Knowing Is Not Enough: A Mixed-Methods Study of Antimicrobial Resistance Knowledge, Attitudes, and Practises Among Maasai Pastoralists

A qualitative exploration of the enablers of and barriers to conformance with antibiotic withdrawal periods on smallholding, peri-urban pig farms in Kiambu County, Kenya

Non-conformance with antibiotic withdrawal period guidelines represents a food safety concern, with potential for antibiotic toxicities and allergic reactions as well as selecting for antibiotic resistance. In the Kenyan domestic pig market, conformance with antibiotic withdrawal periods is not a requirement of government legislation and evidence suggests that antibiotic residues may frequently be above recommended limits. In this study, we sought to explore enablers of and barriers to conformance with antibiotic withdrawal periods for pig farms supplying a local independent abattoir in peri-urban Nairobi. We drew upon semi-structured interviews with farmers and government animal health professionals as well as focus groups which involved private animal health professionals. We also explored farmers' engagement with antibiotic withdrawal periods by visiting thirteen pig farms (supplying one of two local independent abattoirs) weekly for one month in order to capture instances of antibiotic use. We analysed data using reflexive thematic analysis. All farmers participating in the study demonstrated an awareness of the concept of antibiotic withdrawal periods and described intentions to conform, motivated by caring for others, wanting to prevent harm or a perception that regulation around antibiotic withdrawal periods existed for local independent abattoirs. The antibiotic use practices that we identified showed limited opportunities for non-conformance with antibiotic withdrawal periods. Farmers and veterinarians reported that instances of antibiotic use were uncommon, especially in slaughter-weight pigs, and were mainly restricted to the treatment of clinical signs under the supervision of an animal health professional. Local factors presented barriers to antibiotic withdrawal period conformance including farmers' economic constraints, lack of formal medicine recording, an absence of consistent abattoir monitoring and resource emergency, such as water scarcity on farms. This study demonstrates the importance of these contextual factors to conformance with antibiotic withdrawal periods. We highlight the need to account for farm-level influences when planning future research and interventions aimed at reducing the presence of antibiotic residues in meat from smallholding pig farms in peri-urban Nairobi.

Contract governance to reduce antimicrobial overuse in hog farms in China

Antimicrobial resistance caused by the overuse of antimicrobials by farmers is an essential health issue. Currently, signing contracts between farmers and cooperatives has become crucial for small farmers to integrate into the modern agricultural industry chain. Unlike vertical government governance, which aims to intervene in the overuse of antimicrobials by farmers through many mandatory or incentive measures, contract governance refers to the social governance model that clarifies rights and obligations between farmers and cooperatives to ensure the adequate performance of contracts, which is especially beneficial to regulate farmers' safe production behavior such as the standard use of antimicrobials. However, there is a research gap concerning the effectiveness of contract governance in inhibiting farmers' overuse of animal antimicrobials. This study applies propensity score matching and mediation analysis method to assess how contract governance affects the overuse of antimicrobials by hog farmers. The paper uses data from 498 hog farmers of China's Hebei, Henan, and Hubei provinces to explore the impact and underlying mechanisms of contract governance on antimicrobial overuse in agriculture. The results showed that contract governance was found to inhibit the overuse of antimicrobials, with the amount paid for antimicrobials reduced by 118 yuan/household. We found evidence that this effect is exerted through three mechanisms: cooperative supervision (CS), technical guidance (TG), and product premium perception (PP). The CS, TG, and PP mediation effects accounted for 19.94%, 27.90%, and 26.93% of the total impact, respectively. Therefore, policy implications of these results include strengthening the standard of contract signing procedures and the integrity of executing contracts, increasing the market premium for products that meet the antimicrobial residue standards, and enhancing farmers' knowledge and contracting ability.

