Assessing the public acceptability of proposed policy interventions to reduce the misuse of antibiotics in Australia: A report on two community juries

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.

Antibiotic use and resistance in a tertiary care hospital: knowledge and attitude among patients of orthopaedic and surgical wards in Malaysia

Objectives

The prevalence of antimicrobial resistance (AMR) is rising globally as well as in Malaysia. AMR can lead to difficulty in the treatment of chronic infection if being neglected. This study aimed to assess the level of knowledge and attitude about antibiotic usage and AMR.

Methods

A cross-sectional study design was carried out at the Hospital Kuala Lumpur (HKL), Malaysia, where participants were recruited by using the non-probability convenience sampling from the six orthopaedic and four surgical wards. A self-administered questionnaire was used to collect the required data which were then analysed by using SPSS.

Key findings

A total number of 390 adult Malaysians (286 from orthopaedic wards and 104 from surgical wards) were involved in the study. This study showed that the level of knowledge and attitude about antibiotics among the majority of respondents were moderate. However, their knowledge regarding AMR was very low (i.e. lack of knowledge). In contrast, the majority of them (69.8%) showed a positive attitude towards antibiotics. Statistical analysis of data revealed that the level of knowledge of AMR was significantly associated with gender, age, race, marital status, educational level and knowledge about antibiotic resistance terms (P < 0.05) while respondents’ attitude towards antibiotic usage was significantly associated with gender, race, marital status and education level (P < 0.05).

Conclusions

It was necessary to formulate and develop strategies to improve the knowledge and awareness about antibiotics and AMR among health professionals. These might help them to improve their skills in delivering health information to the patients through a proper counselling technique.

Priority allocation of pandemic influenza vaccines in Australia - Recommendations of 3 community juries

BACKGROUND

Pandemic planning has historically been oriented to respond to an influenza virus, with vaccination strategy being a key focus. As the current COVID-19 pandemic plays out, the Australian government is closely monitoring progress towards development of SARS-CoV2 vaccines as a definitive intervention. However, as in any pandemic, initial supply will likely be exceeded by demand due to limited manufacturing output.

METHODS

We convened community juries in three Australian locations in 2019 to assess public acceptability and perceived legitimacy of influenza pandemic vaccination distribution strategies. Preparatory work included literature reviews on pandemic vaccine allocation strategies and on vaccine allocation ethics, and simulation modelling studies. We assumed vaccine would be provided to predefined priority groups. Jurors were then asked to recommend one of two strategies for distributing remaining early doses of vaccine: directly vaccinate people at higher risk of adverse outcomes from influenza; or indirectly protect the general population by vaccinating primary school students, who are most likely to spread infection.

RESULTS

Thirty-four participants of diverse backgrounds and ages were recruited through random digit dialling and topic-blinded social media advertising. Juries heard evidence and arguments supporting different vaccine distribution strategies, and questioned expert presenters. All three community juries supported prioritising school children for influenza vaccination (aiming for indirect protection), one by 10-2 majority and two by consensus. Justifications included that indirect protection benefits more people and is likely to be more publicly acceptable.

CONCLUSIONS

In the context of an influenza pandemic, informed citizens were not opposed to prioritising groups at higher risks of adverse outcomes, but if resources and epidemiological conditions allow, achieving population benefits should be a strategic priority. These insights may inform future SARS-CoV-2 vaccination strategies.

Economic and Behavioral Influencers of Vaccination and Antimicrobial Use

Despite vast improvements in global vaccination coverage during the last decade, there is a growing trend in vaccine hesitancy and/or refusal globally. This has implications for the acceptance and coverage of a potential vaccine against COVID-19. In the United States, the number of children exempt from vaccination for “philosophical belief-based” non-medical reasons increased in 12 of the 18 states that allowed this policy from 2009 to 2017 (1). Meanwhile, the overuse and misuse of antibiotics, especially in young children, have led to increasing rates of drug resistance that threaten our ability to treat infectious diseases. Vaccine hesitancy and antibiotic overuse exist side-by-side in the same population of young children, and it is unclear why one modality (antibiotics) is universally seen as safe and effective, while the other (vaccines) is seen as potentially hazardous by some. In this review, we consider the drivers shaping the use of vaccines and antibiotics in the context of three factors: individual incentives, risk perceptions, and social norms and group dynamics. We illustrate how these factors contribute to the societal and individual costs of vaccine underuse and antimicrobial overuse. Ultimately, we seek to understand these factors that are at the nexus of infectious disease epidemiology and social science to inform policy-making.

