How do policymaker perceptions of antimicrobial resistance drive behaviour and policies for appropriate antimicrobial use? A case study of Pakistan

本文提出的研究旨在设立一个泵启动奖，以确定政策制定者对抗菌素耐药性（AMR）的看法如何推动他们的行为和选择旨在适当使用抗菌素的政策选项，重点关注一个中低收入国家：巴基斯坦。应用定性方法，并聘请具有人类和动物健康专业知识的多学科团队，它将绘制政策参与者及其网络，借鉴社会建设框架，以确定动机，社会建设，权力关系和环境因素如何塑造决策者的行为。研究结果对于实现ESRC的基本目标至关重要，即确定与抗生素相关的具体经济因素，文化规范，经验和实践，从而制定最佳行动战略，为中低收入国家（LMICs）的政策制定者提供具体的知识和工具，因为他们适应并采用适当使用抗菌药物的国家政策。本研究将解决的关键问题包括：a。谁是参与有效实施有关适当使用抗菌剂的干预措施和政策的关键政策行为者？这些行为者目前和潜在的联系是如何的？B.所选择的政策选择是如何在社会上构建的，社会构建又是如何加强或削弱对所选择政策的支持或反对的？C.还有哪些其他动机、权力关系和背景因素推动具体政策的选择？D.在目标1下确定的不同决策者群体之间，这些目标有何不同（例如，动物健康与人类健康或政治派别）？e.根据对上述问题的分析，需要如何提出和制定适当使用的政策，以确保基本的政策行为者群体有效地参与和应对这些问题？该项目侧重于南亚一个高风险AMR国家-巴基斯坦的政策行为者行为的驱动因素。中国拥有1.85亿人口，可能是没有关于AMR的国家政策或指导方针的最大国家（Horton 2013）。适当使用干预措施的一个关键考虑因素是通过营利性和非正规卫生部门提供护理。这一问题在南亚尤为严重，80%的患者在监管不力的私营或非正规部门寻求护理（私营部门健康，2016），巴基斯坦提供了一个理想的案例研究来调查这一点，因为78%的人口自付，私营部门提供了75%的医疗服务（Nishtar 2013）。然后，该项目将采取循序渐进的办法，在国家一级、南亚区域一级以及与全球决策者一起对调查结果进行三角测量。研究成果包括为从事抗生素耐药性研究的政策制定者提供的指南、研究方法以及科学成果和论文。研究将开始，全面绘制一个健康范围内涉及适当使用抗生素的政策过程的政策参与者范围，包括私营和公共部门参与者。使用映射练习生成的政策参与者列表，我们将有目的地选择政策参与者进行深入访谈（IDI）。作为IDI过程的一部分，参与者将被问到一些问题，以探索他们对AMR和AM使用的看法，然后对五种政策选择进行排名，同时使用“大声思考”的方法论方法来讨论他们的理由。 研究将由来自伦敦卫生和热带医学学院、巴基斯坦阿加汗大学、新加坡国立大学和伦敦皇家兽医学院的社会和动物科学家组成的跨学科小组进行。此外，研究还将受益于学术和影响咨询小组的建议和监督，以确保对AMR政策和未来研究产生最大影响。

The research proposed here is for a pump prime award to determine how policymakers' perceptions of Antimicrobial Resistance (AMR) drive their behaviour and selection of policy options aimed at appropriate use of antimicrobials, focusing on one lower middle income country: Pakistan. Applying qualitative methods and engaging a multidisciplinary team with human and animal health expertise, it will map policy actors and their networks, drawing on the Social Construction Framework, to identify how motivation, social constructions, power relations and contextual factors shape policy maker behaviour. Research findings will be essential to achieving the ESRC's underlying objective to identify the specific economic factors, cultural norms, experiences and practices relating to antibiotics that enable the best strategies for action, by providing concrete knowledge and tools for working with policymakers in low- and middle-income countries (LMICs) as they adapt and adopt national policies for appropriate use of antimicrobials. Key questions this research will address include: a. Who are the key policy actors to engage for effective implementation of interventions and policies concerning appropriate antimicrobial use? How are these actors currently, and potentially, connected?b. How are the selected policy options socially constructed and how do social constructions reinforce or weaken support or opposition for the selected policies?c. What other motivations, power relations and contextual factors drive the selection of specific policies?d. How do these differ among different groups of policymakers identified under objective 1 (e.g. animal health versus human health or political affiliation)?e. Based on analysis of the questions above, how do policies for appropriate use need to be presented and framed to ensure that essential groups of policy actors engage with and respond to these effectively? This project focuses on the drivers of policy actor behaviour in one high risk AMR country in South Asia - Pakistan. With a population of 185 million, it is possibly the largest country without a national policy or guideline on AMR (Horton 2013). A key consideration for appropriate use interventions is care provision through the for-profit and informal health sector. This issue is particularly critical in South Asia where 80% of patients seek care within the poorly regulated private or informal sector (Private Sector for Health, 2016), and Pakistan provides an ideal case study to investigate this as 78% of the population pay out-of-pocket and the private sector provides 75% of health services (Nishtar 2013). The project will then follow a step wise approach to triangulate findings at national level, at regional level in South Asia and with global policymakers. Research outputs include guides for policymakers working on AMR, a research methodology, as well as scientific outputs and papers.Research will be begin by comprehensively mapping the range of policy actors involved in policy processes relating to appropriate use of AMs, across the One Health spectrum including private and public sector actors. Using the list of policy actors generated by the mapping exercise, we will purposively select policy actors for in-depth interviews (IDI). As part of the IDI process, actors will be asked questions to explore their perceptions about AMR and AM use and to then rank the five policy options while talking through their rationale using a 'thinking aloud' methodological approach. Research will be conducted by an interdisciplinary team of social and animal scientists from the London School of Hygiene and Tropical Medicine, the Aga Khan University in Pakistan, the National University of Singapore and the Royal Veterinary College in London. Research will in addition benefit from advice and oversight of an academic and an impact advisory panel to ensure maximum impact on policy and future research on AMR.