Challenges and Lessons Learned in the Development of a Participatory Learning and Action Intervention to Tackle Antibiotic Resistance: Experiences From Northern Vietnam

Antibiotic use in the community for humans and animals is high in Vietnam, driven by easy access to over-the counter medicines and poor understanding of the role of antibiotics. This has contributed to antibiotic resistance levels that are amongst the highest in the world. To address this problem, we developed a participatory learning and action (PLA) intervention. Here we describe challenges and lessons learned while developing and testing this intervention in preparation for a large-scale One Health trial in northern Vietnam. We tested the PLA approach using community-led photography, and then reflected on how this approach worked in practice. We reviewed and discussed implementation documentation and developed and refined themes. Five main themes were identified related to challenges and lessons learned: understanding the local context, stakeholder relationship development, participant recruitment, building trust and motivation, and engagement with the topic of antibiotics and antimicrobial resistance (AMR). Partnerships with national and local authorities provided an important foundation for building relationships with communities, and enhanced visibility and credibility of activities. Partnership development required managing relationships, clarifying roles, and accommodating different management styles. When recruiting participants, we had to balance preferences for top-down and bottom-up approaches. Building trust and motivation took time and was challenged by limited study team presence in the community. Open discussions around expectations and appropriate incentives were re-visited throughout the process. Financial incentives provided initial motivation to participate, while less tangible benefits like collective knowledge, social connections, desire to help the community, and new skills, sustained longer-term motivation. Lack of awareness and perceived importance of the problem of AMR, affected initial motivation. Developing mutual understanding through use of common and simplified language helped when discussing the complexities of this topic. A sense of ownership emerged as the study progressed and participants understood more about AMR, how it related to their own concerns, and incorporated their own ideas into activities. PLA can be a powerful way of stimulating community action and bringing people together to tackle a common problem. Understanding the nuances of local power structures, and allowing time for stakeholder relationship development and consensus-building are important considerations when designing engagement projects

Feasibility, acceptability, and bacterial recovery for community-based sample collection to estimate antibiotic resistance in commensal gut and upper respiratory tract bacteria

Abstract Vietnam has high rates of antibiotic use and resistance. Measuring resistance in commensal bacteria could provide an objective indicator for evaluating the impact of interventions to reduce antibiotic use and resistance. This study aimed to evaluate the feasibility, acceptability, and bacterial recovery for different sampling strategies. We conducted a cross-sectional mixed methods study in a rural community in Ha Nam Province, northern Vietnam, and collected structured interviews, samples, and in-depth interviews from households. Out of 389 households invited, 324 participated (83%), representing 1502 individuals. Samples were collected from these individuals (1498 stool, 1002 self-administered nasal swabs, and 496 HW-administered nasopharyngeal swabs). Pneumococci were recovered from 11.1% (128/1149) of the total population and 26.2% (48/183) of those under 5-years. Recovery was higher for health-worker (HW)-administered swabs (13.7%, 48/350) than self-administered swabs (10.0%, 80/799) (OR 2.06, 95% CI 1.07–3.96). Cost per swab was cheaper for self-administered ($7.26) than HW-administered ($8.63) swabs, but the overall cost for 100 positive samples was higher ($7260 and$6300 respectively). Qualitative interviews revealed that HW-administered nasopharyngeal swabs took longer to collect, caused more discomfort, and were more difficult to take from children. Factors affecting participation included sense of contribution, perceived trade-offs between benefits and effort, and peer influence. Reluctance was related to stool sampling and negative perceptions of research. This study provides important evidence for planning community-based carriage studies, including cost, logistics, and acceptability. Self-administered swabs had lower recovery, and though cheaper and quicker, this would translate to higher costs for large population-based studies. Recovery might be improved by swab-type, transport medium, and better cold-chain to lab