The rapid spread of antibiotic resistance around the world has evoked calls at the highest levels of the United Nations and its member governments to urgently adopt measures to tackle the growing problem. While these and other global and national policy initiatives are highly welcome and much needed, the world cannot afford to solely wait for them to be translated into action and change on the ground.
The top-down approach needs to be complemented with action and mobilization on grass-root level since the emergence and spread of antibiotic resistance is tightly linked to the practices and behaviors of individuals.
The World Health Organization released its Global Action Plan on Antimicrobial Resistance in 2015 and several important global policy initiatives have followed since. In 2016, there was a high-level meeting on antimicrobial resistance in the United Nations General Assembly, resulting in the heads of state signing a political declaration that promised multidisciplinary action on the issue.
Recommendations to the UN Secretary General
In the wake of the meeting, an interagency coordination group on antimicrobial resistance was formed, which in April 2019 submitted their recommendations on how to tackle antimicrobial resistance to the UN Secretary General. One of their recommendations was to establish a One Health Global Leaders Group on Antimicrobial Resistance which could serve as a global governance structure. The group was formed in 2020 and is constituted by members from the private sector, civil society and Member States.
National Action Plans on AMR
In many countries the response to the WHO and UN initiatives at the global-level has been to frame National Action Plans on Antimicrobial Resistance (AMR). These plans envisage introduction of new regulations, setting up antibiotic stewardship programs in hospitals and also carrying out public awareness campaigns.
Top-down approaches are not enough
Many of these interventions employ top-down approaches, typically initiated by Ministries of Health and affiliated agencies or hospital managements, using the expertise of infectious disease specialists. While these have the advantage of having the backing of those in authority and the ability to deploy considerable resources the drawback is they employ a uniform strategy, that does not reflect local social, cultural or political conditions.
Few interventions that involve citizens, local bodies and communities directly
There are few interventions currently anywhere also, that involve citizens, local bodies and communities directly in responding to antibiotic resistance. In other words, a very large section of the population is left out of contributing to the various actions and behavior change that are needed to tackle the complex set of factors that drive antibiotic resistance.
This is partly because of the way health systems have evolved over the last century into hierarchical, top-down structures with a very narrow focus on specialized, biomedical interventions. While the role of socio-economic determinants, public perceptions as well as participation has been recognized in principle for quite some time now, it is often not translated into practice.
Health related projects typically initiated by medical professionals
This in turn is because health related projects are typically initiated and managed by medical professionals not familiar with insights from the social sciences, while social scientists mostly remain unaware of the technical aspects of healthcare.
COVID-19 puts social actions in focus
As the experience of dealing with the ongoing COVID-19 pandemic is demonstrating, non-pharmaceutical interventions like social distancing, mask wearing and targeted lockdowns play a critical role in ensuring good health outcomes – and these are not possible to implement without a good understanding of public needs or behavior.
Why does community engagement matter?
The idea of engaging communities in health interventions is not new and based on a rich historical legacy of work of nineteenth century physician activists such as Rudolf Virchow, who promoted the idea of social medicine, that seeks to understand how health, disease and social conditions are interrelated. The concept got reinforced by mid-twentieth century experiments with “barefoot doctors” in China and the Latin American Social Medicine and Collective Health (LASM-CH) movements of the sixties and seventies that challenged technocratic and purely biomedical approaches in medicine.
Alma Ata Declaration – set up of primary health care networks
The key role of communities in health care got special attention in global health policy making following the World Health Organization’s Alma Ata Declaration of 1978, that promoted setting up of primary health care networks as a way forward to tackling major health challenges. The Declaration inspired many governments in low and middle income countries to set up functional universal health coverage (UHC) systems with the vision of providing “Health for All”.
Learn from the HIV pandemic and community actions done
Following, the HIV pandemic, that began in the mid-eighties, affected communities made stellar contributions to advocating patient rights, fighting stigma and discrimination and very importantly in lobbying to lower treatment costs drastically. They also play a key role in delivering services, particularly non facility-based health services, and other social services. In the context of marginalized groups – for example, undocumented migrants, sex workers, sexual minorities or people who use drugs – community action has been essential to ensuring that formal health systems are responsive to their needs(1,2).
