Background: Little attention has been given to the older adult caregivers of spouses with mild and moderate dementia in the caring dynamics process. The aim of this action research was to develop a program for providing support and empowerment to older adult caregivers of spouses with mild and moderate dementia in the community. Methods: The researchers acted as facilitators, with a view to empowering participants. We recruited participants from a day-care center and two community service stations. Data were collected with semi-structured, in-depth interviews with 19 dementia care dyads and from the notes, reflections, and feedback of collaborative researchers. Relevant themes for content analysis were extracted. Results: Three action cycles were completed over 18 months. The results revealed goals of three cycles: to connect the home situation and effective dialogue as a bridge to the researcher, to confirm the daily needs or expectations of the caregiver and the patient, and to enhance the interactions and quality of life of family members with resources and network. This process was cyclical and repetitive, and it also generated partnerships that built relationships among the interdisciplinary team, families, and researchers. At the same time, team workers formed a cooperative and coordinated family service mechanism to reflect the professional values and practice capabilities. Conclusions: The intervention program was based on the promotion of factors for the caregiver, linking to environmental protective factors, and the stabilization of mental and neurological symptoms of dementia patients, thereby enhancing the response capabilities of home caregivers while meeting the patient’s care needs in life. It is a tool that can effectively be used for support and empowerment in this population. Alzheimer’s disease and other forms of dementia rank as the seventh leading cause of death globally, and roughly five percent of the older population globally, approximately 50 million people, are estimated to have dementia . East AsTaiwan has become an aged society, for people over 65 years old now accounting for more than 16.15% of the country’s total population , and thiOlder caregivers of older patients with dementia experience a higher care burden when the patients have more greatly impaired functional autonomy and the Neuropsychiatric Inventory (NPI) symptoms of apathy and irritability, and most of these caregivers are the wives of the patients . SpousalTherefore, this research engaged with people who live with dementia and with their spouses in the community to generate knowledge of the support they need to maintain their abilities and continue to live relatively normal lives for as long as possible. This study recognized people with dementia as experts on their own experiences. Rather than only fulfilling the role of providing health services in the community, the lead researcher wanted to enable people with dementia to break new ground by contributing to the creation of knowledge. Similarly, spouses who support people with dementia have an important contribution to make . The aimThis paper reported on a participatory action research study which arose out of the initiatives of people caring for partners attending dementia programs at one day-care center and two dementia community service stations. Through a democratic decision-making process, the day-care staff and family caregivers consulted with clients to design, implement, and evaluate a new therapy program. The researchers acted as facilitators in this process, with a view to empowering participants at each stage in the action research cycles. In the following sections, the professional and methodological approach to the research are described, followed by an outline of how actions pertinent to the research outcomes were informed by the philosophy of critical hermeneutics.This project adopted an action research methodology to carry out the goal of “reflection” and “participation” at specific natural settings (the homes of patients with dementia). The action research approach is practically orientated with an emphasis on the integration of research theories with practical work. It mainly involves developing knowledge-based actions, verifying knowledge through action, or forming new knowledge in action. Through continuous attempts, reflection, and correction, the cycle of planning, acting, observing, reflecting, and other steps , a familFor the long-term care services, inter-professional collaboration is the cornerstone of successful implementation. In 2018, Taiwan started the dementia care policy, which emphasizes whole-person integrated care and attaches great importance to community-based care activities, the purposes of those activities were to enable the older people or the disabled to stay at home and to live in the community they know well, and to provide accessibility services through a network of formal and informal resources within the community . TherefoDuring the research period, we also linked the services of the long-term care management information platform. When the case family needed the assistance of external professionals, our team also cooperated with geriatric physicians, social workers, psychologists, or pharmacists. This provided appropriate services for dementia cases and support for family caregivers.In this study, an action research framework was developed after consulting relevant literature regarding action research processes and practices . The firIn this study, the setting of data collection took place at a dementia common care center and two dementia community service locations in northern of Taiwan. Based on the inclusion criteria, patients with dementia and their families currently living in the community were solicited to participate in this study.Based on purposive sampling principles and semi-structured interview guidelines, in-depth interviews with 19 pairs of participants  were conducted and recorded. The qualitative analysis software NVIVO 8 was used to extract the relevant themes and further summarize and analyze the themes, sorting them into categories. The data collection period was from August 2019 through December 2020, a period of 1.5 years. In addition to the interview contents, the investigator observed and recorded the participants’ family interactions during home visits and kept notes . Such inIn this study, the inclusion criteria for family caregiver participants were: (1) aged 65 or older; (2) the spouse of a patient, (3) a major care provider for a patient for more than one year, and (4) able to communicate in Mandarin or Taiwanese and agreed to participate in the study. The exclusion conditions were: (1) younger than 65 years old or who were (2) experiencing a major mental illness (such as schizophrenia). For patient participants, the inclusion criteria were (1) living at home, (2) diagnosed with dementia by a physician in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS/ADRDA), and (3) had used community care-related resources for more than half a year. The exclusion conditions were: (1) those who were confused or had delirium or (2) were staying at long-term care institutions or nursing homes.This study administered qualitative interviews and adopted the content analysis method . The intThe outline of the semi-structured caregiver interview included the following elements: (1) Please introduce yourself; (2) How did the patient (he/she) begin to show symptoms of dementia? What was the dominant symptom they experienced, and how did you feel when taking care of that? (3) How long have you been caring for your spouse because of the dementia? What changes have you experienced in your life since you started to providing care? What difficulties have you had? (4) What has been the impact of caring for your sick spouse on your life? (5) How do you feel in the process of caring for your spouse? (6) What does this new life relationship (symbiotic care relationship) mean in each other’s lives? What differences do you find compared to the past? (7) In the current care process, do you need any help? Or what kind of care needs would you want to have fulfilled?At the end of the research project, the findings, observations, and problem-solving outcomes of the program intervention implementation were shared. In other words, the investigators, family members interviewed, and research team members would exchange the results to acknowledge the growing awareness and actions of every family member and team member in empowering dementia care.The semi-structured caregiver interviews were recorded and subsequently transcribed verbatim in Microsoft Word and software NVIVO 8. Using content analysis, the data were coded and categorized . The datRegarding the trustworthiness of qualitative content analysis, the following are presented such as credibility, dependability, conformability, transferability, and authenticity . To applIn this study, the spousal caregivers were in the age ranging from 66 to 78 years, while the patients, 13 with mild dementia and the others with moderate symptoms, were in the age ranging from 71 to 87 years. Six dementia patients regularly participated in daytime activities at the dementia common care center, while others took part in activities at the community dementia service locations irregularly, mainly with the assistance of their spouses in daily activities .The process of action research can be divided into three cycles .The goal of this stage was to become familiar with the home situation via effective dialogue and build a bridge between the participants and the investigators.By establishing an initial relationship, this stage focused on the home life interactions between spouses to evaluate and understand the feelings and difficulties of the spousal caregiver through dialogue to find more information about (1) the mutual influence and symbiotic relationship in a family of two older adults; (2) responsibilities in providing care till the end of life; (3) problems derived from physiological changes with aging, empathy, lowered expectations, coping strategies in breaking through current hardships, and decisions in seeking medical help in the process  emotional support, (2) someone who could substitute or rotate in when the caregiver was physically exhausted and in need of rest, (3) enough rest at night, and (4) when in a healthy and functional mental state, the caregiver would like to have more knowledge about dementia care in order to continue playing the caregiver role to support the patient and further ensure the patient’s