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[Confidential - For internal use only] 1 Report of the workshop ABACUS Qualitative Paper writing workshop 27 th – 28 th November, 2017 Hotel Uman, Umea, Sweden
[Confidential-Forinternaluseonly] 1
Reportoftheworkshop
ABACUSQualitativePaperwritingworkshop
27th–28thNovember,2017
HotelUman,Umea,Sweden
[Confidential-Forinternaluseonly] 2
Listofparticipants
No. Name HDSS Email
1 SabinaAsiamah DodowaHDSS,Ghana [email protected]
2 SamuelAfari-Asiedu KintampoHDSS,Ghana [email protected];
3 NguyenHongHanh FilaBaviHDSS,Vietnam [email protected]
4 FezileMdluli AgincourtHDSS,SouthAfrica [email protected]
5 DrMaleeSunpuwan KanchanaburiHDSS,Thailand [email protected]
6 MdAbdulMatin MatlabHDSS,Bangladesh [email protected]
7 OlgaCambaco ManhicaHDSS,Mozambique [email protected]
8 PeterAsiedu INDEPTHNetworkResourceand
TrainingCentre,Ghana
Facilitators
1 HeimanWertheim NuffieldDept.ofClinical
Medicine,UniversityofOxford
2 JohnKinsman Dept.ofPublicHealth&Clinical
Medicine,Epi&GlobalHealth,
UmeaUniversity
3 JohannesJohn-
Langba
SocialWork
SchoolofAppliedHumanSciences
CollegeofHumanities
UniversityofKwazulu-Natal
Durban,SouthAfrica
4 MargaretGyapong UniversityofHealthandAllied
Sciences,Ho,Ghana
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Opening
ThemeetingstartedonMonday27thNovember,2017at8:30am.
JohnKinsman,thehostwelcomedtheteamtotheworkshopandstatedthemainobjectives
oftheworkshopwhichwere:
a. ToreviewprogressontheABACUSsingle-sitequalitativepapersandtodetermine
whatadditionalsupportmaybeneededtofinalisethepapersforsubmission;and
b. Todiscussanddevelopacross-sitequalitativepaper
c. Todiscussanyothermatters
Therewasageneralintroductionofallparticipantsandfacilitatorstocreatea
condusiveenvironmentforasuccessfulworkshop.
DAY1
Session1–Chair:Prof.JohnKinsman
Draftpapersfromallsitesweresharedamongthecentresforcrosssitepeer
reviews.Belowisthesequenceofthecrosssitepeerreviewsandsitepresentations;
1. ManhicaHDSS,Mozambiquepresentedtheirdraftpapertothegroup.
Title:Awarenessonappropriateantibioticuseinaruraldistrictinsub-saharan
Africa:whereisthestartingpointforpreventionofantibioticresistance?
Objective:Thisstudyaimedtodescribecommunityunderstandingandknowledgeof
antibioticsandantibioticresistance,asameansofprovidinganempiricalbasisfor
messagedevelopmentandpositioning.
AfterwhichtheysharedtheirreviewofthedraftpaperofMatlabHDSS,Bangladesh.
2. MatlabHDSS,Bangladeshpresentedtheirdraftpapertothegroup.
Title:WhatinfluencesonsellingantibioticsinruralBangladesh?Aqualitativestudy.
TheyreviewedthedraftpaperofManhicaHDSS,Mozambique
3. FilaBaviHDSS,Vietnampresentedtheirdraftpaper.
Title:Everybodycandobusinessinmedicineselling
Objective:DescribethedistributionofantibioticsuppliersinFilabavi,andexplorethe
reasonsofinappropriateantibioticuse.
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FilaBaviHDSSpresentedthecommentstheyhadfromthereviewofthedraftpaper
fromKintampoHSDD,Ghana
Session2–Chair:Prof.JohannesJohn-Langba
4. ManhicaHDSSMozambiquepresentedaleafletdevelopedinbothEnglishand
Portuguesetitled‘SafeUseofAntibiotics’/‘usosegurodeantibióticos’.Thisleaflet
hasbeendistributedintheMahicadistrictforeducationonantibioticsanditsuse.It
highlightsissuessuchas;
a. Howtotakeantibiotics
b. Whentotakeantibiotics
c. Wheretostoreantibiotics
d. Whataretherisksofinappropriateuseofantibiotics
e. Whyshouldwetakeantibioticsresponsible
f. Whatisantibioticresistance
g. Whatcausesantibioticresistance
h. Recommendationsonsafeuseofantibiotics
5. KintampoHDSS,Ghanapresentedtheirdraftpapertothegroup.
Title:Tosellornottosell;Regulatorydemandsversescommunitydemandsonthe
saleofantibioticsinruralGhana.
