Reducing expectations for antibiotics in primary care: a randomised experiment to test the response to fear-based messages about antimicrobial resistance

Seeing an apocalyptic post-antibiotic future lowers antibiotics expectations and requests

BACKGROUND

Antibiotic resistance is an ongoing pandemic which represents a global public health threat. To encourage the judicious use of antibiotics, public health discourse and campaigns often engage in threat-based messaging depicting an apocalyptic post-antibiotic future. We studied the effectiveness of the strategy because of mixed evidence for its success, and because it is unclear how experiencing the COVID-19 pandemic might have influenced it.

METHODS

We conducted a randomised controlled trial with 378 participants in three waves (before and during the pandemic in 2021 and 2022). Participants were randomly allocated to either the baseline arm, featuring a control film, or the intervention arm featuring a short film, Catch, depicting a post-antibiotic future. Participants expressed expectations and intended requests for antibiotics for a hypothetical ear infection and their adherence to a prescribed antibiotic for a hypothetical kidney infection. In waves 2 and 3, they also reported any COVID-19-related changes to their antibiotic desires.

RESULTS

Showing participants a film about a post-antibiotic future substantially lowers clinically inappropriate expectations for antibiotics and their intended requests. Participants report that the experience of the COVID-19 pandemic decreased their desire for antibiotics but only when they watched the intervention film. The intervention slightly decreases participants' adherence intentions towards a prescribed antibiotic treatment.

CONCLUSIONS

Presenting a film about an apocalyptic post-antibiotic future lowers expectations and intended requests for antibiotics and therefore has the potential to encourage judicious use of them. However, the adverse effects of such messaging on adherence to a course of antibiotics should be proactively managed.

Influencing attitudes towards antimicrobial use and resistance in companion animals-the impact on pet owners of a short animation in a randomized controlled trial

Objectives

Antimicrobial resistance (AMR) is a vital One Health issue; the rational use of antimicrobials is essential to preserve their efficacy. Veterinarians cite pressure from pet owners as a contributor to antimicrobial prescription. Engaging pet owners in antimicrobial stewardship could reduce this pressure. A short educational animation could facilitate communication of this message. The impact of the animation on participant's opinions relating to antimicrobial prescribing and awareness of AMR was assessed via a randomized controlled trial.

Methods

A survey was created based on the health belief model. Owners attending six UK veterinary centres were randomized to the intervention or control group (ratio 1:1). All owners completed an agreement level survey of two questions followed by 18 statements scored using a Likert agreement scale. The control group responded without interruption, whereas the animation group was shown the animation after answering the first two questions and five statements.

Results

In total, 647 owners participated in the study; 350 complete responses were analysed. Responses to 10 of 13 statements asked after the animation were significantly different (all P < 0.050) between groups, whereas there was no significant difference between groups in response to any of the statements asked before the animation. The animation group were more likely to agree that lower antimicrobial use would help maintain future efficacy (P < 0.001) and that requesting antimicrobials from their vet could increase unnecessary use (P < 0.001). The animation group were more likely to disagree that they would expect antimicrobials if their pet had diarrhoea (P = 0.048).

Conclusions

Pet owners that watched a short AMR engagement animation displayed greater awareness of the impact of AMR and were more likely to support measures in line with antimicrobial stewardship. This behavioural-nudge resource could support owners towards contributing to a multi-faceted approach to AMR.

Perceptions of antibiotic resistance among hospital healthcare professionals in high-income countries: A systematic review of causes, consequences, and solutions

OBJECTIVE

Antibiotic resistance (ABR) is a major threat to public health. Hospital healthcare professionals are important stakeholders in curbing ABR. To be able to encourage healthcare professionals to act against ABR, information on their perceptions is needed. Yet, summary evidence on how healthcare professionals perceive ABR causes, consequences, and solutions is outdated. This review aims to elucidate these perceptions.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL for literature published until July 6th, 2022, and used Web of Science and Scopus to identify reports citing included studies. Reports of quantitative original research from high-income countries were included if they investigated hospital healthcare professionals' perceptions about ABR. Descriptive data and data on perceptions about causes, consequences, and solutions regarding ABR were extracted. PROSPERO registration: CRD42022359249.

