What Happens When "Germs Don't Get Killed and They Attack Again and Again": Perceptions of Antimicrobial Resistance in the Context of Diarrheal Disease Treatment Among Laypersons and Health-Care Providers in Karachi, Pakistan

Influences on use of antibiotics without prescription by the public in low- and middle-income countries: a systematic review and synthesis of qualitative evidence

Objectives

Self-medication with antibiotics is common practice in many low- and middle-income countries (LMIC). This review synthesizes the qualitative evidence on influences on perceptions and practices in relation to self-medication by the public with antibiotics in LMIC.

Methods

A systematic search was conducted of relevant medical, international and social science databases. Searching, screening, data extraction and quality appraisal followed standard methods. A meta-ethnographic approach was used for synthesis, starting with translation of studies and using a line-of-argument approach to develop the final themes.

Results

The search identified 78 eligible studies. Antibiotics were understood as a powerful, potentially dangerous but effective medicine for treating infections. This perception was strongly influenced by the common experience of being prescribed antibiotics for infections, both individually and collectively. This contributed to an understanding of antibiotics as a rational treatment for infection symptoms that was sanctioned by medical authorities. Accessing antibiotics from medical professionals was often difficult logistically and financially. In contrast, antibiotics were readily available over the counter from local outlets. People viewed treating infection symptoms with antibiotics as rational practice, although they were concerned about the risks to the individual and only took them when they believed they were needed.

Conclusions

A new model to explain self-medication with antibiotics is presented. This uses the socio-ecological model to integrate influences that operate at individual, community and wider socioeconomic levels, drawing on theories of medical authority and the medicalization and commercialization of health. Interventions to reduce overuse of antibiotics in LMIC need to address both clinical practice and community self-medication practices together.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n = 173); after removing duplicates and preprints (n = 12) and excluding those that did not meet eligibility criteria (n = 115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). This study is the first to succinctly identify a range of norms, behaviors, and policy contexts driving inappropriate use of antimicrobials in South Asia, emphasizing the importance of working across multiple sectors to design and implement approaches specific to the region.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n=173); after removing duplicates and preprints (n=12) and excluding those that did not meet eligibility criteria (n=115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). The findings highlight the importance of working across multiple sectors to design and implement approaches to antimicrobial stewardship in South Asia.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Implementation of the WHO Approved "Tailoring Antimicrobial Resistance Programs (TAP)" Reduces Patients' Request for Antibiotics

The misuse of antibiotics is a worldwide public health concern. Behavioral Intervention programs that aim to reduce patients' own request for antibiotics during their visit to primary care clinics is an attractive strategy to combat this problem. We tested the effectiveness of a behavioral modification method known as the Tailoring Antimicrobial resistance Programs (TAP) in reducing the request for antibiotics by patients visiting primary care clinics for mild upper respiratory tract infections (URTIs). A stratified cluster randomized design with two groups pre-post, comparing intervention with the control, was conducted in six health centers. TAP was implemented for eight weeks. Request for antibiotics was assessed before (period 1) and after introducing TAP (period 2). The percentage of patients or their escorts who requested antibiotics in period 1 was 59.7% in the control group and 60.2% in the intervention group. The percentage of patients who requested antibiotics did not significantly change between period 1 and 2 in the control group, who continued to receive the standard of care. The above percentage significantly decreased in the intervention group from 60.2% to 38.5% (p < 0.05). We conclude that behavioral change programs including TAP are a viable alternative strategy to address antibiotic misuse in Jordan.

