Enhancing community awareness of antimicrobial use and resistance through Community Conversations in rural Ethiopia

doi:10.21203/rs.3.rs-4240771/v1

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Research Article

Enhancing community awareness of antimicrobial use and resistance through Community Conversations in rural Ethiopia

https://doi.org/10.21203/rs.3.rs-4240771/v1

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Background

Enhanced availability of veterinary drugs in Ethiopia has led to a growing use of these drugs in food-producing animals. However, the use of drugs in livestock production is not commonly supervised. In addition, smallholder livestock keepers often lack sufficient training and information about how the drugs work and their appropriate usage to achieve the intended impact.

Methods

We used Community Conversations to raise awareness and knowledge about antimicrobial use among rural communities. This revealed perceptions and practices of rural households regarding the use of antimicrobials and the risk of drug resistance in livestock. We used women-only, men-only, and mixed-gender discussion groups to explore the gendered perceptions and practices of community members regarding antimicrobial use and resistance.

Results

The discussions with rural communities identified factors that contribute to the misuse of antimicrobials, including poor regulatory system, limited diagnostic capacity, and inadequate knowledge and information among community members regarding the appropriate usage of antimicrobials and the potential resistance emergence.

Conclusions

Raising awareness about antimicrobial use and the potential emergence of resistance is an effective approach to promoting behavior change among rural communities concerning the use of antimicrobials and enhancing livestock management practices. The insights gained from understanding the perceptions and practices of rural communities regarding the use of antimicrobials can help in developing targeted education and training programs for stakeholders involved in the antimicrobial supply chain.

Antimicrobial use in livestock

Antimicrobial resistance

Community conversations

Smallholder livestock production

Ethiopia

Antimicrobial resistance (AMR) is a growing global challenge to human and animal health [1]. AMR can occur because of many factors, including improper prescribing and dispensing practices by animal healthcare professionals, inadequate animal healthcare facilities, and insufficient knowledge among livestock producers about the correct use of antimicrobials and the potential consequences [2]. AMR in both humans and animals is caused by misuse, improper disposal, and the production of counterfeit antimicrobials [3], as well as poor infection prevention and control practices [4]. The rapid development of AMR in disease-causing microorganisms affects both human and animal health as it leads to ineffective treatment of infectious diseases and a rise in healthcare costs [3].

One of the five key strategic objectives of the Global Action Plan on AMR is to improve awareness and knowledge about antimicrobial resistance through effective communication, education, and training [5]. In low- and middle-income countries (LMICs), little is known about the knowledge, perceptions, and practices of rural farming communities regarding the use of antimicrobials and the potential resistance emergence in livestock [6]. In Ethiopia, limited information is available regarding antimicrobial usage in animals and the prevalence of AMR [7]. The surveillance capacity for AMR at the farm and national level is currently underdeveloped [8] and unregulated antimicrobial usage is a widespread practice [9]. Improper use of antimicrobials, mostly without a proper diagnosis, is more common in the intervention sites [7].

Raising awareness and knowledge within rural communities about responsible use as well as ways to reduce the use of antimicrobials in livestock is critical to addressing AMR risks in LMICs [10]. In Ethiopia, previous AMR awareness creation activities usually targeted animal health practitioners rather than livestock producers [8]. There has been little engagement with rural communities to address AMR through participatory processes [11]. Participatory community engagement approaches can create opportunities for awareness creation and co-development of solutions by engaging community members and animal health practitioners together in collaborative analysis and inclusive learning processes [12, 13].

Community Conversations are one such participatory way of involving rural communities and other partners in cooperative learning, introspection, and finding solutions together. They help in reaching out to the community through shared knowledge and the influence of peers [14]. In the livestock development context, Community Conversations have been used as a community engagement approach to change the mindsets and practices of livestock keepers regarding household gender relations and the handling of animal-source foods [15]. Furthermore, they have been used to promote community awareness and knowledge regarding animal welfare and productivity, leading to gradual animal welfare improvements [13].