RESULTS

The database search and citation tracking yielded 13,551 and 694 papers respectively. Forty-eight reports from 46 studies were included in the review. These studies were performed between 1999 and 2023 and included between 8 and 1362 participants. Healthcare professionals perceived ABR as a problem that is more severe nationally than locally and they primarily recognize ABR as a distant and abstract problem. Studies mostly concurred on prescribing behavior as a cause and a solution for ABR, while external causes and solutions (e.g., in agriculture) elicited less agreement.

CONCLUSIONS

Studies with a primary focus on the perceptions of healthcare professionals about ABR are limited. Healthcare professionals perceive prescribing behavior as a major cause of ABR and a focus area for ABR solutions.

Communicating diagnostic uncertainty reduces expectations of receiving antibiotics: Two online experiments with hypothetical patients

The overprescription of antibiotics due to diagnostic uncertainty and inappropriate patient expectations influence antimicrobial resistance. This research assesses (i) whether communicating diagnostic uncertainty reduces expectations of receiving antibiotics and (ii) which communication strategies minimise unintended consequences of such communication. In two experimental online studies conducted in January and April 2023, participants read a vignette describing a doctor consultation for an ear infection and expressed their expectations of receiving antibiotics, trust in their doctor, rated the doctor's reputation and provided their intention to get a second doctor's opinion. Study 1 (N = 2213) investigated whether communicating diagnostic uncertainty and social externalities of antibiotic use (the negative social impacts of developing antibiotic resistance) decreases expectations for antibiotics and explores potential unintended consequences on the doctor-patient relationship. In Study 2 (N = 527), we aimed to replicate and extend the findings by adding specific treatment recommendations. Disclosing diagnostic uncertainty (vs. certainty) and communicating (vs. not communicating) the social externalities of antibiotic overuse reduced patients' expectations of receiving antibiotics. Yet, communicating uncertainty impaired trust in the doctor and the doctor's reputation. Combining the communication of uncertainty with specific treatment recommendations-particularly delayed antibiotic prescriptions-showed important to prevent these unintended consequences.

Decision making on antimicrobial use: Cat and dog owners' knowledge and preferences for veterinary communication

BACKGROUND

Veterinarians' understanding of cat and dog owners' perceptions about antimicrobial use will enhance their ability to communicate with clients to uphold antimicrobial stewardship guidelines.

METHODS

A total of 571 cat and dog owners were surveyed via an online platform to understand their antimicrobial knowledge and preferences for veterinary communication in antimicrobial use decision making. Data were analysed descriptively and inferentially to determine relationships between variables.

RESULTS

Cat and dog owners' backgrounds had an impact their antimicrobial knowledge. Women, individuals with a university degree, those with a health/science background and those identifying as white had a higher level of knowledge of antibiotics and antibiotic resistance. Owners' trust in veterinarians positively impacts adherence to recommendations. Where there was a strong preference for one type of messaging regarding antimicrobial use and stewardship, the owner's background was not predictive of a difference in response.

LIMITATIONS

The study population was mostly white, which reflects the US population and the reported distribution of pet owners who own dogs and cats. Respondents may have been susceptible to recall bias and/or social desirability bias.

CONCLUSION

Veterinarians should tailor their communication to meet clients' level of knowledge and rely on competent communication to enhance understanding and facilitate adherence to antimicrobial stewardship guidelines.

The public's antibiotic use behavioural patterns and their determinants for upper respiratory tract infections: a latent class analysis based on consumer behaviour model in China

Background

The irrational use of antibiotics among the public is a major contributor to antimicrobial resistance (AMR), which is a serious global threat. Prior studies have demonstrated that there are different behavioural patterns regarding antibiotic use among the public, and targeted interventions for subgroups with different behavioural patterns may be more effective. Thus, this study aimed to identify the public's behavioural patterns of antibiotic use for upper respiratory tract infections (URTIs) and their influencing factors.

