Under what conditions can “health promotion” be effective?
Considered by the WHO as one of the greatest threats to public health, AMR is still struggling to be tackled by health authorities. Can health promotion activities carried out by NGOs change this situation? This policy faces serious implementation difficulties.
Antimicrobial resistance (AMR) has been identified by the WHO as one of the ten greatest threats to public health[1]. This phenomenon “occurs when bacteria, viruses, fungi and parasites evolve (…) and no longer respond to drugs, making it more difficult to treat infections”[2]. Some reports[3] estimate that 700,000 people die each year worldwide from resistant infections.
In February 2022, a study published in The Lancet estimated the number of deaths associated with antimicrobial resistance in 2019 at 4.95 million (Laxminarayan, 2022). Given these alarming findings, how can we combat this scourge? And what role can global health players play? Out of personal interest, I wanted to focus on non-governmental organizations (NGOs) and question how they integrate the AMR issue into their operations and advocacy.
As part of my Master’s degree in Health Anthropology at the University of Aix-Marseille and with the support of the operational research unit of Médecins Sans Frontières (MSF) Brussels (LuxOR, Luxembourg Operational Research), I developed a research project on the activities carried out by MSF to limit the emergence of resistant infections. To carry it out, I spent three months in Lebanon with the Middle East Medical Unit (MEMU), MSF’s medical unit that supports AMR work in all the organization’s projects.
Using the ethnographic method, I carried out observations at “AMR days”, an internal MSF event on AMR, at various MEMU meetings and at Bar Elias, an MSF hospital located on the Beqaa plain in eastern Lebanon. The hospital teams had put in place a “full AMR package”, i.e. they had implemented infection prevention and control (IPC) activities, antibiotic stewardship and had access to a bacteriology laboratory. I also conducted over thirty semi-structured interviews with MSF staff working on AMR at headquarters and in projects.
This article focuses on one aspect of the research developed in my dissertation (Trentesaux, 2023): the role of health promotion in limiting the emergence of resistance. I will begin by defining what health promotion means for MSF and the contribution it can make to the fight against AMR. Secondly, based on the data collected during my fieldwork, I will reflect on the difficulties of implementing health promotion activities in the context of Global Health [4]. Finally, I will highlight the limitations of approaches that focus on individual behavior change.
1. Health promotion and its contribution to the fight against AMR
“I think it’s huge [the role of MSF towards the community]. I think patient education is one of the biggest gaps in any country, in any healthcare situation, and I think it can hugely impact the kind of healthcare and community, so even just on the basic reasons to go into the hospital, reasons to not go to the hospital like these, these are basic tenants. How to care for yourself at home, how to do hygiene at home. These have massive repercussions.” (MSF medical staff)
This verbatim highlights the importance attached to health promotion in relation to AMR by the MSF staff I met during my research. Many of them consider that MSF should carry out educational activities aimed at health care staff to improve drug prescriptions, but also at patients and the population the project targets.
MSF’s health promotion activities[5] target patients attending the organization’s care facilities. Health promotion sessions usually take place in the waiting rooms of clinics and hospitals, and cover several medical topics chosen from those covered by the project’s medical strategy. As indicated in the health promotion documents I consulted (ABR-HP Strategic Guidance Paper-MSF OCB, 2020; HP role poster, internal documents), the aim is to empower patients to take greater control of their health. The sessions are aimed at changing behavior.
Here we return to the idea that AMR is largely due to individual behavior, “bad prescribing” and “over-consumption” of antibiotics. It is important to note, however, that these behaviors are not the only factors favoring the emergence of resistance. Structural factors such as access to clean water and sanitation, access to quality medicines in a timely manner, and adequate infection prevention and control measures are all crucial in the fight against AMR.
2. Difficulties in implementing health promotion activities
Some of the health promoters I spoke to pointed to a lack of recognition of their work by medical staff. They explained that they have to deal with doctors who focus on the patient’s sick body, illness or health problem, without taking into account the patient’s history, the environment in which he or she lives and the difficulties he or she may encounter. In other words, health promoters come up against a non-holistic vision of the patient held by certain doctors. This conception is part of an approach to health that tends to consider the physical and biological aspect of the person more than his or her social and historical existence. These ideas were developed by Didier Fassin (2000), who coined the term “biolegitimacy” to describe this logic, in which the body takes precedence over the person.
