Social, behavioural and economic drivers of inappropriate antibiotic use by informal private healthcare providers in rural India.
Lead Research Organisation:
London School of Hygiene & Tropical Medicine
Department Name: Infectious and Tropical Diseases
Abstract
Antibiotics play a life-saving role in reducing mortality and morbidity due to communicable diseases like tuberculosis, typhoid, pneumonia and gastroenteritis. However, the overuse of antibiotics in populations can lead to the disease causing bacteria becoming drug resistant over time. For example, high levels of resistance have been found in gastroenteritis causing bacteria to antibiotics like ampicillin (52.3% - 84.6%), cotrimoxazole (45.5% - 65%), and cephalexin (15.9% - 59.7%) across five sites in India and South Africa. This antimicrobial resistance (AMR) is a global threat because it can reverse the advances made in combating life threatening infections and increase the costs of treatment and hospital stays for the sick, making newer antibiotics even more inaccessible to the poorest and most vulnerable.
One major reason for the overuse of antibiotics in humans is antibiotic over-dispensing and over-prescribing by health care providers. This is a big challenge in low and middle income countries where health systems are weak, regulatory frameworks for health workers and the pharmaceutical industry either do not exist or are weakly enforced, and the majority of poor and rural populations rely on informally trained and unlicenced providers who use antibiotics excessively and inappropriately in their treatments. These informal providers or IPs may constitute from 50% to 96% of all providers in LMICs, including in India, but there is very little in-depth knowledge of the factors that influence their inappropriate antibiotic use and what interventions can feasibly and effectively arrest this inappropriate use. Evidence from the formal sector suggests that antibiotic use is influenced by socio-cultural, behavioural and economic factors. However the precise nature of these factors and how they interact has not been explored in the case of IPs.
In this field study we propose to study a cross section of IPs, and the drivers of their antibiotic use in the state of West Bengal in India. Since IPs lack a clear legal status, few government programmes are willing to engage with them, but the West Bengal government has decided to train and harness more than 100,000 IPs as village health workers, from early 2016. We are therefore locating this timely study in West Bengal. We will explore provider related factors and also the perceptions of communities and various government stakeholders. This will be done through 200 structured and 30 in-depth interviews and observations of IP practices in two socio-economically different districts (Birbhum and South24 Parganas), accompanied by focus groups discussions with community members and key informant interviews with government, pharmaceutical and formal medical sector stakeholders. We will use these findings to conceptualise interventions to reduce antibiotic use among IPs and seek feedback from study participants on the feasibility and effectiveness of these interventions.
The study will be implemented by the London School of Hygiene and Tropical Medicine in collaboration with the Liver Foundation, a non-governmental organisation in West Bengal that has worked with IPs since 2007 and has championed the harnessing of IPs with the state government. We will use the final study outcomes to develop a proposal with the state government to implement and evaluate these interventions in the future, possibly starting in mid to late 2017.
One major reason for the overuse of antibiotics in humans is antibiotic over-dispensing and over-prescribing by health care providers. This is a big challenge in low and middle income countries where health systems are weak, regulatory frameworks for health workers and the pharmaceutical industry either do not exist or are weakly enforced, and the majority of poor and rural populations rely on informally trained and unlicenced providers who use antibiotics excessively and inappropriately in their treatments. These informal providers or IPs may constitute from 50% to 96% of all providers in LMICs, including in India, but there is very little in-depth knowledge of the factors that influence their inappropriate antibiotic use and what interventions can feasibly and effectively arrest this inappropriate use. Evidence from the formal sector suggests that antibiotic use is influenced by socio-cultural, behavioural and economic factors. However the precise nature of these factors and how they interact has not been explored in the case of IPs.
In this field study we propose to study a cross section of IPs, and the drivers of their antibiotic use in the state of West Bengal in India. Since IPs lack a clear legal status, few government programmes are willing to engage with them, but the West Bengal government has decided to train and harness more than 100,000 IPs as village health workers, from early 2016. We are therefore locating this timely study in West Bengal. We will explore provider related factors and also the perceptions of communities and various government stakeholders. This will be done through 200 structured and 30 in-depth interviews and observations of IP practices in two socio-economically different districts (Birbhum and South24 Parganas), accompanied by focus groups discussions with community members and key informant interviews with government, pharmaceutical and formal medical sector stakeholders. We will use these findings to conceptualise interventions to reduce antibiotic use among IPs and seek feedback from study participants on the feasibility and effectiveness of these interventions.
The study will be implemented by the London School of Hygiene and Tropical Medicine in collaboration with the Liver Foundation, a non-governmental organisation in West Bengal that has worked with IPs since 2007 and has championed the harnessing of IPs with the state government. We will use the final study outcomes to develop a proposal with the state government to implement and evaluate these interventions in the future, possibly starting in mid to late 2017.
Technical Summary
This is an exploratory study of the social, economic and behavioural drivers of antibiotic use in informal providers in rural areas of the state of West Bengal in India. In pluralistic health systems of low and middle income countries (LMICs), including in India, the bulk of healthcare at first contact is delivered by providers who may not have a formal medical qualification but practice a range of biomedical treatments, including treatment with antibiotics. They are known by different names such as drug sellers, village doctors or rural medical practitioners and are found all over Asia and Africa. Evidence suggests that their antibiotic use is high and irrational, and interventions that have focused on training and recognition of IPs have not succeeded in lowering their antibiotic use. Antibiotic use is one of the most critical components of IPs' quality of care that needs to be addressed urgently. Excessive dispensing/prescription of antibiotics by healthcare providers including IPs in LMICs is one of the reasons for overuse of antibiotics in humans leading to increasing antibiotic resistance which is a major global health threat today.
We will conduct structured interviews with a sample of 100 IPs each in two districts (total 200), selected through stratified random sampling, followed by in-depth interviews and observations at 30 IP clinics, focus group discussions with community members and key informant interviews with government, pharmaceutical and formal medical sector representatives. In small group workshops with IPs, communities, and with the other stakeholders, we will present ideas for different interventions and seek feedback from participants on what they think would be the most effective and feasible. This will help us develop a plan for implementing and evaluating a comprehensive intervention in future.
We will conduct structured interviews with a sample of 100 IPs each in two districts (total 200), selected through stratified random sampling, followed by in-depth interviews and observations at 30 IP clinics, focus group discussions with community members and key informant interviews with government, pharmaceutical and formal medical sector representatives. In small group workshops with IPs, communities, and with the other stakeholders, we will present ideas for different interventions and seek feedback from participants on what they think would be the most effective and feasible. This will help us develop a plan for implementing and evaluating a comprehensive intervention in future.
Planned Impact
Our team shares a common goal and commitment to improve the quality of healthcare available at first contact to poor, rural, and remote populations that face severe limitations of health care access and affordability from the formal sector. Informal providers are the mainstay for most healthcare needs of these populations. It is critical to harness the advantages of geographical access and basic knowledge of common illnesses that IPs present while simultaneously intervening in harmful practices such as inappropriate antibiotic use. However comprehensive interventions that reduce inappropriate antibiotic use but at the same time utilise IPs to expand access to essential antibiotics have been few because of IPs' blurred legal status as healthcare providers and also because of the opposition of the formal medical sector. We require a combination of strong evidence, constant engagement with key stakeholders, and effective communication and advocacy to bring about a change in this situation.
Our pathway to impact is also a 'pathway to change', and our proposed research represents an initial step in that pathway to change. We nurture a long term view of this change and we will strive to accomplish this in stages. The immediate impact of our research will be the development of an intervention addressing antibiotics use, that will be integrated within the state government's overall IP training programme to improve quality of care of more than 100,000 IPs in the state over five to ten years. The likelihood of success of this intervention will be maximised by its development through engagement and feedback solicited from IPs, communities, the government and formal medical sector representatives in the state. The final blueprint of an intervention will be presented and discussed in a policy engagement meeting with senior officials from the health department, and also from the private formal medical sector. In the mid-term, this is likely to increase the likelihood of success of our intervention to reduce antibiotic use, thereby leading, in the long term to better quality of health care by IPs and better health outcomes in rural and underprivileged communities.
We will also pursue a sustained communication and advocacy drive to foster the uptake of our study findings by other states in India and also in other countries. We have a senior government official from Uttar Pradesh state on our advisory committee who will champion IP related policy shifts and action in his state, with our team's support (using research briefs, presentations and media articles). To build global opinion we will benefit from the presence of two international academics on our advisory committee. With their help we will disseminate our findings to relevant research, policy and action groups including the LSHTM's AMR group, the ReACT (Action for Antibiotic Resistance) network, the Private Sector Thematic group and the Health Systems Hub, an electronic networking platform. We will have discussion meetings with other groups engaged with developing IP interventions in Asia and Africa (we have one such person on our advisory committee). We will also produce formal academic articles for high impact journals, so that our findings can inform and influence the international health community.
Institutional strengthening: As this study is set up as a collaboration between the LSHTM and the Liver Foundation in West Bengal, who will be networking closely with the government of West Bengal, there will be a positive impact on all the teams. There will be a reciprocal sharing of skills and experiences. The team at Liver Foundation will strengthen their research, writing and policy engagement skills. The international counterparts will gain greater understanding of local realities and challenges.