TheylaterpresentedthepeerreviewcommentsofthedraftpaperofDodowaHDSS,
Ghana
6. DodowaHDSS,Ghanapresentedtheirdraftpapertothegroup
Title:Communityexperienceintheacquisitionanduseofantibiotics:Aqualitative
assessmentintwodistrictsinSouthernGhana
Objective:Howcommunitymembersinstudyareaacquireanduseantibiotics.
DodowaHDSSpresentedthepeerreviewcommentsofthedraftpaperfromFilaBavi
HDSS,Vietnam.
Lunchwasfrom12:15–13:15
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Session3–Chair:Prof.MargaretGyapong
7. AgicourtHDSS,SouthAfricawasnexttopresenttheirdraftpaper.
Title:‘Antibioticswearetakingarenotworking’.Communitymembers’
understandinganduseofantibioticsandresistance:AqualitativestudyinruralSouth
Africa
Objectives:Investigatewherepeopleareaccessingandsourcinghealthcare
treatmentandantibioticsfromwithinthisruralcommunity;
Explorecommunitymembers’understandingsandexperiencesofantibioticsand
antimicrobialresistance;
Provideanempiricalbasisforinformingfuture,patient-levelsocialinterventionsfor
appropriateantibioticuse.
TheylaterpresentedthepeerreviewofthedraftpaperofKanchanaburiHDSS,
Thailand.
8. KanchanaburiHDSS,ThailandpresentedtheirdraftpaperandupdateoftheABACUS
workattheirHDSS.
Title:Unknownmedicine:Accessanduseofnon-prescribedpoly-pharmaceutical
packsinthecommunity
Objectives:Thus,thepresentstudydrewpartlyonthe4thphaseoftheBehavioural
ModelofHealthServicesUtilizationwhichcanhelptodiscernhowandwhypeople
stillneedYaChutandraiseawarenessofthedangerofYaChut.
Inaddition,thestudycallsforconverting‘dangerous’YaChutto‘safer’YaChutasan
interimapproachtocontroltheproductinThailand.
KanchanaburiHDSSpresentedthereviewofAgincourtHDSSdraftpaper.
Inadditiontothereviewsbysitemembers,facilitatorsalsoreviewedandgaveinputsinto
thepaperspresentedbyallthesites.
Prof.GyapongledadiscussiononUptakeofresearchresultsatcountrylevel.Sheexplained
howimportantitistoengagepolicymakersthroughouttheprocessofanyresearchproject
fromproposaldevelopmenttopublicationtoensurethattheyfeelpartoftheworkandwill
bewillingtotakeupanyfindingsorrecommendationfromthefromprojects.Itwasagreed
thatsitesshouldidentifyexistingmeetingsandchannelsofcommunicationandshare
progresswiththestudywidely.
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CentreswereaskediftheyhadanyengagementwiththeirrespectiveMinistriesandpolicy
makers’.DodowaHDSS,KintampoHDSS,ManhicaHDSS,MatlabHDSS,andFilaBaviHDSS
hadhadsomelevelofengagementwiththeappropriateMinistriesandpolicymakers’.
AgincourtHDSSandKanchanaburiHDSSareyetenterintosomelevelofengagements.
Theaimofthisexerciseistomakesurethatprogramimplementersandpolicywillbeable
tomakeinformeddecisionswithevidencefromresearch.
Session4–Chair–Prof.Wertheim
Participantswereputintotwogroups,AfricaandAsia;todiscusssimilaritiesanddifferences
betweenwhattheyhavereadandheardfromtheothersitesandwhattheyfoundintheir
ownsite.Theywerealsotaskedtoconsidertheimplicationsoftheinformationtobe
generatedfortheircross-sitepapers.
Thefacilitatorsrotatedamongthetwogroupstojoinintheirdiscussions.Thesummaryof
thediscussionsispresentedbelow.
Africa Asia
Similarities
a. Antibioticsareeasilyavailable
b. Antibioticisseenasapowerful/
strongmedicine
c. Theymostlydonotfinishthecourse
giventhemalthoughtheyareaware
oftheimportanceofcompletingthe
course.
d. Thereareregulationsgoverning
antibioticsanditsuse
e. Eachcountryhasitsuniquelocal
termandmedicaltermtodescribe
antibiotics
Difference
a. AccessibilityiseasyinGhanaand
MozambiquebutnotinSouthAfrica
Similarities
a. Lawenforcement,regulation:
! illegalsuppliersarestill
sellingantibiotics
! alotofnon-licenseproviders
! Moreconveniencetogoto
privatesectorsthan
governmentfacilities
b. Availabilityofantibioticsiscommon
ineverywhere&easytoaccess
c. Trustmechanism:Customers
believesomecertainproviders,
d. Sourceofknowledge:
! Differentgenerationget
differentsourcesof
informationofantibiotics
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b. Self-medicationiscommonin
GhanaandMozambiquebutnotin
SouthAfrica
c. Theregulationsarenotstrictly
adheredtoinGhanaand
Mozambiquebutthisisnotsoin
SouthAfrica
d. Thedescriptionofantibioticsby
colourandshapesarecommonin
GhanaandMozambiquebutnotso
inSouthAfrica.
e. Trustbetweennursesandthe
patientinGhanaandMozambique--
thepatientstrustthatthenurses
arequalifiedtogivethem
medicationbuttheydonotlikethe
waytheyrelatetothem
f. Healthcareprovidersinhealthcare
facilitiescanprovideprescription
butnotinthecaseofSouthAfrica.
