Supporting the National Action Plan on AMR in Tanzania (SNAP-AMR)

Antimicrobial resistance (AMR) is recognised as a global threat to human and animal health, productivity and prosperity. AMR is widespread in both resource-rich nations such as the UK and in low and middle income countries (LMICs). The United Republic of Tanzania is one such LMIC, and in response to a call to action from the World Health Organisation, it has created a National Action Plan (NAP) to combat AMR.

The NAP is an ambitious plan outlining five strategic routes for tackling AMR: i) improved awareness and understanding; ii) enhanced surveillance and research; iii) better sanitation, hygiene and infection prevention; iv) optimized use of antibiotics; and v) sustainable investment in alternatives. In common with many LMICs, the challenge posed by AMR is exacerbated by widespread or unregulated use in both humans and livestock, whilst successful implementation of the NAP is threatened by lack of human and financial resources. Prioritisation of activities and targeting of interventions is therefore an essential component of an effective and efficient campaign to control AMR.

Our research will provide new evidence to support this prioritisation and targeting, taking an approach that recognises that behavioural change is a complex phenomenon depending not just on policy, regulation or knowledge provision but also on cultural background and social norms. Our team of UK and Tanzania-based researchers and policy experts will take an interdisciplinary approach to provide novel insights into the biological, social and cultural drivers influencing antibiotic use in the community and health care system; the spread of AMR between the humans and animals in the community and health care settings; knowledge about AMR; and how to change behaviours to reduce antibiotic use and the spread AMR.

We will contrast doctor prescribing practices in different health care settings (referral hospitals, district hospitals, health centres, dispensaries), as well as investigating community access and attitudes to antibiotics among householders, community 'drug' shops and unregulated sources such as roadside traders. We will use focus groups to examine factors that influence prescribing and usage, e.g. availability of antibiotic drugs, diagnostic facilities, patient demands, medical training and knowledge, coupled with choice-based experiments to establish how best to create change in prescribing behaviour or use. We will also use choice-based experiments to examine use in livestock by individuals with different levels of knowledge about AMR, e.g. district vets, community livestock officers and livestock holders. In parallel, bacterial isolates from people or livestock in hospital and community settings will be DNA-sequenced and examined used genomic tools to establish whether resistant commensal bacteria found in faecal samples in the community are those responsible for illness (respiratory infections, diarrhoea, sepsis and urinary tract infections) in hospitalised children.

The final component will be to assess the knowledge and sources of knowledge held by the public, health care and veterinary workers, policy makers and educators; to design interlinked targeted media campaigns that reflect educational, professional and cultural differences; and to assess the uptake of these materials and their impact on attitudes and approaches to antibiotic drugs and resistance.

The outcomes of our research will help priority setting and targeting in the NAP by identifying the settings (health care system or community) where most effective change can be achieved; showing how to create change in antibiotic usage (e.g. via improved training or education, diagnostic facilities or a social-norm based 'nudge') and identifying the individuals to target to create the most effective change; and by designing and delivering a mass media campaign to create awareness and behavioural change that will help Tanzania to combat the threat posed to its future by AMR.

We aim to provide novel insights into the biological, social and cultural drivers of antimicrobial resistance (AMR) that will help policy makers tasked with implementation of the Tanzanian National Action Plan against AMR to prioritise the use of limited human and financial resources via targeted, evidence-based interventions.

We will use qualitative and economic methods to examine antibiotic prescribing and usage in the community and health system, examining practices and attitudes among hospital doctors, community pharmacists, drug shop workers, district veterinary officers, livestock officers and farmers. Key-informant interviews, surveys and focus-group discussions will provide a rich baseline understanding that will inform the design of stated preference choice experiments to identify trade-offs when making choices about antibiotic use and allow prediction of behavioural change given interventions such as a social norm 'nudge' or improved knowledge.

We will examine genomic data from hospital and community-isolated Escherichia coli using phylogenetic analysis, plasmid reconstruction and identification of niche-indicators, to explore the link between hospital and community resistance (especially ESBL), and the link between AMR in human and livestock E. coli. Our findings will provide evidence to prioritise change in antibiotic usage in the community or health care settings, or in the human or livestock context.

We will use social-science and design based approaches to visualise the pathways taken by antibiotic drugs; to capture the exchange of information between stakeholders at different organisational levels in the delivery of government policy; to design, deliver and evaluate a mass media campaign on AMR that recognises the need for change at the individual, community, cultural and societal levels; and provide social-science based media and communications training to build capacity in Tanzania amongst those in public health policy and communication.

Context: Antimicrobial resistance (AMR) is a major threat to humanity. Most of the direct and indirect impacts of AMR are felt in low- and middle-income countries (LMIC), where basic sanitation and medical provisions are often limited, and treatment of common conditions such as diarrhoea, respiratory disease or urinary tract infection relies on antimicrobials. On the DAC list of ODA recipients, the United Republic of Tanzania (TZ) is classed among the least developed LMIC, and over 30% of its population lives under the national poverty line. To combat AMR and its impacts on people's lives, livelihoods and food security, the World Health Organization adopted a Global Action Plan for AMR, urging all member countries to develop National Action Plans (NAPs). The government of TZ heeded this call and presented its NAP in early 2017. Its 1st objective is to improve awareness and understanding of AMR through effective communication, and the 2nd objective is to strengthen the knowledge and evidence base on AMR through research. Our work aims to support those objectives and, by addressing needs identified by the TZ government, will directly benefit policy makers, professionals and the public.

Policy makers: The NAP includes an analysis of strengths, weaknesses, opportunities and threats. Lack of resources is cited as a major threat to successful implementation of the NAP, whilst inadequate public awareness and communication programmes are recognised as major weaknesses. Implementation of the NAP is coordinated by the AMR Focal point, a unit within the Ministry of Health, Community Development, Gender, Elderly and Children, in collaboration with the Ministry of Agriculture, Livestock and Fisheries and the One Health Coordination Unit under the Prime Minister's Office. Policy makers across those units and ministries are co-investigators and consortium members in our project. They will benefit from our support in development of communication and mass media campaigns on AMR, and from capacity strengthening in media campaign design and impact evaluation. In addition, our research will support prioritisation of audiences and messages to allow for optimal use of limited resources.

Professionals: As prescribers and sellers of antimicrobials for use by people and livestock, the medical, veterinary and pharmaceutical professions play a key role in responsible use of medicines and AMR control. We will work with members of those professions to understand their role in antimicrobial use and drivers of their prescribing behaviour. This provides them with a chance to discuss the pressures and constraints they face in their professional roles as well as their needs, e.g. in development of AMR policy and legislation, communication campaigns for prescribers and users of antimicrobials, or other types of research and capacity strengthening. Moreover, professionals will be benefit from the opportunity to help identify and prioritise the audiences and shape the messages for the media campaign.

Public: The health of all people and animals, in TZ and globally, would benefit from improved control of AMR. Our project, particularly the media campaigns, will help the public understand the threat that AMR poses to their lives, livestock and livelihoods as well as their contribution to the risk of AMR and, importantly, what they can do to reduce that risk. In the UK, in TZ and internationally, massive awareness campaigns are as an essential first step in reducing the demand for antimicrobials. If patients and farmers do not demand antimicrobials, then clinicians, pharmacists, veterinarians and feed mills do not need to feel pressured to prescribe them, dispense them or add them to animal feed unnecessarily. With no major new developments in drug discovery, reduced use and reduced production of antimicrobials are major tools in protecting the public from AMR and safeguarding the efficacy of our existing drugs for future generations.