Tackling AMR through behaviour change: a cross-disciplinary and multi-professional research collaboration

This month’s guest blog reports on the programme of social science and interdisciplinary research that is being carried out within the UK’s three NIHR-funded Health Protection Research Units that focus on Hospital-Acquired Infections and Antimicrobial Resistance. Raheelah Ahmad and Sarah Tonkin-Crine’s report into their annual joint meeting gives a flavour of the wide range of interesting and important work on AMR being undertaken in, or associated with, UK NHS and public health settings. The value of synergies generated by expanding cross-disciplinary collaboration in AMR and HCAI research was evident at the meeting and the report describes a number of interesting issues and opportunities for further research.

by Raheelah Ahmad & Sarah Tonkin-Crine

At the end of last year the NIHR Health Protection Research Units for Antimicrobial Resistance (AMR) and Healthcare Associated Infections (it’s a mouthful), convened for the annual meet, to exchange new investigative approaches, share findings and ensure synergies and collaboration in behavioural research. Professors Alison Holmes (Imperial) and Sarah Walker (Oxford) co-chaired.

Liberally plied with watermelon, sandwiches and hot beverages, researchers from Imperial, Oxford, UCL, Bristol and Public Health England (PHE) grappled and debated what more? what next?  as well as who?  We did our best to refrain from the usual finger pointing (at the different professional groups and different sections of the public); so less of the ‘who dunnit?’ and ‘who should fix it?’ to more ‘how can we fix this together?’ The participant list boasted a healthy smattering of social scientists, behavioural economists, epidemiologists, sociologists and those from cross-disciplinary management sciences. Professionally, GPs, Infectious Disease (ID) consultants, pharmacists, nurses, and microbiologists were around the table.

Following on from the first meeting in November 2015, Sarah Walker kicked off with an update of progress on collaborative projects. Sarah Tonkin-Crine and Annegret Schneider, both Health Psychologists, co-presented findings from a mixed method process evaluation of the latest AMR trial from PHE. Two talks focused on patient/professional communication: Tim Rawson (ID junior doctor and BRC Fellow) reported on his qualitative study to help shape enhanced communication resources and methods in the acute hospital setting; Donna Lecky (PHE) shared learning on the development  of TARGET patient leaflets for urinary tract infections in the GP setting during consultations to change prescribing expectations and behaviour. At the population level, findings on public attitudes to antibiotic use and resistance and implications for national level interventions were the theme of talks from Larry Roope (economist) and Tim Chadborn (Behavioural Insights Lead at PHE). From an international perspective Annegret Schneider gave a whistle stop tour on use of behavioural theories to develop interventions in the context of China. Alastair Hay (GP) provided insights from intervention development targeting GPs and parents to manage children with respiratory tract infections. For capturing the multiple policies implemented in the primary care setting, Raheelah Ahmad (NIHR Knowledge Mobilisation Fellow) used an organisational behaviour and strategic management lens to show the potential of System Dynamics to model knowledge mobilisation activities.

Alison Holmes chaired the afternoon in-depth discussion and Esmita Charani (Research Pharmacist) scribed the action points for the year ahead. The need for capturing evaluation and learning when new national level campaigns are rolled out was reiterated. The group reflected upon the opportunities for interventions aimed at different stakeholders before, during and after consultations within organised healthcare. How to optimise opportunities along the life-course as the public traverse in and out of the ‘patient’ role were also discussed.

The day was eloquently bought to a close with a frank and helpful talk from Helen Lambert. Helen encouraged recognition and use of the full breadth of social science disciplines and also drew on her international experiences. We had certainly exposed ourselves to new ideas, reflected and challenged our own logic models. In addition, as researchers and many as health professionals, we reminded ourselves of the need for reflexivity.

Posted in Uncategorized | Tagged , , , | Leave a comment

Anti-microbial resistance and citizen science

This month the AMR Research Champion blog hosts a piece on the role of citizen science in AMR by an Oxford research team who have been exploring microbes in English kitchens. Their work is illustrated in a short film: Good Germs; Bad Germs. What 14 households in Oxford tell us about public understandings of the microbiome has yet to be seen, but check out our guest writers’ reflections on creating a citizen science project below and their valuable tips on what anyone planning participatory research on AMR needs to consider.

by Timothy Hodgetts, Jamie Lorimer, Richard Grenyer and Beth Greenhough

Citizen science projects have grown in number and ambition over recent years. In part that growth has been made possible by online networks that make it easier to contact and communicate with large groups of interested people. But there has also been a notable shift in the politics of science. The shift has happened through two forms of opening.

