Enablers of conformance with ABWPs.

Theme 1: Farmers are aware of the concept of ABWPs. There are likely to be circumstances where farmer awareness of an ABWP is a necessary prerequisite for the farmer to conform with the ABWP, such as when a pig recovers from disease before the end of the ABWP of the antibiotic administered to treat it. Since approximately 60% of the Kenyan population have been reported to keep livestock [27], livestock farming is not considered a specialism in Kenya, but is part of daily life. Farmers selling to a LIA in our study were generally busy, navigating multiple employments, activities and responsibilities. Therefore, we did not expect farmers to engage in detailed discussion of ABWPs with us during the study, especially given the lack of governmental legislation in this area. Despite this, all farmers described to us the concept of an ABWP: that a delay is required between the administration of an antibiotic and slaughter. This was reflected by AHPs, who reported that most farmers were aware of ABWPs and that farmers buying antibiotics from an agrovet (veterinary medicines store) frequently asked them for the ABWP.

“When you talk to farmers they also know the effects of using antibiotics in their animals and taking them immediately to slaughter.” (KII, Government Veterinarian 1, November 2022)

The length of time of each ABWP is specific to the antibiotic and should be displayed on the packaging. In our study, we specifically did not ask farmers to define an ABWP but asked farmers to describe their actions following a need to treat a pig with a medicine close to slaughter. Therefore, farmers demonstrated an understanding of the concept of an ABWP without necessarily understanding the specific technical language, by answering that they would not send the animal immediately to slaughter and detailing why. Farmers could demonstrate further understanding of ABWPs by describing that the length of the ABWP varied, should be displayed on antibiotic packaging and by explaining the meaning of ABWP labelling when shown an item of antibiotic packaging with the antibiotic withdrawal period correctly displayed.

In our study, eight out of the 13 (62%) participating farmers described to us that the withdrawal period for each antibiotic varied and that the specific time for the ABWP should be detailed on the packaging. They also correctly explained the meaning of ABWP labelling on the antibiotic packaging that they were shown. Importantly, this included all of those participants who kept antibiotics on the farm and reported administering these to pigs themselves. These tended to be larger farms that mainly supplied pigs to the large integrated processor (see Table 1).

“The vet mentioned it [the ABWP] to me and, because the vet knew I was treating my pigs, he had to educate me. […] I remember, once you administer, read the instructions.” (Interview, Farmer 8, November 2022)

Providing insight into participants’ awareness of ABWPs, several farmers reported this to be as a result of discussions with AHPs, although it was frequently unclear whether farmers were referring to discussions held with a veterinarian or a veterinary para-professional.

“So he [the AHP] tells me: this [pig] should go two weeks. This [pig], it must stay here one month. So that if he [the AHP] goes and someone comes to buy the meat, I tell them, ‘No. Just wait for the medicine for the pig to go.’” (Interview, Farmer 13, November 2023)

As the quote demonstrates, participants described how AHPs commonly made them aware of the specific ABWP for each medicine at the time of prescribing and explained that these discussions and the advice given by AHPs influenced their practices.

Theme 2: Farmers want to conform with ABWPs. In cases when a pig recovers from disease before the end of the ABWP of the antibiotic administered to treat it, farmer intention to conform with ABWPs is also a necessary prerequisite for the ABWP to be conformed with. Despite ABWPs not being in law for the domestic market for pigs in Kenya, all farmers in the current study described an intention to conform with ABWPs. Most farmers cited that they were motivated to conform with ABWPs due to food safety concerns and caring for those around them. Farmers often described how these caring intentions were influenced by their religious faith and national values.

“Because you are causing harm to another person knowingly. And us, you know we are Christians.” (Interview, Farmer 9, November 2022)

Other farmers similarly reported intentions to conform with ABWPs, but described this to be due to concerns around repercussions from non-conformance, seemingly believing that a system of monitoring and enforcement at the LIA was present under perceived regulations:

“Because once you slaughter, it will show. I know, the meat will show. […] The vet knows. They will tell you: ‘You have given medicine yesterday, or before 3 days’. They will tell you. I have gone to their slaughterhouse and I have seen the vet saying this meat cannot be consumed. The reason? They had administered some antibiotics before 3 days.” (Interview, Farmer 8, November 2023)

Participating farmers’ intentions around ABWPs were reinforced to us by stories from three participants who described cases in which their intention to conform with ABWPs meant that they did not send pigs to slaughter at a LIA when they might have wished to.

