Background: Antimicrobial resistance (AMR) is a growing global problem. Raising awareness is central to global and national action plans to address AMR in human and livestock sectors. Evidence on the best ways to reduce antibiotic use, and the impact of awareness raising activities is mixed. This paucity of evidence is acute in Low-Middle-Income Country (LMIC) settings, where healthcare professionals who prescribe and dispense antimicrobial medicines are often assumed to have limited awareness of AMR and limited knowledge of the optimum use of antimicrobials. Objectives: This research aimed to explore AMR awareness among human and animal healthcare professionals and the contextual issues influencing the relationship between awareness and practices of antimicrobial prescribing and dispensing across different LMIC settings. Methods: Qualitative interviews and field observations were undertaken in seven study sites in Ethiopia, India, Nigeria, the Philippines, Sierra Leone and Vietnam. Data included transcripts from interviews with 244 purposively sampled healthcare professionals, analysed for crosscutting themes. Results: AMR awareness was high among human and animal healthcare professionals. This awareness of AMR did not translate into reduced prescribing and dispensing; rather, it linked to the ready use of next-line antibiotics. Contextual factors that influenced prescribing and dispensing included antibiotic accessibility and affordability; lack of local antibiotic sensitivity information; concerns over hygiene and sanitation; and interaction with medical representatives. Conclusions: The high awareness of AMR in our study populations did not translate into reduced antibiotic prescribing. Contextual factors such as improved infrastructure, information and regulation seem essential for reducing reliance on antibiotics.

Background Raising awareness of antimicrobial resistance is a cornerstone of action plans to tackle this global One Health challenge. Tools that can reliably assess levels of awareness of antibiotic resistance (ABR) among human or animal healthcare professionals (HCPs) are required to guide and evaluate interventions. Methods We designed and tested an ABR awareness scale, a self-administered questionnaire completed by human and animal HCPs trained to prescribe and dispense antibiotics in six countries—Ghana, Nigeria, Tanzania, Vietnam, Thailand and Peru. Questionnaires also elicited demographic, practice, and contextual information. Psychometric analysis for the scale followed Rasch Measurement Theory. Bivariate analysis was carried out to identify factors associated with awareness scores. Results Overall, 941 HCPs (625 human and 316 animal) from Ghana, Nigeria, Tanzania, Vietnam, Thailand and Peru were included in the study. The 23-item ABR awareness scale had high-reliability coefficients (0.88 for human and 0.90 for animal HCPs) but performed better within countries than across countries. Median ABR awareness scores were 54.6–63.5 for human HCPs and 55.2–63.8 for animal HCPs (scale of 0–100). Physicians and veterinarians scored higher than other HCPs in every country tested. HCPs in this study reported working in contexts with limited laboratory infrastructures. More than 95% of HCPs were interested in receiving information or training on ABR and antimicrobial stewardship. Conclusion HCPs’ awareness of ABR can be reliably assessed with this validated 23-item scale within the countries tested. Using the scale alongside context questions and objective measurement of practices is recommended to inform interventions to improve antibiotic use.

In this Field Note, I share my experiences of an immersive period of ethnography undertaken with river swimmers in and along the River Beane and River Lea in the county town of Hertford, South-East England, from July 2020 until January 2021. As well as my personal experiences of being a swimmer, I include insights and observations from those I swam alongside to reflect on the feeling of wellbeing that river swimming instills in those dipping, swimming, and ‘dwelling’ in their local rivers. I use these insights to expand the notion of therapeutic landscapes, noting not only their temporality during a pandemic period of uncertainty and disconnection but also their minerality. I explore how therapeutic connections and closer relations between humans, non-humans and rivers, all watered by the same chalk aquifer, might be framed through the connective substance of chalk.