AMR in China - how to slow down the bacteria resistance as a designer?
I was interested in AMR at first place is the stories from AMR voice. I was suddenly how many antibiotics I prepare in my home and I don’t even know when and how I should take them. Through boradly research, I found the AMR is closed linked to a huge system, including the hospital, water/waster system, the agriculture and animal husbandry.
After a short interview with medical students major in Gene who had a unit study on AMR, I had more comprehensive knowledge about antibiotics and how it causes resistance from biology, sociology and agriculture perspectives. I am so excited about the complexity of this topic, and I want to dive into this topic and narrow it down to fit my major project.
Fielf of study
My “formal” research began after the tutorial with Alison, who suggest me to focus on AMR in China. Over-counter antibiotics purchase, over-prescription and public misunderstanding of antibiotics are threatening public health. Besides, there is no strict policy to regulate antibiotics use and comsumption. Therefore, I start to explore why AMR is a terrific but invisible topic in China.
Secondary research
Through secondary research on AMR in China, I have collected different data and evidences on the misuse of antibiotics in China from behavior level, society level and policy level.
Personal behavior
Individual behaviour has a significant impact on the current situation of antibiotic abuse in China. A large number of data show that lax policy restrictions cause this and that individual needs and perceptions exacerbate the development of antibiotic misuse and antibiotic resistance.
In terms of antibiotic prescription demand, a comparison of several pieces of literatures shows that individual demand for antibiotic prescription far exceeds the amount of prescriptions reasonably issued.
From the patients/the public perspective
Self-medication with antibiotics for treatment and prophylaxis are the main reasons why Chinese family regularly use antibiotics. The overall prevalence of antibiotic self-medication (for therapeutic purposes) ranged from 7.6% to 82.6% in mainland China, with high prevalence found in Gansu (82.6%), Guangdong (63.5% in Guangzhou City), Shaanxi (60.6% in Xi’an City) and Jiangxi (62%). The prevalence of antibiotic self-medication for prophylaxis in mainland China, ranging from 10.3%19 to 30.6%.
Household storage of antibiotics is a regular habit of many families. The prevalence of household storage of antibiotics ranged from 25.3% to 80.2% in mainland China. Household storage of antibiotics generally due to the perceived barriers, family dynamics, doctor-patient relationship and the easy access to antibiotics (non-prescription antibiotics/over-the-counter purchase/access to antibiotics prescription) and knowledge. Normally for families, perceiving it good to store antibiotics at home was associated with higher risks for keeping antibiotics at home for both animals and humans
The map above shows how people make the decision to purchase antibiotics. We can tell from this model that people are more likely to make the decision by their previous experienc and current demand like quick recovery; there is also some points like the intensive and untrustful doctor-patient relationship lead them to self-medication.
The high demand of antibiotics has few reasons from societ level:
1. The long history of self-medication for treatment and prophylaxia. Chinese people have the habit of self-medication on self-limited illness because the previous history accquire from TCM, which has less drug resistance and serious side effect.
2. Lack of educationa and misled by the social media. There are lots of media suggest to have family medication preparation which normally recomment to store some antiobiotics. The public rarely have proper education on use of antibiotics and they have many misunderstanging on antibiotics, like it helps people recover from nomal cold in a short time, which cause they have a high demand of antibiotics.
From the doctor/Pharmacist perspective
The China Pharmaceutical Business Association vice president once pointed out in a report that the source of antibiotic abuse is actually hospitals, not pharmacies. Most of the sales of antimicrobial drugs have been recorded by doctors who prescribe them to hospitals in recent years.
So why the knowledgeable doctors and pharmacists choose to overprescribe antibiotics?
First of all, from individual-level over-prescription of antibiotics is indeed linked with the clinical capacity of the physicians (measured by behavioural control). The prescription is a decision combined with multiple dimension and trying to satisfied the requirements from different sectors. Of course, for less skilful doctors or physicians, using antibiotics is an insured way to meet patients and healthcare system needs at the same time.
Secondly, many external factors influence their decision making. For example, the policy requirements from different levels would make physicians have a varied understanding of antibiotics’ rational use. In hospital, there are mant restrictions and factors are invloved into doctors’ consideration, such as preferred drug list of their hospital, financial incentives, and prescription system limitation, can also influence physicians’ controllability of antibiotic prescribing, resulting in different prescribing decisions.