“There were three, they came ill. And when they came ill the vet come and he injected them. Now we saw that they are not improving. The time when we wanted to sell them, my husband told me, because these ones they have not even finished one month, even one week, before they were injected. Let them die and then we bury them.” (Interview, Farmer 11, November 2022)

This was despite the precarious financial circumstances in which many of the farming participants in our study lived and the monetary value that fully grown pigs represented.

Theme 3: ABU practices lead to ABWP conformance ‘by default’. An understanding of when, how and why antibiotics are used is crucial to gaining an appreciation of factors shaping ABWP conformance because, for non-conformance with an ABWP, an antibiotic must have been administered and the pig slaughtered within the ABWP for the specific antibiotic. Broadly, participants in our study characterised ABU practices as demonstrating few opportunities for non-conformance with ABWPs at a LIA. This was due to reportedly infrequent use of antibiotics, especially for pigs close to slaughter. Both farmers and AHPs reported that ABU for pigs was avoided and minimised where possible. This was the case for several indications of ABU, including ABU for growth promotion, prophylaxis of disease and treatment of disease.

For ABU for growth promotion or for prophylaxis of disease in pigs, no farmers reported completing frequent (more than six-monthly), routine ABU. This was despite farmers being able to purchase antibiotics at agrovet stores without veterinary prescription (see also [13, 37]) and the availability of products containing antibiotics in the study area which were labelled with indications for use such as to increase growth and improve feed conversion (see also [37]). Farmers did practice measures to combat under-productivity, however, in our experience, these did not include intentional ABU.

“I have not heard about use of antibiotics for growth in pigs […] but I know that they’re used when the pigs are sick. They have also, also, um, farmers have this notion that pigs don’t get sick… They don’t see the needs for antibiotics for pigs.” (KII, Government Veterinarian 3, November 2022)

During our study, participants discussed farmers’ wishes to avoid ABU for growth promotion, prophylaxis or treatment of disease, due to wishing to avoid the costs associated with ABU. This was described in the context of notable financial pressure affecting pig farmers. Further, as the previous quote demonstrates, participants reported a view that infectious diseases in pigs were uncommon, meaning that antibiotics were rarely necessary for the treatment of disease. This was despite reports of notifiable disease in the area, our own observations of extremely emaciated pigs (see also [38]), extensive pig movement due to the need to transfer genetic material (see also [20]), poor biosecurity and very low reported rates of vaccination. Farmers described that pig health could broadly be maintained without antibiotics:

“You keep them warm, you keep them clean, you feed them well. They are there to go. No medicine.” (Interview, Farmer 3, November 2022)

The lack of need for medical treatment was expressed to be especially the case for pigs nearing slaughter weight; most infectious disease and instances of ABU were discussed by both farmers and AHPs as occurring in piglets. In these cases, surviving piglets were held on-farm until far beyond the ABWPs, or died and were reportedly disposed of. It is unlikely, therefore, that these instances of ABU represented non-conformance with ABWPs at a LIA. FGD participants described these instances of ABU in piglets not destined for slaughter anytime soon as ABWP conformance ‘by default’ (FGD, Veterinary Para-professional, November 2022).

Also driven by economic difficulties, where clinical signs of disease did occur, farmers often did not seek AHP advice. Four out of 13 farmers kept a small selection of antibiotics on their farms and administered these in line with their previous antibiotic experiences. As previously discussed, these farmers all understood the meaning of ABWP guidelines on packaging and described intentions to conform with ABWPs. For other farmers, the financial barrier to seeking AHP assistance often led to clinical signs of disease being left untreated. One participant described how some pigs would live without antibiotic treatment and others would die with antibiotic treatment.

“You have to pass through challenges. And the challenge also makes you remember God more. So when you are smooth sailing, you are just settled, God, thank you for the day.” (Interview, Farmer 4, November 2022)

As the quote above demonstrates, these challenges were considered part of the tapestry of farming and life; ‘antibiotic non-use’ was just as interesting to explore as ABU (see also [39]). For example, occasionally, farmers cited goals of low medicine use–aimed at avoiding antibiotic resistance or antibiotic residues–as reasons to avoid ABU.

Participant: “I hate just always giving the medicines. I hate that. Ok so you do that for a very long time, it becomes, what do you call it? Too much drugs…”

Interviewer (CS): “Resistance?”

