TrustedABSellers: citizen surveillance data to incentivise stewardship

Label antibiotics clearly with simple stickers linked via QR-codes to health information co-designed with communities. Citizen scientists monitor drug-seller behaviour using open-source technology. Best performances published on app-based dashboards and rewarded via certification. Monitoring and improved consumer discernment incentivises sellers to pursue AB stewardship to improve market share.

Dr Mike Kesby (PI) University of St Andrews 

Goal: Improve AB stewardship in the community.  

Problem: Unprescribed use of ABs is widespread in LMICs. On the demand side, consumers imagine ABs as a cure-all. On the supply side, sellers lack commercial incentives to pursue stewardship (market forces drive AB sales, often for non-bacterial ailments in sub-therapeutic quantities). While AB sales are regulated, enforcement is expensive and inconsistent. Efforts to improve ‘surveillance’ are focused primarily on biomedical data and the burden of resistant pathogens. ‘Citizen-related’, ‘community-level’ data is limited, and studies are conceived/designed in conventional ways primarily to measure behaviour. Public health information on AMR is increasingly widespread but is too often top-down, generic/not locally specific, and medicalised. It fails to engage the public imagination or mobilise factors that motivate behaviour change. Crucially, existing global and national public health information on AMR and antibiotics relies on people’s ability to distinguish antibiotics from other drugs. Many can’t. This is particularly true in LMICs where many people access ABs without prescription, and without much advice from health professionals or drug sellers. All of this is compounded by pharmaceutical manufacturers’ failure to label antibiotics as antibiotics. Clear labelling of ABs is a missing link in the entire global fight against AMR. 

Audiences: the community, drug sellers, policy makers and pharmaceutical producers. 

Needs identification: via ongoing academic research and NGO AMR activism in East Africa.  

Engagement in development: is integral and ongoing via past and future co-production of health information certificates and stickers, feedback surveys, user engagement with app and stakeholder meetings.      

Support: the needs of both antibiotic sellers (supply-side) and consumers (demand-side) in East Africa’s antibiotic sales market are addressed. Sellers obtain commercial incentives to pursue antibiotic stewardship by differentiating themselves as good service providers.  Consumers/public gain: a voice in the coproduction of locally specific AMR information resources, improved knowledge (some also gain technical skills), a stake in the production/use of AB dispensing surveillance data and improved service from sellers.    

This ‘surveillance-as-market-incentive’ approach complements existing efforts by government/regulators to encourage AB stewardship via professional ethics promotion and penalty-based approaches. Furthermore, stickers allow national governments to implement low-cost labelling reform ahead of more complex international initiatives.  

The needs of international big pharma could also be served if they offer parallel sponsorship for elements of the solution – allowing them to demonstrate immediate action to mitigate the risks presented by their inadequately labelled products – as they work towards longer-term labelling/packaging solutions. 

Our solution provides multiple public goods: (1) a simple and effective way to label antibiotics as antibiotics – notwithstanding in what quantity they are sold or whether manufacturer packaging is present. This will link medications themselves with all existing advice about careful AMU: (2) Improvements in the public’s understanding of AMR/AMU (via, stickers, public health messages, app dash boards and community ‘change-makers’ who will offer local support to these resources): (3) Community empowerment, ownership and ‘voice’ in the development of contextually meaningful AMR education materials: (4) Citizen involvement in science and technology, including science, design and IT literacy capacity building in communities: (5) ‘Consumer guidance’ data via the free-to-use app-based dashboard of trusted drug sellers to aid health decision-making: (6) A system of seller behaviour monitoring that complements official government efforts to improve compliance with dispensing regulations: (7) A new business model for drug sellers – that gives a commercial incentive to pursue AB stewardship and provide good health advice services as a way to compete for more informed and discerning customers: (8) Papers and policy briefs that report the solution and its impact. The solution’s formula facilitates bespoke materials grounded in particular contexts yet is applicable internationally. 

Our solution’s closely linked activities, outputs, and outcomes serve the needs of a broad population who currently misunderstand/misuse AB drugs and struggle to distinguish them from other medicines (https://doi-org.ezproxyberklee.flo.org/10.1016/S2214-109X(22)00423-5 & Kesby et al forthcoming). This includes both the middle class and populations who are under-served (distant from government health facilities) and economically vulnerable (habitually purchase sub-therapeutic quantities of ABs). Public awareness will be raised about the hazards of unprescribed sub-therapeutic AMA/U and that it often represents poor value for money (see participatory research in Tanzania and Uganda https://zenodo.org/records/7319094

https://www.youtube.com/channel/UCIU7Zv9kGdSe1Tw5n7OeFsg ). Those directly involved in the production of health information (including school children) will gain new creative and IT skills and competences. Those directly involved in gathering surveillance data (including pharmacy students), will gain additional awareness of AMR and the regulatory and surveillance systems that will govern them once they qualify. The AB sales market will be impacted: key barriers to stewardship (identified by sellers themselves - Loza et al forthcoming) will be addressed presenting a new competitive business model based on reputation and quality service. The public will be able to use certification and the geolocated app dashboards to identify ‘trusted suppliers’ who give safer, quality advice and service.