The paper aims to show the role of Community Conversations as a participatory community engagement approach to enhance community awareness and knowledge regarding the use of antimicrobials and the risks of AMR. The practical purpose of the paper is to support national efforts in mitigating the effects of AMR by raising the awareness and knowledge of livestock producers about the prudent use of antimicrobials and the role of preventive measures in reducing the use of antimicrobials.

Description of the intervention sites

Two rural communities in Ethiopia, namely the Dharito community in the Yabello district of the Oromia region and the Sine Amba community in the Menz Gera district of the Amhara region, were selected for community dialogues about antimicrobial use and resistance. This community dialogue was part of a series of community engagement interventions designed in the Consortium of International Agricultural Research Centres (CGIAR) program on livestock [13]. The selection of the intervention sites was based on factors such as livestock density, agroecology, and agricultural production systems.

The Menz Gera site is populated mainly by people who practice Orthodox Christianity and identify with the Amhara ethnic group. Whereas, in the Yabello district, the population predominantly belongs to the Oromo ethnic group, with the majority of the Borana community practicing traditional religious beliefs. Table 1 provides the agroecology and production system descriptions of the intervention sites. The Menz Gera district is located at an altitude of 2800-3100 meters above sea level and has different land features such as plains, mountains, gorges, and undulated areas. The district has an average annual rainfall of 900-1000 mm, which occurs in two distinct periods throughout the year. The mean annual temperature in the district is 12°C. The main agricultural system in Menz Gera is a highland mixed crop-livestock production system, with crops being the dominant focus [16]. The population depends predominantly on livestock production, focusing on cattle and small ruminant production.

The Yabello district is categorized as arid and semi-arid grasslands, with some sub-humid areas. The grasslands primarily consist of savanna vegetation, including open grasslands consisting of deciduous perennials [17]. The population in the Yabello district depends primarily on livestock production for food, income, and social status. The main livestock species are goats, cattle, sheep, and camels. The district has two rainy seasons with an average annual rainfall of 500 mm and an average temperature of 24 °C and the altitude ranges from 350 to 1800 meters above sea level [18].

Table 1. Description of the intervention sites [13].

Region	District	Community	Agroecology	Production system	Altitude (m)	Rainfall (mm)	Temperature (⁰C)
Oromia	Yabello	Dharito	Dry lowland	Mixed crop-livestock	1800	500	24
Amhara	Menz Gera	Sine Amba	Moist highland	Mixed crop-livestock	3100	900-1000	12

In the intervention sites, the communities depend predominantly on livestock production for their livelihoods. The main livestock production challenges facing smallholder livestock keepers include feed and water shortages and the occurrence of animal diseases [19].

The Community Conversations approach

Community Conversations are participatory community engagement and learning processes where trained facilitators guide community members in identifying issues, examining constraints, and developing solutions to address those issues [20, 14]). These conversations promote critical discussions and reflections among both women and men community members and local service providers, fostering new perspectives that lead to community-led actions and positive changes [21].

Using the principles and practices of participatory approaches, we developed a Community Conversations material on AMU and AMR [22]. The material provides content and facilitation guidance for the implementation and documentation of Community Conversations in the intervention sites. During the Community Conversations, we used different discussion methods such as posters, visuals, narratives, interactive activities, thought-provoking inquiries, and personal reflections. These interactive learning methods help explore the gendered perspectives and behaviors of community members, raise their awareness about the use of antimicrobials, and understand the concept of antimicrobial resistance within a social context.

We formed a team of local facilitators, consisting of research and development partners, who were familiar with the communities and spoke the local languages. In the Yabello district, the partners who were fluent in both Amharic and Oromiffa languages served as translators during the conversations. In both sites, the local partners played key roles in adapting the discussions to the local context and leading and documenting the conversations. We trained the local facilitators in the Community Conversations approach and documentation techniques.

