Why patients want to take or refuse to take antibiotics: an inventory of motives

Why are African immigrants in Montreal reluctant to use mental health services?: a systematic inventory of reasons

PURPOSE

Previous research has shown that non-Caucasian immigrants in Western countries are less likely than native-born people to use mental health services. This study examined the reasons underlying reluctance to use mental health services among African immigrants in Montreal, Canada.

METHODS

The study participants were 280 African immigrants who had experienced symptoms suggesting depression but did not use formal mental health services. They were presented with a questionnaire that contained 65 statements referring to reasons for not using formal mental health services while experiencing those symptoms and were asked to indicate their degree of agreement with each of the statements on a scale of 0-10. Responses were then analyzed using factor analysis.

RESULTS

An eight-factor structure of reasons was found: "Minimizing symptoms and perceived self-efficacy" (61% of the sample), "Relying on spiritual care" (56% of the sample), "Cost and waiting time" (45% of the sample), "Influence of significant others" (34% of the sample), "Lack of cultural competence" (32% of the sample), "Fear of stigmatization" (23% of the sample), "Nature of the consultation" (10% of the sample) and "Social models" (8% of the sample). Scores on these factors were related to participants' demographics.

CONCLUSION

Effectively addressing the underutilization of mental health services among African immigrants requires a multifaceted approach rather than one focused on a single barrier. Our findings suggest critical points that could help develop tailored interventions to address the various barriers to care.

Addressing Consumer Misconceptions on Antibiotic Use and Resistance in the Context of Sore Throat: Learnings from Social Media Listening

A misunderstanding of the mechanism of action and bacterial targets of antibiotics by consumers may drive inappropriate antibiotic use and antimicrobial resistance (AMR). Tackling AMR requires an in-depth understanding of consumer beliefs and misconceptions. We explored consumer conversations on a number of social media platforms on antibiotic use and AMR in the context of sore throat and how coronavirus disease 2019 (COVID-19) affected online conversations between 1 January 2018 and 25 November 2021 across eight countries. Five distinct consumer groups were identified (antibiotic-preserving peer educators, antibiotic-cautious consumers, medication-resistant antibiotic opponents, believers in the strength of antibiotics, determined pro-antibiotic consumers) with a wide spectrum of beliefs around antibiotics in sore throat. Many opinions were based upon misconceptions, the most prominent of which was that antibiotics are strong medications that can treat all types of sore throat. COVID-19 had a multifaceted effect on the sore throat and AMR conversation. Sore throat triggered anxiety as consumers feared it may be a COVID-19 symptom while engagement in conversations around antibiotics for COVID-19 increased. Finally, consumers sought multiple routes to access antibiotics, such as directly from the pharmacy or by attempting to persuade physicians to prescribe. Knowledge obtained from this study could be used to develop focused approaches to dispel consumer misconceptions and mitigate AMR.

What Does Patient-Centered Communication Look Like?: Linguistic Markers of Provider Compassionate Care and Shared Decision-Making and Their Impacts on Patient Outcomes

Patient-centered communication promotes positive patient outcomes. This study examines the linguistic markers of two key dimensions of patient-centered communication (i.e., provider compassionate care and shared decision-making) and their mediating effects on patient perceived quality of and affective responses to the provider's treatment recommendations. Transcripts (N = 343) of provider talk from provider-patient interactions in medical visits for upper respiratory infection symptoms where patients were not prescribed with antibiotics were analyzed with the Linguistic Inquiry and Word Count (LIWC) dictionary. Results showed that providers' use of affiliation words positively predicted patients' perceptions of their providers' compassionate care. Providers' use of insight words negatively predicted patients' perceptions of provider shared decision-making. Meanwhile, providers' use of first-person singular pronouns, causation and differentiation words, and clout words were positively related to perceived provider shared decision-making. Patient perceived compassionate care and shared decision-making further increased patients' positive affect toward and perceived quality of non-antibiotic treatment recommendations. These perceptions also reduced their negative affect toward the recommendations. Implications of the findings are discussed with regard to patient-centered communication in relation to the promotion of antibiotic stewardship.

