Stephanie Tan

The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD Umbrella Concept: Combatting AMR through Direct Surveillance, Safeguarding Access, and Patient Involvement Population: ​Pediatric patients of Poblacion II, Barangay 14, Tingloy Island, Batangas, Philippines with community-acquired pneumonia (CAP) Intervention​: Standardized Text Notification and Application against Antimicrobial Resistance Strategy (STAR Strategy) General Objective: ​To develop an effective tool to combat cases of antimicrobial resistant PCAP in the Philippines. Specific Objective​: At the end of the study, 50 % decrease in mortality caused by antimicrobial resistant pediatric cases of pneumonia will be achieved at a selected barangay in the Philippines. I. Introduction and Background of the Problem Antimicrobial resistance has been a major threat to public health and economy in various countries throughout the world most especially in ASEAN communities (Archawakulathep, A. et. al. (2014). According to the systematic review on reported data of antimicrobial resistance, the economic burden associated with AMR is calculated to reach an economic cost of US$ 1.35 trillion in the region over the next 10 years (World Health Organization, 2017). The problem is currently a global threat for both human and animal health due to increasing and rapid emergence of the pathogenic strains resistant to many antimicrobials. The emergence of untreatable infections such as drug-resistant gonorrhoea and the recent detection of plasmid-mediated colistin resistance mechanisms (MCR 1) in Enterobacteriaceae highlight the need for containment efforts (Unemo and Nicolas, 2012; Liu et al., 2016). In the Philippines, prescription-sharing, underuse and overuse of drugs and community purchases of antimicrobials without proper prescriptions have been the current trend. There is a widespread lack of knowledge and awareness amongst the community (Bandiola et al., 2016). Financial constraint and discontinuation of the advised antimicrobial course upon relief of symptoms are also major contributing factors in reducing the patient’s compliance to the medications. Public misconceptions and misinformation are also evident, and often perpetuated by the media and people who are not fully knowledgeable about it. The popular local practice of recycling prescriptions for recurring symptoms is also a prevailing dilemma in the fight against The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD AMR (Bandiola et al., 2016). Thus, it is of primary importance to develop and improve policies on AMR education involving the laypeople, health, agricultural, and industrial sectors as well as various stakeholders that could have a huge impact in the existing burden of AMR. Moreover, mobilization of group of experts is also essential to contain the rapid spread of AMR. Pneumonia is one of the leading causes of morbidity, especially among children 5 years of age in the Philippines. Pneumonia is also the leading cause of mortality among children in this age group in 2001 to 2010. ​Childhood pneumonia can impair long-term lung health by decreasing lung function and chronic obstructive pulmonary disease might be related to early childhood pneumonia. In t​he Philippines, being a middle-low income country, pneumonia is ranked as the 1st leading cause of death in children aged 1–4 years according to the annual reports from its Department of Health (DOH). When children develop pneumonia, caregivers may not always take them to hospitals, especially in countries with limited resources, because of various reasons, including financial constraints, lack of knowledge, and poor accessibility to healthcare facilities. Not only is the health-seeking behavior for pneumonia compromised but also the adherence to the treatment regimen due to the same reasons. First line treatments for pneumonia include antibiotics which are to be taken for 3-7 days depending on the risk stratification. These antibiotic regimens, when not taken religiously are important breeding grounds for a widespread antibiotic resistance. The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD II. Proposed Solutions Background of the Target Population and Community The Municipality of Tingloy is officially founded in June 17, 1955. It has a total land area of 33.07 km2, and is politically subdivided into 15 barangays and is a 5th class municipality of the province. Tingloy is comprised of Maricaban Island, Caban Island, and other minor islets, all south of the Calumpang Peninsula. Our chosen community is Barangay 14, Poblacion 2, Tingloy Island, Batangas, Philippines is a community of 886 residents as of 2015 (PhilAtlas, 2015). This community is nearest to the only Rural Health Unit (RHU) in the island. The intervention will focus on pediatric patients diagnosed or highly considered to have community acquired pneumonia who will be requiring prescription antibiotics from the rural health center. Methodology A. Phase I: Application Conceptualization, Community Ocular Inspection, and Municipal Health Officer Dialogue Application Conceptualization Modern technology and advances have paved the way for development and utilization of electronic software applications for mobile devices. There are existing medical software applications on various clinical conditions available for public use but very few target antimicrobial medications (Micallef et al., 2016). In line with this, the researchers will address the threat of AMR by conceptualizing application software for portable phones involving the residents of Barangay 14, Poblacion 2, Tingloy Island, Batangas City, Philippines with approximately 886 population according to the 2015 national census (PhilAtlas, 2015). For this initiative, the researchers will partner with the Doctors to the Barrios program under the Department of Health. ​The Doctors to the Barrios (DTTB) program was created by the DOH in 1993 to address the lack of doctors practicing in rural communities in the Philippines. Since then, 36 batches of doctors have been deployed to various The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD geographically isolated and disadvantaged areas in the Philippines to work in primary care and public health. During the first phase of the study, the researchers will conceptualize the interface of the application. It will include a portal in which the health care provider (Doctor to the Barrio) and the patients can have an access to. They can both create an account, wherein they can update their basic information, input an update regarding their antimicrobial regimen and adherence, and access information about AMR. The patients will also receive an automated