Participants reflect on how their local challenges relate to the WHO Global Guidance on AMR (photo by CE4AMR and HERD International © 2019).
AMR in Nepal
The WHO Global Action Plan on AMR predicts that developing countries such as Nepal are set to bear the highest burden of drug resistant infections in the coming 30 years. This is due to a combination of factors including population growth, poor water, and sanitation services (WASH), and unequal access to healthcare. Nepal has seen huge population growth in the past 20 years putting pressure on healthcare, sewerage, and food production sectors. The infrastructure of the country lags behind its population boom with particular pressure on agricultural industries to provide for this growing number of people. Additionally, crowded settlements, a predominantly rural population, recent natural disasters, and poor sanitation mean Nepal has a higher prevalence of common diseases (gastrointestinal issues, intestinal parasites, leprosy, and TB) than other South-East Asian countries. Antimicrobial usage to treat these and other ailments is not always regulated by healthcare providers. In combination these issues mean antimicrobial usage is liberal, for example antibiotics may be used to treat simple respiratory symptoms in humans or used for growth promotion in livestock. Combined with improper storage and disposal of antimicrobials, these issues are fuelling AMR in both urban and rural regions of Nepal.
The Nepali National Action Plan on AMR identifies clear targets for 2020 and 2025 yet ownership of these remains unclear. The healthcare sector poses many challenges as antimicrobials are routinely available without prescription; courses of drugs may not be finished, and surplus drugs are often stored and used in later self-medication. Agricultural policy is changing with recommendations to avoid the use on non-therapeutic antimicrobials within the food chain yet estimates of compliance with these recommendations are currently unclear. Within the WASH sector, progress has been made to ensure running water is available nationally, but a large proportion of the population does not have access to proper sanitation. Finally, a growing bank of academic studies (Charoenboon et al., 2019; Haenssgen et al., 2018) are revealing that knowledge, attitudes, and practice (KAP) toward AMR are limited in both the general public and health care workers. Public engagement with AMR is considered important at policy-level yet there is a lack of strategic planning to push incentives into action.
Behavioural Change: A participatory video approach
In 2018-19 the University of Leeds and HERD International (a health research organisation in Nepal) were awarded funding to explore AMR from the UK Arts and Humanities and Medical Research Councils. The team used a Participatory Video (PV) approach to better understand the contextual challenges around AMR in the Kathmandu region of Nepal. Over the course of a week-long workshop, a small group of community participants were introduced to the key issues in AMR, as set out in the WHO guidelines, via a number of arts-based interactive exercises designed to allow them to reflect upon these issues from the perspective of their communities. Alongside this, the groups were also given training in film production.
The workshops subsequently led to the production of two cycles of three films focused on engaging with the issue of AMR from the perspective of their respective communities. Each film was conceptualized as a stand-alone piece. However, they were also put together into two anthology films in which each group also described the nature of the overall project, their approach to the production process and how they wished to curate the films both to their local community and to regional and national policy stakeholders. The overview of the project as well as the community produced films can be found via the following link: https://www.youtube.com/watch?v=GBZCunEPD3U. For this case study, please focus on the timeframe from 5:12 to 13:02 which shows the film ‘Behavioural Change’, which is about an urban smallholder. The end of the film contains reflections on the PV process to create societal change on antimicrobial misuse in Nepal.
Reflections upon community engagement endeavours and outcomes
Conflicting interests and behavioural change
In the film we learn of the competing pressures on a farmer (playing himself in the film) and the vet he visits when a cow becomes ill. The decisions made within the film lead to the misuse of antibiotics and are rooted in the fact that the people involved in decision-making do not have enough time to discuss the situation properly. The farmer wants a course of antibiotics to treat a sick cow. Without diagnosing the animal, the vet gives the farmer the drugs to administer himself. As a result, the cow does not recover, and the vet is eventually called out to the farm to confirm the diagnosis and re-administer the medication correctly. Ahead of this visit the farmer continues to drink and sell contaminated milk which the vet then questions him about. The vet advises him to discard milk until the cow is healthy again, and until the antibiotic withdrawal period is over.
Equitable approach to knowledge creation
The film ultimately gives the quite generic message about the correct use of antibiotics, ensuring medicine is properly prescribed and administered. However, despite his mistake, the farmer’s experience is presented as valid. The pressures he faces are very real and the way he negotiates them are very understandable. Moreover, the vet also must accept a level of culpability for the situation that emerges in the film. He should not have allowed the farmer to treat the cow without supervision. Here we see an example of why the larger project aims to develop an equitable approach to knowledge creation pointing at the need for effective two-way dialogue between all the stakeholders involved.