Participant: “Yeah, yeah. It will resist.” (Interview, Farmer 6, October 2022)

Cost is likely to be a notable driver of these goals as, when asked why the same farmer preferred to bring a singular pig into a passageway to treat it with oral antibiotics rather than treat the whole group of pigs, the farmer said:

“Because if maybe you give all of them [the antibiotic], that’s an extra cost too. So I have to be specific to this one [pig].” (Interview, Farmer 6, October 2022)

As the above quote demonstrates, farmers in our study also described the need to isolate antibiotic treatment to as few animals as possible for the shortest time, in order to lessen the financial burden of such interventions.

Barriers to conformance with ABWPs.

Theme 4: Farmers may be unaware of specific ABWPs. We identified several areas as having the potential to challenge farmer awareness of the specific ABWP of antibiotics administered to pigs. These fell into four categories which were: farmers not demonstrating the ability to identify the specific ABWP from antibiotic packaging; AHPs not reliably informing farmers of ABWPs; mislabelling or concealment of the active ingredients of substances containing antibiotics used for pigs; and ABWPs not being reliably displayed on antibiotic packing.

For farmers not demonstrating an ability to identify the specific ABWP from antibiotic packaging, despite having previously demonstrated an understanding of the concept of an ABWP, five out of the 13 farmers participating in the study could not explain the meaning of an ABWP from its indication on antibiotic packaging. Rather than detailing that the length of the ABWP varied between antibiotics, these participants said a more arbitrary time period for the ABWP, which ranged between participants from three days to six months.

It is important to note that each of the five farmers who were unable to explain the meaning of an ABWP from its indication on antibiotic packaging reported that they always called an AHP to administer medicines, which was also confirmed by our observations. In such cases, it is the responsibility of the AHP to make the farmer aware of the ABWP for the specific antibiotics being administered. In our FGDs and KIIs, however, AHPs reported that whether or not AHPs consistently made farmers aware of the specific ABWP varied. In our study, one participant described that:

“It depends on the individual integrity of the vet or the para-vet.” (FGD, Private Veterinarian, November 2022)

Veterinary para-professionals were of the view that veterinarians were unlikely to explain to farmers about ABWP, saying veterinarians are:

“…not that concerned about explaining to the farmers about withdrawal periods.” (FGD, Veterinary Para-professional, November 2022)

In a separate FGD, veterinarians described their experience that veterinary para-professionals did not inform farmers about ABWPs:

“According to my own experience, I have never heard any para-vet explain to the farmers what is withdrawal period. They just treat and go.” (FGD, Private Veterinarian, November 2022)

AHPs in our study also reported that uncertified AHPs–whom they termed ‘quacks’–operated in the area as a result of poor regulatory enforcement (see [9, 14, 40, 41] for similar findings in Kenya and East Africa).

“So they [the farmer] will sometimes even call a quack. Somebody who is not trained. We have a problem that the veterinary practice in Kenya is not very well regulated. So anybody starting, even somebody who has just gone to college and, uh, they have learned animal production, they will parade themselves as a vet out there. And the farmers will not know, because farmers don’t care to ask these things.” (KII, Government Veterinarian 3, November 2022)

Uncertified AHPs were considered by AHPs as unlikely to make farmers aware of ABWPs. In addition to the potential for AHPs to not make farmers aware of the ABWP, one government veterinarian described to us how AHPs may be motivated to administer antibiotics without clinical indication, meaning that farmers may not be aware that pigs had received antibiotics or of the ABWP associated with such ABU:

“Some vets, some animal health technicians–along with a booster, they’ll give an antibiotic just to cover. So you don’t really know what that antibiotic is being injected for. It’s just so that they give more injections and get more money.” (KII, Government Veterinarian 3, November 2022)

We also identified that actors other than AHPs could mislead farmers, meaning that farmers were unaware of the ABWP of administered antibiotics. During our study, participants often showed us substances that they administered to the pigs in order to improve productivity, such as multivitamin ‘boosters’, iron injections or other supplements. Although none of the products that participants showed to us and described to be used for such indications were labelled to contain antibiotics, it is possible that products may be incorrectly labelled meaning that farmers may not always be aware of any antibiotic content (see also [10, 39]). Highlighting a potential example of how this could take place, one participant showed us the ‘mycotoxin binder’ that they had purchased at a market which was a powdered substance that they reported to have been decanted into a clear plastic bag by the seller, although there was no labelling as to its composition; the participant subsequently added this substance to their pigs’ feed. Further, although we did not identify that any of the pig food kept on farms was labelled to contain antibiotics during the study, one AHP raised the possibility that antibiotics may be included in feed, unlabelled and therefore unknown to farmers (see also [39]).

