'Willy nilly' doctors, bad patients, and resistant bodies in general public explanations of antimicrobial resistance

Patient and public understanding of antimicrobial resistance: a systematic review and meta-ethnography

Objectives

To further develop an understanding of laypeople's (adult patients and public) beliefs and attitudes toward antimicrobial resistance (AMR) by developing a conceptual model derived from identifying and synthesizing primary qualitative research.

Methods

A systematic search of 12 electronic databases, including CINAHL, MEDLINE, PsycINFO, PubMed and Web of Science to identify qualitative primary studies exploring patient and public understanding of AMR published between 2012 and 2022. Included studies were quality appraised and synthesized using Noblit and Hare's meta-ethnographic approach and reported using eMERGe guidance.

Results

Thirteen papers reporting 12 qualitative studies were synthesized. Studies reported data from 466 participants aged 18-90 years. Five themes were identified from these original studies: the responsible patient; when words become meaningless; patient-prescriber relationship; past experience drives antibiotic use; and reframing public perception. These themes supported the development of a conceptual model that illustrates the tension between two different assumptions, that is, how can antibiotics be used for the collective good whilst balancing the immediate needs of individual patients.

Conclusions

Findings suggest that AMR is a distinct ethical issue and should not be viewed purely as a prescribing problem. The meta-ethnography-generated conceptual model illustrates many factors affecting the public's perception of AMR. These include laypeople's own knowledge, beliefs and attitudes around antibiotic use, the relationship with the healthcare provider and the wider context, including the overwhelming influence of the media and public health campaigns. Future research is needed to explore effective health messaging strategies to increase laypeople's baseline awareness of AMR as a public threat.

Antibiotics online: digital pharmacy marketplaces and pastiche medicine

The internet enables access to information and the purchasing of medical products of various quality and legality. Research and regulatory attention have focused on the trafficking of illicit substances, potential physical harms of pharmaceuticals, and possibilities like financial fraud. However, there is far less attention paid to antibiotics and other antimicrobials used to treat infections. With online pharmacies affording greater access, caution around antibiotic use is needed due to the increasing health risks of antimicrobial resistance (AMR). The COVID-19 pandemic has helped to normalise digital healthcare and contactless prescribing, amplifying the need for caution. Little is known of how antibiotics are consumed via digital pharmacy and implications for AMR prevention. To expand insight for AMR prevention policy in Australia and internationally, we use digital ethnographic methods to explore how digital pharmacies function in the context of health advice and policy related to AMR, commonly described as antimicrobial stewardship. We find that digital pharmacy marketplaces constitute 'pastiche medicine'. They curate access to pharmaceutical and information products that emulate biomedical authority combined with emphasis on the 'self-assembly' of healthcare. Pastiche medicine empowers the consumer but borrows biomedical expertise about antibiotics, untethering these goods from critical medicine information, and from AMR prevention strategies. We reflect on the implications of pastiche medicine for AMR policy, what the antibiotics case contributes to wider critical scholarship on digital pharmacy, and how medical humanities research might consider researching online consumption in future.

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.

Policy and practices in primary care that supported the provision and receipt of care for older persons during the COVID-19 pandemic: a qualitative case study in three Canadian provinces

BACKGROUND

The effects of the COVID-19 pandemic on older adults were felt throughout the health care system, from intensive care units through to long-term care homes. Although much attention has been paid to hospitals and long-term care homes throughout the pandemic, less attention has been paid to the impact on primary care clinics, which had to rapidly change their approach to deliver timely and effective care to older adult patients. This study examines how primary care clinics, in three Canadian provinces, cared for their older adult patients during the pandemic, while also navigating the rapidly changing health policy landscape.

METHODS

A qualitative case study approach was used to gather information from nine primary care clinics, across three Canadian provinces. Interviews were conducted with primary care providers (n = 17) and older adult patients (n = 47) from October 2020 to September 2021. Analyses of the interviews were completed in the language of data collection (English or French), and then summarized in English using a coding framework. All responses that related to COVID-19 policies at any level were also examined.

RESULTS

Two main themes emerged from the data: (1) navigating the noise: understanding and responding to public health orders and policies affecting health and health care, and (2) receiving and delivering care to older persons during the pandemic: policy-driven challenges & responses. Providers discussed their experiences wading through the health policy directives, while trying to provide good quality care. Older adults found the public health information overwhelming, but appreciated the approaches adapted by primary care clinics to continue providing care, even if it looked different.

CONCLUSIONS

COVID-19 policy and guideline complexities obliged primary care providers to take an important role in understanding, implementing and adapting to them, and in explaining them, especially to older adults and their care partners.

