IntroductionLow-income and middle-income countries (LMICs) are crucial in the global response to antimicrobial resistance (AMR), but diverse health systems, healthcare practices and cultural conceptions of medicine can complicate global education and awareness-raising campaigns. Social research can help understand LMIC contexts but remains under-represented in AMR research.ObjectiveTo (1) Describe antibiotic-related knowledge, attitudes and practices of the general population in two LMICs. (2) Assess the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers.DesignObservational study: cross-sectional rural health behaviour survey, representative of the population level.SettingGeneral rural population in Chiang Rai (Thailand) and Salavan (Lao PDR), surveyed between November 2017 and May 2018.Participants2141 adult members (≥18 years) of the general rural population, representing 712 000 villagers.Outcome measuresAntibiotic-related knowledge, attitudes and practices across sites and healthcare access channels.FindingsVillagers were aware of antibiotics (Chiang Rai: 95.7%; Salavan: 86.4%; p<0.001) and drug resistance (Chiang Rai: 74.8%; Salavan: 62.5%; p<0.001), but the usage of technical concepts for antibiotics was dwarfed by local expressions like ‘anti-inflammatory medicine’ in Chiang Rai (87.6%; 95% CI 84.9% to 90.0%) and ‘ampi’ in Salavan (75.6%; 95% CI 71.4% to 79.4%). Multivariate linear regression suggested that attitudes against over-the-counter antibiotics were linked to 0.12 additional antibiotic use episodes from public healthcare providers in Chiang Rai (95% CI 0.01 to 0.23) and 0.53 in Salavan (95% CI 0.16 to 0.90).ConclusionsLocally specific conceptions and counterintuitive practices around antimicrobials can complicate AMR communication efforts and entail unforeseen consequences. Overcoming ‘knowledge deficits’ alone will therefore be insufficient for global AMR behaviour change. We call for an expansion of behavioural AMR strategies towards ‘AMR-sensitive interventions’ that address context-specific upstream drivers of antimicrobial use (eg, unemployment insurance) and complement education and awareness campaigns.Trial registration numberClinicaltrials.gov identifier NCT03241316.

Education and awareness raising are the primary tools of global health policy to change public behaviour and tackle antimicrobial resistance. Considering the limitations of an awareness agenda, and the lack of social research to inform alternative approaches, our objective was to generate new empirical evidence on the consequences of antibiotic-related awareness raising in a low-income country context. We implemented an educational activity in two Lao villages to share general antibiotic-related messages and also to learn about people’s conceptions and health behaviours. Two rounds of census survey data enabled us to assess the activity’s outputs, its knowledge outcomes, and its immediate behavioural impacts in a difference-in-difference design. Our panel data covered 1130 adults over two rounds, including 58 activity participants and 208 villagers exposed indirectly via conversations in the village. We found that activity-related communication circulated among more privileged groups, which limited its indirect effects. Among participants, the educational activity influenced the awareness and understanding of “drug resistance”, whereas the effects on attitudes were minor. The evidence on the behavioural impacts was sparse and mixed, but the range of possible consequences included a disproportionate uptake of antibiotics from formal healthcare providers. Our study casts doubt on the continued dominance of awareness raising as a behavioural tool to address antibiotic resistance.

Antimicrobial resistance (AMR) threatens to cause ten million deaths annually by 2050, making it a top item on the global health agenda. The current global policy response is multi-faceted, wherein behavioural dimensions like people's medicine use are being predominantly addressed with education and communication campaigns. The social sciences literature suggests that cross-contextual translation of medical knowledge in global awareness campaigns can create misunderstandings and adverse behavioural responses. However, the consequences of AMR communication in low-income and middle-income contexts remain largely undocumented. In response to the empirical knowledge gap, this study presents the case study of educational activity in three northern Thai villages with the objective of contributing to the understanding of the consequences (and their contextual influences) when sharing antibioticrelated information in a rural middle-income setting. The activity's messages were based on World Health Organization AMR awareness-raising material. A mixed-methods research design informed the analysis. Descriptive difference-indifference and geographical analysis based on complete village census surveys with a 3-month interval (n = 1096) was supplemented by qualitative data and observations from the educational activity. The underlying conceptual framework hypothesised that outcomes arise via (a) direct participation and indirect exposure (posters, conversations), subject to translational processes and physical and health system contexts; and via (b) the activity's influence on village social networks. The outcomes demonstrated that participants aligned their antibiotic-related attitudes and behaviours with the activity's recommendations. Aside from language barriers (which excluded non-Thai speakers), fragmented local healthcare landscapes limited villagers' ability to act on the activity but also provided a market opportunity for informal antibiotics sales, and interactions with parallel yet misunderstood public health campaigns created rumours and resistance. Social support from community members also promoted healthy behaviours but remained unaffected by the activity. As one of the most detailed mixed-method assessments of public engagement in AMR, this study challenges the current dominance of awareness-raising campaigns to change population behaviours. We call for comprehensive mixed-method evaluations of future campaigns, mandatory twodirectional knowledge exchange components, and alternative behaviour change approaches that respond to contextual constraints like precarity rather than alleged knowledge deficits.

Understanding the prevalence and types of antibiotics used in a given human and/or animal population is important for informing stewardship strategies. Methods used to capture such data often rely on verbal elicitation of reported use that tend to assume shared medical terminology. Studies have shown the category ‘antibiotic’ does not translate well linguistically or conceptually, which limits the accuracy of these reports. This article presents a ‘Drug Bag’ method to study antibiotic use (ABU) in households and on farms, which involves using physical samples of all the antibiotics available within a given study site. We present the conceptual underpinnings of the method, and our experiences of using this method to produce data about antibiotic recognition, use and accessibility in the context of anthropological research in Africa and South-East Asia. We illustrate the kinds of qualitative and quantitative data the method can produce, comparing and contrasting our experiences in different settings. The Drug Bag method can produce accurate antibiotic use data as well as provide a talking point for participants to discuss antibiotic experiences. We propose it can help improve our understanding of antibiotic use in peoples’ everyday lives across different contexts, and our reflections add to a growing conversation around methods to study ABU beyond prescriber settings, where data gaps are currently substantial.

BackgroundAntimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people’s antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients’ healthcare-seeking pathways?RQ2: Will people’s exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities?MethodsWe apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1–3), social network analysis (RQ2) and latent class analysis (RQ3).DiscussionSocial research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour.Trial registration numberNCT03241316; Pre-results.