Our present pilot (2 communities, 40 sellers in Dodoma) would be extended to cover the whole city in the first year. In the second year we will extend the project to 20 of the 40 municipalities in the Dodoma district, developing the contacts that the IRB Initiative has throughout the region. We will also launch the app, advertise and track its usage.  If fully funded, we will further extend the project to all 7 districts of Dodoma region in following year. The 3rd year will be a consolidation year in which we will explore follow on-funding to ensure the sustainability of the project from international donors, business, and the Tanzanian government (we have existing interest in the scalability of these interventions from multiple government departments , including the Chief Pharmacist, the Pharmacy Council and the Tanzanian Medicines and Medical Device Authority) We will publicise our approach on a project website – produce ‘how-to’ manuals, exemplars and downloads that stakeholders in other LMIC settings can apply in their own contexts. We will seek to work with key international organisations (e.g. WHO/Gates foundation) and industrial interests (e.g. GSK) to gain sponsorship and international buy-in for the use of AB stickers. 

Measurement: is integral to our solution. The MCS observations conducted by citizen scientists (year1-3) will measure behaviour change among drug sellers from a base line. The scenario will test a ‘worst case’ (customer without prescription describes symptoms of cough/cold and requests advice - with one attempt to ask for amoxicillin if an AB is not suggested).  

Metrics of success:  

• Sales: Reduction in the rate of AB sales under test scenario conditions.  
• Service: Increase in the amount and quality of AB stewardship advice given by sellers.  
• Information availability: Presence of solution posters in outlets and seller’s use of the AB stickers 
• User engagement: Online metrics will give real time-data on user access to posters (via QR codes), websites and the app dashboards (including geo-locations) and its interactive educational tools like quizzes. 
• Qualitative metrics: Community ‘change-makers’ will provide feedback on the reception of the solution’s ecosystem of resources in the community, and on certificated seller’s perceptions of the impacts on their market share, allowing fine turning of the resources.  
• Key stakeholder engagement: government and professional bodies linking to our online materials, engage in coproduction of public health information materials and/or integrating our monitoring approach into official systems of seller inspection. 

Technological-1: Coding/engineering of the app dashboard developed from scratch (notwithstanding conceptual design-work completed). Low-risk since expert’s costed time on award will address this challenge.  

Technological-2: Not all in target population have smart phones (to access QR codes/educational videos). However, (i) usage is increasing rapidly (https://itweb.africa/content/P... and https://www.reuters.com/articl...), (ii) solution has parallel analogue technology (posters, certificates), (iii) public health education and local ‘change-makers’ will explicitly encourage networked citizens to share information with others (via extended family/peer networks). 

Managerial: Time required to set up, manage, monitor and develop the solution. Colleagues costed time on award will address this challenge. 

Data quality: Data driving our certification system/app dashboard are based upon the work of grassroots data collectors. There is potential for corruption (e.g. informing select sellers before a survey and/or falsifying entries). Training of data collectors will emphasise integrity and involve CPD activities.

Cultural: Drug-seller resistance. However: (i) we are leaning into seller’s self-reported commitment to community well-being (Loza et al
forthcoming), (ii) seller reps will co-design public health information, (iii) solution gives market incentives, (iv) stickers offer an easy way to demonstrate improved stewardship even if other practices lag.

The Trinity Challenge is a unique opportunity to use research data (and in our case, the methods of data collection themselves) to drive lasting change in East Africa’s antibiotic sales market. Trinity Challenge funding would extend what is currently possible within our existing MRC IAA award, enabling us to: (i) extend our ‘citizen-science’ based seller-behaviour surveillance beyond a limited pilot, (ii) engineer our draft designs for a ‘TrustedABSeller’ app, and ‘bring them to market’, (iii) embed ‘citizen-design-collectives’ that use digitised approaches to the co-production of public health information on AMR, within our NGO partner’s activities in ways that deepens and extends their potential. A Trinity award would also offer connections that help facilitate the scaling of our solution beyond our own activities. This would allow other organisations and agencies to apply our entire data/information ecosystem or just some of its innovative parts. We believe that the core values of The Trinity Challenge align closely with our own, particularly as they relate to the desire to make technology inclusive and people-centred, the recognition that diversity, equity and inclusion can drive innovation, and the realisation that communities, not simply community-level data, are central to solving the global challenge of AMR.

We have ongoing relationships with stakeholders and key figures in the Tanzanian government and associated professional bodies with responsibilities for AMR. These are integral elements of our solution as are the schools and community bodies with whom our partner RBA initiative currently works, together with the many more we would recruit as part of our proposed program.  

We note with interest that members of the Trinity Challenge include major NGOs such as Bill and Melinda Gates Foundation and corporations with interests in the field of health, notably GSK but also McKinsey and Company and Optum. We welcome opportunities to received mentorship from any of these organisations. 
We would benefit from introductions to key stakeholders in the intergovernmental and private sector (specifically WHO and pharmaceutical corporations like GSK). Notwithstanding the other elements of our solution, we believe these organisations might be particularly interested in the idea of ‘aftermarket’ stickers that ‘repair/enhance’ information on pharmaceutical products ahead of more complex changes in manufacture’s labelling.   
We would benefit from mentorship in the areas of photo/video editing to ensure our community generated public health information is high quality and that our transfer of skills and competences to partners and communities is exemplary. 

University research office advertise the webinar  (they will have seen a call)