SCOPH Toolkit on AMR Advocacy 2017/18

Antimicrobial Resistance Advocacy

Toolkit

Table of contents Welcome Message Introduction Umbrella of Advocacy Research Networking Campaigning Lobbying Conclusion & Contributors

Welcome Message Dear reader, If you truly believe that Antimicrobial Resistance is an inevitable public health threat, this advocacy toolkit is for you. Hence, we would like to equip you with the knowledge and diversity of tools to address the current challenges posed by antimicrobial resistance in our era.

As youth, we can have a significant role in influencing our communities and their behavioral change. Through a stepwise approach, we aim to provide you with a compilation of resources and key messages to augment public awareness on antimicrobial resistance.

We also shed some light on the antimicrobial resistance situation within our Eastern-Mediterranean Region and added examples from different countries in the EMR to showcase awareness-raising initiatives in alternative settings.

This toolkit was created based on the work by the SWG on AMR advocacy within EMR developed in SCOPH. It can be easily adapted and used on a local/national level by the activity coordinator, according to the specific needs of your activity.

I hope that the advocacy toolkit will be an enriching and unforgettable journey for all of you, as you explore the uniqueness of each aspect we prepared. Thus, our goal is to enable you to confidently act within the realm of this critical public health issue.

Omnia El Omrani SCOPH Regional Assistant for Eastern Mediterranean Region.

Introduction Is Antimicrobial Resistance a crucial issue in your country? Are you truly mobilized but just don’t know from where to start in confronting AMR? Have you ever considered advocacy as an effective trail to adopt in battling such a tricky public health concern? Do you aspire to see your future self as an independent robust advocate in the field of AMR? If your answer is yes to any of the latter, then this toolkit is designed especially for you and your passionate fired up SCOPHero soul.

Antibiotics represent an integral component in modern medicine through saving millions of lives from former deadly infections and sharing in the success of major surgeries as organ transplants and chemotherapies. Now, we live in fear of bacteria, which are rapidly developing resistance to them. This leads to over 700,000 deaths worldwide, spurring us onto a post-antibiotic era, where minor infections can once again kill. (1) World Health Organisation defines antimicrobial resistance (AMR) as the ability of microorganisms (such as bacteria, fungi, viruses, and parasites) to become resistant when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics) used to treat the infection they cause. They are referred to as “superbugs.� Thus, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others. (1) It is an increasingly serious threat to global public health that requires action across all government sectors and society. Without effective antibiotics, the success of major surgery and cancer chemotherapy would be compromised.

(3) In the Eastern Mediterranean Region (EMR), reported rates of resistance have reached dangerous levels both in healthcare settings and the community, threatening the hard-won gains in health and development, and the sustainability of public health response to many communicable diseases, including pneumonia, diarrhoea, tuberculosis, malaria, HIV/AIDS, sexually transmitted infections and healthcare acquired infections. (4)

How can you make the most out of this toolkit?

Introducttion

Goals: Increase knowledge of medical students on antimicrobial resistance and how to tackle it.

Introduce the Umbrella Approach of Advocacy and apply its 4 domains on antimicrobial resistance.

Demonstrate the emerging evidence and statistics of antimicrobial resistance on a regional and global scale.

Define the basics of Activity Management including vision, mission, objectives, methodologies, and its implementation on antimicrobial resistance.

Highlight the importance of evaluation and impact assessment in antimicrobial resistance activities.

Disclose different success stories of NMOs in EMR and their work on antimicrobial resistance.

Explain different approaches to address different target groups and establish partnerships.

Provide a variety of resources and list of stakeholders involved in antimicrobial resistance internationally and within EMR.

References: http://www.who.int/en/news-room/fact-sheets/detail/antibiotic-resistance O’Neill, Jim. "Review on antimicrobial resistance." Antimicrobial resistance: tackling a crisis for the health and wealth of nations (2014). https://www.reactgroup.org/toolbox/raise-awareness/ World Health Organization. Antimicrobial resistance: global report on surveillance. World Health Organization, 2014.

Umbrella of Advocacy: So why? What’s the point of this whole toolkit?!

This section aims at defining advocacy and the components under its umbrella while linking its application to the concept of AMR One Health approach. So why not start with the latter?

The One Health Approach “AMR”: “all for one and for all” As you all know One Health approach has been introduced by the WHO as ‘...the collaborative effort of multiple disciplines – working locally, nationally, and globally to attain optimal health for people, animals and our environment…’

This approach aims to recognize that the health of people is linked to the health of animals and the environment. AMR has a clear connection to each of these three domains. The contribution of animal production, both terrestrial livestock and aquaculture, to the global AMR crises is immense. Because of the way that many antibiotics are used in animal production, in subtherapeutic doses and with long exposure periods, these production systems create ideal conditions for bacteria to fix genes that confer resistance. These genes can subsequently be transmitted to human-adapted pathogens through contaminated food or the environment.

Of the three domains, human health takes the spotlight, with multidrug-resistance genes now highly prevalent among prominent human pathogens like E.coli, K. pneumoniae and S. aureus. Over-use, abuse and misuse of antibiotics has escalated the prevalence pertinently. Quite apart from the many infectious diseases for which we rely on antibiotics to combat, these drugs underpin modern medicine by allowing us to carry out common surgical procedures and treatments that depress the immune system, such as chemotherapy to treat cancer.

The third One Health pillar, environmental health, including that of crops where antimicrobials are also used in plants and agriculture protection, is involved in this tangled web of antibiotic gene evolution, transmission and persistence.

Environmental bacteria, being quantitatively the most prevalent organisms, serve as sources for AMR genes that can become incorporated, over time, into pathogens of humans and animals. This naturally occurring phenomenon is

Umbrella of Advocacy

exacerbated by the influx to the environment of AMR genes from livestock and human waste and by the vast quantities of antibiotic residues that are disposed in the sewage, soil, water supplies...from the pharmaceutical industry, intensive livestock farms and medical facilities. The impact of such factors is likely to be more pronounced in developing countries with lax environmental legislation and enforcement. The threats of climate change and pollution accelerate the wheel of propagation of this global health peril.

Surveillance of Antimicrobial Resistance

Surveillance of Antimicrobial Use

Combined Analysis and Reporting

References: Robinson, T. P., et al. "Antibiotic resistance is the quintessential One Health issue."

Transactions of the Royal Society of Tropical Medicine and Hygiene :(2016) 110.7 380-377.

Aidara-Kane, Awa, Antoine Andremont, and Peter Collignon. "Antimicrobial resistance in the food chain and the AGISAR initiative." Journal of infection and public health :(2013) 6.3 165-162.

Umbrella of Advocacy

It’s obvious from the previous explanation that AMR should be tackled from all angles and aspects of each domain and on all fronts especially in the Eastern Mediterranean Region, and what better way to do that than through the umbrella of advocacy that includes campaigning, networking, data and research and lobbying.

But what is advocacy per say?

“Speaking Acting” Advocacy is speaking, acting, and writing with minimal conflict of interest on behalf of the perceived interests of a disadvantaged cause to promote, protect and defend welfare and justice.

It encompasses the actions one takes in order to effect change for a cause one is invested in through systematic and strategic approach with skills and techniques of influencing political and institutional policy and the public. Since all law, policy and implementation are just reflections of what people believe, in context of a cause, laws, policies and their implementation are relevant by: Being primarily concerned with the fundamental rights and needs of the cause Remaining loyal and accountable to the cause or group in a way which is e emphatic and vigorous Express the views of the people regarding the cause Access information and services to serve the cause Explore methodologies for creating change for the cause In other words, your job as an advocate is to help change people’s minds or those in power about what they think. So yes, it is really the art of getting policy and practice changed by people, for the people and through the people.

It may or may not lead to policy alteration or the addition of new laws/regulations because it works on a larger scale than that of the government only as we will see under the umbrella of advocacy and what it encompasses.

Umbrella of Advocacy

1. Data and Research: “KNOW your cause” How would you know what to advocate and to whom if you don’t search the roots of the roots?!

Research is a studious and systemic inquiry or examination of the truth. They are essential tools for giving the advocate the credibility when making their assertions and for finding existing solutions. In addition, compelling data itself can be the most persuasive argument.

