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AMR communication activities in the Southeast Asia Region

Authors: Godinho, Natasha, Global Health Strategies; Bezbaruah, Supriya, Global Health Strategies; Nayyar,

Shikha, Global Health Strategies; Gautam, Juhi, Global Health Strategies; Sachdeva, Stuti, Global Health

Strategies; Behara, Indira, Global Health Strategies; Vong, Sirenda, World Health Organization Regional

Office for South-East Asia, Health Security and Emergency Response

There is an urgent need to ramp up communication activities with sound and comprehensive strategies in the

South-East Asian countries to effectively tackle AMR.

Public health communication is the scientific development, strategic dissemination, and critical evaluation of relevant, accurate, accessible, and understandable health information to inform, influence and motivate individual, institutional and public audiences.1 Substantial evidence from developed countries2,3 has shown that effective communication campaigns have contributed toward raising the discourse around antimicrobial resistance (AMR) and in promoting the rational use of antibiotics by prescribers, patients and the agriculture and food industry. However, our analysis shows that limited efforts have been undertaken on AMR related communication campaigns in the WHO South-East Asia Region (SEAR). All countries in the region need to adopt comprehensive and strategic communication campaigns to successfully transform behaviours that lead to antimicrobial resistance. This article highlights key features of government-led public awareness interventions on AMR in South East Asia, and suggests recommendations to aid national level authorities in the development of future campaigns.

Methodology

Our analysis was based on AMR communication activities reported in research papers, government reports, press releases, news articles and blogs across databases available online. We focused on recent periods i.e. in or after the year 2010, in order to align with the inception of the WHO-SEAR Regional Strategy on AMR 2010-2015; and on experiences of the eleven countries in SEAR: Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste. Since online searches might not indicate all communication efforts made by countries in addressing AMR, we attempted to validate our findings by interviewing some WHO focal points on AMR. In summary, our results were corroborated by the 4 interviewees who were willing to participate in and/or were available in their respective host countries. No major interventions were added to the list of interventions that we identified online. Also apart from few countries in our cohort, we reckon increasingly most have started uploading documents on government programs on their websites, especially with regard to communication campaigns, therefore in a sense this is representative of the country’s efforts.

Overview of AMR communications efforts in SEAR countries

As early as 1998, WHO urged member countries to recognise AMR as a priority and to initiate concrete measures; however the desired goal was not achieved. In 2015, WHO adopted a Global Action Plan on Antimicrobial Resistance with a focus on effective communication, education and training.4 Specifically, one of the strategic objectives of the Global Action Plan is to increase awareness and encourage behaviour change through public communication programs targeted at stakeholders in the field of human health, veterinary health, and agricultural health. It proposes inclusion of AMR as a component of medical training, professional certification and continued medical education.5 There is good evidence that public campaigns promoting responsible antibiotic use have contributed to a decrease in antibiotic consumption.6 For example, Belgium’s national awareness campaigns led to

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a decline in resistance of Streptococcus pneumoniae to penicillin from 18% in 2000 to 7% in 2009.7 Similarly, France’s national campaign led to a decrease in the total number of antibiotic prescriptions per 1000 inhabitants by 26.5% between 2002 and 2007.8 For SEAR our findings bring to light an unfortunate deficit of public health communication campaigns addressing AMR. Of the eleven countries studied, Thailand has shown greatest commitment towards addressing AMR by recognizing it as a national priority in 2010. It adopted a multi-sectoral approach that involved the convergence of departments to implement measures at the national and local level. Currently the National AMR Surveillance Center-Thailand, supported by WHO and approximately 60 hospitals, conducts AMR surveillance.9 The National Drug System Development Committee, chaired by the Deputy Prime Minister, is responsible for ensuring the rational use of medicines.10 Thailand has also reclassified several non-prescription drugs to prescription drugs to contain the usage of antimicrobials and has implemented a national level policy prohibiting the advertising of antimicrobials to consumer directly. 11,12

Additionally, Thailand implemented a long term sustained education and communication campaign called Antibiotics Smart Use (ASU) (2007-2011). The campaign encourages patients, doctors, chemists as well as the general public to use antimicrobials rationally. ASU runs at two levels: a network of multidisciplinary groups (i.e. local partners) at the health-care delivery level, and a network of policy-makers, academics and researchers from national agencies and universities (i.e. central partners). Spread over two phases, the ASU campaign was ultimately scaled up nationwide.13 Additionally, using a “One Health” approach, Thailand launched its AMR containment program in 2011 to encourage rational use of antibiotics for humans and animals. 14

Sri Lanka, considered as one of the progressive countries in the region, with significant achievements in the field of maternal and child health, is yet to undertake comprehensive communications efforts for AMR. In 2009, the Antimicrobial Resistance Surveillance Programme was launched, followed by the formulation of the National Alliance of Antimicrobial Resistance in 2010.15,16 However, sporadic communication efforts have been undertaken mainly by pharmaceutical associations and drug regulatory authorities. These efforts have been largely restricted to organizing events around the World Antibiotic Week and conducting sensitisation and consultation meetings to promote the rational use of medicines..

