How our research has helped reduce unnecessary antibiotic prescribing for children in China

This news story was first published on the University of Leeds health news pages. It describes our work at COMDIS-HSD to combat the inappropriate use of antibiotics – a major global risk factor in the development of drug-resistant ‘superbugs’.

collaboration between scientists has helped reduce the prescription of unneeded antibiotics to children in rural China.

Young people in some areas of the country are being given antibiotics, often intravenously, to treat a cold, ear or throat infections – but the drugs are not effective against virus-based illnesses.

The inappropriate use of antibiotics is a major risk factor in the development of drug-resistant “superbugs”.

Antibiotic use halved

The collaboration brought together rural hospitals in two counties in rural China, Chinese health officials and academics at the University of Leeds (COMDIS-HSD) and the University of Toronto.

The aim was to devise and evaluate a system of ‘anti-microbial stewardship’ that could be used in other parts of the Chinese health system and would give doctors the confidence to say no to requests for inappropriate antibiotic treatment.

The stewardship programme was rolled out to a group of primary care hospitals in Guangxi province in Southern China.

Much of the demand for antibiotics in the Chinese primary care sector comes from parents and grandparents who have children with upper respiratory tract infections such as a sore throat or earache.

Doctors working in the primary care hospitals come under considerable pressure from parents to prescribe antibiotics to children who have upper respiratory tract infections

John Walley, Professor of International Public Health at the University of Leeds, said:

“Doctors working in the primary care hospitals come under considerable pressure from parents to prescribe antibiotics to children who have upper respiratory tract infections.

“They can feel that if they don’t give the antibiotic, the parents will just go elsewhere and get it.

“These are difficult decisions for the doctor. They may have a very ill child in front of them – and they do not have a battery of tests results to rely on. They are having to make a clinical judgement about the risks involved in not giving antibiotics.”

New guidelines for doctors

University academics and Chinese experts drew up clinical guidelines based on those produced by the UK’s National Institute for Health and Care Excellence to help doctors decide when it would be appropriate to prescribe antibiotics and alert them to the warning signs of more serious illness.

Two groups of primary-care hospitals in Guangxi were selected for the evaluation. Baseline data was collected about the prescribing practices for children attending with upper respiratory tract infections.

In the first group, containing 12 hospitals, doctors received training in how to explain to parents why antibiotics are not necessary. Medical managers also conducted monthly prescription reviews to monitor doctors’ compliance with the guidelines.

In the second group, made up of 13 hospitals, medical staff continued to prescribe in the usual way.

The results showed that in the group that had received stewardship training, the antibiotic prescription rate had dropped from 82 per cent to 40 per cent

Six months later, several thousand prescriptions were selected at random from the two groups and compared with the baseline findings. The results showed that in the group that had received stewardship training, the antibiotic prescription rate had dropped from 82 per cent to 40 per cent. In the business-as-usual group, the rate went from 75 per cent to 70 per cent.

The findings were reported in Lancet Global Health.

Taking account of statistical issues, the researchers say the stewardship programme resulted in a 48 per cent reduction in the prescribing rate of antibiotics for children with upper respiratory tract infections.

Professor Walley said: “There have been other approaches that have tried to change the behaviour of doctors and patients – but none has delivered the scale of change that we have seen.”

Typically in successful trials the change is between five and 25 per cent.

The Chinese Health Ministry has policies to reduce antibiotic use but the challenge is to get that aim delivered in primary care clinics and hospitals, Professor Walley said.

He said the key to success was to “embed” stewardship programmes within the health system, giving doctors the skills and encouragement to give antibiotics when there is a real clinical need – and to refuse them when their use would be inappropriate.

The problem of the overuse of antibiotics exists in many low and middle income countries, and existed in the UK – although healthcare policies in recent decades have resulted in more careful use of antibiotics.

Read more:

  • See our full research findings: Wei X, Zhang Z, Walley J, Hicks J P, Zeng J, Deng S, et al. (2017) Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: a cluster randomised controlled trial. The Lancet Global Health. DOI
  • Read our policy brief for a summary of our findings and key recommendations and see our research brief for further details on our study methods.


Bold media plan and strong lifestyle messages take ARK’s NCD work to the nation

Rumana being interviewed by TV journalist

ARK’s Dr Rumana Huque being interviewed at the national NCD workshop by a TV journalist

A bold media strategy targeting top TV and print journalists has allowed our ARK Foundation partners to reach millions with their message about better prevention and treatment of non-communicable diseases (NCDs) in Bangladesh.

Strong lifestyle messages about unhealthy food habits, low levels of physical activity, smoking and pollution were at the centre of ARK’s recent national workshop on NCDs and helped secure prominent TV coverage for the event across Bangladesh’s three main news channels, as well as wide coverage in the top-rated newspapers and their online versions.

The event, however, went beyond public health headlines and started a national dialogue on the practical service delivery steps that will help Bangladesh reduce the personal, social and economic impact of NCDs. Currently, NCDs, such as cardiovascular disease and diabetes, are responsible for more than 60% of Bangladesh’s annual mortality and account for 60% of the country’s disease burden (measured by financial cost and years of quality life lost).

The event was co-hosted by ARK and the Non-Communicable Disease Control (NCDC) Unit of the Directorate General of Health Services (DGHS). More than 60 participants from all levels of the health service, including delegates from the World Health Organization, came together to share ideas on how to improve prevention, diagnosis and treatment of NCDs in primary care.

According to Dr Rumana Huque, Executive Director of ARK, a key factor in the success of the event was the decision to include managers from every level of the health service.
‘The participants were diverse and that was very important. We had local level healthcare managers who have the practical knowledge of what is happening on the ground to control and treat NCDs. But we also had mid-level programme managers who support them and the senior-level policymakers who take the final decisions.