Knowledge, Attitudes, Practices on Antimicrobial Use in Animals Among Livestock Sector Stakeholders in Kenya

Background: Antimicrobials are used on farms to manage livestock diseases. In many developing countries, antimicrobial use (AMU) is insufficiently controlled, and antimicrobials are prone to misuse and abuse, thereby fostering the emergence of antimicrobial resistance (AMR). AMR remains a challenge in Kenya, and the extent remains unknown. This study assessed the knowledge, attitudes, and practices (KAP) regarding AMU among multisectoral stakeholders in Kenya. Methods: The cross-sectional survey was conducted in August 2021 among 381 livestock farmers in Busia, Nakuru, and Isiolo Counties, while 47 animal health service providers (AHSPs) and 32 One Health practitioners (OHPs) were enrolled across Kenya. The data collection tool uploaded on KoBoCollect software was used to collect information on demographics, farming systems, KAP on AMR and AMU, and sources of information. Descriptive statistics were performed. Knowledge was either correct or incorrect, while practices were assigned as desirable or undesirable. Bivariable analysis to assess factors associated with KAP using odds ratio (OR) at 95% confidence level (CL). The Pearson correlation test was conducted to test the correlation between demographic independent variables and farmers' KAP, p < 0.05. Results: Most farmers, 234 (61.4%), were young adults between 30 and 49 years old. Additionally, 48.9% of the farmers had less than 5 years of experience in farming. Among the AHSPs, 76.6% were male, with 21 (44.7%) having 2-5 years of experience. All (32) OHPs had over 15 years of experience. Correct knowledge in AMR/AMU was observed in 52.6% of the farmers, 88.2% of AHSPs, and all OHPs. Desirable practices were observed in 133 (34.9%) of farmers, 22 (45.1%) of AHSPs, and 25 (76.4%) of OHPs. Among the farmers, having basic education was associated with correct knowledge (OR 4.07, p=0.0007); however, being male (OR 1.584, p=0.0456) and having a higher education level (OR 1.582, p=0.0165) were associated with desirable practices. There was a significant positive correlation between having correct knowledge and level of education (p < 0.0001), years of farming, and correct knowledge (p < 0.0001). However, years of farming negatively correlated with the desirable practices (p < 0.0001). Farmers' preferred sources of information regarding AMR/AMU were friends 130 (33.9%), farmer meetings/workshops 99 (25.9%), and radio 41 (10.7%). AHSPs obtain information from scientific conferences/trainings (17) (65.4%), workshops (13) (50.0%), and TV and radio (12) (46.2%), while OHSPs mostly get information through college training (14) (58.3%) and workshops (8) (33.3%). Conclusion: Correct knowledge of AMR/AMU did not result in adopting the desirable practices. A better understanding of the socioeconomic aspects of welfare, good livestock production measures, and AMU stewardship will be desired. This study provides a foundation for developing effective antimicrobial stewardship, best farm practices, and intervention programs to reduce inappropriate AMU. Public Implication: Farmers' AHSP practices are likely to promote the emergence of AMR, a health challenge for animals and humans.

Evaluation of cattle farmers' knowledge, attitudes, and practices regarding antimicrobial use and antimicrobial resistance in Rwanda

The misuse of antimicrobials in livestock may lead to the emergence and spread of resistant pathogens harmful to human, animal, and environmental health. Therefore, determining the behavior and practices of farmers regarding antimicrobial use (AMU) and antimicrobial resistance (AMR) is crucial for addressing the growing threat of AMR. This cross-sectional study was conducted in the Eastern Province of Rwanda on 441 participants using a structured questionnaire to determine the knowledge, attitudes, and practices (KAP) towards AMU and AMR. Frequency distributions, chi-square test of association and logistic regression model were used to analyze the data. This study showed poor biosecurity measures at the farm level with various antimicrobials used here; 83.9% of participants obtained them from friends and neighbors and 61.9% used them for growth promotion. Our assessment revealed a low level of KAP towards AMR among cattle farmers from the study districts. Our data showed that at a 69% cutoff, only 52.6% of farmers had correct knowledge, whereas 56% had good attitudes (47% cutoff). Finally, 52.8% had correct practices toward AMR based on a calculated cutoff of 50%. Positive attitudes, correct knowledge, and practices regarding AMU and AMR were associated with higher educational levels. Sex was correlated with knowledge and attitudes, whereas farm location was associated with attitudes and practices. Farmers expressed a need for more access to veterinary services and AMR-related training for themselves, the community animal health workers, and veterinarians. This study highlighted the low levels of KAP associated with using antimicrobials, which may lead to the misuse of antimicrobials and the spread of AMR. It is imperative to develop and implement cross-cutting measures to minimize antibiotic usage and reduce the risk of antibiotic resistance.