India, with a substantial burden of AMR has primarily focussed on fostering a favourable policy and regulatory environment around AMR.17 The Jaipur declaration of 2011 adopted at the 29th WHO-SEARO Health Ministers’ meet led to the formation of the National Policy for Containment of AMR. The National Policy briefly mentions the need of generating public awareness about the threat of AMR and suggests training all prescribers, developing AMR communications materials, and adopting a media-based approach to discourage self-medication.18 More recently, in 2016 an International Conference on Combating Antimicrobial Resistance was held in New Delhi to help further the development of a National Action Plan and Roadmap for India.19 Simultaneously, the ‘Red line’ campaign was launched by the Ministry of Health and Family Welfare to enable easy identification of prescription drugs, however, its effectiveness is yet to be evaluated. However, large scale communications campaigns for providers as well as consumers have not yet been undertaken.

Communications efforts in other countries have also been limited to stakeholder meetings in Bhutan and initiatives such as cycle rallies in Indonesia.20,21 In Myanmar, the high prevalence of Malaria and Tuberculosis has pushed the government to develop a comprehensive national plan on AMR and undertake few targeted initiatives.

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Bangladesh and Timor Leste do not have a final national strategy for AMR control or national surveillance systems to track the prevalence of AMR and therefore limited communication efforts have been initiated.23,24 For example, in Bangladesh workshops and meetings have served as platforms for communicating on AMR.

Similar is the case for the Democratic People’s Republic of Korea and Maldives - understandably without national surveillance data on AMR, limited efforts have been undertaken in these countries.

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Scope and characteristics of the AMR communication efforts in SEAR countries

Huttner B, et al. & CHAMP consortium described recurring themes integral to their public AMR awareness campaigns conducted in high-income countries - audience-centric messages; a diverse target audience; mix of communications channels; and sustained efforts to continuously reiterate the key messages.25 Our detailed analysis of 24 interventions identified in the region against these themes and two additional parameters (involvement of key opinion and presence of a monitoring and evaluation mechanism) indicate major gaps (Table 1).

Firstly, only 4 interventions aimed at behaviour change. Secondly, only Thailand, Indonesia, and

Bhutan used a One-Health approach.26

(Table 2).Thirdly, key opinion leaders unfortunately have not

been engaged in any countries and finally M&E systems assessing the impact of such interventions have been limited. On the other hand, the communication campaigns undertaken in Thailand have incorporated 5 of the 6 parameters mentioned above – they didn’t engage key opinion leaders as part of the campaign. Further details are provided in Tables 1 and 2.

Table 1: Characteristics of interventions by thematic areas, 2010 to present, South-East Asia region

Thematic areas Analysis

Objectives - 19 interventions had clearly documented campaign objectives - 4 interventions focussed on behaviour change

Communications channels

- 16 interventions were one-time consultation/training workshops

- 10 interventions used traditional media - 7 interventions utilised social media platforms - 5 interventions documented the use of IEC materials - 4 interventions involved other methods including cycle

rallies, walkathons, stage concerts, essay competitions, lecture programs and poster presentation

- 7 interventions adopted 3 or more of the above mentioned strategies

Implementing agencies

- 9 interventions were led by international agencies - 8 interventions involved the government - 6 interventions were organized by hospitals and medical

universities - 2 interventions were implemented with involvement of 4-5

agencies - NGOs, pharmaceutical bodies, animal husbandry and others

including professional bodies and associations, regulatory bodies and global network of organizations were less frequently involved

Target audiences

- 8 interventions targeted the general public - 11 interventions targeted policy makers - 10 interventions targeted doctors - 12 interventions targeted 3 or more groups of audience - Other audience groups were less frequently focussed upon

Audience-centric key messages - 12 interventions documented the utilization of key messages.

However, generic messages as opposed audience centric messages have been used in the region.