More philosophical work needed in One Health on ethical frameworks and theory

We thank Zohar Lederman and Benjamin Capps for engaging with our paper on One Health (OH) and ethical frameworks, however we want to take issue with them on three points. First, they appear to misunderstand the distinction we appeal to between ethical theory and ethical frameworks, and so misinterpret what we are trying to achieve in our paper. Second, in spite of what they seem to imply, we agree that an OH approach can obscure differences in values, and that to progress the field there needs to be recognition of competing values and their implications for OH. Finally, we are puzzled by their interest in pursuing a deliberative process, as this seems at odds with other positions they take in their paper, and also opens up many questions that need to be addressed.

Perspectives of Vietnamese, Sudanese and South Sudanese immigrants on targeting migrant communities for latent tuberculosis screening and treatment in low-incidence settings: A report on two Victorian community panels

Background

Tuberculosis (TB) elimination strategies in Australia require a focus on groups who are at highest risk of TB infection, such as immigrants from high‐burden settings. Understanding attitudes to different strategies for latent TB infection (LTBI) screening and treatment is an important element of justifiable elimination strategies.

Method

Two community panels were conducted in Melbourne with members of the Vietnamese (n = 11), Sudanese and South Sudanese communities (n = 9). Panellists were provided with expert information about LTBI and different screening and health communication strategies, then deliberated on how best to pursue TB elimination in Australia.

Findings

Both panels unanimously preferred LTBI screening to occur pre‐migration rather than in Australia. Participants were concerned that post‐migration screening would reach fewer migrants, noted that conducting LTBI screening in Australia could stigmatize participants and that poor awareness of LTBI would hamper participation. If targeted screening was to occur in Australia, the Vietnamese panel preferred ‘place‐based’ communication strategies, whereas the Sudanese and South Sudanese panel emphasized that community leaders should lead communication strategies to minimize stigma. Both groups emphasized the importance of maintaining community trust in Australian health service providers, and the need to ensure targeting did not undermine this trust.

Conclusion

Pre‐migration screening was preferred. If post‐migration screening is necessary, the potential for stigma should be reduced, benefit and risk profile clearly explained and culturally appropriate communication strategies employed. Cultural attitudes to health providers, personal health management and broader social vulnerabilities of targeted groups need to be considered in the design of screening programs.

Inappropriate Dental Antibiotic Prescriptions: Potential Driver of the Antimicrobial Resistance in Albaha Region, Saudi Arabia

PURPOSE

The aim of this study was to analyze and evaluate dental antibiotic prescriptions in Albaha Region, Saudi Arabia.

PATIENTS AND METHODS

A two-year retrospective cohort study was conducted between September 1, 2017 and September 1, 2019 in children and adults. Data collected from the patients' medical records were analyzed using SPSS. The Z-test with Bonferroni correction and descriptive proportions were utilized to compare several levels of categorical variables.

RESULTS

Of the 43,255 dental visits, antibiotics were provided during 12,573 (29.1%). The commonly prescribed antibiotics were amoxicillin and amoxicillin combined with metronidazole (56.3% and 16.9%, respectively). Alarmingly, antibiotics were provided in several conditions for which they are medically neither recommended nor indicated; together, they represented 27.8% of those consultations in which antibiotics were prescribed. Female dentists prescribed more antibiotics than male dentists (30%, P = < 0.000), with male patients receiving more antibiotics than female patients (36%, P = <0.0001).

CONCLUSION

Unnecessary prescription of antibiotics was observed in the present study. Improving knowledge and awareness of Saudi dentists on dental antibiotic prescription is warranted.

Articulating citizen participation in national anti-microbial resistance plans: a comparison of European countries

Background

National action plans determine country responses to anti-microbial resistance (AMR). These plans include interventions aimed at citizens. As the language used in documents could persuade certain behaviours, we sought to assess the positioning and implied responsibilities of citizens in current European AMR plans. This understanding could lead to improved policies and interventions.

Methods

Review and comparison of national action plans for AMR (NAP-AMR) obtained from the European Centre for Disease Prevention and Control (plans from 28 European Union and four European Economic Area/European Free Trade Association countries), supplemented by European experts (June-September 2016). To capture geographical diversity, 11 countries were purposively sampled for content and discourse analyses using frameworks of lay participation in healthcare organization, delivery and decision-making.

Results

Countries were at different stages of NAP-AMR development (60% completed, 25% in-process, 9% no plan). The volume allocated to citizen roles in the plans ranged from 0.3 to 18%. The term 'citizen' was used by three countries, trailing behind 'patients' and 'public' (9/11), 'general population' (6/11) and 'consumers' (6/11). Increased citizen awareness about AMR was pursued by ∼2/3 plans. Supporting interventions included awareness campaigns (11/11), training/education (7/11) or materials during clinical encounters (4/11). Prevention of infection transmission or self-care behaviours were much less emphasized. Personal/individual and social/collective role perspectives seemed more frequently stimulated in Nordic countries.

Conclusion

Citizen roles in AMR plans are not fully articulated. Documents could employ direct language to emphasise social or collective responsibilities in optimal antibiotic use.

