Three villages were selected for the study: 69 households in the first village (344 people), 153 households (746 people) in the second village, and 177 households (775 people) in the last village. The locations are approximately 42 km from Wiang Pa Pao District, Chiang Rai Province, Thailand. A health center is located 8 km from the first village and requires 20 minutes of driving by motorcycle, 11 km from the second village and 45 minutes of driving by motorcycle, and 18 km from the third village and 60 minutes of driving by motorcycle (Fig. 1). The distance from the health center to a district hospital is 28 km, requiring 30 minutes to travel by car. Moreover, an hour is required to travel from the district hospital to the provincial hospital (tertiary hospital) by car. There are approximately 6–8 members in each household in a Lahu family. The majority of the Lahu people were Buddhist (83.0%), and traditional crops such as corn, beans, and rice were planted, with an annual income of 60,000-120,000 baht per family. They did not have livestock and did not use antibiotics in animals.
The health center is responsible for 14 hill tribe villages, encompassing a total population of 9,632 people (4,815 males, 4,817 females). There are 9 public health staff members: two nurses, two public health professionals, and 5 other health professionals. Three different antibiotics were available at the health center: amoxicillin, roxithromycin, and dicloxacillin. The top five infectious diseases reported from the health center between January and December 2019 were 1) diarrhea, 2) pyrexia, 3) dengue fever, 4) conjunctivitis, and 5) hand, foot and mouth disease. The top three infectious diseases among the people living in the selected villages were 1) diarrhea, 2) common cold, and 3) cystitis.
According to the results from the questionnaire, the majority of the participants were females (70.4%), aged 30–40 years (25.4%), and married (82.9%). More than half worked in the agricultural sector (55.4%) and had poor education, which was less than primary school (45.8%) (Table 1).
Table 1
General characteristic of participants.
Characteristic | n | % |
Total | 240 | 100.0 |
Sex Male Female | 71 169 | 29.6 70.4 |
Age (years) 10–20 21–30 30–40 41–50 51–60 61–70 > 70 | 10 40 61 59 22 35 13 | 4.2 16.7 25.4 24.6 9.2 14.6 5.4 |
Mean = 43.5, SD = 15.3, Min = 17, Max = 98 | |
Education No education Primary school High school Vocational certificate and higher | 110 110 14 6 | 45.8 45.8 5.8 2.5 |
Occupation Unemployed Agriculturalist worker Employee Commercial | 23 133 67 17 | 9.6 55.4 29.9 7.1 |
Married status Single Married Ever married | 20 199 21 | 8.3 82.9 8.8 |
Underlying disease* No Yes * Hypertension (n = 47) Gastritis(n = 47) Diabetes mellitus(n = 47) Chronic renal failure(n = 47) Asthma(n = 47) Coronary heart disease(n = 47) | 193 47 23 13 12 4 3 2 | 80.4 19.6 |
* Some participants had more than one list of a disease. |
Urinary tract infectious diseases accounted for the largest group of infections in the past 12 months (67.9%), with 163 cases of urinary tract infection. A community health center (28.8%) was the favored location of healthcare services for the participants, followed by a district hospital (24.6%) and a drugstore or village grocery (21.7%). The top three sources of antibiotic use were district hospitals (51.7%), drugstores or village groceries (27.9%), and private medical clinics (22.5%). Most of these sources showed good knowledge of infectious diseases (82.9%), while knowledge of and attitudes toward antibiotics and practices were poor (66.2%, 51.2%, and 64.6%, respectively). More than half of the participants received information about infectious diseases and antibiotics from health care professionals (Table 2).
Table 2
History of illness and access medical services.