Methods

A cross-sectional survey was conducted among the general population in Chongqing, China. Consumer decision-making (Consumer Behaviour Model, CBM) was used to assess the public's behaviours regarding antibiotic use, including need recognition, information searching, alternative evaluation, obtaining antibiotics, antibiotic consumption, and postuse evaluation. Furthermore, a latent class analysis was used to identify the underlying behavioural patterns among the public. The identified behavioural patterns of antibiotic use were further linked with individuals' capacity, opportunity, and motivation factors of antibiotic use based on a multinominal logistic regression to explore possible determinants.

Results

A total of 815 respondents were enrolled in the study. The public's irrational use of antibiotics was prevalent, including antibiotic self-medication (39.63%), nonprescription antibiotic purchasing (59.02%), and early stopping of antibiotic prescriptions (76.56%). Participants had inadequate knowledge of antibiotics (Mean = 2.33, SD = 1.71), reported high availability to antibiotics (Mean = 7.13, SD = 2.41), held strong belief in antibiotic effectiveness (Mean = 10.29, SD = 2.71), and demonstrated a high perceived threat of AMR (Mean = 12.30, SD = 3.20). Four behavioural patterns regarding antibiotic use for URTIs were identified, namely, "antibiotic self-medicators" (n = 165, 20.25%), "formal health care seekers" (n = 216, 26.50%), "various treatment users" (n = 198, 24.20%), and "self-medication without antibiotics" (n = 236, 28.96%). Individuals' self-efficacy of antibiotic use, belief in antibiotic effectiveness, awareness of antibiotic side effects, perceived antibiotic availability, social influence, and demographics (age, education, medical insurance, and having a medical background) were significantly associated with the public's different behavioural patterns of antibiotic use for URTIs.

Conclusion

This study calls for collaborative efforts among the public, physicians, policy makers, and the implementation of precise and multifaceted interventions to effectively reduce irrational use of antibiotics in the public. Such interventions include identifying subgroups within the public to provide more targeted education about antibiotics and the management of URTIs, reinforcing the regulation of antibiotic dispensing, and improving physicians' rational antibiotic prescriptions.

Misconceptions and Knowledge Gaps on Antibiotic Use and Resistance in Four Healthcare Settings and Five European Countries-A Modified Delphi Study

Misconceptions and knowledge gaps about antibiotics contribute to inappropriate antibiotic use and antimicrobial resistance. This study aimed to identify and prioritize misconceptions and knowledge gaps about antibiotic use from a healthcare professionals' perspective. A modified Delphi study with a predefined list of statements, two questionnaire rounds, and an expert meeting was conducted. The statements were rated by healthcare professionals from France, Greece, Lithuania, Poland, and Spain, and from general practice, out-of-hour services, nursing homes, and pharmacies. A total of 44 pre-defined statements covered the following themes: (1) antimicrobial resistance in general, (2) use of antibiotics in general, (3) use of antibiotics for respiratory tract infections, and (4) use of antibiotics for urinary tract infections. Consensus was defined as ≥80% agreement between the professionals during the second Delphi round. For 30% of the statements, professionals from the four settings together reached consensus. In each setting individually, at least 50% of the statements reached consensus, indicating that there are still many misconceptions and knowledge gaps that need to be addressed. Six educational tools (leaflets, posters, checklists) were developed to address the knowledge gaps and misconceptions. These can be used by patients and healthcare professionals to improve the use of antibiotics in practice.

Impact of the COVID-19 pandemic on antimicrobial stewardship support for general practices in England: a qualitative interview study

BACKGROUND

In England, clinical commissioning group (CCG; now replaced by Integrated Care Systems [ICSs]) and primary care network (PCN) professionals support primary care prescribers to optimise antimicrobial stewardship (AMS).

AIM

To explore views and experiences of CCG and PCN staff in supporting AMS, and the impact of COVID-19 on this support.

DESIGN & SETTING

Qualitative interview study in primary care in England.

METHOD

Semi-structured interviews with staff from CCG and PCNs responsible for AMS were conducted at two timepoints via telephone. These were audio-recorded, transcribed, and analysed thematically.