Because AMR works on so many different layers with 3 diverse health domains, research will enable us to discover the true holes in our local AMR advocacy; the relevant problem statements to tackle each in his/her own country and the most impactful audience to target when going through the phases of campaigning or lobbying.

2. Networking “the Rightful Wasta: know your people” Networking is the process of connecting with other people to exchange information, develop contacts, to further one's career and to further a cause success.

As you have seen, AMR involves all the stakeholders and target groups involved in the agriculture, domestic, pharmaceutical and medical industries along with the environmental and educational parties. So wouldn’t it be wise to know who, how to contact and when; during which phases of campaigning lobbying or researching?

The power of advocacy is found in the number of people who support your goal. Even within an organization, internal coalition building, such as involving people from different departments in developing a new program, can help build consensus for action and same goes for AMR. So why is networking crucial? Well, simply, advocating for a cause needs supporters: NGOs, policy and decision makers, partners etc…

And without networking, your cause is devalued. Having properly built strong networks will empower and ameliorate our impact and accelerate its advance when campaigning and lobbying. I mean, us as EMR countries, do know what it means to be backed up by powerful partners, don’t we?!

Umbrella of Advocacy

3. Campaigning: “basically what we usually do” Your target is the public A lot of people confuse advocacy with campaigning. Well, simply, the first is larger in meaning than the other.

Campaigning, in definition, is mobilizing public concern in particular to achieve a social, political or commercial aim. It is a series of activities designed to influence the policies and practices of the people in terms of knowledge, practice or beliefs. So it is basically advocating to the public!

When discussing AMR, it is essential to highlight campaigning and its effects on the public since education and awareness are always lacking in our EMR community and we do rock at those activities don’t we! ;)

4. Lobbying: “work your way up” Your target is your government Lobbying can be defined as any attempt to influence a politician, public official or the government and its leaders on an issue.

This component of the umbrella is placed separately since each EMR government has its own structure, regulations and policies regarding AMR handling in its economy and trade, agriculture and public health ministries. So yes, creating an activity through the public targeting the government or advocating directly to it is truly influential.

Through these 4 delicate components, all the domains of the one health approach can be efficaciously touched and tackled.

NMO Example: Associa-Med Tunisia was present in the National Congress for implementing AMR in Tunis on February 2018. They actively participated in a variety of organized workshops. Additionally, they attended the 3 follow-up meetings and consultations related to the development of the National Action Plan of AMR. By the end of February 2018, the plan was submitted to the WHO with Associa-Med inputs as youth representatives.

References: CMF-MNA Non profit Advoacy: A Michigan Primer by Erin Skene-Pratt http://umbrellanetwork.org/wp-content/uploads/04/2011/Endevour-Advocate-Booklet.pdf

Research To KNOW your cause, research is the first and foremost pillar in our Umbrella of Advocacy. In AMR, you need data and research to: Identify root causes of AMR in your country Identify target groups to address and make the most impact Influence policy makers using evidence-based advocacy

$ 100 trillion cost of antibiotic-resistant infection by 2050

each square is $1 trillion In the Eastern-Mediterranean Region (EMR), the overall level of awareness on antibiotics use is significantly low. There’s also the threatening lack of research and data on antimicrobial resistance in many parts of the world, especially from EMR countries, where over-the-counter antibiotic use is common. Hence, we need to review the reality of AMR in our region.

Even globally, for instance in the European union, AMR causes 25 000 deaths/year and 2.5 months of extra hospitalization days. In india, over 85000 babies died in one year as a result of infection with resistant bacteria usually passed on from their mothers. As for Thailand, it causes more than 23000 fatality and leads to 2.3 months prolongation of hospital stay. Even in the United States, it is the origin of more than 23000 deaths annually and an increase in illness duration by 2 months. And this is only a few examples, only the tip of the iceberg!

What do we know so far?

The first WHO Antimicrobial Resistance Global Report on Surveillance 2014 revealed extensive antibiotic resistance across the region with high levels of resistance in common bacteria to wide-spectrum antibiotics in use, such as third generation cephalosporins and fluoroquinolones. This threatening revelation is attributed to:

Research

1. Lack of knowledge among general public: A study in southern and eastern Mediterranean countries found that %30 of Egyptian participants had self-medicated with antibiotics during the previous year. This was more than %50 greater than other Mediterranean countries and almost six times the proportion reported from a similar European study. We need to know that in Egypt as in many EMR countries, patients can purchase antibiotics without a medical prescription.

In order to assess general knowledge, beliefs and attitudes of people towards the use of antibiotics, the results of a Jordanian study found that the average knowledge score of the sample was low. This finding is further supported by the high proportion of participants thinking antibiotics are useful for common cold; %20.1 of the participants stated that antibiotics were used for bacterial infections, while %18.3 thought they were used for viral infections and %43.6 for mixed bacterial/viral infections. Also, %21.3 of the participants were willing to self-medicate with antibiotics if they thought that antibiotics were good for their condition.

Another study from Jordan had reported that a self medication rate with antibiotic of about %40.

In Ain Shams University Pediatric Hospital %24 of mothers attending the outpatient clinic prescribed antibiotics to their children.

2. Lack of knowledge among physicians: In addition to self-medication, the rate of physician antibiotic prescription for common infections, such as mild acute respiratory infections (ARIs) that do not require antibiotics is extremely high in many countries.

A study in Minya District in Egypt reported that %8 of physicians and %34 of pharmacists agreed on the supposition that antibiotics were helpful in treating common cold. Only two physicians mentioned that antibiotics do not treat viral infections. Others justified their choice of not to treat mild ARIs with antibiotics by lack of illness severity rather than recognition of a likely viral etiology.

Due to the lack of access to microbiological testing, physicians may underestimate the prevalence of resistant bacterial infections.

A Point Prevalence Survey of Antibiotic Use in 18 Hospitals in Egypt found that among the 736 antibiotics given for medical prophylaxis, only %39.5) 291) were given in association with a documented, medically-accepted indication for antibiotic prophylaxis.

Research

This study identified that %59 of patients in the participating Egyptian hospitals were receiving one or more antibiotic agents at the time of survey completion.

This is substantially higher than the prevalence of antibiotic use reported in similar studies performed in Europe and the US. Discussions with clinicians suggested that it was relatively common practice in some of the participating hospitals for patients to be given antibiotics during their hospital stay to reduce the risk of acquiring healthcare-associated infection. This suggests that efforts to strengthen basic infection prevention practices would eventually improve clinicians‘ confidence in infection prevention and control program which could result in substantial reductions in the use of antibiotic agents and the associated complications among hospitalized patients.

Also, there is the growing evidence that dental practitioners are misusing antibiotics in the treatment of their paediatric patients ,a review from Dental College & Hospital, Taibah University, Al Madinah Al Munawwarah, Saudi Arabia: concluded by an urgent urgent need arises to create more concrete and definitive guidelines for dental antibiotic prescribing in children, for all those involved in the management of orofacial infections in children.

We need to remind that also quality-assured antimicrobials are essential for treating infections successfully; poor quality, degraded and counterfeit antimicrobial medicines can lead to AMR, and counterfeit medicines are a particular problem in the Eastern Mediterranean Region.

EMR shares with other regions a common situation; 30 years of no development of antibiotic’ new classes this would take our human being to a post antibiotic area in which common infection and minor injuries could kill by the end of the 21et century.

In a nutshell, research data and statistics in the EMR region is very limited and incapable of conveying how severe antimicrobial resistance has disseminated in the region.

This study identified that %59 of patients in the participating Egyptian hospitals were receiving one or more antibiotic agents at the time of survey completion.

This is substantially higher than the prevalence of antibiotic use reported in similar studies performed in Europe and the US.

Research

Discussions with clinicians suggested that it was relatively common practice in some of the participating hospitals for patients to be given antibiotics during their hospital stay to reduce the risk of acquiring healthcare-associated infection. This suggests that efforts to strengthen basic infection prevention practices would eventually improve clinicians‘ confidence in infection prevention and control program which could result in substantial reductions in the use of antibiotic agents and the associated complications among hospitalized patients.

Also, there is the growing evidence that dental practitioners are misusing antibiotics in the treatment of their paediatric patients ,a review from Dental College & Hospital, Taibah University, Al Madinah Al Munawwarah, Saudi Arabia: concluded by an urgent urgent need arises to create more concrete and definitive guidelines for dental antibiotic prescribing in children, for all those involved in the management of orofacial infections in children.

