Community Dialogue to address antibiotic resistance in Bangladesh

The study aims to develop, adapt and pilot-test the Community Dialogue Approach for preventing and controlling antibiotic resistance in Bangladesh.

Country: Bangladesh

Donors: Economic and Social Research Council, Higher Education Funding Council for England

Length of project: January 2017 – December 2018

Partners: Nuffield Centre for International Health and Development, University of Leeds, ARK Foundation, Malaria Consortium

Background

The spread of antibiotic resistance is an issue of growing global concern. It is often cited as one of the most critical threats to global health, food security and development. The World Health Assembly’s global action plan to tackle antimicrobial resistance recognises the urgent need to improve understanding of antimicrobial resistance at community level. For example, the general public can help combat antibiotic resistance by preventing infections, using antibiotics only when prescribed by a health professional, completing the full prescription, never using leftover antibiotics and never sharing antibiotics.

This study builds on the assumption that successfully changing people’s behaviour requires innovative and participatory community engagement. However, a critique of community engagement is that achieving impact on health outcomes often requires high levels of financial and human resources, making them difficult to scale, sustain and replicate in low resource settings. It is therefore crucial to embed community engagement interventions within existing health system and community structures.

The Community Dialogue Approach

The Community Dialogue Approach is a community engagement approach that aims to trigger individual and social change in communities for improved health outcomes in low-resource settings. Community-based volunteers facilitate regular community meetings to explore how a health issue affects the community, identify solutions, and decide collectively how to address the issue. The approach is embedded within the health system to provide technical oversight and supportive supervision to the volunteers, as well as strengthen care seeking. It also seeks to link with community structures to increase acceptability and mobilisation of resources.

The study

This study explores the feasibility and acceptability of using a Community Dialogue Approach to improving appropriate use of antibiotics at community level. A mixed-methods design was used to develop the intervention:

1. Exploring the evidence base through an umbrella review of community engagement approaches in low and middle income settings;

2. Conducting exploratory research including a qualitative study of perceptions and misconceptions relating to antibiotics, as well as household survey to quantify knowledge, attitudes and practices;

3. Drawing on appropriate social and behaviour change theories;

4. Applying lessons learned from the research team’s experience training community healthcare providers on correct prescription of antibiotics and implementing Community Dialogue Approach interventions.

Key stakeholders at policy, health system and community level were engaged throughout the development process and played a critical role in shaping the intervention.

The intervention is implemented in the catchment area of five Community Clinics in Comilla district, Bangladesh between April and October 2018. Its feasibility and acceptability will be assessed with the help of routine monitoring and evaluation data, as well as qualitative research with community members, volunteers, supervisors, practitioners and policy makers.

The intervention

55 Community Dialogue volunteers were selected by the communities in the study area. They received a three-day training on the appropriate use of antibiotics, as well as basic communication and facilitation skills. The volunteers were equipped with a flipchart containing images illustrating key messages. The flipchart was designed to stimulate discussion among the community and encourage the sharing of stories and experiences. To embed the community dialogues within the health system, the volunteers are supervised by Community Support Groups linked to the network of Community Clinics.

With the help of community leaders, Community Dialogue volunteers are tasked with organising and hosting regular Community Dialogue meetings in their community. Each meeting is open to the entire community and includes a general overview of antibiotics and antibiotic resistance before focusing on a more specific topic, such as the difference between antibiotics and other medicines.

Preliminary lessons learned

As of July 2018, more than 200 Community Dialogue meetings had been conducted and almost all Community Dialogue volunteers and supervisors were active. Decisions documented by communities included not buying antibiotics without a prescription, visiting the Community Clinic if unwell and encouraging handwashing among community members. A major challenge observed was volunteers’ ability to facilitate rather than dominate Community Dialogue meetings and encourage active participation. Observations also highlighted the need to reinforce some of the key messages in regular feedback meetings with all volunteers to ensure they are communicated correctly.

This study is an essential step in a process of developing, implementing and evaluating a sustainable, scalable and replicable approach to participatory community engagement to prevent and control antibiotic resistance in Bangladesh.

Access the full document here.