Factors | n | % |
Total | 240 | 100.0 |
History of illness 12 months prior* Urinary tract infection (n = 240) Respiratory tract infection (n = 240) Gastrointestinal tract infection (n = 240) | 163 135 81 | 67.9 56.3 33.8 |
First priority on access a medical care while having health problem Community health center District hospital Drugstore Village grocery Private clinic Using leftover drugs Using drugs from family member | 69 59 52 39 13 4 3 | 28.8 24.6 21.7 16.3 5.4 1.7 1.3 |
Frequency of antibiotic use 12 months prior (times) 1 2 ≥3 | 153 58 29 | 63.8 24.2 12.1 |
Source of getting antibiotics* District hospital (n = 240) Drugstore (n = 240) Private medical clinic (n = 240) Private nurse clinic (n = 240) Health center (n = 240) Tertiary hospital (n = 240) Family member or neighborhood (n = 240) | 124 67 54 38 16 10 2 | 51.7 27.9 22.5 15.8 6.7 4.2 0.8 |
Reasons for taking antibiotics* Wish to get better from an illness (n = 240) Doctor or health care professional prescribed (n = 240) Protect severity of illness (n = 240) | 167 151 77 | 69.6 62.9 32.1 |
Ever receiving information on infectious diseases No Yes | 64 176 | 26.7 73.3 |
Source of information about infectious disease * Health care professional (n = 240) Village health volunteer (n = 240) Community leader (n = 240) Television, radio (n = 240) | 129 74 70 66 | 53.8 30.8 29.2 25.5 |
Received information on antibiotics No Yes | 62 178 | 25.8 74.2 |
Source of information about antibiotics* Health care professional (n = 240) Village health volunteer (n = 240) Community leader announcement (n = 240) Television or radio broadcasting (n = 240) | 150 83 76 62 | 62.5 34.6 31.7 25.8 |
Knowledge on infectious diseases Poor Good | 41 199 | 17.1 82.9 |
Knowledge regarding antibiotic use Poor Good | 159 81 | 66.2 33.8 |
Attitudes regarding antibiotic use Poor Good | 123 117 | 51.2 48.8 |
Behavior regarding antibiotic use Poor Good | 155 85 | 64.6 35.4 |
According the comparisons between those who had drug resistance and those who did not, only knowledge regarding antibiotic use was found to be statistically significant (p-value = 0.034). However, two other variables (age and antibiotic use behaviors) were found to have marginally significant differences between groups (Table 3).
Table 3
Factors correlation with antibiotic resistance.
Factors | Resistance | No resistance | χ2 | p-value |
n | % | n | % |
Total | 30 | 12.5 | 210 | 87.5 | N/A | N/A |
Age (years) < 60 ≥ 60 years | 20 10 | 66.7 33.3 | 172 38 | 81.9 18.1 | 3.81 | 0.051 |
Education No Yes | 18 12 | 60.0 40.0 | 92 118 | 43.8 56.2 | 2.77 | 0.096 |
Receiving antibiotic information No Yes | 8 22 | 26.7 73.3 | 54 156 | 25.7 74.3 | 0.01 | 0.911 |
Knowledge on infectious diseases Poor Good | 6 24 | 20.0 80.0 | 35 175 | 16.7 83.3 | 0.20 | 0.650 |
Knowledge regarding antibiotic use Poor Good | 25 5 | 83.3 16.7 | 134 76 | 63.8 36.2 | 4.47 | 0.034* |
Attitudes regarding antibiotic use Poor Good | 19 11 | 63.3 36.7 | 104 106 | 49.5 50.5 | 2.00 | 0.157 |
Behaviors on antibiotic use Poor Good | 24 6 | 80.0 20.0 | 131 79 | 62.4 37.6 | 3.56 | 0.059 |
Frequency of antibiotic use 12 months prior (time) 1 ≥ 2 | 22 8 | 73.3 26.7 | 131 79 | 62.4 37.6 | 1.36 | 0.243 |
* Significant level at α = 0.05 |
Of 240 specimens (participants), 187 samples were found to contain bacterial species, including normal flora. Fifty-five specimens were found to have more than 3 bacterial species, and only 30 samples were found to have drug resistance. The top-five bacterial species were detected in the specimens: Escherichia coli (12.8%), Enterobacter cloacae (8.0%), Klebsiella pneumoniae (4.3%), Enterococcus faecalis (4.3%), and Staphylococcus coagulase negative (4.3%). The prevalence of antibiotic resistance was 16.0%. Klebsiella pneumoniae resisted ampicillin, cefazolin, cefoxitin, ciprofloxacin, levofloxacin and trimethoprim-sulfamethoxazole (TMP-SMX), while Escherichia coli demonstrated resistance to ampicillin, amoxicillin-clavulanate, gentamycin, ciprofloxacin, levofloxacin and TMP-SMX. Ampicillin was found to have the highest resistance rate among the pathogenic bacteria, followed by cefoxitin, cefazolin, amoxicillin-clavulanate, and TMP-SMX (Table 4).
Table 4
Types of bacterial infection and antibiotic resistance (n = 30).
