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.
 
Description Initially, we 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.

Through the related BAbS study, we have extended our learning about what people across a district in Bangladesh know about and do with antibiotics in relation to both humans and animals.

Through the evaluation of the Community Dialogues Approach to assess its feasibility and acceptability to a number of stakeholders, we have learned that it is broadly possible to embed a community engagement intervention into the existing health system infrastructure, but that there are some critical areas of learning as well.
Exploitation Route 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.
Sectors Communities and Social Services/Policy,Healthcare,Government, Democracy and Justice

 
Description We were the winners of a competition held by the Wellcome Trust to identify the most "pioneering" approaches to addressing AMR globally. As a result, we were invited to present our approach at the 2nd Global Call to Action on AMR, held in Ghana in November 2018, and hosted by the Governments of the UK, Thailand and Ghana, and Wellcome Trust, The UN Foundation, and The World Bank. Although difficult to evidence impact at this stage, we see that "public awareness" is the top recommendation in the Ghana Declaration. We do not wish to over-claim the impact of our own approach as a. raising public awareness is a key recommendation in several guidance areas, and b. we are wanting to see a shift towards empowerment and engagement i.e. moving beyond awareness. However, we do feel that we were part of the influence to upfront this recommendation. Furthermore, our emphasis on community engagement in this project (and another linked one that Rebecca King is a Co-I on), has resulted in a decision to establish a Global Platform for Community Engagement to address AMR. The University of Leeds has contributed £350,000 towards this initiative, and GCRF is also supplementing with some additional financial and non-financial contributions in organising a global event in Kathmandu in June 2018.
First Year Of Impact 2019
Sector Healthcare
Impact Types Policy & public services

 
Description Postgraduate education
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
 
Description GCRF HEFCE
Amount £100,000 (GBP)
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 02/2018 
End 07/2018
 
Description Global Impact Acceleration Account
Amount £50,000 (GBP)
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 01/2019 
End 03/2019
 
Description QR Funding to produce a film about the Community Dialogue Approach
Amount £12,000 (GBP)
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 01/2019 
End 07/2019
 
Description QR funding to establish a Global Platform on Community Engagement and AMR
Amount £350,000 (GBP)
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 04/2019 
End 12/2021
 
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 Evaluation data (qualitative) 
Description Transcripts from 7 focus group discussions used to evaluate the pilot study. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? No  
Impact We are currently analysing the data, but this data will tell us about the acceptability and feasibility of the community dialogue approach in Bangladesh from the perspective of a variety of stakeholders. 
 
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 (BAbS) 
Organisation University of Liverpool
Country United Kingdom 
Sector Academic/University 
PI Contribution Our existing research team has collaborated 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 have built on the 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 has further added to our survey tool with questions on the animal dimensions of antibiotic knowledge, attitudes and practice in Bangladesh.
Impact None to date - we completed data collection in August 2018. Data has been analysed and findings will be presented in Bangladesh by members of this team to key national stakeholders on 24th March 2019. A publication is being drafted.
Start Year 2018
 
Description Impact Acceleration (GIAA) 
Organisation ARK Foundation Bangladesh
Country Bangladesh 
Sector Charity/Non Profit 
PI Contribution Under funding awarded by the University of Leeds, we are building further on the new collaboration developed within the BAbS study with the University of Liverpool. The four collaborating institutions (Universities of Leeds, Liverpool, and Malaria Consortium, and ARK Foundation) are holding a series of impact related events in Bangladesh in March 2019. One will be a dissemination meeting to which key stakeholders from multiple sectors engaged in AMR research will be invited. The second is a two day retreat with key members of the relevant ministries to discuss the potential for scaling up the approach in Bangladesh.
Collaborator Contribution Our partners in the University of Liverpool have facilitated the connections with key stakeholders within Bangladesh working in the animal sector including, for example, Chittagong University and relevant stakeholders within the Ministry of Agriculture.
Impact We produced a report of our stakeholder meetings. Moreover we produced a film about the Community Dialogues Approach in Bangladesh.
Start Year 2019
 
Description Impact Acceleration (GIAA) 
Organisation Malaria Consortium
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution Under funding awarded by the University of Leeds, we are building further on the new collaboration developed within the BAbS study with the University of Liverpool. The four collaborating institutions (Universities of Leeds, Liverpool, and Malaria Consortium, and ARK Foundation) are holding a series of impact related events in Bangladesh in March 2019. One will be a dissemination meeting to which key stakeholders from multiple sectors engaged in AMR research will be invited. The second is a two day retreat with key members of the relevant ministries to discuss the potential for scaling up the approach in Bangladesh.
Collaborator Contribution Our partners in the University of Liverpool have facilitated the connections with key stakeholders within Bangladesh working in the animal sector including, for example, Chittagong University and relevant stakeholders within the Ministry of Agriculture.
Impact We produced a report of our stakeholder meetings. Moreover we produced a film about the Community Dialogues Approach in Bangladesh.
Start Year 2019
 
Description Impact Acceleration (GIAA) 
Organisation University of Liverpool
Country United Kingdom 
Sector Academic/University 
PI Contribution Under funding awarded by the University of Leeds, we are building further on the new collaboration developed within the BAbS study with the University of Liverpool. The four collaborating institutions (Universities of Leeds, Liverpool, and Malaria Consortium, and ARK Foundation) are holding a series of impact related events in Bangladesh in March 2019. One will be a dissemination meeting to which key stakeholders from multiple sectors engaged in AMR research will be invited. The second is a two day retreat with key members of the relevant ministries to discuss the potential for scaling up the approach in Bangladesh.
Collaborator Contribution Our partners in the University of Liverpool have facilitated the connections with key stakeholders within Bangladesh working in the animal sector including, for example, Chittagong University and relevant stakeholders within the Ministry of Agriculture.
Impact We produced a report of our stakeholder meetings. Moreover we produced a film about the Community Dialogues Approach in Bangladesh.
Start Year 2019
 
Description Competition winner and invited presentation at 2nd Global Call for Action on AMR 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact We were the winners of a competition held by the Wellcome Trust to identify "pioneering" approaches to addressing AMR globally. As a result, we were invited to present our approach at the 2nd Global Call to Action on AMR, held in Ghana in November 2018, and convened by the Governments of the UK, Thailand and Ghana, and Wellcome Trust, the UN Foundation and the World Bank.

Three members of the team (one from each organisation) participated in the presentation, which was held in front of an audience of global policy-makers, practitioners, representatives from third sector organisations, the media, and industry.

Our objective was to raise the importance of community engagement as a strategy for tackling AMR i.e. to go beyond public awareness and move towards a scenario where communities are empowered to identify the solutions to addressing AMR at community level.

Our respective organisations were subsequently invited to sign the Ghana Declaration on AMR, which is the latest global guidance document.
Year(s) Of Engagement Activity 2018
 
Description Policy-maker engagement workshop in Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We held an engagement workshop with policy makers in Bangladesh to share the early findings from our study. We presented the findings from the formative qualitative study as well as the findings from the first survey. We asked policy makers to feedback on our initial ideas regarding what the key messages to be delivered through the intervention, as well as the delivery mechanisms identified. As a result, we modified our approach for piloting.
Year(s) Of Engagement Activity 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