antimicrobial resistance

bio.research

wtp059551

Exploring the consumer perspective onantimicrobial resistanceJune 2015


Contents1. Background – objectives and project plan2. Qualitative research methodology – a summary3. Findings‐ People’s relationship with antibiotics‐ Current knowledge and understanding of AMR and resistance‐ Reactions to different ‘ways in’ of talking about resistance‐ Current language and how it is understood4. Summary of key insights5. The doctor interviews – summary findings6. A few thoughts on implications1


Objectives and process overviewWhat is the nature of people’s relationship with antibiotics and what is the best languageto use to talk to them about antibiotic resistance?• Explore existing knowledge, attitudes and perceptions around antibiotics and their use• Explore differences by demographic and attitudinal factors• Identify the language people use to talk about this, and their understanding of thewords that others use• Uncover potential ‘routes in’ to talk to people about antibiotics and resistance, that willstrike a chord with themImmersionand deskresearch –includingstakeholderdiscussionsDoctor interviewsFriendship pairsFocus groupsAnalysisand insightsReport3


GroupGroupOur core qualitative methodologies are friendship pair depthinterviews and focus groupsPairLife stageLondon regionEducation1 Pre-parent No education past 16 yearsold2 First time parent University educated3 40-60 year olds University / furthereducation4 Aged 70+ Education up to 18 years oldPairLife stagePAIRS: two hours talking to twofriends – the secure dynamichelps them open up and behonestManchester regionEducation5 Pre-parent University / furthereducation6 First time parent Education up to 18 years old7 40-60 year olds No education past 16 yearsold8 Aged 70+ University educatedAgeLondon region (split urban and suburban)Education / SocialgradeRelationship with antibiotics1 18-25 At university Mix2 18-25 At university Mix3 18-25 Not university educated Mix4 25-39 AB Mix5 40-60 C2DE Mix6 25-50 MixAgeBirmingham / Scotland (urban)Education / SocialgradeStrongly agree: When I’m ill I liketo take antibioticsRelationship with antibiotics7 18-25 Not university educated Mix8 40-60 C2DE Mix9 25-39 AB Mix10 25-50 MixGROUPS: further exploration ofkey areas and interesting angles,using group dynamic to open updiscussionsStrongly agree: When I’m ill I liketo take antibiotics4


Findings1. People’s relationship with antibiotics2. Current knowledge and understanding of AMR and resistance3. Reactions to different ‘ways in’ of talking about resistance4. Current language and how it is understoodNOTE: All verbatims in dark blue are from the focus groups, those inlight blue are from the friendship pairs5


Most people think they know when they need antibiotics –they don’t need the doctor to tell themIt tends to be something they have thought about before they get to the doctor’s surgery– and it shapes their expectations for the appointmentKey factors that drive belief in self diagnosis“I know my body”“I know what’s workedbefore”If I felt really bad [and the doctor didn’tgive them to me] I’d ask to see anotherdoctor. You know your own body.M, 25-39, AB, LondonIf I’d had it already and they’d treatedme with antibiotics then I’d want them.M/F, 18-25, at university, LondonI always know. You just know in yourself.F, 25-39, AB, Birmingham6


The deciding factor is nearly always how ill they feel – it’sabout severity rather than type of illnessNearly everyone thinks you need antibiotics when you’re ‘really ill’ – even the few that getthe distinction between viral and bacterial talk about how you feel not what you’ve gotWhat makes you think you need antibiotics?You feel reallyterrible – unable tofunction‘Regular’ (OTC)medicine isn’thaving an impactIt’s lasting a longtimeNot able to fight itmyselfIt depends on theintensity of thesymptoms. If youcan’t move, it’s anNHS issue.M/F, 18-25, atuniversity, LondonIf it hinders day-todaystuff. If you canget on with it thenit’s nothing major, ifit’s more you mightneed antibiotics.M/F, 18-25, atuniversity, LondonI just know when I havebeen suffering for two orthree weeks that I needmore than Lemsip.They’re stronger thananything else, it has to beantibiotics at this point.F, 40-60, no education past16 years old, ManchesterYou don’t feel like it’sgoing to get betterwhatever you take. It’sall of it together –temperature, lethargic,you can’t cope with it.It’s a stronger pain. Ittakes it out of you.F, 40-60, C2DE, London7


