Community dialogues for preventing and controlling antibiotic resistance in Bangladesh

Lead Research Organisation: University of Leeds
Department Name: School of Medicine

Abstract

Context
We plan to develop and test the "community dialogue" approach for preventing and controlling antibiotic resistance in Bangladesh. The emergence and spread of antibiotic resistance is especially problematic in settings where antibiotics can be bought without a prescription and where they are over-prescribed by health workers and over-used by the public. The World Health Organisation recommends that the general public can help combat antibiotic resistance by preventing infections, using antibiotics only when prescribed by a health professional, completing the full prescription, never using leftover antibiotics and never sharing antibiotics.

The Ministry of Health and Family Welfare has established the Revitalization of Community Health Care Initiative in Bangladesh. They have done so in order to improve access, utilisation and equity of healthcare. This initiative aims to enable community clinics in rural areas to deliver an essential service package to the approximately 6000 people in their catchments areas. So far, around 13,300 community clinics have been built across the country. Members of this research team have already collaborated with MOHFW on developing and evaluating an intervention to improve the quality of essential services provided within the community clinics in Comilla district. A key part of this package was training community health care providers to prescribe antibiotics correctly and this was very successful. Improving provider capacity to prescribe antibiotics correctly is one important component within a range of behavioural issues that impact on the ways in which antibiotics are used. We intend to build on our existing partnership and develop an intervention that improves knowledge and behaviour in relation preventing and controlling antibiotic resistance within communities in Bangladesh, where antibiotics are available not only from community clinics but also from drug stores.

Objectives
The project has five objectives: to conduct research to inform the content of and processes for delivering community dialogues; to adapt the community dialogues approach to the setting; to pilot-test the approach in the catchment areas of five community clinics; to evaluate the feasibility of the pilot intervention in terms of the number of people it reaches, the extent to which it is delivered as intended, and whether or not is it acceptable to a range of stakeholders; and to engage with key stakeholders, such as policy makers, district health officials, community clinic staff and communities to ensure that the intervention is appropriate.

Applications and benefits
We will ensure that the community dialogues are "embedded" within the infrastructure of the community support groups of the community clinics. This means that they will be delivered through existing mechanisms and will, therefore, be replicable across Bangladesh. This intervention has the potential to a. contribute to a body of urgent action recommended by WHO to prevent a post-antibiotic era, in which common infections and minor injuries will kill; b. build health system capacity in Bangladesh to deliver community-based interventions; and c. empower communities in Bangladesh to build cohesion and social capital, thus enabling them to contribute further to the economic and social welfare of the country. Furthermore, it has the potential to be adapted for implementation in other national health systems that support similar infrastructures, and to be adapted to address other areas of ARM, including behaviours that contribute to resistance to drugs to treat infections caused by parasites (e.g. malaria) and viruses (e.g. HIV).

Planned Impact

Who will benefit from this research?
Primary beneficiaries - the Ministry of Health and Family Welfare (MOHFW) in Bangladesh, and the many health NGOs (such as BRAC) that provide health care in the country.
Subsequent beneficiaries - the people of Bangladesh, who will benefit from the actions of MOHFW and the health NGOs.
Wider beneficiaries - the global population.

How will the beneficiaries benefit from this research?
The MOHFW has expressed its strong desire to reduce antibiotic misuse in Bangladesh, and needs strategies, and proven strategies, to do so. The strategy we aim to develop will be designed to be appropriate for context, scalable and sustainable, and thus will be directly useable, without modification, by the MOHFW and health NGOs working in Bangladesh. The MoHFW would also like to have community-based interventions addressing other health conditions (for example, prevention of chronic disease such as CVD/diabetes) and the results of this project will have substantial relevance in designing such interventions; in the nature of Community Dialogues, additional topics can subsequently be added. MOHFW and NGOs will benefit from being better able to achieve their mandate of providing quality health care by reducing patients' demands for inappropriate antibiotic use - primarily by ensuring that people with health conditions for which antibiotics are inappropriate (primarily viral coughs and colds) do not pressure Community Health Care Providers (CHCPs) to provide them, protecting antibiotics for use in conditions where they are effective (bacterial infections). Reducing inappropriate antibiotic provision will also lead to substantial savings in drug costs (antibiotics are provided free at Community Clinics), savings that can be reallocated to provide improved care in other areas. The avoidance of development of antibiotic-resistant strains of pathogens will reduce incidence of disease that is difficult to treat and hence reduce health system costs of second- and third-line antibiotics.