text message or multimedia message reminding them to take their medications on time. In relation to this, the researchers recognize the fact that not all patients will have a smartphone to access or download the application, the patients will also be provided by a booklet that will allow them to have a written documentation of their antimicrobial regimen and adherence. Essentially, they will still receive a notification via a text message since they will be inputting their information in the application that the DTTB/physician can access. For every tablet or capsule taken, they can tick on the booklet and application that they have completed their dose for that day. Moreover, they can state the adverse effects, if there is any, in the booklet and application software provided. In line with Republic Act 10173, otherwise known as the Data Privacy Act of the Philippines (National Privacy Commission, 2012), the amount of information will be limited to only what is necessary in constructing and sending the text messages, such as name initials only. The goal is to minimize the risk of identifying the patient if the message reaches the wrong person. The patients will also have an option to have the notifications sent via text message only or via text message and multimedia message. They will also have the right to choose to have the booklet only if consent was not given by the patients to access their information for the application. They will also be briefed to have a follow-up check-up after their course of treatment. The prescription as well as the empty antibiotic containers should be brought in the follow-up check-up. These will be stamped by the primary physician to avoid misuse or recycling of prescription in the community. Patient contact information will also be verified on each visit. In order to make sure that the application will be feasible and fully functional, a series of meetings will also be scheduled with the application developer or an I.T. The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD consultant. The design and interface will be conceptualized with their guidance and expertise. Prior to the introduction of the application, the researchers will execute a series of ocular inspection and will present the plans to the municipality, specifically to the Municipal Health Officer assigned in the rural health unit. In this case, usually the MHO is the DTTB assigned in the area. It is important to develop rapport with the community before suggesting any intervention. Furthermore, a partnership with the municipality and barangay should also be established. The benefits, advantages, and risks will also be presented to the community. The researchers aim to have an initial user interface application software design to be presented to the people in order to give them a general idea of the project initiative. B. Phase II: Baseline Health Statistics Collection, Survey Implementation, and Application Development The second phase of the project would involve collection of baseline statistics via a questionnaire-based survey, phrased in Filipino. This would be conducted among residents of Barangay 14, Poblacion 2, Tingloy Island, Batangas. The questionnaire will aim to gain information and insight from the residents regarding how much they know about antimicrobial resistance and the concomitant effects/repercussions on discontinuation of antimicrobial treatment and self-medication. The questionnaire will obtain the demographic data of the residents will contain a set of questions aimed at gathering the existing practices of the residents regarding the use of antibiotics. The researchers will work in collaboration with the National Telecommunications Commission (NTC) and an independent application developer since the notification system would be an IT-based monitoring system and would involve telecommunication services. Closely patterned with RA No. 10639, the mobile antimicrobial resistance alerts will mandate telecommunication services to send free reminder messages to enrolled patients detailing a set of instructions on how to take their antimicrobial regimen, specifying the schedule of their treatment. The principal objective of the mobile application will be to optimize the user experience. The application developer will ensure that the features will be user friendly (I.e. use straightforward instructions in the patients’ vernacular language) and will have a simple interface. The The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD application will be developed with encryption tools and security features that will address privacy issues. C. Phase III: Briefing of Community and Healthcare Workers and Launching of the AMR APP Statistical data that will be gathered from phase II of the study will be used to modify the content of the application. A short briefing of all healthcare workers in the barangay will be conducted where in they will be educated on the mechanisms of AMR, and its adverse effects on people using simple flipcharts and pamphlet of IFMSA on AMR translated in Filipino language. By doing so, the HCW will be empowered and they too can give their own lay forums all throughout the study. After the layforum, the participants will be informed of the proposed program to combat AMR in pediatric patients who have pneumonia. A pamphlet containing information about AMR, explanation of the procedure of the study, as well as the introduction of the AMR app will be provided. A demo of the AMR App will be given. Should they consent to become part of the study, the patient’s profile and data will be registered in the application. If their children were diagnosed with pneumonia, they will be invited to partake in the study. They will be given with booklets where they will be instructed to write the adverse reactions experienced by their children upon intake of the antibiotic during the course of their treatment. An option of receiving automated messages that will serve as a reminder to take the medication will also be given. The procured data of the study may be used to by the DTTB to improve the current AMR strategy of the community. D. Phase IV: Implementation of the Standardized Text Notification and Application against Resistance Strategy (STAR Strategy) Pneumonia may be considered if oxygen saturation is less than or equal to 94% at room air in the absence of any comorbid neurologic, musculoskeletal or cardiac conditions that may potentially affect oxygenation; tachypnea (age-specific as defined by WHO; 1.6.1. 3 to12 months – >50/min to <60/min; 1.6.2. 