We need to remind that also quality-assured antimicrobials are essential for treating infections successfully; poor quality, degraded and counterfeit antimicrobial medicines can lead to AMR, and counterfeit medicines are a particular problem in the Eastern Mediterranean Region.

EMR shares with other regions a common situation; 30 years of no development of antibiotic’ new classes this would take our human being to a post antibiotic area in which common infection and minor injuries could kill by the end of the 21et century.

In a nutshell, research data and statistics in the EMR region is very limited and incapable of conveying how severe antimicrobial resistance has disseminated in the region.

How can you start?

Research can be simply divided into: Quantitative – statistical techniques, surveys/market research, experimental techniques. This type of research can be useful to illustrate scale of problem and/or when you want to generalize about an issue or sector.

Qualitative - views, opinions, and beliefs. This type of research can be useful for 'softer' aspects, difficult to quantify (e.g. using focus groups)

This is a link summarizing research bibliography as in how to filter and read relevant articles when initiating any research: https://drive.google.com/file/d/0BxQ0f5zaC3e_djZEcVFoVVNLWTVVMTI xY1prZ0t2RjFZc05R/view

Research

References: https://www.cdc.gov/globalhealth/infographics/antibiotic-resistance/antibiotic_resistance _global_threat.htm Scicluna, E.A.; Borg, M.A.; Gür, D.; Rasslan, O.; Taher, I.; Redjeb, S.B.; Elnassar, Z.; Bagatzouni, D.P.; Daoud, Z. Self-medication with antibiotics in the ambulatory care setting within the Euro-Mediterranean region; results from the ARMed project. J. Infect. Public Health 197–189 ,2 ,2009.

Alzoubi, K., et al. "An audit on the knowledge, beliefs and attitudes about the uses and side-effects of antibiotics among outpatients attending 2 teaching hospitals in Jordan."

(2013).

Sawair FA et al. Assessment of self-medication of antibiotics in a Jordanian population.

Medical Principles and Practice, 25–21:(1)2009,18.

Aboul Fotouh AM, el-Damaty SE, Abdel Megeid FY. Mother’s knowledge about antibiotic and role of self prescription. Journal of the Egyptian Public Health Association, ,1998 69–57:(2-1)73.

Dar-Odeh, Najla, et al. "Antibiotic Prescribing for Orofacial Infections in the Paediatric Outpatient: A Review." Antibiotics 38 :(2018) 7.2.

Antimicrobial resistance: implementing the global action plan in the Region EMHJ, ,2016 2;22.

Darwish DA, Abdelmalek S, Abu Dayyih W, Hamadi S. Awareness of antibiotic use and antimicrobial resistance in the Iraqi community in Jordan. J Infect Dev Ctries. 2014 May;23–616:(5)8.

Kathleen L., et al. "Understanding antibiotic use in Minya District, Egypt: physician and pharmacist prescribing and the factors influencing their practices." Antibiotics 3.2 243-2014:233.

Downes, Kevin J., et al. "Dose optimisation of antibiotics in children: application of pharmacokinetics/pharmacodynamics in paediatrics." International journal of antimicrobial agents 230-223 :(2014) 43.3.

Networking “Who and how to establish your contact” This section helps at providing you with the relevant stakeholders related to AMR’s health approach and how to approach them. They can all be implemented in its umbrella of advocacy; environmental, pharmaceutical, medical, food and animal handling organizations.

1. International Health Organizations: Organizations concerned with public health are definitely potential stakeholders. Those organizations advocate for the proper use of antibiotics and raise awareness about antibiotics as a precious resource that must only be taken with a doctor’s prescription in order to help reduce the threat of antimicrobial resistance. Their aim is to help reduce the improper consumption of antibiotics and to keep antibiotics effective as long as possible in order for those in need to get the best possible treatment. They do this through health workers education, public education, creating guidelines for appropriate use of antibiotics, and urging governments to act on the issue. Moreover, they encourage medical schools and continuing medical education programs to renew their efforts to educate physicians about the appropriate use of antimicrobial agents and appropriate infection control practices, including antibiotic use in the outpatient setting. Lastly, they collaborate with veterinary authorities; encourage their governments to restrict the use of antimicrobial agents as feed additives for animals strictly to those antimicrobials that do not have a human public health impact.

Examples: World Health Organization Regional Office for Eastern Mediterranean (WHO EMRO): http://www.emro.who.int/index.html Doctors without Borders (MSF): https://www.doctorswithoutborders.org/ World Medical Association (WMA): https://www.wma.net/ World Dental Federation (FDI): https://www.fdiworlddental.org/ International Pharmaceutical Federation (FIP): https://www.fip.org/ 2. Animal Health Organizations: Such organizations play a key role in supporting governments, producers, traders and other stakeholders to move towards more responsible use of antimicrobials in agriculture, thus helping reduce antimicrobial resistance in agricultural systems. They do this through improving awareness on AMR and

Networking

related threats, developing capacity for surveillance and monitoring of AMR and AMU (antimicrobial use) in food and agriculture, strengthening governance related to AMU and AMR in food and agriculture and promoting good practices in food and agricultural systems as well as prudent use of antimicrobials.

Examples: Food and Agriculture organizations of United nations http://www.fao.org/home/en/ World Veterinary Association (WVA): http://www.worldvet.org/

(FAO):

3. International student organizations: The easiest to collaborate with. These organizations are involved like world health organizations in advocating, raising awareness, educating and cooperating with higher stakeholders as well.

Examples: International Pharmaceutical Students' Federation IPSF : https://www.ipsf.org/ International Association of Dental Students IADS : http://www.iads-web.org/ International Veterinary Students' Association – IVSA: http://www.ivsa.org/ 4. Grocery and beef producers: These stakeholders are important as they provide safe and healthy products to their consumers by implementing on-farm mitigation strategies.

Examples: Food safety international : https://www.foodsafetyintl.com/ Safe food http://safefoodinternational.org/regions_namideast.html

international:

5. Research Organizations: Research on antibiotic resistance is still shockingly low especially in the EMR. Information and data is needed to encourage interested parties to take up the issue, to facilitate action on the ground and influence global policies. The organizations listed below have the objective of using research to support better decision-making in health policy. Their researchers employ a range of

Networking

expertise—including economics, epidemiology, disease modeling, risk analysis, and statistics—to conduct actionable, policy-oriented research on antibiotic resistance. Such organizations could be a very crucial stakeholder if convinced to collaborate in our region.

Examples: The Center For Disease Dynamics, Economics & Policy (CDDEP): https://www.cddep.org/ ReAct-Action On Antibiotic Resistance: https://www.reactgroup.org/

What about our local stakeholders?

Algeria: Réseau Algérien de Surveillance de la Résistance des Bactéries aux Antibiotiques (AARN) Lebanon: Knowledge to Policy (K2P) Center, American University of Beirut https://www.aub.edu.lb/k2p/Pages/MissionVisionObjectives.aspx Alliance for the Prudent Use of Antibiotics APUA, Lebanon. https://apua.org/lebanon/ Morocco: Institut pasteur http://www.pasteur.ma/microbiologie.php Société marocaine de microbiologie médicale http://smamm.ma

Campaigning This section aims at introducing activity management including problem statement, goals, objectives, target groups, beneficiaries, stakeholders, methodology, SWOT analysis, success indicators, timeline, impact assessment and feedback. It will also manifest the diverse target groups to address with a variety of activities prevailing our AMR battle in the EMR region.

As noted previously, campaigning is mobilizing public, institutions or specific groups concerns through organized actions in order to achieve a social, political or commercial aim and induce a behavioral change. It can easily be the strongest tool of advocacy, once it is initiated appropriately with the right strategies.

To mention a few of its prosperous benefits: It can address the root causes of AMR following adequate research and not just their effects.

Shine a spotlight on an emerging issue such as AMR that have not yet been picked up by policy makers.

Help give a voice to those without one, or bring together disparate voices to create a collective roar especially when it comes to administration of antibiotics and all the misconceptions around it.

It can be the only action possible, especially when that the scale of AMR is large and it cannot be dealt with without state intervention.