Enlisting the support of trusted sources to tackle policy problems: The case of antimicrobial resistance

Antimicrobial resistance represents one of the world's most pressing public health problems. Governments around the world have-and will continue to-develop policy proposals to deal with this problem. However, the capacity of government will be constrained by very low levels of trust in government. This stands in contrast to 'medical scientists' who are highly trusted by the public. This article tests to what extent trusted sources can alter attitudes towards a policy proposal to regulate the use of antibiotics. We find that respondents are much more likely to support a policy put forward by 'medical scientists.' This article provides some initial evidence that medical scientists could be used to gain support for policies to tackle pressing policy challenges such as AMR.

Developing and applying a deductive coding framework to assess the goals of Citizen/Community Jury deliberations

Background

Public participation in health policy decision making is thought to improve the quality of the decisions and enhance their legitimacy. Citizen/Community Juries (CJs) are a form of public participation that aims to elicit an informed community perspective on controversial topics. Reporting standards for CJ processes have already been proposed. However, less clarity exists about the standards for what constitutes a good quality CJ deliberation—we aim to begin to address this gap here.

Methods

We identified the goals that underlie CJs and searched the literature to identify existing frameworks assessing the quality of CJ deliberations. We then mapped the items constituting these frameworks onto the CJ goals; where none of the frameworks addressed one of the CJ goals, we generated additional items that did map onto the goal.

Results

This yielded a single operationalized deductive coding framework, consisting of four deliberation elements and four recommendation elements. The deliberation elements focus on the following: jurors’ preferences and values, engagement with each other, referencing expert information and enrichment of the deliberation. The recommendation elements focus on the following: reaching a clear and identifiable recommendation, whether the recommendation directly addresses the CJ question, justification for the recommendation and adoption of societal (rather than individual) perspective. To explore the alignment between this framework and the goals underlying CJs, we mapped the operationalized framework onto the transcripts of a CJ.

Conclusion

Results suggest that framework items map well onto what transpires in an actual CJ deliberation. Further testing of the validity, generalizability and reliability of the framework is planned.

An Australian community jury to consider case-finding for dementia: Differences between informed community preferences and general practice guidelines

Background

Case‐finding for dementia is practised by general practitioners (GPs) in Australia but without an awareness of community preferences. We explored the values and preferences of informed community members around case‐finding for dementia in Australian general practice.

Design, setting and participants

A before and after, mixed‐methods study in Gold Coast, Australia, with ten community members aged 50‐70.

Intervention

A 2‐day citizen/community jury. Participants were informed by experts about dementia, the potential harms and benefits of case‐finding, and ethical considerations.

Primary and secondary outcomes

We asked participants, “Should the health system encourage GPs to practice ‘case‐finding’ of dementia in people older than 50?” Case‐finding was defined as a GP initiating testing for dementia when the patient is unaware of symptoms. We also assessed changes in participant comprehension/knowledge, attitudes towards dementia and participants’ own intentions to undergo case‐finding for dementia if it were suggested.

Results

Participants voted unanimously against case‐finding for dementia, citing a lack of effective treatments, potential for harm to patients and potential financial incentives. However, they recognized that case‐finding was currently practised by Australian GPs and recommended specific changes to the guidelines. Participants increased their comprehension/knowledge of dementia, their attitude towards case‐finding became less positive, and their intentions to be tested themselves decreased.

Conclusion

Once informed, community jury participants did not agree case‐finding for dementia should be conducted by GPs. Yet their personal intentions to accept case‐finding varied. If case‐finding for dementia is recommended in the guidelines, then shared decision making is essential.

Impartiality and infectious disease: Prioritizing individuals versus the collective in antibiotic prescription

BACKGROUND

Antimicrobial resistance (AMR) is a global public health disaster driven largely by antibiotic use in human health care. Doctors considering whether to prescribe antibiotics face an ethical conflict between upholding individual patient health and advancing public health aims. Existing literature mainly examines whether patients awaiting consultations desire or expect to receive antibiotic prescriptions, but does not report views of the wider public regarding conditions under which doctors should prescribe antibiotics. It also does not explore the ethical significance of public views or their sensitivity to awareness of AMR risks or the standpoint (self-interested or impartial) taken by participants.

METHODS

An online survey was conducted with a sample of the U.S. public (n = 158). Participants were asked to indicate what relative priority should be given to individual patients and society-at-large from various standpoints and in various contexts, including antibiotic prescription.

RESULTS

Of the participants, 50.3% thought that doctors should generally prioritize individual patients over society, whereas 32.0% prioritized society over individual patients. When asked in the context of AMR, 39.2% prioritized individuals whereas 45.5% prioritized society. Participants were significantly less willing to prioritize society over individuals when they themselves were the patient, both in general (p = .001) and in relation to AMR specifically (p = .006).