Our pathway to impact is also a 'pathway to change', and our proposed research represents an initial step in that pathway to change. We nurture a long term view of this change and we will strive to accomplish this in stages. The immediate impact of our research will be the development of an intervention addressing antibiotics use, that will be integrated within the state government's overall IP training programme to improve quality of care of more than 100,000 IPs in the state over five to ten years. The likelihood of success of this intervention will be maximised by its development through engagement and feedback solicited from IPs, communities, the government and formal medical sector representatives in the state. The final blueprint of an intervention will be presented and discussed in a policy engagement meeting with senior officials from the health department, and also from the private formal medical sector. In the mid-term, this is likely to increase the likelihood of success of our intervention to reduce antibiotic use, thereby leading, in the long term to better quality of health care by IPs and better health outcomes in rural and underprivileged communities.
We will also pursue a sustained communication and advocacy drive to foster the uptake of our study findings by other states in India and also in other countries. We have a senior government official from Uttar Pradesh state on our advisory committee who will champion IP related policy shifts and action in his state, with our team's support (using research briefs, presentations and media articles). To build global opinion we will benefit from the presence of two international academics on our advisory committee. With their help we will disseminate our findings to relevant research, policy and action groups including the LSHTM's AMR group, the ReACT (Action for Antibiotic Resistance) network, the Private Sector Thematic group and the Health Systems Hub, an electronic networking platform. We will have discussion meetings with other groups engaged with developing IP interventions in Asia and Africa (we have one such person on our advisory committee). We will also produce formal academic articles for high impact journals, so that our findings can inform and influence the international health community.
Institutional strengthening: As this study is set up as a collaboration between the LSHTM and the Liver Foundation in West Bengal, who will be networking closely with the government of West Bengal, there will be a positive impact on all the teams. There will be a reciprocal sharing of skills and experiences. The team at Liver Foundation will strengthen their research, writing and policy engagement skills. The international counterparts will gain greater understanding of local realities and challenges.
Organisations
- London School of Hygiene & Tropical Medicine (Lead Research Organisation)
- Makerere University (Collaboration)
- Newton Fund (Collaboration)
- UNIVERSITY OF GLASGOW (Collaboration)
- Universidad Antonio Nariño (Collaboration)
- Royal Veterinary College (RVC) (Collaboration)
- UNIVERSITY OF EDINBURGH (Collaboration)
- West Bengal University of Animal and Fishery Sciences (Collaboration)
- UNIVERSITY OF CAMBRIDGE (Collaboration)
Publications
Arnold JC
(2021)
"If It Works in People, Why Not Animals?": A Qualitative Investigation of Antibiotic Use in Smallholder Livestock Settings in Rural West Bengal, India.
in Antibiotics (Basel, Switzerland)
Awor P
(2018)
Delivering child health interventions through the private sector in low and middle income countries: challenges, opportunities, and potential next steps.
in BMJ (Clinical research ed.)
Bloom G
(2019)
Next steps towards universal health coverage call for global leadership.
in BMJ (Clinical research ed.)
Cama J
(2021)
To Push or To Pull? In a Post-COVID World, Supporting and Incentivizing Antimicrobial Drug Development Must Become a Governmental Priority
in ACS Infectious Diseases
Gautham M
(2021)
What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India.
in Social science & medicine (1982)
Gautham M
(2022)
Availability, Prices and Affordability of Antibiotics Stocked by Informal Providers in Rural India: A Cross-Sectional Survey.
in Antibiotics (Basel, Switzerland)
Meenakshi Gautham
(2020)
Mobilising informal healthcare providers in India may help its response to covid-19
in BMJ Opinion
Meenakshi Gautham
(2018)
The role of informal rural healthcare providers in universal health coverage
Saddi F
(2023)
Employing the policy capacity framework for health system strengthening
in Policy and Society
Tayler E
(2019)
Universal health coverage: an opportunity to address antimicrobial resistance?
in The Lancet. Global health
| Description | Overuse of antibiotics is a major driver of antibiotic resistance. In many low- and middle-income countries, people obtain their antibiotics from unlicensed healthcare providers who lack formal medical training. Little is known about the drivers of antibiotic use by these informal providers (IPs). We used a systems framework and mixed methods to investigate the intrinsic (provider specific) and extrinsic (community, health system and pharmaceutical industry related) drivers of antibiotic use by IPs in two contrasting districts in rural West Bengal, India. Using clustered randomised sampling, we surveyed a total of 291 IPs and then interviewed a subset of 30 IPs in-depth. To obtain the perspectives of other stakeholders we conducted eight focus group discussions with male and female community members and 17 key informant interviews with medical representatives, drug wholesalers and retailers, formal doctors and regulatory officials. IPs' intrinsic drivers resulted from an interplay between their knowledge, attitudes and economic incentives. With limited understanding of the action of antibiotics, they viewed them as the most effective therapeutic choice for most illnesses and as standard practice in primary care; without antibiotics they feared losing their patients and therefore income. Extrinsic drivers resulted from IPs' role as indispensable healthcare -and antibiotic providers- for the rural population. For pharmaceutical companies and antibiotic supply chain stakeholders, IPs constituted an expanding commercial segment, making them prime targets for aggressive drug marketing and incentivisation. Formal doctors mentored IPs and received patient referrals from them. Regulators feared that restraining IPs would compromise access to health services by rural populations, and hence overlooked their antibiotic use. These covert interdependencies had developed over the years, resisting regulations related to medical practice and sales of antibiotics and creating an antibiotic impasse. Multi-stakeholder interventions and responsive regulations are needed to establish antibiotic stewardship in these community settings. |
| Exploitation Route | The findings of this study helped us develop and obtain funding for a subsequent proposal (ongoing) that aims to develop an antibiotic stewardship intervention in the same community settings where we did the original research. We can help other researchers as well as local governmental and non-governmental organisations to adapt this intervention (once its ready) to other settings. Other researchers, planners and implementors can also use our study frameworks and tools to carry out similar studies in their own contexts. We have used a 'systems' framework to analyse both the 'intrinsic' (provider specific) drivers and extrinsic drivers (communty, health system and markets related) and this conceptual framework could be adapted for other contexts too, in India and in other geographies. In India, we are in touch with policymakers in other states who are interested in developing effective programmes with informal helathcare providers. |
| Sectors | Communities and Social Services/Policy,Healthcare,Government, Democracy and Justice,Pharmaceuticals and Medical Biotechnology,Security and Diplomacy |
| URL | https://gtr.ukri.org/projects?ref=MR%2FS013598%2F1 |
| Description | We are currently designing a community antibiotic stewardship intervention based on our study findings that will (a) lead to improving quality of care in the rural primary healthcare market by creating suitable public-private and informal-formal linkages, that can advance the country's universal healthcare agenda, and (b) lead to more effective containment of antibiotic resistance in the pluralistic health system for humans and animals at the grass roots. Our plan is to co-design this interention with key stakeholders including health policymakers, regulators, formal doctors and veterinarians, members of medical associations, pharmaceutical leaders, providers and communities, to strengthen participatory governance, accountability and regulation, and plug existing information asymmetries. Working with multiple stakeholders is the best way we can address this double-edged situation in which IPs are the backbone of the rural health service delivery system but also contributors to AMR through overuse of antibiotics due to multiple driving forces. The policy and programmatic changes that take place as a result of this intervention and also through the process of intervention development will contribute to the original study's non-academic impact. We have been able to engage with multiple stakeholders from the medical community and from the health, public policy and regulatory departments. Our project findings have been very well received and we have broad agreement from different interest groups of the need to pilot a multi-component intervention with para health workers in the informal sector. By using our study evidence as a communication device we have gradually brought about a shift in the thinking of powerful interest groups such as medical practitioners and the pharmaceutical industry. They are now working with us to develop antibiotic use guidelines for informal para healthcare providers (something they would have opposed earlier) and a pharmaceutical code of conduct for appropriate marketing. We have been advised by a regulator that once we pilot an intervention we should present our evidence to the regulatory body and provide recommendations for policy shifts around the use of antibiotics. |
| Sector | Communities and Social Services/Policy,Healthcare,Government, Democracy and Justice,Pharmaceuticals and Medical Biotechnology |
| Impact Types | Policy & public services |
| Description | Co-design of a Code of Conduct for Evidence Based Marketing of Antibiotics by the Pharmaceutical Industry |
| Geographic Reach | National |
| Policy Influence Type | Participation in a guidance/advisory committee |
| Impact | Through our work we have gathered substantial evidence on inappropriate marketing of antibiotics through pharmaceutical supply chains. There is no legal regulation of pharmaceutical marketing practices in India. Although a general code of conduct for marketing exists (Uniform Code of Pharmaceutical Marketing Practices or UCPMP), this is a voluntary one and the industry is opposed to legalising it. Through our Task Force we are working on a code of conduct for antibiotics that can be implemented more effectively by the pharmaceutical industry and that can be integrated with the UCPMP. We have developed a new strategy of co-opting the industry into regulatory design, using modern regulatory thinking that includes the perspectives of both the regulators and the regulatees. The process has already influenced and impacted industry leaders as several big and small companies and pharma associations have stepped forward to think together and find collective solutions to this challenge. |
| URL | https://oasisamr.com/intervention-guidelines/ |
| Description | Detailed inputs into the WHO/ UHC2030's Global Multistakeholder Dialogue on Private Sector Engagement. |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
| Impact | I compiled a response for UHC2030 on behalf of the Private Sector Thematic Working Group of Health Systems Global. This was appreciated by WHO and the UHC2030 group and our key 'asks' were read out at the WHA side event co-organized by UHC2030, WEF and WHO on 21 May 2019 in Geneva. We asked for greater recognition of th e 'heterogeneity' of the private health sector, and new non-traditionl partnerships not only between the public and private sectors but also between the private formal and informal sectors. Also wrote a blog about this work: PRIVATE SECTOR CAPACITY FOR PUBLIC GOOD: HOW THE PRIVATE SECTOR CAN CONTRIBUTE TO UHC |