And this means there is a strong sense of ‘validation’connected to antibiotics – getting them is ‘proof’ you’re illIf you get antibiotics it means you’ve got a ‘real illness’ and it’s treatable, if you don’tyou’re not ‘properly ill’, you don’t get medicine for anything else and it ‘doesn’t count’How do you feel when you get antibiotics?Sense of validation– really issomething wrongwith youThe trip to thedoctors was ‘worthit’Means you’ll getbetter, somethingyou can do about itFor some(particularly older)it’s not anythingworseI feel like I haven’t wasted the doctor’stime or my own.M/F, 18-25, not university educated, BirminghamYou get more sympathy onceyou’ve got antibiotics.M/F, 25-50, Mixed, BirminghamIt’s like a magic pill. If Itake these I’ll be sorted.M/F, 18-25, not universityeducated, BirminghamYou know in a couple of days you’ll be better.Plus it confirms I am ill, my girlfriend willbelieve me.M, 25-39, AB, LondonI’m reassuredit’s nothingmore serious, itjust needsantibiotics.M, 73, education upto 18, London8


We see this reflected in the emotions people associate withgetting antibioticsWe used a mapping exercise to get people to identify emotions they do and don’t feelwhen they get antibiotics100%90%80%70%60%50%40%30%20%10%0%Disagree Unsure Agree9


And many have plans in place for the doctor’s surgery, tomake sure they get themPrimary antibiotic-getting ‘tactics’Look up symptomsbeforehand so theyknow what to sayDial everything up afew degreesBe a pain and refuse tomoveIt’s how well you play it. If you say, I’mgoing to die, they’ll give you something. Acouple of headaches, they won’t.M/F, 18-25, at university, LondonIf you’ve looked it up online beforehand and knowyou should be prescribed something it helps. You goin with a goal and say you need them.M/F, 18-25, at university, LondonI just said I hear what you’re saying but Idon’t agree. I could see him getting red,thinking I’ve got to get rid of this woman.He gave me a lecture about giving out toomany. I thought I don’t care what you’resaying, I feel really, really rough. I lied tohim and said I’d had symptoms for 5-6days and I hadn’t. I said I’m here for aprescription, I’m not moving. I was thereabout 10 minutes.M/F, 25-50, Mixed, London10


But that’s not to say everyone is ‘happy’ to get them – it’smore complicated than that, and it variesNecessary evilRelationship with ‘putting things into my body’Perfect solutionAll about ‘natural’Think your bodymight ‘get used tothem’Want anything togive you a ‘fix’Hate taking anykind of pillThink you need tobuild up yourimmune systemCan’t accept theidea of being illI don’t like to take them. I don’t getill, sometimes colds, but I just restup with chamomile. Antibioticsshould be a last resort. If possible,natural remedies are always better.F, 33, pre-family, university, PolishIt’s your tolerance level.Your body adapts to it.M, 25-39, AB, LondonI had a persistent cough but itwas a virus so they said no. Youfeel desperate. You leavethinking no, I want to get better!F, 40-60, C2DE, London11


Where people sit on this spectrum is often linked – thoughvaguely – to how people think antibiotics workNo one has a clear understanding of how antibiotics work in the body, and most haven’tthought much about it, but the associations they have are part of the overall mix thatshapes their attitudesHave a notion that they are‘harsh’ in their impact on yourbodyImagine them as ‘targetedkillers’ honing in on the‘baddies’ inside youMore likely to think of themas ‘necessary evil’More likely to think of themas the ‘perfect solution’It’s like going through chemo. It kills the bacteria but all the goodthings too. It makes me think I have to eat extra healthy. I’m awareit is damaging to my system so I must replenish the good bacteriaand vitamins.F, 33, pre-family, university, PolishThey kill off what’s notsupposed to be there, don’tknow how but it’s amazing.F, 40-60, C2DE, London12