needs were satisfied. The caregiver also realized that when he or she was frustrated, his or her emotional distress may aggravate the patient’s symptoms because the caregiver and the patient influenced each other in their daily lives and were in a symbiotic relationship. Through communicating with the inter-disciplinary team, collaboration, and resource coordination at this stage, connecting the participants with appropriate resources can enhance family strength and promote the caregiver’s protective factors, coupled with environmental protective factors. By stabilizing the patient’s mental and neurological symptoms, the home caregiver’s response capability was strengthened while the patient’s care needs were met  more empathy and understanding of the patient’s illness can help the caregiver accept the current conditions, (2) expectations for the sick spouse were lowered, (3) excessive interference with the patient’s activities was reduced, (4) a balance between “self-needs” and “care responsibilities” was achieved, and (5) the expansion of the care support network and the acquisition of social resources made the caregiver feel more comfortable and meaningful in the care process. The quality of life in terms of day-to-day interactions was also improved (Lower panel, A participatory action research framework is embedded within the project design . The actThis study is the first action research to explore the care process for older adult spouses with mild or moderate dementia and implement an empowerment intervention. The results of this study help to create an understanding of the care process and needs of older adult spouses with mild and moderate dementia. A family-based empowerment intervention program was developed. During the action research, the needs of family caregivers and patients were identified and the necessity to look at the advantages the family members had before the illness onset was recognized. The program provided caregivers with social support and resources so that the patient could continue to live in a familiar community.In 2017, the WHO passed the Global Action Plan on the Public Health Response to Dementia, calling on governments of all countries to actively strengthen the care capacity for people with dementia, enhance family caregiver support networks, provide counseling and multiple supportive services, and increase the education and training of care skills to help relieve the burden of care . In the In the home care of dementia patients, the existence of a symbiotic relationship in a family of two older adult individuals who mutually influence one another was found to be meaningful. Although the communication, intimacy, mutual benefits, and assistance in decision-making in a couple’s relationship greatly changed due to the disease ,31, the In the second stage of the action research, the investigators developed an action plan based on the dialogue, observations, insights, and reflections of home care, which formed a basis for evaluating the effectiveness and responding to feedback . In thisOn the other hand, the study showed that the neuropsychiatric symptoms of dementia patients brought many challenges and distress to the spousal caregivers in the care relationship, especially the negative emotions caused by not knowing how to deal with the behavioral changes related to dementia. Many family members in the community have major problems associated with patient care because they fail to actively allow dementia patients to receive treatment as they lack an understanding of the concepts of the disease and had insufficient experience in managing symptoms or stereotypes ,37. In aIn the process of supporting the empowerment of home caregivers, it should be emphasized that caregivers did not passively accept professional suggestions but rather actively selected meaningful and executable information from recommendations and then took the appropriate actions . In otheThe application of the empowerment concept began with the formation of partnerships between patients and caregivers, implying the establishment of mutual respect and trust. The health professionals had to encourage the participants to reflect and review care experiences, learn critical thinking, and make decisions that were conducive to health. Ultimately, through feedback sharing, the caregiver’s confidence in providing care for dementia patients increased and their self-efficacy improved. Consequently, the caregivers were able to stay motivated and maintain behaviors for managing their own health . TherefoAccording to the caregivers’ self-reflections, the symbiotic care relationship was meaningful to their lives. Many spousal caregivers mentioned that they lowered their expectations of sick partners, allowed them to have autonomy, and decreased excessive interferences with their behaviors. This not only helped caregivers accept the patients’ conditions, but also helped strike a balance between “self-demand” and “care responsibilities.” The study aligned with the WHO’s “Global Action Plan on the Public Health Response to Dementia” in which the empowerment and participation of dementia patients and caregivers, an important action of policy implementation, was mentioned .During the research process, the investigators and inter-disciplinary team members established a team for the action interventions. This formed a collaborative and coordinated in-home service mechanism in the current dementia care mode, particularly for maintaining the mental function of the caregiver, improving the patient’s medication compliance, and stabilizing the patient’s symptoms and daily routines. By implementing the home care policy for patients with dementia, the program guided the spousal caregivers to communicate and connect with community organizations or workers and allowed community resources to be channeled into the patient’s home, thereby linking the family with the community support networks while allowing the patient to continue living in a familiar community . Such anIn the process of this study, the investigators and team members liberated themselves from professional authority and autonomy, upheld the principles of equality and respect, and formed partnerships with the caseworkers in the field of home care. They recorded their deliberations in the research log, which provided insights, reflections, and an understanding of the problems related to the home care situation of patients with dementia. Such information can be used as a reference for the evaluation of the program’s effectiveness and modifications. This study also allows continuous and cyclic dialectics and adjustments of a three-stage empowerment intervention for home care of dementia patients, namely the research cycles of continual planning, acting, observing, and reflecting.Furthermore, there is an issue worth pondering in this study, that is, the family view of Confucian philosophy. In eastern culture, harmony and integrity of the family is emphasized, and the care of the older adult should be given priority to family care . HoweverIn this study, four elements that appear to be important in enhancing success emerged. The first is contextualization; a study must be adapted to the context wherein local community services and partners operate. Only when the family partners perceive the project as valuable can they be expected to engage extensively. Second, trust needs to be built during the collaboration process with the families, and respect and understanding among professional partners and family members must be created. Third, the accessibility of project activities for all families and partners must take language and culture into consideration. This also creates a certain feeling of empowerment and was found beneficial to engagement. Finally, an open mind and transparency are especially important for professionals, family partners, and researchers. We should communicate openly with the spousal caregivers and respond to their needs and priorities.Although the results of this study provide useful information about older adult spousal caregiving in people with mild and moderate dementia and their interactions with an interdisciplinary team in the dynamic process, the following limitations should be considered. First, information regarding the status of the participants’ family members with dementia was limited. The content analysis method that was selected had a potential for bias regarding the researchers’ implications when they were analyzing the data and drawing conclusions. Further research is needed to design a study with analysis triangulation. Second, the disease progression of the dementia patents might have contributed to the participants’ subjective perceptions or experiences. Third, the time required to build relationships, collect anecdotes from family members, and understand their experiences does not fit neatly into this intervention. From a future long-term perspective, it would be interesting to contemplate the application of empowerment, as well as to examine the effectiveness of the intervention when applied differently. Fourth, local community context factors, such as family friendly policies and practices, may confound or change the connections between aged spouses’ experiences and their negative effects, for different urban agglomeration networks have different characteristics and structures.The aim of this study was conducted to develop a program for support and empowerment among older adult caregivers of spouses with mild and moderate dementia in the community. This study is the first action research to implement an empowerment intervention and explore the care process of older adult spousal caregivers for patients with mild and moderate dementia. In this study, via continuous attempts, reflections, and modifications, the project team developed an intervention program based on family empowerment. The process includes a cycle of steps, including “planning”, “acting”, “observing”, and “reflecting.” The results of this study demonstrated three stages of objectives in a family care empowerment program. The intervention program was based on the promotion of factors for the caregiver, linking to environmental protective factors, and the stabilization of mental and neurological symptoms of dementia patients, thereby enhancing the response capabilities of home caregivers while meeting the patient’s care needs in life. The multifaceted outcomes and intervention effectiveness derived from this study can be used as a reference for the future development of home care policies for dementia.