Knowledge, attitudes, and practices regarding antibiotic use and resistance among health science and non-health science university students in Thailand

Antibiotic-resistant bacteria (ARB) have been recognized as one of the global health issues affecting humans, animals, and the environment. A lack of knowledge, negative attitudes, and irrational drug use can make significant contributions to the spread of ARB. This study aimed to assess the knowledge, attitudes, and practices (KAP) regarding antibiotic use and resistance among health science (HS) and non-health science (NHS) students and to determine the factors that influence their KAP concerning antibiotic use and resistance. A cross-sectional study was conducted among 404 HS and NHS students in Southern Thailand from December 2021 to March 2022. The students who fulfilled the study inclusion criteria responded to a questionnaire that had five dimensions. Descriptive statistics were used to analyze the qualitative variables, and Fisher's exact test was applied to compare the demographic variables, KAP responses between the HS and NHS students. The KAP regarding antibiotic use and resistance for each variable were compared using the Mann-Whitney U test and Kruskal-Wallis H test. Spearman's correlation test was used to estimate the correlation between the variables and KAP. A total of 404 (HS,162; NHS,242) students completed the self-administered questionnaire. The students' highest score was for attitude, followed by practice and knowledge. Our findings revealed that the HS students had higher levels of KAP correlated with antibiotic use and resistance than the NHS students (P < 0.001). The higher KAP scores were among the more senior students, which indicates that instruction on antibiotics was effective in their curriculum. Antibiotic use and resistance knowledge and attitudes should be conveyed to all university students via academic curriculum. Such interventions could set the standard for rational antibiotic use as well as long-term prevention and control of antibiotic-resistant bacteria.

Education and Awareness on Antimicrobial Resistance in the WHO African Region: A Systematic Review

This review documents the status of AMR education and awareness in the WHO African region, as well as specific initiatives by its member states in implementing education and awareness interventions, as a strategic objective of the Global Action Plan on AMR, i.e., improve knowledge and understanding on AMR through effective communication, education, and training. A systematic search was conducted in Google Scholar, PubMed, and African Journals Online Library according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, for articles published in English. Retrieval and screening of articles was performed using a structured search protocol following a pre-set inclusion/exclusion criterion. Eighty-five published articles reporting 92 different studies from 19 Member States met inclusion criteria and were included in the final qualitative synthesis. Nigeria (21) and Ethiopia (16) had most of the studies, while the rest were distributed across the remaining 17 Member States. The majority of the articles were on knowledge, attitude, and practices with regard to AMR and antimicrobial use and most of them documented a general lack and suboptimal knowledge, poor attitude and practices, and widespread self-medication. This review shows low levels of knowledge of AMR coupled with extensive misuse of antimicrobial medicines by different target audiences. These findings underscore the urgent need for enhanced and context-specific educational and positive behavioural change interventions.

Prioritization of livestock diseases by pastoralists in Oloitoktok Sub County, Kajiado County, Kenya

INTRODUCTION

Livestock diseases are a big challenge for the livelihood of pastoralists in sub-Saharan Africa because they reduce livestock productivity and increase mortality. Based on the literature available there is limited understanding on how pastoralists prioritize these diseases in the context of their culture, ecosystems and livelihoods. A study was conducted to provide insights on lay prioritization of animal diseases by pastoralists in Kenya.

