Facilitators and barriers of the rational drug use hospital program in Thailand

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Jeerisuda Khumsikiew https://orcid.org/0000-0002-1930-5977
Saksit Sripa https://orcid.org/0000-0002-1528-8006
Summana Moolasarn https://orcid.org/0000-0003-2243-0880
Li Shean Toh https://orcid.org/0000-0002-9228-6266
Claire Anderson https://orcid.org/0000-0002-5406-2296
Teeraporn Supapaan https://orcid.org/0000-0002-6887-8181


Rational drug use, Policy, CIPP framework


The Thailand Ministry of Public Health has started a rational drug use (RDU) policy, which includes multifaceted strategies as well as the RDU hospital program to tackle irrational drug use. Objective: To investigate facilitators and barriers related to the CIPP model of the RDU hospital program in Thailand. Methods: This is a qualitative study. Data were collected through semi-structured interviews with regional policymakers who were members of the executive board for RDU management in the 10th health region. The interviews were conducted via telephone using a topic guide informed by the CIPP framework and reviewed for content validity by the research team. Data were transcribed, and thematically analyzed. Results: Fifteen pharmaceutical policymakers were interviewed. The main facilitators related to context, input, and process were the national policy on RDU, RDU awareness/practices among health professionals, particularly prescribers, and multidisciplinary teamwork under the organization’s leadership to use data feedback to improve the program. The main barriers related to context, input, and process were a lack of policy advocacy at the regional and provincial levels, doctor-related reasons such as medicolegal concerns, and a lack of multidisciplinary teamwork. For the product theme, participants were very satisfied and perceived positive impacts at both the individual and organizational levels, such as increased RDU awareness in patients and multidisciplinary teams, as well as RDU prescription. However, negative impacts, such as tensions surrounding professional responsibility and accountability, have been observed. Conclusion: Although the participants expressed high satisfaction levels and positive impacts, there is still room for improvement in the specified themes. In addition, drug regulatory policies in all accessible channels, a multidisciplinary RDU curriculum, and public education to control irrational medication use and raise patient awareness should be increased to encourage sustainable RDU behavior..

