Optimising the use of antibiotics and increasing knowledge antimicrobial resistance in a rural healthcare setting in northern Ghana and wider community

Background – why did we do this work?

Antimicrobial resistance (AMR) is when microbes (tiny living things that exist all around us) evolve to become resistant to antimicrobials (which can kill or slow down the spread of microbes), for example when bacteria changes over time and stops responding to medicines such as antibiotics. This has serious consequences for public health, as it means medicines can stop being effective for the treatment and prevention of illnesses. Antimicrobial stewardship is a term used to describe changing how and how often antibiotics are prescribed by clinicians can help slow down antimicrobial resistance.

Aims – what did we hope to achieve?

A multi-disciplinary team of healthcare practitioners, behavioural scientists and researchers from the UK partnered with AG Care hospital in Saboba, Ghana. The aim of the partnership was to explore the challenge of antimicrobial resistance (AMR) in Northern Ghana, to think about interventions to improve infection control practices, build skills and opportunities for antimicrobial stewardship (AMS).

Design – how did we do it?

There were two visits during 2019 to Saboba, Ghana. The first visit in May 2019 and second in November 2019.

The initial visit was a scoping exercise in which the UK team spent three days with the hospital staff in Saboba and within the local community:

Day 1: Orientation day, including a hospital tour, meeting with relevant staff and purchasing of unlicenced antibiotics, to be returned to the UK for testing.

Day 2: UK pharmacists helped hospital staff to fill out the Global Point Prevalence survey (Global PPS), a survey which is used by the World Health Organisation to compare antibiotic use with other local hospitals. The infection control nurse and behaviour change consultants explored infection control practices through interviewing and observing staff. The team then attended a meeting with licenced pharmacists and hospital staff to discuss the challenge of AMR.

Day3: The team visited the hospital pharmacy to see their medicine prescribing system and visited licenced pharmacist shops. Two training sessions were delivered to hospital staff.

The second visit involved the UK team spending five days with the hospital staff, local communities, and pharmacists in Saboba.

Day 1: Attendance of a local Ghanaian Durbar ceremony (gathering)

Day 2: Orientation day, including a hospital tour, meeting with relevant staff and being greeted by regional health directors.

Day 3-4: Attendance of several local Ghanaian Durbar ceremonies.

Day 5: The regional health directors raised the issue of the need for behaviour change, as well as other members of the hospital team in Saboba. The request to measure behaviour was made, but to the complexity of this on such a large scale (e.g. all the communities) and multiple behaviours involved, it was felt training was needed to introduce behaviour change and its potential role in this project. The presentation briefly covered the theory behind behaviour change (COM-B), how the findings of the previous trip in relation to behaviour change theory, and potential opportunities to incorporate behaviour change into practice.

Additionally, over the five days, members of the team attended a local radio station to record public health messages around AMR and answers questions from community members.

Results- what did we find?

In line with behaviour change theory, the findings from the two visits to Saboba were based on the COM-B model (Michie et al, 2013). The COM-B model focuses on the importance of three areas for behaviour change: Capability (e.g., is a person able to perform the behaviour?), Opportunity (e.g. do they have the opportunity to perform the behaviour?) and Motivation (e.g. do they want to perform the behaviour?).

The team identified three key areas of behaviour as potential targets for intervention. These are:

1) Hospital infection control practices

These include handwashing, personal protection equipment (PPE) and cleaning/disinfecting the environment and safe disposal of waste.

  • For handwashing, staff showed they knew how to do this (Capability), although staff were supported, there was limited running water (Opportunity), and staff felt motivated to wash hands, and did this out of habit (Motivation)
  • For PPE, staff knew about it and followed guidelines (Capability), though PPE was not easy to access (Opportunity), but nurses were motivated to protect themselves (Motivation).
  • The knowledge around creating a clean environment varied across wards (Capability), inconsistent practices were performed across wards (Opportunity) and there was awareness of general risks (Motivation).

Based on these findings we recommended the following:

  • Identification of a well-known song (like Happy Birthday in the UK) to ensure hand washing occurs for recommended 30 seconds.
  • Training for all hospital staff to include skills practice, consequences of poor practices, coping strategies to cope with lack of PPE.
  • Notification system to tell staff when they were low on PPE
  • Visual reminders (e.g. posters) placed throughout the hospital to encourage positive infection control behaviours (e.g. handwashing, use of PPE).

2) Patient healthcare seeking behaviours

The lack of regulation around medications was a key issue in Saboba. For this we focussed on the barriers and facilitators to buying medication from unlicenced market vendors:

  • There was a lack of knowledge around best treatments and around AMR, a lack of understanding around hospital roles in treating patients, and literacy affecting ability to read packaging/prescriptions (Capability).
  • It was easier and cheaper to buy medicines from market vendors, and community members were more likely to seek the advice of village elders regarding the best treatments (Opportunity).
  • People were unaware of consequences of purchasing medicines from unlicensed market vendors, hospitals could be viewed negatively and as a last resort, whereas markets were part of their weekly routine (Motivation).

Based on these findings, we recommended the following:

  • Public health campaigns to increase awareness of medications and the role of the hospital.
  • Hospital teaching moments- encouraging clinical staff to discuss medications and prescriptions with patients when in hospital.
  • Chemist shop teaching moments – licenced pharmacists could similarly provide more information to patients when purchasing medication.
  • Increasing accessibility of healthcare, such as creating a network between chemist shop and hospital staff to promote good practice.

3) Healthcare provider behaviours

This focused on the assessment of prescriber and dispenser behaviours, to ensure that antibiotics are prescribed in line with national guidelines:

  • There was good knowledge of guidelines, but the wrong doses were sometimes dispensed because of misreading handwriting (Capability)
  • Guidelines were not available in many accessible formats. Medications were not always available, and local chemists were often under patient pressure for particular medications or doses (Opportunity)
  • All involved wanted the best for their patients, but AMR was not always their priority (Motivation).

Based on these findings, we recommended the following:

  • Provide easy to read and portable versions of the national guidelines.
  • Provide training to ensure all relevant staff were aware of the guidelines.
  • Provide further Behaviour change training and training in starting conversations (e.g. Motivational Interviewing) to explore a patient’s barriers and facilitators to taking the prescribed medication.
  • Create standardised prescription pads to help stop mistakes that come about from poor handwriting.
  • Hospital to have coping plans (e.g. if X is unavailable, I will do Y) for when medication were not available.

Using behavioural science, this work highlighted some of the challenges of AMR and gave some very clear recommendations as to how to overcome these. Due to the coronavirus pandemic, we were unable to take part in a third visit.

Dissemination- where has this study been shared?

This work has not yet been published.

Credits- Who was involved in this work?

Behavioural scientists: Jane Lomax, Martin Lamb, Rebecca Turner, Jo Hart, Lucie Byrne-Davies

Partnership staff: Esther Johnston, Gillian Taylor, Anwen Metastasio, Elaine Thrower, Nishta Nemchand, Samuel Odonkor, Jean Young.

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