In the Dharito community, the Community Conversations were held on the 18^th and 19^th of October 2019, and in the Sine Amba community on the 6^th and 7^th of November 2019. In both intervention sites, we engaged 106 community members (48 women including married and household heads, and 58 men) and 10 (of which 2 were female) local service providers. In selecting the participants, we tried to ensure a wide range of opinions and perspectives among the participants to foster a more dynamic discussion, promoting collaborative learning, and inspiring community actions. Based on prior research, community members were expected to influence their household members, neighbors, and other community members by sharing information from the conversations using different informal spaces and networks [21, 23].

In circular sitting arrangements that created a level playing field and a safe discussion environment, the Community Conversations happened in open spaces (such as under a tree or a convenient community place) running typically through 2-3 hours and engaging about 50 participants in each community. In a world café setup [24], we used single-sex discussion groups and a plenary discussion to explore community members’ gendered perceptions and practices of antimicrobial use and awareness of AMR.

Discussion content and questions

The Community Conversations approach addressed the following content and discussion questions (Table 2). The discussion questions served as a checklist to steer the conversations, while the use of probing techniques allowed for deeper exploration of the issues at hand.

Table 2. Community Conversation topics and discussion questions on AMU and AMR [25].

Topics	Discussion questions
Community understanding of antimicrobials	What are antimicrobials? How does the understanding of antimicrobials differ by gender?
Information and knowledge sources on antimicrobials	What information and knowledge sources do women and men have on antimicrobials? How trustworthy are the different information sources?
Sources and quality of veterinary drugs	Where do women and men community members get veterinary drugs? Which drug sources are trustworthy and preferred? Who regulates the supply of veterinary drugs?
Gender differences in the use of antimicrobials	How does the use of veterinary drugs vary by gender? Do you use human drugs for veterinary purposes?
Community understanding of antimicrobial resistance, its causes, and effects	How do women and men community members understand antimicrobial resistance? What do you think are the causes of antimicrobial resistance? What do you do with leftover veterinary drugs? What is your understanding of withdrawal periods for antimicrobials? What do you think are the consequences of antimicrobial resistance in livestock?
Preventive measures to reduce antimicrobial resistance	What preventive measures can you take to reduce the use of antimicrobials? What role can women and men community members play to reduce the risk of antimicrobial resistance?

Data collection and analysis

Qualitative data on the Community Conversations process and outputs were collected using iterative process documentation techniques. We used a participant-led narrative approach to data collection guided by a pre-determined set of discussion topics and questions. Data collection methods used were observation, interviews, storytelling, and reflections. The use of process note-taking and reflection tools made it possible to document the results of the conversations, think about the process, summarize emerging patterns, analyze the outcomes, and draw valuable insights, which were recorded in conversation reports [25]. Through post-event reflection and meaning-making processes, we analyzed, interpreted, and validated the results, experiences, and contextual insights of the Community Conversations.

According to Nowell and others [26], we used an inductive content analysis approach to analyze the data contained in the conversation reports [25]. We thoroughly analyzed the reports for common themes to identify categories and emerging patterns. We then highlighted these by including direct quotes from community members and local service providers. Furthermore, literature was used to support and give meaning and validity to the themes. We considered factors such as socio-cultural, demographic, and agroecological aspects when comparing the data from the intervention sites and participants.

Ethics statement

Ethics approval for this work was obtained from the Institutional Research Ethics Committee of the International Livestock Research Institute (ILRI-IREC 2018-24).

Rural communities' understanding of antimicrobials

Across the intervention sites, we found that community members had the same understanding of antimicrobials. In Yabello, they viewed antimicrobials as medications used to treat sick animals. Similarly, in Menz Gera, community members described antimicrobials as "medicines such as antibiotics and anthelmintics used for treating sick animals." Female participants in Yabello considered antimicrobials to include both traditional treatments and veterinary drugs.

