Sourcing Community Solutions to Antibiotic Resistance in Nepal

This project will develop, pilot test and evaluate a high-quality intervention aimed at preventing and controlling antibiotic resistance in Nepal. Community-led solutions to the growing problem of antibiotic resistance will be promoted through a participatory digital film-making intervention that will lead to a health-education campaign within communities, and to an advocacy campaign targeting policy makers. This will directly support the delivery of the UN's Sustainable Development Goals, in particular SDG 3: 'ensuring healthy lives and promoting well-being for all at all ages'.

In Nepal, antibiotic-treatable infections are a significant public health burden. A recent review of studies examining antibiotic resistance to common bacterial diseases in Nepal indicates that antibiotic resistance is a growing threat to public health (Basnyat 2015: 6-10). Indeed globally, as the World Health Organisation warns, "without urgent action we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill" (WHO 2016). Although the development of new medicines is critical, without behaviour change antibiotic resistance will continue to be a major threat to population health. Our project seeks rigorously to evaluate the potential of participatory arts interventions in supporting such behaviour change.

The project has three phases. Phase One will focus on the development of methodologies of co-production and participatory film-making, a health-education campaign, and an advocacy campaign. Phase Two will focus on pilot-testing the participatory film-making, health-education campaign and advocacy campaign in one urban and one rural setting, and on evaluating the approach for reach, implementation fidelity, and acceptability to a variety of stakeholders. Phase Three will focus on refining the approach prior to scale-up, evaluation of outcomes and impact.

Our specific intervention consists of four stages:
1) The co-production of short comics (drawing on the 'grass-roots comics for development' methodology) which identify critical barriers to preventing and controlling antibiotic resistance at the individual, household and community levels, and which develop community-led solutions to overcoming those barriers.
2) The development of these comics into documentary films that can be utilised both as health-education tools, which are appropriately tailored for the locality, and as advocacy tools, which are aimed at policy makers at the district and national levels;
3) The utilisation of the documentary films in a health-education campaign within localities;
4) The delivery of an advocacy campaign at the district and national levels.

Working at the intersection of humanities, social sciences and public health, and bringing together the expertise of The Centre for World Cinemas and Digital Cultures (Paul Cooke, PI), the Nuffield Centre for International Health and Development (James Newell and Rebecca King, Co-Is) and HERD International (Sushil Baral, Sudeepa Khanal, Co-Is), and working in collaboration with the Ministry of Health and Population in Nepal, this partnership will pilot an innovative approach to dealing with a significant public-health issue. Drawing on participatory-arts methodologies of co-production with community stakeholders, we aim to explore the powerful socio-cultural, political and economic issues at play in the misuse of antibiotics and support the development of community-led solutions to this issue, thus helping to increase the effectiveness of, and adding significant value to, government-led campaigns. The project will, moreover, help build capacity for the use of participatory arts as a tool for public-health campaigning, synergising the expertise of the project team to produce an outcome that none of the partners could achieve on their own.

Our aim is to have impact both on the ground on the behaviour of the communities we will be supporting and on district and national-level policy. Engagement with non-academic stakeholders has been central to our project's design and is central to our impact strategy.

From the outset, we have discussed the aims of this project with the Nepal Ministry of Health and Population (MoHP), with whom we have a long-standing and trusted relationship. Nuffield and HERD have reputations in Nepal for delivering research findings that address priority problems and are policy-relevant, and for committing to supporting large-scale take-up of interventions that we have demonstrated to be effective.

In developing this project, we have held discussions with Mr Bhogendra Dotel, Director - MoHP, Policy Planning and International Cooperation Division, Mahendra Shrestha, Chief Public Health Administrator, MoHP, District Public Health Office Kathmandu, Rajendra Prasad Pant, MoHP Assistant Director, Department of Health Services, Kathmandu and their teams, who are the appropriate policy-makers and programme implementers in MoHP. Avoidance of antibiotic resistance in Nepal is a high MoHP priority (Government of Nepal 2015).

To ensure that the intervention we develop is acceptable to the intended users (that is, the general population), and hence more likely to be effective, we will obtain information from members of communities including locally elected representatives involved through interviews and focus group discussions to ensure that their knowledge and experience informs intervention design. Issues of gender and equity, to which MoHP is committed (Government of Nepal 2015), will be critical here, so we will take care to involve both men and women, and identify and involve other key equity groups.

Equally key to achieving impact are the concepts of feasibility, appropriateness for context, scalability and sustainability. To ensure that the intervention we develop is feasible, appropriate to the context, scalable and sustainable, and hence more likely to be adopted nationally, we will closely involve MoHP and District Authority officials and their development partners (who play a vital role in shaping policies and resource distribution) in design of the intervention. They are best placed to know the realities and constraints of the health system within which the intervention must be integrated. Ensuring their ownership of the project is key to facilitating impact, and care will be taken to ensure their opinions are respected and guide intervention development. The campaign package will include guidelines, materials to be used by presenter/facilitators, training materials, and training methods, to ensure that we provide an integrated package ready for assessment and use without further modification.

We will mirror implementation as it would be if going to scale, to avoid any 'demonstration site effect' of funding, human resourcing or monitoring that would not be feasible at scale. To inform future assessments, we will investigate how to measure multiple potential outcomes - in a complex intervention such as this, assessment of effectiveness and cost effectiveness will not be sufficient, since there are also likely to be wider impact benefits/dis-benefits related to community cohesion, gender relationships, health ownership etc.

To monitor our impact activities, which are integral to the whole project, we will hold regular virtual meetings between partners. This will ensure any problems are identified early and mitigation can be initiated early.