Antibiotic Bacterial species | Amount of infection | Ampicillin | TMP-SMX | Penicillin | Amoxicillin + Clavulanic acid | Cefoxitin | Cefazolin | Doxy cycline | Gentamycin | Cipro foxacin | Levofloxacin | Vancomycin | Oxa cillin | Methicillin |
Escherichia coli | 7 | 6 | 6 | | 1 | | | | 2 | 1 | 1 | | | |
Enterobacter cloacae | 3 | 4 | | | 4 | 4 | 1 | | | | | | | |
Klebsiella pneumoniae | 7 | 7 | 1 | | | 1 | 1 | | | 1 | 1 | | | |
Staphylococcus coagulase negative | 3 | | | 3 | | | | 1 | | | | | 1 | 1 |
Salmonella spp. | 1 | 1 | 1 | 1 | | | | | | 1 | 1 | | | |
Citrobactor Freundii | 1 | 2 | | | 1 | 1 | 1 | | | | | | | |
Enterococcus faecalis | 3 | | | | | | | 3 | 1 | | | | | |
Staphylococcus aureus | 2 | | | 2 | | | | 1 | | | | 1 | | |
Klebsiella aerogenes | 1 | 1 | | | 1 | 1 | 1 | | | | | | | |
Proteus mirabilis | 1 | 1 | 1 | 1 | | | | | 1 | | | | | |
Streptococus agalactiae | 1 | 1 | | | | | | | | | | | | |
Citrobacter koseri | 1 | 1 | | | | | | | | | | | | |
Klebsiella oxytoca | 1 | 1 | | | | | | | | | | | | |
Total | | 25 | 9 | 7 | 7 | 7 | 4 | 4 | 4 | 3 | 3 | 1 | 1 | 1 |
* 1 person could infect more than one type bacterial species and antibiotics |
Two variables were found to be associated with antibiotic drug resistance among the Lahu people: knowledge and behaviors regarding antibiotic drug resistance. In the multivariate model, these two variables remained associated with antibiotic resistance, including knowledge and behaviors regarding antibiotic resistance. Those who had poor knowledge reading antibiotic use had a 2.56-fold greater chance (95% CI = 1.09–5.32) of having antibiotic resistance than did those who had good knowledge of antibiotic use. Those who had poor antibiotic use behaviors had a 1.79-fold greater chance (95% CI = 1.06–4.80) of having antibiotic resistance than did those who had good antibiotic use behaviors (Table 5).
Table 5
Factors associated with antibiotic resistance in univariate and multivariate analyses.
Factors | Drug-resistance (n = 30) | No drug-resistance (n = 210) | OR | 95% CI | p-value | ORadj | 95% CI | p-value |
n | % | n | % |
Total | 30 | 12.5 | 210 | 87.5 | N/A | N/A | N/A | N/A | N/A | |
Age (years) < 60 ≥ 60 | 20 10 | 66.6 33.3 | 172 38 | 81.9 18.1 | 1.00 2.26 | 0.98–5.22 | 0.056 | | | |
Education No Yes | 18 12 | 60.0 40.0 | 92 118 | 43.8 56.2 | 1.92 1.00 | 0.88–4.19 | 0.100 | | | |
Received antibiotic information No Yes | 8 22 | 26.7 73.3 | 54 156 | 25.7 74.3 | 1.05 1.00 | 0.44–2.49 | 0.911 | | | |
Knowledge on infectious diseases Poor Good | 6 24 | 20.0 80.0 | 35 175 | 16.7 83.3 | 1.25 1.00 | 0.48–3.28 | 0.651 | | | |
Knowledge regarding antibiotic use Poor Good | 25 5 | 83.3 16.7 | 134 76 | 63.81 36.2 | 2.8 1.00 | 1.04–7.71 | 0.041* | 2.56 1.00 | 1.09–5.32 | 0.048* |
Attitudes regarding antibiotic use Poor Good | 19 11 | 63.3 36.7 | 104 106 | 49.5 50.5 | 1.76 1.00 | 0.80–3.88 | 0.161 | | | |
Behavior regarding antibiotic use Poor Good | 24 6 | 80.0 20.0 | 131 79 | 62.4 37.6 | 2.41 1.00 | 1.02–6.16 | 0.046* | 1.79 1.00 | 1.06–4.80 | 0.041* |
Frequency of antibiotic use last 12 month (time) 1 ≥ 2 | 22 8 | 73.3 26.7 | 131 79 | 62.4 37.6 | 1.00 0.60 | 0.25–1.41 | 0.24 | | | |
* Significant level at α = 0.05 |