Engaging communities to address antimicrobial resistance: Identifying contextualised and sustainable community-led solutions in low resource settings

This study will make a significant contribution to addressing antimicrobial resistance (AMR). AMR is a major challenge to global health, food sustainability and security, and socio-economic development. If we do not address AMR, in the future we will be less able to prevent and treat common infectious diseases, and major surgery, cancer chemotherapy and organ transplants will become much more dangerous in the absence of effective antibiotics. The quantity of antimicrobials used in food production internationally is at least the same as that in humans, and in some places is higher. Some last-resort antibiotics for humans are being used extensively in animals, and there are currently no replacements. There is a huge global effort to address AMR. One area that is emphasised in global guidance is the importance of raising public awareness on the issue. However, it is important to go beyond raising awareness and actively engage with individuals and communities, by enabling them to identify, develop and implement community-led sustainable solutions. To the best of our knowledge, community engagement approaches to address AMR have not been evaluated anywhere in the world. In order to address this gap, we have established a world-leading research group, which builds partnerships between six research organisations and project partners in Bangladesh, Nepal and the United Kingdom.

Members of this team have already developed two approaches to using community engagement to address AMR. The Community Dialogue Approach (CDA) has previously been used in several countries to address other health issues and we adapted it to address the misuse of antibiotics by humans in Bangladesh. Participatory Video (PV) is an approach whereby community members are supported to make short films about issues that concern them and these films are used to demonstrate to policy makers how people interact with the issue. We adapted this approach to explore the misuse of antibiotics in Nepal. In this study, we plan to combine these two approaches: The PV will help us to identify critical themes to address through the CDA, and it will help to raise the profile of community engagement on national and international policy agendas.

At the start of this study, we will use PV (and other methods) to help us develop materials that are needed to deliver the CDA in Bangladesh and in Nepal. We will ensure that these materials address different issues that impact on AMR in rural communities - these include the ways that humans use antimicrobials, the way they are used for animals, and the way they enter into soil and water. We will implement the CDA across the district of Comilla in Bangladesh to see whether it changes people's knowledge, attitudes and reported behaviour in relation to AMR. We also want to find out how much it would cost to implement it on a national scale and to see whether it is equitable i.e. that it reaches and is used by different population groups, such as males and females, and the poorest in society. We will also introduce our approach into a hill region in Nepal so that we can find out how easy or difficult it is to deliver it in different types of settings. Finally, we will use the outputs from the PV methods - especially films that have been made by community members - to help us to increase awareness of the importance of community engagement in Nepal, Bangladesh, the UK and beyond.

This study will make a major contribution to our understanding of how to address AMR by working with individuals and communities to enable them to identify, develop and implement solutions. It will also help us to understand how our approach to community engagement can be implemented on a large scale and in different settings. Ultimately, we aim to ensure that this study influences policy makers internationally to include community engagement approaches as one of the key strategies for addressing AMR.

Antimicrobial resistance (AMR) is a major challenge to global health, food sustainability and security and socio-economic development. Multi-sectoral action that addresses human and animal health, agriculture, and the environment through a "One Health" approach is required to address the profound implications of AMR. Public awareness and/or public education on AMR is highlighted in most international guidance. However, to tackle AMR it is critically important to go beyond raising awareness and actively engage with individuals and communities globally. Community Engagement (CE) to address AMR is an under-used and under-researched strategy for addressing AMR globally, and receives little mention in global policy. We interpret CE to mean a participatory process through which equitable partnerships are developed with community stakeholders, who are enabled to identify, develop and implement community-led sustainable solutions using existing or available resources to issues that are of concern to them and to the wider global community.

We will (1) develop contextualised intervention materials for community engagement that address AMR through a One Health perspective; (2) implement and evaluate an approach to CE that tackles AMR at the community level and assess: a. its effectiveness for improving knowledge, attitudes and reported behaviours in relation to AMR; b. its cost-effectiveness and the cost of scale-up; c. the extent to which it is equitable, gender sensitive and participatory; d. its potential for implementation on a national scale (Bangladesh); and e. its potential to be replicated to a different health system and community context (Nepal); (3) implement a capacity building strategy based on principles of equitable partnership; and (4) implement a robust research uptake strategy to increase the visibility of CE approaches within, and their potential impact on, the wider AMR research landscape.

This research will benefit a wide range of stakeholders, including the research community, national and international policy makers, development partners, the media, the communities with whom we are working, and individuals employed to work on the studies.

Researchers in Bangladesh, Nepal and beyond will benefit from our investigation into the potential of community engagement approaches as a core strategy to tackle the implications of antimicrobial resistance. Knowledge will be shared with them through academic publications, conference presentations and research briefs.

Policy makers and development partners in Bangladesh, Nepal and beyond will benefit from our study through our focus on examining how to embed the Community Dialogue Approach CDA) into existing systems and community infrastructures and our examination of the potential costs to delivering such approaches on a national scale. They will be equipped with information to enable them to make informed choices regarding the extent of the financial and other resource inputs required to deliver the CDA in relation to the potential impact that it may have on preventing disease, addressing the drivers of AMR at community level, and potentially addressing other health and development issues in the longer term.

The communities with whom we will be working will benefit from the research in several ways. First, stakeholders within communities will be equipped with new knowledge and skills. These stakeholders include participants within the PV workshop process, participants within CDAs, facilitators and supervisors of CDAs, Community Health Workers (CHWs) (Community Health Care Providers in Bangladesh; Female Health Volunteers in Nepal), and local leaders. Specifically, participants within CDAs gain new knowledge on AMR, the skills to develop community-led solutions to addressing the drivers of AMR and the skills to monitor shifts in behavioural and social norms; facilitators and supervisors gain new knowledge on AMR and skills in facilitating and supervising CDs; and CHWs and local leaders gain skills in guiding community-based interventions. Moreover, both the PV models and CDA models generate wider impact within communities through (in the case of PV) the dissemination of knowledge and facilitation of dialogue through film-showcasing events; and (in the case of CDA) the implementation of community-led solutions through the diffusion of information within and beyond families and peer networks.

Staff working on the project will build their capability to work across disciplines and in cross-sectoral partnerships, to co-design, analyse and disseminate research, and to build leadership skills. We anticipate building capacity in terms of subject knowledge and a range of research skills, particularly amongst early career researchers, which could be applied in other employment sectors.

This study will directly benefit Bangladesh and Nepal, both on the list of least developed countries on the DAC list of ODA relevant countries. The study proposed here builds on pilot work in which we developed participatory community mobilisation and engagement approaches to address antimicrobial resistance. Here, we plan to evaluate the approach to assess its effectiveness, cost-effectiveness, the extent to which it is equitable and participatory, its potential for implementation on a national scale (Bangladesh), and its potential to be replicated to a different health system and community context (Nepal). If the intervention is shown to be effective, shows potential for scale, and is replicable, we would expect it to have potential for adaptation and replication in multiple low and middle income countries that have the required health system and service infrastructure, in which case it could eventually benefit multiple countries on the DAC list.

This study will be registered with the ISRCTN registry and links to our protocol and main results will be supplied.