Information and knowledge sources on antimicrobials

In Yabello, community members obtained information and advice on the use of antimicrobials from different sources, such as veterinary drug stores, veterinary clinics, government vaccination officers, and community animal health workers (CAHWs). They received information and advice from these sources on different aspects of the use of antimicrobials, including the types of antimicrobials, where to administer the medication, the appropriate dosage, how long the treatment should last, and specific conditions to consider, such as pregnant animals not swallowing bolus. The community members considered veterinary drug stores, veterinary clinics, and government vaccination officers as the most reliable and trustworthy sources of information.

Similarly, community members in Menz Gera identified different sources such as public veterinary clinics, researchers, private veterinary service providers, and fellow farmers to seek information and advice regarding the proper dosage, treatment duration, and withdrawal periods for veterinary drugs. However, there were differences in access to such information and advice based on gender. According to the community members, men had greater accessibility to knowledge and information about veterinary drugs compared to women due to factors such as higher mobility, exposure, confidence in reaching out to animal health practitioners, veterinary clinics, and pharmacies, as well as ownership of mobile phones and radios.

Sources and quality of veterinary drugs

In Yabello, the community members considered public veterinary clinics and private veterinary drug stores as the most preferred and trusted drug sources for factors such as better storage facilities and the provision of reliable information and advice. They believed that drugs from veterinary drug stores are not exposed to sunlight, do not easily deteriorate, and can be stored for longer periods. They also identified additional sources of veterinary drugs such as roadside markets, private human pharmacies, and CAHWs. However, they expressed concerns about the quality of drugs obtained from these sources. A male participant commented, “we lack information about the veterinary drugs from roadside markets and CAHWs.” Community members claimed that they could recognize expired drugs, asserting that drugs purchased from roadside markets undergo a color change. For example, a male participant said, “oxytetracycline turns black when it expires.” On the other hand, female participants mentioned that they depend on CAHWs to help them check the expiry dates of drugs.

Similarly, community members in Menz Gera identified different sources of veterinary drugs such as public veterinary clinics, research centers, private veterinary drug stores, and informal markets. They emphasized that public veterinary clinics are the main source of veterinary drugs. During the conversations, they revealed hesitance to buy drugs from private veterinary drug stores and informal markets due to concerns about the quality or expiration of the drugs from these sources. A male participant commented, “drugs could be kept for longer periods as there are not many people buying drugs from private drug stores.” Stating her disapproval of obtaining drugs from informal sources, a female participant said, “veterinary drugs are not everyday commodities like coffee and sugar that one buys from shops.” Community members asserted that they could recognize the quality of veterinary drugs through ways such as smell, changes in color, texture, and expiration dates.

Gendered community use of antimicrobials

In Yabello, the use of veterinary drugs differed between genders. Female participants reported treating diarrhea in smaller animals like poultry, goats, and sheep using tablets. For poultry, they mixed human tetracycline with water or maize flour. For calves, they mixed human tetracycline with water and administered it orally. They treated sick sheep and goats by mixing crushed anthelmintic bolus with water. On the other hand, male participants reported treating larger animals such as cattle and camels with antibiotic injections. They reported crushing tablets and mixing them with water to administer to sick animals. A male participant said, “if we don’t have animal drugs at home, we use tetracycline in newborn camel calves to prevent infection.”

Community members used a step-wise approach to caring for sick animals. Initially, they used traditional medications to treat sick animals. If these treatments did not work, they would then buy drugs from a veterinary store and administer them themselves. A male participant said, “we only seek help from CAHWs when we are faced with difficulty or when our attempts to treat animals ourselves were unsuccessful. If CAHWs are unable to provide treatment, we then turn to a veterinary clinic.” They reported considering the age, size, and body condition of animals to determine the appropriate dosage and duration of treatment.

