Protocol: WASH and biosecurity interventions for reducing burdens of infection, antibiotic use and antimicrobial resistance: a One Health mixed methods systematic review

Antimicrobial resistance (AMR) is a growing global problem. Like many other public health issues, research points to the important role of structural factors in shaping the emergence, transmission and burden of AMR. However, mirroring other areas of public health, the evidence-base of interventions that address these structural issues is slim and infrequently synthesised. Structural interventions (SIs) seek to alter the context that produces or co-produces ill-health4. AMR has been configured as a One Health problem to be understood in terms of human-animal-environment interconnections. Infection control and prevention is recognised as essential to addressing AMR, but how best to achieve this through a One Health perspective remains a challenge. This review addresses this gap by identifying and synthesising evidence of interventions that operate on a structural level to Improve water, hygiene, sanitation and biosecurity in communities that live and/or work with animals In Low- and Middle-Income Countries (LMICs). The premise of this review is that interventions to improve water, sanitation, hygiene (WASH), and biosecurity intend to reduce burdens of infection and have the potential to reduce reliance on antibiotics for humans and animals. Therefore, such interventions have the ability to reduce both transmission and emergence of AMR. Two further observations inform the focus of this review: growing evidence of the insufficiency of purely technical or behavioural WASH/biosecurity Interventions to reduce disease burdens across LMICs, accompanied by calls for structural Interventions; and that most reviews retain classificatory silos of either human WASH or animal biosecurity which belies the realities of many rural and urban populations whose lives are interconnected with animals across LMIC settings. This review, therefore, addresses the potential for structural interventions on WASH/biosecurity to have an impact on Infections, antibiotic use and AMR in LMICs. Methodologically, this review is influenced by impact assessments in development studies, where interventions are often complex in design and implementation and their effects multifaceted. The kinds of intervention that operate at a structural level are similarly challenging to identify and to characterise neatly, and are unlikely to be restricted to a randomised controlled trial design. Therefore, our search criteria and strategy are wide and our methods mixed, in order to capture potential interventions that could have an impact on our set of outcomes. In addition, in this review we recognise that interventions have impacts beyond a particular pre-defined outcome, and to be able to recommend a particular intervention strategy requires consideration of not only what that intervention comprised and required, but also what unintended consequences or co-benefits the intervention may have produced. Finally, a key consideration for this review is that many studies undertaken in Spanish, Portuguese and French speaking countries, where different interventions may have been developed and piloted, can be excluded due to language criteria, and in this case, we deliberately include studies in these languages in addition to English in the search and review. This systematic review will summarise evidence on how WASH and biosecurity interventions could have the potential to reduce the burden of infections, antimicrobial use and/or AMR in animal agriculture and in people in contact with animals in different country settings, with a focus on LMICs. WASH and biosecurity interventions for reducing burdens of infection, antibiotic use and antimicrobial resistance: a One Health mixed methods systematic review Included studies have to examine the impact of WASH and biosecurity interventions on reducing burden of infections and therefore promote healthier production systems where the use of antibiotics is reduced or limited. Our review will categorise these interventions according to the context where they were performed (e.g., LMICs country, region, urban or rural, type of productions systems, livelihoods systems, agroecological situation, beneficiaries, climate conditions). The aim of this study is to identify points for WASH and biosecurity interventions at structural and system levels that will enable reduction in reliance on antibiotics in the everyday lives of people living with animals in urbanised and rural landscapes

Motivation, money and respect: a mixed-method study of Tanzanian non-physician clinicians.

Poor quality of care is a major concern in low-income countries, and is in part attributed to low motivation of healthcare workers. Non-physician clinicians (mid-level cadre healthworkers) are central to healthcare delivery in half of the countries in Africa, but while much is expected from these clinicians, little is known about their expectations and motivation to perform well. Understanding what motivates these healthworkers in their work is essential to provide an empirical base for policy decisions to improve quality of healthcare. In 2006-2007, we conducted a mixed-method study to evaluate factors affecting motivation, including reasons for varying levels of motivation, amongst these clinicians in Tanzania. Using a conceptual framework of 'internal' and 'environmental' domains known to influence healthworker motivation in low-income countries, developed from existing literature, we observed over 2000 hospital consultations, interviewed clinicians to evaluate job satisfaction and morale, then designed and implemented a survey instrument to measure work motivation in clinical settings. Thematic analysis (34 interviews, one focus group) identified social status expectations as fundamental to dissatisfaction with financial remuneration, working environments and relationships between different clinical cadres. The survey included all clinicians working in routine patient care at 13 hospitals in the area; 150 returned sufficiently complete data for psychometric analysis. In regression, higher salary was associated with 'internal' motivation; amongst higher earners, motivation was also associated with higher qualification and salary enhancements. Salary was thus a clear prerequisite for motivation. Our results are consistent with the hypothesis that non-salary motivators will only have an effect where salary requirements are satisfied. As well as improvements to organisational management, we put forward the case for the professionalization of non-physician clinicians