In 2008 the Global Fund to Fight AIDS, TB and Malaria introduced the concept of Community Systems Strengthening (CSS), that identifies or develops structures and mechanisms through which community members, community-based organizations and other actors respond to the challenges and needs they face. The aim of CSS was to achieve improved health outcomes by developing the role of key affected populations and communities and of community-based organizations in the design, delivery, monitoring and evaluation of services and activities.
Community responses a critical enabler
The 2014 UNAIDS Strategic Investment Framework, identified community responses as a “critical enabler” of service delivery and identifies community mobilization as key to achieving ambitious global targets set for HIV treatment and prevention targets. More recently the relaunch of the primary health care concept in 2018 brought communities back into focus within global health policy making. While engaging communities in health interventions brings many benefits, there are many challenges involved too.
Project: Antibiotic Smart Communities in India
There is a broad consensus that community-based action on antimicrobial resistance is vital to supplement the top-down initiatives being implemented through the National Action Plans on AMR.
Global documents call for engaging local communities
All the global policy documents call for engaging local communities and groups in efforts to contain antimicrobial resistance. The WHO’s Global Action Plan on AMR, for example points out that the implementation process of National Action Plans should take into consideration the local governance arrangements, to maximize impact of the interventions. The final report of the Inter-Agency Coordination Group (IACG) on AMR, also recognizes the importance of engaging with communities.
Local initiatives critical for sustainability
Several drivers of antimicrobial resistance are directly linked to poorer hygiene practices, water scarcity and sanitation issues in households, farms and healthcare institutions of low- and middle-income countries. In the context of low-resource settings local initiatives are critical for ensuring sustainability of National Action Plans.
Antibiotic Smart Communities – a pilot in Kerala, India
However, there are currently few to no interventions, which involves local bodies and citizens directly in responding to antimicrobial resistance. The proposed “Antibiotic Smart Community” pilot project, being implemented by ReAct Asia Pacific since 2018 in Kerala, tries to fill this gap by tackling antimicrobial resistance at the level of individual communities.
The basic idea behind the “Antibiotic Smart Community” concept involves identifying communities and local institutions, that can promote safe use of antibiotics and reduce antimicrobial resistance in their areas. A community will be declared as “Antibiotic Smart”, depending on its performance as measured against a broad set of indicators related to antimicrobial resistance and factors that drive the phenomenion.
The project hopes to create a template for working with communities and local governance mechanisms on antimicrobial resistance in a way that helps implement National Action Plans and also provides crucial information to policy makers on the larger structural barriers to such implementation.
Challenges of the bottom-up approach
Designing and implementing interventions involving communities needs considerable background work to understand the context and also clearly define objectives, methods, rules of engagement, duration of involvement as well as both quantitative and qualitative measurements of success. Bottom-up strategies are also difficult to implement because very often members of the community must accept enhanced responsibilities in decision-making actions and need to be adequately motivated for this purpose.
Complexity of engagement with communities
To begin with, there is a need to acknowledge the considerable complexity involved in any kind of engagement with communities. This is evident from the fact that, while terms like community participation and development have been widely used by many different kinds of social intervention projects over the last several decades there is no common definition of what the term ‘community’ means.
Community – those who share characteristics or vulnerabilities
For example, according to a technical brief from the Global Fund for HIV, TB, Malaria, which promotes the concept of Community Systems Strengthening, broadly speaking, communities are formed by people who are connected to each other in distinct and varied ways. Examples include those who share particular characteristics or vulnerabilities due to: geography, living situations, health challenges, culture, gender, age, religion, identity and sexual orientation.
When setting up an awareness raising initiative it is important to identify and involve the relevant stakeholders. Here you find useful tools and strategies in the process.
