Category: Research

Research

Quantifying antibiotic use in urban and peri-urban Malawi

eleanormacpherson

Increases in drug-resistant infections have been blamed on “uncontrolled access” to antibiotics. But, what antibiotics do community members recognise and use in Malawi? In this pre-print, myself and researchers from the Malawi-Liverpool-Wellcome Research Programme, Liverpool School of Tropical Medicine and London School of Hygiene and Tropical Medicine, present findings from a cross-sectional survey on antibiotic use practices in Malawi.

In Malawi, there is no Chichewa word for an antibiotic as a group and this poses a significant challenge for asking survey questions, particularly when trying to measure the different types of antibiotics used. During our earlier ethnographic studies, we worked with partners to develop the drug-bag method. Sourcing as many antibiotics from formal and informal sources and placing the drugs in a pile allowed participants to identify which medicines they regularly used.

In this study, we used this method to ask about household use, including current and recent (the past 6 months). The number of antibiotics recognised was significantly lower among people with poorer formal healthcare access and amongst men, who are less likely to support healthcare-seeking for family members. Reported antibiotic use was mostly limited to a small number of antibiotics (amoxicillin, erythromycin and cotrimoxazole), with current antibiotic use reported by 67/1051 (6.4%) and recent use (last 6 months) by 440/1051 (41.9%). Our study seeks to the need for improved access to quality healthcare in urban and peri-urban African settings to promote appropriate antibiotic use and limit the development and spread of AMR

Ndirande, Malawi: Thoko Chikondi
Research

Antibiotic use practices in homes in rural Malawi

eleanormacpherson

I have a new paper published in PLOS Global Public Health exploring antibiotic use in homes in Chikwawa Malawi. It was part of the FIEBRE study a multi-disciplinary study working in five countries in Africa and Asia exploring fever and antimicrobial use.

Photo credit: Thoko Chikondi

 Drug-resistant infections are increasing globally and urgent action is required to preserve current antibiotic classes. Antibiotic use in low-and-middle-income countries has gained international attention due in part to the number of medicines accessed informally. Public awareness campaigns have gained popularity, often conceptualising antimicrobial resistance as a problem of excess, precipitated by irrational behaviour. Insufficient attention has been paid to people’s experiences of accessing medicines in low-income contexts. Our ethnographic study was based in the Chikwawa District, Malawi, a place of extreme scarcity, and aimed to understand the care and medicine use practices of households dependent on subsistence farming. In Chikwawa, extreme weather events are becoming more frequent including excessive heat and catastrophic flooding. Creating significant damage to homes and crops. Making everyday life more precarious.

Key findings
We found the most frequently used antibiotics were cotrimoxazole and amoxicillin. Both antibiotics are on the access list according to the WHO AWaRe Classification, which means they should be easily accessible to patients when clinically needed. Participants spoke of the need to visit formal health systems for care and medicines. Recognizing to keep, share & buy medicines informally was not the “right thing” reflecting normative messages communicated by global health and development initiatives. Our ethnographic findings showed how incompatible these messages were for many residents and it was commonplace for residents to seek medicines informally. Often shaped by economic position of the household with free health care more costly than buying medicines. For women in particular helping neighbours through sharing drugs was an important part of broader social relations that included sharing and reciprocity.  In this context of scarcity, the notion that antibiotics could be taken as unthinkingly as sweets challenges the prevailing discourse that antibiotics overused everywhere.

Policy Implications
Our findings suggest in contexts of extreme scarcity policy actors need to be equipped with interventions to address AMR through strengthening health systems. Considering carefully the suitability of awareness campaigns that foreground antibiotic overuse. If antibiotic awareness campaigns are used the messaging needs to be tied into broader economic development to ensure that basic needs are met and that communities have basic levels of security to cope with future illness and economic shocks.

Research

Antibiotic vulnerabilities in primary health care in rural Malawi

eleanormacpherson

Globally, antimicrobial resistance has often been framed as either a problem of access or excess, with stewardship interventions and overall reductions the dominant intervention to ‘rationalise’ use. Insufficient attention has been paid to care relations beyond the binary of ‘too many’ or ‘too few’ – particularly in low-income contexts – and how these relations shape, and are shaped by, antibiotic prescribing. Addressing this gap, our ethnographic work provides an in-depth examination of the practices that comprise care in rural Chikwawa. In this context, we found that care was centred around provision of an antimicrobial. Amid chronic lack of essential medicines and other resources, clinic interactions were tightly scripted, providing patients little time to question or negotiate their treatment. Based on our empirical work we developed the concept of ‘antibiotic vulnerabilities’ to reveal multiple ways in which provision of antimicrobials in rural Malawi impacts care in conditions of extreme scarcity.

Chileka, Malawi Photo credit: Thoko Chikwondi

Implications of our work
Ensuring a stable drug supply is vital, but must be accompanied by wider changes that enable quality care to be performed and received beyond antibiotic-oriented case management. We propose programmes be designed not only to protect vulnerable antibiotics, and patients vulnerable to antibiotic resistance but also to protect patients from systems that have come to be organised around antibiotics which leave patients with insufficient care.