CONCLUSIONS

Participants' attitudes were more oriented to society and sensitive to collective responsibility when informed about the social costs of antibiotic use and when considered from a third-person rather than first-person perspective. That is, as participants came closer to taking the perspective of an informed and impartial "ideal observer," their support for prioritizing society increased. Our findings suggest that, insofar as antibiotic policies and practices should be informed by attitudes that are impartial and well-informed, there is significant support for prioritizing society.

Managing the risk of Hendra virus spillover in Australia using ecological approaches: A report on three community juries

BACKGROUND

Hendra virus (HeV) infection is endemic in Australian flying-fox populations. Habitat loss has increased the peri-urban presence of flying-foxes, increasing the risk of contact and therefore viral 'spillovers' into horse and human populations. An equine vaccine is available and horse-husbandry practices that minimize HeV exposure are encouraged, but their adoption is suboptimal. Ecological approaches-such as habitat creation and conservation-could complement vaccination and behavioural strategies by reducing spillover risks, but these are controversial.

METHODS

We convened three community juries (two regional; one metropolitan) to elicit the views of well-informed citizens on the acceptability of adding ecological approaches to current interventions for HeV risk. Thirty-one participants of diverse backgrounds, mixed genders and ages were recruited using random-digit-dialling. Each jury was presented with balanced factual evidence, given time to ask questions of expert presenters and, after deliberation, come to well-reasoned conclusions.

RESULTS

All juries voted unanimously that ecological strategies should be included in HeV risk management strategies but concluded that current interventions-including vaccination and changing horse-husbandry practices-must remain the priority. The key reasons given for adopting ecological approaches were: (i) they address underlying drivers of disease emergence, (ii) the potential to prevent spillover of other bat-borne pathogens, and (iii) there would be broader community benefits. Juries differed regarding the best mechanism to create/conserve flying-fox habitat: participants in regional centres favoured direct government action, whereas the metropolitan jury preferred to place the burden on landholders.

CONCLUSIONS

Informed citizens acknowledge the value of addressing the drivers of bat-borne infectious risks but differ substantially as to the best implementation strategies. Ecological approaches to securing bat habitat could find broad social support in Australia, but disagreement about how best to achieve them indicates the need for negotiation with affected communities to co-develop fair, effective and locally appropriate policies.

Critical knowledge gaps and research needs related to the environmental dimensions of antibiotic resistance

There is growing understanding that the environment plays an important role both in the transmission of antibiotic resistant pathogens and in their evolution. Accordingly, researchers and stakeholders world-wide seek to further explore the mechanisms and drivers involved, quantify risks and identify suitable interventions. There is a clear value in establishing research needs and coordinating efforts within and across nations in order to best tackle this global challenge. At an international workshop in late September 2017, scientists from 14 countries with expertise on the environmental dimensions of antibiotic resistance gathered to define critical knowledge gaps. Four key areas were identified where research is urgently needed: 1) the relative contributions of different sources of antibiotics and antibiotic resistant bacteria into the environment; 2) the role of the environment, and particularly anthropogenic inputs, in the evolution of resistance; 3) the overall human and animal health impacts caused by exposure to environmental resistant bacteria; and 4) the efficacy and feasibility of different technological, social, economic and behavioral interventions to mitigate environmental antibiotic resistance.1.

Assessing the public acceptability of proposed policy interventions to reduce the misuse of antibiotics in Australia: A report on two community juries

Objective

To elicit the views of well‐informed community members on the acceptability of proposed policy interventions designed to improve community use of antibiotics in Australia.

Design

Two community juries held in 2016.

Setting and participants

Western Sydney and Dubbo communities in NSW, Australia. Twenty‐nine participants of diverse social and cultural backgrounds, mixed genders and ages recruited via public advertising: one jury was drawn from a large metropolitan setting; the other from a regional/rural setting.

Main outcome measure

Jury verdict and rationale in response to a prioritization task and structured questions.

Results

Both juries concluded that potential policy interventions to curb antibiotic misuse in the community should be directed towards: (i) ensuring that the public and prescribers were better educated about the dangers of antibiotic resistance; (ii) making community‐based human and animal health‐care practitioners accountable for their prescribing decisions. Patient‐centred approaches such as delayed prescribing were seen as less acceptable than prescriber‐centred approaches; both juries completely rejected any proposal to decrease consumer demand by increasing antibiotic prices.

Conclusion

These informed citizens acknowledged the importance of raising public awareness of the risks, impacts and costs of antibiotic resistance and placed a high priority on increasing social and professional accountability through restrictive measures. Their overarching aim was that policy interventions should be directed towards creating collective actions and broad social support for changing antibiotic use through establishing and explaining the need for mechanisms to control and support better prescribing by practitioners, while not transferring the burdens, costs and risks of interventions to consumers.