‘So what came out at the workshop were the challenges that service providers are already facing and the recommendations that we have generated through or work at ARK.

‘Through our research we know that we need more counselling for NCD patients, better training for doctors and health providers, a better supply of medications, improved record keeping and stronger referral links between different parts of the health service.’

Dr Huque, who is part of the core team drafting the Sector Programme – the strategic investment programme for the next five years – added that workshop had been very timely.

‘The workshop helped everyone focus on the priorities; specifically improved NCD services and better lifestyle education. Senior managers and policy makers took note and said that they would be feeding what they had learned into the next Sector Programme.’

Giving the keynote speech at the workshop, Professor Dr Abul Kalam Azad, DGHS Additional Director General (Planning and Development), told delegates that NCDs are responsible for 62% of deaths happening every year in Bangladesh.

Key speakers at ARK’s national NCD workshop. From left: Dr Rumana Huque, Executive Director of ARK, Prof Dr Abul Kalam Azad, DGHS Additional Director General (Planning and Development), Prof Dr Enayet Hussain, NCDC Unit Line Director

He said that Bangladesh had not placed sufficient importance on NCDs, with catastrophic results in terms of premature mortality.

As part the COMDIS-HSD programme, ARK has been working with primary health care facilities in Bangladesh to establish better screening, treatment and referral processes for people with NCDs. Their experience and research findings were fed into group discussions to identify urgent actions that will help Bangladesh achieve its Sustainable Development Goal target of reducing NCD premature mortality by one third by 2030. These include the more timely supply of medicines, a wider range of medicines and dedicated doctors and health educators in ‘NCD corners’ in district hospitals.

Find out more:

COMDIS-HSD partners active players at 12th International Conference on Urban Health

Source: joiseyshowaa, Flickr. CC-BY-SA

Source: joiseyshowaa, Flickr. CC-BY-SA

COMDIS-HSD partners joined urban health experts from across the world at the 12th International Conference on Urban Health (ICUH) held in Dhaka, Bangladesh in May.

Playing an active role across the 4-day event, our Nepal partners, HERD and Bangladesh partners, ARK Foundation, gave detailed presentations on their ongoing research in the urban health field.

HERD presented some key issues from its Urban Health Project aimed at supporting the government to develop an urban health policy and strategy in Nepal. These included the need for clear evidence about the extent of urban poverty and the needs of the urban poor.

Following an in-depth exploration of the urban policy development process in Nepal by HERD senior research officer, Sudeepa Khanal, her colleague and HERD programme manager, Hom Nath Subedi, contributed to a detailed Q&A session answering questions from the floor about their experiences so far in developing the strategy.

ARK research associate, Farid Ahmed, gave a presentation on the rationale behind their current study on Public-Private Partnerships (PPPs) to improve access to family planning services in Bangladesh. Specifically, the presentation focused on using the PPP model to increase access among the urban poor to Long-Acting Reversible Contraceptive (LARC)..

ARK also presented on the limitations of existing household surveys in identifying the health needs of the poorest urban dwellers. In the presentation ARK volunteer Ru-Yi Lin illustrated how samples used in existing surveys are skewed towards the wealthiest urban residents.

Solutions to these challenges, such as new sampling and mapping techniques, were presented by Dana Thomson (Harvard Medical School), and HERD’s Uden Maharjan presented on the use of these techniques in Kathmandu in the initial phases of HERD’s urban household survey.

The conference, the first ICUH to be hosted in Asia, acknowledged that cities are drivers of national development. Delegates used their joint concluding statement to agree that the health of people in cities should be a central concern in sustainable development, pointing specifically to the need for capacity building, applied research and stronger governance for urban health.

Currently more than half the world’s population lives in cities and by 2050 it is estimated that 70% of the world’s population will be urban dwellers. While this presents challenges for all countries, delegates emphasised that the pace and scale of urbanisation is now most rapid in low and middle-income countries.

Read more about our partners’ reflections on ICUH 2015.

The COMDIS-HSD embedded approach

comdis-pdf-coverThe COMDIS-HSD team have produced an illustrated guide to describe the successful embedded approach used by programme partners for health research and service development. The purpose of the guide is to enable partners and other researchers to replicate the approach.

Guidance on the following is included within the document; designing and developing the service delivery package, pre-testing and piloting the package, implementing and evaluating the intervention and supporting policy and practice change nationally and internationally.

Click here for a pdf version of the document.

Package of care for CVD

CVD is the leading cause of mortality worldwide, accounting for 30% of deaths, with the vast majority of these in low and middle income countries. CVD is largely preventable, and straightforward cost-effective measures could mitigate intolerable increases in disease burden in the future.

The challenge is to develop a systematic, feasible and effective approach to chronic care for patients with CVD.  COMDIS HSD recently developed a package of care for cardiovascular disease (CVD), hypertension and type II diabetes in low and middle income countries.

The package of care consists of a number of tools, specifically a Case Management Desk Guide for Clinicians and a Health Educator Desk Guide for Health Workers.

New Field Communications Toolkit Launched

The Field Communications Toolkit was developed to be used as a resource for COMDIS HSD partners and the broader research communication community in general.
Its main purpose is to:

  • Develop more effective communications about research for wider research uptake
  • To support staff to gather relevant materials when working in the field
  • To enable COMDIS HSD to effectively communicate information about projects to policy makers, donors and other stakeholders

Through the communication of new learning and successes, COMDIS HSD works to influence both policy and practice globally. Read more...»