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1. Holloway K, Dijk LV. The World Medicines Situation 2011 Rational Use of Medicines. 3rd ed. WHO Press; 2011.
2. World Health Organization. Promoting rational use of medicines: core components. 2020. http://archives.who.int/tbs/rational/h3011e.pdf
3. World Health Organization: Regional Office for South East Asia. Medicines in Health Care Delivery Thailand: Situational Analysis. New Delhi, India: The WHO/SEARO Workbook Tool for Undertaking a Situational Analysis of Medicines in Health 
Care Delivery in Low and Middle Income Countries; 2016.
4. Rational Use of Drug Subcommittee. Rational Drug Use Hospital Manual. Publishing House of the Agricultural Cooperatives Association of Thailand; 2015.
5. Rattanachotphanit T, Waleekhachonloet O. Effect of a Rational Drug Use Policy on the prescribing safety in outpatient settings in Thailand. Int J Pharm Pract. 2020;28(6):608-616. https://doi.org/10.1111/ijpp.12665
6. Waleekhachonloet O, Rattanachotphanit T, Limwattananon C, Thammatacharee N, Limwattananon S. Effects of a national policy advocating rational drug use on decreases in outpatient antibiotic prescribing rates in Thailand. Pharm Pract. 2021;19(1):2201. 
7. Sumpradit N, Wongkongkathep S, Malathum K, et al. Thailand’s national strategic plan on antimicrobial resistance: progress and challenges. Bull World Health Organ. 2021;99(9):661-673. https://doi.org/10.2471/BLT.20.280644
8. Tangcharoensathien V, Limwattananon S, Soontornpas C, Limwattananon C, Waleekhachonloet O, Rattanachotphanit T. Effects from the Rational Drug Use Hospital Policy on Prescribing Behaviours and Patient Outcomes. Health Systems Research 
Institute; 2020.
9. Rakchai N, Chaowanapulpol H, Prasertsuk S. Results of the service plan rational drug use hospital under the office of the permanent secretary for public heath, reginal 8th. IJPS. 2019;15(4):50-64.
10. Health Information Group, Ministry of Public Health. Searching for information on health services. Office of the Permanent Secretary, Ministry of Public Health. Accessed May 20, 2020; updated 
February 20 2019.
11. Ministry of Public Health. Thailand Regional Health Profile 2012-2017. Chinaksorn Press; 2018.
12. Toosi M, Modarres M, Amini M, Geranmayeh M. Context, Input, Process, and Product Evaluation Model in medical education: A systematic review. J Educ Health Promot. 2021;10(1):199. https://doi.org/10.4103/jehp.jehp_1115_20
13. Lee SY, Shin JS, Lee SH. How to execute Context, Input, Process, and Product evaluation model in medical health education. J Educ Eval Health Prof. 2019;16(40):40. https://doi.org/10.3352/jeehp.2019.16.40
14. Stufflebeam DL. CIPP Evaluation Model Checklist: A Tool for Applying the CIPP Model to Assess Projects and Programs. Western Michigan University Evaluation Center; 2015.
15. Stufflebeam DL, Coryn CL. Evaluation Theory, Models, and Applications. 2nd ed. John Wiley & Sons; 2014.
16. Vasileiou K, Barnett J, Thorpe S, et al. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018;18(1):148. https://doi.
17. Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131: AMEE Guide No. 131. Med Teach. 2020;42(8):846-854. https://doi.org/10.1080/0142159X.2020.1755030
18. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. https://doi.org/10.1093/intqhc/mzm04219. Holloway KA, Ivanovska V, Manikandan S, et al. Identifying the most effective essential medicines policies for quality use of 
medicines: A replicability study using three World Health Organisation data-sets. PLOS ONE. 2020;15(2):e0228201. https://doi.org/10.1371/journal.pone.0228201
20. Holloway KA, Rosella L, Henry D. The impact of WHO essential medicines policies on inappropriate use of antibiotics. PLOS ONE. 2016;11(3):e0152020. https://doi.org/10.1371/journal.pone.0152020
21. Asaria M, McGuire A, Street A. The impact of management on hospital performance. Fisc Stud. 2022;43(1):79-95. https://doi.org/10.1111/1475-5890.12293 
22. Jones B, Horton T, Home J. Strengthening NHS Management and Leadership: Priorities for Reform. The Health Foundation; 2022.
23. Teixeira Rodrigues AT, Roque F, Falcão A, et al. Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies. Int J Antimicrob Agents. 2013;41(3):203-212. https://doi.org/10.1016/j.ijantimicag.2012.09.003
24. Melanie D, Giovanni A, Tjeerd P, et al. General practitioners’ accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices. BMC Fam 
Pract. 2019;20(1):1. https://doi.org/10.1186/s12875-019-1065-x
25. Mao W, Vu H, Xie Z, et al. Systematic review on irrational use of medicines in China and Vietnam. PLOS ONE. 2015;10(3):e0117710. https://doi.org/10.1371/journal.pone.0117710
26. Geerligs L, Rankin NM, Shepherd HL, et al. Hospital-based interventions: a systematic review of staff-reported barriers and facilitators to implementation processes. Implement Sci. 2018;13(1):36. https://doi.org/10.1186/s13012-018-0726-9
27. Yağar F, Dökme S. Evaluation of factors affecting drug choice of physicians. Int J Health Manag Tourism. 2017;2(1):62-19.
28. Davari M, Khorasani E, Tigabu BM. Factors influencing prescribing decisions of physicians: a review. Ethiop J Health Sci. 2018;28(6):795-804. https://doi.org/10.4314/ejhs.v28i6.15
29. Monmaturapoj T, Scott J, Smith P, et al. What influences the implementation and sustainability of antibiotic stewardship programmes in hospitals? A qualitative study of antibiotic pharmacists’ perspectives across South West England. Eur J Hosp 
Pharm. 2022;29(e1):e46-e51. https://doi.org/10.1136/ejhpharm-2020-002540