Demonstrate that it is not just your NMO that is concerned about AMR, but also members of the public. (“grassroots”, refer to the “lobbying section”) Campaigning is an engine for social change. It doesn’t only educate the public about AMR, but also motivates them to speak and act in support of change.

Campaigning

Activity Management Before you start to plan your activity on antimicrobial resistance, you should firstly know what is an activity and why we do it. You need to define your vision and mission. We will be using the analogy of a mountain to explain these tricky concepts.

Mission

Vision

Goals Objectives

VISION: “YOUR WHY? Why am I doing what I am doing?”

The vision defines why you do what you do, where you are heading. It’s usually a short and broad statement that could fit lots of ideas but shows exactly the purpose of your idea, your motivation.

If we are the climber, the vision is the considered the top of our activity mountain, that we want to strive for and always aspire to.

It is characterized by being idealistic and utopic, seeking perfection and projected in the future. We, as public health leaders usually follow the vision of our association (IFMSA). Our mission and goals as a Standing Committee (SCOPH) are derived from it. Those are our steps towards the ultimate end of the mountain.

Campaigning

An example of this for AMR would be: A world where AMR will be eradicated A world where no one will suffer from the adverse effects of AMR A world where no one will die from AMR related causes

MISSION: “Vision= someday, Mission=everyday” The mission defines how you do it. The methods you are going to use, kind of activities you will perform, etc. It’s a statement written in present tense that shows the approach towards your aim.

A mission is usually more reachable, realistic, directional, bound with time but still inspiring. It falls under the sky of the vision and falls in the range between goals and vision as we shall see.

According to our analogy of the mountain, it represents the tip of the mountain in which our goals should be set towards it.

Once you have set your Vision and Mission. The next step is to think of your goals and objectives.

An example of a mission for AMR would be: A world where medical students are proactive in AMR A world where all governments secure regulations to fight AMR

GOAL: “How to Follow that Mission” The goals are tightly related to the Mission. In fact the Mission could be the summary of the goals. If our mission is “A world where all doctors acknowledge the issue of AMR and learn how to approach it.”

Going back to the mountain example, if we are the climber, goals are the ways we can reach the top of the mountain (the vision). For instance, we can slowly trek, hike, take a helicopter, build an elevator, etc.

Campaigning

Of course, goals are narrower in scope, even more realistic and therefore are designated as the cornerstones/stations we take on the a certain trail as way to reach the tip of the mountain “the mission.”

A well-crafted goal answers WHAT you do and WHO benefits.. All in all, the purpose is to help you stay focused on the activities of today that further your dreams of tomorrow “the mission.”

Example of goals on AMR for the previously stated mission (1): Equip medical students with the knowledge to understand the root causes of AMR.

OBJECTIVE: “What do I need in order to use Goal as a methodology; Be SMART” Once we have set at least one or more goals, we can start developing our objectives. Objectives are specific measures that will help you complete your goal.

In the mountain concept, the objectives are what the climber would need to tread the specific way (goal) we chose. For instance, if we as the climber chose to hike, we would need hiking boots, equipment, food supplies etc.

Objectives are the methodologies in which you choose to accomplish the goal.

Usually, each goal has several SMART objectives.

When coming up with them, we should make sure they are SMART. What do we mean by that?

Specific Answers the question - Who, What and How? So it contains your methodology as in how did you choose to execute you activity to attain your goal Measurable.

Answers the question - How do I measure this step?

The success toward meeting the goal can be measured with numbers, dates, percentages.

Campaigning

Achievable.

Answer the question - Can it be done?

Goals are realistic and can be achieved in a specific amount of time and are reasonable.

Relevant.

Answer the question - Is what I am doing relevant to the goal in specific and vision in general?

Goals are aligned with current tasks and projects and focus in one defined area; include the expected result.

Time-bound.

Answer the question - How long would it take for me to complete this step?

A clearly defined time-frame including a target or deadline date.

The more SMART our objectives are, the easier to conduct the activity since we state exactly how we want it to be.

Examples to the previously set objectives on AMR: Record a 10 minute video regarding AMR from at least 5 NMOs to reach a X number of medical students during the AMR Campaign Week from (Starting Date-Ending Date) Organise a workshop on AMR at the EMR Regional Meeting in February next year for X number of medical students

Level of specificity: It is crucial to understand that the level of specificity at each level can be different. Vision, mission, goals and objectives are not distinguished on the basis of their specificity only, but rather their inherent characteristics defined above.

Example: Vision A world with no Antimicrobial Resistance. (Less Specific) A world where all physicians are aware about the dynamics of AMR. (More Specific)

Campaigning

Problem Statement: “BUT FIRST: know your problem” When it comes to AMR and any public health threat, one must assert this problem statement before determining the mission, goals and objectives.

This step depends largely on your research to explore the true roots of AMR present in your community and a dense brainstorming process. “Refer to the research section” Factors causing emergence of AMR: AMR is a natural process that occurs naturally in microbes in a long lapse of time, nevertheless, there are several factors that are speeding up this process: 1. Misuse of antimicrobials by farmers : Farmers need more help to feed the world in a safe and sustainable way.

Antimicrobials are important to treat sick animals and keep pathogens off our plates, but when they overuse it and misuse it as for prophylaxis or as growth promoters, this causes AMR. A big majority of farmers are not aware of the proper use of antibiotics or their effects on animals, plant and soil.

The root cause for this issue could be related to lack of education and awareness of farmers of this topic, as well as lack of clear and strict guidelines that direct the use of antimicrobials in the agricultural sector.

2. Misuse of antimicrobials by the general public: In our communities, patients either access antibiotics directly without a prescription or request antibiotics from physicians. They tend to ask for antibiotics and use them for any simple fever or cold. Patients also tend to go for automedication, without following any scientific regime or dosage. They would stop the treatment once symptoms are gone or alleviated, giving the chance to surviving bacteria to grow and become resistant.

The root causes of those issues are: Low levels of public awareness in the EMR region due to absence of education programmes that would equip them with enough knowledge to change their attitude and behaviour to become more positive.

Campaigning

Lack of political engagement towards the topic: Easy access to automedication and antimicrobials without prescription is mainly due to the lack or poor application of legislations that guide and control this use.

The passive attitude of healthcare professionals: Health care professionals are mainly involved in the AMR issue, since doctors are responsible for prescribing antibiotics just to win patient’s satisfaction and get a potential client.

Pharmacists also dispense and sometimes prescribe antibiotics, knowing that they shouldn’t, but they do it.

It’s because if they don’t, patients would go to another pharmacy.

Lack of knowledge of healthcare professionals. This is the main reason we get to see cases poor antimicrobial prescribing practices or incorrect choice of drugs by doctors due to inadequate teaching of such topics in universities.

Factors causing the spread of AMR: The reason why AMR is considered one of the most dangerous health threats in history is the ability of resistant microbes to spread and affect more people easily.

1. Favorable environment: Resistant bacteria can spread once they find the appropriate environmental conditions. In our communities, we still suffer from many challenges related to environment which lead to more infections especially by resistant microbes. Such issues include: Lack of proper housing and working conditions Lack of safe water Lack of food safety Lack of air quality Lack of hygiene and sanitation

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2. Lack of individual hygiene and preventive measures: Our populations tend to neglect simple preventive measures and daily hygiene habits, such as regular washing of hands, which is considered the most powerful way of protection from infections. Another important measure is avoiding contact with sick personnels. However, the large number of people living in the same place, house or neighbourhood make infection spread more frequently. Other measures such as; clean diet, vaccination, using insect repellents and vaccinations.

3. Poor infection control in hospitals and clinics: Hospitals are the origin of infection spread, and usually contain multi and ultra resistant microbes that constitute a serious threat for patients as well as healthcare professionals. Our hospitals still lack infection control and hygiene measures which leads to a higher rate of nosocomial infections

How does AMR spread?

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Key elements of an effective awareness campaign strategy: When initiating a campaign, you must ask yourself how you will develop a preliminary image or framework of how the campaign needs to be arranged from its very early phases till its application.

This is a brief diagram regarding awareness campaigning to be adopted in addition to the stages mentioned above:

Reasearch Repeat

Set target plan the campaign

Evaluate the impact

Use the right skills

Implementation

Develop the campaign

Communications brief

Seek Expertise

Research for the selection of the target group and materials to be used as simplified credible data to transmit to the target group.