And this all goes into the mix when it comes to how peopletake antibioticsMany of those who have some reluctance around taking antibiotics will purposefullyavoid taking the whole course – while for others it’s more about the inconvenienceMotivation for not finishing courseMinimise the impact onmy bodyInterferes with otherthings in my lifeTook one and it gave me aboost for my body to healnaturally. I threw the rest away.M/F, 18-25, not at university, LondonIf it’s on the weekend and youwant to go out drinking, youskip the pill. It’s a bit of adilemma.M/F, 18-25, not at university, London13


Findings1. People’s relationship with antibiotics2. Current knowledge and understanding of AMR and resistance3. Reactions to different ‘ways in’ of talking about resistance4. Current language and how it is understood14


‘AMR’ means nothing to people – they can’t even guess atwhat it stands forWhen we ask about ‘AMR’ and ‘antimicrobial resistance’ we just get blank faces all round– even when we’ve just been talking about resistance more generallyI need a dictionary for that.F, 40-60, no education past 16 years old,ManchesterThat sounds like somethingmade up.M/F, 18-25, not at university, LondonNo idea.M/F, 25-50, Mixed, BirminghamI think my doctor gave me soapthat’s that.M/F, 18-25, at university, London15


And ‘resistance’ is either not on the radar or misunderstood –everyone assumes it’s the person that becomes resistantMost don’t really know what resistance is, but when they stop and think they imagine the bodybuilding up resistance not the bacteria – the idea that the more you take the less effective they’ll beon you makes intuitive sense to many people and is hard to shakeConnections that make sense to peopleImmunityToleranceGetting used tothemThink you’re immune to it.When you’ve had so much theyjust don’t work anymore.F, 40-60, C2DE, LondonIt’s your tolerance level.Your body has adapted to it.M, 25-39, AB, LondonIf you rely too much on antibioticsthen your body gets used to them.F, 40-60, no education past 16 years old,ManchesterIf you take too much of anything theneventually you become immune to it.M/F, 25-50, Mixed, BirminghamThe more you take, the more your body becomesresistant to it. They’re not working any more.M/F, 18-25, at university, London16


There’s also a bit of suspicion about the idea of resistanceThere’s a natural tendency to dismiss the idea – or to purposefully blank it outCommon misconceptions/ ‘theories’GPs/ NHS trying tosave moneyDrug company‘conspiracy’Scare story/problem ‘elsewhere’Terms like superbug and superflu, they’rethere to induce concern in the public. It’s a bittoo much, we’re becoming desensitised to it.M/F, 18-25, at university, LondonDoom and gloom, heard it all before, lies andmedia hype. You never see anything come ofit all do you? It’s scaremongering tactics.M/F, 18-25, not university educated, BirminghamYou hear about GPs trying to cut down as they only have acertain pot of money. I’m a bit cynical really. Things seems tocome into the media in line with what the government is doing.F, 25-39, AB, BirminghamIf you walk around blindto everything it’s the bestway.M/F, 25-50, Mixed, Birmingham17


And there’s a belief that ‘they’/ scientists will sort it outbefore it becomes a real problemAt the end of the day, everyone assumes that the experts will work it out – they are confident thattime and money will be spent to find a “cure” and that it will eventually all be “sorted”What do you think will happen?The experts are on itTime and money willbe spentThere’s always a cureThere’s always beenadvancements. In years to comethey’ll advance more and findsomething. They found a curefor cancer which they never hadbefore. They have so muchmoney behind them, presume itwill be sorted.M/F, 18-25, at university, LondonThey always have a plan B.M/F, 18-25, at university, LondonThere are always going to be issuesaround something. If the drugs wedon’t have now don’t deal withthem then someone else will workovertime to find one that works.F, 40-60, C2DE, LondonThere’s a cure for everything.M/F, 25-50, Mixed, BirminghamI know the bestpeople in the worldare working on it.M/F, 18-25, atuniversity, London18