Consumer perceptions of community pharmacists' involvement in antimicrobial stewardship: A quantitative study

Background Community pharmacist involvement in antimicrobial stewardship (AMS) within primary care is underutilised. Despite this view being consistently held across the pharmacy sector's policy, academic and professional spheres, there is limited understanding of how this positioning aligns with consumers' perceptions and expectations. Objective To explore participants' experience using antibiotics and their engagement with pharmacists to support their use. Methods Online survey of Australian adults recruited via Dynata's research panel in November 2022. Questions were organised into three sections: 1) understanding the participant's use of antibiotics, including their information needs; 2) exploring engagement with pharmacists on a cold and flu enquiry using a vignette question; and 3) demographic information. Results Doctors (42.0%), pharmacists (29.8%) and the internet including general searches (14.3%) were the top three sources for antibiotic information. Information about side effects and anticipated time to effect were more broadly sought from pharmacists than what was provided. Over 50% of respondents indicated alignment between the best practice example of a pharmacist providing cold and flu management advice with their own experience. 17% of respondents indicated that they would seek doctor's advice when considering cold and flu management options compared to 10% seeking pharmacist's advice. No statistically significant results between age groups or gender were observed. Conclusion Better visibility of community pharmacists' involvement in managing minor ailments in primary care, including more explicit linkage of pharmacist-administered vaccination services as an AMS strategy can support optimal antimicrobial use.

Understandings and practices related to risk, immunity and vaccination during the Delta variant COVID-19 outbreak in Australia: An interview study

Background

The aim of this study was to use indepth social research to better understand the relationships and intersections between understandings and practices of COVID-19 risk, immunity and vaccination in lay people’s accounts.

Methods

This article reports findings from a qualitative research project involving semi-structured telephone interviews with a diverse group of 40 adults from around Australia about their experiences of the COVID crisis, conducted in late 2021 during the Delta variant outbreak. The participants’ responses to questions about COVID risk, COVID vaccines and how they thought they could best protect their health were analysed using an inductive thematic approach.

Results

A notion of ‘communal risk’ was expressed together with ‘individual risk’. Relatedly, people’s understandings of what might be characterised as ‘communal immunity’ as well as individual immunity also dominated in their accounts. Both communal risk and communal immunity are influenced by a range of constantly changing and interrelated factors. Locale was a strong factor in shaping people’s experiences and stances related to COVID risk. The participants referred to aspects such as their community’s geographical location; the number of COVID cases and the level of COVID vaccination by others living in their state or territory; adoption of preventive measures; vaccine availability, scheduling and take-up; viral testing and tracing reporting; and the extent and timing of viral spread in the population. These factors were continually related back to highly specific conditions and practices in their community or state of residence.

Conclusions

Understandings and practices related to COVID risk, immunity and vaccination were based both on individual experiences and broader ideas about the role of community. Spatial contexts are influential but there is also a strong temporality to these understandings and practices. There is a fine balance to be maintained between individual-level protection from COVID risk and community-level actions.

Parents' awareness of antimicrobial resistance: a qualitative study utilising the Health Belief Model in Perth, Western Australia

OBJECTIVE

This study aimed to determine local factors that promote or prevent parents' responsible use of antibiotics for their children in Perth, Western Australia.

METHODS

The Health Belief Model was used to guide this study. Four focus group discussions were conducted, with 26 participants. Participants were recruited purposively through a parent group organisation. The Framework Method was utilised to analyse the data.

RESULTS

Participants agreed that antimicrobial resistance (AMR) is a serious health problem. However, participants admitted that they lacked awareness of AMR, inhibiting their ability to assess the risks of developing AMR infections among their children. Participants knew the indications and risks of antibiotic use but still viewed antibiotics as a time-saving solution that minimised disruption to their routine. Participants' previous experiences in managing their children's illness increased their confidence and linked their positive and negative experiences with their general practitioners in their judicious use of antibiotics.

CONCLUSIONS

While parents demonstrated awareness of the indications of antibiotics, they continue to lack AMR awareness and overvalue antibiotics.

IMPLICATIONS FOR PUBLIC HEALTH

The findings highlight that incorporating parent empowerment and participation in decision-making regarding antibiotics use, and maintaining a positive relationship with healthcare providers, were important strategies to encourage the appropriate use of antibiotics.

Comparing public attitudes, knowledge, beliefs and behaviours towards antibiotics and antimicrobial resistance in Australia, United Kingdom, and Sweden (2010-2021): A systematic review, meta-analysis, and comparative policy analysis

BACKGROUND

Social and behavioural drivers of inappropriate antibiotic use contribute to antimicrobial resistance (AMR). Recent reports indicate the Australian community consumes more than twice the defined daily doses (DDD) of antibiotics per 1000 population than in Sweden, and about 20% more than in the United Kingdom (UK). We compare measures of public knowledge, attitudes and practices (KAP) surrounding AMR in Australia, the UK and Sweden against the policy approaches taken in these settings to address inappropriate antibiotic use.

