Translating antimicrobial resistance: a case study of context and consequences of antibiotic-related communication in three northern Thai villages

Abstract

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.

New impulses from international development for more comprehensive and balanced public engagement evaluation

“…In terms of goal achievement, Objective 1 focused on sharing information about drug resistance with the village communities where we hosted the workshops. The survey data demonstrated that workshop participants had a 30 percentage-point higher awareness about drug resistance after the event, compared to an increase of 17 percentage points in the villages more generally [44,45]. This indicates that, at least on the face of it, Objective 1 had been achieved.…”

“…Furthermore, we hypothesised that the main mechanism leading to behavioural impact was the exchange of ideas and information. However, our survey data analysis in Charoenboon et al [44] showed that knowledge exchange appeared to play less of a role for people's behaviour than social cohesion: When patients involved another person in their illness (for instance to look after them or drive them to a hospital), their behaviour appeared to be more in line with recommendations of the World Health Organization (this appeared to happen irrespective of the workshops, which did not change social relationships in the villages). Behavioural sciences research more broadly suggests that knowledge, information, and reflective motivation only play a minor role among other drivers of human behaviour [56].…”

“…The research project involved several forms of public engagement, which were carried out between 2017 and early 2019. Firstly, the survey teams hosted halfday workshops in 2017 in all five census survey villages [described in detail in 44,45]. The half-day workshops catered to 20 to 35 adult participants and intended to facilitate bi-directional knowledge exchange between residents and the research team through activities like community mapping, categorisation of common medicines through pile sorting, drug-resistance-themed games and role-plays, and poster making to feedback participants' workshop interpretations to the study team.…”

“…In contrast, survey and interview data collected alongside the village-level workshops offered an opportunity to measure changes in health behaviour and medicine use and the flow of information within the villages [44,45]. The short-term impact within 3 months was mixed, however.…”

“…From an equity perspective, the exhibition and online content were primarily consumed by urban and international populations with higher levels of formal education. Even information about the workshop content only circulated in more privileged circles, that is, among villagers with more formal education and wealth [44,45]. Despite active attempts to be inclusive, the distribution of information was therefore not especially equitable.…”