The people of Bangladesh will benefit from the research findings through the MOHFW and health NGO provision of behaviour change interventions that are appropriate for context, that are designed to be scaled up across the country, and that are designed to be sustainable. Encouraging the population to reduce inappropriate antibiotic purchase from drug stores - as very commonly occurs at present - will lead to substantial savings in drug costs for individuals. The avoidance of development of antibiotic-resistant strains of pathogens will reduce incidence of disease that is difficult to treat and hence reduce patient costs of second- and third-line antibiotics.

Given the increasingly global nature of spread of disease, reducing inappropriate antibiotic use in Bangladesh is likely to also benefit the global population, by reducing formation of antibiotic resistance that is then transmitted through individuals' movements to other countries, for example through regular travel by people of Bangladeshi heritage between the UK and rural Bangladesh.

What will be done to ensure that these potential beneficiaries have the opportunity to benefit from this research?
As described in more detail in the pathways to impact, we will use our long-term and close contacts with MOHFW to ensure that the strategy resulting from this research is assessed and, if effective, implemented at scale.

Publications

10 25 50
 
Description To date, we have developed our learning in two key areas. First, we have detailed understanding of what people within five community catchment areas in Bangladesh know about and do with antibiotics. Second, we have worked with policy makers, health professionals, and communities to discover the best ways to embed a community engagement approach within the existing health system infrastructure of Bangladesh.
Exploitation Route We have not yet published these findings. However, when we do (which we anticipate to be in the next few months), we hope that others will use our data collection tools to develop understanding of antibiotic knowledge, attitudes and practice in other settings and compare to what we found. We also hope they will learn from our detailed work on how to embed a community engagement intervention. However, this is still early days and we have not yet explored the feasibility of the approach.
Sectors Communities and Social Services/Policy,Healthcare,Government, Democracy and Justice

 
Description GCRF HEFCE
Amount
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 02/2018 
End 07/2018
 
Title Survey tool 
Description Our medical statistician has developed a survey tool that we have used to investigate antibiotic knowledge, attitudes and practices in a low resource rural setting. There were very few examples in the existing literature and he drew on the little that was available and, through careful discussion and piloting, we have developed a tool that we are satisfied captures the issues that are particularly relevant to the World Health Organisation's guidance on "what individuals can do" to address antibiotic resistance. Please note that the tool will be made available when we publish. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact We have administered a cross-sectional survey in five communities (i.e. a relatively small scale survey) as part of the pilot work within this project. We are now working with colleagues at the University of Liverpool to expand the tool to cover animal dimensions and will be running a district wide survey this year, for which we have secured separate funding. We are also part of a new proposal to the MRC on addressing AMR in Cambodia and, if successful, expect to use this tool within that setting too. 
 
Title Exploratory qualitative data 
Description We have collected data from a series of semi structured interviews and focus group discussions with a wide range of participants through which we explore patterns of understanding around appropriate antibiotic use, as well as the best mechanisms through which to embed community dialogues into the existing health system infrastructure of Bangladesh. The transcripts will all be made available when we publish this part of the study. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact The data was used to inform our intervention design. 
 
Title Survey data 
Description We have conducted a cross sectional survey on antibiotic knowledge, attitudes and practices in the catchment areas of five community clinics in Bangladesh. This survey data will be share when we publish this part of the study. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact This data was used to inform the development of our pilot intervention. 
 
Description Bangladesh Antibiotics Survey 
Organisation University of Liverpool
Country United Kingdom 
Sector Academic/University 
PI Contribution Our existing research team is collaborating with a colleague in the University of Liverpool to develop and implement a district wide survey on antibiotic knowledge, attitudes and practice in Bangladesh. We are building on our existing survey tool that we have developed within this project to understand antibiotic use in humans.
Collaborator Contribution Our colleague in the University of Liverpool is further adding to our survey tool with questions on the animal dimensions of antibiotic knowledge, attitudes and practice in Bangladesh.
Impact None to date - we have only commenced our work on 1st Feb 2018
Start Year 2018
 
Description Workshop with community stakeholders 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact The objective of the workshop was to discuss and refine pilot intervention design aspects (coverage and frequency, support and supervision). Participation was lively and critical insights were enabled to help with the design of the pilot intervention.
Year(s) Of Engagement Activity 2017
 
Description Workshop with mid-level policy makers in Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact The objectives of the workshop were:
- To discuss and refine key messages developed for the pilot intervention;
- To discuss and refine pilot intervention design aspects (coverage and frequency, selection of community dialogue facilitators, support and supervision. The workshop was lively with active engagement from participants, and resulted in very useful refinement of the key messages that had been developed for the pilot intervention and in critical areas of the pilot intervention design aspects.
Year(s) Of Engagement Activity 2017