School and CHWs platform against inappropriate use of antibiotics

An integrated platform to simultaneously target antibiotic supply and demand. This will involve strengthening the capacity of CHWs and training school-age children to improve treatment compliance and reduce street sales of antibiotics.

The team lead is Dr Hamidou Niangaly who is also the solution lead.

Self-medication with antibiotics purchased from street vendors or pharmacies without a doctor's prescription, on the one hand, and failure to take the antibiotics prescribed by health workers within the prescribed time (non-adherence to treatment), on the other, are common practices in Mali. All social strata are affected by these practices. Still, people with low incomes or low levels of education are likely to be the most affected, especially in rural areas, due to the constraints they face in accessing healthcare and health information. These inappropriate practices, which contribute to the emergence or spread of antimicrobial resistance, could explain the high rates of resistance to common antibiotics such as amoxicillin (93.8%), cotrimoxazole (92.6%), Ceftriaxone (52.3%), or ciprofloxacin (55.7%) reported in a study carried out in Mali (Diarra B et al., 2024). Our pilot study showed that treatment compliance rates were higher among mothers with schooling (94%) than those without (86%). Self-medication rates varied between 34% and 62% (EMOP 2018, JSTM site). This implementation research aims to combat the sale of antibiotics outside the healthcare system and reduce non-compliance with treatment at the community level through an integrated platform of schools and community health workers (CHWs).

Teachers, schoolchildren and community health workers are at the heart of the platform to help reduce the inappropriate supply and use of antibiotics. Teachers will be involved in the development and delivery of the training module. Image boxes will be designed with key messages to facilitate their transmission. Health professionals will be involved in the development of the module.  Community health workers will identify illicit drug sales points and transmit awareness-raising messages to street vendors. GPS coordinates of antibiotic sales points will be recorded for mapping purposes. CHWs will be equipped with smartphones to collect and report data on illegal drug sales points. Antibiotics will be catalogued by class.

The training module for school-age children will be public and accessible to all. The module will be published on the Antimicrobial Resistance and World Health Organization websites under the heading "Health promoting schools".  The research database will be made available free of charge on request. The article will be published in an open-journal.

The final outcome indicators are: (i) the rate of treatment compliance, (ii) the rate of self-medication, and the quantity of antibiotics circulating in the streets. By educating school-age children, adults will be made aware of the consequences of non-compliance with treatment and self-medication, which may reduce their inappropriate behavior. The mapping of street drug outlets and the creation of a database will enable targeted, coordinated action to be taken by the State. This will be a dynamic database, updated each time a new point of sale is identified. Awareness-raising combined with coercive measures could reduce the number of points of sale and have a significant impact on the circulation of antibiotics on the streets, and therefore on their use.

The results of this research will be shared with the ministries in charge of health, education, and the family, and with organizations involved in the fight against antimicrobial resistance, through the organization of a workshop. This will enable the results to be appropriated by political decision-makers. In the first year, action research will be carried out in two health districts. Based on the results of the research, a plan to reach the program to fight the inappropriate use of antibiotics and their sale on the streets (PFIA) will be drawn up and validated by political decision-makers. Over the next three years, the outreach program will be extended to two other regions of Mali. At the end of the three years of implementation, the impact of the program will be evaluated.  A national training module for schoolchildren in the appropriate use of antimicrobials will be available, and a national database of points of sale for antimicrobial drugs will be compiled. A policy note will be drawn up and submitted to decision-makers for analysis and adoption of the program into national policy.

A plan for monitoring the implementation of the PFIA will be put in place. This plan will make it possible to analyze strengths, weaknesses, opportunities, and threats as the program is implemented. A team made up of researchers in charge of implementing national health, education, and family promotion programs will be set up to monitor the program's implementation. Periodic meetings will be organized to assess the various aspects of PFIA implementation, to identify bottlenecks and resolve them.

As in our pilot study, we will use the randomized clinical trial approach to impact assessment. To this end, two groups of health areas will be randomly assigned to receive PFIA or not. The mean treatment effect and local mean treatment effect methods will be used to measure the impact of PFIA.

The main barrier we face in implementing PLIA is financial. The funding we received from TDR/WHO ($9,000) enabled us to implement the program on a very small scale. We'll certainly need experts in monitoring and evaluation, and in drawing up policy documents.

We are submitting our project to the Trinity Challenge for funding so that we can continue the implementation research we started in 2023. In addition to funding, we need national and international experts to support us in implementing our research.

We will need the assistance of experts from the Global Health Network to help us build capacity and improve processes for evaluating the implementation of our program. We remain open to other expertise relevant to our research program.