Timing of the campaign

- 3 interventions were in the form of campaigns with regular activities over a period ranging from 3-8 years

- 14 interventions documented were isolated events extending to 1-3 days

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Involvement of key opinion leaders

- None of the interventions leveraged popular personalities or key opinion leaders for disseminating messages or engaging with the audience

Phase-wise evaluation - 2 interventions incorporated a monitoring and evaluation

framework with 1 intervention having reported parameters for measuring programme success and challenges

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Table 2: Characteristics of interventions by country, 2010 to present, South-East Asia region

Type of intervention/ Country

Pre-defined campaign objective

Implementing Agency Intervention Design

Regular Frequency

NGOs27

Govt. Hospitals/ Medical Universities

Pharmacists

International agencies

Animal Husbandry

Others

Stakeholder meetings/ conferences

Training

IEC 28material

Trad.Media

Social media

Others

Communications Campaign

3 2 2 2 2 1 1 1 1 1 2 2 2 1 2

Indonesia29 1 1 0 0 0 0 0 1 1 0 0 1 1 1 0

Thailand30,31 2 1 2 2 2 1 1 0 0 1 2 1 1 0 2

Event/workshop/meeting

12 0 4 4 1 5 2 5 12 1 2 5 4 2 1

Bangladesh32,33,34 1 0 1 3 1 0 0 0 1 1 0 1 0 0 0

Bhutan35,36 2 0 1 0 0 1 1 0 1 0 0 0 0 0 0

Democratic Republic of Korea37

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

India38,39,40 3 0 1 0 0 0 0 1 3 0 1 2 2 0 1

Indonesia41 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0

6

Maldives42 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0

Myanmar43 0 0 0 0 0 1 0 0 1 0 0 1 1 1 0

Sri Lanka44,45 2 0 0 0 0 0 0 2 1 0 0 0 0 1 0

Timor Leste46,47,48 2 0 1 1 0 3 0 0 3 0 1 1 1 0 0

World Antibiotic Awareness Week

4 2 2 0 0 3 0 0 1 0 1 3 1 1 0

Bhutan49 1 0 1 0 0 1 0 0 0 0 1 1 0 0 0

India50 1 1 0 0 0 0 0 0 1 0 0 1 0 0 0

Indonesia51 1 1 0 0 0 1 0 0 0 0 0 0 1 0 0

Nepal52 1 0 1 0 0 1 0 0 0 0 0 1 0 1 0

Grand Total 19 4 8 6 3 9 3 6 14 2 5 10 7 4 3

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Table 2 (Contd.)

Type of intervention/ Country

Pre-defined campaign objective

Target Audience Key messages documented

Defined M&E

Success Factors defined

Gaps & Challenges documented

National level KOLs leveraged

Policy makers

Doctors

Healthcare workers

Pharmacists

Media CSOs53

Public

Animal Husbandry

Others

Communications Campaign

3 3 2 2 1 0 3 2 0 0 3 2 1 1 0

Indonesia 1 1 0 0 0 0 1 1 0 0 1 0 0 0 0

Thailand 2 2 2 2 1 0 2 1 0 0 2 2 1 1 0

Event/workshop/meeting

12 6 6 4 1 2 3 2 3 4 6 0 0 0 0

Bangladesh 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0

Bhutan 2 1 0 0 0 0 0 0 1 1 2 0 0 0 0

Democratic Republic of Korea

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

India 3 2 2 2 1 0 2 1 0 1 2 0 0 0 0

Indonesia 1 1 0 0 0 0 1 0 1 1 0 0 0 0 0

Maldives 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0

Myanmar 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0

8

Sri Lanka 2 0 1 1 0 0 0 1 0 0 1 0 0 0 0

Timor Leste 2 2 3 1 0 1 0 0 1 0 0 0 0 0 0

World Antibiotic Awareness Week

4 2 2 3 1 0 0 4 0 1 3 0 0 0 0

Bhutan 1 1 0 1 0 0 0 1 0 0 1 0 0 0 0

India 1 0 1 1 1 0 0 1 0 0 0 0 0 0 0

Indonesia 1 0 0 0 0 0 0 1 0 1 1 0 0 0 0

Nepal25 1 1 1 1 0 0 0 1 0 0 1 0 0 0 0

Grand Total 19 11 10 9 3 2 6 8 3 5 12 2 1 1 0

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AMR communication in SEAR: Moving from commitment to action

For communication initiatives to be effective, their objective should be centred on changing behaviour, rather than merely providing information and building awareness. 54 Based on the gaps identified earlier, below is a recommended framework for policy makers in the region to consider.

a. Defining the objectives, the desired outcomes and appropriate target audiences

National governments in SEAR should design communication campaigns within the ambit of a larger national action plan on AMR. As per country context, communication campaigns should be designed with well defined objectives, intended outcomes and a set target audience. Lastly, keeping in line with the ‘One Health’ approach, stakeholders ranging from government officials to scientists, from physicians to medical colleges, from NGOs to the media across human, agricultural and animal health should play a role in the conceptualisation and development of the campaign.

b. Developing key messages in line with the overall campaign goals

Key messages must be strong and be sufficiently tailored so that they resonate and compel the target audience to take action. The existing knowledge, attitudes and practices of the target audience should form the foundation for developing key messages. Additionally, key messages should be field tested with a sample population before being employed in a large scale communication campaign.