Histories of Antibiotics: A One Health account of the arrival of antimicrobial drugs to Zimbabwe, Malawi and Uganda. Report for the Improving Human Health Flagship Initiative, Agriculture for Nutrition and Health research programme, CGIAR

The overall aim of this short project is to uncover some of the socio-historical roots of antibiotic use in both humans and non-humans outside of the European and American histories that are now well understood. We provide an historical account of the arrival and generalisation of use of antibiotics in three Eastern African countries: Zimbabwe, Malawi and Uganda. Drawing upon historical and ethnographic data, we describe when, how and in what context antibiotics arrived in these countries, providing an account of their early uses – both human and non-human. This project follows antibiotics as commodities, investigating how they were inserted within broader markets and the channels through which they were introduced in the African continent. The project pursues four distinct but interrelated objectives. First, to establish when and which antibiotics were first introduced in each country of focus. We find that this was not so different from Europe: the earliest mentions of antibiotics in Africa date from the mid-1940s, and refer to the same antibiotics that were being discovered and used in the rest of the world. Second, to investigate the context in which antibiotics arrived. We describe this as a set of already-functioning healthcare and veterinary systems, which were established by the colonial governments and missionary organisations throughout the first decades of the twentieth century. Third, to gain insight into the supply chains through which antibiotics were procured and distributed in each country. This was primarily through pharmaceutical companies from the UK and the US, which saw the market opportunities that drugs (and particularly antibiotics) offered in the colonised African territories. Finally, our fourth objective is to explore the actors behind the introduction of antibiotics, and the interests motivating them. We identify these as colonial governments, medical practitioners (private, colonial officers and missionaries) and pharmaceutical companies, who variously worked to ease the healthcare burden, and improve productivity and profit. Understanding the arrival and further spread of antibiotics in the focus countries can provide important insights about their current use. These findings show how antibiotics and biomedicine came to be associated together. Considering the interests that brought and kept antibiotics in African settings reveals how antibiotics have come to exist in the intersection between health, political agendas, economic interests, cultural identities and international relations. We intend this report to contribute to the development of initiatives to tackle AMR under a One Health framework, expanding the scope to include a diachronic perspective on the health of humans, animals and the environment

Addressing antibiotic use: insights from social science around the world

Antimicrobial resistance (AMR) is a major threat to global health and economies, the harmful effects of which are disproportionately experienced by those living in Low- and Middle-Income Countries (LMICs). Tackling this complex problem requires multidisciplinary and multisectoral responses. In the last few years, there has been a growing acknowledgement of the vital role of social science in understanding and intervening on antibiotic use, a key driver of AMR. Existing reviews summarise evidence of specific aspects of antibiotic use and specific intervention types. The growing concern that our off-the-shelf toolkit for addressing antibiotic use is insufficient in the face of rising use across humans, animals and plants, requires that we take a fresh look at the ways we are understanding this problem and possibilities for solutions. The ambition of this report is to provide a timely intervention into this global debate, by formulating a conceptual map of the insights from the growing body of social science research on addressing antibiotic use conducted in a diverse range of economic, social, and health system settings around the world. A series of panel presentations and discussions was held in 2020 with leading social scientists working on antibiotic use in different settings. Analysis of the proceedings of these panels, together with a literature review which snowballed from the work of the 76 researchers profiled through the antimicrobialsinsociety.org community of practice, led to a grouping of the key points of entry for recommendations to act on antibiotic use. The report identifies three main areas of focus of social science recommendations to address antibiotic use: Practices, Structures and Networks. The Practices grouping, in which the majority of the social research on antibiotic use has been carried out over the years, focuses on addressing end user antibiotic use. It shows how scholarship has moved away from knowledge deficit models to embracing an ‘ecological’ approach and to considering practice as embedded in lives and livelihoods. This body of work emphasizes the centrality of the local context to identify possible targets for intervening to change practice. The Structures grouping assembles the growing body of work that understands antibiotic use as a product of economic and political conditions. This research draws from political economical perspectives to identify the ways antibiotics have taken on critical roles in modern societies. Based on research investigating water, hygiene, sanitation (WASH), health systems and the political economy, the report considers how interventions that target these societal structures might reduce recourse to antibiotics as a ‘quick fix’. The Networks grouping collates recent work that draws attention to the mundane networks of logics, classifications and flows within which antibiotics are entangled. Research exploring agricultural and development imperatives, global health architectures, and circulating discourses has revealed the material and meaningful connections between human and non-human actors – animals, medicines, microbes, technologies, for example – that extend through time and space far beyond the moment of antibiotic use. These studies help render visible for action the apparatus such as clinical guidelines, delivery chains and models of care that have previously been overlooked when studying and addressing antibiotic use. The domains for action on antibiotic use presented in this report raise important questions for the AMR community. First, how can we move from standardised approaches to developing, refining, and monitoring impacts of interventions locally? Second, what time horizons should we set for interventions that aim to address AMR, and what other impacts should we expect of efforts to optimise antibiotic use? Third, what forms of evidence are most relevant, and what professional and infrastructural investment is required for this to support meaningful and responsive evaluation? The analysis in this report suggests new forms of transnational and intranational engagements to address this pressing bio-social-political issue could provide a platform for widening the options for addressing antibiotic use and its associated challenges