1 to 5 years – >40/min to <50/min; 1.6.3. >5 years – >30/min to <35/min); chest wall retractions; fever; decreased breath sounds; nasal flaring; cyanosis; crackles; or localized chest findings at any age. Once the criteria have been met, an antibiotic may be administered if a patient is beyond 2 years of age or with high grade fever without wheeze. For those without previous The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD antibiotic use, regardless of the immunization status against ​Haemophilus influenzae type b ​or Streptococcus pneumoniae,​ amoxicillin trihydrate may be given. It may be given at 40-50 mg/kg/day, maximum dose of 1500 mg/day in 3 divided doses given for a minimum of 3 days or it may be given in 2 divided doses for a minimum of 5 days. For known hypersensitivity to amoxicillin and suspicion of atypical organisms particularly Mycoplasma pneumoniae, azithromycin [10 mg/kg/day OD for 3 days, or 10 mg/kg/day at day 1 then 5 mg/ kg/day for day 2 to 5, maximum dose of 500 mg/day], or clarithromycin [15 mg/kg/day, maximum dose of 1000 mg/day in 2 divided doses for 7 days] may be given. After the physician provides the necessary prescription instruction, a booklet will be given to the patient’s primary caregiver which contains the child’s name, date of birth, place of birth, address, mother’s/father’s/primary caregiver’s name, weight and height. It should also contain the health center issuing the booklet. On the main section, the date of prescription, name of antibiotic, route, dose and frequency should be stated in addition to the indication for antimicrobial therapy, intended duration and the review date or follow-up date. The prescriber must enter the administration times and days in which the primary caregiver will check once the patient has taken the antibiotic. Underneath the check mark, ample spaces will be provided for recording of any adverse effects. Date consult Route Dose of Antibiotic and Frequency Duration Review Date Indication Time/Day 06:00 14:00 22:00 Day 1 Day 2 Day 3 The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD Once the instructions for the booklet have been made clear, the primary caregiver will be informed about the Standardized Text Notification and Application against Resistance Strategy (STAR Strategy). An informed consent will be sought from the primary caregiver as to divulging their contact numbers and receiving text messages for the entire duration of treatment regimen. Once consent is given, the availability of a smartphone with Internet access will be asked so as to proceed with the next process which is the installation of the application. The application, already installed on the physician’s or health center’s smartphone, will also be installed on the primary caregiver’s smartphone. The physician will now input the patient’s identifying data, based on the information from the booklet in order to create a profile for the patient and assign a patient code. The date of prescription, name of antibiotic, route, dose, frequency, indication for antimicrobial therapy, intended duration and the review date or follow-up date will be entered on the physician’s or health center’s smartphone under the patient’s profile. Once all the necessary data have been uploaded, the primary caregiver will now access the patient’s profile using the patient code and will be given instructions on how to operate the application especially the checking of times that the antibiotic was taken and noting any adverse effect observed. These updates by the primary caregiver will automatically synchronize into the physician’s or health center’s smartphone. Basically, the application will be the virtual version of the booklet, both sharing the same purpose as monitoring whether the prescribed treatment has been followed. A major difference will be the real-time notifications in the application which will indicate the name, image, route and dose of the antibiotic on specified times. There will also be antimicrobial stewardship information and frequently asked questions regarding antibiotic use. However, in places where internet connection is unstead and unavailable, primary caregivers are advised to input both ways – booklet and application. This is to ensure that no data is lost and outcome assessment will not be compromised. The Standardized Text Notification will be implemented whether the primary caregiver opted for the booklet or application monitoring. Once an informed consent is given, the primary caregiver’s cell phone number is recorded correctly and confirmed that all devices used to send messages are secure at all times. The text notification should be professional at all times and should not use abbreviations. Text messages should be short and concise so as not to exceed the maximum amount of text. To prevent the drawback of individuals not reading the messages they've received, an The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD interactive or two-way messaging that elicits a response from message recipients should be utilized. If possible, primary caregivers should reply to the text notification or a notification be sent back to the sender’s phone stating whether or not the text has been sent, delivered or read. Another drawback is the possibility that recipients may become annoyed at receiving multiple messages over time. This is mitigated by explaining early on the intervention that the main purpose of the standardized text notification is to improve adherence to medication, achieve successful treatment outcomes and prevent antimicrobial resistance. E. Phase V: Feedback and Evaluation The last phase of the project involves strategic and targeted evaluation of various aspects of the implementation and of the application itself. This phase will also elicit relevant and constructive feedback from the involved population. Evaluation is the process of systematically and objectively determining the relevance, effectiveness, efficiency, sustainability and impact of activities in the light of a project or programme performance (OECD DAC Glossary, 2002). This also focuses on the analysis of the progress made towards the achievement of the stated objectives. Evaluations can be executed either during the project cycle in the form of a mid-term evaluation or a formative evaluation, or at the end of a project or programme in the form of an ex-post evaluation, a final Evaluation, an impact evaluation or a summative evaluation (Austrian Development Agency Evaluation Unit, 2009). Five basic evaluation criteria can be utilized in this project (Austrian Development Agency Evaluation Unit, 2009). Relevance assesses if the intervention is actually doing the right and intended purpose. It also questions the importance of the relevance or significance of the intervention regarding local and