This paper examines the uneven geography of COVID‐19‐related excess mortality during the first wave of the pandemic in Europe, before assessing the factors behind the geographical differences in impact. The analysis of 206 regions across 23 European countries reveals a distinct COVID‐19 geography. Excess deaths were concentrated in a limited number of regions—expected deaths exceeded 20% in just 16 regions—with more than 40% of the regions considered experiencing no excess mortality during the first 6 months of 2020. Highly connected regions, in colder and dryer climates, with high air pollution levels, and relatively poorly endowed health systems witnessed the highest incidence of excess mortality. Institutional factors also played an important role. The first wave hit regions with a combination of weak and declining formal institutional quality and fragile informal institutions hardest. Low and declining national government effectiveness, together with a limited capacity to reach out across societal divides, and a frequent tendency to meet with friends and family were powerful drivers of regional excess mortality. Just in the first 6 months of the year a total of more than 167,000 excess deaths relative to the average of the previous 5 years were computed in the 23 countries included in this analysis. The outbreak of the pandemic took the population and governments by surprise and, in some cases, led to a collapse or a near collapse of the health system and to a raft of containment and mitigation measures—including increased testing, contact tracing, lengthy lockdowns, quarantines, and restrictions to mobility—that had an uneven impact in the containment of the spread of the virus.The pandemic, however, did not strike the whole of Europe in an even way. Some countries were hit far harder than others. In the UK, excess mortality during the first 6 months of 2020 surpassed 59,000. In Spain it topped 41,000, while in Italy and France the number of excess deaths almost reached 36,000 and 21,000, respectively. Relative to the population, the highest incidence took place in Belgium, Italy, Spain, and the UK. In contrast, many Central and Eastern European countries were spared. Deaths in the Baltic States, Bulgaria, Czechia, Hungary, and Slovakia were below the average for the preceding 5 years. Denmark and Germany also had no overall excess mortality during the first half of 2020.Differences in excess mortality within countries were often higher than among them. Madrid, in Spain, witnessed the highest lethality in percentage terms across all the regions included in the analysis. The neighboring region of Castile‐La Mancha came third. At the opposite end, two other Spanish regions, Galicia and the Balearic Islands registered no excess deaths in the first half of 2020. Lombardy, in Italy, came second in this grim ranking and the pandemic impacted other rich Northern Italian regions, such as Trento, Bolzano, the Aosta Valley, or Emilia‐Romagna. In contrast, seven regions in the central and southern half of the country—Lazio, Molise, Sicily, Campania, Umbria, Basilicata, and Calabria—registered below average mortality levels. Some big cities, such as Paris, London, or Stockholm (on top of Madrid and Milan) were also hotspots of the illness. But other large cities remained mostly unaffected. Mortality was below trends in recent years in Norway, most of Finland, most of northern Germany, Denmark, Slovakia, Hungary, Bulgaria, and in many regions of South West France.Since it became clear that COVID‐19 was no ordinary seasonal flu and that its effects could be devastating for, especially, certain groups of the population, scientists and decision‐makers have scrambled to try to study the factors behind the uneven geography of the COVID‐19 pandemic in Europe. At stake was far more than pure intellectual curiosity. Understanding not just the causes of the pandemic but what provoked its differential spread could lead to more adequate prevention, detection, and response measures for new waves of COVID‐19 and future epidemics. It would also help prevent situations like the collapse or near collapse of health systems that drove European societies to the brink in the months of March and April 2020.This paper looks at these factors at the subnational level, where, despite some exceptions  and was extended into May and June Figure .In contrast, in many other regions of Europe the incidence and lethality of COVID‐19 was far lower. In some regions, such as North Holland, excess mortality was also concentrated around Week 15 of the year, but more subdued than in regions with a similar population size and density , the Quality of Government Institute, the Regional Authority Index (RAI), and the OECD.4.1The dependent variable is excess mortality rates at a regional level in Europe during the first 6 months of 2020. The choice of excess mortality as the indicator of the incidence of the COVID‐19 pandemic in Europe is related to its far greater reliability in comparison to potential alternatives, such as the number or share of COVID‐19 cases or the official toll of COVID‐19 certified deaths. As indicated by numerous commentators  and the average deaths for the same weeks in the period 2015–2019. We do this both as a percentage change as well as relative to the population  in a region.4.2The independent variables include population in 2019 and GDP in 2018 as a proxy for regional agglomeration .One of the main effects during the peak of the first wave of COVID‐19 was the saturation of hospitals and intensive care units. We control for the capacity of regional health care systems using two variables: the number of doctors per capita in 2017 and the number of hospital beds in that same year.2e/cap), and the average household carbon footprint both at regional level in 2010  at regional level in 2016 (using OECD data), as well as the total household carbon footprint  data, a survey directed by the University of London within the European Research Infrastructure Consortium Forum. The primary aim of the ESS is to collect information at the individual level on personal and social well‐being, social capital and social trust, social exclusion, education and occupation, among other themes. This survey is conducted every 2 years and targets persons older than 15 years. Our measure of sociability and interaction is computed as the share of population in each region interacting at least once a week with members of his/her family or with friends. Generalized trust is used as our indicator of trust in the system. Social capital is proxied, following Putnam , 2000, bThe name, description, and source of each variable is reported in Appendix 4.3The analysis is conducted by means of a set of ordinary least square regressions, introducing each regional  characteristic alone, first, with the final model including all explanatory variables together.i are individual European regions. To mitigate for error correlation within regions, standard errors are clustered at regional (NUTS2) level. We also compute the variance inflation factor test (VIF) to control for potential multicollinearity among regressors  increase in government effectiveness in 2018 or in improvements in government effectiveness between 1998 and 2018 was connected to a reduction in excess mortality during the first half of 2020 of 0.44 SDs in both cases , regional autonomy (0.30 reduction) and sociability, proxied by the frequency of meeting with friends and family (0.28 reduction) , but hardly changes the significance and association of the different variables to excess mortality during the first half of 2020. This is particularly the case for the full model  and help explain this below average mortality in many parts of Central and Eastern Europe, but also in Northern Germany, South East France, and in the Nordic countries, outside Sweden.The main message coming from the analysis is that the early incidence of COVID‐19, in terms of excess mortality, has been related to a rather complex set of factors, some of which—such as accessibility, climate, pollution, or the preparedness of the local health system—had already been pointed out by the literature, whereas the role of others may have been somewhat overstated. A whole raft of institutional factors, which, until recently, have attracted limited attention, may also be at the forefront of differences in the incidence of the virus. Overall, the most affected European regions during the first wave of the pandemic have been relatively large and connected regions, in colder and dryer climates, with high air pollution levels and relatively poorly endowed health systems. Most agglomeration factors and, in particular, population density have been relatively marginal to the impact of the disease, while excess mortality seems much more related to advantages in accessibility by road rather than by air.While these results add interesting nuance to existing knowledge, the biggest novelty lies in how institutional factors have shaped the impact of the virus. The most ravaged regions of Europe by COVID‐19 were those with a combination of weak and declining formal institutional quality and brittle informal institutions. Low and declining government effectiveness at the national level—much more than at the regional one—emerges as one of the key factors behind excess mortality in the first half of 2020. Regions in countries with weak and declining government effectiveness were less capable of adopting, implementing, and monitoring the often‐tough decisions that have been proven to be more effective in the fight against the pandemic. Citizens in these countries consequently endured the lower capacity of their governments to prepare and rapidly respond to the challenges of COVID‐19 and to garner the necessary political consensus to take tough decisions. Weak and weakening national government effectiveness also restricted their capacity to react early to what was taking place elsewhere and to learn from the successes and mistakes of measures adopted in other places. Weaker and weakening government and bureaucratic efficiency may have also led to frequent changes of direction in the adoption and implementation of policies and may have been at the source of chronic failures in protecting key health and other types of essential workers from infection. They may have produced an inability to coordinate public intervention effectively in all types of measures, including in areas such as the procurement of medical and protective equipment for key workers. A better local performance in those regions with more regional autonomy did not compensate for the failures in national government effectiveness.Informal institutions also played their part in the striking differences in excess mortality. COVID‐19‐related excess mortality was far higher in regions where people meet more often, but where the capacity to build bridges across different groups to create consensus is weak.Weak government effectiveness, weak consensus building capacity, and frequent within group meetings have led to a fragile response to the COVID‐19 pandemic. These conditions limited the capacity to find consensual solutions understood, respected, and followed by the population. Hence “every man/woman for himself/herself” type of strategies often prevailed in these regions. Even in the case of widely accepted measures, their implementation over time may have left a lot to be desired, relative to other areas of Europe. Overall, this type of regions struggled to put in place effective and co‐ordinated responses when the virus struck and failed to instill the necessary trust to bring the population on board over the long periods required to combat the pandemic. Unfortunately, this possibly resulted in higher death rates linked to the pandemic.Confronting the challenges of COVID‐19 and future health or natural shocks requires effectively tackling institutional bottlenecks. While little can be done in terms of addressing agglomeration and density and climate is an exogenous factor, improving national government effectiveness and redressing government quality decline should be priorities to respond to this pandemic and to prepare societies for future social, economic, and political challenges. Addressing profound social cleavages and finding the mechanisms to reach greater consensus across divides is also essential. Any delays or failure to improve in this respect have, as we have seen during the first wave of the COVID‐19 pandemic, an important cost in lives.Supporting information.Click here for additional data file.


