- Start date: 1 January 2017
- End date: 31 December 2018
- Primary investigator: Rebecca King
Antibiotic resistance is especially problematic in settings where antibiotics can be bought without a prescription and where they are over-prescribed by health workers and over-used by the public. WHO recommends that the general public can help combat antibiotic resistance by preventing infections, using antibiotics only when prescribed by a health professional, completing the full prescription, never using leftover antibiotics and never sharing antibiotics. We adapted and piloted the Community Dialogue Approach (CDA) for addressing antibiotic resistance in Bangladesh. The CDA assumes that a stimulus is required to trigger dialogue among community members about issues that are of concern for the community. In the CDA, the stimulus is both external (provision of training and tools) and internal (selection of volunteers, volunteers mobilise participants to attend community dialogue sessions) to the community.
While volunteers are given the flexibility to tailor each community dialogue session to the specific needs and requirements of the community, the sessions are designed to be highly participatory. Each Community Dialogue session concludes with participants committing to a course of action. Participants are also encouraged to spread information through word of mouth, set a positive example among family, friends and neighbours and to hold each other to account for applying decisions reached during Community Dialogue sessions. We set out to explore whether the CDA can be embedded into the existing health system and community infrastructure of Bangladesh. We did so by conducting a systematic review and an exploratory mixed methods study, and undertaking a rigorous process of intervention development in collaboration with policy and community stakeholders. We piloted the CDA in the catchment areas of five Community Clinics (which provide primary healthcare to around 30,000 people in total) and assessed its feasibility and acceptability to a range of stakeholders.
The emergence and spread of antibiotic resistance is especially problematic in settings where antibiotics can be bought without a prescription and where they are over-prescribed by health workers and over-used by the public. The World Health Organisation recommends that the general public can help combat antibiotic resistance by preventing infections, using antibiotics only when prescribed by a health professional, completing the full prescription, never using leftover antibiotics and never sharing antibiotics.
The project had five objectives: to conduct research to inform the content of and processes for delivering community dialogues; to adapt the Community Dialogue Approach to the setting; to pilot-test the approach in the catchment areas of five community clinics; to evaluate the feasibility of the pilot intervention in terms of the number of people it reaches, the extent to which it is delivered as intended, and whether or not is it acceptable to a range of stakeholders; and to engage with key stakeholders, such as policy makers, district health officials, community clinic staff and communities to ensure that the intervention is appropriate.
Our project had three stages.
1) The intervention was developed using a sequential mixed methods study design. This consisted of: exploring the evidence base through an umbrella review, and identifying key international standards on the appropriate use of antibiotics; undertaking detailed exploratory research through a) a qualitative study to explore the most appropriate mechanisms through which to embed the intervention within the existing health system and community infrastructure, and to understand patterns of knowledge, attitudes and practice regarding antibiotics and antibiotic resistance; and b) a household survey – which drew on the qualitative findings - to quantify knowledge, and reported attitudes and practice regarding antibiotics and antibiotic resistance within the target population; and c) drawing on appropriate theories regarding change mechanisms and experience of implementing community engagement interventions to co-produce the intervention processes and materials with key stakeholders at policy, health system and community level.
2) We piloted the CDA in the catchment areas of five Community Clinics (which provide primary healthcare to around 30,000 people in total).
3) We evaluated the feasibility and acceptability of the approach through a qualitative study.
We trained 55 volunteers from the catchment areas of five Community Clinics (which provide primary healthcare to around 30,000 people in total) on the appropriate use of antibiotics and on basic communication and facilitation skills. These volunteers then convened over 400 meetings, each of which was attended by 40 community members on average. The volunteers were supervised by members of the network of Support Groups that manage the Community Clinics. Decisions documented by communities included not buying antibiotics without a prescription, visiting the Community Clinic if unwell, and encouraging handwashing among community members. A major challenge observed was volunteers’ ability to facilitate rather than dominate the meetings and to encourage the active participation of attendees. This highlighted the need for the programme to reinforce key training messages via regular feedback meetings with volunteers. Observations also revealed a need to strengthen communities’ capacity to plan for putting decisions into action and to monitor progress.
We held a series of stakeholder engagement workshops throughout the duration of the project, which included a two day retreat with key policy, civil society and academic stakeholders to determine next steps for the study. Key decisions include expanding the content of the CDA to incorporate a One Health approach, with an initial focus on the use of antimicrobials in animals and on preventing infections in humans and animals. This requires further multisectoral collaboration. An application to fund the development of new content for the CDA, its expansion across a district, and its evaluation through a cRCT is under review.
A key achievement for the project was being one of the winners of a global competition to identify “pioneering” approaches to addressing AMR. We presented our work at the second Global Call to Action on AMR, held in Ghana in November 2018.
Partners and Team Members
Nuffield Centre for International Health and Development, University of Leeds, UK Dr Rebecca King (PI), Professor James Newell, Dr Joseph Hicks, Dr Mahua Das, Dr Helen Elsey, Dr Kate Questa
ARK Foundation, Bangladesh Professor Rumana Huque, Fariza Fieroze, Sameena Huque, Zunayad Al-Azdi
Malaria Consortium, UK Christian Rassi, Muhammad Shafique, Prudence Hamade
2) Policy brief
The study received funding from the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils (Grant Reference ES/P004075/1). It also receives support from the Global Challenges Research Fund.
We will ensure that the community dialogues are “embedded” within the infrastructure of the community support groups of the community clinics. This means that they will be delivered through existing mechanisms and will, therefore, be replicable across Bangladesh. This intervention has the potential to a. contribute to a body of urgent action recommended by WHO to prevent a post-antibiotic era, in which common infections and minor injuries will kill; b. build health system capacity in Bangladesh to deliver community-based interventions; and c. empower communities in Bangladesh to build cohesion and social capital, thus enabling them to contribute further to the economic and social welfare of the country. Furthermore, it has the potential to be adapted for implementation in other national health systems that support similar infrastructures, and to be adapted to address other areas of ARM, including behaviours that contribute to resistance to drugs to treat infections caused by parasites (e.g. malaria) and viruses (e.g. HIV).