Providers' shared decision-making as a predictor of healthcare outcomes for college-aged adults managing upper respiratory tract infections

OBJECTIVES

Strategies that assist patients with upper respiratory tract infections (URTIs) to endorse non-antibiotic treatments are vital to curbing antibiotic resistance. This study examines the potential of shared decision-making (SDM) for improving stewardship-relevant outcomes and investigates patient affect as a mechanism that explains the beneficial impact of perceived SDM.

METHOD

Patients (N = 433) seeking care for URTIs at a university student health center and not prescribed antibiotics completed a pre-visit questionnaire and two surveys one day and 14 days post-visit. The day-one survey assessed perceived SDM, affect, and immediate stewardship-relevant outcomes, and the day-14 survey assessed long-term stewardship-relevant outcomes.

RESULTS

Perceived SDM was negatively associated with negative affect and positively associated with positive affect, favorable perceptions of non-antibiotic treatments and providers, and self-efficacy to manage symptoms and obtain follow-up care. Patient affect and day-one outcomes were mediators between perceived SDM and retrospective self-efficacy two weeks post-visit.

CONCLUSION

The study illustrated the beneficial influence of patient perceived SDM on antibiotic stewardship in both short and long terms and elucidated the mechanisms through which the influence occurs.

PRACTICE IMPLICATIONS

SDM can be an effective strategy for primary care providers to improve patients' outcomes with URTI visits without prescribing unwarranted antibiotics.

Behavioral determinants of antibiotic resistance: The role of social information

The increasing development of resistant pathogens is one of the greatest global health challenges. As antibiotic overuse amplifies antibiotic resistance, antibiotic intake poses a social dilemma in which individuals need to decide whether to prosocially reduce their intake in the collective interest versus to (over)use it even in case of mild diseases. We devise a novel behavioral game paradigm to model the social dilemma of antibiotic intake. Using this new method in an incentivized laboratory experiment (N = 272 German participants), we varied whether players had mutual knowledge about their antibiotic intake. The results indicate that there was substantial antibiotic overuse in the absence of social information. Overuse decreased when social information was present. Our postexperimental survey data further suggest that social information impacts people's behavioral motivation, evaluation of the other player, and positive affect. Taken together, providing social information about people's antibiotic intake may help in reducing antibiotic overuse. On a more general level, the novel behavioral game may be adapted to study other aspects of antibiotic intake to promote prudent use of antibiotics.

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.

Ethical Tenets of PRN Medicines Management in Healthcare Settings: A Clinical Perspective

Prescription and administration of pro re nata (PRN) medications has remained a poorly discussed area of the international literature regarding ethical tenets influencing this type of medication practice. In this commentary, ethical tenets of PRN medicines management from the clinical perspective based on available international literature and published research have been discussed. Three categories were developed by the authors for summarising review findings as follows: 'benefiting the patient', 'making well-informed decision', and 'follow up assessment' as pre-intervention, through-intervention, and post-intervention aspects, respectively. PRN medicines management is mainly intertwined with the ethical tenets of beneficence, nonmaleficence, dignity, autonomy, justice, informed consent, and error disclosure. It is a dynamic process and needs close collaboration between healthcare professionals especially nurses and patients to prevent unethical practice.

Preferences for Prophylactic Oral Antibiotic Use in Dermatologic Surgery: A Multicenter Discrete Choice Experiment

BACKGROUND

Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood.

OBJECTIVE

To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions.

MATERIALS AND METHODS

Multi-center, prospective discrete choice experiment (DCE).

RESULTS

Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics.

CONCLUSION

Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.

Safety of reducing antibiotic prescribing in primary care: a mixed-methods study

Background

The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.

Objectives

To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.