The increasingly global scope of biomedical research and testing using animals is generating disagreement over the best way to regulate laboratory animal science and care. Despite many common aims, the practices through which political and epistemic authority are allocated in the regulations around animal research varies internationally, coming together in what can be identified as different national constitutions. Tensions between these periodically erupt within the laboratory animal research community as a ‘cultural war’ between those favouring centralised control and those advocating local flexibility. Drawing on long-term engagement with key events and actors in these policy debates, I propose these national differences in the constitution of animal research can be understood through the intersection of two key variables: i) the location of institutional responsibility to permit research projects and ii) the distribution of epistemic authority to shape research practices. These variables are used to explain the development of different policy frameworks in the UK, Europe, and the USA, and identify where there is convergence and divergence in practice. Concluding, I suggest the way these approaches are combined and enacted in different countries reflects different national civic epistemologies, which are coming into conflict in the increasingly global networks of laboratory animal science. The specific legal frameworks around animal research, which the UK has shared with the EU since 2013, have been transposed into UK law, meaning current regulations will continue to apply to this area of research. However, as Hilgartner et al. argue, the constitution of political and epistemic authority to do something like animal research “encompasses but is not limited to the formal, legal realm” . Social permissions to carry out research on animals change over time through the clarification of guidelines, the application of harm-benefit review, and the licensing of projects. Scientific research practices shift through the setting of standards, the interpretation of protocols, and the intervention of experts who oversee research. Even without formal legal changes, there are many potential decisions involved in the re-constitution of UK animal research. The UK has opportunities to realign its research practices with international collaborators in the USA, Europe, or Asia, but it also faces challenges given differences in the way animal research regulations are already constituted globally. It is not yet clear which ways UK regulation might shift to align itself with different countries and, given international complexities in the policies governing animal research, it is also hard to predict the practical consequences of change.In this paper, I develop a framework for understanding international differences in the regulation of animal research, focusing on discussion of policy and practice in the UK“The debate about harmonising between Europe and Canada and North America is a waste of time, only because in all three situations the animals appear to be doing well enough. Tweaking the size of the cage, or whatever other variables you want to tweak, is going to have zero or minimal impact on the welfare of the animal, unless you can come up with some new metrics that are scientifically based and not just on our impressions of how the animals may feel better. It's a very cold American attitude. […] ICLAS2and ICH3and harmonisation and some of these other cultural wars, to me are silly.”These regulatory differences may seem obscure, but some are so significant they have been characterised as a ‘cultural war’ by those who work in the field. This term was used by someone active in debates about laboratory animal use and care in the USA, when we talked during an intense period of international regulatory review in the early 2010s. They suggested:Guide for the Care and Use of Laboratory Animals  and those elements of UK policy and practice incorporated into EU Directive 2010/63 represent two poles of this culture war. In this period, the Washington-based Institute for Laboratory Animal Research (ILAR) had just published revisions to the 8th edition of The Guide  the distribution of epistemic authority to shape research and care. In section In what follows, I draw on long-term engagement with key events and actors in these policy debates, integrating empirical insights from research and committee experience with the academic and policy literatures on animal research.22.1“The oversight of animal care and use occurs through a wide variety of local, national, and international mechanisms, some based on legislation [the European Union (EU)]; others on peer review or other forms of nonlegislated oversight (Canada) and yet others on a combination of legislated and nonlegislated oversight (United States). This patchwork of mechanisms can cause problems, given the global nature of science.” , p. 700National regulations for animal research not only need to balance the interests of science, industry, publics, and animal protection, but also consider how to manage scientific collaborations, set standards, share research data, and protect international trade. As one review suggests this involves negotiating a complex mosaic of geography, law, and science:These complexities can be hard for even policy-makers and stakeholders to grasp. They are distributed across national and international documentation that detail licensing procedures and accreditation rules, define standards and indicators, provide codes of practice, offer guidelines and guidance, proffer concordats and declarations, and seek to anchor the principles of the 3Rs internationally. These documents, a selection of which are discussed in more detail below, both explain what is required by national laws and often extend what is mandated by national legislation by applying local regulations to overseas collaborations.There is now consensus around many key points. The role of the animal use and care committee,Sheila Jasanoff has worked for over twenty years on the entanglements between science, the state, and political culture, primarily in the USA, the UK, and Germany . Her worA different strand of work on the changing geographies of science starts with the management of international scientific networks and technological zones , 2006, rlocation of institutional responsibility to permit research and the distribution of ‘epistemic authority’ to shape research and care with animals.The third element accelerating change within the international landscape of animal research is the growth of risk-based regulatory processes. This has been a prominent development across UK regulation and public management  and can 2.2location of institutional responsibility to permit research is relatively easy to identify as it is given by law or explained in guidelines. The allocation of this responsibility in different countries indicates who is seen as the ultimate ethical decision-maker around animal research and reflects how far the adjudication between enabling research and protecting animals is seen as the role of the state or assigned to another body or person. Most countries that have laws to protect animal welfare have a concomitant process by which certain people, in certain places, and for certain permitted purposes can be allowed to carry out research on animals. These permit something to happen to an animal, which is not in the best interests of that animal, so would generally be considered to be animal cruelty through law. The STS literature has indicated how animal bodies are transformed into experimental objects through the outcome of legal arguments  whose responsibility is to ensure animal care, support staff, review procedures, and promote the 3Rs. You will need to apply for a personal licence, which in turn demands you have completed relevant ASRU Training Modules,The different elements for licensing animal research in the UK are laid out on the ASRU website.Rattus, mice of the genus Mus, as well as all cold-blooded animals. The amendments were directed by budgetary constraints at the USDA, the agency charged with implementing the act, rather than by a specific ethical argument. There were insufficient resources made available to extend the record keeping and regulatory oversight that the act required for larger animals to the growing numbers of laboratory mice and rats in laboratory research, leaving many of these creatures in a legal limbo.In contrast, in the USA, only some animal research is covered by federal law and as indicated above animal research is regulated through a mix of legislated and non-legislated oversight. The amended 1966 Animal Welfare Act famously excludes legal protection for the most commonly used mammals in research: mice and rats. The initial assumption, under the 1966 Animal Welfare Act, was that all warm-blooded animals would be covered, unless specifically exempted – as in farm animals, understood only as food or fibre. The initial act covered “any live or dead cat, dog, hamster, rabbit, nonhuman primate, guinea pig, and any other warm-blooded animal determined by the Secretary of Agriculture for research, pet use or exhibition”.The Guide introduced above, which operates through a “system of [both] self-regulation and regulatory oversight” (p.1). The US Animal welfare Act explains “Every institution that uses animals for federally funded laboratory research must have an Institutional Animal Care and Use Committee (IACUC). Each local IACUC reviews research protocols and conducts evaluations of the institution's animal care and use, which includes the results of inspections of facilities that are required by law”.The Guide is mandated for federally funded research and advisory for other research. Learned societies, funders, and other organisations further extend responsibilities outside of these funding requirements and national contexts. Voluntary accreditation by AAALAC which is often valued by collaborators requires facilities to participate in their international animal care programme, based on ‘The Guide’, whilst also complying with local laws regulating animal research. There are fewer premises and projects excluded from law than first appear in the USA.However, all US publicly-funded research does require adherence to and regulate laboratory animal research. As Valverde suggests, the use of licences means actors are “not so much regulated as “responsibilized” to regulate themselves and the spaces they control” .In addition, the technology of the licence, which is a central facet of the regulation of animal research in the UK, challenges some of the assumptions about the rigidity of centralised governance. As critical legal theorist In many ways, this comparison demonstrates opposing positions in the location of institutional