In the era of many routine activities going online there are even virtual communities, where members’ main form of contact is through electronic media, as well as communities that come together temporarily due to circumstances, as during natural disasters, or to lobby with state authorities for specific changes to policy. In other words, communities are diverse and dynamic and a person may be part of more than one community.
Meaningful collective identity seems to be key for success
Which set of people are defined as the “community” one plans to engage with depends on the purpose and objectives of the intervention. A review of research on community mobilization interventions (CMI) for HIV prevention in low- and middle- income countries found that such interventions appear to be more successful with groups who have a meaningful collective identity rather than with more generalized populations. Similarly, the review found, that mobilizing a sub-set of a population, like youth, the elderly or children, is easier than mobilizing entire communities.
Seven categories of community participation
In recent decades researchers on community involvement in development projects have developed an operational typology of participation – useful in research and development activities – comprising seven categories:
1. Manipulative participation. Participation is simply a pretence, with unelected people’s representatives on official boards who have no power.
2. Passive participation. People participate by being told what has already been decided or has already happened. It involves unilateral announcements by project management who do not listen to people’s responses. The information being shared belongs only to external professionals.
3. Participation by consultation. People participate by being consulted or by answering questions. External agents define problems and information-gathering processes, and so control analysis. There is no sharing in decision-making and professionals are under no obligation to take account of people’s views.
4. Participation for material incentives. People participate by contributing resources, for example labour, in return for food, cash or other material incentives. Often they will have no stake in prolonging the technology or practice when the incentives end.
5. Functional participation. This is seen by external agencies as a means to achieve project goals, especially reduced costs. People may participate by forming groups to meet predetermined objectives; their involvement may be interactive but it tends to be after external agents have already made the major decisions.
6. Interactive participation. People participate in joint analysis, development of action plans and formation or strengthening of local institutions. The process involves interdisciplinary methodologies. As groups take control over local decisions and determine how the available resources are used, they have a stake in maintaining structures and practices.
7. Self-mobilization. People take initiatives independently of external institutions to change systems. They develop contacts with external agencies for resources and technical advice, but retain control over how the resources are used.
Community mobilization interventions also seems more likely to generate favorable outcomes if accompanied by efforts for change at the structural level. For example one study in Africa reviewed identified the low status of young people in the community as a barrier to attaining better results as well as females’ lower social status and financial reliance on males (3). Such socio-cultural factors, among other issues, point to the need to work not only with the ‘target group’ but also with other community groups, in order to tackle structural barriers to effectiveness of community mobilization interventions.
Community mobilization – and engage powerful stakeholders – for structural changes
Many of the interventions also fail to engage with the broader social and political context and power relations that structure health in very disadvantaged communities (4). Communities alone rarely have the power to make the social changes needed to sustain healthy behavior, and hence, alongside community mobilization, efforts to engage powerful stakeholders and to move towards structural changes are also required.
Bottom-up approach in Latin America
Governments are key actors in responding effectively to antibiotic resistance – but engaging them require different tactics in different regions. ReAct Latin America takes a bottom-up approach whereby social mobilization and community participation is at the center of their work, guided by the notion that the commitment of an engaged and empowered community is a prerequisite for implementation of both local and national action plans on antimicrobial resistance. Commitment grows when social movements and grass root organizations are allowed to participate and take ownership of the processes ensuring that on the ground realities are appropriately reflected.
Empowering society during COVID-19
The strength of this approach has been reflected during the COVID-19 where primary health care strategies in many countries have included empowering society, communities and individuals through education to increase their health literacy has been important.
Civil society in Latin America is generally very well organized and has great influence on health, agriculture, and environmental issues.
From COVID-19 to antibiotic resistance
The pandemic has aroused interest among various social and environmental movements, academic sectors, trade union organizations of health professionals and indigenous peoples, on the importance of the One Health approach. ReAct Latin America, together with its peers, has highlighted in different dialogues, seminars, and events, the importance of a comprehensive approach to the problem of antibiotic resistance. PAHO / WHO is presenting the One Health approach to the governments of the region.
