Knowing antmicrobial resistance in practice: a multi-country qualitative study with human and animal healthcare professionals.

Background: Antimicrobial resistance (AMR) is a growing global problem. Raising awareness is central to global and national action plans to address AMR in human and livestock sectors. Evidence on the best ways to reduce antibiotic use, and the impact of awareness raising activities is mixed. This paucity of evidence is acute in Low-Middle-Income Country (LMIC) settings, where healthcare professionals who prescribe and dispense antimicrobial medicines are often assumed to have limited awareness of AMR and limited knowledge of the optimum use of antimicrobials. Objectives: This research aimed to explore AMR awareness among human and animal healthcare professionals and the contextual issues influencing the relationship between awareness and practices of antimicrobial prescribing and dispensing across different LMIC settings. Methods: Qualitative interviews and field observations were undertaken in seven study sites in Ethiopia, India, Nigeria, the Philippines, Sierra Leone and Vietnam. Data included transcripts from interviews with 244 purposively sampled healthcare professionals, analysed for cross-cutting themes. Results: AMR awareness was high among human and animal healthcare professionals. This awareness of AMR did not translate into reduced prescribing and dispensing; rather, it linked to the ready use of next-line antibiotics. Contextual factors that influenced prescribing and dispensing included antibiotic accessibility and affordability; lack of local antibiotic sensitivity information; concerns over hygiene and sanitation; and interaction with medical representatives. Conclusions: The high awareness of AMR in our study populations did not translate into reduced antibiotic prescribing. Contextual factors such as improved infrastructure, information and regulation seem essential for reducing reliance on antibiotics

The Health Care Professional Antibiotic Resistance Awareness Scale v1: report on development and testing

As the threat of antimicrobial resistance (AMR) grows, multilateral bodies are mobilising support for national and global action. A cornerstone of action plans is to increase awareness of resistance amongst different groups, including human and animal health care professionals. Understanding current levels of awareness is required for targeting interventions as well as for assessing change. This project designed a questionnaire tool to assess awareness of AMR amongst HCPs in different low- and middle-income countries. The content of the questionnaire was developed through qualitative research, review of literature and existing tools, and expert consultations in a range of settings. The resulting set of 88 questions – to assess awareness, practice and context – were then piloted from April to September 2018 with human and animal health care professionals in six countries. A total of 1091 participants completed the survey online or on paper – 43 in Peru (human HCPs, in Spanish), 122 in Peru (animal HCPs, in Spanish), 112 in Nigeria (human HCPs, in English), 106 in Ghana (human HCPs, in English), 124 in Tanzania (human HCPs, in English) 40 in Tanzania (human HCPs, in KiSwahili), 253 in Vietnam (human HCPs, in Vietnamese), 183 in Vietnam (animal HCPs, in Vietnamese), and 43 in Thailand (animal HCPs, in Thai). The 49 items in the questionnaire intended to capture awareness and awareness-in-practice were evaluated using the psychometric analytic approach of Rasch Measurement Theory. A total of 23 items were retained after less well-performing items were removed, and the Rasch analysis was then re-run. The 23 items constitute the Health Care Professional (HCP) Antibiotic Resistance (ABR) Awareness Scale v1, to include four domains: awareness of mechanisms of antibiotic resistance; the ways antibiotic use drives antibiotic resistance; the ways antibiotic resistant infections can be transmitted and controlled; and how antibiotic resistance can be recognised. Overall, the 23-item HCP ABR Awareness Scale v1 performed sufficiently well to be used within certain parameters – in the languages tested and to perform within-country rather than between-country comparisons. It is also recommended that awareness is measured alongside practice and context indicators to capture practice in relation to antibiotic use as well as contextual factors that may explain levels of awareness

Awareness of antibiotic resistance: a tool for measurement among human and animal health care professionals in LMICs and UMICs

BACKGROUND: Raising awareness of antimicrobial resistance is a cornerstone of action plans to tackle this global One Health challenge. Tools that can reliably assess levels of awareness of antibiotic resistance (ABR) among human or animal healthcare professionals (HCPs) are required to guide and evaluate interventions. METHODS: We designed and tested an ABR awareness scale, a self-administered questionnaire completed by human and animal HCPs trained to prescribe and dispense antibiotics in six countries-Ghana, Nigeria, Tanzania, Vietnam, Thailand and Peru. Questionnaires also elicited demographic, practice, and contextual information. Psychometric analysis for the scale followed Rasch Measurement Theory. Bivariate analysis was carried out to identify factors associated with awareness scores. RESULTS: Overall, 941 HCPs (625 human and 316 animal) from Ghana, Nigeria, Tanzania, Vietnam, Thailand and Peru were included in the study. The 23-item ABR awareness scale had high-reliability coefficients (0.88 for human and 0.90 for animal HCPs) but performed better within countries than across countries. Median ABR awareness scores were 54.6-63.5 for human HCPs and 55.2-63.8 for animal HCPs (scale of 0-100). Physicians and veterinarians scored higher than other HCPs in every country tested. HCPs in this study reported working in contexts with limited laboratory infrastructures. More than 95% of HCPs were interested in receiving information or training on ABR and antimicrobial stewardship. CONCLUSION: HCPs' awareness of ABR can be reliably assessed with this validated 23-item scale within the countries tested. Using the scale alongside context questions and objective measurement of practices is recommended to inform interventions to improve antibiotic use

​​River Swimming Through Uncertainty​: Pandemic Immersions in a Therapeutic Chalkscape

In this Field Note, I share my experiences of an immersive period of ethnography undertaken with river swimmers in and along the River Beane and River Lea in the county town of Hertford, South-East England, from July 2020 until January 2021. As well as my personal experiences of being a swimmer, I include insights and observations from those I swam alongside to reflect on the feeling of wellbeing that river swimming instills in those dipping, swimming, and ‘dwelling’ in their local rivers. I use these insights to expand the notion of therapeutic landscapes, noting not only their temporality during a pandemic period of uncertainty and disconnection but also their minerality. I explore how therapeutic connections and closer relations between humans, non-humans and rivers, all watered by the same chalk aquifer, might be framed through the connective substance of chalk. &nbsp

In Vitro and in Vivo Characterization of Molecular Interactions between Calmodulin, Ezrin/Radixin/Moesin, and L-selectin*S⃞

L-selectin is a cell adhesion molecule that tethers leukocytes to the luminal walls of venules during inflammation and enables them to roll under the force of blood flow. Clustering of L-selectin during rolling is thought to promote outside-in signals that lead to integrin activation and chemokine receptor expression, ultimately contributing to leukocyte arrest. Several studies have underscored the importance of the L-selectin cytoplasmic tail in functionally regulating adhesion and signaling. Interestingly, the L-selectin tail comprises only 17 amino acids, and yet it is thought to bind simultaneously to several proteins. For example, constitutive association of calmodulin (CaM) and ezrin/radixin/moesin (ERM) to L-selectin confers resistance to proteolysis and microvillar positioning, respectively. In this report we found that recombinant purified CaM and ERM bound non-competitively to the same tail of L-selectin. Furthermore, molecular modeling supported the possibility that CaM, L-selectin, and moesin could form a heterotrimeric complex. Finally, using fluorescence lifetime imaging microscopy to measure fluorescence resonance energy transfer, it was shown that CaM, L-selectin, and ERM could interact simultaneously in vivo. Moreover, L-selectin clustering promoted CaM/ERM interaction in cis (i.e. derived from neighboring L-selectin tails). These results highlight a novel intracellular event that occurs as a consequence of L-selectin clustering, which could participate in transducing signals that promote the transition from rolling to arrest