| URL | https://www.healthsystemsglobal.org/blog/344/Private-Sector-Capacity-for-Public-Good-How-the-private... |
| Description | I have been invited to attend and present my research findings in a session on private sector and Universal Health Coverage at the The Global Conference on Primary Health Care, co-hosted by Government of Kazakhstan, the World Health Organization and UNICEF, on 25-26 October in Astana, Kazakhstan on the occasion of the 40th anniversary of the Declaration of Alma-Ata. |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Contribution to a national consultation/review |
| URL | http://www.cvent.com/events/global-conference-on-primary-health-care/event-summary-9d66051d95cc49568... |
| Description | Invited to join the advisory committee of a large research consortium :"Supporting the National Action Plan for Antimicrobial Resistance in Tanzania" - (SNAP-AMR) of interdisciplinary scientists from the University of Glasgow and a number of partner institutions in Tanzania. |
| Geographic Reach | Africa |
| Policy Influence Type | Participation in a guidance/advisory committee |
| URL | https://gtr.ukri.org/projects?ref=MR/S004815/1 |
| Description | Presented my research evidence at a High-level Meeting on Universal Health Coverage as a Tool to Combat Infectious Diseases 30-31 May 2018, Tokyo, Japan. The Asia-Europe Foundation (ASEF) Public Health Network and Ministry of Foreign Affairs of Japan co-hosted a multi-country, High-level Meeting focusing on Universal Health Coverage (UHC) in relation to effective management of infectious diseases including possible future pandemic as well as Antimicrobial Resistant (AMR). The overall aim of this meeting were to facilitate agreement between governments and other stakeholders on practical actions to ensure access to effective treatment of infectious diseases, while reducing the risk of the emergence of AMR. |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Contribution to a national consultation/review |
| Impact | My presentation increased the awareness and knowledge of senior policymakers and health officials on the role of the private sector, in particular the informal private health sector, in both combating AMR and realising universal healthcare. |
| URL | http://www.asef.org/projects/themes/public-health/4433-high-level-meeting-%E2%80%93-universal-health... |
| Description | Antibiotic stewardship in agricultural communities in Africa and Asia: A unified One Health strategy to optimise antibiotic use in animals and humans |
| Amount | £129,456 (GBP) |
| Funding ID | EP/T02500X/1 |
| Organisation | Engineering and Physical Sciences Research Council (EPSRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 06/2020 |
| End | 05/2021 |
| Description | Health Systems Research Initiative - A multi-stakeholder approach towards operationalising antibiotic stewardship in India's pluralistic rural health system |
| Amount | £779,322 (GBP) |
| Funding ID | MR/S013598/1 |
| Organisation | Medical Research Council (MRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 02/2019 |
| End | 01/2022 |
| Description | Smart regulation of antibiotic use in India: Understanding, innovating and improving compliance |
| Amount | £515,426 (GBP) |
| Funding ID | ES/S000321/1 |
| Organisation | Economic and Social Research Council |
| Sector | Public |
| Country | United Kingdom |
| Start | 08/2018 |
| End | 07/2021 |
| Title | Antibiotic audit sheet for informal provider clinics |
| Description | We developed this audit sheet to collect details of the antibiotics available in the providers' stocks at the time of the survey. We developed two different types of stock sheets for (a) Tablet/Granules/Suppository and (b) for syrup/injections. We collected the following information about each antibiotic that was present in the stock: generic name, brand name, strength of antibiotic, manufacturer, dosage form (table/granules/suppository/syrup/injection), package size of antibiotic, total quantity in stock, whether a Fixed Dose Combination, the amount dispensed in last 7 days, total number of patients who received that AB in the last seven days, the Maximum Retail Price, source of ABs procurement, wholesale purchase price and selling price of that AB. The tool was piloted twice along with the survey tool with 17 providers, before being finally administered together with the survey tool. After completing the survey at each provider clinic and ensuring that sufficient rapport had been built, the researcher would request the provider to show any antibiotics that were available in the clinic. The antibiotic stock sheet would then be completed for each available antibiotic by observing and noting all information that was available on the packet, supplemented by patient and price related information obtained from the provider. This tool will be available on the website of Liver Foundation by March 31, 2018. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2018 |
| Provided To Others? | Yes |
| Impact | The stock sheet is proving to be a robust data source of antibiotics available in the clinic, as it is based mostly on observed data. It has given us information on the different classes and amounts of antibiotics available in informal provider clinics, their prices, and the amounts that were dispensed in the last seven days. This is new information and has already made some impact on the health department. We are also sharing these study tools with LSHTM student researchers of an M.Sc course in 'One Health' who are studying human and animal drug shops in a rural district in Uganda, in terms of their antibiotic practices. |
| Title | In-depth Interview Guide for Informal Providers |
| Description | This interview guide was designed to collect in-depth insights into the patterns and the social, economic and behavioural drivers of antibiotic use by informal providers. The questions probed the details of how informal providers made a diagnosis and arrived at a decision to use a certain antibiotic, how they managed doubt and uncertainty, whether any diagnostics tests were used, the dosages given and patient management and follow up. We also explored use of antibiotics with animals with those providers who treated animals. There were detailed probing questions on the the economics of antibiotic use, on the influence of formal doctors, the market and pharmaceutical representatives and their own knowledge of and experience with antibiotics. We questioned them about their understanding and perceptions of resistance and of their perceived role in it, and also of the regulatory environment. Finally we asked them for their ideas on possible antibiotic reduction strategies with informal providers. The interview tool was piloted with 5 informal providers before being finally administered to 15 providers per district. Method of informal provider selection for In-Depth Interview: On the basis of following criteria to provide sufficient variability we selected a total of 30 IPs, 15 from each district: 1. Level of AB use: Using the quantitative survey data, we categorized IPs into 3 broad categories : a. Low User of ABs: Provider dispenses at least 1 ABs to 1-3 patients out of 10 patients. b. Medium User: Provider dispenses at least 1 ABs to 4-6 patients out of 10 patients. c. High User: Provider dispenses at least 1 ABs to 7-10 patients out of 10 patients. 2. Any Training from Liver Foundation received or not 3. Years of practice 4. Veterinary treatment or Animal treatment We categorized the 150 surveyed IPs (in each district) into three broad groups based on their level of AB use. Then we randomly selected 15 IPs in each category. For the final selection of 15 IPs from these categories, 5 from each category in each district, we considered other factors also including any training from Liver Foundation, number of years of practice, provision of veterinary treatment, and AB dispensing vs prescription. The researchers were trained by the project PI to conduct in-depth interviews and then supervised in the field as they conducted the interviews. Researchers went in pairs to conduct these interviews so that one could ask questions and the other could take notes. Interviews were audio recorded for those providers who gave their consent to be recorded. Interviews were then transcribed and translated into English for further analysis. This tool will be available on the website of Liver Foundation by March 31, 2018. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2018 |
| Provided To Others? | Yes |
| Impact | The tool has allowed us to gather valuable in-depth information on the patterns and drivers of antibiotic use. Our preliminary findings have already made an impact on health department officials in West Bengal. It has helped us understand the multitude of actors and the nature of incentives and knowledge deficiencies that need to be addressed systemically in order to develop an antibiotic stewardship programme for this level of the health system in rural India. These findings have formed the basis of an intervention proposal that we have recently submitted in response to the Health Systems Research Initiative Call 4, as an outline proposal. |
| Title | Informal healthcare provider survey tool |
| Description | This tool was designed for quantitative data collection on informal providers' profile and nature of practice and patterns of use of antibiotics. This tool aims to collect information on key independent variables to include in a regression model to quantitatively analyse the determinants of antibiotic use by informal providers. The survey tool has different sections as follows: a. Section 1: i. Identification: This section contains all the required provisions for identification of providers and enumerators. For provider's identification, we have included questions to record detailed location of provider, i.e. District Code, Block Code, Gram Panchayat Code and Name; Provider's Name, Unique Number and Full ID; Provider's Clinic Address and mobile phone number. ii. Interview visits: This part is designed to record the timings of each interview in case the interview could not be completed in one visit i.e. Date, Start Time, End Time and the final status of the interview (whether the interview has completed or not, which module/s were completed in which visit), date for next visit if required. b. Section 2: This section contains 7 modules with structured questions: i. Module 1: Screening questions: This section was designed to screen providers in order to determine their eligibility for inclusion in the study. We included those providers who did not not have a formal qualifications and who used allopathic drugs in their routine treatment. The responses obtained in this module helped determine each providers' eligibility. ii. Module 2: Health Provider Characteristics Provider's Services: This part is related to the nature of service of the Informal Providers, i.e. type of clinic, duration of the clinic time, years of practice, types of health services for humans and types of animal treated, etc. Provider's level of Practice and Economic Status: In this section we aimed to get information about the level of practice and the economic status of IPs. So, we designed questions to collect information about the nature of clinic, number of clinics they have, and clinic equipment including mobile phones and use of internet. Provider's Background and Education Training: We wanted to get information about the providers' background. So we designed questions on their age and religion and their education and any training allied to their profession including working as assistants to formal doctors. iii. Module 3: Patients: This module has questions on types of patients, patient load and patients' socio-economic characteristics. iv. Module 4: Knowledge and Use/Practice of Antibiotics by providers Use/Practice of Antibiotics: This section is designed to obtain information on providers' use of