METHODOLOGY

A qualitative study was undertaken between March and July 2021. Thirty in-depth interviews and six focus group discussions (FGDs) were conducted with community members to explore community attitudes on livestock diseases prioritization. Male and female livestock keepers were purposively selected and interviewed and they were all long-term residents of the area. Fourteen key informant interviews (KIIs) were conducted with professionals from different key sectors to provide detailed stakeholder perspectives on livestock diseases. The interviews were analyzed thematically using the QSR Nvivo software to identify the emerging themes related to the study objectives.

RESULTS

The pastoralists prioritized livestock diseases based on effect on their economic wellbeing, cultural values and utilization of ecosystem services. There were gender variabilities in how diseases were prioritized among the pastoralists. Men cited high priority diseases as foot and mouth disease and contagious bovine pleuropneumonia due to their regular occurrence and effect on livelihood. Notably, women regarded coenuruses as very important because it affected sheep and goats with a high mortality rate and lumpy skin disease because it rendered the meat from the carcasses inedible. Malignant catarrhal fever and trypanosomiasis were noted as some of the common diseases in the livestock-wildlife interface but not cited as priority diseases. Challenges related to disease control in pastoralist contexts exist including limited access to livestock treatment services, inadequate information on disease impact and complex environmental factors.

CONCLUSION

This study sheds light on the body of knowledge in Kenya regarding livestock diseases and their prioritization by livestock keepers. This could aid in the development of a common disease control framework and prioritization at the local level which would take into consideration the dynamic socio-cultural, ecological, livelihood and economic contexts of the communities.

Assessment of knowledge, attitudes and practices relating to brucellosis among cattle farmers, meat handlers and medical professionals in Namibia

BACKGROUND

Brucellosis is a re-emerging zoonosis of significant socio-economic, animal and public health importance. It is principally a foodborne or occupation-associated infection of humans, whose effective control depends on maximum cooperation of high-risk populations.

OBJECTIVES

The study assessed knowledge, attitudes and practices relating to brucellosis among cattle farmers (communal and commercial), meat handlers (abattoir and butchery workers) and medical professionals (nurses and doctors) in Namibia.

METHODS

Between June 2019 and September 2020, self-administered questionnaires and questionnaire interviews were carried out in cattle farmers (n = 264), meat handlers (n = 143) and medical professionals (n = 124) in Namibia.

RESULTS

Overall, 43.50% (231/531) of respondents were aware of brucellosis, with the highest awareness among medical professionals (73.39%, 91/124) and the least in meat handlers (13.99%, 20/143). Awareness of brucellosis was associated with tertiary education (p < 0.001) and the medical profession (p < 0.001). However, most medical professionals (98.39%, 122/124) did not consider brucellosis as a differential diagnosis in cases of persistent febrile illness. A proportion of communal (85.60%) and commercial (71.00%) farmers; abattoir workers (44.40%); butchers (53.50%); nurses (55.60%); and medical doctors (28.00%) consumed raw milk.

CONCLUSIONS

The study identified the purchase of animals of unknown health status; assisting cow delivery; handling of aborted fetuses with no protective wear; consumption of raw milk, homemade cheese, cattle testes and undercooked livers, as risk factors for Brucella infection in cattle and humans. Thus, intensified risk communication, including public health education, is recommended, in particular, among meat handlers and communal farmers, to promote awareness and discourage risky practices.