Set the target based on you problem statement, goals and validity of the cause Plan the campaign to be conducted by a worthy leader and supported on the political, social and media platform if possible Use the right skills to design an appealing tailored content to the audience to successfully convey your message. Marketing is a prominent corner at this point.

Communications brief; by deriving from information collected in previous steps and will serve as a personalised guide for the campaign in question.

Seek expertise, whether internal or external experts to be engaged in order to put together a high quality campaign in collaboration with your OC. Develop the campaign and how to approach the audience in conjunction with the stakeholders.

Implementation.

Evaluate the Impact.

Repeat.

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Methodologies: Workshops: It usually involves two main aspects: Knowledge and Skills. They include giving lectures/sessions on AMR. Training sessions could be held to equip medical students with the baseline knowledge concerning AMR. It is IFMSA mission to equip medical students with adequate knowledge and skills on several medical issues to allow them to be outstanding future physicians and leaders. Secondly, those medical students are going to be the manpower in other types of the campaigns, so it is vital that they are able to deliver the right message in a suitable manner.

NMO Example: Following the “One Health Approach”, Associa-Med Tunisia have collaborated with Dental, Veterinary and Pharmacy Tunisian Students’ Organizations in order to have a better impact on our society. They have organizing a Public Health Leadership Training (PHLT) on AMR, gathering over 20 students from four different associations to thoroughly equip them with the knowledge and competency to become better advocates for AMR. Physical campaigns: These type of campaigns involves delivering information to the audience in need but the key point is to be as creative as possible, otherwise, your message drowns in the ocean of data that our audience swims in on a regular daily basis . It includes distributing poster/brochures/pamphlets/entertaining explanatory games on stands or face to face or during a celebration, coupled with an adequate explanation.

NMO Example: STIK TIK antibiotic - IFMSA Morocco: This year, IFMSA-Morocco decided to take action and to reduce the emergence of AMR in the future, by controlling and fighting the anarchic use of antibiotic. They focused on raising awareness of the general public on the danger of auto-medication with antibiotics. They filmed a dramatic video to get the message across. The video was seen by more than 30,000 people until now, in addition to articles in 8 of the most popular electronic press. It was a golden opportunity to clarify and answer people’s questions in the comments. Moreover, they organized radio and TV passages for a larger reach. In order to encourage pharmacists not to deliver antibiotics without a

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prescription, they had posters in a diversity of pharmacies and spurred pharmacists onto educating patients and encouraging them to visit doctors before buying any drugs. Another focal point of their project was encouraging physicians to limit the prescriptions and raise awareness regarding this matter to their patients.

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Online & media campaigns: This type involves delivering the information online in the form of interactive and attractive posts, videos, pictures. It has a wider outreach than physical campaigns. Feedback and impact evaluation on this example is a challenge, but it depends on your method and the indicated success indicators.

NMO Example: During the AMR week celebrated by IFMSA, LeMSIC-Lebanon launched its one of a kind successful online campaign comprised of 5 infographics, each tackling a different aspect of AMR and delivering sensible simple precautions to follow by the general public. The campaign lasted for 4 days and reached more than 18000 with an immense number of shares and likes and it was present on our official facebook and insta pages as well as other pages that were impressed by the initiative.

The posts were actually shared worldwide from Romania, Greece, Brazil and spain to Jordan, Egypt, Algeria, Morocco and Tunis… the campaign adopted a delicate friendly and funny approach using proverbes and animated characters. The latter also participated in IFMSA’s competition for the funniest comics delivering a message on AMR.

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Conferences: Conferences can be the last step. It includes a representation of what we have done throughout the whole project or campaigns.

Conferences can aim for changes; real world changes. Policy makers can be invited in these conferences, where required changes can be discussed and preliminary agreements for changes can be planned.

NMO Example: Dwa machi 7elwa FASEM Algeria: A national campaign that was initiated this year to fight AMR. Choosing a title ‘’dwa machi 7elwa‘’ or ‘’drugs are not candy’’ to send the message that drugs are not to be easily consumed in a simple way. The campaign started by a conference for students of Constantine University to increase their knowledge with a quiz in the end to evaluate the improvement of the attendees knowledge.

After that, SCOPHeroes went to the tramway of the city of Constantine, where they talked to the people raised their awareness of the importance of consulting doctors before using drugs. The third event was in a primary school, where we did a conference for parents and educated them on the topic. After that, they organized an awareness day in a public place in the city of Constantine. They shared materials and flyers to make them aware of the dangers and risks of the anarchic use of antibiotics. They also did another conference targeting general doctors, that was facilitated by a specialist professor on infectious diseases to thoroughly discuss AMR and the prescription of antibiotics.

Medical Health Days Curriculum alterations in schools and universities to educate on the topic of AMR Vaccination Activities JUST GO WILD and CREATIVE!

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Target groups: 1. General population including all ages 2. Farmers and agricultural sector personnels 3. Healthcare professionals Information delivered to these target groups should tackle the roots as well as the causes of spread of AMR and they can be: General: includes knowledge on the causes of AMR and how it spreads. those can be found in the previous paragraph.

Specific: delivered to each target group alone depending on their level of involvement and contribution in AMR. Concerning the general information to be adopted: General Public: WHY: The general population is the main target in the campaigning work.

Every person can be affected by AMR or is already contributing to the problem.

It plays a crucial role in increasing the emergence of AMR through misuse and all myths they hold around it. The aim is to rectify those wrong habits and conceptions through campaigning.

HOW: To reach the general public, you can organize campaigning events in: Public spaces such as shopping centres, parks, clubs, streets, public transports.

Online outlets such as: social media, TV and radio programs and journals.

Specific campaigns targeting youth in universities or concerts. parents of kids in schools.

WHAT: Useful measures to transmit to the public effective prevention and control of AMR in the community.

Only use antimicrobials when prescribed by certified health professionals.

Never use antibiotics for flu or cold unless told by a doctor: those are caused by viruses that don’t require antibiotics.

Always complete your treatment regimen even if you feel better (In the case of antiviral drugs may require lifelong treatment: usually the normal course of administration is from 10 to 14 days max) Don’t use leftover antibiotics.

Avoid sharing antibiotics with others.

Avoid infections by simple lifestyle habits:

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Regularly wash your hands.

Avoid contact with sick people.

Follow a strict updated vaccination schedule as announced by medical facilities (it is wise to share the official vaccination schedule adopted in your country and which are offered free of charge as indicated by the who expanded program on vaccination) Using condoms is crucial.

Healthy diet and safe handling of food with properly washed vegetables/fruits and adequately cooked meat without the excessive use of detergents.

Use insect repellants.

Farmers & Agricultural Sector: WHY: Antibiotic use for animals and agriculture accounts for the elevated emergence of AMR. Those are considered a primary target group to always consider in your campaigning work HOW: To reach this target group, try to Approach them in their working places: farms, shopping areas, where they sell their products, countrysides, factories for animals’ and plants’ products.

Seek their representatives and organizations and have meetings with them. (refer to “the networking section”) Establish guidelines for proper and effective use of antimicrobials for animals and plants.

Offer trainings to farmers on the uses of antimicrobials and offer alternatives.

WHAT: Ensure that they can accomplish the following: Ensure that antibiotics given to animals are only used to control or treat infections and are under veterinary supervision.

Vaccinate animals as required to reduce the need for antibiotics.

Encourage using natural and healthy alternatives to antibiotics for plants growth and protection.

Promote and apply good practices at all steps of production and processing of foods and other products from animals and plants sources.

Implement sustainable systems with improved hygiene, biosecurity and stress-free handling of animals.

Implement international standards for the effective use of antibiotics and guidelines set out by OIE, FAO and WHO.

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WHO recommendations: “what they should be doing” WHO strongly recommends an overall reduction in the use of all classes of medically important antibiotics in food-producing animals, including complete restriction of these antibiotics for growth promotion and disease prevention without diagnosis.

Healthy animals should only receive antibiotics to prevent disease if it has been diagnosed in other animals in the same flock, herd, or fish population.

Where possible, sick animals should be tested to determine the most effective and prudent antibiotic to treat their specific infection.

Antibiotics used in animals should be selected from those WHO has listed as being “least important” to human health, and not from those classified as “highest priority critically important”. These antibiotics are often the last line, or one of limited treatments, available to treat serious bacterial infections in humans.