RESULTS

Twenty-seven interviews were conducted with 14 participants (nine CCG, five PCN) in December 2020-January 2021 and February-May 2021. The study found that AMS support was (1) deprioritised in order to keep general practice operational and deliver COVID-19 vaccines; (2) disrupted as social distancing made it harder to build relationships, conduct routine AMS activities, and challenge prescribing decisions; and (3) adapted, with opportunities identified for greater use of technology and changing patient and public perceptions of viruses and self-care. It was also found that resources to support AMS were valued if they were both novel, to counter AMS 'fatigue', and sufficiently familiar to fit with existing and/or future AMS.

CONCLUSION

AMS needs to be reprioritised in general practice in the post-pandemic era and within the new ICSs in England. This should include interventions and strategies that combine novel elements with already familiar strategies to refresh prescribers' motivation and opportunities for AMS. Behaviour change interventions should be aimed at improving the culture and processes for how PCN pharmacists voice concerns about AMS to prescribers in general practice and take advantage of the changed patient and public perceptions of viruses and self-care.

The role of efflux pumps ın antıbıotıc resıstance of gram negatıve rods

Antibiotic resistance is an important public health problem today, causing increased morbidity and mortality. Resistance to antibiotics in bacteria can develop by various mechanisms such as a change in the target site of the drug, a change in the outer membrane permeability, enzymatic defusing of the drug and efflux of the antimicrobial compound. Some bacteria have the potential to develop resistance to more than one drug by using several mechanisms together. One of the important resistance mechanisms of bacteria is active efflux pumps (EPs). EPs are pump proteins found in all cell types, located in the cell membrane. They are responsible for the excretion of various intracellular and extracellular substances (antibiotics, etc.) out of the cell. There is much research on various antimicrobials that cause antibiotic resistance in Gram negative rods, but studies on EPs are relatively few. Due to the concern that antibiotics will be insufficient in the treatment of diseases, a good understanding of EPs and the discovery of new EP inhibitors will shed light on the future of humanity. In this review, the structure of bacterial EPs in Gram negative bacteria, the role of EPs in multidrug resistance, the importance of EP inhibitors in the fight against antibiotic resistance and the phenotypic and genotypic detection methods of EPs are discussed.

Factors Influencing Inappropriate Use of Antibiotics in Infants under 3 Years of Age in Primary Care: A Qualitative Study of the Paediatricians' Perceptions

Antibiotic consumption in infants of less than three years is higher than average the average consumption for general population. The aim of this study was to explore paediatricians' opinions regarding factors influencing inappropriate use of antibiotics in early infancy in primary care. A qualitative study based on the grounded theory using convenience sampling was conducted in Murcia Region, Spain. Three focal discussion groups were developed with 25 participants from 9 health areas (HA) of Murcia Region. Paediatricians perceived that health care pressure was an influential factor in the prescribing behaviour, forcing them to prescribe antibiotics for a rapid cure in unjustified circumstances. Participants believed that antibiotic consuming was related to parents' self-medication due to their perceptions about the curative potential of antibiotics together with facilities to obtain these agents from pharmacies without prescription. The misuse of antibiotics by paediatricians was associated to the lack of education on antibiotic prescription and the limited use of clinical guidelines. Not prescribing an antibiotic in the presence of a potentially severe disease generated more fear than an unnecessary prescription. The clinical interaction asymmetry was more evident, when paediatricians use trapping risk strategies as a mechanism to justify a restrictive prescribing behaviour. The rational model of clinical decision-making in antibiotic prescribing among paediatricians was determined by factors associated with health care management, social awareness and knowledge of the population and pressure of families' demands. The present findings have contributed to the design and implementation of health interventions in the community for improving awareness of the appropriate use of antibiotics, as well as for a better quality of prescription by peadiatricians.

