Optimisation de l'Usage d'Antibiotiques et contrôle Des Infections au Niveau Communautaire Par un Paquet d'Interventions Ciblant le Comportement au Burkina Faso et en République Démocratique du Congo

Background A major driver of AMR emergence in LMICs is community- and individual-level antibiotic consumption, which have both been associated with an increased risk of acquisition of AMR bacteria for individuals in the general community. As a result of difficult or delayed access to hospitals and formal health centres, the principal sources of antibiotics in many LMIC communities are medicine stores, i.e. community pharmacies or informal medicine vendors. Staff at these outlets are frequently not medically qualified, and informal selling of medicines is common. Two recent systematic reviews estimated the pooled prevalence of reported self-medication with antibiotics in LMICs at 78%, in sSA at 56%, and in West-Africa at 70%. Furthermore, in sSA, over two thirds of visits to community medicine stores were found to result in dispensing prescription-free antibiotics. Appropriately trained and motivated pharmacy staff can be part of a successful AMR control programme, in particular through their role in educating patients, promoting appropriate usage of dispensed antibiotics, and providing guidance to healthcare colleagues on appropriate antibiotic prescribing. In the absence of a clinical or microbiological diagnosis, medicine stores often dispense antibiotics without a clear rationale. Importantly, these antibiotic courses frequently consist of Watch antibiotics. Among the different types of providers listed, and even among those with a good understanding of AMR, there is a need for supporting appropriate antibiotic prescription practices.

A recent study in 6 LMICs showed that context-specific tailored intervention packages are key to improve community antibiotic use. In any stewardship programme targeting unregulated community dispensing of antibiotics, it is therefore crucial to co-develop interventions with medicine stores, and to incorporate the identification of alternative (economic) incentives, as well as targeting communities, to enable sustainable take-up by both medicine stores and their communities. Existing behavioural change interventions have been categorised as persuasive (eg. peer-to-peer feedback on dispensing), enabling (eg. guidelines, training sessions), restrictive (eg. expert approval before dispensing some specific antibiotics) or structural (eg. introducing a clinical algorithm). The effect of individual interventions targeting outpatient dispensing of antibiotics in LMIC has been heterogeneous, with multi-faceted interventions combining educational material with audits and feedback or peer-to-peer comparisons more effective at reducing inappropriate antibiotic use than stand-alone interventions.This project proposes a robust participatory-driven behaviour change intervention to reduce the use of Watch antibiotics from medicine stores, targeting both the demand (community) and supply (medicine store) side, and to reduce emergence and transmission of AMR.

To develop locally acceptable, feasible and relevant interventions, the COM-B model for behaviour change has been found highly suitable. This model forms the centre of the well-known Behaviour Change Wheel which is widely used in designing interventions and has been used by NICE and the UK Department of Health. COM-B identifies three essential conditions for behaviour - capability, opportunity, motivation - which thereby provide intervention opportunities for behaviour change. Capabilities include psychological (e.g. knowledge) and physical (e.g. skills) capabilities. Opportunity includes social and physical opportunities (e.g. social influences and environmental context and resources). Motivation includes reflective and automatic motivation such as beliefs about capabilities and consequences, goals, and ideas about professional role and identity. The intervention bundle in this study therefore aims to address AMR using three intervention components which each address the three conditions of behaviour change of the COM-B model. Target behaviours for the intervention are based upon considerations around impact potential, likelihood for change, potential spill-over effects as well as ease of measurement. The COM-B model would thus be highly suitable to guide ABU interventions addressing highly complex behaviour, and will be used to design the intervention bundles to achieve a joint change in antibiotic demand and supply.

At the same time, ongoing transmission of newly emerging or existing (drug-resistant) bacteria and the exchange of AMR genes between bacteria harboured by human hosts, animals and their environment, is facilitated by substandard hygiene and sanitation practices. Household transmission was recently found to be a more important mode of bacterial strain sharing than transmission from livestock in urban Nairobi.

The widespread environmental rummaging behaviour of rodents implies that they can serve as a proxy for AMR prevalence in the natural environment . This is of major relevance in settings where sewage surveillance, an alternative measurement to estimate environmental prevalence, may not (yet) be feasible because of the absence of sufficient sewage systems.