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

1

ABSTRACT

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.

SPECIAL ISSUE:

• Antimicrobial Resistance

KEYWORDS:

• Public health
• antibiotic prescribing
• antibiotic dispensing
• antimicrobial resistance
• healthcare professionals

View publisher note:

Publisher’s Note

Responsible Editor Stig Wall, Umeå University, Sweden

Responsible Editor Stig Wall, Umeå University, Sweden

Acknowledgments

We are grateful to Anne Doble, Rachel Glogowski, Stella Ibezim, Tom Lazenby, Ayda Heilie-Redai, Nabila Shaikh, Ashley Treharne, Selin Yardakul and Rahel Yemanaberhan for carrying out data collection activities. We thank all respondents in the studies for their time and engagement and for permitting their insights to be shared. We acknowledge Lucy Reynold’s work in developing and supporting field activities. We thank our in-country partners Behzad Nadjm, Nasir Umar, Abhijit Chowdhury, Dipesh Das, Meenakshi Gautham, Sayak Manna, Partha Sarathi Mukherjee, Indranil Samanta, Nishi Ananth, Alakananda Bagchi, Ketevan Kandelaki, Subha Sundarmoorthy, Carmella Barcelona, Adamu Addissie, Tenaw Tadege, Gebremedhin Gebretekle, Michael Callaghan, Imogen Clarke, Danny McLeron-Billows, Raj Rajarman.

Author contributions

The first draft of this paper was written by Maddy Pearson. Later drafts were constructed by Maddy Pearson with significant input from Clare Chandler.

Disclosure statement

None of the authors have any competing interest.

Ethics and consent

Ethical approval was obtained from the London School of Hygiene and Tropical Medicine and the relevant in-country ethics board for each study site (see methods section for full details). Potential participants were given full information about the purpose of interviews and were required to provide written consent before being interviewed.

Paper context

Existing literature on AMR highlights irrational antimicrobial prescribing and dispensing and lack of awareness as crucial problems. There remains a dearth of research assessing awareness of AMR and contexts of antimicrobial usage. This paper shows high levels of awareness among healthcare professionals across LMIC settings which linked to the ready use of next-line antibiotics, and contextual factors that heavily influenced antimicrobial practice. Addressing contextual restraints will be as important as raising awareness in tackling AMR.

Additional information

Funding

Funding for this research was provided by the World Health Organization AMR Secretariat to the London School of Hygiene and Tropical Medicine (grant number PHGHZL40).