antibiotics (ABs) including dispensing/prescribing practices and the AB classes and amount of ABs they typically use in their daily practice and for which conditions. Provider's knowledge of Antibiotics and AB resistance: In this section we focused on providers' knowledge of different ABs and their mode of action, use of ABs in different condition (through vignettes) and knowledge about AB resistance. We also designed questions on the source of knowledge about ABs and AB resistance. Charges: This section mainly aimed to get data about the minimum and maximum treatment charges for three key conditions seen at the primary level (fevers, cold and cough and diarrhea). v. Module 5: Influence of the Market: This module investigated interactions between informal providers and pharmaceutical representatives as well the procurement of ABs by informal providers. vi. Module 6: Regulatory Environment: This module examined the existence of and awareness amongst IPs of any laws and regulations related to antibiotic use. vii. Module 7: Attitudes/Interventions: This module was designed to elicit the opinion and views of IPs regarding interventions to control the use of ABs. Method of implementing the survey: Sample selection: This study was located in districts South 24 Parganas and Birbhum in West Bengal state in India. For the survey we required a sample of 150 IPs per district. This sample size calculation was based on a 50% prevalence of indicator of interest with 95% confidence interval and 10% margin of error, a design effect of 1.5 (due to our clustered random sampling approach) and 10% allowance for dropouts. We used village clusters as our sampling units, defining a cluster as a 'Gram Panchayat' which is an administrative grouping of 5-12 villages based on population size. In each selected cluster we conducted an exhaustive survey of all the informal providers in the villages in that cluster. S-24 Parganas: We proposed from our previous field experience that the average number of IPs in a Gram Panchayat (GP) of S-24 Parganas was 15. So we randomly selected 11 GPs out of total 310 GPs to get 150 IPs. Birbhum: We proposed from our previous field experience that the average number of IPs in a GP of Birbhum was 9-10. So, we decided to pair the GPs in order to get a similar number of IPs (15) per cluster. We randomly selected 8 GP pairs in Birbhum (approx. 2/3rd the number of GPs in South 24 Parganas) so as not to over sample in Birbhum which appeared to have 2/3rds the number of IPs per GP compared to South 24 Parganas. Mapping and survey of IPs: The tool was piloted twice with 17 informal providers in a district close to Kolkata. It was then finally implemented in the study sites as follows: In the selected GPs, we first visited the Gram Panchayat office. There we collected the village list under that particular panchayat. We also collected any available information about the number and contact details of informal providers from the panchayat office. Simultaneously, we also contacted the ASHA workers (government grass roots workers) and other key informants in the villages of selected GPs to get an idea about the number, contact details of informal providers in their villages. We surveyed every IP providing services to each village in the cluster and used snowballing techniques to obtain from each IP visited, the details of additional IPs whom we may have missed. This tool will be available on the website of Liver Foundation by March 31, 2018. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2018 |
| Provided To Others? | Yes |
| Impact | This tool has yielded valuable quantitative data about the profile, characteristics and services of informal providers in West Bengal. In a meeting with our research team one senior health department official from the government commented that this study provided good numerical data on the services being provided by informal providers, not only for humans but also for animals as this survey tool captured information on how many providers also treated animals and what types of animals they treated. Ours is the first documentation of animal services by informal providers in West Bengal and also in India. As we disseminate our findings to wider audiences, this tool can also be used by other research teams to document important characteristics of similar providers in other locations in India. It has already been shared with a group of student researchers doing an M.Sc course in 'One Health' who are studying human and animal drug shops to study their antibiotic use practices. |
| Title | Prospective data sheet for informal providers |
| Description | We developed a novel seven day prospective patient data sheet for informal providers to record the details of their patients who received antibiotics over a 7 day period. The sheet included the patients' gender, primary condition, antibiotic given and its dosage. We did this as a trial (it was not part of the original study design), and around 30% of the providers maintained this sheet and returned it to us. We are still analysing this data and it provides a useful tool to triangulate the data reported by the IPs in the survey and in-depth interviews. We could also refine it in the future to collect daily patient data in a cost effective way. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2018 |
| Provided To Others? | Yes |
| Impact | We are still analysing this data. |
| Title | Stakeholder interview topic guide |
| Description | We developed a topic guide and adapted it to interview different groups of stakeholders including pharmaceutical representatives and medicine wholesalers, health department and regulatory department officials, formal doctors and representatives of medical associations including the Indian Medical Association. The core topics for exploration included the stakeholders' perceptions and awareness of antibiotic resistance; their perceptions of informal providers in general and specifically with respect to antibiotic use; details of their interactions if any, with informal providers; views and awareness of regulatory frameworks; their own relationships with antibiotics (role of antibiotics in their own livelihoods); and their views and ideas related to the development of strategies for reducing AB use by informal providers. Interviews were selected based on their relevance to the study, their importance as actors of influence to the local informal providers, or as regular contacts of the informal providers (e.g. whole sale drug sellers who were a popular source of drug procurement by the informal providers or formal doctors regularly consulted by some informal providers). We interviewed a total of 16 key stakeholders across the two districts. The research teams in pairs, trained and supervised by the project PI, conducted the interviews. Interviews were audio recorded where consent was available, transcribed and translated into English for further analysis. This tool and its adaptations will be available on the website of Liver Foundation by March 31, 2018. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2018 |
| Provided To Others? | Yes |
| Impact | Our preliminary analysis using these tools has thrown light on many new aspects of stakeholder influence on informal providers' use of antibiotics. The combined findings from the quantitative and qualitative tools have helped us build a conceptual framework of social, economic and behavioural drivers that has made an impact wherever we have presented it so far. Our planned publications for later this year will further disseminate these findings and strengthen the impact. |
| Title | IP survey dataset |
| Description | This dataset contains 353 records of informal providers surveyed in the study sites in districts South 24 Parganas and Birbhum. This dataset is stored in excel as well as Stata 14. There are 137 variables covering provider characteristics and their knowledge and practice of antibiotics. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2017 |
| Provided To Others? | No |
| Impact | We are in the process of conducting our in-depth analysis with this dataset (for potential publications). In the original proposal we had proposed 12 months of exclusive data use before making it fully accessible to others after removing the identifier information. We plan to make it available to others by October/Nov 2018. We have used this data in our preliminary analysis and presented the initial findings to government policymakers, informal providers and pharmaceutical representatives in West Bengal who have appreciated the data as it provides a number of new quantitative estimates about informal providers that were not known earlier. |
| Title | Qualitative interviews |
| Description | This is a qualitative dataset that includes 30 English transcripts of in-depth interviews with informal providers and 16 English transcripts of key informant interviews with key stakeholders. The files are stored in MS word and audio files are stored as MP3 files. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2017 |
| Provided To Others? | No |
| Impact | We are in the process of doing an in-depth analysis of this data for potential publications. Our preliminary analysis based on this data has been valued by the local audiences in West Bengal to whom we have presented our initial findings (like in the intervention appraisal workshops). This data is helping us develop a conceptual framework of the social, economic and behavioral drivers of antibiotic use in informal providers and in future it may be possible to apply and adapt this framework to other studies of antibiotic use and of other types of providers. The data will be made accessible to others in Oct/Nov 2018 after a period of exclusive use by our own research team. |
| Description | GCRF Cluster project: Antibiotic stewardship in agricultural communities in Africa and Asia |
| Organisation | Makerere University |
| Country | Uganda |
| Sector | Academic/University |
| PI Contribution | My LSHTM colleague Professor Sian Clarke and I conceptualised, developed, and won this Global Challenges Research Fund cluster project. This grant scheme aimed to bring together several different projects under a common overarching goal. We reached out to our networks and gathered a group of inter-disciplinary collaborators from across different countries of Asia, Africa and South America, to compare the situations, norms, experiences, and motivations that affect antibiotic use in humans and animals across a across these contexts, pool this knowledge and identify processes that can deter misuse of these valuable medicines and/or incentivize good practice. Our particular focus is on antibiotics purchased from drug shops and informal providers in rural agricultural areas with limited access to healthcare. Our projects also look at the influence of interactions between private providers, government health workers and public officials, to gain a better understanding of how health systems in low-income countries can more effectively raise the quality of care available from private providers and improve treatment practices. Since the project began in June 2020, we have organised 5 virtual workshops with the collaborators, developed a framework to synthesise information from across the different projects and contexts, developed plans for joint publications and are now working on designing an overarching intervention strategy, comprised of mutually-reinforcing components, aimed at combatting misuse of antibiotics purchased from drug shops/informal providers and improving rural treatment services for humans and animals. This strategy will be tested in future studies. |
