Background Antimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices. Methods We did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2•5-year study period (July 1, 2016-Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions. Findings Vietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55•2% of antibiotics dispensed without prescription), Bangladesh (45•7%), and Ghana (36•1%), but less so in Mozambique (8•0%), South Africa (1•2%), and Thailand (3•9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through healthcare facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia. Interpretation Contextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance. Funding Wellcome Trust and Volkswagen Foundation.

BackgroundIt has been suggested that rural–urban migration will have adverse consequences for older parents left behind.AimsTo describe correlates of outmigration and to estimate any association between outmigration of children and depression in rural-dwelling older parents.MethodPopulation-based survey of 1147 parents aged 60 and over in rural Thailand. We randomly oversampled parents living without children. We defined an outmigrant child as living outside their parent’s district, and measured depression as a continuous outcome with a Thai version of the EURO–D.ResultsOutmigration of all children, compared with outmigration of some or no children, was independently associated with less depression in parents. This association remained after taking account of social support, parent characteristics, health and wealth. Parents with all children outmigrated received more economic remittances and they perceived support to be as good as that of those with children close by.ConclusionsOutmigration of children was not associated with greater depression in older parents and, after taking account of a range of possible covariables, was actually associated with less parental depression. This could be explained by pre-existing advantages in families sending more migrants and by the economic benefits of migration.

Thailand has undergone rapid modernization with implications for changes in sexual norms. We investigated sexual behavior and attitudes across generations and gender among a probability sample of the general population of Nonthaburi province located near Bangkok in 2012. A tablet-based survey was performed among 2,138 men and women aged 15–59 years identified through a three-stage, stratified, probability proportional to size, clustered sampling. Descriptive statistical analysis was carried out accounting for the effects of multistage sampling. Relationship of age and gender to sexual behavior and attitudes was analyzed by bivariate analysis followed by multivariate logistic regression analysis to adjust for possible confounding. Patterns of sexual behavior and attitudes varied substantially across generations and gender. We found strong evidence for a decline in the age of sexual initiation, a shift in the type of the first sexual partner, and a greater rate of acceptance of adolescent premarital sex among younger generations. The study highlighted profound changes among young women as evidenced by a higher number of lifetime sexual partners as compared to older women. In contrast to the significant gender gap in older generations, sexual profiles of Thai young women have evolved to resemble those of young men with attitudes gradually converging to similar sexual standards. Our data suggest that higher education, being never-married, and an urban lifestyle may have been associated with these changes. Our study found that Thai sexual norms are changing dramatically. It is vital to continue monitoring such changes, considering the potential impact on the HIV/STIs epidemic and unintended pregnancies.

We investigate the impacts of rural-to-urban migration on the health of young adult migrants. A key methodological challenge involves the potentially confounding effects of selection on the relationship between migration and health. Our study addresses this challenge in two ways. To control for potential effects of prior health status on post-migration health outcomes, we employ a longitudinal approach. To control for static unobserved characteristics that can affect migration propensity as well as health outcomes, we use fixed-effects analyses. Data were collected in 2005 and 2007 for a cohort of young adults in rural Kanchanaburi province, western Thailand. The migrant sample includes individuals who subsequently moved to urban destinations where they were reinterviewed in 2007. Return migrants were interviewed in rural Kanchanaburi in both years but moved to an urban area and returned in the meantime. A rural comparison group comprises respondents who remained in the origin villages. An urban comparison sample includes longer-term residents of the urban destination communities. Physical and mental health measures are based on the SF-36 health survey. Findings support the “healthy migrant hypothesis.” Migrants are physically healthier than their nonmigrant counterparts both before and after moving to the city. We did not find an effect of migration on physical health. Rural-to-urban migrants who stayed at destination experienced a significant improvement in mental health status. Fixed-effects analyses indicate that rural-to-urban migration positively affects mental health. Return migrants do not fare as well as migrants who stayed at destination on both physical and mental health status—evidence of selective return migration.

BackgroundIt is not known whether social support modifies the association between depression and impairment or disability in older people from developing countries in Asia.MethodWe used a Thai version of the EURO-D scale to measure depression in 1104 Thai rural community-dwelling parents aged ⩾60 years. These were all those providing data on depression who were recruited as part of a study of older adults with at least one living child (biological, stepchild or adopted child). Logistic regression modelling was used to determine: (a) whether impairment, disability and social support deficits were associated with depression; (b) whether social support modified this association.ResultsThere were strong graded relationships between impairment, disability, social support deficits and EURO-D caseness. Level of impairment, but not disability, interacted with poor social support in that depression was especially likely in those who had more physical impairments as well as one or more social support deficits (p value for interaction=0.018), even after full adjustment.ConclusionsSocial support is important in reducing the association between physical impairment and depression in Thai older adults, especially for those with a large number of impairments. Enhancing social support as well as improving healthcare and disability facilities should be emphasized in interventions to prevent depression in older adults.