Article Summary by Marco J Haenssgen, Nutcha Charoenboon, Patthanan Thavethanutthanawin and Kanokporn Wibunjak

Listen to Nutcha (Ern) Charoenboon discuss the research project below (full script below bionotes):

Read the full article on the Medical Humanities journal.

 

Global health has often been critiqued for neglecting the voices of poor, rural, and indigenous peoples around the world.^1,2 The medical humanities give us a platform and media to help express these voices and in that way also challenge groupthink in global health.^3,4,5 Our paper on Tales of Treatment and public engagement⁶ builds on this logic. The study touched on drug resistant infections – a priority topic on global health agendas – and how people practise health and wellbeing in Thailand. We followed convention by surveying and interviewing villagers from across the northern Thai province of Chiang Rai to understand what these practices were,⁷ but we also consulted with villagers directly and gathered and exhibited stories of traditional healing from indigenous groups. We used this participatory and co-production approach as part of our public engagement activities to give our research partners and audiences more freedom over the information they wished to present to us.

Extending our toolkit into the medical humanities enabled new research insights. Firstly, the unfettered and less directed input from the villagers during three community meetings produced new ideas about how people might think about and use medicines like antibiotics. Awareness campaigns normally assume that people have just one common notion of “antibiotic.” Our participants instead suggested that villagers on the one hand distinguish between those antibiotics that “you can buy … over the counter” and those that require a prescription from a doctor, and on the other hand follow the instructions of antibiotics given to children strictly but tend to be less strict with medicine that they use for themselves. Another idea was that younger people would more often buy antibiotics for themselves or otherwise dispute the treatment advice of doctors as they assert their independence.

Because we gathered these insights alongside a survey of health practices and medicine use, we were able to test them as hypotheses with our detailed data from 2,422 villagers. The findings were not altogether conclusive, but some interesting patterns emerged: if villagers referred to antibiotics for example as “TC Mycin” or “red-and-black pills” that are often available prescription-free in pharmacies and shops, then their attitude was also much more likely to buy them over the counter – compared to villagers who used the technical Thai term for “antibiotic” to describe the medicine. Differences between adult and child antibiotic use were also subtle but it seemed that adults would more often buy non-prescription antibiotics for themselves than for their children. Studying other relationships such as those between age and antibiotic use was less informative but, thanks to these community inputs, future surveys can develop and study such initially unforeseen hypotheses further.

Secondly, we gathered 15 stories of traditional healing from Thai and indigenous villages across Chiang Rai, letting healers choose the stories they considered worth telling. You can read some of these stories below and the full exhibition booklet is available via http://warwick.ac.uk/mjhaenssgen/talesoftreatment.

 

The story content helped us reflect on health, healing, and drug resistance outside the confines of mainstream global health ideology. A grandma’s “at-home medical unit” produced, packaged, and administered herbal medicines for sore throats. The practice of modern medicine had for decades criticized and replaced such traditional remedies in place of its own pharmaceutical solutions. But as people had become accustomed to taking pharmaceuticals like antibiotics to treat their sore throats (and thus risk aggravating the development of drug-resistant infections), modern medicine is now ironically increasingly depending on herbal “alternatives” for its own survival.⁸ Other stories would spark reflections on how patients might judge “quality of care” by how painful (i.e. good) a treatment is, and a story of ghost healing would lead us to question what healthcare even is if people would seek remedies for fights with their parents but also who indeed a “healthcare provider” is and should be if every household could at any point practise such healing rituals. The creative and undirected process in storytelling therefore sparked a process of reflection and shed light on aspects of health and well-being that our standard research tools were not prepared to document on their own.^9,10

Thirdly, we seized the opportunity to share these stories with – and learn from – urban publics interested in photography, culture, and alternative systems of medicine. More than 500 visitors attended the Tales of Treatment exhibitions in Thailand (Chiang Rai & Bangkok) and the UK (Oxford & Coventry), many of whom shared their own stories and experiences of healing, drew connections between the tales and Western (ethno-)medicine,¹¹ or even contemplated directions for future research on drug resistance (e.g. the co-evolution of local forms of healing and the spread of drug resistant infections). An evaluation specifically in Coventry reported positive reviews and “worthwhile” visits to the exhibition, but it also led us to consider the costs and possible unintended consequences of engaging, for example if attendees read stories as if they were medical treatment recommendations.^12,13

On the whole, our public engagement activities had a complementary purpose in relation to other research methods used in our project; they would be less effective on their own. But it was exactly this integration of medical humanities approaches into our more conventional survey research that enabled us to,

• understand better the vast diversity of health and wellbeing practices,
• appreciate that people’s diverse understandings antibiotics could influence how they use medicine, and
• reflect on ironic contradictions in the global fight against drug resistance.

Although it does not come free of cost and effort, our main recommendation is that global health research requires public engagement informed by the medical humanities to remain relevant for the realities and perspectives of local populations.