! Knowledgeaboutantibiotics:
amedicinefortreatingsome
certaindiseasesuchassore
throat,wound,diarrhea.
Communitymemberdon’t
knowaboutthereal
meaningofantibiotics
! Definitionofantibiotic
resistance:peopledidn’t
understandmedicalterm.
Thestaffsneedtoexplainby
localterm.
Difference
a. Usinghealthinsuranceistime
consumingsopeopleprefertopay
outofpocketbutthereisnot
insurancetocoverformedicationin
Bangladesh
b. localtermandmedicaltermarethe
sameinVietnamanddifferentin
othercountries
c. Doctorsandpharmacists(in
Thailand)canprovideprescription
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Day2
Session5,6,7-Chair:Prof.MargaretGyapong,Prof.JohnKinsman,Prof.JohannesJohn-
Langba
Prof.Kinsmanmadea20minutespresentationonanarticleintheLancetGlobalHealthfor
thecross-sitepapers.Thisistoaidthediscussionandagreeonappropriatejournalsto
publishin,authorship,timelineandtasks.
Belowaretheagreedpapers,thepotentialjournalstopublishinandthefacilitatorsto
supportthevariousteams;
Site Journalsuggestion/s Mainsupportfromcore
abacusteam
MatlabHDSS,Bangladesh BMCPublicHealth;Journalof
PharmaceuticalPolicyandPractice
Johannes
AgincourtHDSS,SouthAfrica JournalofGlobalPublicHealth(Journalof
EquityinHealth)
John
KanchanuburiHDSS,Thailand PLOSOne(trytosuggestanEditorwho
willbesupportive…)
John
FilabaviHDSS,Vietnam BMCPublicHealth Heiman
DodowaHDSS,Ghana JournalofPharmacyPractice;Journalof
GlobalAntimicrobialResistance;BMC
PharmacologyandToxicology
Margaret
KintampoHDSS,Ghana JournalofPharmaceuticalPolicyand
Practice(50%waiverforLMIC)
Heiman
ManhicaHDSS,Mozambique JournalofPharmaceuticalPolicyand
Practice(50%waiverforLMIC)
Johannes,Margaret
Heiman,John,Osman:writetositePIs/leaderswithproposalforprinciplesofco-authorship
forthesitepapers.Deadline:December15
! Primarypointsofcontact(J,H,M,J)foreachpaper
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! Basisforlastauthor
! Co-authorshipofABACUSPIsandadvisors
Tobearinmindforfuturepapers:
! Cross-sitepaper2:InternationalJournalofAntimicrobialAgents?
! PossibilityforaSpecialIssueinJournalofGlobalAntimicrobialResistancefor
futuresite-specificABACUSpapers?
Tasks:
! DodowaandKintampoHDSS,Ghanawereencouragedtowriteacombinepaper
whichwillbeagreatwork.
! AllHDSSsitesweretaskedtoproduceapagesummaryofthepolicies/regulatory
frameworkinrelationtoantibioticsaccessanduse.
! Centresaretoconfirmyourjournalwithco-authors,andthenformatthe
manuscriptaccordingtotheirguidelines,alreadyforthenextdraft.
Lunchwasobservedfrom12:15-13:15
Seesion8–Chair:Prof.HeimanWertheim
HeimandemonstratedtheSiteProgressandPreliminarydataofHouseholdsurveyand
CustomerexitinterviewusingREDCap.
SiteProgress
Site Redcaptraining Householdsurvey Customerexitinterview
Agincourt Nov-Dec Startsoon Startsoon
Dodowa 28–30Aug 108HHs 318EIs
Filabavi 11-13Jul 67HHs 248EIs
Kintampo 20-22Nov Startsoon Startsoon
Kanchanaburi 05-07Sep 1000HHs 90EIs
Manhica 05–08Jun 460HHs 496EIs
Matlab 18-20Jul 1015HHs 928EIs
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Studydesignoverview
NextStepindatacollectionforsites
! Continuewithhouseholdsurveys(1st&2ndround;6monthsapart)andexit
interviews(2nd,3rd,and4thround;3monthsapart).Nofurtherchangestothe
questionsinRedcapdatabasetoproceedwithfinaldatacollectionfollowing
timeline.