responsibility to permit animal research I introduced above. In the UK, this responsibility resides through law with central government; in the USA, much of the state's legal responsibility for animal research is discharged through local institutions. However, in practice both systems involve a mix of law and professional judgement, and central and local practices, in the discharge of responsibilities for permitting animal research. In the UK, licensing is a rather more flexible form of regulation than it first appears. Valverde provocatively suggests that licensing practices involve both “epistemological creativity”  and “a swamp of discretion” , p. 116 3.2A second contrast between US and European animal research is whether performance or engineering standards are seen as the best method for furthering laboratory animal welfare in practice. There has been relatively little attention given to the determination and use of standards in the social scientific literatures on laboratory animal research, though there is a related, but rarely linked, literature on the development of input versus output measures of animal welfare in farming . In animinter alia assessment of pain, suffering distress and lasting harm caused to the animals. It requires regular risk-based inspections and improves transparency through measures such as publication of non-technical project summaries and retrospective assessment. The development, validation and implementation of alternative methods is promoted through measures such as establishment of a Union reference laboratory for the validation of alternative methods supported by laboratories within Member States.“UK Code of Practice (2014b). The level at which standards should be set across Europe was a key point of discussion in the development of the EU Directive. Engineering standards are seen as playing a key role in assuring high standards of welfare across Europe. Countries that did not meet the new standards, for example increased cage sizes for mice, had a set time period to ensure they were compliant. However, member states were only allowed to adopt higher standards than new European ones if they were in their previous legislation. Engineering standards have become the preferred approach to many elements of European regulation, which has to manage a diversity of states. Engineering standards make compliance easier to evaluate, by setting baselines from which to judge contraventions and prevent countries erecting barriers to trade through setting higher standards.18Engineering standards generally refer to those aspects of animal housing and care that can be specified numerically: including cage sizes, housing densities, temperature ranges, humidity levels and so forth. Engineering standards tend to be applied to facility design and animal accommodation but can also be found in the detailed parameters required of experimental protocols and reporting. The opening page of the Directive explains the role that minimum standards, common inspection and reporting requirements, and central repositories play in the governance of animal research in the EU. “It lays down minimum standards for housing and care, regulates the use of animals through a systematic project evaluation requiring The Guide  with the aim of “supporting our partners in embedding the 3Rs in their science, thus supporting collaborations between UK and Chinese scientists”  the distribution of epistemic authority to shape research and care. I have illustrated this through exploring the legal frameworks for ethical review in the UK and USA and the differences between performance and engineering standards for animal welfare. I have also argued this framework matters for two reasons. First, it is useful retrospectively for identifying different constitutional forms around animal research, locating these within histories and geographies of public knowledge-making, understanding their potential vulnerabilities, and examining the relationships between them. Even with increased mobility in science, research carried out by In this paper, I have suggested international differences in the constitution of animal research can be understood through the interplay of two key variables: i) the This account also connects to the academic literatures increasingly engaging with the scientific, policy, and spatial practices of laboratory animal research. Scholars in the humanities and social sciences are increasingly trying to scale up accounts of how responsibility and care operate in laboratory animal research from discussions of corporeal encounters based on co-presence , to the However, it is important to acknowledge the limitations of this paper's focus on the constitutional mechanisms for regulating animal research. The overall aims of regulation do still vary from place to place, with significant consequences for animal use and care. At the end of this long analysis of regulatory responsibilities it is still not possible to answer the question implied in the opening quote from ten years ago clearly: is it really the case that in all three situations in Canada, the USA, and Europe the animals appear to be doing well enough? The increasingly standardised cage structures that shape animal care and the demands of international collaboration that require ethical review do likely mean that the mice have a similar experience. Given enrichment and the opportunity to thermoregulate in their housing perhaps the mice are doing well enough, though the conversation about links between welfare and data continue . However10.13039/100010269Wellcome Trust . For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. The work underpinning this also supported by an 10.13039/501100000269ESRC Impact Accelerator Award [2015–6], a further Wellcome Trust small grant , and an ESRC Research Fellowship .This research was funded in whole, or in part, by the Due to the sensitive nature of the research area, and in accordance with conventions and offers of confidentiality made at the time data was collected, I do not have permission to make the interview transcripts and other observational data from this research publicly available.


The importance of greenery in urban areas has traditionally been discussed from ecological and esthetic perspectives, as well as in public health and social science fields. The recent advancements in empirical studies were enabled by the combination of ‘big data’ of streetscapes and automated image recognition. However, the existing methods of automated image recognition for urban greenery have problems such as the confusion of green artificial objects and the excessive cost of model training. To ameliorate the drawbacks of existing methods, this study proposes to apply a patch-based semantic segmentation method for determining the green view index of certain urban areas by using Google Street View imagery and the ‘chopped picture method’. We expect that our method will contribute to expanding the scope of studies on urban greenery in various fields. The importance of greenery in urban areas has been discussed from both ecological and esthetic perspectives. For instance, Since the beginning of the service in the US in 2007, Google Street View GSV;  has beenSince mid-2010, automated image recognition has been applied for the identification of objects in GSV images. In the present study, we propose the application of the method of determining the GVI of certain urban areas using GSV imagery and a deep learning method to ameliorate the weaknesses of existing methods To obtain the imagery of streetscapes in the target districts of an urban area, we downloaded GSV image data via Google’s application programming interface (API). The API provides GSV images by referring to several parameters, including the coordinates of the location, vertical and horizontal angles, and the size of the image. We extracted the coordinates of places where people would be living using open data provided by the government.Densely Inhabited District in the census by ward. In this way, 224 districts were selected. Second, we combined the geographical boundaries in the census and polygon data of buildings in the target districts .Convolutional neural networks (CNNs) are widely used in various visual recognition problems , the present study focused only on greenery and ignored differences in vegetation types and conditions.The greenery coverage rate of each collected image was calculated using a machine-learning model. For model training, one or two target districts were randomly extracted from each ward, depending on the total number of target districts within each ward, and 3,528 images were separated as training datasets from the collected images. Using the training dataset, we built a machine learning model to identify greenery in the remaining collected images used as the target dataset.,785 smaller square patches were created for training the model.At the beginning of the training process, areas of living leaves (greenery) in the images of the training dataset were trimmed for positive imagery such as street trees and garden trees , and areFinally, the model was trained with the smaller square patches using the deep learning framework Keras on Python 3.6.9, running on Ubuntu 18.04. The CNN was applied, and its architecture is shown in The batch size was set to 32. The optimizer used was Adam , and theUsing the built model, we recognized the areas of living leaves in each image of the target dataset. As shown in For the evaluation, we calculated the overall accuracy, precision, and recall. Four raw GSV images including 1,600 square cells in total that were not used in the training were extracted see , and a 2To demonstrate the advantage of CPM in the classification performance of greenery on GSV imagery over a previous method, we also applied an automatically unsupervised classification of greenery for the raw GSV images used in the evaluation process. In this process, we reproduced the color-based method developed by By using this model, we were able to extract the green parts of street trees and garden trees from the GSV. Regarding the details of the output by the model, Meanwhile, if greenery occupied only a small proportion of the square cell, or dark leaves or grass occupied, different judgement between our AI model and the human rater tended to occur .The GVI in The results of greenery extraction by a color-based method of Generally, calculating GVI requires a large-scale field survey. However, by using GSV, we were able to acquire 47,104 images over 224 areas in Kyoto City. The GSV survey covered a wide range of survey areas and allowed us to easily acquire data. However, as shown in the lower right and lower left of Finally, we mapped the GVI of the 196 districts where we were able to obtain at least 10 images per district