“So most of the animal feeds they won’t tell you, but they do put antibiotics.” (FGD, Private AHP, November 2022)

It should be noted that other participants in the FGD vehemently disagreed with this participant’s statement.

Finally, whilst acquiring antibiotics for the ‘Drug Bag’, we identified that awareness of the specific ABWP of an antibiotic being administered could also be limited by the ABWP not being displayed on antibiotic packaging (see also [9, 10]).

Theme 5: ABU practices challenge conformance with ABWPs. Conversely to the ABU practices participants described as enabling ABWP conformance under Theme 2, other ABU practices may have acted as barriers to conformance with ABWPs. These were: a lack of recording of ABU meaning that ABWP could be misremembered; the possibility of ABU practices being different outside of our study period; and the potential for the extent of ABU to be under-reported by participants in our study.

The most common antibiotics which farmers reported had been used on their farms during our study had active ingredients including oxytetracycline (n = 10), trimethoprim sulphate (n = 9) and penicillin and streptomycin (n = 4). The antibiotics which farmers reported had been used most commonly (defined as those antibiotics which were reportedly used more than twice across all farms during the study period) had ABWPs displayed on packaging which were between five and 28 days. Participants in our study described how instances of ABU administered to pigs were rarely recorded by pig farmers (see also [22, 42]) and, as described in our related manuscript [28], the reasons for this appeared complex and were contextual. For example, both farmers and AHPs described how some AHPs hid the identity of antibiotics being administered to pigs, so that farmers could not purchase the antibiotic themselves in future without first seeking AHP assistance (see Scott et al. [28]). Without knowledge of the antibiotic, farmers described being unable to keep ABU records which might have included reference to the withdrawal periods. Further, as also described in our related work [28], farmers demonstrated errors in remembering time periods. Therefore, lengthy ABWPs of commonly used antibiotics represented a barrier to conformance with ABWPs in the context of rare medicine recording and recall problems.

For the possibility that ABU practices could be different outside of our study period, participants implied that ABU for near-slaughter-weight pigs could be higher during the cold season (from June to September), especially in pigs close to slaughter, meaning that conformance with ABWPs might be more regularly challenged over a different time than when our study took place. Here, participants discussed initiating antibiotic treatment for shaking pigs, which they described as having pneumonia.

“Mainly, they get pneumonia when the weather changes. But when there is no change of weather, I don’t see any problem with them.” (Interview, Farmer 11, October 2022)

For this purpose, one participant picked out of the ‘Drug Bag’ a gentamicin product which was labelled with a 45-day ABWP for kidneys that might be consumed. The ABWP for the consumption of meat (muscle tissue) after administration of gentamicin is just seven days, however offal (kidneys, liver, etc.) is commonly consumed in Kenya and is sometimes given as payment to slaughtermen at LIAs [16], meaning that antibiotics which concentrate in organs consumed as offal may hold specific risk.

We also experienced occasions where the lines between growth promotion and treatment of disease appeared blurry (see also [43]) meaning that ABU which constituted as being for growth promotion may have, in reality, occurred more frequently than farmers and AHPs reported in their more general discussions on the topic under Theme 2. For example, one participant reported the administration of antibiotics by an AHP to ‘get them [the pigs] on proper weight’ and ‘bring back the body condition’ (Interview, Farmer 5 through translator, November 2022). Here, we were unable to ascertain whether pigs had been showing clinical signs of weight loss–possibly due to an infectious disease–or whether antibiotics were being used for growth promotion. In this way, it was not consistently possible to neatly divide instances of ABU into those for growth promotion, prophylaxis, metaphylaxis or treatment of disease to decipher whether antibiotics were used routinely in the production cycle. These gaps in our understanding were confounded by the methodological challenges we experienced determining ABU on farms, which we describe in our related manuscript [28] and included both over- and under-reporting of ABU.