national requirements and priorities. Effectiveness probes if the objectives of the development interventions are being achieved. It also aims to question how big is the impact of the project compared to the objectives planned, thus comparing the actual end results to those generated in the planning phase. Efficiency assesses if the objectives are being achieved economically by the development intervention. It assesses how big is the efficiency or utilisation ratio of the resources used, comparing the resources applied in the implementation with the actual end results. Probing on the intervention’s impact is also essential. The aspect of impact is interested on the development intervention’s contribution to reaching higher The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD level development objectives or to the overall general objective. It further asks the effect of the intervention in proportion to the overall situation of the target group or those affected. Lastly, sustainability of the intervention also needs to be assessed. It establishes the sustainability of the impacts or of the positive effects generated by the intervention. The permanence of the intervention and its effects are to be assessed in this aspect. In addition, other criteria may be applied to the intervention evaluation such as Participation or Responsibility. Every project or programme must be evaluated once internally within the project or programme cycle. In this project, we aim to utilize internal evaluation strategically after each implementation month and collectively after one whole implementation year. At this time, a summative evaluation or study conducted at the end of an intervention to determine the extent to which anticipated outcomes were produced can be executed. A summative evaluation can also be implemented to provide information about the collective worth of the intervention. The table below enumerates the following questions for each evaluation criteria that can be asked in this phase: Evaluation Criteria Relevance Sample Evaluation Questions ● ● ● ● Effectiveness ● Are we doing the right things? What is the relevance or significance of the intervention regarding local and national requirements and priorities? To what extent does the intervention comply with development policy and planning of the recipient country or the partner government? How important is the intervention for the target group, and to what extent does it address their needs and interests? Have the objectives of the development intervention been The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD ● ● ● ● ● ● ● ● ● ● achieved? How big is the effectiveness or impact of the project compared to the objectives planned? To what extent will the objectives of the intervention be (most likely) achieved? To what extent is the target group reached? To what extent were the originally defined objectives of the development intervention realistic? To what extent do they still meet the most recent requirements and the most recent standard of knowledge? To what extent have the (direct) objectives of the development intervention been achieved in accordance with the (adjusted, if applicable) target system? What are the (concrete) contributions of interventions for achieving the objectives of the development intervention? What factors were crucial for the achievement or failure to achieve the project objectives so far (indication of strengths and weaknesses, e.g. the monitoring and evaluation system)? What is the quality of development-policy and technical planning and coordination What other effects – also negative ones – can be established regarding services and (project/programme) objectives? The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD Efficiency ● ● ● ● ● ● ● ● ● Are the objectives achieved in a cost-efficient manner by the development intervention? How big is the efficiency or utilisation ratio of the utilised resources? (comparison: provided means – results) Is the relationship between input of resources and results achieved appropriate and justifiable? What is the cost-benefit ratio? To what extent have individual resources been used economically? Are there any alternatives for achieving the same results with less inputs/funds? How high were the costs? (e.g. by instruments, sectors, interventions)? To what extent were the costs and benefits of the development interventions in a reasonable proportion to each other from a business and economic point of view? Would there have been cheaper solutions/alternatives concerning the utilisation of instruments and the conceptualization of the development intervention achieving the objectives on a sustainable basis? Are the services, capacities created and potentials used appropriately? Were services provided in time and impacts achieved within an The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD appropriate time period? Impact ● ● ● ● ● ● ● ● ● What has happened as a result of the programme or project? What real difference has the activity made to the beneficiaries? How many people have been affected? Does the development intervention contribute to the achievement of overall development objectives (tendentially, overall goal)? What is or are the impact(s)/effects of the intervention compared to the total situation of the target group or those affected? To what extent were originally intended, overriding objectives in terms of development policy (goals) realistic? To what extent do they still correspond with the most recent requirements and the most recent standard of knowledge? To what extent have (according to the most recent requirements and the most recent standard of knowledge) appropriate overriding effects regarding development been achieved so far? What has the development intervention contributed to so far and what is it still contributing to? To what extent was the development intervention exemplary, created structures The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD ● ● Sustainability ● ● ● ● ● ● and/or had a broad effect/impact in terms of leverage (e.g. adaptation among target groups and organisations)? What other effects – also negative ones – can be determined on a goal level? What would the development have been like without the development intervention? Are the positive effects sustainable? How is the sustainability or the continuity of the intervention and its effects to be assessed? To what extent will activities, results and effects be expected to continue after donor intervention has ended? To what extent does the intervention reflect on and take into account factors which, by experience, have a major influence on sustainability like e.g. economic, ecological, social