On the other hand, community members in Menz Gera indicated that there were no gender differences in the use of antimicrobials for animals. They mentioned that both women and men brought their animals to veterinary clinics and followed the prescriptions or advice given by animal health practitioners. They claimed to adhere to the recommended dosage and duration of treatment. If they stopped the treatment prematurely, the community members believed that the animal would not be fully cured. They believed that, although it might initially appear healthy, the disease could still be present and returned, which would make it more difficult to treat. A male participant expressed the belief that “either the first or the last administered drug would be effective, so the animal needs to receive the recommended treatment duration and dosage.”

During the conversations, community members reported that they rarely treated their animals themselves because they lacked knowledge about the disease, treatment methods, and the quality of drugs. However, they acknowledged that some farmers might treat their animals, particularly for gastrointestinal parasites, since they were familiar with the drugs commonly prescribed by animal health practitioners for diseases with common clinical signs.

Community understanding of antimicrobial resistance, its causes, and effects

In both intervention sites, community members found it difficult to understand the concept of antimicrobial resistance. Initially, they described it as a scenario where “drugs are effective for the animal.” However, upon further exploration, they began to understand it as a situation where “diseases develop a tolerance to drugs over time.”

During the conversations, community members shared their experiences which demonstrated their growing understanding of drug resistance in animals. For example, in Menz Gera, a male participant mentioned, “even after multiple treatments, sick animals do not always get better. We think that the disease is incurable, or that the animal is naturally diseased. Therefore, rather than trying repeated treatments, we choose to sell the animal." Through these discussions, community members understood that diseases can become resistant or tolerant to drugs over time. They shared stories about situations where animals showed no improvement after receiving veterinary drugs or instances where the drugs did not work.

In Yabello, community members identified the incorrect use of antimicrobials as the main cause of drug resistance in animals. During the discussions, a male participant emphasized, “drug resistance occurs due to the frequent and prolonged use of the same drugs, as well as the use of expired drugs.” Similarly, in Menz Gera, community members associated drug resistance with “the use of expired or poor-quality drugs, drugs for unknown diseases, and under-dose drugs.” A male participant emphasized that “not completing the treatment duration could lead to the development of drug resistance.” Additionally, other participants noted that “using poor-quality drugs could worsen the condition in sick animals, as the disease may become more tolerant to the drugs over time.”

In both intervention sites, community members identified inadequate diagnostic capacity as the main gap in the veterinary service. They reported that veterinarians do not usually physically examine sick animals. A male participant said, “they commonly rely on farmers’ descriptions of diseases and observation of clinical signs to prescribe drugs.” Community members were concerned about this practice as it could cause drug resistance.

In Yabello, community members showed a lack of understanding about the withdrawal periods for veterinary drugs. They mentioned consuming animal-source foods like milk and meat, as well as selling animals shortly after antimicrobial treatment. They were unaware of the potential health risks of consuming animal-source foods immediately after treating sick animals with antimicrobials. They believed that animal drugs do not affect humans. Conversely, in Menz Gera, community members showed some understanding of withdrawal periods for antimicrobial use, as demonstrated by their knowledge of avoiding the consumption of milk, eggs, and meat immediately after treating sick animals. However, the main reason for this was the fear of disease transmission from sick animals to humans. Further exploration revealed that community members had a growing awareness of the potential transmission of drug residues to humans through the consumption of animal-source foods, such as milk, eggs, and meat, which could lead to the development of drug resistance in humans.

In Yabello, community members mentioned that they stored leftover drugs for future use and disposed of expired drugs in the open environment. A male participant said, “we dispose of expired drugs by burying them in holes like termite mounds or latrine pits.” On the other hand, in Menz Gera, community members stated that they did not store leftover drugs for future use. A male participant mentioned that “veterinarians only prescribe the required drugs for sick animals, so there would be no excess drugs.” However, other participants acknowledged that some farmers may keep leftover drugs for use on other animals. One participant shared a story about a farmer who bought drugs to treat sick animals and stored the unused drugs. However, they believed this practice should be discouraged. The community members were aware that storing leftover drugs for too long could cause them to expire and lose their effectiveness in treating sick animals. A female participant expressed a concern that “expired drugs could even be harmful and potentially kill animals.” Some community members believed that “expired drugs could even lead to the development of diseases in animals.” Due to concerns about children finding them, community members claimed to dispose of leftover drugs in toilets or by burning them, rather than disposing of them in the open environment.