Does antibiotic awareness campaigns exposure decrease intention to demand antibiotic treatment? Testing a structural model among parents in Western Australia

Antimicrobial resistance (AMR) is one of the key public health concerns the world is facing today. The effect of antibiotic awareness campaigns (AACs) on consumer behaviour has been documented in the literature with mixed results. Understanding the mechanism for how AACs affect target populations is vital in designing effective and tailored campaigns. Using structural equation modelling our study examined the relationships among people's exposure to antibiotic awareness campaigns, knowledge of AMR prevention, AMR risk perception, and intention to seek antibiotic treatment. This study also tested the moderating effect of anxiety and societal responsibility on preventing AMR, and on their intention to demand antibiotic treatment mediated by knowledge of AMR prevention and risk-perception. Primary data was generated using an online survey of 250 Western Australian parents. We tested our hypotheses using reliability and validity tests and structural equation modelling. Our results show that exposure to AACs alone may not be enough to change parental intention to demand antibiotic prescription for their children. Parental risk perception of AMR and parental anxiety affect intention to demand antibiotics, and the view that AMR is a social responsibility has a moderating effect on intention to demand antibiotics. These factors could be considered and combine messaging strategies in designing future antibiotic awareness campaigns.

The vicious cycle of the public's irrational use of antibiotics for upper respiratory tract infections: A mixed methods systematic review

Background

The public's irrational use of antibiotics for upper respiratory tract infections (URTIs) is prevalent worldwide. This study aims to synthesize evidence on how people use antibiotics to treat URTIs, its prevalence and determinants.

Methods

A mixed methods systematic review was conducted using a convergent segregated approach. Relevant studies were searched from PubMed, Cochrane Library, Embase, and Web of Science. A qualitative analysis was initiated, exploring the public's antibiotic use experience for URTIS based on the Consumer Behavior Model (CBM). This was followed by a quantitative synthesis, tapping into the prevalence and predictors of public behavior in antibiotic usage for URTIs. The segregated syntheses complemented each other and were further integrated.

Results

A total of 86 studies were included: 48 quantitative, 30 qualitative, eight mixed methods studies. The included studies were conducted in Europe (n = 29), Asia (n = 27) and North America (n = 21), assessing the behaviors of patients (n = 46), their parents or caregivers (n = 31), or both (n = 9). Eleven themes emerged covering the six CBM stages: need recognition, information searching, alternative evaluation, antibiotic obtaining, antibiotic consumption, and post-consumption evaluation. The six stages reinforce each other, forming a vicious cycle. The high prevalence of the public's irrational use of antibiotics for URTIs is evident despite the high heterogeneity of the studies (ranging from 0.0 to 92.7%). The perceived seriousness of illness and misbelief in antibiotics were identified consistently across the studies as the major motivation driving the public's irrational use of antibiotics for URTIs. However, individual capacity (e.g., knowledge) and opportunity (e.g., contextual restriction) in reducing antibiotic use have mixed effect.

Conclusion

Systemic interventions concerning both supply and demand sides are warranted. The public needs to be educated about the appropriate management of URTIs and health care providers need to re-shape public attitudes toward antibiotic use for URTIs through communication and prescribing practices.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier: CRD42021266407.

Exploring companion animal caretakers' attitudes, perceptions and behavioural drivers of antimicrobial use within the social context of veterinary care

OBJECTIVE

To explore companion animal caretakers' attitudes, perceptions and behavioural drivers of antimicrobial use within the social context of veterinary care.

MATERIALS AND METHODS

Five semi-structured focus groups were conducted with 26 cat and dog owners. Transcripts were subjected to thematic analysis to systematically code and classify themes related to the study objectives.

RESULTS

Thematic analysis revealed five themes - trust-building/relationships, shared decision-making/empowerment, clear communication, judicious use and concerns surrounding antimicrobial use. Strong veterinarian-client relationships were the underlying factor influencing acceptance of antimicrobial use stewardship principles. Participants viewed themselves as advocates for their animals and preferred a relationship-centred approach to care facilitated through competent communication. They cited the importance of clear communication related to diagnosis and antimicrobial recommendations including using client-friendly terminology, providing explicit instructions for antimicrobial use, and having a shared plan for next steps and follow-up communication. Participants reported challenges with administering antimicrobial drugs, expressed concerns with potential side effects and development of antimicrobial resistance. Consequently, they reported an interest in alternatives to antimicrobial drugs and a focus on preventive medicine that was counterbalanced with concerns for animal comfort and welfare.