All of which means it’s really hard to make it feel relevant tothe individual – and that’s one of the biggest battlesBody becomes resistant– I don’t take them veryoften so it won’t affectmeSceptical/ ‘elsewhere’ –never going to impactme / my family withinmy lifetimeThe girl who takes them all thetime might become resistantbut not people like us.M, 40-60, C2DE, BirminghamSensationalist. Don’tbelieve the hype.M/F, 40-60, C2DE, London19


When people really understand resistance and ‘get it’ itmakes a difference – but it’s really difficult to graspWhat is antibiotic resistance?Antibiotic resistance is the ability of bacteria to resist the effectsof an antibiotic. Antibiotic resistance occurs when bacteria changein some way that reduces or eliminates the effectiveness of drugsdesigned to cure or prevent infections. The bacteria survive andcontinue to multiply causing more harm.Why should I be concerned about antibiotic resistance?Antibiotic resistance has been called one of the world's mostpressing public health problems. Almost every type of bacteria hasbecome stronger and less responsive to antibiotic treatment whenit is really needed.A common misconception is that a person's body becomesresistant to specific drugs. However, it is bacteria and othermicrobes, not people, that become resistant to the drugs. If abacteria is resistant to many drugs, treating the infections itcauses can become difficult or even impossible. And theseantibiotic-resistant bacteria can quickly spread from person toperson – in this way a hard-to-treat illness can be spread throughthe community.Antibiotic resistance can also mean that children and adults whohave common infections, once easily treatable with antibiotics,can no longer be treated.We read out this explanation ofresistance in the groups, and it wasoften a watershed moment, themoment when a general sense ofresistance being irrelevant/ not reallyworth worrying about switched togenuine worry and concern.But we often had to read it severaltimes and discuss it with people beforethey understood it – it’s difficult forthem to get their head around andmany never quite get there – theyrevert to the person becomingresistant five minutes later…20


And some then struggle with what they personally can reallydo about itVery few people self-identify as someone who badgers their GP for antibiotics, most thinkthey only use them when they need them. And some then find the actions they personallycan take to help address resistance – taking antibiotics as prescribed and general bacteriacontrol/ hygiene – feel a bit ‘limp’I still think I’d take my antibiotics, itis still the last resort. This doesn’tchange that. I will still fight mybattle for my son. Maybe I’d thinktwice now, but if I’m honest I’dprobably still want antibiotics.F, 40-60, no education past 16 years old,ManchesterI don’t think there is anything we can do. It issomething people should be made more aware of,but as one person it is limited in what they can do.F, 33, pre-family, university, PolishThere’s nothing I can do about it, is there?What can I do except worry about it?M, 40-60, C2DE, Birmingham[Anything you can do?] Not really.Stay healthy, keep hands clean, useanti-bac gel.F, 40-60, left school at 18, LondonWhat’s the point inbringing this topeople’s attention ifthey can’t fix it.F, 40-60, C2DE, LondonBecause we don’t abuse themthere’s not much we can do.M/F, 30-40, first time parent,university educated, LondonI don’t feel any personalresponsibility as I don’t overusethem. GPs are accountable, drugcompanies are accountable. Ithink the government ultimatelyhas to take control. The publicaren’t really to blame, people arevery reliant on the doctor now, sothe doctor is responsible.F, 40-60, no education past 16 yearsold, Manchester21


Findings1. People’s relationship with antibiotics2. Current knowledge and understanding of AMR and resistance3. Reactions to different ‘ways in’ of talking about resistance4. Current language and how it is understood22


