Supporting the National Action Plan for Antimicrobial Resistance (SNAP-AMR) in Tanzania

Antimicrobial resistance (AMR), the ability of bacteria to resist the effect of drugs, is a threat to human and animal health in resource rich nations like the UK and low and middle income countries like the United Republic of Tanzania. In Tanzania, as in many low and middle income countries, the AMR problem is compounded by the fact that people and livestock often live close together and widespread use of antimicrobials in both. In response to a global call to action from the World Health Organisation, Tanzania has created an ambitious National Action Plan to combat AMR, including improving awareness and understanding of the AMR problem among policy makers, professionals and the public and enhancing surveillance, research, infection prevention and antimicrobial stewardship in people and livestock. Successful implementation of the NAP is challenged by lack of human and financial resources, making prioritisation of activities and interventions 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 individuals are part of a larger system and that behaviour of professionals and the public may depend on policy, regulations or knowledge, but also on cultural background, social norms and access to medical, veterinary or diagnostic infrastructure and drugs. Our team of UK and Tanzania-based researchers and policy experts will take an interdisciplinary approach, working with a wide range of biological and social scientists as well as health professionals and community members, to provide novel insights into cultural, socio-economic and biological drivers of antimicrobial use (AMU) in hospitals and the community and in contextually appropriate methods of communication around those issues.

The origin of AMR problems can be described as hospital-, community- or livestock-associated so we will work with doctors and nurses, householders and patients, and veterinarians and livestock keepers as well as (in)formal drug providers and other stakeholders to investigate knowledges, beliefs, attitudes and practices around health and AMU/AMR. We will compare health care settings (health centres, district, regional and referral hospitals) and livestock keeping communities (Chagga, Masaai and Sukuma) to reflect a range of professional and cultural contexts. Using focus group discussions, questionnaires and interviews, we will examine factors that influence prescribing and use of antimicrobials and through choice experiments we will examine how changes in e.g. knowledges, social norms or access might change such behaviour. To complement the socio-economic investigations, we will use DNA-sequencing of hospital -, community - or livestock-associate bacteria in combination with mathematical modelling approaches to establish the relative contribution of different sources and transmission routes to the clinical and economic burden of AMR. The combination of insight into the drivers and relative importance of behaviours that may contribute to the AMR problem provides a unique opportunity to identify and prioritise levers of behavioural change to reduce AMU and limit the risk and impact of AMR.

Finally but importantly, we will work with policy makers, professionals and the public to design context-specific messages and methods to communicate AMR awareness and infection prevention and control messages in hospitals and community settings, and evaluate the impact of those communication campaigns using a combination of the social and biological sciences methods described above. The combined outcomes of our research will help priority setting in AMR control by identifying the settings where change is practicable and cost-effective. It will inform implementation of the National Action Plan in Tanzania and serve as a generalisable transdisciplinary model of AMR control in low and middle income country settings.

We aim to provide novel insights into biological, social and cultural drivers of AMR within and out with hospitals at individual (inherent), micro- (community), meso- (institutional) and macro- (policy) level to prioritise use of limited human and financial resources in targeting evidence-based levers of behavioural change that will reduce the risk and burden of AMR.

Socio-anthropological methods to elicit information on knowledge, attitudes, practices and access to antimicrobials across tiers of the hospital system and distinct livestock keeping communities include focus group discussions, surveys, questionnaires, in depth interviews and observations to foster stakeholder discussion, elicit community views, provide quantitative data, seek detailed information on key knowledges, and cross check responses. This will provide a rich baseline understanding to inform the design of stated choice experiments, which will complement a micro-costings approach to generate evidence on (non-)pecuniary incentives to motivate intentions for behaviour change in antimicrobial use.

We will examine genomic data from hospital, community and livestock associated Escherichia coli using phylogenetic and diversity analysis and source attribution methods to explore the contribution of within- and between hospital transmission and human or animal associated AMR in the community to clinical burden. This evidence will enable us to prioritise levers of change in hospitals and livestock-keeping communities based on predicted impact and cost-benefit.

Using a bespoke theoretically informed approach we will co-construct, design, deliver and evaluate an AMR awareness campaign at hospital and community level to learn how best to communicate in a culturally appropriate context and manner. By involving professionals, the public and policy makers these campaigns will also contribute to capacity strengthening across all layers of society in Tanzania.

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 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 Tanzania heeded this call and presented its NAP in early 2017. Our transdisciplinary research into the drivers and burden of AMR in Tanzania will support the NAP's objectives of strengthening the knowledge and evidence base on AMR and improving awareness and understanding of AMR across policy, professional and public stakeholders.

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 Livestock and Fisheries and the One Health Coordination Unit under the Prime Minister's Office. Policy makers across those units will benefit from our research on culturally relevant communication methods and messages for professional and public audiences, 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 government resources for AMR control.

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. Although our focus is on health care professionals, we will also provide capacity building in other disciplines, e.g. health economics, to support development of a whole system thinking to AMR control.

Public: The health of all people and animals, in Tanzania and globally, would benefit from improved control of AMR. However, the need to limit AMR must not be misconstrued as an obstacle to access to antimicrobials as life-saving drugs. We will investigate how people understand and access health care for themselves and their animals, and how this access might be improved to obtain a better balance between underuse and overuse of antimicrobials. Our project, particularly the co-design and implementation of awareness campaigns, will help the public and us understand the threat that AMR poses to their lives, livestock and livelihoods as well as their contribution to the risk of AMR and what they can do to reduce that risk. 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.