Theme 6: Economic fragility and resource constraints challenge ABWP conformance. Under this theme, we identified that farmers’ social and economic circumstances did not consistently provide the opportunity for conformance with ABWP guidelines. In our study, financial precariousness and high production costs–mainly associated with increased feed prices–appeared to underline many farmer practices. These included whether farmers consulted AHPs, ABU practices and conformance with ABWPs. For the latter, by leaving farmers in a situation of financial fragility where they were not able to absorb costs around unforeseen events, farmer economic fragility appeared to prohibit delays in slaughter that might have been associated with ABWP conformance:

“You come in a situation whereby you are forced to do it [send a pig to slaughter within an ABWP]. You don’t have any other option. You don’t have rentals, you don’t have any other thing. And you have a situation so you sell the pig, you see? And it is not your fault. Even God can see, it is the situation that you are in.” (Interview, Farmer 13, November 2022)

This was reflected in the only case of potential ABWP non-conformance identified during our study. As also described in our related manuscript [28], one farmer picked out nine different antibiotic-containing products from the ‘Drug Bag’ exercise completed on our final visit to the farm, as having been used in the last month. Although this account was not captured through any of the other methods we employed to determine farm-level ABU, the participant reported that these antibiotics had been administered by an AHP who had visited the farm in the second week of the study, with an aim to improve growth in near finishing-weight pigs. Notwithstanding the potential reliability issues with this reported instance of ABU (methodological challenges experienced in the current study are described in Scott et al. [28]), during the semi-structured interview, the participant described their intention to wait three weeks between the administration of medicines and slaughter of pigs. However, due to water scarcity on the farm (at the time of the study Kenya was suffering its worst drought for forty years; [44]), pigs were sold, on an emergency basis, just two weeks after the reported administration. This was within the ABWP for several of the antibiotics reportedly administered.

“Ok so he [the farmer] is saying for most of these drugs, they were injected two weeks before. They were injected and then they were sold two weeks after.” (Interview, Farmer 5 through translator, November 2022)

In this example, seven pigs which may have been within an ABWP were sent to slaughter at a LIA by this farmer. Across our small sample of 13 farms over a one-month study period, 14 pigs in total were reported to have been sent to slaughter at a LIA. (There was a total of 387 pigs on all 13 farms on the first visit.) In this way, for our study, resource scarcity may have represented a notable barrier to conformance with ABWPs for pigs sent to a LIA.

Theme 7: Poor regulatory frameworks may weaken farmer motivation to conform with ABWPs. In the final theme, AHPs described how the lack of enforcement around antibiotic residues at LIAs facilitated non-conformance with ABWPs.

“You will find, if the pig is sent in a withdrawal period, it is taken to local slaughterhouses. It is really hard for it to be condemned. So the farmer will realise, ‘I sold my pig after a drug administration within say two weeks […] so why not repeat’.” (FGD, Veterinary Para-professional, November 2022)

This view of poor regulation at the LIA amongst AHPs was described as being due to a lack of government funding to carry out enforcement activities such as meat inspection. Further, AHPs participating in our study reported instances of meat inspectors being undermined, bribed and pressured (see also [16]) to turn a blind eye to sick animals at slaughter and permit carcass damage suspected to be caused by injection of medication to be cut out of carcasses in order to avoid whole-carcass condemnation.

“You [the farmer] had injected it yesterday, you don’t tell that person [meat inspector]. So during the slaughter, that site of injection is removed.” (KII, Government Veterinarian 2, November 2022)

Participants described how this lack of enforcement was particularly utilised by brokers and traders, who were reported to buy pigs from farmers within ABWPs at a lower price but immediately send such animals for slaughter at a LIA.

Participant: “Traders, I don’t think they ask [about ABWPs]. I don’t think so. Actually, the only reason they will ask is so that they buy it [the pig] at a lower price. Yeah. They will [say]: ’Oh, this pig is sick. It has been treated for three days and, and it’s not getting better.’ It means the trader will buy it at a lower price.”

Interviewer (CS): “But sell it to [LIA] for the same price?”

Participant: “Yes. The only reason they will ask that is because of that [so that they can buy the pig at a lower price], not because that they’re concerned about the withdrawal periods.” (KII, Government Veterinarian 3, November 2022)

AHPs also raised the possibility that the perception of a tight regulatory and enforcement framework at the large integrated processor, relative to the LIA, might have led farmers to feel motivated to use LIAs as the salvage abattoirs for the county.

“Also, if an animal falls sick just before slaughter and they [the farmers] are taking to [large integrated processor]–they had better take less animals. […] That is not the case if they’re going to the other local slaughterhouses. If that happens, the pig is taken for slaughter the same day, if they fall sick.” (KII, Government Veterinarian 3, November 2022)

In such cases, whether or not ABWPs were conformed to would be dependent on whether antibiotic treatment had been completed before sending the pig to slaughter. For example, if a sick pig was sent straight to slaughter rather than being treated with an antibiotic, ABWPs would likely be conformed to. If antibiotic treatment was applied unsuccessfully and, instead, the LIA was used as salvage for non-recovering pigs, it is likely that ABWPs would not be conformed to.