Knowledge, Attitudes, and Practices of Community Pharmacy Professionals on Poultry Antibiotic Dispensing, Use, and Bacterial Antimicrobial Resistance in Zambia: Implications on Antibiotic Stewardship and WHO AWaRe Classification of Antibiotics

Globally, the inappropriate dispensing and use of antibiotics in animals has contributed to the development of bacterial antimicrobial resistance (AMR). In Zambia, there is insufficient information among community pharmacy professionals on antibiotic use (ABU) and AMR in food-producing animals. This study assessed community pharmacy professionals' knowledge, attitudes, and practices regarding poultry antibiotic dispensing, use, and bacterial AMR in the Lusaka district of Zambia. A cross-sectional study was conducted among 178 community pharmacy professionals between February and April 2022 using a semi-structured questionnaire. Data were analyzed using Stata version 17. Of the total participants (n = 178), 51.1% (n = 91) were pharmacists. The most dispensed antibiotic was oxytetracycline, a Watch antibiotic, mainly without prescriptions. Good knowledge of ABU and AMR was associated with work experience for more than one year (p = 0.016), while good practices were associated with male gender (p = 0.039) and work experience of more than one year (p = 0.011). The study found moderate knowledge, positive attitudes, and moderate practices of pharmacy professionals on poultry ABU and AMR. There was high dispensing of poultry antibiotics without prescriptions, which calls for strict implementation of antimicrobial stewardship and surveillance programs in poultry production in Zambia to reduce AMR.

Achieving Antimicrobial Stewardship on the Global Scale: Challenges and Opportunities

Antimicrobial resistance (AMR) has been clearly identified as a major global health challenge. It is a leading cause of human deaths and also has a toll on animals, plants, and the environment. Despite the considerable socio-economic impacts, the level of awareness of the problem remains woefully inadequate, and antimicrobials are not generally recognized as a global common good, one that everyone has a role and responsibility to conserve. It is imperative for antimicrobial stewardship to be more widely implemented to achieve better control of the AMR phenomenon. The Food and Agriculture Organization (FAO) of the United Nations plays an important role in promoting and facilitating antimicrobial stewardship. The specific needs to be addressed and barriers to be overcome, in particular, in low- and middle-income countries in order to implement antimicrobial stewardship practices in agrifood systems are being identified. As a global community, it is essential that we now move beyond discussing the AMR problem and focus on implementing solutions. Thus, FAO provides multi-pronged support for nations to improve antimicrobial stewardship through programs to strengthen governance, increase awareness, develop and enhance AMR surveillance, and implement best practices related to antimicrobial resistance in agrifood systems. For example, FAO is developing a platform to collect data on AMR in animals and antimicrobial use (AMU) in plants (InFARM), working on a campaign to reduce the need to use antimicrobials, studying the use of alternatives to the use of antimicrobials (especially those used for growth promotion) and actively promoting the implementation of the Codex Alimentarius AMR standards. Together, these will contribute to the control of AMR and also bring us closer to the achievement of multiple sustainable development goals.

Factors Influencing Antibiotic Prescribing Behavior and Understanding of Antimicrobial Resistance Among Veterinarians in Assam, India

This study investigates factors influencing veterinarians' antibiotic prescribing behaviors and their understanding of antimicrobial resistance (AMR). The study used a telephone survey of 50 veterinarians conducted in five districts in Assam state, India. The survey sought information on the most prevalent animal diseases, veterinarians' awareness of potential preventive measures, including factors determining antimicrobial prescribing; the types of antimicrobials used for different health conditions in different species, and possible options to reduce antimicrobial use (AMU). The majority (86%) of respondents worked for the government, 98% reported having no written policy for the use of veterinary health products, and 58% have no on-site diagnostic facilities. Ceftriaxone, Enrofloxacin, and Oxytetracycline were the antibiotics (ABX) most frequently prescribed, by 76, 68, and 54% of veterinarians, respectively. These ABX were prescribed mainly for respiratory health problems and mastitis in cattle, and gastrointestinal infections in buffaloes, sheep, goat, and pigs. Severity of clinical symptoms, economic status of the livestock owner, and withdrawal period for ABX were ranked as very important factors for giving ABX. Less than two thirds (64%) were aware of the government ban for Colistin and only 2% were aware of a national plan for AMR. This study highlighted that ABX prescription is mostly based on tentative diagnosis given the lack of diagnostic facilities in most veterinary clinics. There is a need to enhance veterinary healthcare and to improve communication between policy makers and field veterinarians and, importantly, a need to disseminate clear prescribing guidelines on prudent AMU.