In both intervention sites, due to the conversations, community members were aware of the economic impact of drug resistance. One male participant stated, "Not only do we waste money on drugs that don't work, but the animals also suffer from diseases, their productivity declines, and in some cases, we may even lose animals due to incurable diseases."

Preventive measures to reduce antimicrobial resistance

Due to the conversations, community members believed that they had the opportunity to lower the risk of antimicrobial resistance. They understood that using drugs responsibly could help reduce antimicrobial resistance. They also recognized practical measures to prevent infections, such as vaccination, biosecurity, and providing adequate nutrition (through sufficient feed, water, and minerals). One male participant in Menz Gera mentioned that “good livestock husbandry could decrease the chances of animals getting sick and needing treatment.” Another participant stated that “maintaining good animal health could save money on treatments.” However, despite these beliefs, community members acknowledged that they faced challenges due to limited resources, limited knowledge, and poor animal health services to maintain the health and welfare of their animals.

Community actions to curb AMR

The Community Conversations aimed to not only explore community perceptions and practices regarding the use of antimicrobials and the risks of AMR, but the main goal was to capacitate community members to take action to curb AMR risks (Table 3). Through the conversations, community members agreed and committed to promote and advocate for the responsible use of antimicrobials within their communities. This involved disseminating information from the conversations regarding antimicrobial usage to fellow community members, as well as seeking information and advice from animal health practitioners on the proper usage of veterinary drugs. Furthermore, community members acknowledged the significance of preventive measures and were fully committed to enhancing their infection prevention strategies. To effectively implement these actions, community members emphasized the urgent need for improved animal health services, which include access to regular vaccination services, mobile treatment options, diagnostic facilities, and animal health advice that can be easily accessed through mobile phones. Additionally, the regulation of informal drug markets was deemed crucial to ensure the availability of safe and effective drugs for animals within the communities.

Table 3. Community actions to reduce the spread of AMR [25].

AMU and AMR issues	Community actions
Limited awareness and knowledge of AMU and AMR among rural communities	Share information and influence other community members Do not use human drugs for veterinary purposes Do not use expired drugs or treat animals with leftover drugs Store drugs in a safe and clean place Avoid consumption of animal-source foods before the withdrawal periods for drugs Reduce or use antimicrobials only when needed
Sources and quality of veterinary drugs	Consult trained veterinarians and drug dispensers Regulate the informal drug market
Infection prevention measures	Vaccinate to prevent infectious diseases Improve sanitation of animal premises Isolate sick and treated animals from the flock Properly dispose of carcasses Prepare balanced feed resources to improve animal nutrition

Due to the Community Conversations, local service providers gained a deeper understanding of community issues and were able to incorporate community actions into local planning and implementation processes. This has the potential to enhance the capacity of both community members and local service providers to address and reduce the spread of AMR. The local service providers appreciated the valuable knowledge shared by the communities and found the experience of engaging with community members to be highly educational and insightful. In Menz Gera, the animal health team leader, expressing concern about the threat of antimicrobial resistance to their work, emphasized the need to integrate community actions into their plan and maintain ongoing engagement with community members to address drug resistance issues. Likewise, local partners in Yabello highlighted the significance of Community Conversations in raising awareness and knowledge about the proper use of antimicrobials and AMR emergence. They emphasized the importance of conducting conversations at various levels within the veterinary drug supply chain, including livestock keepers, animal health experts, drug regulatory bodies, and drug dispensers.

