The public engagement activity

Development and design

The educational activity was part of the public engagement portfolio of a social survey on antibiotics, medicine, and treatment-seeking behaviour in Chiang Rai, Thailand, and Salavan, Lao PDR (Haenssgen et al. 2018b). The design of the activity responded to our previous research in Southeast Asia with “translating AMR” as a conceptual starting point. On the one hand, the activity aimed at sharing some ideas about antibiotics and drug resistance. Using local media and local language, we did not only translate the medical language into popular terms, but “translating AMR” also meant harmonising the language with local conceptions of illness. On the other hand, the activity was meant to be a learning opportunity for our team to gain insights into the local context of medicine and healing, and to understand how our messages were received.

The educational activity was developed by a team of four Southeast Asian social scientists. Two of the researchers—Thai and Burmese, with experience in public engagement with science and youth development and leadership—were directly involved in preceding qualitative AMR research in Southeast Asia. This research laid the foundation for the current study, involving qualitative development studies research with fever patients in rural Chiang Rai and Yangon (Myanmar) and problematising the disjunction between technical and global biomedical language and local conceptions of antibiotics (Haenssgen et al. 2018a; Khine Zaw et al. 2018). The other two researchers—Thai and Lao, with experience in development studies and youth development and leadership—contributed their expertise in rural development and community-based activities in northern Thailand and southern Lao PDR. This range of backgrounds enabled the team to translate WHO messages into content and media more accessible to the rural population in Chiang Rai and Salavan. More specifically, we considered the following messages from the Campaign Toolkit for the WHO World Antibiotic Awareness Week 2016:

“only use antibiotics when prescribed by a certified health professional,”

“never demand antibiotics if your health worker says you don’t need them,”

“always follow your health worker’s advice when using antibiotics,” and

“never share or use leftover antibiotics” (WHO, 2016, p. 6).

A major complication of these messages in our field sites was that people were often unfamiliar with the technical term “antibiotic” (Tangcharoensathien et al., 2018), people might not realise which medicines have antibiotic ingredients (e.g. Mybacin Lozenges cough drops, containing 2.5 mg neomycin), and vernacular notions like “germ killer” in Thailand may not be congruent with biomedical definitions of antibiotics (including e.g. anthelmintic and antifungals). In addition, WHO awareness-raising material commonly includes notions of drug-resistant bacteria and that antibiotics should not be used for viral infections, but our previous research indicated that distinctions between bacteria and viruses as disease-causing agents were uncommon in our sites. Our translations and adaptations therefore involved references to antibiotics through pictures and the popular and fairly unambiguous interpretation as “anti-inflammatory medicine” (which also alludes to ideas of illness as “inflammation” of the body), references to generic “germs” that evolve in response to specific types of medicine, the health implications when these germs spread, and narrated and sung stories that featured ill villagers and their treatment choices in the local context. We field-tested the educational activity in two villages in Chiang Rai. Following extensive feedback sessions with volunteer facilitators from the School of Social Innovation at Mae Fah Luang University in Chiang Rai, we shortened the length of the activity, included ice-breaking activities, and made the role of the volunteers as moderators rather than educators more explicit.

The ensuing product was a half-day activity in which the research team (six to eight volunteers) and the villagers (20–35 adult participants from across the village) got to play the roles of message sender and receiver equally. The list of sessions (including expected outcomes, incorporated message, and direction of communication) is detailed in Table 1, all of which were delivered in central Thai.Footnote 5 The first of the six sessions was a mapping activity to learn about the local healthcare landscape, treatment-seeking behaviours, and the social networks involved in villagers’ treatment-seeking processes. Secondly, a medicine sorting game helped us understand local categories of medicine and their purpose, while also suggesting to the participants that antibiotics should not be bought over the counter. Thirdly, a “resistance” game introduced the participants to the idea that germs can become stronger if they are not treated correctly. Following a short break, the fourth and fifth sessions comprised the adaptation of a traditional pop songFootnote 6 and a narrative about a “sick village” and a “healthy village” as familiar channels of communication. The last activity—poster making—allowed us to see how the participants understood and interpreted the content to which they were exposed during the activity. At the end of the poster-making session, participants would present and explain their work to all attendees, and the moderators would discuss and edit the content on the spot in case of potentially detrimental interpretations like “medicines are dangerous”Footnote 7 or “you need a prescription for any medicine [incl. paracetamol]” (which could scare people off life-saving medicine or overburden healthcare providers, see Lambert, 2016; the section “Implementation process” provides actual examples of the edited posters). The edited posters would subsequently be displayed at shops, community halls, and schools in the village as a means of communicating between the activity participants and the remaining villagers.

