 Okay. My name is Hung and I'm from the Oxford University clinical research unit in Vietnam and today I'm going to share with you our experience in antimicrobial stewardship or AMS implementation from the health system approach in Vietnam. Okay, so AMS is an important structures in the global and also national action plans around the world. And usually an AMS program will contains a number of core elements that are providing the important structural foundation for the implementation of the program, including the leadership commitment, accountability and responsibilities of the team, drug expertise, specific set of actions to improve the behaviors, tracking indicators, reporting and feedback and also education and training. So AMS or an AMI is not confined in any department or any area. So that's why we need a whole system approach. We need to involve different stakeholders and players. We also need to bring in the implementation science and so shows the science methods in order to address the factors and the contextual determinants in which influence the prescribing behaviors within the hospitals. We have lots of evidence, evidence-based interventions are there from previous experience around the world. However, we need to identify and use suitable implementation techniques in order to tailor these interventions to the specific context of each hospital setting. Okay, an important aspect of our AMS program is networking and sharing of the AMS knowledge and experience internationally and locally. We started the AMS since 2013 with the VNRS project which initiated the concept of the AMS in the VNRS hospital network across Vietnam. But not until 2019 we were able to organize a national AMS stakeholder meeting together with the Ministry of Health and with the WHO, where we share the experience in implementations, identify the issues and challenges, and also identify the way forward. We also collaborate with the Duke antimicrobial stewardship outreach network in the US in trying to implement the AMS models in provincial hospitals in Vietnam. And we connected the local hospitals with the local experts who have experience in implementation and also with international experts. And recently we are working together with our sister units in Indonesia, Thailand and Nepal in a CDC funded project together with the other groups in Central and South America, America and Southern Africa to try to develop a contextualized AMS assessment tool to help the local hospitals in evaluating and improving their implementation in AMS. It is very important that we need to have an understanding of the barriers and the opportunities for AMS implementation in order to design our AMS program. So this is shown in our recent paper from a mixed method study in the VNRS network hospitals. And from this qualitative data, we identified salient aspects that need to be addressed within the future programs. For example, from the important roles of different stakeholders like leadership doctors and pharmacists and microbiologists to the practice that need attention. For example, taking culture prior to antibiotic treatment or using antimicrobiology data to help guide treatment or the escalation for the patients. So these are very important and give us the foundation to design our programs. In our implementation approach, we consider hospitals as complex adaptive systems, which is such as by a growing body of literature. So a complex adaptive system is a collection of individual agents with freedom to act in ways that are not always totally predictable and whose actions are interconnected so that one agent actions change the context for other agents. So conceptualizing hospitals as complex adaptive systems has an important implication for us in trying to find ways to how to intervene within the systems. And it's also reinforced the idea that hospital is unique, each hospital is unique and we can sort of move intervention from one hospital to another with predictable results. So we need to look at, we need to have a system thinking that we need to look at the interconnections between parts of the system. We try to incorporate multiple perspectives, try to consider the local conditions and also leverage the local resources and capabilities. We need to think in the context and also in dynamic that is trying to be responsive and also adaptive to the change in the in the within the hospitals with the system over time. And we need to involve different levels within the system from the senior management to the frontline staff. And in our MS program, it needs to consist of consist of ongoing rather than one of activities. So this flow chart kind of give you an impression of how the different actors and actions within the that influence the antimicrobial prescribing and use within the hospital system and you can see there are a number of of them and we need to all have a good understanding of all this and trying to identify the areas and also where we can find the scenery and the coordination between the different action and actors and stakeholders. And of course context matters in a mass implementation. And we need to assess the context your need to be in from different levels from micro level like factors related to prescriber or patients factor related to organize at the level factor related to the cultural the support the structures the writing readiness to change. And also at the macro level at the national level the guidance networks and regulation and evidence available. And we also need to take into account the, the factors that are at the multi level that happening at the multi level layers like the show so relationship the financial matters leadership styles time availability feedback mechanisms and also the physical environment. So here I present an example of our implementation study that we are doing at the moment with a mess program in several hospitals across Vietnam. Here is the process where the in each hospital, starting from baseline evaluation through to identifying the opportunities for intervention, and then planning phase implementing phase and then evaluation and with reporting and feedback. And along this cycle, we provide training and technical support and monitoring. For our hospitals MS team specifically a multidisciplinary MS team proceeding of different key department represent representative and also expertise from the hospital. And they work on those for analysis which is a strength witness and opportunities and threat analysis and then develop the annual implementation plan. And with the specific activities activities like training audit and feedback by the clinical pharmacist, performing what rounds with regards to antibiotics and review of the antibiotic prescription and provide feedback to the, to the clinical work. And also analyzing the routine data and reporting, and we also conduct the knowledge attitude and practice surveys to inform the implementation. So the few next slides I present to show some so that you understand that we can see the various and between the hospitals and even between the words within each hospitals. And for example, we in some hospitals we can identify the words are similar so that we can select some of them for control work and some of them for intervention words but for some other hospital days impossible. So we need to design our study in a way to fit into these conditions and trying to find the best, the best available methods in order to compare and to monitor the process. Okay, there are also large variations in the process indicators like the guy like compliance or the level of appropriateness in antibiotic prescriptions for some hospitals very high level of in appropriateness as reviewed by the reviewing doctors, for example in hospital to here up to 85% in appropriate. However, at the same time the level guy like compliance is quite high. Actually, up to 70%. So this might reflect the fact that the guidelines are not up to date and, and the local doctors do not find really find the guidelines are applicable or easy to use in their local settings. And also observes a lot of various in the reported practice in from the KP surveys across the hospitals. And from this we can identify an important factors, and that might explain the over-prescribing in in doctors for example the psychology of doctors in trying to cover the patients expectations or in trying to avoid potential problems. So these are the type of areas that we can look at in our MS programs. And for the further details in the process of implementation, you can refer to this paper just recently published. So initial analysis at one hospital show some promising results in the overall antibiotic use, for example, after the independent, after the start of the intervention, we started to see the amount of antibiotic use over time. And it seemed to be sustained over the implementation period. However, in the in the control words, the chance seemed to be even increasing. So, it is kind of promising but also warrant further further further investigation into how this can be the, how this can be sustained over time, and what are the issues that we can explore further in in the next analysis and also the next step implementation and research. So in summary, for AMS program interventions and call elements need to be put into the local context and need to be implemented within with an interdisciplinary approach in order to provide sustainable impact on antibiotic use and help to tackle the challenge. So with that I would like to acknowledge the contribution from different hospital MS teams across the hospitals in our network, and also different collaborators and funders to this work. And with that, I thank you very much for your attention.