from the target dataset using ArcGIS 10.8.1 . In the The purpose of this study was to propose a simpler method for calculating GVI in cities than existing methods. In existing methods, semantic segmentation is the primary approach for calculating GVI. However, because most semantic segmentation methods are dependent on numerous images with detailed semantic segmentation masks, it is considerably labor intensive to manually annotate these masks. Such annotations are time-consuming, frustrating, and commercially expensive (In this study, we suggest using CPM (The CPM has been used for moss classification using digital cameras (The overall accuracy, precision and recall were 0.96, 0.73 and 0.90, respectively in our AI model. The result of the overall accuracy shows that our AI model has adequate accuracy using GVI investigation. Additionally, the result of the recall shows few false negatives. However, the precision was relatively lower than the overall accuracy, and the recall shows our AI model has false positives to a certain degree. The primary reason for the moderate precision compared with the recall, is that the model seemed to be more sensitive to sparse or dark leaves or grass than the human rater (In a previous study using color-based classification , 9D showIn recent years, GVI calculations have been used in various scenarios, such as research and government reports. In the future, the standards for calculating GVI may change depending on the purpose and features of the survey areas. For example, it may be necessary to detect mountains and weeds in a distant view as greenery. The annotation process of semantic segmentation is quite time-consuming, and minor changes will take time. Therefore, because our method can efficiently produce training images, it is easy to expand the detection target. This is a useful method for model creation and extension.Herein, we demonstrated the feasibility of the CPM and GSV for the assessment of greenery in Kyoto city. We showed that our method can provide helpful information on greenery in urban areas, which was not previously understood. However, several issues remain to be resolved.The first issue is false positives for square cells with only a small proportion of greenery, such as tree heads and branch tips or those cells occupied by dark leaves or grass . It coulIn this study, we focused on the CPM and used GSV to suggest the application of the method of determining the GVI of certain urban areas by using GSV imagery and a deep learning method to ameliorate the weaknesses of existing methods. We expect that our method can form the foundation for future social activities and academic research on GVI research improvement.TK collected and analyzed data using GIS software and wrote the Results and Discussion sections. AU designed the study, collected and analyzed the data by using the API and the machine learning model, and wrote the Introduction and Materials and Methods sections. YS trained a machine-learning model. TI guided all the steps of the experiments and manuscript preparation.Supplemental Figures


High levels of antimicrobial resistance (AMR) in Indonesia are caused by the use of inappropriate antimicrobials (AM) in healthcare services and the livestock and fisheries sector. The available data and information about overused antibiotics and the AMR threat in Indonesia are limited. The aim of the study is to describe the AMR situation in Indonesia based on perceptions of government officials, health professionals, and the community to determine actions needed to develop AMR-related strategy and policy. The study was done in eight provinces in Indonesia and included reviewing AMR-related policy, collecting antibiotic use reports in primary health care from health offices and hospitals, and conducting in-depth interviews and focus group discussions with informants from health and nonhealth sectors. The results of the study show that AM misuse happens not only in healthcare facilities but also in communities. Medical officers are unfamiliar with AMR-related policy, as are officers in the livestock and fisheries sectors. There is limited coordination between sectors regarding the AMR situation in Indonesia. The government has to take stronger measures to oversee better implementation of AMR policies. Antimicrobial resistance (AMR) is a global public health concern. The World Health Organization (WHO) reports that AMR constitutes a serious threat to public health worldwide . AccordiE.coli and K. pneumonia. Those include Carbapenems, Fluoroquinolones, and third generation Cephalosporins [Escherichia coli and Klebsiella pneumoniae, which caused UTIs, revealed that the resistance to commonly available treatments was quite high in Indonesia [National data regarding AMR in Indonesia refers to Global Antimicrobial Resistance and Use Surveillance System (GLASS). Indonesia just started joint GLASS in 2019. The data for GLASS collection was limited to 20 selected hospitals spread in Indonesia. These hospitals act as sentinel sites for AMR data. The result from GLASS reported in 2019 for Indonesia was an increase in the percentage of antimicrobial resistances for some bacteria such as osporins . A survendonesia . All of ndonesia , 6. In undonesia –9. Anothndonesia . The prandonesia .Escherichia coli and Klebsiella pneumoniae the average prevalence rate of resistance ranged from 26% to 56% [The availability of data and information about the role played by misuse of antibiotics in the AMR threat in Indonesia is limited. Basic national health research in Indonesia showed that around 10% of communities kept antibiotics in their homes, and 86.1% obtained these antibiotics without a doctor's prescription . AnotherIn relation to the situation outlined above, the Ministry of Health (MOH) issued several policies such as “General Guidelines of Antibiotic Use” (MOH Decree No. 2406/2011). This guideline is a reference for practitioners in health care services for rational use of antibiotics. The latest policies issued are MOH Decree No. 02.02/2014 “Formation of Antimicrobial Resistance Control Committee” and MOH Decree No. 8/2015 “Antimicrobial Resistance Control Programme in Hospitals.” These policies aim to control AMR in health care facilities. Furthermore, in the livestock sector, there is the Ministry of Agriculture Decree No.18/2009 “Animals Medicines and Feed Addictive” that intents to protect consumers from veterinary drugs including antibiotics that do not meet the requirements quality, efficacy, and safety. In the fisheries sector, there are the Ministry of Marine Affairs and Fisheries Decree No.52/2014 “Classification of Fish Medicines” and Decree No.02/2007 “Good Fish Cultivation.” This decree aims to provide assurance of quality assurance and safety of fishery products from the dangers of fish drug residues, chemicals, biological materials, and contaminants, so that fish cultured results are safe for human consumption.The WHO states that, to overcome the current AMR situation, participation and collaboration are required from all stakeholders; therefore, governments and people have to work together comprehensively . This stThe study consisted of several activities, i.e., the review of existing antimicrobial resistance-related policy documents, a qualitative study by means of in-depth interviews and focus group discussions with informants from the health and other sectors and hospital patients, and collection of antibiotic use reports in primary health care (PHC) from district health offices and hospitals.The review of existing antimicrobial resistance-related policy documents took several steps: firstly, collecting documents, especially documents that are already legalized by the government by online research and in governments offices such as Ministry of Health, Directorate General of Livestock and Animal Health, Ministry of Agriculture, and Ministry of Marine Affairs and Fisheries. Then, learn about these documents including their purposes and goals. After that, highlight documents' contents or issues related to AMR control. Discuss the findings from documents and the study results within the team.The study sites and sample locations were selected purposively. The study sites were located in eight provinces in Indonesia, which were categorized into four parts: DKI Jakarta represents the capital city; DI Yogyakarta, East Java, and North Sumatra represent the western part; Bali and South Kalimantan represent the central part; South Sulawesi and East Nusa Tenggara represent the eastern part. In each province, we collected data from urban area, i.e., capital city of the province, and the rural area; thus, there were 16 districts in the eight provinces.The sample locations selected met the following criteria: one (1) public hospital in urban, one (1) private hospital in urban, and one (1) public hospital in rural areas, because not all of the rural areas have private hospitals. Other sample locations were two (2) primary health cares that are located around public hospitals. Furthermore, sample locations also involved the provincial and district health offices, fisheries offices, and livestock offices.This study was conducted between September 2014 and June 2015. However, the authors in writing this manuscript also considered the current situation of AMR in Indonesia.The interview with informants in the health, livestock, and fisheries sectors lasted between one and two hours, depending on the informant's level of knowledge, understanding, and interest. The FGDs lasted approximately two hours. The interview and the FGDs were structured around the following themes: “AMR situation and current use of AM”; “the policy related to AMR and its technical policy and guidelines”; “the communication of the policy and its target”; “implementation of the policy and its problems”; and “monitoring and evaluation.” An in-depth interview was also conducted to the patients/patients' family members in the hospital.A written consent agreement was requested from the informants before the interviews began in accordance with the direction of the ethics committee of the National Institution of Health Research and Development, which issued the ethical clearance for this study.This qualitative study aimed to explore the AMR situation and its related problems in Indonesia and to determine what actions are needed in order to develop strategy and policy related to AMR. Data and information were collected through focus group discussions (FGD) and in-depth interviews as follows.FGD was conducted with two types of groups. Group I consisted of participants who were responsible for the AMR program in hospitals. In this group, the participants were medical doctors and pharmacists, as they are health professionals who were appointed by their hospital directors to be responsible for