Table 1 Description of educational activity Full size table

Field sites

We implemented the activity in three villages in northern Thailand (Chiang Rai; see map in Fig. 2), which serve as our case study in this paper. Although low-income and middle-income countries in Southeast Asia have been described as a hotbed for AMR (Chereau et al., 2017), Thailand has increasingly been treated as a regional example of successful antimicrobial stewardship, whose extensive national policies and local initiatives have made it a country with one of the lowest antibiotic prescription rates in the region (Tangcharoensathien et al., 2017; WHO SEARO, 2016; Holloway et al., 2017, p. 11). For example, bans on informal antibiotic sales have been introduced (and increasingly enforced) in Chiang Rai province, the government has been conducting long-term antibiotic stewardship and public education programmes, and public health facilities themselves have initiated small-scale education campaigns that target their clients and rural populations. Yet, extensive private healthcare provision and persistent access to medicine through informal channels (e.g. grocery stores, retired doctors) have also catered to a continuing demand for pharmaceuticals (incl. antibiotics) as an established form of “good care” (Sringernyuang, 2000, p. 37, p. 80; Chuengsatiansup et al., 2000, pp. 8–9, pp. 28–29). For example, a recent study in Chiang Rai district found that 46.9% out of 84,000 public primary care patients with acute infections in 2015 and 2016 received an antibiotic, which the authors deemed “likely to represent […] overuse” (esp. for pharyngitis; Greer et al., 2018, p. 8).

Fig. 2 Map of field sites in Chiang Rai province, northern Thailand. To reflect the diversity of the province, one village each was selected in the districts Chiang Khong (peri-urban, industrialised), Chiang Rai (poor, remote), and Mae Fah Luang (ethnically diverse, statelessness). Source: authors, adapted from Google Inc. (2017) Full size image

The three case study villages represented the diversity of rural Chiang Rai (peri-urban vs. remote vs. ethnically diverse), which we selected purposively with local partners from Mae Fah Luang University. Implementing our educational activity in these diverse settings was not only a challenge, considering village accessibility and our uniform implementation of the educational activity. The village-specific context was also an opportunity to learn how the diverse social, economic, and geographic confounders may interact with and influence the delivery and reception of AMR communication even within a single province.

The first village represented the peri-urban and industrialised facet of rural Chiang Rai. It was located in a special economic zone at the Thai-Lao border in Chiang Khong district. Residents of this village had received more formal education (5.3 years completed years of schooling on average) and were better-off in terms of wealth compared to the other two villages.Footnote 8 They were also closer to mass media and health information sources and had a wider range of public, private, and informal healthcare options owing to their proximity to the district capital city, which could be reached within 10 min by car. Among the three villages, the Chiang Khong village was also most visibly involved in AMR-related public health campaigns during the study period (long-term programmes also existed in the other two districts but tended to target health facilities rather than the general population). After we completed the first round of the survey and the educational activity, the district-level Public Health Office became stricter regarding sales of antibiotics in local shops. Village leaders were informed about these developments, but the looming threat of penalties led Chiang Khong shop owners to stop the sale of medicines almost altogether (including e.g. paracetamol, although it was not part of the policy). As we will explain in more detail in the section “Results”, these salient health policy developments interacted with our educational activity, contributing to antagonism among villagers who felt that we were agents of the (misunderstood) public health intervention.

