Supporting the National Action Plan for Antimicrobial Resistance (SNAP-AMR) in Tanzania

抗菌素耐药性（AMR），即细菌抵抗药物作用的能力，在英国等资源丰富的国家和坦桑尼亚联合共和国等中低收入国家对人类和动物健康构成威胁。与许多低收入和中等收入国家一样，在坦桑尼亚，由于人和牲畜往往生活在一起，而且两者都广泛使用抗微生物药物，抗生素耐药性问题更加严重。为响应世界卫生组织的全球行动呼吁，坦桑尼亚制定了一项雄心勃勃的国家行动计划，以对抗抗菌素耐药性，包括提高决策者、专业人员和公众对抗菌素耐药性问题的认识和理解，并加强对人和牲畜的监测、研究、感染预防和抗菌素管理。由于缺乏人力和财政资源，国家行动计划的成功实施受到了挑战，因此确定活动和干预措施的优先次序是有效和高效控制抗生素耐药性运动的重要组成部分。我们的研究将提供新的证据来支持这种优先次序和目标，采取一种认识到个人是更大系统的一部分的方法，专业人员和公众的行为可能取决于政策，法规或知识，但也取决于文化背景，社会规范和获得医疗，兽医或诊断基础设施和药物。我们在英国和坦桑尼亚的研究人员和政策专家团队将采取跨学科的方法，与广泛的生物和社会科学家以及卫生专业人员和社区成员合作，对医院和社区使用抗菌素的文化、社会经济和生物驱动因素提供新的见解，并围绕这些问题采用适当的交流方法。抗菌素耐药性问题的根源可被描述为与医院、社区或牲畜有关，因此我们将与医生和护士、住户和患者、兽医和牲畜饲养者以及（非）正式药物提供者和其他利益攸关方合作，调查有关卫生和抗菌素/抗菌素耐药性的知识、信念、态度和做法。我们将比较保健设施（保健中心、地区、区域和转诊医院）和牲畜饲养社区（查加、马萨伊和苏库马），以反映各种专业和文化背景。通过焦点小组讨论、问卷调查和访谈，我们将研究影响抗菌素处方和使用的因素，并通过选择实验，我们将研究知识、社会规范或获取途径等方面的变化如何改变这种行为。为了补充社会经济调查，我们将对医院、社区或牲畜相关细菌进行dna测序，并结合数学建模方法，以确定不同来源和传播途径对抗菌素耐药性临床和经济负担的相对贡献。结合对可能导致AMR问题的驱动因素和行为的相对重要性的洞察，提供了一个独特的机会来识别和优先考虑行为改变的杠杆，以减少AMU，限制AMR的风险和影响。最后，但同样重要的是，我们将与决策者、专业人员和公众合作，设计针对具体情况的信息和方法，在医院和社区环境中传播抗菌素耐药性认识和感染预防和控制信息，并综合运用上述社会科学和生物科学方法，评估这些宣传活动的影响。我们研究的综合结果将通过确定变化是可行的和具有成本效益的设置来帮助AMR控制的优先级设置。它将为坦桑尼亚国家行动计划的实施提供信息，并作为中低收入国家抗菌素耐药性控制的可推广的跨学科模式。

Antimicrobial resistance (AMR), the ability of bacteria to resist the effect of drugs, is a threat to human and animal health in resource rich nations like the UK and low and middle income countries like the United Republic of Tanzania. In Tanzania, as in many low and middle income countries, the AMR problem is compounded by the fact that people and livestock often live close together and widespread use of antimicrobials in both. In response to a global call to action from the World Health Organisation, Tanzania has created an ambitious National Action Plan to combat AMR, including improving awareness and understanding of the AMR problem among policy makers, professionals and the public and enhancing surveillance, research, infection prevention and antimicrobial stewardship in people and livestock. Successful implementation of the NAP is challenged by lack of human and financial resources, making prioritisation of activities and interventions an essential component of an effective and efficient campaign to control AMR.Our research will provide new evidence to support this prioritisation and targeting, taking an approach that recognises that individuals are part of a larger system and that behaviour of professionals and the public may depend on policy, regulations or knowledge, but also on cultural background, social norms and access to medical, veterinary or diagnostic infrastructure and drugs. Our team of UK and Tanzania-based researchers and policy experts will take an interdisciplinary approach, working with a wide range of biological and social scientists as well as health professionals and community members, to provide novel insights into cultural, socio-economic and biological drivers of antimicrobial use (AMU) in hospitals and the community and in contextually appropriate methods of communication around those issues.The origin of AMR problems can be described as hospital-, community- or livestock-associated so we will work with doctors and nurses, householders and patients, and veterinarians and livestock keepers as well as (in)formal drug providers and other stakeholders to investigate knowledges, beliefs, attitudes and practices around health and AMU/AMR. We will compare health care settings (health centres, district, regional and referral hospitals) and livestock keeping communities (Chagga, Masaai and Sukuma) to reflect a range of professional and cultural contexts. Using focus group discussions, questionnaires and interviews, we will examine factors that influence prescribing and use of antimicrobials and through choice experiments we will examine how changes in e.g. knowledges, social norms or access might change such behaviour. To complement the socio-economic investigations, we will use DNA-sequencing of hospital -, community - or livestock-associate bacteria in combination with mathematical modelling approaches to establish the relative contribution of different sources and transmission routes to the clinical and economic burden of AMR. The combination of insight into the drivers and relative importance of behaviours that may contribute to the AMR problem provides a unique opportunity to identify and prioritise levers of behavioural change to reduce AMU and limit the risk and impact of AMR.Finally but importantly, we will work with policy makers, professionals and the public to design context-specific messages and methods to communicate AMR awareness and infection prevention and control messages in hospitals and community settings, and evaluate the impact of those communication campaigns using a combination of the social and biological sciences methods described above. The combined outcomes of our research will help priority setting in AMR control by identifying the settings where change is practicable and cost-effective. It will inform implementation of the National Action Plan in Tanzania and serve as a generalisable transdisciplinary model of AMR control in low and middle income country settings.