| Collaborator Contribution | Our Challenge Cluster comprises six different projects - all address the common challenge of the overuse and misuse of antibiotics, and focus on medicines supplied through the private retail market and informal providers/drug sellers to characterise patterns of antibiotic use in humans and in animals. The projects are: Understanding Health System Linkages in Uganda, A Multistakeholder Approach to Operationalising Antibiotic Stewardhip in India, SNAP-AMR in Tanzania, One Health Poultry Hub (multiple countries), Drivers of Inappropriate Antibiotic Use by Informal Providers in India, Policymakers' Perceptions in Pakistan, and Monitoring antibiotic stewardship in livestock and poultry production systems in Colombia. Several of these projects have recently noted the occurrence of cross-over use of antibiotics (medicines formulated for humans being used in animals, or humans using medicines formulated for use in animals) at community level, particularly where there policy is weak and supply chains overlap between the medical and veterinary sectors, underlining the need for unified interventions based on a One Health approach. Project partners have demonstrated keen engagement in the project by participating in the workshops conducted so far, sharing their knowledge and lessons learnt between the human and animal health sectors in agricultural community settings and are currently contributing to the design of a webinar and a digital photo exhibition using 'photo voice' methodology. They are also conceptualising a cross-sectoral intervention strategy to improve antibiotic use in agricultural communities in Africa and Asia. |
| Impact | Collectively, our team combines a well-balanced range of academic disciplines, encompassing expertise in infectious disease epidemiology, disease control, health systems, anthropology, health economics, health policy, pharmacy, drug quality, veterinary science, food systems and agricultural economics. Through our established research partnerships with local academics and decision makers in public health, we are also able to draw upon a complementary mix of disciplinary expertise and public health implementation experience of direct relevance to the proposed work. We are not able to report outputs as yet but hope to do so in time for the next round of research fish submission. |
| Start Year | 2020 |
| Description | GCRF Cluster project: Antibiotic stewardship in agricultural communities in Africa and Asia |
| Organisation | Royal Veterinary College (RVC) |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | My LSHTM colleague Professor Sian Clarke and I conceptualised, developed, and won this Global Challenges Research Fund cluster project. This grant scheme aimed to bring together several different projects under a common overarching goal. We reached out to our networks and gathered a group of inter-disciplinary collaborators from across different countries of Asia, Africa and South America, to compare the situations, norms, experiences, and motivations that affect antibiotic use in humans and animals across a across these contexts, pool this knowledge and identify processes that can deter misuse of these valuable medicines and/or incentivize good practice. Our particular focus is on antibiotics purchased from drug shops and informal providers in rural agricultural areas with limited access to healthcare. Our projects also look at the influence of interactions between private providers, government health workers and public officials, to gain a better understanding of how health systems in low-income countries can more effectively raise the quality of care available from private providers and improve treatment practices. Since the project began in June 2020, we have organised 5 virtual workshops with the collaborators, developed a framework to synthesise information from across the different projects and contexts, developed plans for joint publications and are now working on designing an overarching intervention strategy, comprised of mutually-reinforcing components, aimed at combatting misuse of antibiotics purchased from drug shops/informal providers and improving rural treatment services for humans and animals. This strategy will be tested in future studies. |
| Collaborator Contribution | Our Challenge Cluster comprises six different projects - all address the common challenge of the overuse and misuse of antibiotics, and focus on medicines supplied through the private retail market and informal providers/drug sellers to characterise patterns of antibiotic use in humans and in animals. The projects are: Understanding Health System Linkages in Uganda, A Multistakeholder Approach to Operationalising Antibiotic Stewardhip in India, SNAP-AMR in Tanzania, One Health Poultry Hub (multiple countries), Drivers of Inappropriate Antibiotic Use by Informal Providers in India, Policymakers' Perceptions in Pakistan, and Monitoring antibiotic stewardship in livestock and poultry production systems in Colombia. Several of these projects have recently noted the occurrence of cross-over use of antibiotics (medicines formulated for humans being used in animals, or humans using medicines formulated for use in animals) at community level, particularly where there policy is weak and supply chains overlap between the medical and veterinary sectors, underlining the need for unified interventions based on a One Health approach. Project partners have demonstrated keen engagement in the project by participating in the workshops conducted so far, sharing their knowledge and lessons learnt between the human and animal health sectors in agricultural community settings and are currently contributing to the design of a webinar and a digital photo exhibition using 'photo voice' methodology. They are also conceptualising a cross-sectoral intervention strategy to improve antibiotic use in agricultural communities in Africa and Asia. |
| Impact | Collectively, our team combines a well-balanced range of academic disciplines, encompassing expertise in infectious disease epidemiology, disease control, health systems, anthropology, health economics, health policy, pharmacy, drug quality, veterinary science, food systems and agricultural economics. Through our established research partnerships with local academics and decision makers in public health, we are also able to draw upon a complementary mix of disciplinary expertise and public health implementation experience of direct relevance to the proposed work. We are not able to report outputs as yet but hope to do so in time for the next round of research fish submission. |
| Start Year | 2020 |
| Description | GCRF Cluster project: Antibiotic stewardship in agricultural communities in Africa and Asia |
| Organisation | Universidad Antonio Nariño |
| Country | Colombia |
| Sector | Academic/University |
| PI Contribution | My LSHTM colleague Professor Sian Clarke and I conceptualised, developed, and won this Global Challenges Research Fund cluster project. This grant scheme aimed to bring together several different projects under a common overarching goal. We reached out to our networks and gathered a group of inter-disciplinary collaborators from across different countries of Asia, Africa and South America, to compare the situations, norms, experiences, and motivations that affect antibiotic use in humans and animals across a across these contexts, pool this knowledge and identify processes that can deter misuse of these valuable medicines and/or incentivize good practice. Our particular focus is on antibiotics purchased from drug shops and informal providers in rural agricultural areas with limited access to healthcare. Our projects also look at the influence of interactions between private providers, government health workers and public officials, to gain a better understanding of how health systems in low-income countries can more effectively raise the quality of care available from private providers and improve treatment practices. Since the project began in June 2020, we have organised 5 virtual workshops with the collaborators, developed a framework to synthesise information from across the different projects and contexts, developed plans for joint publications and are now working on designing an overarching intervention strategy, comprised of mutually-reinforcing components, aimed at combatting misuse of antibiotics purchased from drug shops/informal providers and improving rural treatment services for humans and animals. This strategy will be tested in future studies. |
| Collaborator Contribution | Our Challenge Cluster comprises six different projects - all address the common challenge of the overuse and misuse of antibiotics, and focus on medicines supplied through the private retail market and informal providers/drug sellers to characterise patterns of antibiotic use in humans and in animals. The projects are: Understanding Health System Linkages in Uganda, A Multistakeholder Approach to Operationalising Antibiotic Stewardhip in India, SNAP-AMR in Tanzania, One Health Poultry Hub (multiple countries), Drivers of Inappropriate Antibiotic Use by Informal Providers in India, Policymakers' Perceptions in Pakistan, and Monitoring antibiotic stewardship in livestock and poultry production systems in Colombia. Several of these projects have recently noted the occurrence of cross-over use of antibiotics (medicines formulated for humans being used in animals, or humans using medicines formulated for use in animals) at community level, particularly where there policy is weak and supply chains overlap between the medical and veterinary sectors, underlining the need for unified interventions based on a One Health approach. Project partners have demonstrated keen engagement in the project by participating in the workshops conducted so far, sharing their knowledge and lessons learnt between the human and animal health sectors in agricultural community settings and are currently contributing to the design of a webinar and a digital photo exhibition using 'photo voice' methodology. They are also conceptualising a cross-sectoral intervention strategy to improve antibiotic use in agricultural communities in Africa and Asia. |
| Impact | Collectively, our team combines a well-balanced range of academic disciplines, encompassing expertise in infectious disease epidemiology, disease control, health systems, anthropology, health economics, health policy, pharmacy, drug quality, veterinary science, food systems and agricultural economics. Through our established research partnerships with local academics and decision makers in public health, we are also able to draw upon a complementary mix of disciplinary expertise and public health implementation experience of direct relevance to the proposed work. We are not able to report outputs as yet but hope to do so in time for the next round of research fish submission. |
| Start Year | 2020 |
| Description | GCRF Cluster project: Antibiotic stewardship in agricultural communities in Africa and Asia |
| Organisation | University of Glasgow |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | My LSHTM colleague Professor Sian Clarke and I conceptualised, developed, and won this Global Challenges Research Fund cluster project. This grant scheme aimed to bring together several different projects under a common overarching goal. We reached out to our networks and gathered a group of inter-disciplinary collaborators from across different countries of Asia, Africa and South America, to compare the situations, norms, experiences, and motivations that affect antibiotic use in humans and animals across a across these contexts, pool this knowledge and identify processes that can deter misuse of these valuable medicines and/or incentivize good practice. Our particular focus is on antibiotics purchased from drug shops and informal providers in rural agricultural areas with limited access to healthcare. Our projects also look at the influence of interactions between private providers, government health workers and public officials, to gain a better understanding of how health systems in low-income countries can more effectively raise the quality of care available from private providers and improve treatment practices. Since the project began in June 2020, we have organised 5 virtual workshops with the collaborators, developed a framework to synthesise information from across the different projects and contexts, developed plans for joint publications and are now working on designing an overarching intervention strategy, comprised of mutually-reinforcing components, aimed at combatting misuse of antibiotics purchased from drug shops/informal providers and improving rural treatment services for humans and animals. This strategy will be tested in future studies. |