AMR control programs in hospitals. The FGDs for this type of group were conducted in the provincial health offices. Six persons, each representing a different hospital, participated in the FGD in each province. The total number of participants in these focus groups in the eight provinces was thus 48. Group II consisted of medical doctors who work in primary health care facilities. Between six and eight persons from six and eight primary health care facilities participate in the FGD in each province. The total number of participants in this type of group in the eight provinces was 56.In-depth interviews in the health sector: the informants were two program managers who were responsible for the rational drug use program in the Directorate General of Pharmaceutical Affairs and Drug Control, Ministry of Health, and 24 program managers from provincial and two district health offices .In-depth interviews in the livestock sector: the informants were two program managers who were responsible for the healthy meat consumption program in the Directorate General of Livestock and Animal Health, Ministry of Agriculture, and 23 program managers from provincial and district livestock offices. We also included three persons from research centers that conduct research into local meats. These research centers, which operate under the Ministry of Agriculture, were located at the study sites. There were research centers in only two of the provinces visited; the other six provinces did not have such research centers. The purpose of these centers is to examine the local meats for research.In-depth interviews in the fisheries sector: the informants were two program managers who were responsible for the healthy fish consumption program in the Directorate General of Fisheries Production, Marketing and Processing, Ministry of Marine Affairs and Fisheries, and 22 program managers from provincial and district fish offices. Likewise, we included four persons from three research centers that conduct research into local fishes. These research centers, which operate under the Ministry of Marine Affairs and Fisheries, were located at the study sites. There were research centers in only three provinces visited, four provinces did not have research centers, and one research center was not available to be interviewed. These centers examine the local fishes for research.In-depth interviews with patients (or patients' families) were held in three hospitals in each province. The number of patients was 10 to 12 persons for each hospital. The total number of patients interviewed was 271 persons.Patients/patients' family members were selected for interviewing based on the criteria that they were outpatients who had recently received antibiotics from the hospital pharmacy and were voluntarily available to be interviewed. The patients' ages ranged from 17 to 65. Each interview lasted between 20 and 30 minutes. Age 17 in Indonesia is an adult age. At the age of 17, a person will get an identity card from the government. The interviews were structured around topics such as “the experience of patients using antibiotics”; “knowledge of patients about antibiotics, such as how to consume antibiotics”; “source of information of antibiotic knowledge”; “antibiotics are used for what kind of diseases”; “what are the dangers of consuming antibiotics”; “how can one obtain antibiotics, can one purchase it without a doctor's prescription”; and “the practice of consuming antibiotics.”Researchers transcribed the information collected, then summarized it. A theme-based approach  was applied. Key information was entered into a matrix and coded; highlighting with several colors was used to identify different themes, opinions, and language. Researchers did it manually. This matrix was discussed within the study team several times. Themes resulting from these analyses can be seen in appendix C. Triangulation was applied using multiple sources, such as document reports, documents policies, and compatibility between information from different informants in order to improve the objectivity and internal validity. After that, it was discussed with academics who are experts in public health policy, which resulted in several optional conclusions and recommendations. Finally, a round table discussion was organized with stakeholders from government , universities, health providers, and community organizations to determine the best possible policy recommendation for AMR situation in Indonesia.The results of the study that will be shown based on in-depth interview with program managers in health, livestock, and fisheries sectors. Those also include the results of FGDs with health practitioners in hospitals and primary health cares. The results of patients' interview will also be shown. Other than qualitative information, the pattern of AM uses in hospital and primary health care for three (3) years period will be displayed.In-Depth Interviews and Focus Group DiscussionsAMR situation and current use of AM: most informants in health offices, hospitals, and primary health care facilities confessed that controlling of AM use had not worked properly either in health care settings or in communities. One thing that causes this is “easy access” to AM due to weak oversight, with the result that people can buy antibiotics without prescriptions and even purchase them in drugstores, which is prohibited by regulations.Within the community, knowledge of, attitudes toward, and practices regarding AM use were limited and incorrect. In an FGD forum in April 2015, for example, a doctor from a primary health care facility in Bogor, West Java, said:“Sometimes patients get angry at us because we did not prescribe antibiotics for their therapy, they think that antibiotics are the best medicines for their diseases.”The policies related to AMR and its socialization: to control AMR-related problems, the government has issued several policies and guidelines, as mentioned above. However, many doctors and pharmacists who work in district health offices, hospitals, and PHCs are unaware of these policies. They are only familiar with the National Formulary, as all prescribed medicines are associated directly with a payment mechanism system for National Health Insurance. It can be said that the policies, including the guidelines, have not been communicated well.Implementation of the policy and its problems: only a few large public hospitals already have a program of antimicrobial controls, as it is mandatory for hospital accreditation assessment and also regulated in MOH Decree No. 8/2015 “Antimicrobial Resistance Control Program in Hospitals,” while many other hospitals do not have such a program. Doctors and pharmacists in hospitals said that there was a lack of support from the directors and management of hospitals to implement the antimicrobial program just like in hospital in Kenya . DoctorsThe health professionals in primary health care blamed the drug supply management from district health offices since medicines for PHCs are mostly distributed from local health offices. The availability and the efficacy of medicines were lacking. The PHCs created the medicine plans that were suited to their needs and submitted them to the district health offices. Then, health offices procured the medicines and delivered them to the PHCs. However, based on FGDs, many of the medicines, including antimicrobials, were given only in limited amount or not enough to fulfil the need of the PHCs and the patients. Accordingly, for example, amoxicillin, which should be prescribed for five days to the patients, were given for only three days. A pharmacist from a primary health care in Bali district told the researchers in FGD forum in March 2015 what follows:“… we tried to make a good medicine plan for our needs, however it did not surprise us when only small quantities of medicines (including antibiotics) came from the district health office.”Doctors and pharmacists in PHCs and hospitals need continuing education for better implementation of the rational use of medicines, including antibiotics, especially for freshly graduated doctors . There aMonitoring and evaluation: monitoring of Guideline about Rational Use of Medicines including antibiotics for primary health cares was conducted routinely by district health offices. Evaluation refers to the subject about the compliance of practitioners to prescribe medicines that have to refer to national formulary. However, most of health care services visited by researchers had not conducted evaluation about AM use, except the hospitals that have already implemented AMR control program.The pattern of AM use in hospitals and primary health care facilities from 2012 to 2014 is shown in Tables As in the health sector, the distribution of AM for animals was poorly controlled. According to regulations, the use of AM for animals can be prescribed only by veterinaries; however, this guideline is not implemented well. Many farmers give AM to their livestock by themselves, because it is easy to obtain AM and it seems that no one cares about these practices. In addition, the large number of small farms makes it difficult to control them.There are also feed additives containing growth promoters for chickens. These products actually go against regulations. In addition, in several places, penicillin and streptomycin resistance has been found in pigs. Veterinary research centers also report that there are many animal products that contain antibiotic residues. However, problems related to AM residues in the livestock sector have not been prioritized, as this sector is still focusing on other safety issues, such as misuse of formalin, borax, and hormones in animal products as the following quotation from a program manager in Ministry of Agriculture makes clear:“… our program focused on meats for domestic consumption … related to the healthy meats, we tried to minimize formalin and borax used in meats, we have not reached to antibiotics residue control …”Several policies and guidelines have been issued by the government in order to control AMR in animals, e.g., Law No. 41/2014 about livestock and animal health, Law No. 18/2009 about animal's medicines and feed additives, and other policies relating to general meat safety and health, and halal meats. There are several underlying causes for the policies not being effective. Communication of the policies does not go smoothly because of the decentralization of the tiered regions. From the center to the provinces, the communication is quite good, but from province to district it is still questionable because in Indonesia decentralization is on the district levels. It creates a situation in which each district tends not to follow central policies in terms of controlling their own community. The number of veterinarians who work in government