In contrast, the second village represented the living conditions of remote mountain villages in Chiang Rai. It was part of Chiang Rai district, situated in one of the poorest sub-districts in Thailand, and populated by the Thai-speaking Mien ethnic group.Footnote 9 Access required a four-wheel-drive vehicle (1.5 h from the nearest district capital), solar cells were the main source of electricity, and government policies had prevented the village from infrastructure investments because of its location in a national park. The village was isolated, owing to which visitors were rare and typically included non-governmental development workers and legal advocates (whose visits tended to be shorter and less extensive than our survey activities, making our team a rather prominent visitor). Contrary to our expectations, however, isolation did not mean that the village community was close-knit. Young villagers would not normally chat with older groups in the village, and villagers more generally would refrain from socialising outside their homes considering that no lighting was available in the solar-powered village after they returned from work.

The last village reflected the ethnic and social diversity of rural Chiang Rai through a clear geographic segmentation of its ethnic groups Lahu, Akha, and Thai. The village was located near the border area to Myanmar in Mae Fah Luang district, owing to which a small part of the population was also stateless. The village had only acquired paved road access one year prior to the survey, which enabled travel times of 45 min to the nearest town. Before having gained road access, villagers would only receive half-yearly visits from village health volunteers (who would otherwise typically reside in villages) and report that it was common to die in the village or on the way to reaching formal healthcare facilities in the district capital. Further road construction—which was completed shortly after the educational activity—reduced travel times to the district town by another 15 min and thereby effectively increased healthcare supply parallel to our educational activity—at least for villagers with cars and motorcycles (note this does not imply that formal healthcare access was suddenly “easy”). Furthermore, social interactions within the village were often confined within the respective ethnic groups, who would typically stay among each other at ordinary village gatherings like village meetings or bonfires during the colder winter months.

We summarise some of these village idiosyncrasies graphically in Fig. 3. Row 1 displays the distribution of ethnic groups, Row 2 represents language ability, and Row 3 indicates antibiotic-related knowledge and attitudes prior to the activity (measured as the number of “desirable” answers out of four questions related to WHO AMR messages; see Table 4 in the section “Data ollection”). Among others, the figure illustrates the ethnic uniformity of the Chiang Rai village and clear geographic divisions between ethnic groups in Mae Fah Luang and Chiang Khong. The Chiang Khong village comprised almost exclusively Thai speakers (central and/or northern dialects), whereas people who did not speak Thai were more prevalent in the other two villages, especially in Mae Fah Luang (we describe in the following section and in the section “Translation, language barriers, and social exclusion” that non-Thai speakers were more likely to be excluded from the activity and from indirect exposure). Antibiotic knowledge and attitudes seemed to be distributed evenly, but Table 2 demonstrates that different ethnic groups exhibited systematically different responses (with mainstream Thai ethnicities not necessarily scoring highest). Further baseline data from the three villages will be presented in the “Results” section as part of the difference-in-difference analysis.

Fig. 3 Geographical representation of ethnic composition, language, and antibiotic knowledge in case study villages: Ethnic groups (1) were more clearly separated in the Chiang Khong a and Mae Fah Luang villages c than in the Chiang Rai village b. Non-Thai speakers (2) were common and equally distributed in the Mae Fah Luang village b. Antibiotic-related attitudes measured by the number of “desirable” answers to four attitude and knowledge questions (3) were spread relatively evenly across all three villages but low responses appeared to cluster in the Lahu segment of the Mae Fah Luang village c. Notes: “Baseline” (R.1) data, using full sample data. n = 204 a, n = 200 b and n = 222 c. Marker size adjusted to distinguish overlapping responses Full size image

Table 2 Antibiotic knowledge and attitude scores by ethnic group across survey villages Full size table