First, there has been an opening-up of laboratories from the inside. This movement starts from within scientific laboratories and moves towards an outside of concerned publics. The outward shift has been variously motivated: education for its own sake, a desire to ‘get people excited about science’ and to make an ‘impact’, a concern around communicating the uncertainty inherent in (most) scientific outputs, a recognition by funders that public funding requires public support, and an understanding that scientific futures require inspired apprentices. Furthermore, there has been a realisation amongst some practitioners that taking certain (but by no means all) forms of science out of the laboratory can lead to better science. Such research is ‘better’ in the sense that results are more accurate, or more reflective of the ‘real-world’ situations that they seek to inform.

Second, there has been opening-up of laboratories from the outside. This move is slightly different. It rests on the political claim that ‘better science’ involves the inclusion of interested publics from the earliest stages of scientific endeavour. Not only because including non-scientists might make the resulting research more robust, by voicing the contingencies of real-world situations that laboratory scientists might overlook. But also because the early stages of research are inherently political. There is always a politics involved in deciding what questions get asked, and what kinds of answers are deemed admissible. Excluding publics from this process amounts to an elitist exercise of undemocratic power. Including non-scientists in the early stages of research allows participation in setting the agenda, direction, and means of scientific practices. Such democratization is valuable in itself, but is also desirable if it makes the outputs of research (and their assumptions, caveats, and uncertainties) more translatable and palatable to a sceptical public.

Of course, none of this is new. These various opening-up movements have been occurring for many years now, albeit to differing extents depending on the context. These forms of participation seem particularly relevant for contemporary research into anti-microbial resistance (AMR), given the intersection of scientific and social uncertainties that characterize current concerns around public health. But the question of how to facilitate these trends – for more accurate and grounded research, and for more democratic and participatory public science – in the context of AMR is pressing and not (as yet) fully answered. Incorporating citizens simply as data gatherers is less complicated. Indeed, some projects have already been designed and enacted on these lines, although there are some real and not inconsequential ethical issues involved in so doing (as we will discuss more below). But incorporating citizens as scientists, who are involved in formulating the aims and objectives of research, in designing research interventions, and in evaluating their outcomes poses greater challenges. After all, microbiology can be complicated. The methods involved can be difficult to understand, the tools require specialist knowledge, and interpreting results can be an exercise in navigating ambiguity.

How then to facilitate a participatory form of research into contemporary anti-microbial resistance? Drawing on our current work in participatory microbiology, we suggest there are three key issues that need to be addressed:

(1) Mapping multiple understandings. Public understandings of microbiology differ. People in the UK have been educated in different eras of scientific knowledge, and to different levels of detail. Popular media have a tendency towards alarmist, and often contradictory, messages. Microbes, bacteria, and germs carry differing meanings for people and shape public practices in various ways. Horizontal Gene Transfer doesn’t get much airtime, or perhaps as much as it deserves. Future participatory research into AMR needs to take account of this heterogeneous context without simply seeking to ‘educate’ participants.

(2) Democratising methods. Democratising scientific practice requires involving public participants ‘upstream’, in question-setting and methodological design, not simply in collecting data. Microbiology tends to rely on specialized methods that assume significant pre-existing knowledge. The onus here thus falls on microbiologists and their academic co-investigators, to reflect critically on their methods and communicate the capabilities of these methods to participants. The co-production of research (assumed in democratized forms of science) relies on both publics and scientists to work together in order to make sense of experimental possibilities.

(3) Engaging with ethical challenges. Researching anti-microbial resistance through participatory methods poses some significant ethical challenges. The most pressing relate to the implications of emphasizing to public participants the extremity of the threat posed by resistant pathogens in particular circumstances; combined with the ambiguous state of knowledge around the social and ecological factors that generate AMR. The message: this is very scary, and we don’t know how to fix it (yet). There is a very real risk that in seeking to develop participatory forms of science, researchers may inculcate significant and health-altering fears and anxieties in participating publics; and not even have the prospect of a ready ‘solution’ to serve as antidote. In part, these concerns can be addressed by strict protocols that exclude at-risk participants with relevant health histories. They also need to be addressed through managing the narrative of scientists and the tools made available to publics. Researchers must therefore tread a line between the lofty goals of democratic science articulated above, and the grounded reality of avoiding harm to participants; and the latter concern must always come first in this form of research.