References

1. Keller, RC. (2006). Geographies of power, legacies of mistrust: colonial medicine in the global present. Historical Geography, 34, 26-48.
2. Pratt, B, Sheehan, M, Barsdorf, N, & Hyder, AA. (2018). Exploring the ethics of global health research priority-setting. BMC Medical Ethics, 19(94). doi: 10.1186/s12910-018-0333-y
3. Sweeney, KG, Edwards, K, Stead, J, & Halpin, D. (2001). A comparison of professionals’ and patients’ understanding of asthma: evidence of emerging dualities? Medical Humanities, 27(1), 20-25. doi: 10.1136/mh.27.1.20
4. Treffry-Goatley, A, Lessells, RJ, Moletsane, R, de Oliveira, T, et al. (2018). Community engagement with HIV drug adherence in rural South Africa: a transdisciplinary approach. Medical Humanities, 44(4), 239-246. doi: 10.1136/medhum-2018-011474
5. Jerke, L, Prendergast, M, & Dobson, W. (2018). Smoking cessation in mental health communities: a living newspaper applied theatre project. In M Capous-Desyllas & K Morgaine (Eds.), Creating social change through creativity: anti-oppressive arts-based research methodologies (pp. 171-186). Cham: Springer.
6. Haenssgen, MJ, Charoenboon, N, Thavethanutthanawin, P, & Wibunjak, K. (2020). Tales of treatment and new perspectives for global health research on antimicrobial resistance. Medical Humanities, 47(4). doi: 10.1136/medhum-2020-011894
7. Haenssgen, MJ, Charoenboon, N, Zanello, G, Mayxay, M, et al. (2018). Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation, and knowledge diffusion. BMJ Global Health, 3(e000621). doi: 10.1136/bmjgh-2017-000621
8. Sumpradit, N, Chongtrakul, P, Anuwong, K, Pumtong, S, et al. (2012). Antibiotics Smart Use: a workable model for promoting the rational use of medicines in Thailand. Bulletin of the World Health Organization, 90(12), 905-913. doi: 10.2471/BLT.12.105445
9. Jordanova, L. (2014). Medicine and the visual arts. In V Bates, A Bleakley & S Goodman (Eds.), Medicine, health and the arts: approaches to medical humanities (pp. 41-63). Abingdon: Routledge.
10. Stahl, D, & Stahl, DG. (2016). Seeing illness in art and medicine: a patient and printmaker collaboration. Medical Humanities, 42(3), 155-159. doi: 10.1136/medhum-2015-010838
11. Hahn, RA, & Kleinman, A. (1983). Biomedical practice and anthropological theory: frameworks and directions. Annual Review of Anthropology, 12(1), 305-333. doi: 10.1146/annurev.an.12.100183.001513
12. Bleakley, A. (2014). Towards a ‘critical medical humanities’. In V Bates, A Bleakley & S Goodman (Eds.), Medicine, health and the arts: approaches to medical humanities (pp. 17-26). Abingdon: Routledge.
13. Charoenboon, N, Haenssgen, MJ, Warapikuptanun, P, Xayavong, T, et al. (2019). Translating antimicrobial resistance: a case study of context and consequences of antibiotic-related communication in three northern Thai villages. Palgrave Communications, 5(23). doi: 10.1057/s41599-019-0226-9

 

 

Nutcha (Ern) Charoenboon is PhD Student in Population Health Science at the University of Bristol, where she studies the social context of antibiotic use and drug-resistant infections in Thailand. She directed and curated the Tales of Treatment exhibitions and led the survey research of the associated Antibiotics and Activity Spaces project.

Patthanan (Mind) Thavethanutthanawin is Program and Art Director at the World Business Broadcast Company. As Research Intern in the Antibiotics and Activity Spaces project, she produced the audio-visual materials underlying the exhibition, collected research data, and implemented the exhibition and its evaluation activities.

Kanokporn (Joobjang) Wibunjak is Lead Talent Acquisition Specialist at Wongnai Media. As Research Intern in the Antibiotics and Activity Spaces project, she documented the narratives for Tales of Treatment, collected research data, and implemented the exhibition and its evaluation activities.

Marco J Haenssgen is Assistant Professor in Global Sustainable Development at the University of Warwick. He designed and oversaw the Antibiotics and Activity Spaces project and its public engagement portfolio, of which Tales of Treatment was a part.

 

Transcript

Hi, I’m Ern and I worked as research officer and Tales of Treatment exhibition curator in this project. You might have already read our blog summary of the project and what we learned from it, and here I just wanted to share what this process involved for all of us!

It all started really from within the ongoing survey project. So to an extent, this was a standard interdisciplinary research project. We did qualitative research in Southeast Asia, and then based on what we learned, we developed a survey project to study antibiotic use in Thailand and Laos. We had at that stage already planned to have some public engagement components, being quite keen to involve our study communities beyond just the socio-medical data collection. In the first instance that involved workshops, which were a really great way to expand our data collection from semi-structured interview guides and survey questionnaires to more creative media and less foreseeable inputs. You can see in the paper how this even inspired some new research hypotheses!

But what was most striking was how we visited more than 70 villages and realised that even our carefully developed questionnaire can’t really capture the rich heritage of traditional healing in Thailand. So during the survey implementation with our colleagues Mind and Joobjang and the larger survey team, we kept thinking about how we can do justice to the realities we encountered, and the medical humanities provided a really rich toolkit to that end. Combining then our research on health behaviours and antibiotic use with stories and photography of traditional healing was an amazing learning experience. The assumptions we made! Many really subtle points, like how we as academics think about health systems and healthcare, were suddenly open to debate. And we were really grateful for the healers to share their stories with us. It is only a tiny contribution, but it is also some comfort for us that we could document and share these tales.

Sharing them actually was another highlight! It was really exciting to work with the team to create and host the exhibitions in four different venues – and see what the participants made of them. Evaluation! It sounds like the most boring part of a creative project, but actually helped us reflect on what we are doing. It is very easy to get drawn into the question, “but is it fun?!” when engaging with the public, because that ends up the most direct experience. But hearing from the participants if any of the content held meaning for them and what they made of it was just as important – be it what we expected or even something quite unintended. So that is just a little backstory on the project, but I hope you found our article on “Tales of Treatment and new perspectives for global health research on antimicrobial resistance” interesting! Thank you for listening and bye!