and cultural aspects? How self-supporting in particular is the assisted local counterpart? To what extent are the positive changes and effects of the development intervention (summarily) sustainable compared to the objectives regarding development policy? How stable is the situation in the surrounding field of the development intervention The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD ● ● ● ● ● regarding social justice, economic efficiency, political stability and ecological balance? What risks and potentials are visible regarding the sustainable effectiveness of the development interventions and how likely is their occurrence? Will the effectiveness of the development intervention most likely improve or worsen in the future? To what extent is/are the target group(s) capable and prepared to receive the positive effects of the development intervention without support in the long term? To what extent are the people involved capable and prepared to maintain the positive effects of the development interventions without support in the long term? To what extent are the target groups and counterparts able to adapt sufficiently to external changes and shocks? The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD III. Implementation IV. Key Indicators and Anticipated Outcomes Several indicators that will qualify the intervention’s success include (1) lowered reports of AMR cases on morbidity and mortality, (2) increased participation of each sector of the healthcare team, and (3) increased patient compliance in taking antimicrobials as assessed by the rural healthcare professionals. Anticipated outcomes after the implementation of the intervention include the following: (1) minimize damages and costs due to AMR in the long run, (2) patient empowerment and engagement, (3) increased healthcare efficiency by decreasing lapses in between healthcare professionals and teams, (4) increased collaborative opportunities towards universal healthcare, (5) strengthened patient safety and delivery of quality patient care, and (6) improved baseline knowledge on AMR and antibiotics. The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD V. Required Resources Since the researchers will be working on the grassroots level, we will be needing more funding and support from the government. Partnership with the Doctors to the Barrios program is also vital since they will be the ones who will be mobilized for this project initiative. VI. Sustainability Plan Should our study gain significant results, we propose to acquire funding from the stakeholders , specifically the government to continue the project. If the STAR strategy was proven effective, we propose that the program be implemented in the neighboring barangays. If a lot of barangays have decreased mortality rate after a year, we can propose to apply it into the whole island. If successful, we propose to apply it to each barangay in the country which has a DTTB program. We believe that in order to achieve our vision of having a country without AMR, our program should be implemented in a long term basis, and concentrate in the remote areas who have less access to information regarding AMR. In behavior analysis, to strengthen a desired behavior, the behavior has to be repeated in a lot of times until it becomes a habit and over time, a norm in the community. We hope that our study might influence other research that will help our country in fighting AMR. VII. Risks and Mitigations One of the major risks is still non-compliance to the program. The patients can remain uncooperative during the project implementation. With this, the researchers are planning to give positive reinforcements for those who will comply with the intervention and for patients who will have high adherence to their antimicrobial regimen. Hygiene kits and vaccines not included in the free vaccination program of the DOH can be given as rewards for positive behavior. People who will be lost to follow-up will not be able to receive these rewards. The accessibility and interface of the application can also be a risk. The difficulty in using the application can be minimized by simplifying the user interface and properly The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD educating the public on how it is used. Mobile signal strength can also be a problem since the community is located remotely. The community should also be closely monitored and the researchers should strictly adhere to the timeline of the intervention so as to assess accordingly the pre and post-intervention data. REFERENCES: Aslam, B., Wang, W., Arshad, M. I., Khurshid, M., Muzammil, S., Rasool, M. H., … Baloch, Z. (2018). Antibiotic resistance: a rundown of a global crisis. ​Infection and drug resistance,​ ​11​,-. doi:10.2147/IDR.S173867 Austrian Development Agency Evaluation Unit (2009). Guidelines for Project and Programme Evaluations. Retrieved from: https://www.oecd.org/development/evaluation/dcdndep/-.pdf Cole-Lewis, H., & Kershaw, T. (2010). Text messaging as a tool for behavior change in disease prevention and management. ​Epidemiologic reviews,​ ​32​(1), 56–69. doi:10.1093/epirev/mxq004 Davari, M., Khorasani, E., & Tigabu, B. M. (2018). Factors Influencing Prescribing Decisions of Physicians: A Review. ​Ethiopian journal of health sciences,​ ​28(​ 6), 795–804. doi:10.4314/ejhs.v28i6.15 Archawakulathep, A. et. al. (2014). Perspectives on Antimicrobial Resistance in Livestock and Livestock Products in ASEAN Countries. ​The Thai Journal of Veterinary Medicine, 44​(1): 5-13. Bandiola, T., Amoin, R., Bautista, J.P., Birog, J.A., Cayanga, D., & Tejada, J. (2016). Awareness, knowledge, and practice of community residents on antimicrobials and the development of antimicrobial resistance. Retrieved 09/12/19 from https://www.researchgate.net/publication/-_AWARENESS_KNOWLEDGE_AND_PR ACTICE_OF_COMMUNITY_RESIDENTS_ON_ANTIMICROBIALS_AND_THE_DEVELOPMEN T_OF_ANTIMICROBIAL_RESISTANCE/link/59dcfa3c0f7e9b11b6234f04/download The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD Kannisto, K. A., Koivunen, M. H., & Välimäki, M. A. (2014). Use of mobile phone text message reminders in health care services: a narrative literature review. ​Journal of medical Internet research,​ ​16(​ 10), e222. doi:10.2196/jmir.3442 Kosai H, Tamaki R, Saito M, Tohma K, Alday PP, Tan AG, et al. (2015) Incidence and Risk Factors of Childhood Pneumonia-Like Episodes in Biliran Island, Philippines—A Community-Based Study. PLoS ONE 10(5): e-. https://doi.org/10.1371/journal.pone- Liu, Y. et al. (2016). Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. ​Lancet Infectious Diseases. 