A scoping review to assess the impact of public education campaigns to affect behavior change pertaining to antimicrobial resistance

Improving healthcare professionals' interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators

Introduction

Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions.

Methods

We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels.

Results

Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation).

Conclusion

The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.

Assessment of global antimicrobial resistance campaigns conducted to improve public awareness and antimicrobial use behaviours: a rapid systematic review

INTRODUCTION

Public health campaigns with a well-defined outcome behaviour have been shown to successfully alter behaviour. However, the complex nature of antimicrobial resistance (AMR) creates challenges when evaluating campaigns aimed at raising awareness and changing behaviour.

AIMS

To determine what campaigns have been conducted and which reported being effective at improving awareness of antimicrobial resistance and changing behaviour around antimicrobial use in members of the public. It also sought to determine the outcome measures studies have used to assess campaign effectiveness.

METHODS

A systematic search of Ovid MEDLINE and Embase, was conducted in October 2022 using a predefined search strategy. Studies which were published between 2010 and September 2022 that outlined a campaign or invention aimed at the public and focusing on AMR or antibiotic usage were eligible for inclusion and studies which solely targeted healthcare professionals (HCP) were excluded.

RESULTS

Literature searches retrieved 6961 results. De-duplication and screening removed 6925 articles, five articles from grey literature and reference screening were included, giving a total of 41 studies and 30 unique interventions. There was a distribution of campaigns globally with the majority run in Europe (n = 15) with most campaigns were conducted nationally (n = 14). Campaigns tended to focus on adult members of the public (n = 14) or targeted resources towards both the public and HCPs (n = 13) and predominately assessed changes in knowledge of and/or attitudes towards AMR (n = 16). Campaigns where an improvement was seen in their primary outcome measure tended to use mass media to disseminate information, targeted messaging towards a specific infection, and including the use of HCP-patient interactions.

DISCUSSION

This review provides some evidence that campaigns can significantly improve outcome measures relating to AMR and antibiotic usage. Despite a lack of homogeneity between studies some common themes emerged between campaigns reported as being effective. However, the frequent use of observational study designs makes it difficult to establish causation between the campaign and changes seen in the studies outcome measures. It is important that clear evaluation processes are embedded as part of the design process for future campaigns; a campaign evaluation framework for use by campaign developers may facilitate this.

Antimicrobial resistance as a super wicked problem: how do we engage the public to be part of the solution

Antimicrobial resistance (AMR) is now regarded as one of the greatest global challenges of the 21st century. The complexity, urgent timeframe, and lack of clear solution to AMR have contributed to its classification as a 'super wicked problem'. Yet knowledge surveys of the general public have found that they still harbour numerous misconceptions linked to both the sources and impact of AMR. This confusion is compounded by AMR being a One Health issue, and therefore a factor in not just human health but in other industries, such as farming. This can further inhibit understanding and knowledge transfer around AMR for those without a prior knowledge base. In order to address the escalating risk that AMR presents, however, it is essential to address this knowledge gap and engage with the public to support wide scale changes in behaviour and consumer choice. The WHO now requires national action plans tackling AMR to include patient and public involvement/engagement (PPI/E) to support changing the trajectory of AMR. Despite this, little detail is available as part of strategic plans on how PPI/E should be undertaken in order to aid implementation. This paper discusses a number of approaches to support the design and delivery of PPI/E in relation to AMR, including the different social behaviour models underlying successful PPI/E strategies, and key considerations linked to specific activity types. The framework produced includes features for steps from initial planning and design through to evaluation. The aim is to help improve the ability of scientists and healthcare professionals to produce high quality AMR PPI/E.

An intervention to promote positive homeworker health and wellbeing through effective home-working practices: a feasibility and acceptability study

BACKGROUND

In the wake of Covid-19, the prevalence of working from home ('home-working') is expected to rise. Yet, working from home can have negative health and wellbeing impacts. Interventions are needed to promote effective ways of working that also protect workers' health and wellbeing. This study explored the feasibility and acceptability of an intervention intended to promote home-working practices that would protect and promote health behaviour and wellbeing.

METHODS

An uncontrolled, single-arm mixed-methods trial design was employed. Forty-two normally-office-based UK workers, working from home between January-February 2021 (during the Covid pandemic), consented to receive the intervention. The intervention: a digital document offering evidence-based recommendations for home-working in ways conducive to health behaviour and wellbeing. Feasibility and acceptability were quantitatively indexed by: expressions of interest within 1 week (target threshold ≥ 35); attrition across the one-week study period (threshold ≤ 20%); and the absence of any apparent detriments in self-reported physical activity, sedentary behaviour, snacking, and work-related wellbeing prior to and one week after receiving the intervention. Qualitative think-aloud data, obtained while participants read through the intervention, and analysed using reflexive thematic analysis, explored acceptability. Semi-structured interviews conducted one week after intervention exposure were content-analysed to identify whether and which behaviour changes were adopted.