| Collaborator Contribution | Our Challenge Cluster comprises six different projects - all address the common challenge of the overuse and misuse of antibiotics, and focus on medicines supplied through the private retail market and informal providers/drug sellers to characterise patterns of antibiotic use in humans and in animals. The projects are: Understanding Health System Linkages in Uganda, A Multistakeholder Approach to Operationalising Antibiotic Stewardhip in India, SNAP-AMR in Tanzania, One Health Poultry Hub (multiple countries), Drivers of Inappropriate Antibiotic Use by Informal Providers in India, Policymakers' Perceptions in Pakistan, and Monitoring antibiotic stewardship in livestock and poultry production systems in Colombia. Several of these projects have recently noted the occurrence of cross-over use of antibiotics (medicines formulated for humans being used in animals, or humans using medicines formulated for use in animals) at community level, particularly where there policy is weak and supply chains overlap between the medical and veterinary sectors, underlining the need for unified interventions based on a One Health approach. Project partners have demonstrated keen engagement in the project by participating in the workshops conducted so far, sharing their knowledge and lessons learnt between the human and animal health sectors in agricultural community settings and are currently contributing to the design of a webinar and a digital photo exhibition using 'photo voice' methodology. They are also conceptualising a cross-sectoral intervention strategy to improve antibiotic use in agricultural communities in Africa and Asia. |
| Impact | Collectively, our team combines a well-balanced range of academic disciplines, encompassing expertise in infectious disease epidemiology, disease control, health systems, anthropology, health economics, health policy, pharmacy, drug quality, veterinary science, food systems and agricultural economics. Through our established research partnerships with local academics and decision makers in public health, we are also able to draw upon a complementary mix of disciplinary expertise and public health implementation experience of direct relevance to the proposed work. We are not able to report outputs as yet but hope to do so in time for the next round of research fish submission. |
| Start Year | 2020 |
| Description | GCRF Cluster project: Antibiotic stewardship in agricultural communities in Africa and Asia |
| Organisation | West Bengal University of Animal and Fishery Sciences |
| Country | India |
| Sector | Academic/University |
| PI Contribution | My LSHTM colleague Professor Sian Clarke and I conceptualised, developed, and won this Global Challenges Research Fund cluster project. This grant scheme aimed to bring together several different projects under a common overarching goal. We reached out to our networks and gathered a group of inter-disciplinary collaborators from across different countries of Asia, Africa and South America, to compare the situations, norms, experiences, and motivations that affect antibiotic use in humans and animals across a across these contexts, pool this knowledge and identify processes that can deter misuse of these valuable medicines and/or incentivize good practice. Our particular focus is on antibiotics purchased from drug shops and informal providers in rural agricultural areas with limited access to healthcare. Our projects also look at the influence of interactions between private providers, government health workers and public officials, to gain a better understanding of how health systems in low-income countries can more effectively raise the quality of care available from private providers and improve treatment practices. Since the project began in June 2020, we have organised 5 virtual workshops with the collaborators, developed a framework to synthesise information from across the different projects and contexts, developed plans for joint publications and are now working on designing an overarching intervention strategy, comprised of mutually-reinforcing components, aimed at combatting misuse of antibiotics purchased from drug shops/informal providers and improving rural treatment services for humans and animals. This strategy will be tested in future studies. |
| Collaborator Contribution | Our Challenge Cluster comprises six different projects - all address the common challenge of the overuse and misuse of antibiotics, and focus on medicines supplied through the private retail market and informal providers/drug sellers to characterise patterns of antibiotic use in humans and in animals. The projects are: Understanding Health System Linkages in Uganda, A Multistakeholder Approach to Operationalising Antibiotic Stewardhip in India, SNAP-AMR in Tanzania, One Health Poultry Hub (multiple countries), Drivers of Inappropriate Antibiotic Use by Informal Providers in India, Policymakers' Perceptions in Pakistan, and Monitoring antibiotic stewardship in livestock and poultry production systems in Colombia. Several of these projects have recently noted the occurrence of cross-over use of antibiotics (medicines formulated for humans being used in animals, or humans using medicines formulated for use in animals) at community level, particularly where there policy is weak and supply chains overlap between the medical and veterinary sectors, underlining the need for unified interventions based on a One Health approach. Project partners have demonstrated keen engagement in the project by participating in the workshops conducted so far, sharing their knowledge and lessons learnt between the human and animal health sectors in agricultural community settings and are currently contributing to the design of a webinar and a digital photo exhibition using 'photo voice' methodology. They are also conceptualising a cross-sectoral intervention strategy to improve antibiotic use in agricultural communities in Africa and Asia. |
| Impact | Collectively, our team combines a well-balanced range of academic disciplines, encompassing expertise in infectious disease epidemiology, disease control, health systems, anthropology, health economics, health policy, pharmacy, drug quality, veterinary science, food systems and agricultural economics. Through our established research partnerships with local academics and decision makers in public health, we are also able to draw upon a complementary mix of disciplinary expertise and public health implementation experience of direct relevance to the proposed work. We are not able to report outputs as yet but hope to do so in time for the next round of research fish submission. |
| Start Year | 2020 |
| Description | Member, Centre for Science and Policy (CSaP), University of Cambridge |
| Organisation | University of Cambridge |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | CSaP is a network of academics and decision-makers to improve the use of evidence and expertise in public policy. I engage with policy makers and programme implementers through the network to address critical questions on health systems and AMR policies. |
| Collaborator Contribution | My last meeting was with Myung Soo Chu, Head of the Programme Planning, Monitoring, & Strategic Partnership Unit in the HIV/AIDS Section in Health Programme Group, United Nations Children's Fund (UNICEF). We discussed realist evaluations of policy formulation and implementation using a variety of analytical frameworks. Chu observed that this platform 'could be very useful for UN systems and through them to national governments whom they assist with policy development.' |
| Impact | I am part of a network of academics at the Centre for Science and Policy pooling their expertise and evidence for improving public policy. The network is likely to lead to future collaborations. |
| Start Year | 2020 |
| Description | SMART regulations for AMR in India: understanding, innovating and imroving compliance |
| Organisation | University of Edinburgh |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | I am a Co-investigator in this study which is led by Mr. Gerard Porter at the University of Edinburgh. I am involved in primary and secondary data collection to understand the challenges to AMR regulations across four different sectors - hospital AMR, poultry, pharmacy OTC sales, and pharmaceutical effluents. |
| Collaborator Contribution | This is an Indo-UK collaborative study led by Gerard Porter (PI) at the School of Law, University of Edinburgh. Other Co-investigators on the UK side include Prof. Javier Guitian at he Royal Veterinary College, and Prof Lucy Kimbell at the University of the Arts, London. The Indian Co-investigators are Prof Anita Kotwani at the Vallabhai Patel Chest Institute, University of Delhi, Dr. Nagendre Hegde at the Institute for Animal Biotechnology in Hyderabad, India and Dr. Jyoti Joshi and Dr. Anjana Sankhil at the Centre for Disease Dynamics, Economics and Policy. |
| Impact | The study began in August 2018, and it is too early to report outcomes. This is a multi-disciplinary collaboration involving senior academics from various fields. Our multi-disciplinary and international team of researchers has the skills, knowledge, experience and professional connections needed to successfully implement the project (Porter: law and regulation; Kotwani: pharmacology, population medicine , containment of AMR; Joshi: community medicine, infectious disease, policy & health systems research, AMR; Gautham: epidemiology, health systems research, AMR; Guitian: veterinary public health, AMR; Sankhil: medical anthropology, qualitative studies; Hegde: veterinary virology, immunology and microbiology, AMR; Kimbell: participatory design and open policy making). Although our project is relatively small, research of this type is critical if 'biological' research on the drivers of emergence and alternatives to AMR is to produce real-world change. Our project on smart regulation will help create a more effective regulatory system for addressing AMR and also maximise the impact of other ongoing research. |
| Start Year | 2018 |
| Description | UK-India Antimicrobial Resistance (AMR) Sandpit Event: 'Addressing the challenge of antimicrobial resistance in India' |
| Organisation | Newton Fund |
| Country | United Kingdom |
| Sector | Public |
| PI Contribution | I was selected through a competitive process to participate in this 4-day AMR Sandpit event that brought together 40 delegates from the UK and India to interact and develop collaborative proposals to address Antimicrobial Resistance in India. I brought social science expertise to this meeting, especially knowledge about the social, economic and behavioural drivers of antibiotic use by healthcare providers in India; knowledge that I had discovered through my MRC research award. I attribute a large part of my AMR Sandpit selection to the research I was able to conduct through my present MRC award. |
| Collaborator Contribution | The AMR India Sandpit has helped connect me with multiple national and international collaborators from different disciplines and this in turn will help me build upon and expand my current portfolio of research in AMR. I have learned more about the biology and epidemiology of resistance, about veterinary factors influencing human AMR and about integrating biological and social knowledge on AMR in order to develop coherent AMR reduction strategies and interventions. I was part of two interdisciplinary proposals that were shortlisted for full proposal submission on the last day of the Sandpit. The details of these proposals are given in the outputs section below. We submitted the full proposals in Jan 2018. The results are still awaited and should be announced in March 2018. |