16(2)​:161–8 Magarey, A. M., Pettman, T. L., Wilson, A. undefined, & Mastersson, N. undefined. (2013). Changes in Primary School Childrens Behaviour, Knowledge, Attitudes, and Environments Related to Nutrition and Physical Activity. ISRN Obesity, 2013, 1–10. doi: 10.1155/2013/752081 Micallef, C., McLeod, M., Castro-Sanchez, E., Gharbi, M., Charani, E., Moore, L.S. et al. (2016). An evidence-based antimicrobial stewardship smartphone app for hospital outpatients: Survey-based needs assessment among patients. ​JMIR Mhealth Uhealth,​ 4(​ 3): e83. . doi: 10.2196/mhealth.5243 National Privacy Commission. (2012). ​Republic Act 10173 – Data Privacy Act of 2012. Retrieved September 16, 2019 from ​https://www.privacy.gov.ph/data-privacy-act/ OECD. DAC Evaluation Network. Glossary of Key Terms in Evaluation and Results Based Management. OECD. June 2002. http://www.oecd.org/site/0,3407,en_-_-_1_1_1_1_1,00.html PhilAtlas.(2015). ​Tingloy, Batangas.​ Retrieved September https://www.philatlas.com/luzon/r04a/batangas/tingloy.html 16, 2019 from Philippines Academy of Pediatric Pulmonologists (2016). 3rd PAPP Update in the Evaluation and Management of Pediatric Community-acquired Pneumonia. ​2016 PAPP Task Force on pCAP.​ The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD Pulcini, C., & Gyssens, I. C. (2013). How to educate prescribers in antimicrobial stewardship practices. Virulence, 4(2), 192–202. doi: 10.4161/viru.23706 Singh, S., Menon, V. P., Mohamed, Z. U., Kumar, V. A., Nampoothiri, V., Sudhir, S., … Patel, P. K. (2018). Implementation and Impact of an Antimicrobial Stewardship Program at a Tertiary Care Center in South India. ​Open forum infectious diseases,​ ​6(​ 4), ofy290. doi:10.1093/ofid/ofy290 Unemo, M. and Nicolas, R.A. (2012). Emergence of multi-drug resistant, extensively drug-resistant and untreatable gonnorrhea. ​Future Microbiology, 7(12):​1401–22. World Health Organization. (2014). ​Antimicrobial resistance: global report on surveillance. Geneva: WHO. World Health Organization. (2017). ​Antimicrobial resistance in the Asia Pacific region: a development agenda​. The LAWPHiL Project . (n.d.). https://www.lawphil.net/statutes/repacts/ra2014/ra_10639_2014.html Retrieved from Harleen K. Flora, Xiaofeng Wang, Swati V.Chande,"An Investigation into Mobile Application Development Processes: Challenges and Best Practices", IJMECS, vol.6, no.6, pp.1-9, 2014.DOI: 10.5815/ijmecs- ______________________________________ Stakeholders and Partners Involved A. AMR education for the laypeople Stakeholders The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD The main stakeholders involved here are the student youth & their families, school owners, administrators, & associations, and teachers & trainers. Students Under the One Health approach developed by the WHO and adopted by DOH, combating antimicrobial resistance should ideally be addressed by multifaceted programs. Thus the primary goal we propose in terms of education of the community members is to shape the younger generation’s beliefs to promote judicious use of antimicrobials from as early as primary school. The behavior and culture change approach has been applied with overall positive outcomes for other areas such as nutrition and healthy eating in an Australian school setting following implementation of a five-year school-based initiative (Margarey ​et al., 2013). Furthermore, since the students of today are not only some of the main consumers of antimicrobials during childhood but also potential parents of future children, a change in antimicrobial culture and consumption behavior is preferable to ensure sustainability. Since our current K to 12 curriculum is designed to build up knowledge in different aspects of Science throughout the whole curriculum, lessons on the responsible use of antimicrobials may be fragmented across the grade levels as well. We suggest that the modules be prepared in coordination with healthcare workers, researchers, and academe members through the Department of Health and Department of Science and Technology using current best evidence in the field and research. These topics should include: basics of AMR (what is AMR and why is it happening?), current strategies being employed to address the issue (what is being done?), and student involvement (as part of the young lay community, how can I help?). Before being taught to children, Science teachers should also attend seminars on AMR first as further detailed in the next section. As part of integration in the educational curriculum, it is also feasible to encourage events in schools and students as a form of support and participation in the National Antibiotic Awareness Week held in November. Activities already being held for existing school celebrations (e.g. Nutrition Month in July) may be readily adapted with AMR as the theme. Teachers Teachers are professionals under the Professional Regulation Commission and are likewise subject to the rules set for their profession, including acquisition of necessary continuing professional development (CPD) units under Republic Act 10912 before license renewal. It is suggested that teachers be required to attend a seminar or short course on AMR before engaging with the students to teach. These courses should be targeted at improving personal The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD understanding and aid classroom teaching. We propose that these seminars take place at least once every three years, since that is the current validity of any professional license. B. AMR education for the health sector Education is important for healthcare workers, with the most significant impact on the prescribers of antimicrobials to ensure that they prescribe appropriately, consider alternatives to antibiotics for the treatment and control of bacterial diseases, and have appropriate support to assist in communicating with patients effectively. To be able to effectively complement measures on preventing emergence and spread of antimicrobial resistance, behavioral interventions must largely target prescribers through measures that provide relevant information and seek to set the correct behavior as the default option. Coming up with antibiotic guidelines for treating common infections must take into account prevalent patterns of AMR, or the antibiograms. These antibiograms are to be incorporated and emphasized in the Clinical Practice Guidelines that physicians follow in the management of diseases. In these guidelines, there should be appropriateness of prescription defined in terms of “5 Rs” or ​Right drug (​when the antimicrobial is the narrowest and the most effective option)​, Right indication (​when the prescribed antimicrobial is the most appropriate selection in terms of