! InterimanalysisforPhase3datacollectedtobetriangulatedwiththequalitative
datatodesignthe2ndroundofsite-specificin-depthinterviewsandFGDs
! Conductsecondroundofin-depthinterviewsandFGDstoexplainanypotential
discrepanciesbetweenhouseholdsurveyandcustomerexitsurvey
! SitestosharedatafromlongitudinalINDEPTHdatabaseonselectedindicators:
individualeducation/occupation,maritalstatus,healthstatus,vaccination
status,smoking,alcoholuse,non-communicablediseases,internetaccess,
socioeconomicstatus
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ABACUS2–SomeinitialideaspresentedduringtheUmeåmeeting,November2017
! Support to be obtained from Wellcome Trust?
! A focus on Social Interventions
! We will need to reflect on what additional expertise may be required, that we
don’t already have in the team: Advertising companies, mathematical
modellers…?
! We have identified serious stewardship problems with community and suppliers.
The community is not knowledgeable about ABs.
! We also need to improve knowledge and behaviour of suppliers, within the
context of them working as a BUSINESS – how to address this (conflict of
interest)?
! Education – building on the trust of the community in the people who will be
educating them, the suppliers (e.g. Thailand, take out the AB from the Ya Chut
and replace with something else).
! Develop Behaviour Change and Communication intervention – communications
materials/social marketing – to target both the health system (formal and informal
suppliers, who community also trust) and the community level. There is a thirst
for knowledge on both sides. We also need to inform the suppliers about issues
going on in the community (that they may not already know about).
! We need to develop a package of interventions, based on ABACUS 1 evidence
(which has identified, for example, the channels we should use to inform people;
also the fact that different messages should target different interest groups.
! Highlight the things that people DON’T need ABs for (pain, ‘bones’ etc) – and
make simple messages for this.
! Social mobilisation should be a part of this, related to AB and ABR. Micro and
macro targets to be identified and addressed: also need a policy intervention to
improve enforcement of the existing policies. Include a health systems-
strengthening component – stewardship role of HRH. Pharmaceutical boards
should also be involved. Evaluation of the interventions a part of this.
! Evaluate the impact of the Mozambique AB leaflet.
! South Africa: Explore more about trust in HCWs and how this can be used as an
opportunity for them to teach the community about appropriate AB use. Focus on
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public health care system (which caters for the majority), as it has no financial
incentive to prescribe/sell the wrong drugs.
! Relying on existing structures to make an impact with the messages. Licensed
Chemical Seller’s association in Ghana can be used, for example, for
disseminating messages and ideas. CHW education house-to-house – how can this
also be used as a channel for AB messages?
! How can we balance out adequate access and also appropriate use? Ensuring
access but also ensuring appropriate use once people access them…
! Knowledge and enforcement – but not restricting access, rather improving it.
Campaigns are often not good enough – how to produce accountability and
resilience that don’t need continuous fuelling to keep the ideas alive? Develop a
community-based antibiotic stewardship team – including not only health
workers, but also other community leaders and champions.
! Use alternative channels, multi-sectoral interventions, identify who are the
influencers and how can we engage them to disseminate the messages/create new
social norms concerning safe AB use? Include: schools (educating the next
generation), traditional healers, doctors.
! ABACUS should be based on a global concept for the AB intervention that can be
locally adapted and applied. Needs to fit into the WHO Global Action Plan.
ABACUSTimelinesfor2018
ABACUSTimeline-2018 Jan Feb March April May June July Augt. Sept. Oct. Nov. Dec.
Site-specificqualitative
paperssubmitted
**
REDCAPDatasummaries
tobesentouttosites
**
Cross-sitepaper
submitted
**
ExitinterviewsandHH
surveycompleted
** **
Developphase4methods
+questions
** ** ** **
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Phase4fieldwork **
Phase4analysis ** ** **
FinalMeeting(ASTMH,
NewOrleans/
Amsterdam)
**
NewsandTasks
! Prof.wertheiminformedtheteamoftheplantoapplyfora‘NoCostExtension’to
theendof2018toenabletheteamcompletethework.
! ContractsbetweentheINDEPTHNetworkandparticipatingsitesshouldbeextended
tillDecember,2018.
! FinalMeetingwithWellcomeTrustwillbeheldinAmsterdamorrequestfora
sessionattheASTMHmeeting,NewOrleans,USAinOctober,2018
! TherewillbetwoskypecallsforAfricaandAsiaforsummaryupdate.
! Astatisticianwillbeneededtodothedataanalysis.
! SamuelAfari-AsiedufromKintampoHDSS,GhanahasbeenawardedaPhD
scholarshipfromtheABACUSProject.
! Alloutstandingfinancialissuestobeworkedonandsitestoreceivetheirproject
funds
! AllissuesonREDCaptobesortedout.