CLINICAL SIGNIFICANCE

Conversations about antimicrobial use can be reframed to include alternatives to antimicrobials as part of the treatment plan, and clients can be empowered to play a more active role in their animals' care. Veterinarians can apply core communication skills to advance antimicrobial stewardship principles and thereby contribute to preserving the effectiveness and availability of antimicrobials while preserving the trusting relationship and shared decision-making between clients and veterinarians.

Polish Medical Doctors’ Opinions on Available Resources and Information Campaigns concerning Antibiotics and Antibiotic Resistance, a Cross-Sectional Study

Background: Antibiotic resistance (ABR) is at the top of global health threats. This paper aims to assess Polish physicians’ readiness to impact ABR through prescribing routines. Methods: Surveying Polish physicians participating in specialization courses at the Center for Postgraduate Medical Education in Warsaw, Poland from October 2019 to March 2020. Results: Information was obtained from 504 physicians aged 25–59, mean 32.8 ± 5.9 years, mainly women (65%). Most doctors (78%) prescribed antibiotics at least once a week. Physicians indicated clinical practice guidelines as resources most often consulted in the management of infections (90%). However, clinical experience was also declared a powerful resource. In total, 54% of respondents recalled receiving information about the prudent use of antibiotics within 12 months, which partially translated into changing views (56%) and practice (42%). Physicians disagreed that national campaigns provide good promotion of prudent antibiotics use (75%) or that they are effective (61%). Only 40% of doctors were aware of the national campaign promoting responsible antibiotics use, 24% had heard about the European Antibiotic Awareness Day and 20% knew about the World Antimicrobial Awareness Week. Conclusions: Prescribers most often rely on clinical practice guidelines and their own experience as resources for antibiotics use. Doctors’ awareness of available resources and information campaigns concerning antibiotics and antibiotic resistance should be improved.

Antibiotic dispensing during the COVID-19 pandemic: analysis of Welsh primary care dispensing data

BACKGROUND

The COVID-19 pandemic led to rapid changes in demand and delivery of primary care services that could have led to increases in antibiotic prescribing.

OBJECTIVE

We investigated the impact of the COVID-19 pandemic on oral antibiotic dispensing rates in primary care in Wales using longitudinal analysis of monthly oral antibiotic dispensing data from 1 April 2018 to 30 April 2021.

METHODS

We used All-Wales primary care dispensing data. We examined trends in oral antibiotic dispensing per 1,000 people for Wales and for individual Health Boards. We used interrupted time series analysis to estimate changes in trends pre- and post-April 2020 to assess the impact of the first and subsequent lockdowns.

RESULTS

Between April 2020 and April 2021, antibiotic dispensing in Wales was lower compared with the same period in 2018 and 2019, with an average monthly decrease of 14.00 dispensed items per 1,000 registered patients (95% confidence interval 19.89-8.11). The overall prepandemic monthly antibiotic dispensing rate ranged from 48.5 to 67.4 antibiotic items per 1,000 registered patients. From the onset of the pandemic, it ranged from 40.3 to 49.07 antibiotic items per 1,000 registered patients. This reduction was primarily driven by narrow-spectrum antibiotics. Statistically significant reductions were also observed for antibiotics commonly dispensed for the treatment of respiratory tract infections. Dispensing of antibiotics primarily used for urinary and skin infections remained stable.

CONCLUSIONS

Despite complexities of consulting during the COVID-19 pandemic in primary care we found no evidence of an increase in antibiotic dispensing during this time.

Public Health Interventions to Improve Antimicrobial Resistance Awareness and Behavioural Change Associated with Antimicrobial Use: A Systematic Review Exploring the Use of Social Media

Introduction: Over the years there have been several interventions targeted at the public to increase their knowledge and awareness about Antimicrobial Resistance (AMR). In this work, we updated a previously published review by Price et al. (2018), on effectiveness of interventions to improve the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials to identify which interventions work best in influencing public behaviour. Methods: Five databases—Medline (OVID), CINAHL (EBSCO), Embase, PsycINFO, and Cochrane Central Register of Controlled Trials (CENTRAL-OVID)—were searched for AMR interventions between 2017 and 2021 targeting the public. All studies which had a before and after assessment of the intervention were considered for inclusion. Results: In total, 17 studies were found to be eligible for inclusion in the review. Since there was a variety in the study interventions and in particular outcomes, a narrative synthesis approach was adopted for analysis. Whereas each study showed some impact on awareness and knowledge, none measured long-term impact on behaviours towards antibiotic use, awareness, or knowledge. Engagement was higher in interventions which included interactive elements such as games or videos. Social media was not used for recruitment of participants or as a mode of communication in any AMR interventions included in this review.