RESULTS

Two feasibility criteria were met: 85 expressions of interest indicated satisfactory intervention demand, and no detriments were observed in health behaviours or wellbeing. Forty-two participants (i.e., maximum capacity for the study; 26 females, 16 males, aged 22-63) consented to take part. 31% dropped out over the one-week study period leaving a final sample of 29 (18 females, 11 males, aged 22-63), exceeding identified attrition thresholds. Think-aloud data showed that participants concurred with intervention guidance, but felt it lacked novelty and practicality. Follow-up interviews produced 18 (62%) participant reports of intervention adherence, where nine recommendations reportedly prompted behaviour change in at least one participant.

CONCLUSIONS

Mixed evidence was found for intervention feasibility and acceptability. Whilst the information was deemed relevant and of value, further development is required to increase its novelty. It may also be more fruitful to provide this information via employers, to encourage and emphasise employer endorsement.

The moderating effect of parental skills for antibiotic identification on the link between parental skills for antibiotic use and inappropriate antibiotic use for children in China

BACKGROUND

Inappropriate antibiotic consumption promotes antibiotic resistance. However, findings on the association between antibiotic-related knowledge and behaviors are inconsistent and contradictory, resulting in unjustified guidance of interventions. The mechanisms between the different kinds of antibiotic-related skills contained in knowledge modules in some previous studies are indistinct and rarely studied.

METHODS

A cross-sectional survey was conducted between June 2017 and April 2018 in three Chinese provinces, investigating 9526 parents with children aged 0-13 years old. Data from 1944 parents who self-medicated their children and 2478 respondents whose children sought care were analyzed.

RESULTS

Skills for antibiotic identification were found to be a moderator for the association between skills for antibiotic use and two inappropriate behaviors. Compared with parents with low levels of both skills for antibiotic identification and use, those mastering both skills at either medium (OR = 0.48, 95% CI [0.26-0.88]) or high (OR = 0.15, 95% CI [0.07-0.34]) level were less likely to self-medicate their children with antibiotics. Parents with a medium level of skills for antibiotic identification and high level of skills for antibiotic use (OR = 0.18, 95% CI [0.08-0.44]) and those with a high level of both skills (OR = 0.15, 95% CI [0.05-0.47]) were less likely to ask doctors for antibiotics when seeking care.

CONCLUSION

Parents' high level of skills for antibiotic identification is revealed to promote inappropriate antibiotic use when parents master a low level of skills for antibiotic use. Conversely, based on excellent skills for antibiotic use, better skill for antibiotic identification is associated with a greater reduction in inappropriate behaviors. We recommend future health education to strengthen skills for antibiotic identification along with guidance on antibiotic use.

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research

Background

Behavior change interventions that aim to improve rational antibiotic use in prescribers and users have been widely conducted in both high- and LMICs. However, currently, no review has systematically examined challenges unique to LMICs and offered insights into the underlying contextual factors that influence these interventions. We adopted an implementation research perspective to systematically synthesize the implementation barriers and facilitators in LMICs.

Methods

We conducted literature searches in five electronic databases and identified studies that involved the implementation of behavior change interventions to improve appropriate antibiotic use in prescribers and users in LMICs and reported implementation barriers and facilitators. Behavior change interventions were defined using the behavior change wheel, and the coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research (CFIR).

Results

We identified 52 eligible studies, with the majority targeting prescribers practicing at tertiary facilities (N=39, 75%). The most commonly reported factors influencing implementation were found in the inner setting domain of the CFIR framework, particularly related to constraints in resources and the infrastructure of the facilities where interventions were implemented. Barriers related to the external policy environment (e.g., lack of national initiatives and policies on antibiotic use), and individual characteristics of target populations (e.g., reluctance to change prescribing behaviors) were also common, as well as facilitators related to intervention characteristics (e.g., embedding interventions in routine practice) and process (e.g., stakeholder engagement). We also provided insights into the interrelationships between these factors and the underlying causes contributing to the implementation challenges in LMICs.

Conclusion

We presented a comprehensive overview of the barriers and facilitators of implementing behavior change interventions to promote rational antibiotic use in LMICs. Our findings suggest that facilitating the implementation of interventions to improve rational antibiotic use needs comprehensive efforts to address challenges at policy, organizational, and implementation levels. Specific strategies include (1) strengthening political commitment to prompt mobilization of domestic resources and formulation of a sustainable national strategy on AMR, (2) improving the infrastructure of health facilities that allow prescribers to make evidence-based clinical decisions, and (3) engaging local stakeholders to improve their buy-in and facilitate contextualizing interventions.