Where possible, sick animals should be tested to determine the most effective and prudent antibiotic to treat their specific infection.

Many countries have already taken action to reduce the use of antibiotics in food-producing animals. For example, since 2006, the European Union has banned the use of antibiotics for growth promotion. Consumers are also driving the demand for meat raised without routine use of antibiotics, with some major food chains adopting “antibiotic-free” policies for their meat supplies.

Alternative options to using antibiotics for disease prevention in animals include: Improving hygiene better use of vaccination changes in animal housing and husbandry practices.

Healthcare professionals: WHY: Healthcare professionals are one of the easiest target groups to approach, yet their role in prevention or aggravation of AMR is very demanding. They represent the direct influencer of population’s use of antimicrobials, they are also the ones to detect, treat and surveil infections and microbes.

HOW: To reach healthcare professionals you can : Target their organizations and representatives (doctors council, board of pharmacists…)

Online campaign in medical forums, groups and websites.

Target medical forums, conferences and events.

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WHAT: Healthcare professionals include many sub-target groups and every one of those has a critical and specific task to play in our fight against AMR: 1. Dentists: Dentists should be advised to: Always follow infection prevention and control protocols Only prescribe antibiotics when needed and according to international current guidelines Talk to patients about the dangers of AMR, misuse of antibiotics and how to take them correctly.

Ask their patients about their previous and present antibiotic use Instruct patients on good hygiene and preventive methods such as : vaccination, hand washing, safe intercourse, covering mouth and nose while sneezing‌.

2. Doctors: Doctors should be advised to: Always follow infection prevention and control protocols Use diagnostics to make informed treatment decisions Talk to patients about the dangers of AMR, misuse of antibiotics and how to take them correctly.

Only prescribe antibiotics when needed and according to international current guidelines Instruct patients on good hygiene and preventive methods such as : vaccination, hand washing, safe intercourse, covering mouth and nose while sneezing‌ 3. Pharmacists: They should be advised to: Only dispense antibiotics when needed according to current guidelines ( does the patient have valid prescription, is it for the right drug/dose/duration ? ) When patients are seeking treatment for cold or flu, explain that antibiotics are not needed Educate patients about the dangers of AMR, misuse of antibiotics and how to take them correctly.

Remind patients to contact their health professional if symptoms persist.

Instruct patients on good hygiene and preventive methods such as : vaccination, hand washing, safe intercourse, covering mouth and nose while sneezing‌ 4. Hospitals and clinics managers: They should be advised to: Prevent the spread of infections by ensuring regular and accessible handwashing for staff, as well as sterilization for instruments Implement programmes and guidelines to optimize antibiotic use and monitor prescribing and resisting patterns.

Dedicate resources (human, financial, IT) to tackle AMR and prevent the spread of infections as well as establishing hospital surveillance systems

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Discharge patients as soon as they are well enough to lower the risk of infection Establish adequate and regular cleaning measures : adequate toilets, safe water and and proper waste management.

Isolation of infected patients to prevent infection spread 5. Health Students and Universities: Why? Medical, pharmaceutical, dentist, nurse, and other health students can be hugely invested in the cause of AMR and its prevention and control as they are in direct contact with patients. They will be the future healthcare professionals that will shape health sector in the community, this is why it is a necessity to educate them and improve their knowledge about AMR. Another important target is universities and faculties, it is very important to advocate in order to implement AMR education and include it as a main topic in the curriculum of medical and health students, in order to improve student’s knowledge and extend their contribution to the situation.

6. Midwives: Why? Midwives still have a significant presence in our societies and should therefore be tackled as a target group in our campaigns.

What? They should be advised to: Always follow infection prevention and control protocols Screen mothers and babies for infections Encourage breastfeeding practices for mothers, and show its importance in boosting the child’s immunity Discharge mothers and babies as soon as they are in good condition to lower the risk of infection Teach mothers about hygiene and infection prevention (vaccination, hand washing, safe intercourse, covering mouth and nose while sneezing…)

7. Nurses: They should be advised to: Always follow infection prevention and control protocols When patients need antibiotics, ensure they are taking the right dose, for the right time and by the best route.

Educate patients about dangers of AMR, misuse of antibiotics and how to take them correctly.

Instruct patients on good hygiene and preventive methods such as : vaccination, hand washing, safe intercourse, covering mouth and nose while sneezing….

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8. Healthcare Workers: Healthcare workers are all those who work in hospitals ( other than doctors and nurses) those are in continuous contact with patients.

They should be guided to: Ensure that hand, instruments and environment are always clean Prescribe and dispense antibiotics only when needed, according to current international guidelines.

Report drug-resistant infections to surveillance teams.

Talk to patients about the dangers of AMR, misuse of antibiotics and how to take them correctly.

Talk to patients about preventing infections by sticking to hygienic instructions like: vaccination, hand washing, safe intercourse, covering mouth and nose while sneezing...

Please do note that all of the above is just a suggestion whether it was the target group or the examples of activities. We are sure you have plenty of unique original ideas to apply what is in this toolkit to its out-most use and create some amazing impact.

Timeline: “Your Activity Calendar” The timeline helps you managing deadlines according to your needs. If you have to perform an activity in 6 months, you can set specific times to work on different tasks. For example, brainstorming during the first month, activity planning during the next week and fundraising for 2 more months etc. Different tasks can happen simultaneously or in order of succession and in this way you can see the whole picture of what’s going on.

So try to come up with a timeline schedule, mark your dates and follow up on the progress of the activity.

Evaluation Did you manage to achieve what you set out for {goals}? How well did you do it?

What do you need to change? Of course, it should be planned and outlined before the execution of the event.

Why do we evaluate?

Because you want to know if your methodology works Choosing the project/activity that aligns best with your mission Improving or changing your activities Being accountable to your partners and funders

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It usually includes: A feedback to evaluate the methodology you chose in your objective on the target group (Was it appealing? Was it suitable? Should it be done again?)

An impact assessment which is basically evaluating the success and reach of your activity that you previously set in your goal and objectives (were the objectives reached?

Were the indicators of success met? Is my goal fulfilled?). It is usually the hardest to accomplish.

Methodology Online campaign: -Posts -Videos.

-Toolkit

Conference

Workshop Training

Feedback

Impact assessment

Online poll on likability Follow-up on the number of likes, shares and comments Follow-up on the reach and views through the admin of pages Follow-up on its spread on different social media through SCOPH members worldwide

Online knowledge testing poll shared on the same pages.

Online quiz with a certain prize related to the campaign.

Follow-up with national officers on any questions regarding the info shared in the campaign by the members

Feedback stand with prepared forms present in the event.

Email if possible for feedback and impact assessment.

Direct evaluation of knowledge following the conference through live questions or distributed forms.

Follow up with the participants to record any change in behavior.

Direct live training feedback method Follow-up email to the participants

Follow-up evaluation form email Live pre/post evaluation form filled during the event, they can be knowledge based or aim to evaluate if it lead to change in behavior (starting an activity etc.)

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Methodology Health day

Article publication

Public awareness campaign

Feedback

Impact assessment

Feedback form sent on whatsapp or through emails to the volunteers/ OC members Verbal communication with the participants on the approach of the event.

Feedback stand present in the event Attendance number

Follow-up with the participants on their medical visits with the affiliated centers.

Follow up with the affiliated doctors and their participants if possible.

Possible record of pre and post detection of AMR cases in a followed local hospital

Journal impact factor Number of downloads and viewers Follow-up with the journal

Verbal assessment through a training method Follow up diary distributed to the students on the day of the event Regular visits with assessment forms to the students.

Noted change in practice by the school’s administration and staff Introducing AMR to be part of the curriculum

Feedback stand Verbal/written feedback Collection of phone numbers/emails and continuous follow-up Successful repetition/replication of the event

Observed change in behavior in the target group if possible.

Decrease in the cases of AMR in a certain hospital following several campaigns for example.

Collection of phone numbers/emails and continuous assessment follow-up.