Design

Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.

Data sources

The Clinical Practice Research Datalink.

Setting

This took place in UK general practices.

Participants

A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.

Main outcome measures

Sepsis and localised bacterial infections.

Results

Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.

Limitations

Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.

Conclusions

Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.

Future work

The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

Antibiotic Resistance, Still a Global Challenge

The use of antibiotics represents a major health problem worldwide because they are often administered without medical prescription. This has led to different situations starting from a large use in inappropriate cases without medical recommendation, to a major issue that represents antimicrobial resistance. Our aim was to identify the opinion of healthcare workers (physicians and pharmacists) about the most effective solution at reducing antimicrobial resistance, helping the policy makers to take a decision. The present study was conducted from March 15th, 2021 to April 15th, 2021, using a virtual questionnaire. A total of 397 respondents provided a complete response to our questionnaire: 313 physicians and 84 pharmacists. Our results provided valuable insights that can be used to inform the development of a national health policy, resulting in population health gains. Our work provided an indication of physicians' preferences toward solutions as "A tax on antibiotic consumption, which could be used to fund innovation strategies." (41.53%) and "An educational program for patients that highlights the causes and effects of antimicrobial resistance." (42.49%). The pharmacists preferred the solutions as "An educational program for patients that highlights the causes and effects of antimicrobial resistance." (52.38%) and "Elimination of antibiotics from the list of the emergency pharmaceutical services." (42.86%). A small number of physicians (2.24%) and pharmacists (3.57%) recommended as the most effective solution at reducing antimicrobial resistance "Restrain antibiotic use in the food industry."

Revisiting patient expectations and experiences of antibiotics in an era of antimicrobial resistance: Qualitative study

OBJECTIVE

To investigate contemporary patient expectations and experiences of antibiotic prescribing in England.

BACKGROUND

Primary care providers' compliance with patient influences has been identified as a motivation for antibiotic-prescribing behaviour. Since 2013, there have been concerted efforts to publicize and address the growing threat of antimicrobial resistance. A fresh qualitative insight into patient expectations and experiences is needed.

DESIGN

Qualitative study using semi-structured interviews.

SETTING AND PARTICIPANTS

Two English regions, one an urban metropolitan area and the other a town in rural England. Patients who recently consulted for infections were recruited. The information power approach was used to determine the number of participants, yielding a sample of 31 participants.

MAIN MEASURES

Thematic analysis was carried out to analyse the interview data.

RESULTS

Five themes were identified: beliefs, expectations, experiences of taking antibiotic, experience of antimicrobial resistance and side-effects, and experiences of consultations. The accounts reflected improved public knowledge: antibiotics were perceived to be much-needed medicines that should be prescribed when appropriate. The data showed that patients formed expectations of expectations, trying to read the prescribers' intentions and reflect on the dependency between what prescribers and patients wanted. Patient experiences featured as nuanced and detailed with knowledge of AMR and side-effects of antibiotics in the context of positive consultation experiences.

CONCLUSIONS

The study highlighted complex interplays between adherence to antibiotics and consuming antibiotics in reflexive, informed ways. Ensuring that present and future patients are informed about potential benefits and harms of antibiotic use will contribute to future antimicrobial stewardship.

Cavitary Pneumonia: A Complication of Antibiotic Noncompliance

In this report, we present a complicated case of community-acquired pneumonia in a 5-year-old boy. The patient first presented to the pulmonology clinic with the diagnosis of asthma and a recent history of recurrent pneumonia. Poor compliance to two courses of outpatient oral antibiotics resulted in persistent pneumonia symptoms with unresolved radiographic findings warranting parenteral antibiotics. Despite 2 symptom-free weeks, the patient returned to the emergency department with recurrence of symptoms where imaging revealed a cavitary lesion requiring a prolonged course of parenteral antibiotics. This report further supports the detrimental impact of partially treated infections related to poor compliance to antibiotic regimens.