METHODS

National antimicrobial stewardship policies in Australia, Sweden, and the UK were reviewed, supplemented by empirical studies of their effectiveness. We searched PubMed, EMBASE, PsycINFO, Web of Science and CINAHL databases for primary studies of the general public's KAP around antibiotic use and AMR in each setting (January 1 2011 until July 30 2021). Where feasible, we meta-analysed data on the proportion of participants agreeing with identical or very similar survey questions, using a random effects model.

RESULTS

Policies in Sweden enact tighter control of community antibiotic use; reducing antibiotic use through public awareness raising is not a priority. Policies in the UK and Australia are more reliant on practitioner and public education to encourage appropriate antibiotic use. 26 KAP were included in the review and 16 were meta-analysable. KAP respondents in Australia and the UK are consistently more likely to report beliefs and behaviours that are not aligned with appropriate antibiotic use, compared to participants in similar studies conducted in Sweden.

CONCLUSIONS

Interactions between public knowledge, attitudes and their impacts on behaviours surrounding community use of antibiotics are complex and contingent. Despite a greater focus on raising public awareness in Australia and the UK, neither antibiotic consumption nor community knowledge and attitudes are changing significantly. Clearly public education campaigns can contribute to mitigating AMR. However, the relative success of policy approaches taken in Sweden suggests that practice level interventions may also be required to activate prescribers and the communities they serve to make substantive reductions in inappropriate antibiotic use.

Antibiotics in the Community During the COVID-19 Pandemic: A Qualitative Study to Understand Users' Perspectives of Antibiotic Seeking and Consumption Behaviors in Bangladesh

INTRODUCTION

The COVID-19 pandemic is thought to have led to increased "inappropriate" or "unjustified" seeking and consumption of antibiotics by individuals in the community. However, little reference has been made to antibiotic seeking and using behaviors from the perspectives of users in Bangladesh during this health crisis.

PURPOSE

This study seeks to document how antibiotic medicines are sought and used during a complex health crisis, and, within different contexts, what are the nuanced reasons why patients may utilize these medicines sub-optimally.

METHODS

We used an exploratory, qualitative design. Forty semi-structured telephone interviews were conducted with people diagnosed with COVID-19 (n=20), who had symptoms suggestive of COVID-19 (n=20), and who had received care at home in two cities between May and June 2021 in Bangladesh. In this study, an inductive thematic analysis was performed.

RESULTS

The analysis highlighted the interlinked relationships of antibiotic seeking and consumption behaviors with the diversity of information disseminated during a health crisis. Antibiotic-seeking behaviors are related to previous experience of use, perceived severity of illness, perceived vulnerability, risk of infection, management of an "unknown" illness and anxiety, distrust of expert advice, and intrinsic agency on antimicrobial resistance (AMR). Suboptimal adherence, such as modifying treatment regimes and using medication prescribed for others, were found to be part of care strategies used when proven therapeutics were unavailable to treat COVID-19. Early cessation of therapy was found to be a rational practice to avoid side effects and unknown risks.

CONCLUSION

Based on the results, we highly recommend the take up of a pandemic specific antimicrobial stewardship (AMS) program in the community. To deliver better outcomes of AMS, incorporating users' perspectives could be a critical strategy. Therefore, a co-produced AMS intervention that is appropriate for a specific cultural context is an essential requirement to reduce the overuse of antibiotics during the COVID-19 pandemic and beyond.

Changes in the Framing of Antimicrobial Resistance in Print Media in Australia and the United Kingdom (2011-2020): A Comparative Qualitative Content and Trends Analysis

Educating the public about antimicrobial resistance (AMR) is considered a key part of an optimal public health response. In both media depictions and policy discourses around health risks, how a problem is framed underpins public awareness and understanding, while also guiding opinions on what actions can and should be taken. Using a mixed methods approach we analyse newspaper content in Australia and the United Kingdom (UK) from 2011 to 2020 to track how causes, consequences and solutions to AMR are represented in countries with different policy approaches. Analyses demonstrate greater variability in the frames used in UK newspapers reflecting large hospital and community outbreaks and a sustained period of policy reform mid-decade. Newspapers in Australia focus more on AMR causes and consequences, highlighting the importance of scientific discovery, whereas UK coverage has greater discussion of the social and economic drivers of AMR and their associated solutions. Variations in the trends of different frames around AMR in UK newspapers indicate greater levels of public deliberation and debate around immediate and actionable solutions; whereas AMR has not had the same health and political impacts in Australia resulting in a media framing that potentially encourages greater public complacency about the issue.