Implementation process

The educational activity was implemented at local village halls, and Fig. 4 contains impressions from the implementation. Between 20 and 35 adults participated in each village, who were recruited through contacts made during the first survey round and with the help of village leaders. For those 82 activity participants whom we later re-surveyed, Table 3 shows that they were on average younger and included a high share of women and Thai speakers than the population average (albeit Thai was not the mother tongue for more than half of the participants). However, the recruitment of the participants aimed at a diverse range of ethnic backgrounds from across the village. The result is depicted in Fig. 5, which visualises respondents who reported participating in the activity (i.e. direct exposure, blue dots), having talked about it (i.e. indirect exposure, light-green dots), having seen the posters (i.e. indirect exposure, yellow dots), or both of the latter (green dots). The figure demonstrates that the educational activity involved respondents from all geographical parts of the villages, and all major ethnic groups were involved in the activity. Although participants in Mae Fah Luang were clustered geographically in the Lahu segment of the village, indirect communication still exposed all village segments to the activity.

Fig. 4 Impressions of various sessions within the educational activity. Photographs include both trial runs and final implementation. Photo credits: Nutcha Charoenboon (community mapping, medicine matching, resistance, song, poster), Patchapoom U-thong (roleplay); reproduced with permission Full size image

Table 3 Characteristics of individuals by participation in educational activity Full size table

Fig. 5 Geographical overview of educational activity exposure across the case study villages: Unlike the Chiang Khong village (a, n = 185) and the Chiang Rai village (b, n = 167), participants of the activity in the Mae Fah Luang village (c, n = 196) were concentrated in one village segment (inhabited by the Lahu ethnic group). However, indirect exposure to the activity though conversations and poster display was spread evenly across all three villages. Notes: Exposure based on self-reported data whether respondents had participated in the activity, had talked about the activity, and/or had seen the activity posters. “Endline” (R.2) data, matched panel data. Marker size adjusted to distinguish overlapping responses Full size image

The delivery of the activity took place in what our team described as an engaging atmosphere. Compared to the survey interviews (see following sub-sections), the team described the interactions with the villagers as more open and uninhibited. This suggested that the villagers were less afraid of sharing ideas about medicine and well-being, which may be unsurprising considering that knowledge sharing took place in a group environment involving music and games rather than a conventional face-to-face interview setting. This degree of openness enabled our team to learn about the village context beyond the qualitative and quantitative research data. For example, in the “Medicine Sorting” session, we learned that Mae Fah Luang villagers categorised medicine into “medicine for adults” and “medicine for children.” The participants explained during this session that they would be extra careful with “medicine for children” and follow instructions closely, while they would buy “medicine for adults” for themselves over the counter. Antibiotics fell into both categories and would be treated differently thus. Examples like this impressed the team and helped them to contextualise the survey responses around the language and purposes of antibiotic use.Footnote 10

Despite the open atmosphere, and even though only Thai non-medical volunteer facilitators participated in the delivery of the activity, villagers afterwards recalled that our team primarily “came in to teach” rather than being learners themselves. This indicated that our interaction was still perceived as one-directional from the villagers’ perspective, while our messages were less authoritative than medical staff’s (whose role as educators would be more established). We also observed that interactions among the participants were mostly limited to existing groups in the villages, especially in the Chiang Rai village (young and old interacting among each other) and the Mae Fah Luang village (ethnic groups interacting among each other). Further minor impediments were late-comers and playing children in the village halls who would divert attendees’ attention away from the activity.

Our team’s overall impression was that the messages were not delivered fully despite the half-day engagement with the participants. Especially the feedback mechanism through the final poster-making session revealed the limitations and drawbacks of the activity. Figure 6 exemplifies two posters with edits by the study team. The top example shows that the messages from the activity were fed back as, “You shouldn’t take medicines that you have never seen before;” the bottom example shows how the content extended into more general topics of well-being, like exercise and nutrition. The potentially less “powerful” delivery of our message may therefore not have been altogether disadvantageous because it may have attenuated the gravity of possible misinterpretations of our messages.