30. Howard P, Pulcini C, Levy Hara G, et al. An international cross-sectional survey of antimicrobial stewardship programmes in hospitals. J Antimicrob Chemother. 2015;70(4):1245-1255. https://doi.org/10.1093/jac/dku497
31. Rzewuska M, Duncan EM, Francis JJ, et al. Barriers and facilitators to implementation of antibiotic stewardship programmes in hospitals in developed countries: insights from transnational studies. Front Sociol. 2020;5:41. https://doi.org/10.3389/
32. Zheng K, Xie Y, Dan L, et al. Effectiveness of educational interventions for health workers on antibiotic prescribing in outpatient settings in China: A systematic review and meta-analysis. Antibiotics (Basel). 2022;11(6):791. https://doi.org/10.3390/
33. Iles V, Sutherland K. Managing change in the NHS: organisational change: a review for health care managers, professionals and researchers. Natl Co-Ordinating Cent NHS Serv Deliv Organ. 2001.
34. World Health Organization. The Role of Education in the Rational Use of Medicines. WHO Regional Office for South-East Asia; 2006.
35. Management sciences for health:MDS-3. Managing Access to Medicines and Health Technologies. Management Sciences for Health; 2012.
36. Mosadeghrad AM. Factors influencing healthcare service quality. Int J Health Policy Manag. 2014;3(2):77-89. doi: https://doi.org/10.15171/ijhpm.2014.65
37. Yang J, Zheng L, Guan YY, et al. Drug and therapeutics committee interventions in managing irrational drug use and antimicrobial stewardship in China. Front Pharmacol. 2022;13:829408. https://doi.org/10.3389/fphar.2022.829408
38. Fulop NJ, Ramsay AIG. How organisations contribute to improving the quality of healthcare. BMJ. 2019;365:(l1773):1-6. https://doi.org/10.1136/bmj.l1773
39. Lachman P, Runnacles J, Dudley J, et al. Equipped: overcoming barriers to change to improve quality of care (theories of change). Arch Dis Child Educ Pract Ed. 2015;100(1):13-18. https://doi.org/10.1136/archdischild-2013-305193
40. Wu S, Tannous E, Haldane V, et al. Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research. 
Implement Sci. 2022;17(1):1-19. https://doi.org/10.1186/s13012-022-01209-4
41. Apisarnthanarak A, Kwa AL-H, Chiu CH, et al. Antimicrobial stewardship for acute-care hospitals: an Asian perspective. Infect Control Hosp Epidemiol. 2018;39(10):1237-1245. https://doi.org/10.1017/ice.2018.188
42. Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: a systematic review. PLOS ONE. 2017;12(8):e0183062. https://doi.org/10.1371/journal.pone.0183062
43. Bright TJ, Wong A, Dhurjati R, et al. Effect of clinical decision-support systems: a systematic review. Ann Intern Med. 2012;157(1):29-43. https://doi.org/10.7326/0003-4819-157-1-201207030-00450
44. Holloway KA, Kotwani A, Batmanabane G, et al. Antibiotic use in South East Asia and policies to promote appropriate use: reports from country situational analyses. BMJ. 2017;358(1):j2291. https://doi.org/10.1136/bmj.j2291
45. Ferreira MBC, Heineck I, Flores LM, et al. Rational use of medicines: prescribing indicators at different levels of health care. Braz J Pharm Sci. 2013;49(2):329-340. https://doi.org/10.1590/S1984-82502013000200015
46. Gad M, Salem A, Oortwijn W, et al. Mapping of current obstacles for rationalizing use of medicines (CORUM) in Europe: current situation and potential solutions. Front Pharmacol. 2020;11(144):144. https://doi.org/10.3389/fphar.2020.00144
47. Religioni U, Pakulska T. Rational drug use in hospital settings – areas that can be changed. J Med Econ. 2020;23(10):1205-1208. https://doi.org/10.1080/13696998.2020.1801455
48. Isareethikab JC, Nipaporn U, Pard T. System Dynamics Analysis of Factors Affect Rational Antibiotic Use Behavior in Public Sector Provincial Level Model: A Case Study of Nakhon Nayok Province. Health Systems Research Institute; 2019.
49. Tan KH, Pang NL, Siau C, et al. Building an organizational culture of patient safety. J Patient Saf Risk Manag. 2019;24(6):253-261. https://doi.org/10.1177/2516043519878979
50. Malik RF, Buljac-Samardžić M, Akdemir N, et al. What do we really assess with organisational culture tools in healthcare? An interpretive systematic umbrella review of tools in healthcare. BMJ Open Qual. 2020;9(1):e000826. https://doi.org/10.1136/
51. Wagner C, Mannion R, Hammer A, et al. The associations between organizational culture, organizational structure and quality management in European hospitals. Int J Qual Health Care. 2014;26(Suppl 1):74-80. https://doi.org/10.1093/intqhc/mzu027
52. Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. Int J Prod Econ. 2007;106(2):368-392. https://doi.org/10.1016/j.ijpe.2006.07.005
53. Peragine C, Walker SAN, Simor A, et al. Impact of a comprehensive antimicrobial stewardship program on institutional burden of antimicrobial resistance: a 14-year controlled interrupted time-series study. Clin Infect Dis. 2020;71(11):2897-2904. https://
54. Mahmoudi L, Sepasian A, Firouzabadi D, et al. The impact of an antibiotic stewardship program on the consumption of specific antimicrobials and their cost burden: A hospital-wide intervention. Risk Manag Healthc Policy. 2020;13:1701-1709. https://doi.
55. Al-Omari A, Al Mutair A, Alhumaid S, et al. The impact of antimicrobial stewardship program implementation at four tertiary private hospitals: results of a five-years pre-post analysis. Antimicrob Resist Infect Control. 2020;9(1):95. https://doi.
56. Machen S, Jani Y, Turner S, et al. The role of organizational and professional cultures in medication safety: a scoping review of the literature. Int J Qual Health Care. 2019;31(10):G146-G157. doi: https://doi.org/10.1093/intqhc/mzz111

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