This report outlines public engagement activities carried out by Global Scholars in Owerri, Nigeria to pilot an antibiotic resistance campaign. They visited various settings like hospitals, schools, and churches to gather perspectives on antibiotic resistance and inform their messaging. Key findings included that poverty leads many to self-medicate or visit traditional healers rather than hospitals due to costs. Engagements provided opportunities to refine messaging and gain insights into contextual drivers of antibiotic misuse in Nigeria. The campaign achieved its goals of developing awareness and collaborating across disciplines to address the growing threat of antibiotic resistance.

1. Antibiotic Resistance:
The Nigerian Context
Global Scholars Report
12.06.16 22.06.16
Adesoji Peter Agbaje, Elvie Tusamba, Esther Chinenye Echegini, Kelechi
Akudo Onuoha, Siân Eleri Jones, Ulonwa Cordelia Ibe
Abstract
This report outlines the public engagement activities carried out whilst
in Owerri. The main objective of our visit was to pilot a campaign on
Antibiotic Resistance (AR) whilst simultaneously improving our
contextual understanding to better inform our work.

2. 2
Content
1. Introduction 3
2. Federal Medical Centre (FMC) Owerri, Imo State 4
3. Sapphire International Primary School, Owerri, Imo State 6
4. Alvan Ikoku Federal College of Education, Owerri, Imo State 8
5. Emekukwu Hospital, Owerri, Imo State 9
6. Pubic Engagement at Churches, Owerri, Imo State 10
7. Government Office, Owerri, Imo State 12
8. Conclusion 13
References 14

3. 3
1. Introduction
We decided to apply for Going Global funding to extend the civic
engagement work we had been doing over the past academic year and
take our AR health promotion campaign to Nigeria. Although our
Going Global application was unsuccessful, we were lucky to secure
funding for a Global Scholars project and our lecturer Siân who has
been leading us in the civic engagement project here in London was
happy to support us in Nigeria.
We chose Nigeria because it has been projected that middle and
low-income countries will be the most affected by AR (O neill 2016)
Nigeria is one of those contexts. It is not only that Nigeria bears a high
burden of infectious disease, but antibiotics are also freely accessed
on the black market and antibiotic misuse and self-medication is
highly prevalent (WHO 2015).
Whilst in Owerri, Imo State Nigeria we visited various settings
such as medical centres, schools, higher education institutes,
churches, and government house to gather the consumer s and
professional s perspectives of AR and to use this information to inform
the delivery of our pilot health promotion campaign.

4. 4
2. Federal Medical Centre (FMC)
we met with the heads of department from across the hospital. This
meeting gave us the opportunity to introduce ourselves, meet his
colleagues and state the aims for our visit to Nigeria. The
conversation was based on AR as a global health concern and we
immediately found ourselves discussing some of the issues these
health professionals faced in the day-to-day running of the hospital.
The following day, we were greeted by the head of health
education at FMC, Clementina Evans-Njoku, who introduced us to her
team and we discussed the work we each do in our prospective
contexts. Following this knowledge exchange they took us to various
clinics, such as the paediatric, orthopaedic, and outpatients units
where we would begin to engage the patients with our health
promotion message.
The first contact we had with the general outpatients unit was
very challenging as we have no idea whom we were going to see and
the environment was nothing as we had imagined. Despite English
being the National language, we quickly realised that we needed to use
speak the language. This enabled us to communicate effectively and
ensure our message was fully understood. We also learnt from
Clementina who sometimes translated for us and who exhibited a
unique style of delivery similar to the passion of preaching that
really engaged the patients in this environment.
On our third visit to FMC we had the opportunity to discuss with
the house doctors, the nurses, and laboratory scientists. The meeting
was held as a focus group where everybody contributed to the
discussion and we learnt about their experiences of treating patients
with resistance.
Findings from this meeting told us that patie
to the hospital s pharmacy once they have been prescribed antibiotics;

5. 5
rather, due to financial restrictions they purchase their medication
from unregulated pharmacist. In doing so patients sometimes chose
to buy a cheaper antibiotic or to buy a shorter dose than was
prescribed. Sometimes they are even persuaded by these unqualified
pharmacists to purchase a different drug. They quality of these
unregulated drugs can also not be known.
Some patients also tend to seek care from traditional healers.
One doctor gave the example of a woman with breast cancer who after
diagnosis sought the care of a native healer; when she finally returned
to the hospital her cancer had become too advanced and she died.
These kinds of self-medicating behaviours derive from economic
pressures. However, the doctors claimed that self-treatment would in
the long-term cost the patient more as they would require longer
courses of treatments for more complex needs.
We also had the opportunity to speak with the heads of the
pharmacology department who confirmed that poverty was the main
reason why people did not access qualified and regulated health care
and thus resorted to self-medication. We were told that there are
regulations concerning medication but they are not implemented and
enforced. It was also stated that lab scientists providing diagnostic
testing were often times prescribing drugs rather than referring
patients to their doctors. This was also due to the burden of affordable
health care but in turn adds to the misuse of antibiotics, which
increases the pervasiveness of resistance.
Piloting our campaign at FMC we were able to adjust our
message in accordance with who we were addressing and we were able
to hone it based on the contextual understanding we gleaned from the
health professionals. In all we engaged with approximately 750
patients and staff.