| Impact | I was part of two interdisciplinary collaborative proposals that were successful in the first stage of selection and were invited as full proposals. We submitted these full proposals on 9th January 2018 and the final results are awaited. The proposal titles and team details are: (1) Smart regulation of antibiotic use in India: Understanding, innovating and improving compliance. Team: Indian PIs: Anita Kotwani, VP Chest Institute, University of Delhi (Pharmacology); Co-PI: Jyoti Joshi, CDDEP (Social Science); Co-I's: Nagendra Hegde, National Institute of Animal Biotechnology (Veterinary Microbiology); Anjana Sankhil , CDDEP (Anthropology). • UK PI: Gerard Porter, University of Edinburgh (Law); Co-I's: Meenakshi Gautham, LSHTM (Social Science); Javier Guitian, Royal Veterinary College Uo London (Veterinary Epidemiology); Lucy Kimbell, UAL (Service Design). (2) Zonal Ecology of AMR: Integrating social, biological and systems knowledge for targeted AMR reduction. Team: Indian PIs: Neelam Taneja, PGIMER Chandigarh (Medical Microbiology); Durg Vijay Singh, Institute of Life Sciences Bhubaneshwar (Infectious Diseases Biology); (3) Zunjar Dubal, Indian Veterinary Research Institute (Veterinary Public Health); UK PIs: Helen Lambert, University of Bristol (Population Health Sciences); Elizabeth Wellington, University of Warwick (Biological Sciences); Meenakshi Gautham, LSHTM (Social Science and Public Health); Javier Guitian, Royal Veterinary College (Veterinary Epidemiology) |
| Start Year | 2017 |
| Description | A study of the multiple drivers of antibiotic use by informal healthcare providers in rural India. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Other audiences |
| Results and Impact | First International Meeting of the International Society to Improve the Use of Medicines. The meeting was held in partnership with the Drug System Monitoring and Development Centre (DMDC), Chulalongkorn University, and the Thai RDU Subcommittee of the Thai Food and Drugs Administration (FDA). The title of the meeting was 'People Improving the Use of Medicines: What we know and don't know'. I was part of important deliberations related to antibiotic use in low and middle income countries, especially on issues of access vs excess. My comments on the irrationality of restricting all antibiotics as prescription drugs when 50% of the world's population does not have access to a qualfied medical practitioner who can provide a prescription sparked a discussion and urged many participants to challenge their own views. |
| Year(s) Of Engagement Activity | 2020 |
| URL | https://www.isium.org/isium-conference-bangkok-2020-2/ |
| Description | A virtual presentation for AMR scientists, practitioners and champions in India. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | This presentation on the informalities of antibiotic practices that were common to informal as well as formal providers, the role of the pharmaceutical industry and the regulatory challenges, was much appreciated for its clarity and depth. In fact a senior physician cum researcher sent a funny text message afterwards: 'When I grow up I want to be a researcher like you!' The study findings inspired the audience to understand the multi-factorial and multi-stakeholder nature of the challenges and some members of this group have expressed an interest in supporting further dialogue with stakeholders. The talk was arranged by the Indian Initiative for the Management of Infectious Diseases, and the WHO Collaborating Centre for Research in Surgical care Delivery in LMICs at the University of Mumbai, India. |
| Year(s) Of Engagement Activity | 2021 |
| Description | A virtual seminar for a One Health academic group at the University of Glasgow |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Postgraduate students |
| Results and Impact | About 45 students and faculty at the Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences,University of Glasgow, attended my talk on the 'challenges of antibiotic stewardship in community settings in India'. The talk was followed by an animated discussion about the study findings as well as methods, especially analytical tools. A number of interesting comparisons were identified between the India work and the experiences of some of the faculty in Tanzania. We hope to keep the dialogue going in the months to come. |
| Year(s) Of Engagement Activity | 2021 |
| Description | Antimicrobial Stewardship Governance Workshop at the 7th Global health Systems Symposium, Bogota, Colombia |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Other audiences |
| Results and Impact | I co-organised, with Dr. Nelson Arenas, my collaborator at the University of Antonio Narino in Bogota, Colombia, a half day workshop on 'Antibiotic stewardship in India's frontier health markets: Learning from new forms of private sector partnerships to co-design One Health interventions and influence private sector policy shifts'. We presented our work to a audience consisting of international researchers and practitioners and we also shared antibiotic usage tools and guidelines developed for frontline providers (both human and veterinary) in India with experts from Colombia and obtained their feedback. |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://healthsystemsglobal.org/wp-content/uploads/2023/01/Report-PSIH-TWG-satellite-session.pdf |
| Description | Blog on the LSHTM website |
| Form Of Engagement Activity | Engagement focused website, blog or social media channel |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Media (as a channel to the public) |
| Results and Impact | This was a blog that I co-authored with my LSHTM colleague Timothy Powell Jackson. The blog drew attention to the evaluation of a training programme for informal providers in West Bengal that had just been published in the Science journal, that also included a commentary by Powell-Jackson. Our blog lifted the debate on informal providers by making a scientific case for harnessing them as primary care providers in the short term in India. We discussed the importance of our ongoing MRC study on understanding the drivers of inappropriate antibiotic use by informal providers in the context of improving their quality of care in a meaningful way. |
| Year(s) Of Engagement Activity | 2016 |
| URL | http://blogs.lshtm.ac.uk/news/2016/10/21/are-informal-providers-a-short-term-fix-for-indias-primary-... |
| Description | Health systems related challenges of operationalising antimicrobial stewardship in low- and middle-income countries |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Other audiences |
| Results and Impact | This was an invited talk at the Third International Antibiotic Resistance Conference, organised by the New University of Lisbon, Portugal. This conference is organised once in two years and is a unique environment for African, American, Asian, Australian and European scientists to present and discuss their research in the field of antibiotic resistance in bacteria and other microorganisms as well as in the social science aspects of AMR. |
| Year(s) Of Engagement Activity | 2019 |
| URL | http://www.ic2ar2019.com/ |
| Description | Intervention appraisal workshops with key stakeholders |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Study participants or study members |
| Results and Impact | The research team along with the PI (Gautham) and Co-I (Chowdhury) conducted 3 half day workshops with three different groups of stakeholders who were important actors in this study. These included a group of informal providers who participated in the study as interview subjects, representatives of the pharmaceutical industry (state and regional level officials), and government and civil society representatives. The goal of these workshops was to present key findings from the study and seek feedback from the participants around potential areas for interventions to improve antibiotic use by informal providers. The specific objectives were to: 1. To provide the audiences an overview of antibiotic resistance, its causes and consequences 2. To present summary findings from Liver Foundation & LSHTM study of antibiotic use by informal providers (IPs) in South 24 Parganas and Birbhum districts 3. To discuss practical and effective strategies to optimise antibiotic use by informal providers and communities. With each of the three groups we began with an overview of antibiotic resistance and some examples of resistance prevalence in India. This was quite an eye opener for everyone as there was limited existing awareness about resistance and its implications for rural health markets and antibiotic stewardship in India. The study findings that we presented included a profile of the IPs and the range of the services they provided including the fact that about 30% also treated animals; the range of antibiotics that were found in IP clinics (belonging mainly to WHO's ACCESS and WATCH categories) and the experimental and inappropriate manner in which these were used (small dosages, arbitrary changes, no testing); the role of the pharmaceutical industry in aggressively promoting and marketing antibiotics in rural health markets; the health system's reliance on IPs for rural health care in the face of suitable alternatives and the regulatory system's lack of capacity to create awareness about or monitor antibiotic use. The IPs and the pharmaceutical industry participants received the study findings with some honesty and some defensiveness. IPs too accepted their excessive antibiotic use but also laid the blame on the pharmaceutical industry and on formal providers (whose prescriptions they often followed) and on patients for not following instructions. The pharma reps lay the blame on sub-standard companies and also on the intensity of competition ('150 products being produced by 50,000 companies') that increased the need for aggressive marketing of drugs including antibiotics. The government officials appreciated the study findings which provided new data on informal providers and their use of antibiotics. The government official in charge of a statewide training programme for informal providers in West Bengal shared more details of the government's training programme and also shared that it was difficult for the state government to address drug use by informal providers due to the medico-legal issues involved. He recommended that we start a dialogue with the national government in order to develop any rational drug use guidelines (especially if they include use of some essential antibiotics) for informal providers. Overall the workshops generated a lot of interest in our study findings with the participants expressing their desire and willingness to support us for a future intervention to reduce antibiotic use by informal rural providers. Key strategies for an intervention would have to include community awareness building, improving informal providers' knowledge of antibiotic use and developing guidelines for this at the central level, working with formal providers to improve their knowledge as well as harnessing them as regular supervisors and referral sources for informal providers, and working with the pharmaceutical industry to reduce unregulated marketing of antibiotics amongst informal providers. We have already brought these recommendations together into a grant proposal for a multi-stakeholder intervention in the same setting. We have submitted this proposal as an Outline Proposal for the most recent round of the Health Systems Initiative Call for 2017-18. |
| Year(s) Of Engagement Activity | 2017 |
| Description | Interview - Meenaksh Gautham - React Newsletter - 2021-01-25 |
| Form Of Engagement Activity | A magazine, newsletter or online publication |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Third sector organisations |
| Results and Impact | React is a global network dedicated to advocating and stimulating global engagement on antibiotic resistance. The publication of this interview in the React newsletter led to invitations for other presentations (like the IIMAR one described separately). A research group also reached out from the University of Oslo to discuss collaboration potential. |
| Year(s) Of Engagement Activity | 2021 |
| URL | https://www.reactgroup.org/news-and-views/news-and-opinions/year-2021/dr-meenakshi-gautham-informal-... |
| Description | Interview for an article on One Health |
| Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Media (as a channel to the public) |