Antimicrobial Use/Consumption Surveillance in Zimbabwe: Desk Review Report

Antimicrobial Resistance (AMR) now poses a significant global threat to animal and human health, and over the years, inappropriate antimicrobial use (AMU), both in animals and humans, has been identified as the most significant driver of AMR. Recognizing the urgent need to tackle AMR, in 2015, the WHO, WOAH and FAO endorsed a Global Action Plan (GAP) on AMR, which includes five strategic objectives targeted at curbing AMR development. Amongst these objectives is the need to “strengthen knowledge through surveillance and research”. Zimbabwe, one of many African countries experiencing challenges arising from AMR in both the animal and human health sectors, needs to map a way forward to address this critical challenge. The objectives of this report were firstly to determine the current status of antimicrobial use or consumption (AMU/C) surveillance in Zimbabwe in the animal sector and identify gaps in knowledge. Secondly, to explore AMU/C surveillance strategies in food-producing animals in other countries, including data collection methods, data entry platforms, data analysis and reporting. Finally, to provide a situational analysis of existing systems, plans, software platforms and human and physical resources in relevant institutions in Zimbabwe to identify potential strategies for implementing AMU/C surveillance in the country. Methods The objectives were addressed through various methods, including key informant interviews of personnel in key government institutions such as the Department of Veterinary Services (DVS) and the Medicines Control Authority of Zimbabwe (MCAZ), among others. Information was also derived from relevant publications searched from scientific databases, including PubMed and PLOS. Key findings The first part of the report describes the situation analysis of Zimbabwe, which details the country’s animal production sector and the Department of Veterinary Services (DVS), and AMR & AMU/C surveillance initiatives in the country, including the reporting of AMU/C data to the WOAH. The second part of the report reviews global standards and methods for AMU/C in animals, including the WOAH standards for AMC data collection. Also included in this section are the AMU/C surveillance strategies in food-producing animals in Low-and Middle-Income Countries (LMICs) and high-income countries (HICs). The report also includes a brief on the different types of antimicrobial use metrics and indicators used in AMU/C surveillance in food-producing animals, as well as their advantages and disadvantages. The last section of the report includes proposals for implementing AMU/C surveillance in Zimbabwe and a feasibility assessment for each proposal. Conclusion and recommendations Zimbabwe generally has adequate human resource capacity to implement AMU/C surveillance in food-producing animals. The key personnel to perform these activities will need to be identified and adequately capacitated through training and provision of other key resources. To coordinate the AMU/C surveillance activities, the relevant institutions, the DVS and MCAZ, will need to collaborate closely to conduct the process activities efficiently. Of paramount importance is that the two government institutions will also need to establish funding mechanisms for AMU/C surveillance in food-producing animals in order to make it sustainable

Antibiotic ‘entanglements’:Health, labour and everyday life in an urban informal settlement in Kampala, Uganda

Antibiotics are a routine part of everyday life in many contexts, contributing to the development of antimicrobial resistance (AMR). Our ethnographic research documents the ways that antibiotics have become a key part of everyday life for precariously employed urban day-wage workers living in a large informal settlement in Kampala, Uganda. We found that for many people, their daily work and ongoing health was entangled with antibiotic use; that is, people showed us how their antibiotic use cannot be separated from the realities of living in a politically, economically and environmentally degraded ‘informal’ landscape. Thinking through entanglement as itself a politics, we show how limited political power, inability to demand change, and inequitable access to good health care, are associated with high rates of infection and disease, precarious work, and polluted environments. Antibiotics, we argue, have become a way to negotiate the inequalities written into these informal urban landscapes; their use entangled with ongoing relations with labour, environment and bodily suffering. Through this approach, we show how antimicrobials are used in society, with an attention to how vulnerabilities, risks, and forms of abandonment and exclusion shape their everyday use. Antibiotic use is entangled with everyday life in informal settlements, and the politics that produce ‘informality’. In Kampala today, the entanglement of antibiotics with life in informal settlements reveals how forms of urban segregation, life in ‘slums’ and their everyday acceptance, shape the pathways and uses of antimicrobials

Use of antibiotics to treat humans and animals in Uganda: a cross-sectional survey of households and farmers in rural, urban and peri-urban settings.