‘Superbugs’: raising public awareness of antimicrobial resistance through a pop-up science shop

‘Superbugs: A Pop-up Science Shop’ was a public engagement event in the school summer holidays of 2019, organised by members of Cardiff University’s School of Medicine. We transformed an empty retail unit in the centre of Wales’s largest shopping centre into an interactive and immersive microbiology experience. We facilitated two-way dialogue to impart positive impact on the awareness of antibiotic resistance, while concurrently evaluating the efficacy of an engagement strategy focused on the utilisation of public spaces to attract public demographics diverse to those who would normally engage with conventional science, technology, engineering and mathematics (STEM) outreach. Over the course of 14 days, we welcomed 6,566 visitors, with 67 per cent attending as part of the natural footfall of the shopping centre. We created 1,626 young Antibiotic Resistance Champions, located in over two hundred schools, across many of the most deprived areas in Wales. We imparted a positive impact to our stakeholders, with a significant increase in the knowledge and understanding of the subject of antimicrobial resistance (AMR); 91.7 per cent indicated that they had a better understanding after the event. In this article, we discuss the evolution of ‘Superbugs’ from concept, planning and design, to the logistics of delivering an engagement event of this scale. We focus in particular on the learning outcomes of the project, and on how this will shape the future of our ‘Superbugs’ project, and engagement events beyond.

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.

Ten ways to make the most of World Antimicrobial Awareness Week

One fundamental strategy to address the public health threat of antimicrobial resistance (AMR) is improved awareness among the public, prescribers, and policy makers with the aim of engaging these groups to act. World Antimicrobial Awareness Week is an opportunity for concerted and consistent communication regarding practical strategies to prevent and mitigate AMR. We highlight 10 ways for antimicrobial stewards to make the most of World Antimicrobial Awareness Week.

Public Health and Epidemiology Informatics: Recent Research Trends

OBJECTIVES

To introduce and analyse current trends in Public Health and Epidemiology Informatics.

METHODS

PubMed search of 2020 literature on public health and epidemiology informatics was conducted and all retrieved references were reviewed by the two section editors. Then, 15 candidate best papers were selected among the 920 references. These papers were then peer-reviewed by the two section editors, two chief editors, and external reviewers, including at least two senior faculty, to allow the Editorial Committee of the 2021 International Medical Informatics Association (IMIA) Yearbook to make an informed decision regarding the selection of the best papers.

RESULTS

Among the 920 references retrieved from PubMed, four were suggested as best papers and the first three were finally selected. The fourth paper was excluded because of reproducibility issues. The first best paper is a very public health focused paper with health informatics and biostatistics methods applied to stratify patients within a cohort in order to identify those at risk of suicide; the second paper describes the use of a randomized design to test the likely impact of fear-based messages, with and without empowering self-management elements, on patient consultations or antibiotic requests for influenza-like illnesses. The third selected paper evaluates the perception among communities of routine use of Whole Genome Sequencing and Big Data technologies to capture more detailed and specific personal information.

CONCLUSIONS

The findings from the three studies suggest that using Public Health and Epidemiology Informatics methods could leverage, when combined with Deep Learning, early interventions and appropriate treatments to mitigate suicide risk. Further, they also demonstrate that well informing and empowering patients could help them to be involved more in their care process.