Last but not least, a systematic review confirmed that patient demands are a significant contributor to the over-prescription of antibiotics. What makes me worried the most the pressure from the intensive doctor-patient relationship. Lack of trust and intense patient-doctor relationships have become a significant concern in China, which force doctor to over-precribe the antibiotics.
From the policy perspective
Through the article from NHC Key Laboratory of Health Economics and Policy Research, I can clearly devided thejourney of policy making on antibiotics into three stages. Chinese policy on antibiotic start last centry but mainly on regulation on medication quality and management. China’s first nationwide crackdown on antimicrobial drugs began in 2010 when the NDM-1 super bacterium brought pressure to the world. The 2010 law strictly required the management of the production, circulation and all links of the drugs, laying the foundation for releasing the policies in the latter three stages. It start the second stage of the antibiotics management at clinical level. Then the following year, the National Health Commission starts to advocate to make comprehensive governance strategies involving multiple sectors.
However, it is plain to see that the state drug administration management perspective is too limited, provisions are too broad. As a result, the policy lack maneuverability, the lack of specific content of the antibiotic drug control, and the unbalanced city and county development make implementing the antibiotic resistance management policy challenging to achieve the ideal effect of control and governance. The good news is that antibiotic drug quality supervision and clinical control are moving into a good phrase in recent years.
The opportnity from policy level is that the government suggest to build “One Health” strategy, but they have less idea on how to design and implement with interdisciplinary knowledge.
Primary Research
I was trying to understand how the role of the Chinese medcine in AMR, so I interview a TCM clinical interns who had two intern experience in the hospital.
What surprised me is the prescription system is limiting doctors’ prescription, but it the patient stronglt require the antibiotics, the doctor would give them the precription to purchase in invidual clinic or pharmacy.
The interview with a expreienced clinical chief of pediatrics proved that the AMR in children shows a rising trends, the intensive of doctor-patient relationship is main reason of over-prescription. From a family level, lack of education on childrem and drug is the main reason.
Research Question
My research quesiton my look like:
How can relevant service design approaches help the public to build proper knowledge and awarness to reduce antibotics resistance through the education and policy making?
Methodology
Double Dimond
I want to use the double dimond as my main methodology to guide me exploring the antibiotics resistance. I will follow the process of discovery, define, develop and deliver to exploe an issue more widely or deeply and then taking focused action, mindset, context and policy making. Through the discovery, I want to have wider understanding of the patients, doctors, pharmarist and policy managers, based on the research and understanding, I want to gathered insight from the discovery phase to define the challenges in a different way. In develop pharse, I want to explore inspiration from elsewhere and co-designing with a range of different people. Finally I want to test out different solutions, iterating and improving the ones that has postive feedback from the different stakeholders
Cross
The cross methodology is helping to gain the knowledge fromt eh three sources: poeple, process and products. It also combined in the double dimond process. The Cross will help the focusing on people firstly, like how they make the decison on self-medication and self-prescribe. Through the workshop, I want to figure out how different stakeholders to co-desgin for AMR, and how they understand the education. Secondly, I will move on to the process, it guides me to focus on the precription system and how medecine regulation works. It will also guide me to think about how I prevent the AMR through education and policy making. Thirdly, I will on the artfacts and prototypes, and test with stakeholders. Based on the prototyping I will iterate the final outcome to fit different stakeholders’ needs.
Conclusion
I have some expectation on the major project. I hope it will encourage me to find a partner and have access to contact and understand the healthcare system and contact different healthcare staff, like physicians, nurses, pharmacists, etc. I am attracted by the complex system in hospital or healthcare system. Through the major project, I have an ambition to understand the complexity of the system and propose how I can improve the system according to the demands of the stakeholders and emergency of some issues. In addition, I was inspired by the CU unit and read some case of how designers are leading policy design, and I want to have a try.
The following stage I want to explore some parternship to support me to research and test for my major project. At the same time, I will also contact the relevant organizations in UK and try to build internationship knowledge sharing to strengthen my project.