The big figures around financial cost or number of lives losthave minimal impact – they’re meaningless to peopleHuge numbers ofpredicted deathsStill don’t think it’llhappen to you.F, 40-60, C2DE, LondonI don’t believe it. That’s a lot of people, just frombacteria. There’s been a health boom in our society.That sounds dramatic.M/F, 18-25, at university, LondonDrug-resistant infectionscould lead to 10 million extradeaths a year globallyResistance to antimicrobial drugsalready causes an estimated700,000 global deaths annuallyImpossible to grasp ormake real; feels foreignDoesn’t humanise it. Youcan’t even imagine thatmany people. It distancesyou from the problem.M/F, 18-25, not universityeducated, LondonThat’s globally. It’shuge numbers but notin the UK. Think it’s abit misleading.F, 40-60, C2DE, LondonWhere do they getthese numbersfrom?M/F, 18-25, atuniversity, LondonIncredible cost to theworld economyDrug-resistant infectionscould cost the globaleconomy $100 trillion by2050Antibiotic resistance is a seriousthreat, one that could cost theEuropean economy $15 trillionby 2050Impossible to grasp ormake real; feels foreignDoesn’t ring home to me. That sort ofnumber, you can’t quantify it in yourhead. Seems like a silly number.M/F, 18-25, at university, LondonWhat does it mean on a personal level,what does it mean to each of us and ourfamilies.M/F, 18-25, at university, LondonIt’s not true. The numbers are so bigit just seems ridiculous. How manynoughts on the end of a trillion?M, 40-60, C2DE, BirminghamWhat’s a million? And what’s a dollar?It’s not in pounds and it’s more moneythan I’m ever going to have.M/F, 25-50, Mixed, London24


The analogy to climate change is equally ineffectual andsuperbugs doesn’t fare much better, though chimes with a fewAs big a threat asclimate changeClimate change was a massive thing ages ago.Even though it’s still happening now youforget about it. You don’t really care.M/F, 18-25, not university educated, LondonTotally irrelevant. It hasn’tbeen going on for yonks andyonks.M, 25-39, AB, LondonAntibiotic resistance more ofa threat to world thanclimate changeAMR and climate change:two global problems only set toget bigger in the futureNo impact – because most havedismissed climate changeI wouldn’t link it with anythingthat isn’t medical.M, 40-60, C2DE, BirminghamNo matter how long it takes, we won’t be there.M/F, 18-25, not university educated, BirminghamSuperbugs can’t betreated with antibioticsUse of antibiotics helping tocreate new drug-resistantsuperbugsFatal superbugs:Antibiotics losingeffectivenessMany connect to Ebola/ swine fluwhich they dismiss, hard to ‘get’Not really phased by it. Ebola didn’t really affect meor many people in London, so I’d think it won’thappen to me anyway.M/F, 18-25, not university educated, LondonQuite worrying but doesn’t have any personal storyin it so I don’t really connect myself with it. Think I’mnot going to get it.M/F, 18-25, not university educated, LondonI think of superbugs asswine flu and things.F, 25-39, AB, BirminghamMakes me think ofsomething we have tofight.F, 25-39, AB, Birmingham25


It’s only when we get into the detail of the individual‘superbugs’ that people really stand to attentionStaphylococcus aureus (MRSA)Illness caused: pneumonia,and other infectionsClostridium difficileNeisseria gonorrhoeaeIllness caused:gonorrhoeaEscherichia coli (E.coli)People have heard of most of these bugs,and can imagine them/ someone theyknow getting one of them, so they make itall feel realIt makes a difference. Superbugs is a blanket termthat doesn’t really enter my head, swine flu etc. ButE. Coli, it could affect you.F, 40-60, C2DE, LondonIllness caused: diarrhoeaAcinetobacter baumanniiIllness caused: severefood poisoningStreptococcus pyogenesThe sore throat one, I don’t want itfor the rest of my life. Superbugs,they’ll never happen to me, butthese are quite common so theyhit home a bit more.M/F, 18-25, at university, LondonMRSA is really big inhospitals. Gonorrhoea isgoing around youngpeople. It makes you think.M/ F, 18-25, at university,LondonIllness caused: Urinary TractInfection, skin or woundinfection, meningitisIllness caused: sorethroat, skin disordersWould be awful for UTIs. Antibiotics are theonly thing that works.M/F, 18-25, not university educated, London27