Effect of information on reducing inappropriate expectations and requests for antibiotics

People often expect antibiotics when they are clinically inappropriate (e.g., for viral infections). This contributes significantly to physicians' decisions to prescribe antibiotics when they are clinically inappropriate, causing harm to the individual and to society. In two pre-registered studies employing UK general population samples (n₁  = 402; n₂  = 190), we evaluated the relationship between knowledge and beliefs with antibiotic expectations, and the effects of information provision on such expectations. We conducted a correlational study (study 1), in which we examined the role of antibiotic knowledge and beliefs and an experiment (study 2) in which we assessed the causal effect of information provision on antibiotic expectations. In study 1, we found that both knowledge and beliefs about antibiotics predicted antibiotic expectations. In study 2, a 2 (viral information: present vs. absent) × 2 (antibiotic information: present vs. absent) experimental between-subjects design, information about antibiotic efficacy significantly reduced expectations for antibiotics, but viral aetiology information did not. Providing antibiotic information substantially diminishes inappropriate expectations of antibiotics. Health campaigns might also aim to change social attitudes and normative beliefs, since more complex sociocognitive processes underpin inappropriate expectations for antibiotics.

Awareness of Appropriate Antibiotic Use in Primary Care for Influenza-Like Illness: Evidence of Improvement from UK Population-Based Surveys

Influenza-like illnesses (ILI) account for a significant portion of inappropriate antibiotic use. Patient expectations for antibiotics for ILI are likely to play a substantial role in ‘unnecessary’ antibiotic consumption. This study aimed to investigate trends in awareness of appropriate antibiotic use and antimicrobial resistance (AMR). Three sequential online surveys of independent representative samples of adults in the United Kingdom investigated expectations for, and consumption of, antibiotics for ILI (May/June 2015 (n = 2064); Oct/Nov 2016 (n = 4000); Mar 2017 (n = 4000)). Respondents were asked whether they thought antibiotics were effective for ILI and about their antibiotic use. Proportions and 95% confidence intervals (CI) were calculated for each question and interactions with respondent characteristics were tested using logistic regression. Over the three surveys, the proportion of respondents who believed antibiotics would “definitely/probably” help an ILI fell from 37% (95% CI 35–39%) to 28% (95% CI 26–29%). Those who would “definitely/probably” visit a doctor in this situation fell from 48% (95% CI 46–50%) to 36% (95% CI 34–37%), while those who would request antibiotics during a consultation fell from 39% (95% CI 37–41%) to 30% (95% CI 29–32%). The percentage of respondents who found the information we provided about AMR “new/surprising” fell from 34% (95% CI 32–36%) to 28% (95% CI 26–31%). Awareness improved more among black, Asian and minority ethnic (BAME) than white people, with little other evidence of differences in improvements between subgroups. Whilst a degree of selection bias is unavoidable in online survey samples, the results suggest that awareness of AMR and appropriate antibiotic use has recently significantly improved in the United Kingdom, according to a wide range of indicators.

Clinician and Patient Factors Influencing Treatment Decisions: Ethnographic Study of Antibiotic Prescribing and Operative Procedures in Out-of-Hours and General Dental Practices

Operative treatment is indicated for most toothache/dental abscesses, yet antibiotics instead of procedures are often prescribed. This ethnographic study aimed to identify clinician and patient factors influencing urgent dental care for adults during actual appointments; and to identify elements sensitive to context. Appointments were observed in out-of-hours and general dental practices. Follow-up interviews took place with dentists, dental nurses, and patients. Dentist and patient factors were identified through thematic analysis of observation records and appointment/interview transcripts. Dentist factors were based on a published list of factors influencing antibiotic prescribing for adults with acute conditions across primary health care and presented within the Capability-Opportunity-Motivation-Behaviour model. Contextually sensitive elements were revealed by comparing the factors between settings. In total, thirty-one dentist factors and nineteen patient factors were identified. Beliefs about antibiotics, goals for the appointment and access to dental services were important for both dentists and patients. Dentist factors included beliefs about the lifetime impact of urgent dental procedures on patients. Patient factors included their communication and negotiation skills. Contextual elements included dentists’ concerns about inflicting pain on regular patients in general dental practice; and patients’ difficulties accessing care to complete temporary treatment provided out of hours. This improved understanding of factors influencing shared decisions about treatments presents significant opportunity for new, evidence-based, contextually sensitive antibiotic stewardship interventions.