Understanding of local culture key
Practitioners of community mobilization interventions also talk about how many such programs fail despite good intentions because of inappropriate processes, without comprehensive understanding of local culture, including political culture and decision-making. Short time horizons of intervention programs, within which goals cannot be reached, are also a reason for failure.
Another common problem is that while the merit of community mobilization interventions lies in building sustainable community strengths and agency at the community level(5) in practice, however, the concept is often used to refer to static and tokenistic activities in which researchers gather “the community” and establish contact with relevant stakeholders. Again, while an important premise of community mobilization interventions is that interventions must be appropriate, and thus adapted to specific local contexts based on community ownership and leadership(6), actual adaptations to the original intervention were made to fulfill research needs rather than on the basis of community demands.
A clear idea will help success
Among the important steps required for success of community mobilization interventions is have a clear idea of program objectives and benefits and collection of evidence to determine if intended beneficiaries are actually benefitting. Good quality facilitation, to ensure the community is well informed and motivated to participate in the intervention, is also critical to the program outcomes
Learning by doing and participatory methods
Some recommend using a ‘learning by doing’ approach and “participatory research” methods. Here, instead of a target-oriented, top-down approach to getting specific community members to engage as “beneficiaries of programs” community members are mobilized to participate in decision-making, planning, implementation, and evaluation of programs’. “Learning by doing” requires building in reflexivity and flexibility into the design of project activities, to step back and reflect together with community members about what is working, what isn’t, and how to address shared challenges.
Learning by doing: child-to-child methodology in Kenya
Such an example is an ongoing child-to-child methodology approach in Kisumu and Siaya counties of Kenya where elementary school-going children are agents of change in creating awareness and understanding of AMR. The project, dubbed “Alforja Kenya” and based in four schools, utilizes the Alforja Guide (originally developed by ReAct Latin America) to help children relate their environment and behavior to development of antimicrobial resistance.
School teachers develops work plan and interventions led by the children
The respective schools’ teachers, with the assistance from ReAct Africa and Ace Africa, developed the work plan and proposed interventions that are led by the children. The interventions were informed by the most common public health issues that are considered AMR-sensitive, e.g. WASH and food security among others, within the counties.
The children create awareness amongst their families and communities
The children in turn, create awareness amongst their families and communities at large, through art, skits, songs and skillful projects such as building Tippy Taps from locally available materials and establishing kitchen gardens.
An increase in hand washing practices amongst the children and related households has been reported as well as decreased diarrhoeal diseases. Furthermore, the children have been known to discourage their parents from buying antibiotics without a prescriber’s prescription.
Will you Go Blue for antimicrobial resistance? Learn more about the WHO global color campaign for World Antimicrobial Awareness Week!
1) WHO. Community involvement in tuberculosis care & prevention. Geneva: WHO; 2008. Accessed 4 November 2021.
2) Roll Back Malaria/WHO. Community involvement in rolling back malaria. Geneva: Roll Back Malaria/WHO; 2002. Accessed 2 November 2021.
3) Wight DE, Plummer ML, Ross DA. The need to promote behavior change at the cultural level: one factor explaining the limited impact of the MEMA kwa Vijana adolescent sexual health intervention in rural Tanzania. A process evaluation. BMC Public Health. 2012;12(1):788.
4) Campbell C. ‘Letting them die’ Why HIV/AIDS programmes fail. Oxford: James Currey; 2003.
5) Rosato M, Laverack G, Grabman LH, et al. Community participation: lessons from maternal, newborn and child health. Lancet. 2008;372:962–71.
6) Campbell C. ‘Letting them die’ Why HIV/AIDS programmes fail. Oxford: James Currey; 2003.
This year ReAct is celebrating 15 years of action on antibiotic resistance and this them article is part of the celebration!
The story of ReAct started 15 years ago with a small group of people, many who are still with the network today. They all shared a passion for global health, and felt the urgency to address the growing problem of antibiotic resistance. The network has since grown, with the presence of offices in 5 continents and many passionate members working together.
Read more about ReAct 15 years celebrations and learn more about the story of ReAct!
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