An ethnographic exploration of diarrheal disease management in public hospitals in Bangladesh: From problems to solutions

Biswas, Debashish; Hossin, Raduan; Rahman, Mahbubur; Bardosh, Kevin; Watt, Melissa H.; Zion, Mazharul Islam; Sujon, Hasnat; Rashid, Mahbubur; Salimuzzaman, M; Flora, Meerjady Sabrina; Qadri, Firdausi; Khan, Ashraful Islam; Nelson, Eric J.

doi:10.1016/j.socscimed.2020.113185

Cited by 22 publications

(45 citation statements)

References 34 publications

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“…Such a feature was highly desirable by clinicians and will be appropriate for the app’s use in contexts similar to Bangladesh at both specialty diarrhea and government hospitals. In general, CDS and mHealth tools in LMIC contexts must always consider resource limitations and allow for adaptation within the tool itself depending on resource availability [ 40 ].…”

Section: Discussionmentioning

confidence: 99%

Designing a Novel Clinician Decision Support Tool for the Management of Acute Diarrhea in Bangladesh: Formative Qualitative Study

Rosen¹,

Garbern²,

Gainey³

et al. 2022

JMIR Hum Factors

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Background The availability of mobile clinical decision support (CDS) tools has grown substantially with the increased prevalence of smartphone devices and apps. Although health care providers express interest in integrating mobile health (mHealth) technologies into their clinical settings, concerns have been raised, including perceived disagreements between information provided by mobile CDS tools and standard guidelines. Despite their potential to transform health care delivery, there remains limited literature on the provider’s perspective on the clinical utility of mobile CDS tools for improving patient outcomes, especially in low- and middle-income countries. Objective This study aims to describe providers’ perceptions about the utility of a mobile CDS tool accessed via a smartphone app for diarrhea management in Bangladesh. In addition, feedback was collected on the preliminary components of the mobile CDS tool to address clinicians’ concerns and incorporate their preferences. Methods From November to December 2020, qualitative data were gathered through 8 web-based focus group discussions with physicians and nurses from 3 Bangladeshi hospitals. Each discussion was conducted in the local language—Bangla—and audio recorded for transcription and translation by the local research team. Transcripts and codes were entered into NVivo (version 12; QSR International), and applied thematic analysis was used to identify themes that explore the clinical utility of an mHealth app for assessing dehydration severity in patients with acute diarrhea. Summaries of concepts and themes were generated from reviews of the aggregated coded data; thematic memos were written and used for the final analysis. Results Of the 27 focus group participants, 14 (52%) were nurses and 13 (48%) were physicians; 15 (56%) worked at a diarrhea specialty hospital and 12 (44%) worked in government district or subdistrict hospitals. Participants’ experience in their current position ranged from 2 to 14 years, with an average of 10.3 (SD 9.0) years. Key themes from the qualitative data analysis included current experience with CDS, overall perception of the app’s utility and its potential role in clinical care, barriers to and facilitators of app use, considerations of overtreatment and undertreatment, and guidelines for the app’s clinical recommendations. Participants felt that the tool would initially take time to use, but once learned, it could be useful during epidemic cholera. Some felt that clinical experience remains an important part of treatment that can be supplemented, but not replaced, by a CDS tool. In addition, diagnostic information, including mid-upper arm circumference and blood pressure, might not be available to directly inform programming decisions. Conclusions Participants were positive about the mHealth app and its potential to inform diarrhea management. They provided detailed feedback, which developers used to revise the mobile CDS tool. These formative qualitative data provided timely and relevant feedback to improve the utility of a CDS tool for diarrhea treatment in Bangladesh.