sectors is also still limited, and these veterinarians are needed for providing coaching and supervision to farmers. The implementation of policies regarding food safety sometimes contradicts policies about food security and economic development; for example, national need for meats is the first priority; then, healthy meats will be the next priority.The situation in the fisheries sector is a bit better when compared to the other two sectors mentioned before, especially regarding fishes and shrimps intended for export. This is because the inspection of fishes and shrimps for export is rigorous. The quarantine centers conduct monitoring and evaluation every six months. Of special concern are fishes and shrimps for domestic consumption since they are not under as tight control as export products. An informant from the district fisheries office in South Sulawesi said:“ … we did not inspect fisheries for local market as tightly as for export.”There are inspections for AM residues in shrimps in shrimp farms every year. These activities can only be done by quarantine centers and universities since district fisheries offices have no capability to do the inspection of AM residues due to lack of facilities, skilled persons, and other resources. Several informants said that, based on their annual reports, the most significant residue of AM found in fishes was chloramphenicol. Once again, easy access to AM and the large number of small fish farms are the principal underlying factors for residual AM in fishes.One of the policies related to AMR in the fisheries sector is Law No.45/“Fisheries.” It states that the use of several medicines is prohibited, for example, chloramphenicol and nitrofuran. Another policy is Ministry of Marine Affairs and Fisheries Decree No.02/2007 “Good Fish Cultivation.” The informants stated that communication of the polices was conducted directly to the stakeholders, at least once a year. The contents of the communications were about the regulations, fish medicines, and chemical and biological substances that are allowed or prohibited in the fisheries sector. However, there were still farmers, especially small farmers, who have not understood the policy well.The number of patients or patients' family members interviewed was 271. The age of these informants interviewed ranged from 17 to 65. The education of these informants was high school (152 persons) and university (89 persons), and the rest only had an elementary educational background. Based on the analyses of the in-depth interview, results lead to three (3) main themes. Theme 1 is “Knowledge of patients about AMR and AM use”; this can be seen from the following information. There were 145 who said that they knew that a course of antibiotics had to be finished. Only 65 persons said that antibiotics could be used for people with infectious diseases, and 62 persons said that there was a risk of resistance if antibiotics are not used properly. There were also 65 persons who stated that antibiotics could only be purchased based on a doctor's prescription.Theme 2 is “Compliance to the dosage of antibiotics as doctor's prescription.” This leads to the following information. There were 151 persons who said that they complied with it, while the rest of them only took the antibiotic until they feel healthier. Theme 3 is “The source of information about antibiotics.” Many of the patients got information of antibiotics from health professionals such as doctors, pharmacies, and nurses (191 patients), while others reported getting information from media, family, friends, and educational institutions.The study result shows that the irrational use of AM occurred not only in health care facilities , but also in communities. In the livestock and fishery sectors, the irrational use of AM occurred mostly on the farms. This is similar to the situation in other developing countries such as India, Philippines, and Vietnam , 17.In the pandemic era, the use of antibiotics is more uncontrolled. Digitalization and telemedicine are health care services that have suddenly emerged and are widely used by the public; on the other hand, private providers use this opportunity to gain profits. Many people infected with COVID-19 chose to self-isolate, and they received telemedicine treatment, and some of them receive azithromycin treatment if the symptoms of Covid-19 are accompanied by fever. Telemedicine in Indonesia is popular based on applications and makes it much easier for patients to get access to treatment and medicines such as azithromycin. Meanwhile, the government has not issued regulations related to application-based telemedicine treatment, so that the purchase of antibiotic drugs can occur without the supervision of qualified health workers and the government .Problems related to irrational use of AM in health care facilities are due to several factors. The policies and guidelines related to the use of AM have not been communicated well. Many doctors and pharmacists did not know about these policies. Kakkar et al. 2018) stated that several countries in South East Asia have some policy systems to overcome AMR; however, this is not supported by mature implementation plans and monitoring systems . The ava18 statedThe study also showed that amoxicillin was the AM that was most used in health facilities and communities. However, there was high resistance to amoxicillin . Study rEscherichia coli (ETEC) [Study meropenem was included in the ten most used AM in hospitals. Many of the cases in which meropenem was used were not based on preceding sensitivity test results. In other words, meropenem was used for empirical therapy. A study at Sultan Qaboos University Hospital (SQUH), Muscat, Oman, showed that meropenem was prescribed empirically in 382/400 (96%) of the cases . Based oi (ETEC) . This tri (ETEC) . The inaProblems related to the irrational use of AM in communities, farms, and the livestock and fisheries sectors are in consequence of several factors. Easy access to AM occurred because of poor oversight. A survey conducted by Purwaningsih on 16 chicken farmers in Jakarta regarding the use of antibiotics in chickens showed that 31.30% of farmers admitted to using antibiotics for their livestock with the reasons that the chickens would be healthy and fat, while the rest of them were because the chicken is sick. Similarly, adherence to antibiotics based on a veterinarian's prescription was only 25%, while others said that antibiotics were only given when their livestock showed signs of sickness .The regulations and policies of AMR in the central government have not been synchronized with regulations in the district level. The regulations related to AMR control should be adopted and integrated in regional regulations; thus, this will be more straightforward . AccordiCommunity perception as well as their knowledge, attitudes, and behavior in terms of AM use is still incorrect. This similar situation also happened in Poland and Lithuania , 31. ThiAn information system for AMR has not been established. If there was an interconnected information system, it could warn health workers to be more aware about the AMR problems and could lead to responsible behavior regarding using or prescribing AM .There was little (no) coordination between sectors in relation with the AMR situation in Indonesia –37. TherFurthermore, the results of analyzing the AMR situation using tree analyses are shown in It was clear from the tree analyses that since AMR problems bond to multiple sectors, the solution to these problems has to be multisectorial, too. In China, the leading cause of AM resistance is the irrational use of antimicrobial agents in healthcare and veterinary environments as well as the use by the general public. The same study also reveals that, in the last ten years, the Chinese health administrative authorities have been unsuccessful in coping with this problem due to lack of mandatory regulations . NowadayIn the COVID-19 era, the AMR situation is getting worse. At present, many experts are concerned that global efforts to control AMR may encounter setbacks during the COVID-19 pandemic. This can be seen from the existence of premature trends regarding the benefit of using antibiotics for COVID-19 therapy, such as taking azithromycin in combination with hydroxychloroquine. Moreover, shortage will occur as a result of a massive use of the drugs .The policy about AMR control is still stagnant in Indonesia. The National Committee of Antimicrobial Resistance Control, a committee under the Ministry of Health, is still unable to tackle AMR. The sectors that are accountable to this committee work by themselves to deal with AMR. Coordination with other sectors might appear easy on paper, yet hard to do. Indonesia still needs a robust legal framework that can bind multisector to tackle AMR simultaneously. The harmonization between central and regional/district governments also needs to be strengthened. Likewise, the AMR policy interventions in both governments need to be compatible. Therefore, Indonesia needs an approach in health settings to integrate all related sectors. This approach can be in the form of national policies that cover multiple sectors and can be performed at the regional level. Collaboration with other countries is also needed as an important support to implement “One Health” .The study has several limitations: the information collected depended on the knowledge and interest of the informants, and the supporting documents  were not always available.The government faces a big challenge in overcoming the AMR problem in Indonesia. The AMR situation in Indonesia is not getting any better; in fact, it has worsened. Policies related to AMR are limited, and those alone cannot solve the AMR problem. The communication of these policies has not reached its targets. Many doctors, pharmacists, and even district health officers are unaware of these policies. Accordingly, the implementation of these policies cannot work properly.The study results for the livestock and fisheries sectors also showed a similar situation. The policies relate to AMR were known partially by their targets, such as officers who work in district offices.There was little (no) coordination between sectors in relation to the AMR situation in Indonesia. In relation to easy access due to weak oversight, the government has to take stronger measures to oversee better implementation of AMR policies.Further research, for example, on the economic impact of AMR, will complement this study.The government should issue a national policy that directly addresses the solution of the AMR situation in Indonesia. This policy should be an umbrella for all related sectors and can be integrated into regional policies. It also needs global collaboration to support the implementation of the policies.