Narratives of veterinary drug use in northern Tanzania and consequences for drug stewardship strategies in low-income and middle-income countries

INTRODUCTION

Awareness-raising campaigns play a central role in efforts to combat drug resistance. These campaigns assume that knowledge deficits drive poor practices that increase resistance. Therefore, increasing awareness will promote prudent practices and reduce resistance. However, most awareness campaigns have been developed and evaluated in high-income and public health settings. Consequently, it is not clear whether these campaigns are effective in low-income and middle-income countries and/or within animal health settings.

METHODS

Focus group discussions and in-depth interviews were used to collect narratives of veterinary drug use among Maasai pastoralists (n=70), animal health professionals (n=10) and veterinary drug sellers (n=5). Thematic analysis was used to identify recurring themes across narratives and groups.

RESULTS

Narratives of Maasai and animal health professionals indicated that Maasai treated their livestock with limited input from the professional sector and that non-prudent treatment practices were observed (eg, using antimicrobials as 'energizers'). Professionals linked these practices to knowledge and attitudinal deficits among the Maasai, while Maasai narratives highlighted the importance of climatic uncertainties and cultural beliefs surrounding veterinary care.

CONCLUSION

Narratives of veterinary drug use from animal health professionals are consistent with the knowledge deficit assumption guiding awareness-raising efforts. In contrast, Maasai narratives highlight how animal health practices are patterned by cultural norms interacting with factors largely outside of Maasai control, including a constrained professional veterinary sector. If these cultural and structural contexts remain unconsidered in awareness-raising strategies, current campaigns are unlikely to motivate practices necessary to limit drug resistance, especially within low-income and middle-income settings.

OUP accepted manuscript

Objectives

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Results

Conclusions

"He Who Relies on His Brother's Property Dies Poor": The Complex Narratives of Livestock Care in Northern Tanzania

Background: Endemic zoonoses have important impacts for livestock-dependent households in East Africa. In these communities, people's health and livelihoods are severely affected by livestock disease losses. Understanding how livestock keepers undertake remedial actions for livestock illness has the potential for widespread benefits such as improving health interventions. Yet, studies about livestock and human health behaviours in the global south tend to focus on individual health choices. In reality, health behaviours are complex, and not solely about individualised health experiences. Rather, they are mediated by a range of “upstream” factors (such as unequal provision of services), which are beyond the control of the individual.

Methods: This paper presents qualitative research conducted from 2014 to 2019 for a study focused on the Social, Economic, and Environmental Drivers of Zoonoses in Tanzania (SEEDZ). Qualitative data were collected via focus group discussions, community meetings, informal interviews, formal in-depth interviews, observations and surveys that addressed issues of health, disease, zoonotic disease risks, and routes for treatment across 21 villages. Thematic analysis was carried out on in-depth interviews and focus group discussions. Conceptual analyses and observations were made through application of social science theories of health.

Findings: Livestock keepers undertake a range of health seeking strategies loosely categorised around self and formal treatment. Two key themes emerged that are central to why people make the decisions they do: access to resources and trust in health care providers. These two issues affect individual sense of agency which impacts their ability to act to improve livestock health outcomes. We suggest that individual choice and agency in veterinary health seeking decisions are only beneficial if health systems can offer adequate care and health equity is addressed.

Significance: This study demonstrates the value of in-depth qualitative research which reveals the nuance and complexity of people's decisions around livestock health. Most importantly, it explains why “better” knowledge does not always translate into “better” practise. The paper suggests that acknowledging and addressing these aspects of veterinary health seeking will lead to more effective provision.