BACKGROUND: Use of antibiotics to treat humans and animals is increasing worldwide, but evidence from low- and middle-income countries (LMICs) is limited. We conducted cross-sectional surveys in households and farms in Uganda to assess patterns of antibiotic use among humans and animals. METHODS: Between May and December 2018, a convenience sample of 100 households in Nagongera (rural), 174 households in Namuwongo (urban) and 115 poultry and piggery farms in Wakiso (peri-urban) were selected and enrolled. Using the 'drug bag' method, participants identified antibiotics they used frequently and the sources of these medicines. Prevalence outcomes were compared between different sites using prevalence ratios (PRs) and chi-squared tests. RESULTS: Nearly all respondents in Nagongera and Namuwongo reported using antibiotics to treat household members, most within the past month (74.7% Nagongera versus 68.8% Namuwongo, P = 0.33). Use of metronidazole was significantly more common in Namuwongo than in Nagongera (73.6% versus 40.0%, PR 0.54, 95% CI: 0.42-0.70, P < 0.001), while the opposite was true for amoxicillin (33.3% versus 58.0%, PR 1.74, 95% CI: 1.33-2.28, P < 0.001).Veterinary use of antibiotics within the past month was much higher in Wakiso than in Nagongera (71.3% versus 15.0%, P < 0.001). At both sites, oxytetracycline hydrochloride was the most frequently used veterinary antibiotic, but it was used more commonly in Wakiso than in Nagongera (76.5% versus 31.0%, PR 0.41, 95% CI: 0.30-0.55, P < 0.001). CONCLUSIONS: Antibiotics are used differently across Uganda. Further research is needed to understand why antibiotics are relied upon in different ways in different contexts. Efforts to optimize antibiotic use should be tailored to specific settings

Community case management of malaria: exploring support, capacity and motivation of community medicine distributors in Uganda.

BACKGROUND: In Uganda, community services for febrile children are expanding from presumptive treatment of fever with anti-malarials through the home-based management of fever (HBMF) programme, to include treatment for malaria, diarrhoea and pneumonia through Integrated Community Case Management (ICCM). To understand the level of support available, and the capacity and motivation of community health workers to deliver these expanded services, we interviewed community medicine distributors (CMDs), who had been involved in the HBMF programme in Tororo district, shortly before ICCM was adopted. METHODS: Between October 2009 and April 2010, 100 CMDs were recruited to participate by convenience sampling. The survey included questionnaires to gather information about the CMDs' work experience and to assess knowledge of fever case management, and in-depth interviews to discuss experiences as CMDs including motivation, supervision and relationships with the community. All questionnaires and knowledge assessments were analysed. Summary contact sheets were made for each of the 100 interviews and 35 were chosen for full transcription and analysis. RESULTS: CMDs faced multiple challenges including high patient load, limited knowledge and supervision, lack of compensation, limited drugs and supplies, and unrealistic expectations of community members. CMDs described being motivated to volunteer for altruistic reasons; however, the main benefits of their work appeared related to 'becoming someone important', with the potential for social mobility for self and family, including building relationships with health workers. At the time of the survey, over half of CMDs felt demotivated due to limited support from communities and the health system. CONCLUSIONS: Community health worker programmes rely on the support of communities and health systems to operate sustainably. When this support falls short, motivation of volunteers can wane. If community interventions, in increasingly complex forms, are to become the solution to improving access to primary health care, greater attention to what motivates individuals, and ways to strengthen health system support are required

The development of effective behaviour change interventions to support the use of malaria rapid diagnostic tests by Tanzanian clinicians.