6. 6
3. Sapphire International Primary School
Our visit to Sapphire International Primary School was full of so much
expectation as they were the only school that responded to numerous
emails sent out prior to our visit. From the content of their emails and
website we were full of expectations and excited to deliver, for the
first time, a workshop to primary aged children. This morning would
be another opportunity to pilot our message and learn better ways to
make it relevant to this Nigerian context.
On our arrival we met with some surprises. We expected a
bigger school with more pupils aged from 10-12. Nonetheless, we
were amazed by the warm welcome we received from the staff,
management, and pupils. They had placed a banner outside the school
gate welcoming students from University of East London and had
prepared songs and an assembly to welcome us.
We spent the morning at Sapphire running a workshop with 30
children aged 5-10 at which teachers and parents were also present
and involved. Some of the activities carried out included using
balloons to demonstrate AR which was a highlight of the morning;
using UV light to talk about the spread of bacteria and the importance
of good hand washing which was less successful due to having too
many demonstration volunteers crowding the light; and poster design
where students were able to exhibit the knowledge gained from the
workshop. It was great to see both pupils and adults asking so many
relevant questions which showed us they were engaged and
understanding the message being communicated, even for those as
young as 5.
During our delivery it was evident that teaching approach used
at the school was very hierarchical, as the children were reticent at
first to interact freely with us. This meant that we had to exaggerate
our energy and encouragement to get the pupils enjoying and
learning. Doing this workshop enabled us to develop skills such as
how to manage a classroom, how to communicate effectively in

7. 7
presentations, and that sticking to agreed lesson plan prior to any
workshop is of a paramount importance to avoid repetition of
information. We also learnt ways of communicating our AR message to
children as young as 5, which was a new experience for us and one
that will go on to inform our future work.

8. 8
4. Alvan Ikoku Federal College of Education
We had not initially planned to visit Alvan Ikoku Federal College of
Education but thanks to our driver we were able to connect, through
his wife, with the Head of Department for Biology. This kind of
informal networking whilst in the country was a very successful means
of planning far more successful that during the planning stages in
the UK.
When we arrived to hold a seminar with staff and students from
the department we were surprised at the number people present
(around 100 students and 8 lecturers) and the formality of the setting.
As we settled down we made a very quick plan allowing each of us to
present one aspect of the campaign and lead on one part of the
discussion. We had an open conference where we began by presenting
to the audience who we were, why we had come to Nigeria, and the
work that was currently happening in the UK around AR ( Neill 2016
& Wellcome Trust 2015). We then went on to gather their consumer
perspective and understand their awareness toward AR.
There was a bigger awareness than expected, all participants
were absorbed throughout our discussion and each group member
shared responsibility to respond to the many questions which often
turned into short discussions. Despite the space being difficult to
engage small groups due to the formality and size of the setting,
thanks to our quick planning and responsiveness we were able to hold
an engaging afternoon. Being able to think and react quickly to a given
situation is imperative when doing public engagement. Ulonwa for
example demonstrated this when she took the move out from behind
the lectern to the front in order to build a connection with her
audience and encourage them to share their antibiotic stories.

9. 9
5. Emekukwu Hospital
At Emekukwu, we held a seminar with trainee medical staff nurses,
midwifes, and lab scientists and the teaching and practicing staff at
the hospital, around 80. We concluded with a more engaging
questions and answer session and gifted them a Public Health England
hand washing poster and some of our leaflets. This engagement was
organised by Peter as he had a connection with the school from
previous years. It was therefore important that we maintain this
network by providing quality engagement for the school.
One of the key strengths of this engagement was that we were
responsive. Initially we assumed the participants would already know
about AR, we therefore did not want patronise them by delivering
information but wished to share and exchange knowledge with them.
We began by asking participants about their experiences dealing with
AR, but after realising that they did not have in-depth experience or
knowledge about AR we began explaining the mechanisms and
concerns of the issue. It was also quickly evident that they were
passive which we felt was a reflection on the type of education they
usually receive. This was one of our last activities and our experience
had taught us to be reflective in our action. Our ability to quickly
change our plan mid-seminar shows our ability to be flexible and
address the needs of our participants.
It would be better had we more time to develop a relationship
with our participant to know them better in order to design a suitable
programme for them. We could also improve our breadth of
knowledge which would allow us to feel more confident when
engaging with different audiences with little preparation.
In line with what we had discovered elsewhere, we learnt that
the factors contributing to the misuse of antibiotics in this context
were lack of enforcement of antibiotic regulation, non-professionals
providing medical advice, lack of access to health care, unaffordable
doctors consultation fee, and overall poverty.