the pathogen, if known, and the site of infection)​, Right dose ​(when the loading dose and maintenance dose of the prescribed antimicrobial is appropriate and accurate for the patient’s diagnosis as per standard recommendations)​, Right frequency (​when the frequency of the prescribed antimicrobial dose is appropriate for the patient’s diagnosis as per standard recommendations )​, and Right duration (​when the prescribed antimicrobial has been administered for the correct duration based on the patient’s diagnosis as per standard recommendations) (Singh, 2018)​. ​Prescribers should use antibiotics, based on the recommendation of guidelines and ASPs, and through considering various data such as PK/PD and MIC/MPC of antibiotics, diagnostic testing results, AST results, clinical response, and effects on the microbiota. Evidence-based medicine is a popular educational tool for clinicians so it is important that all clinicians who care for patients receiving antimicrobials are educated about unbiased sources of information, hence, the importance of timely, accurate and well-appraised evidence. All guidelines must be updated more often and have to be emphasized more prudently since antibiotic resistance patterns are continuously and consistently emerging. The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD According to Ventola (2015), 30-50% of antibiotics are prescribed incorrectly or unnecessarily with the majority of these instances stemming from the primary healthcare setting. There is a need for routinely updated, timely, and engaging educational reforms, means, and opportunities for private, hospital, and community-based healthcare providers. Republic Act No. 10912, otherwise known as the “Continuing Professional Development (CPD) Act of 2016”, is an act which requires CPD as the mandatory requirement for the renewal of Professional Identification Card. ​All seminars attended by licensed professionals should be recognized as CPD units and shall be accepted as valid for the renewal of their licenses. An effort to require at least one of these seminars to include a topic mainly dedicated to antimicrobial resistance will allow at least timely updates to the forerunners of antibiotics usage. The clinician can ​contribute more fully to AMS when they are provided with regular education to safely and appropriately use antimicrobials. Another similar strategy to undertake continuing professional development is by maintaining a continuing education record or portfolio which shows participation in different activities to maintain, improve and broaden knowledge, skills and performance to help clinicians deliver antimicrobial stewardship. A cohesive framework for continuing professional development seminars for healthcare providers essentially directed to supplement current knowledge on antimicrobial usage and options and update practices on antimicrobial prescription should center on the extent and causes of antimicrobial resistance, including the role of antimicrobials in driving resistance, role of infection prevention and control, general principles of antimicrobial therapy, interpretation of antimicrobial susceptibility reports and local antibiograms, allergies to antimicrobials, and therapeutic drug monitoring (Aslam, 2018). Most importantly, clinicians must be aware of local AMS programs which includes availability of national and local diagnostic and treatment guidelines, organizational policies on antimicrobial prescribing, clinical decision support systems, local restrictions and approval systems and who to go to for advice. Specialized and directed continuing professional development (CPD) sessions for the healthcare providers will reiterate the (Access, Watch, and Reserve) AwaRe tri-group classification by the World Health Organization for the optimal usage of antibiotics. To reduce cases of resistance, these sessions must spark initiative to become prudent physicians that recognize access, watch, and reserve antibiotics. prescribe antimicrobials only for specific and limited indications beneficial to the patient’s condition. Topics for CPD sessions can further extend to discuss updates on drugs for neglected and infectious diseases, new diagnostic tools relevant to antimicrobial resistance, developments in vaccinations against pathogens associated with antibiotic resistance. In the aspect of patient education, CME sessions on engaging means The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD of communication for antimicrobial prescription, ensuring and assessing patient compliance based on patient profile, risks assessment of poor antimicrobial compliance, and follow-up surveillance of antimicrobial resistance can be offered to the licensed medical professionals. For undergraduate medical students, a firm educational grounding to achieve optimal prescribing and use of antimicrobials must be included in the medical curriculum. Such topics include principles of microbiology, identification and clinical pharmacology, with emphasis on appropriate antimicrobial prescribing and use of more cases of diagnostic uncertainty in medical undergraduate education. Students can be involved in improvement projects for AMS so that although still in the early formative years, they can improve clinical care and build the capability and capacity of the workforce. AMS education need not be limited only during antimicrobial stewardship trainingsa but can also be incorporated in the clinical practice especially in teaching hospitals where prescribers are more likely to be team based, with the opportunity to work collaboratively with other clinicians in the workplace, and their prescribing decisions are more likely to be subject to review by infectious diseases physicians, pharmacists or other members of the healthcare team (Davari, 2018). Using case studies can engage physicians especially for tutorials and grand rounds sessions where interactive sessions using problem-based learning with case vignettes are recommended. Meetings where management of individual patients can be discussed within clinical teams or with peers, can help to engage clinicians from different disciplines by making AMS relevant to patient management. Clinicians can provide feedback on the results of audits, with recommendations for improving prescribing behaviors, supplemented with electronic messages, posters and online resources. This must also highly apply to other essential members of the health sector. Pharmacists and pharmacy assistants can benefit from specialized training sessions that focus on patient engagement once in the pharmacy, addressing lapses in interpreting drug prescriptions and dispensing antimicrobials, and