In Ethiopia, the AMR situation in veterinary practices in most areas of the country remained unveiled, and evidence on antimicrobial usage is limited [7]. This paper aimed to explore awareness of antimicrobial resistance among rural communities and how it is related to their antimicrobial use and livestock husbandry practices. While there were some differences between the intervention sites, we found limited awareness and knowledge about antimicrobial use, as well as the causes and effects of antimicrobial resistance within rural communities.

In both sites, community members were not aware of the existence of antimicrobial-resistant disease-causing microorganisms, rather when therapeutic failure happened, they assumed it could be due to either uncurable disease or inherent disease. However, while it was initially challenging for community members to understand the concept of antimicrobial resistance, they could gradually describe situations that showed their growing understanding of the risk of treatment failure in animals. In this line, Pearson and Chandler [2] show that human and animal healthcare professionals identify AMR mainly by observing treatment failures where symptoms do not improve after antimicrobial treatment or when illnesses keep coming back despite receiving treatment.

The paper shows differences between the intervention sites in awareness about the use of antimicrobials, the risk of drug resistance, and its public health risks. Compared to Yabello, community members in Menz Gera demonstrated a better understanding of the use of antimicrobials. This may be because of relatively better access to veterinary services including education and advisory services. In pastoral areas like Yabello, antimicrobials are poorly stewarded and easily obtained over the counter with minimal drug regulation, oversight, or quality control. Therefore, to ensure the survival of livestock, pastoralists often self-treat their animals with a high risk of either overdosing or under-dosing the sick animals [7]. In Yabello, common patterns of veterinary practices have led to community members becoming acquainted with them and subsequently trying to treat their animals. Animal health practitioners often advise the same thing or prescribe the same medicine for a range of disease conditions. This may be due to the working constraints of veterinarians such as the lack of rapid diagnostic facilities and limited antimicrobial options. Similarly, Pearson and Chandler [2] show that both human and veterinary professionals have been employing antibiotics to treat viral infections. However, there have been issues with the improper dosing and duration of antibiotic treatments, as well as the use of low-quality antibiotics, including those that are illegal or past their expiration date, or those that have been stored in inappropriate conditions.

The improper use and disposal of expired and leftover drugs are also a major concern in pastoralist communities. Drug disposal practices are currently inadequate and face many challenges such as a lack of standard drug disposal procedures specifically addressing medications at the household level [27].

Pastoral communities in Yabello revealed the use of human tetracycline for veterinary purposes. The use of human tetracycline in animals has also been previously documented in the intervention area [7]. This practice has the potential to cause adverse drug reactions and contribute to the development and spread of antibiotic resistance between humans and animals [28].

While there were no gender differences in the use of antimicrobials in Menz Gera, women and men community members in Yabello showed differences in the type of antimicrobials used and animal species treated. Gemeda and others [7] show that livestock producers in pastoral systems use antibiotics more frequently than their counterparts in highland mixed crop-livestock systems, who mostly use anthelmintics. However, both women and men lack an understanding of the withdrawal periods for veterinary drugs and the public health risks of AMR. Zoonotic AMR pathogens in farm animals can transfer to humans through the consumption of contaminated water or food and direct contact with animals [29]. As women are more involved in cleaning barns, caring for sick animals, feeding animals, and processing animal-source foods, they can be more exposed to the risks of antimicrobial resistance [30].

The last topic of the conversations focused on preventive measures to reduce the use of antimicrobials. It was not a difficult task for most community members to discuss preventive measures to reduce antimicrobial resistance. It is believed that the conversations encouraged the participants to identify and discuss infection prevention and control strategies and the prudent use of antimicrobials.

Awareness and knowledge of rural communities are critical to promoting the rational use of antimicrobials and implementing improved infection prevention and control measures, which can substantially reduce the use of antimicrobials [10]. Furthermore, Haenssgen and others [31] show that education and awareness raising are the primary tools of global health policy to change public behavior and tackle antimicrobial resistance.