| Results and Impact | I was interviewed by a UK based journalist, Jacqui Thornton, who was writing an article on the use of antibiotics in humans and animals, using material from various studies going on in LSHTM. The article highlighted human as well as non-human usage of antibiotics as a factor for growing resistance and explained the close links between humans and animals with respect to transmission of zoonotic diseases as well as antibiotic resistance. This article was posted on the LSHTM website and was extensively tweeted. |
| Year(s) Of Engagement Activity | 2017 |
| URL | https://www.lshtm.ac.uk/research/research-action/features/where-humans-and-animals-collide-emerging-... |
| Description | Invited presentation at a workshop on 'Accountability for Health Equity' |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | In July 2017 I was an invited speaker at a workshop titled 'Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity', organised by the Institute of Development Studies at Brighton, Sussex.This workshop was 'conceived as an opportunity to convene key thinkers, activists and health practitioners in the emerging field of "accountability for health equity," to push the boundaries of our collective knowledge and to strengthen our ability to mobilize for positive change. The workshop brought together 80-plus activists, researchers, public health practitioners and policy makers to examine critically the forces that shape accountability in health systems, from local to global levels.' I drew upon my study of the drivers of antibiotic use by informal providers in a talk titled: 'Misuse of Antibiotics by Informal Providers: Who is Accountable?The purpose of my talk was to show that the entire system and the actors within that system are responsible for what is seen as the biggest problem related to a group of marginalized healthcare providers. The greatest impact was that this gave me the opportunity to discuss similar issues about pluralistic health systems with participants from other countries including Mangolia, China and Brazil, and also from other parts of India, with the resulting development of a strong coalition of researchers and practitioners working towards greater health equity and accountability. |
| Year(s) Of Engagement Activity | 2017 |
| URL | https://www.ids.ac.uk/publication/unpicking-power-and-politics-for-transformative-change-towards-acc... |
| Description | Invited talk on One Health and the Drivers of Antibiotic Use in India, Uganda and Colombia, for the Society for One Health, University of Cambridge |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Postgraduate students |
| Results and Impact | I delivered an invited one-hour lecture on One Health and the drivers of antibiotic use in India, Uganda and Colombia at the ANTIMICROBIAL RESISTANCE: ONE HEALTH CONFERENCE 2023. This was organised by the CAMBRIDGE UNIVERSITY ONE HEALTH SOCIETY AND ONE HEALTH BRISTOL, comprising mainly post graduate students of One Health. The lecture was very well received and I was asked several questions by the audience ranging from policy challenges to provider attitudinal barriers. I also received good feedback via linked in from one of the students who was pursuing a PhD at Cambridge. |
| Year(s) Of Engagement Activity | 2023 |
| Description | Presentation at the IInd International Caparica Conference on Antibiotic Resistance |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | This was a small multidisciplinary conference organised by the University NOVA of Lisbon, in Caparica, Portugal.The primary objective of this meeting was to 'bring together researchers involved in antibiotic resistance prevention and control. The meeting took an integrated approach to research by bringing together researchers specializing in different subjects related to antibiotic resistance to present a universal vision of the importance of antimicrobial resistance in different ecosystems and what can be done about it.' I presented a poster on the Drivers of Antibiotic Use by Informal Providers in West Bengal India and I was among the few participants providing a social and public health perspective on AMR. I discussed my study findings and implications with several researchers from the fields of microbiology, chemistry and genomics with a special focus on developing inter-disciplinary and 'One Health' approaches to AMR. |
| Year(s) Of Engagement Activity | 2017 |
| URL | http://www.ic2ar2017.com/index.php/scientific-program/poster-contributions-and-participants/ |
| Description | Presentation at the Prince Mahidol Award Conference 2018 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | The Prince Mahidol Award Foundation, together with the World Health Organization, the World Bank, the United Nations Development Programme, the U.S. Agency for International Development, and many other development partners co-hosted the Prince Mahidol Award Conference 2018 on "Making the World Safe from the Threats of Emerging Infectious Diseases". The conference took place 29 January - 3 February 2018 in Bangkok, Thailand. This is an annual Conference that is well know for influencing global health policy and it is highly prestigious to be invited for a presentation in this Conference. The PMAC 2018 theme focused on the importance of multi-sectoral alliance across the animal, human and environmental sectors to address the threats posed by infectious diseases and antimicrobial resistance (AMR). I was invited to present a poster with the title: 'Social, Economic and Behavioural Drivers of Antibiotic Use By Informal Providers in Rural West Bengal in India'. The Conference was attended by close to 1000 international delegates and I had the opportunity to discuss my research findings and implications with key stakeholders such as the Director of AMR at WHO and also the Director General of WHO Dr. Tedros. The poster number was E08 on the weblink given below. |
| Year(s) Of Engagement Activity | 2018 |
| URL | http://pmac2018.com/site/poster |
| Description | Presentation entitled 'Engaging with the Private Sector for Primary Healthcare' at the Global Health Conference on Primary Healthcare in Astana, Kazakhstan |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Policymakers/politicians |
| Results and Impact | The Astana Global Conference in October 2018, came 40 years after the Alma Ata declaration in which world leader committed themselves to primary healthcare. The Astana declaration endorsed a renewed commitment to primary healthcare efforts towards ensuring the highest possible attainable standards of health for everyone all over the world. I was invited by UNICEF New York to deliver a keynote talk on the role of the private health sector, especially focusing on the frontlines of healthcare. |
| Year(s) Of Engagement Activity | 2018 |
| URL | https://www.who.int/primary-health/conference-phc |
| Description | Setting up committees for development of standard antibiotic use guidelines for para health providers in the human and veterinary sectors |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | Since January 2021, our project team held extensive consultations with groups of medical, veterinary, pharmaceutical and high-level government stakeholders. All groups have strongly recommended four clear areas for interventions. These include tierwise guidelines for antibiotic use in human and livestock health starting with para-professionals, continuing training and orientation (ideally digital) about antibiotics for all supply chain actors and communities, prescription audits for professionals and a code of conduct for pharmaceutical industry stakeholders. Moving forward with these recommendations, we constituted Expert Committees to work with the project team on developing a set of guidelines focusing especially at the primary level of the health care system for human and livestock health. Guidelines do not exist for para workers and this is an essential first step for standardizing antibiotic practices. The two committees are focusing on a set of priority conditions that are most frequently seen and treated with antibiotics by para health providers. A significant impact has been that medical experts who were earlier opposed to para health providers using any medicines and antibiotics have gradually shifted their views and realised that a more practical and effective approach would be to allow some essential antibiotics to be widely available so that the rest can be more strictly monitored. |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://oasisamr.com/intervention-guidelines/# |
| Description | Stakeholder consultations with groups of medical, veterinary, pharmaceutical and policy/regulatory stakeholders. These were conducted as part of our intervention co-design process to develop antibiotic stewardship for community settings in India. |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | Aim of the workshops: To co-design, with diverse stakeholders, a One Health antibiotic stewardship intervention for community settings in India. Objectives of the workshops: Present evidence to stimulate reflection and dialogue amongst stakeholders regarding their roles within the healthcare system in the context of AMR. Enable a deeper understanding of the alignments and misalignments between antibiotic stewardship practices and the realities of the health and antibiotic systems (private and public), supply chain incentives and business models, and community needs. Engage stakeholders in the co-design of an intervention for antibiotic stewardship in primary care and community settings. Develop and evaluate a strategy for multi-stakeholder engagement to influence policy. We organised four workshops with groups of medical and veterinary practitioners, pharmaceutical industry leaders and senior managers, and policymakers. Workshop participants (approximately 50 in total) agreed with our study findings and participated in animated discussions. Several common recommendations that emerged across the four groups. These included: -Development of tier-wise guidelines for antibiotic use in human and livestock health, starting at the level of the para healthcare providers (as these do not exist at present). -Continuing training and orientation about antibiotics for all supply chain actors and communities -Antimicrobial resistance surveillance at different tiers of the health system to understand patterns of resistance -Prescription audits for health professionals - Development of an evidence based code of conduct/marketing for the pharmaceutical stakeholders to align the promotion and marketing of antibiotics with guidelines. - Strengthening mentorship and referral links between formal and informal providers in human and veterinary sectors, to create stepped care models for less accessible rural areas. As a next step, we have established two task groups to work on antibiotic use guidelines for para health providers for human and for animal health, and a third one will develop a pharmaceutical code of conduct with industry stakeholders. |
| Year(s) Of Engagement Activity | 2021,2022 |
| URL | https://oasisamr.com/key-stakeholder-consultations/ |
| Description | Talks on AMR in a multidisciplinary course in Kolkata, India |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | A small group of four staff members from LSHTM including myself, organised a one week multidisciplinary course in the essentials of Antimicrobial Resistance in Kolkata from Feb 19-24, 2018. The course was organised in collaboration with the Indian Institute of Public Health-Kalyani, and the Post Graduate Institute for Medical Education and Research, Kolkata. The course was attended by 25 multidisciplinary post graduate students and practitioners including medical doctors, microbiologists and veterinarians from Kolkata and New Delhi. I delivered three lectures that drew upon my work in the area of AMR through the MRC study that I have been engaged in. These included an 'Overview of One Health', the 'Social Science Aspects of AMR' and 'Interventions to Address AMR'. I also organised a field visit for the students to four different sites on the last day, to gain a practical engagement with AMR. The field visits were to an informal provider clinic, a government primary healthcare centre, a poultry farm and a large private in-patient care hospital. Information about this course will appear by March 31st on the LSHTM website and the Liver Foundation website. |
| Year(s) Of Engagement Activity | 2018 |