Perspective of Pakistani Physicians towards Hospital Antimicrobial Stewardship Programs: A Multisite Exploratory Qualitative Study

Background: Antimicrobial resistance (AMR) is a global threat and the antimicrobial stewardship program (ASP) is a globally used tool to combat AMR. There is little information on the views among Pakistani physicians regarding AMR and the benefits of hospital antimicrobial stewardship implementation. This study was designed to explore the physicians’ views about ASP. Methods: Qualitative face-to-face and telephonic interviews were conducted by using purposive sampling method with 22 physicians working in seven tertiary care public hospitals of Punjab, Pakistan. All interviews were audio recorded and transcribed verbatim. Qualitative software was used, and a thematic analysis was conducted. Results: Three broad themes were identified: (1) the growing concern of antimicrobial resistance in Pakistan, (2) the role(s) of healthcare professionals in antibiotic prescribing, and (3) managing antibiotic resistance in hospitals. Inadequate resources, poor healthcare facilities, and insufficiently trained medical staff were the major hurdles in ASP implementation in Pakistan. Conclusions: Our study found a poor familiarity of hospital ASP among physicians working in public sector tertiary care teaching hospitals, and a number of distinct themes emerged during this study that could be helpful in establishing the concept of hospital ASP in Pakistan. Overall, physicians showed a positive attitude towards the enforcement of ASP in all healthcare settings, including teaching hospitals.

Pathways of antibiotic use in Bangladesh: qualitative protocol for the PAUSE study

INTRODUCTION

Global actions to reduce antimicrobial resistance (AMR) include optimising the use of antimicrobial medicines in human and animal health. In countries with weak healthcare regulation, this requires a greater understanding of the drivers of antibiotic use from the perspective of providers and consumers. In Bangladesh, there is limited research on household decision-making and healthcare seeking in relation to antibiotic use and consumption for humans and livestock. Knowledge is similarly lacking on factors influencing the supply and demand for antibiotics among qualified and unqualified healthcare providers.The aim of this study is to conduct integrated research on household decision-making for healthcare and antibiotic use, as well as the awareness, behaviours and priorities of healthcare providers and sellers of antibiotics to translate into policy development and implementation.

METHODS AND ANALYSIS

In-depth interviews will be conducted with (1) household members responsible for decision-making about illness and antibiotic use for family and livestock; (2) qualified and unqualified private and government healthcare providers in human and animal medicine and (3) stakeholders and policy-makers as key informants on the development and implementation of policy around AMR. Participant observation within retail drug shops will also be carried out. Qualitative methods will include a thematic framework analysis.A holistic approach to understanding who makes decisions on the sale and use of antibiotics, and what drives healthcare seeking in Bangladesh will enable identification of routes to behavioural change and the development of effective interventions to reduce the health risks of AMR.

ETHICS AND DISSEMINATION

Approval for the study has been obtained from the Institutional Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh following review by the Research and Ethics Committees (PR-16100) and from Loughborough University (R17-P081). Information about the study will be provided in a participant information letter in Bangla (to be read verbally and given in writing to participants). A written informed consent form in Bangla will be obtained and participants will be informed of their right to withdraw from the study. Dissemination will take place through a 1 day dissemination workshop with key stakeholders in public health and policy, practitioners and scientists in Bangladesh, and through international conference presentations and peer-review publications. Anonymised transcripts of interviews will be made available through open access via institutional data repositories after an embargo period.

Use of mathematical modelling to assess the impact of vaccines on antibiotic resistance

Antibiotic resistance is a major global threat to the provision of safe and effective health care. To control antibiotic resistance, vaccines have been proposed as an essential intervention, complementing improvements in diagnostic testing, antibiotic stewardship, and drug pipelines. The decision to introduce or amend vaccination programmes is routinely based on mathematical modelling. However, few mathematical models address the impact of vaccination on antibiotic resistance. We reviewed the literature using PubMed to identify all studies that used an original mathematical model to quantify the impact of a vaccine on antibiotic resistance transmission within a human population. We reviewed the models from the resulting studies in the context of a new framework to elucidate the pathways through which vaccination might impact antibiotic resistance. We identified eight mathematical modelling studies; the state of the literature highlighted important gaps in our understanding. Notably, studies are limited in the range of pathways represented, their geographical scope, and the vaccine-pathogen combinations assessed. Furthermore, to translate model predictions into public health decision making, more work is needed to understand how model structure and parameterisation affects model predictions and how to embed these predictions within economic frameworks.