While the technical areas of antimicrobial use and resistance were not new to the local service providers, they found it challenging to communicate these issues to community members in an understandable way. They often play the role of experts [12] and fail to engage in collaborative discussions to learn from and problem-solve with community members and understand their perspectives [11]. This can limit community members’ understanding and uptake of animal health messages, including antimicrobial use and resistance. Previous studies show the importance of improving the communication and advisory skills of animal health practitioners [32, 33, 12]. Animal health service providers must be familiar with the conceptualization and thinking frame of community members who often name animal diseases based on contributing stress factors, clinical signs, and effects on the animal. Alemu and others [34] provide insights into the description of local names and clinical signs of small ruminant diseases by farmers and pastoralists in the intervention areas. Community members often name veterinary drugs by their color and relate drug shapes with objects they are familiar with. For example, in Menz Gera, community members name dewormers ‘madaberia’ in the local language meaning ‘fertilizer’; they associate the use of dewormers with the potential for weight gain in thin animals, like how chemical fertilizers can promote robust growth in crops. It is shown that community engagement approaches such as Community Conversations are beneficial to exploring awareness and understanding of the risks and potential harms associated with AMR among community members and encourage them to take practical measures that reduce the spread of antimicrobial resistance more sustainably.

Awareness and knowledge about rational antimicrobial use in livestock and the consequences of antimicrobial misuse are limited within rural communities in Ethiopia. Community Conversations enabled community members and local service providers to better understand the causes and effects of antimicrobial resistance and how this can be reduced by optimal use of antimicrobials as well as implementing appropriate infection prevention measures. However, awareness and knowledge about antimicrobial use and resistance alone do not usually lead to a reduction of the problem. It requires addressing animal health service system challenges. Improving the quality and coverage of animal health services, increasing access to reliable information and advice, improving the diagnostic capacity of veterinary services, and enforcing regulatory measures must be in place to translate AMR awareness and knowledge into practice in the intended way. This requires the engagement of several stakeholders to explore multiple perspectives, identify constraints, and develop and implement locally appropriate solutions to sustainably address the problem.

AMR Antimicrobial resistance

CAHW Community animal health workers

CGIAR Consortium of International Agricultural Research Centres

LMIC Low- and middle-income country

Acknowledgments

We are grateful to the women and men community members who shared their wisdom and valuable knowledge during the conversations. We also thank research and development partners who actively engaged in the implementation of the Community Conversations.

Author Contributions

The concept of the Community Conversations on antimicrobial use and resistance was developed by BA, ML, and BW. Fieldwork was conducted by BA and ML. A first draft of the manuscript was prepared by ML, expanded by BA, BW, KA, and TKJ, and then further revised by ML. All authors reviewed and approved the final version.

Funding

The work was conducted as part of the CGIAR Research Program on Livestock and was supported by contributors to the CGIAR Trust Fund. CGIAR is a global research partnership for a food-secure future. www.cgiar.org. The authors declared that no funds, grants, or other support were received during the preparation of this manuscript.

Data Availability Statement

The data for this paper have been published as a report and can be available at https://hdl.handle.net/10568/106395.

Ethics approval

Ethics approval for this work was obtained from the Institutional Research Ethics Committee of the International Livestock Research Institute (ILRI-IREC 2018-24).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests

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Enhancing community awareness of antimicrobial use and resistance through Community Conversations in rural Ethiopia

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Version 1

Abstract

Background

Methods

Results

Conclusions

Background

METHODS

Results

Rural communities' understanding of antimicrobials

Information and knowledge sources on antimicrobials

Sources and quality of veterinary drugs

Gendered community use of antimicrobials

Community understanding of antimicrobial resistance, its causes, and effects

Preventive measures to reduce antimicrobial resistance

Discussion

Conclusions

Abbreviations

Declarations

References

Status:

Version 1