Possible record of antibiotic purchase in certain followed local pharmacies

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Methodology

Feedback

Impact assessment

Verbal feedback Amount of money collected

Amount of money collected and its employment in AMR

Exhibition

Written feedback present on a stand

Follow up on cases of AMR and antibiotic purchase if possible

Direct lobbying activity

Verbal feedback from the decision makers on the approach

Implementation of change or set up of a new legislation (goal achieved)

Previously mentioned examples depending on your activity “Refer to the lobbying section�

Implementation of change or set up of a new legislation (goal achieved)

Fundraisers

Indirect lobbying activity

Lobbying This section aims at elaborating the concept of lobbying and mentioning related applicable advocacy activities. It will also include on section on how to approach the government and assess the impact of the advocacy performed.

Lobbying is divided into 2 major categories, feel free to follow/apply any manner you find more achievable and fruitful.

Direct lobbying: Any attempt to influence new or existing legislation via communication with a member of the legislative body or other government representative who has a say in the legislation. In order for this communication to be considered direct lobbying, it must refer to specific legislation and must reflect a view on such legislation. It usually involves meeting with decision makers, discussing an issue, arguing your cause and making concrete recommendations.

Indirect or “Grassroots” lobbying: Asking the general public to contact their legislator and/or mobilizing the public around a legislative issue for AMR in this case. So NGOs and federations like ours cannot only ask their members to contact their legislators or government agencies regarding the legislation, though, as this is considered direct lobbying. They have to go through activities alarming the general population about AMR to pressure the higher authorities on decision making and law amendment.

To be considered grassroots lobbying, the communication must refer to specific legislation, it must reflect a view on the legislation and must encourage the recipient of the communication to take action with respect to the legislation.

There is a wide creative range for the application of indirect lobbying. It can often be done through the purchase of media such as newspaper and radio advertisements and TV commercials and billboards. These are very effective tools to get your message out there. It can also include creating an online petition to generate public support for a cause, distributing flyers, and organizing a public demonstration or protests, door to door canvassing, surveys…

Direct lobbying:

“You vs. the legislatures” Several simplified steps can be followed to exercise successful direct lobbying and will be shortly expanded: -1 Know the current situation on AMR and this can be achieved through research as thoroughly elucidated in the “data and research section”:

Lobbying In order to intervene in the political decision-making process it is not enough to be fighting for a just cause. A convincing argument is also needed, with evidence to support and focus the debate. It needs to be backed up with facts, research, analysis and even scientific evidence to help decision-makers make their decisions.

Make sure that lobbying comes as the final step in your work after you’ve done your research and field activities to have a better position in your lobbying work.

-2 Study the opposition and the stance decision makers hold regarding AMR in your country and what kind of interventions they are practicing if any regarding the 3 domains of AMR’s one health approach.

-3 Study the political process adopted in your country by contacting professors of law or direct exposure to the constitution and its regulation if possible: -4 Define your problem statement: which legislation to engage, any possible compromises to be made, reasons for such a choice and a suggestion for amendment to be prepared.

-5 Understand what the reaction of your lobbying can create on political figures as well as your media in your country and so work on your timing. A priceless point to consider. “Timing” -6 Establish a strong network of local, national and international stakeholders willing to back your advocacy as demonstrated in the “networking section” -7 Connect successfully with political figures capable of supporting your lobbying from the inside and this would truly be the hardest step to apply if possible.

-8 Contact the Media/Press Gallery and let them know who is involved, what your case is, what you are looking for and when your campaign events are.

Today the media’s power overwhelms are other reaches towards raising the voice on a matter, lifting an injustice or pausing a serious cause.

-9 Back up your direct lobbying with indirect lobby such as events, publications, media appearances and other forms of publicity.

-10 Make sure there are no open disagreements within your campaign.

-11 Keep up the campaign until succeeding or reaching a dead end. Your impact assessment depends on your success criteria you have already placed for the direct lobbying activity.

Lobbying Please bear in mind that planning for such advocacy follows the activity planning and management validated in the “campaigning section” as this applies to any sort of activity involving all the components of the advocacy umbrella.

For steps 2,3 and 4: The AMR action points to shed the light on for decision makers include the following:

human domain

animal domain

environment domain

For the human domain of the one health approach: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training in the educational system and through the media to the general adult public.

Strengthen the knowledge and evidence base through surveillance and research conducted by funded neutral governmental facilities Optimize the use of antimicrobial medicines in human health through direct legislation on the restriction in use and prescription by the corresponding ministries on pharmacies, medical facilities and outpatient clinics.

Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures to be implemented in all community facilities: schools, hospitals, markets, governmental institutions…

Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.

For the animal domain of the one health approach: Optimize the use of antimicrobial medicines in animal health through direct legislation on the restriction in use and prescription by the corresponding ministries (public health, environment, agriculture and domestic care, economy…)

Lobbying Set a monitoring system for the malpractice in the use of antibiotics by farmers, landowners, production companies and veterinarians.

Place strict legislations regarding the types of antibiotics imported and used on cattle.

For the environment domain of the one health approach: Set legislations for the control of pollution and climate change (plastic use, recycling facilities, awareness, fuel consumption regulation, sewage and medical waste management.

Same measures mentioned above for the regulation of antibiotic use in agriculture.

The previous are only a few suggestions for direct lobbying of course, depending on your political and constitutional status; you can construct you action point(s) based on your AMR situation and related legislations present in your corresponding government.

For steps 5,6 and 7: This is an effective maneuver when approaching maker/stakeholder: Make sure you check the validity of this point first:

a

decision

-1 Check the website if your country has adopted a national action plan to combat AMR: http://www.who.int/antimicrobial-resistance/national-action-plans/library/e n/ If the country has already a plan established, encourage them to give more priority to AMR, and make sure to ask to be included as a main stakeholder in the implementation and review of the plan.

-2 If not yet, here is the WHO guide to establishing a national action plan, make sure to use it What you need to know about the WHO AMR Global Action Plan: In response to the AMR crisis, the May 2015 World Health Assembly adopted a global action plan on antimicrobial resistance following the “one health� approach, which outlines five objectives: to improve awareness and understanding of antimicrobial resistance through effective communication, education and training; to strengthen the knowledge and evidence base through surveillance and research; to reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures;

Lobbying to optimize the use of antimicrobial medicines in human and animal health; to develop the economic case for sustainable investment that takes account of the needs of all countries and to increase investment in new medicines, diagnostic tools, vaccines and other interventions.

The action plan recognizes and addresses both the variable resources nations have to combat antimicrobial resistance and the economic factors that discourage the development of replacement products by the pharmaceutical industry.

At the national level, the WHO requires the Member States to establish their national plans within two years from 2015 to 2017, in accordance with the One Health Approach, global action plan and standards and guidelines established by intergovernmental bodies such as the Codex Alimentarius Commission, FAO and OIE. All national action plans should reflect the following principles: Whole-of-society engagement including a one health approach Prevention first.

Access: the aim to preserve the ability to treat serious infections requires both equitable access to, and appropriate use of, existing and new antimicrobial medicines.

Sustainability Incremental Targets for Implementation: flexibility will be built into the monitoring and reporting arrangements in order to allow each country to determine the priority actions that it needs to take in order to attain each of the five strategic objectives and to implement the actions in a stepwise manner that meets both local needs and global priorities. http://www.who.int/antimicrobial-resistance/national-action-plans/manual/en/ Presentation and Discussion with Decision-makers: -1 Contact the political figure/stakeholder by phone call or email to establish a meeting. Make sure to mention an intro to your NMO, committee, problem statement and the request for a meeting as concisely and professionally as possible.

-2 Choose an equipped trained member/position holder of your committee who is an eloquent public speaker to establish the contact with the government and communicate your lobbying efficaciously and sufficiently.

-3 Introduce everyone to your committee and NMO, explain why you wanted to meet and ask if you can begin by presenting your views and concerns and then get his/her reaction:

Lobbying -4 Facts and stories: When presenting your issue and views it is important to have AMR facts and statistics that show you have done some research.

However, also find a few stories that illustrate your arguments. Stories personalize an issue and may resonate with a politician more than statistics since we are medical students and it is already credible and suitable to mention our everyday scenarios of AMR cases.

-5 Stick to the basics: Try to keep your conversation focused on a few basic points. The more complicated and convoluted your message, the greater the chance the conversation will wander into uncharted territory.

-6 Questions: Ask if there are any questions and do your best to answer them.

If you do not know an answer, say so and offer to try to find the answer and get back to them.