Research

Infection prevention and control on a neonatal intensive care unit in Malawi

eleanormacpherson

About an hour after my son was born, he developed breathing difficulties. He was my first child and the labour like many first labours was long and exhausting. Meeting my child for the first time, and then having him taken away by the doctors has always stayed with me. My son recovered after a stint in the neonatal intensive care unit. Memories of his difficult start came back to me often during weekly debriefing sessions for an ethnographic study we have now completed and published in Wellcome Open. The study was exploring the implementation of infection prevention and control (IPC) policies in a neonatal intensive care unit in Blantyre. The department has seen frequent outbreaks of neonatal sepsis associated with drug-resistant Klebsiella pneumoniae.

Emotions and Ethnographic fieldwork

Helen Mangochi lead the fieldwork and drew on her 28 years of nursing and midwifery work in Malawi to undertake participant observation.

Helen Mangochi

She provided care and captured the lived experiences of mothers, caregivers (the women who provide critical care to babies on the unit), and front-line workers (including clinical and auxiliary staff). Together we analysed the data meeting weekly to reflect on the findings, identify any new avenues for research inquiry and discuss any ethical dilemmas Helen faced. In an incredibly resource-limited context, Helen captured many heartbreaking stories, speaking of the powerlessness she sometimes felt when trying to provide care. I found it hard not to relate my own story to the many hardships these mothers faced navigating a health system typified by extreme scarcity. We both shed many tears during the debriefings speaking to the emotional labour conducting research can have.

IPC on the ward

Our findings showed that while both caregivers and staff had a good understanding of ideal infection prevention and control (IPC) practices they faced challenges implementing policies and procedures. For health workers overwhelming workloads, staff shortages and a lack of material resources including intermittent access to water. For caregivers the lack of basic resources, including insufficient chairs and lack of access to clean linen were barriers. Power dynamics shaped who had access to the material resources including the washing basins with caregivers often told to use ones outside the ward.

Implications for policy

Drug resistant infections are increasing rapidly across the world. The structural and material conditions of low-income countries mean that the ramifications will be more acutely felt in these settings. Our work speaks to the critical need to provide improved WASH infrastructure, address staff shortages and cocreate solutions that meet the hygiene and IPC challenges that staff and caregivers’ encounter.

A qualitative study exploring health workers and patient caregivers’ hand hygiene practices in a neonatal unit in Blantyre, Malawi, implications for controlling outbreaks of drug resistant infections. Published on Wellcome Open

Research

Antibiotics and small-scale intensive farming in Blantyre Malawi

eleanormacpherson

For the past four years, my team and I have been working with collaborators on a range of projects that have aimed to understand household antibiotic use practices in different contexts in Malawi. I am delighted to say that we have a new publication that focuses specifically on antibiotic use and small-scale intensive farming in Malawi.

Chicken sellers in Ndirande, Malawi Photo credit: Thoko Chikondi

Antibiotics and meat production
Since the 1960s, routine use of antibiotics in meat production has reduced the cost of food and enabled radical gains in both yield and profit. Yet, the regular dosing of food animals with sub-therapeutic doses of antibiotics to promote growth and prevent disease has been identified as a potential driver of antimicrobial resistance in both humans and animals. There are significant knowledge gaps around antibiotic use practices, particularly in sub-Saharan Africa.

Our paper A Qualitative Study of Antibiotic Use Practices in Intensive Small-Scale Farming in Urban and Peri-Urban Blantyre, Malawi: Implications for Antimicrobial Resistance was published in Frontiers in Veterinary Science, on the 24th May 2022 attempts to address this gap. The fieldwork was conducted by my team at the Malawi-Liverpool-Wellcome Trust as part of the DRUM study funded through the Liverpool School of Tropical Medicine. John Mankhomwa is the first author of the paper. We used a qualitative research methodology (participant observation, medicine use survey and interviews) to provide an in-depth understanding of antibiotic use practices in households in urban and peri-urban Blantyre. We provide information on the types of antibiotics used, how they are used and why we see this pattern.

Small-scale intensive farming
Chickens were most frequently farmed animals by scale-scale intensive farmers. To raise the birds quickly and ensure they remained healthy, farmers relied heavily on antibiotics. There were also times when farmers unknowingly gave antibiotics to their birds through feed and vitamin mixes. The dependence on antibiotics by these farmers was shaped by intersecting factors including livelihood precarity, unequal market conditions, timeliness, and affordability of access to veterinary advice and services. All animal antibiotics used were manufactured internationally and imported. The political economy and governance of medicines underpinned these immediate drivers.

Implications of our work
Our findings speak to the need for a holistic approach to interventions to optimise the use of antibiotics in food animals in Malawi. Interventions to reduce dependence on antibiotics are required. These should include efforts to improve farmers’ timely access to affordable veterinary services and provide more information about appropriate antibiotic use including withdrawal periods and feed supplementation. At the policy level efforts are also needed to strengthen regulation and the enforcement of legislation nationally and globally.