c. Employing a mix of communication channels

A mix of communication channels should be used based on the target groups to be addressed. These can vary from mass media campaigns leveraging traditional and social media to interpersonal communication. Further, the tonality of communication should resonate with each target group (e.g. factual information for providers vs. entertainment for consumers). For most of the country initiatives, such strategic communication plans seem to be absent. While developing communication campaigns it is important to understand which communication channels appeal to which stakeholder groups.

d. Deciding the correct frequency and placement of the communication campaigns

KEY MESSAGES USED IN THE REGION

Generic key messages with a focus on completion of dosage and rational use of antibiotics have been used for AMR in the Region. These include ‘Save the pill for the very ill’, ‘Where there is a will, there is a way’, ’Save Antibiotics, Save Lives’, and ‘Antibiotics should never be shared and the full course of treatment should be completed – not saved for the future’. These messages are not targeted towards addressing AMR behaviour but instead aim to encourage continuation of treatment beyond the resolution of symptoms to avoid a relapse. Therefore these messages do not inform the target audience on what they need to do to prevent AMR. Most successful AMR campaigns, on the other hand, have been based on simple messages which provide information on the problem and the actions the reader can undertake through easy to remember slogans. WHO during the World Antibiotics Awareness Week recommended the use of antibiotics when prescribed by a health professional; completion of dosage as prescribed; discouraged sharing or using left over antibiotics; encouraged hygiene and prevention through vaccination.

Table 3: Key Messages Used in the Region

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- While the Global Action Plan to combat AMR (2015) clearly put-forth public awareness as a

strategic priority, SEAR countries have undertaken limited awareness campaigns in this

regard

- Communication interventions have been restricted to stand alone, sporadic events restricted

in terms of their audience, messaging and intervention design.

- Strategic, comprehensive and well defined communication campaigns need to be designed

and implemented by country governments incorporating essential elements of effective

communication campaigns.

The frequency and placement of communication campaigns is a key factor when designing communication campaigns. Analysis suggests that increasing the frequency of communication campaigns during peak periods of antibiotic usage and increasing the exposure of the campaigns at waiting rooms in health facilities and schools,can be beneficial.

e. Utilising popular personalities as part of the communication campaigns

None of the interventions analysed, appear to have leveraged popular personalities or key opinion leaders for disseminating messages or engaging with the audience. In the past, using public personalities has been proven to be successful in creating awareness - as was the case of the Polio Eradication Campaign in India which had Amitabh Bachchan, a popular Bollywood actor as the face of the campaign. 55 To elicit support from the public and policymakers, it is critical to create public pressure and influence the overall environment for discussions to take place. This can be achieved by roping in leaders and celebrities who have the potential to generate public support and initiate movements that can impact policy decisions.

f. Monitoring and evaluation (M&E) of the communication campaigns

In order to understand the correlation between various communication initiatives and the resulting

effect on antibiotic usage, an M&E system is imperative. The main objectives of the M&E system should be to a) ascertain whether the design of the communication campaign resonates with the target audience and b) to recalibrate design to account for any unexpected factors. AMR communication efforts should be regularly monitored to gather information on the progress made against health outcomes and to tailor strategies accordingly.

How do we realise this?

Despite resolutions passed by the 69th World Health Assembly56 and the commitment of member-states to the Global Action Plan’s objectives57, the near absence of awareness and communication interventions in SEAR is a cause of concern. Reports reviewed recommend that public awareness and behaviour change campaigns are an intrinsic part of a larger AMR control strategy58 and a global awareness campaign is an urgent necessity.59 Experiences of some of the developed countries leading AMR control efforts around the world further indicate the need for designing and implementing effective AMR communications campaigns in SEAR.60

In order to be effective, communication efforts should be institutionalised within the larger AMR program with clearly defined strategies, locally relevant key messages and a mix of communication channels that effectively disseminate key messages to target audiences. Since WHO recommends improving awareness and understanding of AMR through effective communication, education and training in its Global Action Plan, WHO should continue supporting countries in their communication campaigns. Periodic WHO cross country meetings could help track progress and encourage the sharing of best practices in the field of AMR communications. Further standardised guidelines issued by WHO will provide the impetus to accelerate communication initiatives in the region.

Table 4: Key Takeaways

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Competing Interest Section

This work was commissioned by the WHO Regional Office of South-East Asia using the UK

Government’s Fleming Fund. The authors alone are responsible for the views expressed in this article,

which does not necessarily represent the views, decisions, or policies of the institutions with which

the authors are affiliated.

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27 Non-Governmental Organizations

28 Information, Education & Communication

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