ReAct Asia Pacific: Antibiotic Smart Communities as a way forward

2022-11-14

Can there be such a thing as an antibiotic smart community? If so, how could processes towards this be initiated and systematically approached? These questions, and an urging feeling that to be able to implement the National Action Plans on Antimicrobial Resistance there is a need for a bottom-up engagement approach. Communities need to engage for action on the global health challenge we all are facing - drug-resistant bacteria. With this mindset, ReAct Asia Pacific initiated the project Antibiotic Smart Communities.

The need for a bottom-up engagement in NAP implementation

The Antibiotic Smart Communities project of ReAct Asia Pacific came out of a realisation that the implementation efforts around the Global Action Plan on Antimicrobial Resistance (AMR) and National Action Plans on AMR were mostly top-down in character.

Many policies and interventions were planned at high-level meetings – and very little involvement of the target stakeholder groups and communities in the design of the initiatives. Additionally, there was very little resource mobilization happening at the grassroots level and poor local ownership.

Robust community engagement as a way forward

Therefore, ReAct Asia Pacific hypothesized that implementation of National Action Plans on AMR will increase if there is robust community engagement at least during the operationalization phase. The need for engaging communities and stakeholder groups has also been mentioned in the report of the Interagency Coordination Group on AMR (IACG-AMR).

“ReAct Asia Pacific has been working with us for raising awareness and empowering community groups on antibiotic resistance in Mallappuzhasserry Panchayat, since 2018.

The work involved partnership with several others like the Panchayat (local self-government institution), women’s self-help groups, local non-governmental organizations and religious organizations.

ReAct’s work could generate a lot of community assets and resources, besides improving the community ownership of these activities.”

Dr Mathew Koshy Punnakkad, Director, CSI Community Health Project
(one of the major partners in implementing the project in a small community in the state of Kerala, India)

Few models at hand – need to explore best practices

However the challenge has been that there were very few models for engaging local communities on a seemingly distant and silent issue like antimicrobial resistance.

Local governance structures, especially in low- and middle-income country contexts, may not prioritize antimicrobial resistance due to competing and more visible priorities.

Therefore, the Antibiotic Smart Communities project was meant to create a template for community engagement on the issue and explore best practices so as to increase the local ownership of interventions on antimicrobial resistance. Additionally, there was a want to design a holistic indicator framework to measure the level of preparedness of local communities to address the global health issue of drug-resistant bacteria.

Engaging a rural community in India

ReAct Asia Pacific initiated the Antibiotic Smart Community Project for concrete action on drug-resistant bacteria. It was launched in 2018. Video: ReAct Asia Pacific. 

The Antibiotic Smart Community Project was launched in 2018 in a small rural community in the state of Kerala, India. The initial steps were:

1. A preliminary sensitization meetings with community leaders.
2. Subsequently, a Geographical Information System (GIS) mapping of non-domestic antibiotic use sites was done.
3. A community survey was undertaken using a local language translation of the Eurobarometer 445 tool, to assess the level of awareness in the community.
4. The following year the project had a round of focus group discussions to map the perceptions of various community stakeholder groups on health, disease, infections and antimicrobial resistance.
5. A comprehensive situational analysis was undertaken to anchor our work with the local community. To gain access and build confidence, we used a healthcare delivery project managed by a local medical school and a community organisation for piggybacking.

Besides the planned community engagement activities, ReAct Asia Pacific used other opportunities that came its way. For example, a local folk music troupe was used to perform songs on health & hygiene during community events.

During the early phase of COVID-19 when there was severe shortage of medical masks, ReAct Asia Pacific facilitated local stitching and distribution of double layer cloth masks. During the time of the prolonged lockdown, the node also distributed vegetable seeds to more than 500 households, to help them develop “kitchen gardens” and understand locally-produced food as an alternative to agricultural intensification.

Designing and piloting the indicator framework

In 2019, ReAct Asia Pacific started the work on designing an indicator framework for measuring “antibiotic smartness” of local communities in low-and middle-income country settings. Consultation meetings were held with:

• public health,
• animal health and
• environment/development experts

to identify the domains to be included in the indicator framework.

List of 34 indicators

Based on the insights gathered through the community engagement exercise and feedback from the experts, a draft list of 34 indicators (along with methodology to measure and categorize) was prepared.

20 experts reduced indicators to 15

This list was presented to 20 selected experts with global experience on designing AMR-specific interventions. The experts used a well-defined process to prioritize the indicators and the number of indicators was reduced to 15. The indicators covered:

• human health,
• animal health,
• environment,
• water, sanitation & hygiene (WASH) and
• background socio-economic development of the community.

“We could apply the indicator framework in our community, with very minimal training delivered online over a week.

Most of the indicators are easily observable and do not require an intensive data collection process.

This framework can also be used as a situational analysis tool for understanding the deficiencies of the community in implementing projects aimed at strengthening systemic capacities”

Mr Sumit Kalkho, Research Coordinator, Duncan Hospital, Raxaul, Bihar state of India
(one of the places where the indicator framework was applied)

Indicators piloted in 5 communities

The indicators was piloted in the community that the ReAct Asia Pacific node were working – to assess the ease of application and quality of data collected. It was also applied in four other communities in other states in India – to assess the validity in diverse socio-cultural contexts.

After this ReAct Asia Pacific framed an action agenda for the community that the project were engaging in the state of Kerala, this based on the scores obtained through the piloting process.

The action agenda consisted of 12 specific activities, delivered over a period of 6 months with full community ownership, to improve the scores.

Training in the community followed

The activities and programs included innovative ones such as training the local school children on soap-making, demonstrating compost/soakage pit construction, and sensitization of AMR-issues to retail pharmacies.

When the indicator framework was reapplied at the end of six months, we found a significant increase in scores showing that the framework is sensitive to changes.