responding appropriately to patient queries, among other relevant topics. C. AMR education for the other sectors Based on the Six policy package developed and promoted by the World Health Assembly resolutions, we propose programs to address AMR on other settings such as agriculture, veterinary, and industry. Upon research, we found out that there are already existing initiatives The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD from the government in partnership with different local sectors ( Department of Agriculture, Department of Health, Department of Science and Technology,Research Institute of Tropical Medicine and Department of Interior Local Government) and international agencies such as UN-FAO ( Food and Agriculture Organization of United Nations) that the public has not been aware of. Upon further analysis, we identified that the gap lies on the continuity and strengthening of implementing these programs in the long run: the challenge to make these programs impactful. Therefore, we propose that existing programs against AMR be strengthened and implemented nationally. We start by educating stakeholders, stating the facts on how AMR will affect not only their produce and profit but also their health by conducting seminars on proper use of antimicrobials in agriculture , using media in spreading infographics, creation of standardized protocols on proper use of antibiotics in veterinary, agriculture and food safety and making it available to the public, and the use of different tools to disseminate information about AMR. By spreading the UN-FAO’s ​“iAMResponsible” campaign and our country’s “One Health” approach in the different regions of the archipelago, combined with the efforts of our country’s stakeholders, we hope to promote awareness among farmers, veterinarians, and local leaders on the importance of practicing responsible use of antimicrobials, including antibiotics on agriculture, husbandry, and veterinary. Since the causation of AMR is inter-related and inter-sectoral thereby requiring collaborative multidisciplinary work at local, national, and global levels to attain optimal health for all, we propose interagency conferences or summit every five years, where in members from all sectors, public and private, Veterinary, Agriculture, Government leaders, Academe , and WHO, come together and discuss, to evaluate and update existing policies and programs regarding our fight against AMR. We believe that a multidisciplinary dialogue is vital in improving the system, and this can only be achieved through the contribution of the different sectors. We have also devised a plan on how we can promote awareness about AMR in the grassroots level. First we must identify the baseline knowledge of our stakeholders about AMR , its current state, causes and impact on their respective industry, through descriptive method such as surveys. After data gathering, we would then focus on those areas with poor understanding regarding AMR, and create informative tools catered to their needs (translated in their dialect, with visual aids) and are readily accessible to them (local office, websites, veterinary clinics, etc) to introduce the policies on AMR. A surveillance team will be created for each region for monitoring and surveillance. A quarterly report shall be made regarding the adherence and feedback of the stakeholder to the introduced policy/ies. Data will then be evaluated and The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD reported in the summit every 5 years and results shall be reviewed if statistically significant or not. VIII. Anticipated Impact From Guidelines to Concrete Actions Our group envisions the Philippines to take the initial step in the eradication of AMR. We aim to adopt a long term action plan that aligns with the existing guidelines of antimicrobial stewardship under an interdisciplinary/multisectoral approach. We anticipate that our action plan will create an impact in the various sectors of our society spanning from social, educational, economical, health, agricultural, and industrial aspects. The root of AMR, globally, is lack of awareness and misinformation; awareness overpowered by misinformation. The interdisciplinary dialogue would be an efficient tool for our selected population to have a greater understanding about AMR. The priority of integrating AMR into the educational curriculum would increase awareness and propagate informed choices about the appropriate use of antimicrobial agents. Subject matter experts exchanging best practices knowledge in multisectorial conferences would reduce the level of unnecessary prescription and its unintended consequences. Regular training of healthcare professionals would also ensure the delivery of high quality patient care and guarantee patient safety. We hope that a task force would be created to manage the establishing of data, implementing and monitoring of the progress of the study. Implementing our model of antimicrobial stewardship will help curb inappropriate antibiotic use and effect changes in antimicrobial consumption trends in both outpatient and hospital settings. This national directive will act as a catalyst not only to thwart the unregulated use of antimicrobial agents, but will similarly enhance cooperation and promote better collaboration among agencies. In undertaking this health security objective, we also hope to accelerate pharmaceutical investment in research and development efforts to create opportunities for developing new antibiotic drugs. The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD Our multilateral approach would alleviate the burden of antimicrobial resistance and be a model for others to emulate. We stand united under the dictum of a country without AMR. The STAR Initiative The Efficiency of the Standardized Text Notification and Application against Antimicrobial Resistance (STAR) Strategy as a Tool against Antimicrobial Resistance (AMR) in a Remote Area of the Philippines with Limited Access to Healthcare Resources Krystal April Joy O. Curso, Mianne Airish C. Hernandez, Alfredo Lorenzo R. Sablay; Stephanie M. Tan, Kimberly Jane F. Vent Kenneth Hartigan-Go MD, MD (UK) Jonathan Salansang, MD Advisers: MD A. Multisectorial conference highlighting interdisciplinary dialogue involving the Agricultural, Health, Industrial, and the Education sector. B. Educational Curriculum Integration of AMR C. AMR Trainings prior to certifications and permit renewals of pharmaceutical companies and hospital institutions D. Monitoring system in place for antimicrobials consumption. E. Enhancing coordination between countries to develop a true global action plan to address the pressing issues on AMR.