BACKGROUND: Parasitological confirmation is now recommended for all cases of suspected malaria. The roll-out of rapid diagnostic tests (RDTs) is hoped to enable this goal in low resource settings through point of care testing. However, simply making RDTs available has not led to high uptake of the tests or adherence to results by clinicians, with malaria continuing to be overdiagnosed in many settings. We undertook to design an evidence-based intervention package that would be sufficient to support the introduction of RDTs at dispensaries in Tanzania, to be evaluated through the Targeting Artemisinin Combination Therapy (TACT) cluster randomised controlled trial. METHODS: We describe five steps in our intervention design: formative research, review of existing evidence and theory, a workshop to define the intervention approach and content and results of formative research, engagement with behaviour change theory and literature, detailed design of intervention materials and piloting and pretesting of intervention materials. This involved fieldwork with a total of 19 health workers and 212 community members in northeast Tanzania. RESULTS: The formative research suggested that RDTs were a potential source of conflict in the health worker-patient interaction, but that health workers used various techniques to resolve this, including provision of antimalarial drugs for RDT-negative patients. Our reviews showed that evidence was mixed regarding the effectiveness of different methods and theories to support change in prescribing practice. Our design process is presented, drawing from this collective evidence. We describe the final TACT intervention package (including interactive small group workshops, feedback text messages, motivational text messages and patient information leaflets and posters) in terms of its programme theory and implementation theory. CONCLUSIONS: Our study suggests that evidence-based design of complex interventions is possible. The use of formative research to understand malaria overdiagnosis in context was central to the design of the intervention as well as empirical research to test materials and methods prior to implementation. The TACT interventions may be appropriate for other settings where clinicians face similar challenges with malaria diagnostics. TRIAL REGISTRATION: NCT01292707

Measurement of antibiotic use on poultry farms in Zimbabwe: Evaluation of a tool and procedures

Introduction The emergence of antimicrobial resistance (AMR) as a major global threat to human and animal health and development cannot be overemphasised. Since the misuse and overuse of antimicrobials have been identified as the main drivers of AMR globally, Zimbabwe, through a collaboration between the Department of Veterinary Services (DVS) and the Food and Agriculture Organization (FAO), developed and piloted an antimicrobial use (AMU) tool in the poultry production sector, to quantify antimicrobial use. The purpose of this study was to evaluate the tool and procedures used in the pilot survey and its ability to collect quality AMU data. We identified areas of improvement and developed recommendations for implementation in future AMU surveys in the poultry sector in Zimbabwe. Methods This research used mixed methods, involving quantitative and qualitative approaches. This involved initially piloting a predesigned antibiotic use (ABU) data collection tool in practice, then assessing the tool's ability to collect quality data, and finally evaluating the procedures that enabled and limited the collection of ABU data. The tool was assessed by evaluating the completeness of data collected in the pilot survey and its consistency, appraising the items included in the tool, and determining the analysability of data collected. The procedures used were evaluated by observing the tool's administration in the field and through a focus group discussion involving all data collectors of the pilot survey. Findings AMU data was collected from 191 farms, about 50% of the initially targeted 384 broiler farms. There were missing data on various questions in the tool, including farm georeferences, bird populations, and information about the treatment, including the identification of the antibiotic active ingredient and their concentrations, routes of administration, treatment dosage and duration, as well as the age and weight of birds at the time of treatment. Inconsistencies were also noted in the data collected, particularly in the way antibiotics were recorded. The analysability of data collected was negatively affected by the missing data and question phrasing, in particular, those to do with the treatment of birds with antibiotics, which were found to have excluded the majority of survey respondents from further analyses. Broiler farms in communal areas were over-represented in the pilot survey due to most data collectors working in these areas. Various challenges were encountered during the recruitment of participants, including farmers not keeping birds at the time of the survey, farmers declining to participate in the study due to lack of incentives, some farms being in remote locations, and political interference. Most data collectors in the pilot survey, who were recruited from the Agricultural Extension Services (AGRITEX) department within the Ministry of Agriculture, indicated that the timing of the survey (January to May of the calendar year) was not conducive for them since it coincided with the cropping season in Zimbabwe, which induced high workloads, leaving less time to participate in data collection activities. Conclusions and recommendations The pilot AMU survey in broiler production serves as an important milestone in establishing a monitoring system for the use of antimicrobials in food producing animals in Zimbabwe. To a moderate extent, the pilot tool and procedures used in broilers enabled the collection of AMU data, but some key challenges also arose, mainly related to questionnaire design (i.e., question formulation), data collection procedures, participant recruitment, timing of the survey and inadequate training of data collectors, among other issues. Key recommendations made included using the ‘Drug Bag’ method in monitoring the use of antibiotics in poultry, carefully selecting enumerators to ensure representation of different farming scales, adequately training data collectors prior to surveys, and giving them standard operating procedures to use in data collection to ensure consistency. More research needs to be done in this area of monitoring the use of antimicrobials in food producing animals in Zimbabwe and beyond, to strengthen capacities to collect quality AMU data, thereby contributing to antimicrobial stewardship efforts, and in turn with the global fight against AMR