Community engagement approaches that have impacted on health outcomes are often time intensive, small-scale and require high levels of financial and human resources. They can be difficult to sustain and scale-up in low resource settings. Given the reach of health services into communities in low income countries, the health system provides a valuable and potentially sustainable entry point that would allow for scale-up of community engagement interventions. This study explored the process of developing an embedded approach to community engagement taking the global challenge of antibiotic resistance as an example. We undertook detailed formative research through a qualitative study to explore the most appropriate mechanisms through which to embed the intervention within the existing health system and community infrastructure, and via a quantitative survey to understand patterns of knowledge, attitudes and practices regarding antibiotic usage in humans.We plan to develop and test the "community dialogue" approach for preventing and controlling antibiotic resistance in Bangladesh. The emergence and spread of antibiotic resistance is especially problematic in settings where antibiotics can be bought without a prescription and where they are over-prescribed by health workers and over-used by the public. The World Health Organisation recommends that the general public can help combat antibiotic resistance by preventing infections, using antibiotics only when prescribed by a health professional, completing the full prescription, never using leftover antibiotics and never sharing antibiotics. The Ministry of Health and Family Welfare has established the Revitalization of Community Health Care Initiative in Bangladesh. They have done so in order to improve access, utilisation and equity of healthcare. This initiative aims to enable community clinics in rural areas to deliver an essential service package to the approximately 6000 people in their catchments areas. So far, around 13,300 community clinics have been built across the country. Members of this research team have already collaborated with MOHFW on developing and evaluating an intervention to improve the quality of essential services provided within the community clinics in Comilla district. A key part of this package was training community health care providers to prescribe antibiotics correctly and this was very successful. Improving provider capacity to prescribe antibiotics correctly is one important component within a range of behavioural issues that impact on the ways in which antibiotics are used. We intend to build on our existing partnership and develop an intervention that improves knowledge and behaviour in relation preventing and controlling antibiotic resistance within communities in Bangladesh, where antibiotics are available not only from community clinics but also from drug stores. The project has five objectives: to conduct research to inform the content of and processes for delivering community dialogues; to adapt the community dialogues approach to the setting; to pilot-test the approach in the catchment areas of five community clinics; to evaluate the feasibility of the pilot intervention in terms of the number of people it reaches, the extent to which it is delivered as intended, and whether or not is it acceptable to a range of stakeholders; and to engage with key stakeholders, such as policy makers, district health officials, community clinic staff and communities to ensure that the intervention is appropriate. We will ensure that the community dialogues are "embedded" within the infrastructure of the community support groups of the community clinics. This means that they will be delivered through existing mechanisms and will, therefore, be replicable across Bangladesh. This intervention has the potential to a. contribute to a body of urgent action recommended by WHO to prevent a post-antibiotic era, in which common infections and minor injuries will kill; b. build health system capacity in Bangladesh to deliver community-based interventions; and c. empower communities in Bangladesh to build cohesion and social capital, thus enabling them to contribute further to the economic and social welfare of the country. Furthermore, it has the potential to be adapted for implementation in other national health systems that support similar infrastructures, and to be adapted to address other areas of ARM, including behaviours that contribute to resistance to drugs to treat infections caused by parasites (e.g. malaria) and viruses (e.g. HIV).

Qualitative: interviews were conducted with four community health care providers (CHCPs) who work in community clinics. Ten focus group discussions (FGDs) each with 6-8 participants were held with community members. Quantitative: a household survey was conducted in five rural clusters of villages, where we interviewed women (aged 18-49 who had at least one child) about their knowledge, attitudes and practices regarding antibiotic usage in humans, and that of their husbands' and children.