Fig. 6 Examples of posters produced by participants of educational activity: The top example shows that the messages from the activity were fed back as, “You shouldn’t take medicines that you have never seen before;” the bottom example shows how the content extended into more general topics of well-being like exercise and nutrition. Notes: English text in red indicates edits by the study team on the poster. “Anti-inflammatory” medicine refers to the colloquial notion of antibiotics in Thailand. Source: activity participants. Photo credit: Nutcha Charoenboon; reproduced with permission Full size image

The edited posters were subsequently displayed in prominent village locations (3–5 posters per village, shown at shops, village halls, and schools), but exposure varied across the villages. In Mae Fah Luang, the posters were hung up in the village hall where the activity took place but were removed prior to our second visit 3 months later. The posters in the Chiang Khong village were salient and talked about, but rather because they were rumoured to be part of a governmental public health campaign to ban all informal medicine sales, and some shops reported removing them to avoid trouble. Poster exposure was possibly more effective in the Chiang Rai village where local stores and a school displayed them, and villagers reported having seen them for an extended period.

Research design

We use a mixed-method triangulation design with a dominant quantitative component to explore the processes and mechanisms underlying the outcomes of AMR-related educational activities (Creswell et al., 2008). The activity was embedded in a large-scale rural survey research project in Thailand and Lao PDR, interspersing two rounds of village census data collection (see Fig. 7 for a timeline of surveys and activity). The two rounds of complete census survey data for all adults in the three villages permitted us to trace changes in attitudes and behaviours among participants and non-participants of the educational activity, taking into account the complete social composition, relationships, and spatial distribution of the villages. The quantitative survey data thereby enabled difference-in-difference (i.e. before/after) analyses among directly and indirectly exposed participants, and non-participants as a “control group.” Qualitative methods contextualised and validated the quasi-experimental quantitative analysis results. Note, however, that our assessment cannot legitimately claim the status of a formal impact evaluation, considering the obvious conflict of interest that an evaluation of our own project would entail.

Fig. 7 Timeline of surveys and educational activity. Second-round surveys took place approximately 3 months after each educational activity. Note: Logistical factors led to delays between survey round R.1 and activity in Chiang Khong village Full size image

The overall study was designed as an interdisciplinary project led by a social scientist and situated in the field of development studies with contributions from medical anthropology, economics, sociology, tropical medicine, and clinical research. It was designed to explore the role of marginalisation and knowledge in rural treatment seeking and antibiotic use, drawing on a framework that problematises behaviour at the interface between patients and the health system (Haenssgen et al. 2018b). The disciplinary orientation of the educational activity followed the direction of the project, namely social sciences (development studies) rather than medical sciences.

We obtained ethical clearance from the University of Oxford Tropical Research Ethics Committee (Ref. OxTREC 528-17) and the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099), and permission to access the study villages from the local government (from the provincial to the village level). Access to the villages was enabled through introductory letters from the sub-district authorities and personal introductions to the village leaders, the latter of whom would also announce the survey and the educational activity via the villages’ public broadcasting system. People’s participation in the survey and educational activity was voluntary, for which we obtained informed verbal consent, which was audio recorded and documented by the survey field investigators with a written record of oral consent for each participant. The participants received a small financial token of appreciation equivalent to GBP 1.00 for the survey and GBP 3.00 for the educational activity.

Data collection

The data to inform this study included survey data supplemented with cognitive interviews and observational data from the educational activity. The quantitative data represented a subset of the larger survey, covering complete censuses of adults in the three Chiang Rai villages where we carried out the AMR-themed educational activity. Within the selected villages, we approached all available households, enumerated their members, and interviewed all adults who provided (audio-recorded) informed consent.

Our survey instrument was a 45-min face-to-face questionnaire, collected electronically through tablets using the SurveyCTO software (Dobility Inc., 2017). The instrument captured location and demographic information of our respondents, individual and household characteristics, social networks, and healthcare provider preferences. We also evaluated the “desirability” of our respondents’ attitudes and knowledge regarding antibiotic use, for which we presented them with images of common antibiotics (and recorded their knowledge thereof) and judged their answers to four attitude/knowledge questions as described in Table 4. A further important feature of the questionnaire was the collection of sequential healthcare pathway data (Haenssgen and Ariana, 2017), from which we extracted information on healthcare choices, medicine use, and the activation of social networks during the course of acute illnesses or accidents that were resolved within the 2 months prior to the survey.