The equitable nature of the PV approach can be recognised in the overall construction of the anthology film which ends with a number of interviews with national and regional policy-makers. These interviews, conducted on behalf of their respective communities by members of the HERD international team, emphasize the need for good communication between policy-makers and communities if the Nepali national AMR plan is to be effectively implemented. While it is clear that a key emphasis in this ‘dialogue’, for policymakers, is for local communities to be better educated on the topic of AMR, it is also clear that public education can only be effective if those in positions of power are cognizant of the particular challenges faced by members of the community and that key messages are communicated and contextualized in a way that makes sense to, and values, the everyday experience of these communities.
Raising public awareness – clarifying context and local knowledges
When showcased at a local community event, this film (and the others included within the YouTube link) elicited a positive reaction from community and government stakeholders. The audience were impressed by the fact that people like them had made these films, that they had been able to step out from their everyday lives and reflect upon these kinds of bigger issues. This made the films more effective tools for communication. Or, as the Mayor of the region put it, the project was able to ‘mobilize the local people’ both as producers and consumers of the films, thereby helping local people to take ‘ownership’ of the issue. When reflecting on the project the participants who co-produced the films were particularly proud to have learnt about the WHO AMR guidance. However, the audience at the showcasing events was interested in discussing the specific contextual factors at work in the films and the need for these to be taken into account when people are looking to address AMR – be that members of the community or policy-makers. Thus, the audience at the showcasing events did not recognize the knowledge hierarchy we find at work in the feedback from participants or in many other public health-related PV projects. Both the ‘official’ knowledge of the health care experts and the local contextual knowledge presented by community participants were equally valued. Finally, audience members also appreciated the interconnected nature of animal and human health, such as expressed through the One Health approach
Points of discussion
What are the socioeconomic factors one may need to consider when watching this scenario?
– The vet is clearly in a rush when the farmer initially visits him, possibly trying to maximise his income through visiting more patients.
– The farmer continues to sell the milk whilst the cow is ill and on treatment because he is dependent on the income. What are the income implications of prudent antimicrobial use?
AMR is a long-term rather than immediate concern. How can this lead to disengagement with policy and prescribing practices?
– The farmer is clearly keen to find a quick and easy solution to the cow’s illness. Unfortunately, we see that this approach backfires as he then needs to call the vet out and purchase more medication. Following good antimicrobial practices in the first place could have prevented the second veterinary consultation.
Consideration of gender roles:
– The role of the only woman in this film (the farmer’s wife) is minimal and generally to be subservient to her husband. However, she is still involved in practices associated with AMR such as the sale and preparation of milk products. How do you think gender roles, and other intersectionality issues, impact upon the type of AMR engagement/training needed?
PV as a strategy to tackle AMR:
– The showcasing participants felt that hearing messages from within their community was meaningful and impactful. How could policy makers harness this impact to create meaningful change on AMR behaviours?
Professor Paul Cooke, Dr Rebecca King, Dr Catherine Tait, Ines Soria-Donlan, Dr Jessica Mitchell, Nichola Jones (University of Leeds, UK) and Dr Sushil Baral, Abriti Arjyal, Romi Giri, Ashim Shrestha (HERD International, Nepal).
Post-doctoral research fellow University of Leeds
Professor of World Cinema and Digital Cultures, University of Leeds
Associate Professor of Global Health, University of Leeds
Full details of this study: Cooke, P., Shrestha, A., Aryjal, A., Giri, R., Jones, N., King, R., Mitchell, J., Tait, C., Soria-Donlan, I., Baral, S. (2020). What is Antimicrobial Resistance’ and why should anyone make films about it? Using ‘Participatory Video’ to advocate for community-led change in public health. New Cinemas 17(1), pp. 85-107.
Training manual for PV: HERD International, University of Leeds – Nuffield Centre for International Health and Development and Centre for World Cinemas and Digital Cultures (2019). Community Arts Against Antibiotic Resistance in Nepal (CARAN) – Facilitators’ Manual.
Overview of the CE4AMR team’s approach to Community Engagement: Mitchell, J., Cooke, P., Baral, S., Bull, N., Stones, C., Tsekleves, E., Verdezoto, N., Arjyal, A., Giri, R., Shrestha, A. & King, R. (2020). The values and principles underpinning community engagement approaches to tackling antimicrobial resistance (AMR). Global Health Action 12(sup1), 1837484.