When we compare the impact of all the ‘ways in’ we see aclear and consistent picture100%90%80%70%60%50%40%30%20%10%0%Actual bugsRegularsurgeryNegativeside effectsMinorailmentsSuperbugs Deaths ClimatechangeEconomyDoesn't work Indifferent Works28


And this was reinforced by reactions we saw when weshowed people recent newspaper headlinesIt creates public fear. Terms like ‘superbug’and ‘superflu’, they’re there to induceconcern in the public. It’s a bit too much,we’re becoming desensitised to it.M/F, 18-25, at university, LondonThe media are negative about everything.It’s always the worst case scenario. Birdflu, then SARS, they’re going to kill us all.M, 25-39, AB, LondonIt’s scaremongering. Where do theypluck the numbers from? All a bit vague.Where have they got 80,000 from?M/F, 25-50, Mixed, Birmingham29


It’s only when it feels direct, personal and relevant thatpeople take noteMy worldOur worldThe worldIf resistance feels part of myworld (me/ my family) or toa lesser extent our world (mycommunity) it starts tomatterWhen it feels like a ‘theworld’ issue it just doesn’thit homeIf you walk around blind toeverything big it’s the best way.M/F, 25-50, Mixed, Birmingham30


Findings1. People’s relationship with antibiotics2. Current knowledge and understanding of AMR and resistance3. Reactions to different ‘ways in’ of talking about resistance4. Current language and how it is understood31


‘Antibiotic resistance’ is not a term that people instantlyunderstandIt doesn’t take people to the right place, and it doesn’t help overcome misconceptionsIssues with the termDoesn’t suggest thebacteria are becomingresistantDoesn’t make intuitivesense to peopleDoesn’t sound that badto peopleResistance. We knew what the word meantbut we didn’t understand what it wasresisting. It’s a bit of a flip flop term as youthink of resisting a bug as being good.F, 25-39, AB, BirminghamResistance makes it sound like there’s still a chance itmight work, it’s not completely hopeless. Whereasyou’re saying eventually it might become completelyhopeless, so think that needs to be drummed home.M/F, 25-50, Mixed, London32


‘Superbugs’ has lost its impact, and there is a generalreaction against ‘sensationalist’ languageWords become meaningless and people tend to ‘glaze over’ very easily; simple, plain language ispreferred, the challenge then is cut throughKey challenges with languageSuperbugs feelsabstract/ dated/confusing‘Panic’ and shock putspeople offMaking it relatable iscrucialTrying to scare with ‘superbug’.I’d think, oh another thing weneed to look out for.M/F, 18-25, at university, LondonI wish they’d just say‘worrying’. It’s not sosensationalist.F, 40-60, C2DE, LondonSay one in whatever gets this.For cancer it works well.M/F, 18-25, not university educated,BirminghamI always think of super as a good thing. Mychild would be thrilled if he had a ‘super’ bug.F, 25-39, AB, BirminghamUse simple language. Don’t talk in billions ortrillion or superbugs. We’ve heard it all before.M/F, 25-50, Mixed, London33


Language that focuses on the bacteria (or the illness?) andthe implications may have more impact with peopleBacteria / illnessMakes it real and helpsget over the ‘personbecoming resistant’ issueAntibacterial resistant illnessesM,40-60, C2DE, Birmingham(Written reply to question ‘ how would you explainit’ at end of session)‘Stronger’Drugs/ medicinedon’t workThinking about bacteriabecoming stronger makesintuitive sense to peopleThe idea of medicine ‘notworking’ hits home withpeopleYou could die from E. Coli that’s resistantto antibioticsM, 25-39, AB, London(Written reply to question ‘ how would you explainit’ at end of session)Got to use plain language – the bacteriathat is going around is getting stronger.M, 40-60, C2DE, BirminghamAntibiotics work no moreM/F, 18-25, not university educated,Birmingham(Written reply to question ‘ how would youexplain it’ at end of session)34