10. 10
6. Pubic Engagement at Churches
Initially, we had planned to visit lots of churches but we could not
because of difficulty making contact beforehand and during the short
and busy time we were in Owerri. Eventually, we were able to visit
Watchman, Catholic charismatic renewal
church, Akwakuma.
Watchman Catholic Charismatic Renewal
We had the opportunity to deliver health promotion to the
congregation at two different occasions. Sadly, on the second occasion
we were unable to deliver owing to the fact we had not confirmed an
exact time and our expectations and theirs did not meet because it
would mean us missing our afternoon appointment. Nonetheless, this
was a good lesson to learn in regards to planning.
On the occasion we were able to deliver we spoke to around 300
We made sure for this activity
that we each stuck to our relevant parts so there was clarity in our
message. We also adopted the cultural style of delivery; by delivering
in a manor reminiscent to preaching we were able to engage the
women in a familiar way that impassioned them about AR.
There was an understanding of the message we passed and this
was evident by the relevant questions asked. It was revealed that
people believed there was no need completing courses of antibiotic
when they started to feel well. Gladly, this notion was changed and we
expect a positive impact henceforth on AR via completion of doses
irrespective of where the drugs are obtained. We also recognised the
challenges of accessing health care but enforced that a hospital and
doctor was the safest and most cost effective place to obtain medical
treatment.

11. 11
St. L
The audience here included around 120 children, highly literate men
and women. We spent the morning participating in the service, which
allowed us to build a relationship with the congregation prior to
engaging them around our AR message. However, this also meant that
our time for delivery came at the end of the service when people were
keen to get home and move on with their next activity. This made the
engagement more challenging as it was hot, the sound system wasn't
working, and we had to work hard to make our message clearly
understood and interesting enough to hold peoples attention.
In the process of presenting we were able to clarify some
misinformation about AR. For example, that it is not the human body
that becomes resistant to antibiotics but the pathogens in question. As
such, we discussed how care must be taken to concentrate on control
of antibiotic over use in animal husbandry and we reminded the
congregation of the cost-effectiveness of being treated in hospital by
medical professionals.

12. 12
7. Government Office
Navigating our way in the government house was challenging because
we had not been able to have an appointment beforehand;
nonetheless, it was worth it to meet with officials who supported our
work.
We were able to meet with the Special Adviser to the Governor
on health who was actually the former Commissioner for Health in the
people have access to health care because he recognised that poor
access contributed to self-medication, which contributes to increased
AR.
We were also able to meet with the chief press secretary who
should continue should funds be secured from the government. We
are considering a proposal to put forward to them at this time.
Finally, we also had an audience with the Secretary to the State
government to inform them of our work and what we had discovered
from exchanging ideas with health professionals in the state. He
assured us that the message would continue even after we left for the
purpose of promoting better health for the citizens of Imo state.

13. 13
8. Conclusion
In conclusion, the health promotion campaign to Nigeria achieved a
number of outcomes. Firstly, it satisfied the most important
2016) to develop a global health awareness campaign. Secondly, it
allowed for cross-collaboration of students from different educational
disciplines and different educational settings thereby giving an
opportunity to exchange knowledge. Thirdly, it showcased University
of East London as a leading university in civic engagement activities
within the global arena (UEL News 2016).
These outcomes will have lasting impacts on those involved in
running the project as well as those engaged by us. Whilst we have
learnt the importance of making relevant our message to different
audiences and developed the skills of reflection on action and
responsiveness to diverse situations, we have also learnt about the
contextual use and misuse of antibiotics in this environment.
In short, we hope to avoid a future where people die of common
infections, where doctors are unable to treat what was previously
easily curable, where carrying out routine operations so relied upon is
not longer possible. This campaign is a step towards a future free of
the threat of AR. We have begun this work and plan to continue our
mission to accomplish more impact on reducing AR.

14. 14
References
Neill, Jim (2016) Tackling Drug-resistant infections globally: final
report and recommendations, Review on Antimicrobial Resistance, HM
Government, Available online at: http://amr-
review.org/sites/default/files/160525_Final%20paper_with%20cover.p
df [Accessed 25.05.16]
UEL News (2016) UEL Students travel to West Africa to highlight threat
of Antibiotic Resistance, Available online at:
https://www.uel.ac.uk/News/2016/07/AR-Nigeria [Accessed
08.07.16]
Wellcome Trust (2015) Exploring the consumer perspective on
antimicrobial resistance, Available online at:
http://www.wellcome.ac.uk/stellent/groups/corporatesite/@policy_co
mmunications/documents/ web_document/wtp059551.pdf [Accessed
17.09.15]
WHO (2015) Antibiotic Resistance Multi-country Public Awareness
Survey, Available online at:
http://apps.who.int/iris/bitstream/10665/194460/1/978924150981
7_eng.pdf?ua=1 [Accessed 16.01.16]