Even so, the doctors I met all stressed the value of health promotion activities, while acknowledging that they do little work with health promotion teams.
“We cannot measure the concrete and tangible impact of health promotion so it’s harder to sell internally” (health promotion MSF staff).
The second difficulty raised by health promoters is linked to the place taken by quantitative evaluation of interventions in global health. This movement has been accurately described by anthropologist Vincanne Adams (2016; in. Biehl & Petryna, 2013). The latter shows that evaluation methodology takes precedence over the purpose of the intervention – the health intervention is said to be successful because its evaluation has been conducted according to predefined criteria rather than by the yardstick of the intervention’s own effects. The researcher also points out that the importance of quantitative data influences not only the way in which projects are evaluated, but also what is evaluated, and therefore the type of intervention implemented. This observation is shared by some respondents, who argue that health promotion activities tend to be overlooked because their impact is not easily measurable.
3. The limits of approaches focusing on changing individual behavior
I feel it’s important to close this article with a few cautionary remarks about approaches that advocate individual behavior change. While it is essential to give patients the keys to taking care of their health, it should also be noted that the link between knowledge and behavior change is far from automatic (Willis & Chandler, 2018; Yoder, 1997). Furthermore, it is important not to over-responsibilize the individual as if he or she were the sole master of his or her health, when the latter is largely influenced by elements that are not controlled by that individual alone. The individualization of health care tends to reduce the responsibility of the collective and the state, as demonstrated by João Biehl (2009) in his work on Brazilian health policies on HIV. Other authors (Musso & Nguyen, 2013; Hunsmann, 2013) also highlight the risk of depoliticizing health, which becomes a purely individual issue over which the state no longer has any control.
These limitations are recognized by the health promoters I met. They apply the socio-ecological model to take account of the social and institutional determinants that influence individual health.Research participants also call for interventions to limit AMR, such as improving the quality of medical interventions or lobbying health authorities to take up the issue.
In conclusion, health promotion is seen by the MSF staff I met as a means of combating AMR. The implementation of health promotion interventions comes up against an approach to medicine that focuses on the suffering body at the expense of the patient’s history, and the need for quantitative impact assessment, although this is difficult to apply to activities aimed at long-term behavior change.
These obstacles prompt us to reflect on ways of improving collective work between medical and social staff in NGO projects. On the other hand, this study invites us to rethink the place given to quantitative data as the only acceptable evidence of the success of an intervention. Finally, with regard to antimicrobial resistance, if education of medical staff and patients is really important, it needs to be complemented by interventions that target the structural factors of AMR and not just individual behaviours.
After studying anthropology and humanitarian policy at Nanterre University and Sciences Po Paris, Madeleine Trentesaux specialized in health anthropology and the evaluation of local development policies. In spring 2023, she carried out a field study in Lebanon, with Fondation Mérieux and Médecins Sans Frontières (MSF), on practices in the fight against antimicrobial resistance. Madeleine Trentesaux also works on research missions with various organizations in the healthcare sector.
Find more from Madeleine Trentesaux:
On LinkedIn : www.linkedin.com/in/madeleine-trentesaux-1257a8185
On Défis Humanitaires : How can anthropology and humanitarian action be better combined?
[1] « Résistance aux antimicrobiens », WHO, https://www.who.int/fr/news-room/fact-sheets/detail/antimicrobial-resistance, consulted on the 19th october 2023.
[2] Ibid.
[3] “Tackling drug-resistant infections globally: final report and recommendations”, 2016, Jim O’Neill, Available here: https://amr-review.org/ consulted on the 19th october 2023.
[4] Global Health is the international public health governance regime that dates back to the 2000s.
It is characterized by a biomedical vision of health, a strong anchoring in the neoliberal economy and the importance of scientific evidence. My first thesis returns in detail to the definition of Global Health (Trentesaux, 2022).
[5] The main principles of health promotion are set out in the Ottawa Charter of 1986, which defines it as follows: “Health promotion is the process of enabling people to increase control over, and to improve, their own health. (Charte d’Ottawa, 1986, available here : https://www.canada.ca/fr/sante-publique/services/promotion-sante/sante-population/charte-ottawa-promotion-sante-conference-internationale-promotion-sante.html, consulted on the 19th october 2023).
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This article is based on research validated by the MSF ethics committee and a national ethics committee.