-7 Don't lose your temper: Don't get angry, sarcastic or discourteous. In rare cases, you may find a stakeholder is unresponsive or even openly hostile to your concerns. If that's the case, and you cannot find any common ground, you may wish to reiterate your key points and end the meeting.

-8 Get a commitment: Ask your politician to do something concrete to show support for battling AMR. After the Meeting with the Decision-maker: 1. Write a note of thanks for the time you were given to present your case also through an email or phone call is possible.

2. If there were requests for more information ensure that they are followed up.

3. Keep the record of what was said at the meeting on file, especially if the contacted person made any commitments to your group. Files of meetings can be useful for preparing for future meetings or presentations.

A proposed training method to secure the previous in brief encounters with any governmental personal (in a conference, lecture, event…) is through the known “The elevator pitch”: An elevator pitch is a brief, persuasive speech that you can use to spark interest in your cause. You can also use one to create interest in your project or idea for AMR. It needs to be succinct, while conveying important information.

The elevator pitch is an essential element in your lobbying work, you never know when you are going to meet with a decision maker, and once you get the chance you must make good use of it.

To craft a great pitch, follow these steps.

• Identify your goal.

• Explain what you do.

• Communicate your USP. • Engage with a question.

• Put it all together.

• Practice.

Lobbying 1. Identify Your Goal Start by thinking about the objective of your pitch.

For instance, do you want to tell potential clients about your NMO? Do you have a great new project on AMR you want to pitch to an executive?

2. Explain What You Do Start your pitch by describing the situation of AMR briefly, then what your NMO does or proposes as a solution. Focus on the problems that you want to solve and how it can help people. If you can, add information or a statistic that shows the value in what you do.

Ask yourself this question as you start writing: what do you want your audience to remember most about you?

Keep in mind that your pitch should excite you first;. People may not remember everything that you say, but they will likely remember your enthusiasm.

3. Communicate Your USP Your elevator pitch also needs to communicate your unique selling proposition, or USP. Identify what makes you, your NMO, or your idea, unique. You'll want to communicate your USP after you've talked about what you do.

4. Engage With a Question After you communicate your USP, you need to engage your audience. To do this, prepare open-ended questions (questions that can't be answered with a "yes" or "no" answer) to involve them in the conversation.

Make sure that you're able to answer any questions that he or she may have.

5. Put It All Together When you've completed each section of your pitch, put it all together.

Then, read it aloud and use a stopwatch to time how long it takes. It should be no longer than 30-20 seconds. Otherwise you risk losing the person's interest, or monopolizing the conversation.

6. Practice Like anything else, practice makes perfect. Set a goal to practice your pitch regularly. The more you practice, the more natural your pitch will become. You want it to sound like a smooth conversation, not an aggressive sales pitch.

Make sure that you're aware of your body language as you talk, which conveys just as much information to the listener as your words do.

Lobbying A live example on direct lobbying: Specific labelling on antibiotics’ packaging: in February 2016 the Indian Ministry of Health and Family Welfare launched a campaign called “Medicines with the Red Line” following a direct lobbying attempt, with a clearly identifiable red line on the box of prescription drugs. In July 2016, the U.S. Food and Drug Administration approved safety labelling changes for a class of antibiotics (fluoroquinolones) to enhance warnings about their association with disabling and potentially permanent side effects and to limit their use in patients with less serious bacterial infections.

Indirect lobbying: “you and the public vs. the legislatures” Similar steps as previously stated can also be followed to exercise successful grass-rooting: -1 Know the current situation on AMR and this can be achieved through research as thoroughly elucidated in the “data and research section” -2 Study the opposition and the stance decision makers hold regarding AMR in your country and what kind of interventions are they practicing if any regarding the 3 domains of AMR’s one health approach.

-3 Study the political process adopted in your country by contacting professors of law or direct exposure to the constitution and its regulation if possible: a. Don’t be afraid to seek advice and always be realistic, concise and to the point -4 Define your problem statement: which legislation to engage, any possible compromises to be made, reasons for such a choice and a suggestion of amendment to be prepared.

-5 Understand what the reaction of your lobbying can create on political figures as well as your media in your country and so work on your timing. A priceless point to consider “Timing” -6 Establish a strong network of local, national and international stakeholders willing to back your advocacy as demonstrated in the “networking section” -7 Create your activity engaging the public regarding the legislation or the problem statement you perceived according to the activity planning and management validated in the “campaigning section” as this applies to any sort of activity involving all the components of the advocacy umbrella. At this point, just go wild in ideas and methodology!

Lobbying A live example on direct lobbying: Specific labelling on antibiotics’ packaging: in February 2016 the Indian Ministry of Health and Family Welfare launched a campaign called “Medicines with the Red Line” following a direct lobbying attempt, with a clearly identifiable red line on the box of prescription drugs. In July 2016, the U.S. Food and Drug Administration approved safety labelling changes for a class of antibiotics (fluoroquinolones) to enhance warnings about their association with disabling and potentially permanent side effects and to limit their use in patients with less serious bacterial infections.

Indirect lobbying: “you and the public vs. the legislatures” Similar steps as previously stated can also be followed to exercise successful grass-rooting: -1 Know the current situation on AMR and this can be achieved through research as thoroughly elucidated in the “data and research section” -2 Study the opposition and the stance decision makers hold regarding AMR in your country and what kind of interventions are they practicing if any regarding the 3 domains of AMR’s one health approach.

-3 Study the political process adopted in your country by contacting professors of law or direct exposure to the constitution and its regulation if possible: a. Don’t be afraid to seek advice and always be realistic, concise and to the point -4 Define your problem statement: which legislation to engage, any possible compromises to be made, reasons for such a choice and a suggestion of amendment to be prepared.

-5 Understand what the reaction of your lobbying can create on political figures as well as your media in your country and so work on your timing. A priceless point to consider “Timing” -6 Establish a strong network of local, national and international stakeholders willing to back your advocacy as demonstrated in the “networking section” -7 Create your activity engaging the public regarding the legislation or the problem statement you perceived according to the activity planning and management validated in the “campaigning section” as this applies to any sort of activity involving all the components of the advocacy umbrella. At this point, just go wild in ideas and methodology!

An example on grassroots: A boycott campaign Media campaign on an AMR related legislation An awareness week with strike stands to change a certain logislation The previously mentioned ideas in the “campaigning section”

Conclusion & Contributors: It’s undeniably true how it is always better to light a candle than curse the darkness. Hence, if you are reading this, then yes you are one of those who will light up this world and what better way to do so as medical students other than to advocate for a global health cause that involves all the creatures of this earth.

To recap on some of the terms we have evoked in this manual, we can safely say now that advocacy is identifying, embracing and promoting a cause. As simple as that!

Individuals tend to fear approaching advocacy as if it were too complex, but advocacy is simply an activity that comes second nature to most people and can become second nature to you..

Our chief purpose is to further your mission on fighting AMR and create changes to the system by shaping public policy at the local, state and federal levels. It is a golden opportunity to get off the sideline and participate in the significant decisions that will impact your community.

To do so, one must cover all of the components under its vast umbrella, from researching your area in order to depict your problem statement contributing to AMR in your country, to campaigning as in creating a beneficial activity targeting this problem based on our activity planning and management model, to networking which is basically connecting yourself with the right stakeholders to reach your set goals and objectives and of course lobbying by communicating with your government and altering legislations serving your cause.

Know your cause, know your people “the wrightful wasta”, “what we usually do best” and “work your way up”, were the catch-phrases we used to depict this intricate and detailed concept of advocacy “speaking acting”.

Always do remember that fighting AMR through this approach is a thorough extended and extensive process but as we all know inspiring progress is a journey and never a one act show.

Keep it up: educate patiently, advocate passionately and inspire CONSTANTLY! ×

Conclusion & Contributors: Contributors: SWG Coordinator: Ghaidaa Elsaddik, Lemisc-Lebanon SWG Members: Saad Ukkas, IFMSA-Morocco Khadija Elshamarka, IFMSA-Egypt Mohamed Mamdouh, IFMSA-Egypt Mohab Orz, IFMSA-Egypt Omar Daoud, LeSouk Algeria Haider Noori, IFMSA-Iraq SCOPH-D: Nishwa Azeem SCOPH RA: Omnia El Omrani