SUMMARY OF KEY INSIGHTS35


Summary of key insights1Getting antibiotics means you’ve got a ‘real’ illness – it’s ‘proof’ you’re ill23Antibiotics make you better, and mean the trip to the doctor was ‘worth it’ – so many seethem as the ‘perfect solution’ and will take them without hesitationSome are more reluctant – this often stems from understanding the impact they have onyour body (‘good bacteria’) and/or preferring ‘natural’ options4AMR means nothing to people and resistance is only on the radar of a few5The concept is very hard to grasp – and nearly everyone assumes it’s the person not thebacteria becoming resistant – though when it’s understood it has impact67Making it feel relevant and real and part of ‘my world’ is vital, and the ‘ways in’ mostregularly used (cost/ deaths) do not achieve this; specific bugs have more impactThe language of ‘antibiotic resistance’ and ‘superbugs’ doesn’t help – the challenge is tofind simple, clear language that focuses on illness and implications


WHAT WE LEARNT FROM DOCTORS37


Before starting the groups, we completed our interviewswith GPsGPs: one hour telephone interview with GPs across the UKDate Location Size of practice Patient population Status05/02/15 South Wales (urban) Small (4,000 patients) Largely elderly and workingclass.05/02/15 Birmingham (urban) Medium (6,000 patients) Largely poor or deprivedsocial backgrounds. Largeimmigrant population.05/02/15 London (suburban) Large (7,000 patients) Mixed – immigrant, elderly,poor or deprived andaffluent.11/02/15 South West (rural) Large (11,000 patients) Mixed – affluent anddeprived.12/02/15 Scotland (urban) Large (7,000 patients) Largely elderly, from largelypoor or deprivedbackgrounds.CompleteCompleteCompleteCompleteComplete17/02/15 North East (suburban) Large Poor and deprived Complete38


The doctors gave us another perspective on the doctorpatientinteraction at the time of appointmentDiscussions around antibiotics are a dominant theme indoctors’ surgeriesAntibiotics come up often during appointmentsUnderstanding of what they’re used for and howthey work is lowIt can be hard to say no – some patients are fixed on gettingthemThere tend to be some that insist – often those thatare acting on behalf of someone elsePeople want them because they offer ‘validation’that they’re illSide effects don’t come up that oftenPrevious experience is a really important factorPerception that many don’t always finish thecoursePerception that some think the reason the doctor isnot prescribing them is to cut costA third will expect antibiotics […] some will needthem and some I try to convince that it’s a viralinfection, but if they insist then we just give them.Large, suburban, LondonThe biggest factor is whether they receivedantibiotics last time for the same thing. They arethe hardest to convince.Medium, urban, South West39


And across the course of the interviews, differences inapproach emergedWithin surgeries, some doctors are more willing to prescribe than others, and patients know thisSome practices are part of local initiatives, while others have addressed prescribing rates themselvesWhile some GPs are keen for any help they can get, others think they’ve ‘nailed it’Part of a prescribing initiative from the old PCT NICE strategy and PHE. Weshared best practice within the city and signed up to a scheme results wereaudited on a quarterly basis. The act of auditing switched our attention.Medium, urban, Birmingham[What would be most helpful?]An increase in general awareness of antibioticresistance. Public health education.Small, urban, South WalesWe don’t need anything because we have itnailed. We’re one of the lowest prescribingsurgeries, we get quarterly figures.Large, urban, Scotland40


A FEW THOUGHTS ON IMPLICATIONS41


The findings of the research do seem to have some relativelyfar-reaching implicationsAs we reflect on what we’ve learnt, the following four things stand out1The current language needs to change – AMR is meaningless and ‘antibiotic resistance’does not take people to the right place2The focus of the resistance ‘story’ for the general public needs to shift away from macrofactors such as number of deaths, cost to the economy and epidemics/ pandemics3There is a need for a communications campaign for the public which makes the issuefeel real and relevant, so that the tide of opinion is behind taking action4Doctors (and dentists) are key – while more research may be needed it appears there isa need for a behaviour change programme for doctors which provides clear guidelinesand targets around when to prescribe antibiotics, and advice on how to manage patients42


