.5 %
29.0 %
21.4 %
7.6 %
3.4 %
1.4 %
26.3 %
39.7 %
3.9 %
25.5 %
48.3 %
3.4 %
Results
3
Where did URIs cases receive the antibiotics?
During the illness episode, 44% of viral URIs cases and
54% of bacterial URIs cases had used an antibiotic.
Antibiotic use was clearly higher among those who sought
care outside their home.
Table3. Antibiotics used at each setting
Setting
Self-prescribed
at home
at drug store
Recommended by others
at drug store
at clinical settings
at other settings
Viral URIs
Bact. URIs
10.6 %
21.3 %
9.5 %
35.5 %
65.5 %
61.4 %
13.3 %
64.9 %
71.6 %
0%
Results
4
Cost of Drug Use in URIs Treatment
 On average, viral URIs spent 84.6 baht ($2.2)
while bacterial URIs spent 101.3 baht ($2.6).
 The most frequently used pattern of care seeking
costs 112.1 baht/episode ($2.9) (0.83% of average
national household income).
 In viral URIs, there is a lost of 59.5 baht/episode
($1.6) compared between the most appropriate and
most inappropriate pattern of care seeking.
 In viral URIs treatment, self-prescribing with
antibiotic costs the lost of 23.3 baht/episode ($0.6)
and unnecessary visiting of clinical settings costs
the lost of 88.7 baht/episode ($2.3).
Discussions
Limitations
Potential misclassification of diagnoses and
problem in identifying type of drug use by patients
as they seldom knew their own medicines.
Application of the results
Researchers use the results to feedback and
encourage the active citizen to take action in
solving drug use problem in their community.
Interventions designed together by community
research team are now implementing, such as
local URIs management guideline, Network
rational drug use, newsletters, radio broadcast,
discussion forum.
and
the
for
and
Conclusions
What’s New?
This study adds about study in developing country
and in adults, and patterns of care seeking and
antibiotic use in viral and bacterial URIs.
Conclusions
Antibiotics are misused for viral URIs by selfmedication at home but more frequently misused
when patients visit drug stores and clinical
settings.
Interventions should be implemented
symptomatic self-treatment of URIs.
interventions should be implemented
appropriate antibiotic use for URIs in
and clinical settings as well.
to promote
In addition,
to promote
drug stores
Acknowledgement
We thank Ms. Ratana Somrongthong for her continuing
support coordinating the project. We also thanks staff
at Duangprateep Foundation and community committees
of each study communities for facilitating the data
collection process.
Funding:
Thailand Research WHO Essential Drugs and
Fund
Medicines Policy Department
Applied Research on
Child Health