Table 4 Sample responses to guide evaluation of survey answers to antibiotic questions Full size table

The study team developed the survey instrument in English, discussed the Thai meaning-based translation and its various interpretations, and subsequently piloted and revised the questionnaire with the help of cognitive interviewing (Willis, 2005). Involving several techniques like “thinking aloud” and explanations of the local interpretation of concepts, cognitive interviews enabled insights into how respondents understand and answer selected survey questions. Yet, we experienced that the “communicative norms from the English language and Western cultures” embedded in the cognitive interview method clashed with the communication style of our respondents (Park et al., 2014, p. 643), owing to which we dropped the “thinking aloud” components from the interviews. The local adaptation of the cognitive interview method nevertheless enabled a refinement of the survey instrument (e.g. in terms of questionnaire structure, question order, and the range of answer categories).Footnote 11 The scope of the ensuing qualitative data also enabled us to triangulate and contextualise the quantitative survey results, for instance by prompting an examination of informal medicine sources and their composition in the case study villages and by shedding light on village living conditions beyond the information in the questionnaire. Regular survey team meetings during the survey and observations during the educational activity provided further contextualising information.

Overall, we surveyed 626 adults in the three villages during the first survey round and 637 during the second, the characteristics of whom are summarised in Table 5. Panel attrition was 12.5%, meaning that 87.5% (548) of the first-round respondents could be re-interviewed. We further collected 30 cognitive interviews within the larger study, 9 of which were collected in the three case study villages.

Table 5 Sample characteristics of two rounds of census survey in three Thai villages Full size table

Analysis

We analysed the survey data across two survey rounds descriptively in a difference-in-difference framework to compare villagers who were and who were not exposed to the educational activity.Footnote 12 We considered the outcome of the activity to be people’s knowledge of and attitudes towards antibiotic use, and their treatment-seeking behaviour relating to healthcare utilisation and medicine use. We limited ourselves to general medicine access because earlier research had highlighted the generally high rates of medicine use in Thailand (WHO SEARO, 2016, p. 47) and in order to accommodate people’s uncertainty when describing medicine that might have been an antibiotic (Tangcharoensathien et al., 2018). In addition to these overall outcomes for Research Question 1, the descriptive analysis also involved a specific analysis of contextual factors for Research Question 2:

1. interpretations of and exclusion from the activity by language ability; 2. the distribution of results across physical and health system landscapes (with a focus on public health campaigns and healthcare access), and 3. the relationship between the involvement of social contacts during people’s illnesses and activity outcomes.

Aside from descriptive statistical analysis, we used geographical information from the survey to explore the distribution of outcomes through visual inspection of the geo-information coded with respondents’ characteristics (antibiotic knowledge/attitudes, treatment choices, ethnic/linguistic background). Qualitative data complemented all parts of the quantitative data analysis through triangulation and contextualisation. We used holistic (rather than categorial) content analysis using field notes (educational activity observations and survey team reflections) and cognitive interview transcripts (Lieblich et al., 1998), which we screened and synthesised according to their relation to specific outcome variables and analysis topics.

The analysis of the quantitative and qualitative analysis proceeded independently, but the process of triangulating the quantitative findings using the qualitative material prompted further and more detailed quantitative analyses (e.g. into the sources of medicine access following reports of idiosyncratic medicine access patterns in one of the case study villages). The quantitative data was analysed by the project leader (MJH) using Stata 13 (StataCorp, 2013); the qualitative data was analysed by the Thai leader of the current study (NC) using standard word processing software. The research team members involved in conceptualising the educational activity (NC, PW, TX, YKZ) discussed the qualitative and quantitative results and reflected on any disagreements arising between them.