1The current language needs to change – AMR is meaningless and ‘antibiotic resistance’does not take people to the right place• The chasm between current public awareness and understanding and the term‘AMR’, or ‘anti-microbial resistance’ too big to close• ‘Antibiotic resistance’ should not replace it as the short-hand as it doesn’t helppeople understand the issue or make intuitive sense to people• One simple option, which would make a difference, is to add ‘infection’ (or‘bacteria’) to ‘antibiotic resistance’ this would help, particularly in combinationwith a broader awareness campaignFROM‐ AMR‐ ANTIMICROBIAL RESISTANCE‐ ANTIBIOTIC RESISTANCETO‐ ANTIBIOTIC RESISTANTINFECTIONS43


2The focus of the resistance ‘story’ for the general public needs to shift away from macrofactors such as number of deaths, cost to the economy and epidemics/pandemics• At the moment, people ‘blank out’ most of the headline stories about resistance -they feel sensationalist, lack personal relevance, and are often set in the future• The challenge is to drive immediacy and bring resistance into ‘my world’• The best ‘ways in’ are those that make people feel ‘this could happen to me’• Driving understanding of the impact taking antibiotics has on your ‘good bacteria’may have a part to play too – it doesn’t get to resistance but does give people a‘real’ reason not to take too many of themFROMTO‐ GLOBAL ECONOMY‐ TOTAL NUMBER OF DEATHS‐ FUTURE DATES - ‘BY 2020’‐ RISK OF EPIDEMICS ANDPANDEMICS‐ SPECIFIC, RECONGISABLE & FAMILIARBUGS AND THE ILLNESSES THEY CAUSE‐ HOW IT MIGHT AFFECT A COMMONSURGERY, EXPLAINING THE ROLEANTIBIOTICS PLAY‐ THE IMPACT ANTIBIOTICS HAVE ONYOUR GUT AND ‘GOOD BACTERIA’44


3There is a need for a communications campaign for the public which makes the issuefeel real and relevant, so that the tide of opinion is behind taking action• The more resistance is on people’s radar and understood, the more momentum willbuild for action from all stakeholders – from doctors to government to pharmacompanies to international bodies• This can also help ease the ‘prescription conversation’ in the doctor’s surgery andincrease the extent to which people take antibiotics as prescribed• It does feel more like communications than behaviour change though – as while thepublic clearly have a role to play, the actions they can take are relatively limitedILLUSTRATIVE CAMPAIGN GOALS‐ Help people grasp the (complicated) concept of resistance‐ Take on the person/bacteria misconception directly‐ Get people to realise you can be really ill and not need antibiotics‐ Make them feel that everyone else will understand that‐ Help people understand the personal negative implications of takingantibiotics45


4Doctors (and dentists) are key – while more research may be needed it appears there isa need for a behaviour change programme for doctors which provides clear guidelinesand targets around when to prescribe antibiotics, and advice on how to manage patients• Our research focused primarily on the public, not doctors, but the interviews we didwith them makes it clear they need help and guidance• And they are at the ‘coal face’ of the issue – and this is something people bring up,running campaigns for doctors and the public would make sense for people and thetwo would be mutually reinforcing• For doctors, it is a clear behaviour change challenge – there are a number of actionsthat need to be taken, the frame of behaviour needs to be resetThis is supported by a reportrecently published by Public HealthEngland and the Department ofHealth: ‘Behaviour change andantibiotic prescribing in healthcaresettings Literature review andbehavioural analysis’ (Feb 2015):Considerable opportunities are apparent from the analysis of the public and patientaspects. Building awareness is likely the first step in addressing the public’s behaviour. Thistype of work lends itself more to social marketing based approaches than perhapsbehavioural science. The costs of any campaign are likely to be significant. The picture toemerge from primary care is more promising. The healthcare environment offers a rangeof opportunities to intervene in workflows and with professionals. The high rate ofprescribing and ability to collect meaningful behavioural outcomes is attractive insofar astrials of the interventions might be feasible.46

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