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Section: Discussionmentioning

confidence: 99%

Designing a Novel Clinician Decision Support Tool for the Management of Acute Diarrhea in Bangladesh: Formative Qualitative Study

Rosen¹,

Garbern²,

Gainey³

et al. 2022

JMIR Hum Factors

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“… 67 An ethnographic study conducted in Bangladeshi public hospitals found adherence to antibiotic use guidelines for diarrhoea patients was hampered by overcrowding, understaffing and lacking hygiene and sanitation. 68 In Ghana, a mixed-methods study identified how ‘inappropriate’ antibiotic use was driven by out-of-pocket payments, limiting patients’ contact with the formal health system and the unaffordability of complete antibiotic courses. 69 These studies highlight the importance of interventions to enhance access to healthcare insurance, healthcare and affordable medication through universal healthcare coverage, a key structural intervention to tackle AMR.…”

Section: Structuresmentioning

confidence: 99%

Understanding antibiotic use: practices, structures and networks

Tompson

Manderson

Chandler

2021

JAC-Antimicrobial Resistance

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In this article, we consider how social sciences can help us to understand the rising use of antibiotics globally. Drawing on ethnography as a way to research how we are in the world, we explore scholarship that situates antibiotic use in relation to interactions of pathogens, humans, animals and the environment in the context of globalization, changes in agriculture and urbanization. We group this research into three areas: practices, structures and networks. Much of the public health and related social research concerning antimicrobial resistance has focused on antibiotic use as a practice, with research characterizing how antibiotics are used by patients, farmers, fishermen, drug sellers, clinicians and others. Researchers have also positioned antibiotic use as emergent of political-economic structures, shedding light on how working and living conditions, quality of care, hygiene and sanitation foster reliance on antibiotics. A growing body of research sees antibiotics as embedded in networks that, in addition to social and institutional networks, comprise physical, technical and historical connections such as guidelines, supply chains and reporting systems. Taken together, this research emphasizes the multiple ways that antibiotics have become built into daily life. Wider issues, which may be invisible without explication through ethnographic approaches, need to be considered when addressing antibiotic use. Adopting the complementary vantage points of practices, networks and structures can support the diversification of our responses to AMR.

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“…Antibiotics shorten the frequency and duration of diarrhoea 16 . In practice, guideline adherence in cholera endemic regions may be low out of clinical concern that a patient ‘might have cholera’ and that the patient may develop severe dehydration, contributing to rates of inappropriate antibiotic usage that can rise above 90% 17, 18 . Strong regional associations between antibiotic use and rise of AMR have been observed across enteric taxa, including V. cholerae 19–21 .…”

Section: Introductionmentioning

confidence: 99%

Genome-wide association studies reveal distinct genetic correlates and increased heritability of antimicrobial resistance inVibrio choleraeunder anaerobic conditions

Creasy-Marrazzo

Saber

Kamat

et al. 2021

Preprint

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Antimicrobial resistance (AMR) in Gram negative enteropathogens is an urgent threat to the antibiotic formulary. These taxa undergo anaerobic respiration within the host, yet little is known about how anaerobic conditions influence antimicrobial resistance (AMR). The facultative enteropathogen Vibrio cholerae was chosen as a model to determine the impact of anaerobic growth on AMR because cholera is one of the few non-invasive diarrhoeal diseases for which antibiotics are indicated, albeit conditionally. V. cholerae isolates from a single outbreak were tested for resistance by minimal inhibitory concentrations (MIC) under aerobic and anaerobic conditions against clinically relevant antibiotics. Here we show that the odds of classifying isolates as resistant under anaerobic compared to aerobic conditions increased over 20 times for ciprofloxacin and 50 times for azithromycin, yet for doxycycline, all isolates remained below the breakpoint for resistance. Genome-wide association studies (GWAS) found significant associations between known and unknown genetic elements and AMR phenotypes that varied by oxygen exposure and antibiotic concentrations. In most cases, AMR phenotypes were more heritable, and more genes significantly associated with AMR were discovered, under anaerobic conditions compared to aerobic conditions. These findings challenge the paradigm of testing facultative enteropathogens for AMR under aerobic conditions alone. This experimental approach establishes a new, more sensitive framework to track and investigate mechanisms of AMR.

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An ethnographic exploration of diarrheal disease management in public hospitals in Bangladesh: From problems to solutions

Cited by 22 publications

References 34 publications

Designing a Novel Clinician Decision Support Tool for the Management of Acute Diarrhea in Bangladesh: Formative Qualitative Study

Designing a Novel Clinician Decision Support Tool for the Management of Acute Diarrhea in Bangladesh: Formative Qualitative Study

Understanding antibiotic use: practices, structures and networks

Genome-wide association studies reveal distinct genetic correlates and increased heritability of antimicrobial resistance inVibrio choleraeunder anaerobic conditions

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