Trial registration

PROSPERO: CRD42021252715.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01209-4.

Identifying global research gaps to mitigate antimicrobial resistance: A scoping review

OBJECTIVE

Identify research gaps relevant to the global effort to combat antimicrobial resistance.

METHODS

Web of Science, PubMed, Scopus, and Ovid MEDLINE were searched for reviews on antimicrobial resistance published between January 1, 2015 and December 31, 2019. Recommendations for future research were identified.

FINDINGS

Seventy-four reviews met inclusion criteria; 300 research gaps and recommendations were identified. The largest number were from the human health sector (105; 35%) followed by environmental health (72; 23%), animal health (66; 22%), food and feed (14; 5%), and plants and crops (8; 3%); 35 (12%) involved more than one sector. The largest number of gaps concerned surveillance of resistance (68; 23%), followed by study design or methodology (52; 17%), interventions (41; 14%), risk assessment and modeling (35; 12%), ecological (26; 9%) and biochemical (28; 9%) aspects of resistance, interface between reservoirs of resistant pathogens (24; 8%), and economic (15; 5%) and awareness- and behavior-related (11; 4%) aspects of antimicrobial resistance.

CONCLUSIONS

Important research gaps remain in our complete understanding of antimicrobial resistance, and more research is needed about its development, transmission, and impact across the interface of human, animal, and environmental reservoirs.

A scoping review on the influential cognitive constructs informing public AMR behavior compliance and the attribution of personal responsibility

BACKGROUND

Antibiotic resistance is a growing threat to public health. Despite various attempts at educating the public on antimicrobial resistance (AMR) and judicial antibiotic use, fallacies and misconceptions remain. To successfully promote behavior change, various cognitive constructs pertaining to antibiotic behavior need to be identified and targeted.

METHODS

Using the Arksey and O'Malley (2005) methodological framework, a credible reflexive examination of literature was conducted, permitting identification of a breadth of literature that pertained to the influence of cognitive constructs on public antimicrobial behavior.

RESULTS

From 393 abstracts identified, 67 full articles were screened, and 43 papers were chosen for review. Three themes were identified (1) sociodemographic influences; (2) knowledge, misconceptions, and fallacies; and (3) public attitudes and the social influence of friends and family. Geographical location, education level, cognitive dissonance, and social norms were found to influence AMR cognition, resulting in disproportionate risk assessments that are facilitated by social information brokering.

CONCLUSIONS

Public AMR resilience, responsibility, and behavior compliance are influenced by cognitive constructs, which are liable to the appropriation of misconceptions, fallacies, and social behavior models obtained via information brokering. A cohesive multidisciplinary participatory approach to AMR management and interventional design that applies the influence of cognitive constructs to inform public AMR behavior compliance is recommended.

Prescriber Commitment Posters to Increase Prudent Antibiotic Prescribing in English General Practice: A Cluster Randomized Controlled Trial

Unnecessary antibiotic prescribing contributes to Antimicrobial Resistance posing a major public health risk. Estimates suggest as many as half of antibiotics prescribed for respiratory infections may be unnecessary. We conducted a three-armed unblinded cluster randomized controlled trial (ISRCTN trial registry 83322985). Interventions were a commitment poster (CP) advocating safe antibiotic prescribing or a CP plus an antimicrobial stewardship message (AM) on telephone appointment booking lines, tested against a usual care control group. The primary outcome measure was antibiotic item dispensing rates per 1000 population adjusted for practice demographics. The outcome measures for post-hoc analysis were dispensing rates of antibiotics usually prescribed for upper respiratory tract infections and broad spectrum antibiotics. In total, 196 practice units were randomized to usual care (n = 60), CP (n = 66), and CP&AM (n = 70). There was no effect on the overall dispensing rates for either interventions compared to usual care (CP 5.673, 95%CI -9.768 to 21.113, p = 0.458; CP&AM, -12.575, 95%CI -30.726 to 5.576, p = 0.167). Secondary analysis, which included pooling the data into one model, showed a significant effect of the AM (-18.444, 95%CI -32.596 to -4.292, p = 0.012). Fewer penicillins and macrolides were prescribed in the CP&AM intervention compared to usual care (-12.996, 95% CI -34.585 to -4.913, p = 0.018). Commitment posters did not reduce antibiotic prescribing. An automated patient antimicrobial stewardship message showed effects and requires further testing.