In our current research, we have had to navigate all three of these issues. Rather than AMR, our project revolves around public understandings of the microbiome – both the ‘good’ and ‘bad’ bacteria found in the human built environment (and inside humans). Working with 14 households in Oxford, we have been piloting a form of ‘participatory metagenomics’ in order to help people explore the microbial communities of their kitchens. We enable our participants to use cutting-edge microbiological tools, and to design their own experiments. We work together to make sense of the methodological possibilities, and to interpret the results. There are, of course, all manner of subtle and hidden power dynamics that structure this co-production. Our scientists retain a position of knowledge with respect to the dark arts of metagenomic sequencing. Our social scientists have a not inconsequential hand in steering the group’s overall direction. We have had to navigate different levels of formal microbiological education amongst the group, whilst making space for diverse forms of practical knowledge, experience and beliefs. We have deliberately avoided using microbiological tools that can identify specific pathogens (despite the call for their inclusion from some of our participants) in order to avoid unnecessary anxieties and to focus the discussion on wider microbial ecologies. We thus continually tread the lines between science-education and multiple knowledges, and between science-democratization and the avoidance of harm.

We think participatory forms of science of the kind outlined here have much to offer the AMR research agenda. Instrumentally, we suggest they might lead to ‘better’ research: more applicable to the challenges faced by people in their everyday lives. Ethically, we suggest they may lead to more inclusive forms of public science that work to dissipate the contemporary distrust of ‘experts’. Economically, we suggest that such methods therefore represent excellent value for money. We hope that the guidelines above might aid researchers embarking on this route.

You can read more about our project, and watch a short introductory film, at www.goodgerms.org. We have drawn on a wide-range of work in the argument above, but key resources include:

Callon M, Lascoumes P & Barthe Y 2009. Acting in an uncertain world: An essay on technical democracy, Cambridge, Mass., MIT Press.

Whatmore, S 2009. Mapping knowledge controversies: science, democracy and the redistribution of expertise. Progress in Human Geography, 33, 587-598.

Posted in Uncategorized | Tagged , , , | Leave a comment

The rhetoric of resistance

by Helen Lambert

In the run up to the UN Global Assembly’s high-level meeting on antimicrobial resistance (21st September 2016), lobbying by European policymakers is stepping up a gear. The meeting is seen as a unique opportunity to make a concrete impact on measures to stem the rise of drug-resistant infections at global level.  The WHO has been ratcheting up efforts to push AMR up the global health agenda  and the UK’s Chief Medical Officer Dame Sally Davies has been a key player in turning what has been a significant concern among infectious disease experts for nearly two decades into a high visibility political issue. The Wellcome Trust has published a report with policy recommendations to tackle ‘drug-resistant infections’ from the ‘high level’ international summit it held earlier this year and has launched a public petition that focuses concern on the use of antibiotics in animals.  And news media have widely circulated the words of commentators including the UK’s former Prime Minister threatening ‘a return to the dark ages’ or an ‘antibiotic apocalypse’.

In Europe a clear consensus is developing, based on northern European experiences of attempting to limit antibiotic use.  Last week a major European public health organisation devoted its annual meeting to the issue of AMR. A favoured tool was a map that highlights in stark red and blue the contrasts between countries where antibiotic use is declining or stable (Scandinavia and several other northern European countries) and those (parts of southern Europe and huge swathes across the low and middle-income countries of Africa, Asia and South America) where antibiotic consumption is ‘still’ increasing.  The audience was told that ‘high’ standards found in the ‘good’ (blue) countries need to ‘set the bar’, or ‘lead the way’, for the ‘bad’ (red) countries. Ministers of Health and heads of influential organisations described the steps their countries and professional associations (of pharmacists, nurses, clinicians and microbiologists) are already taking to combat AMR.  Bar charts and diagrams showing worrying levels of ‘irrational’ antibiotic use in countries outside northern Europe were used to demonstrate the ‘threat’ of AMR that, as we were reminded, does not respect national borders. Some speakers described the ‘excess’ antibiotic use and ‘lack’ of microbiological testing found in many poorly resourced countries in the kind of indignant tones usually reserved for the most deeply irresponsible, even wilfully negligent, behaviour.

What seems to be happening is that the widespread consensus on the need for concerted action is being treated as though we already know what kinds of action will be effective and what will be acceptable to policymakers worldwide. Is the direction in which the proposed interventions take us the right one for our shared future health and wellbeing? And is the language of threat and misdemeanour the best way to get everyone on board? Three issues are worth considering: equity, awareness-raising, and context-appropriateness. And in all of these, language is crucial.

First and most obviously, the use of oppositional language by Europeans – high vs low, good vs bad, even red vs blue – is unhelpful for galvanising collective action when low and middle-income countries are continually placed on the negative side of the divide.  If nothing else, the politics of diplomacy should alert those seeking to create global consensus to the dangers of this kind of language. Portraying resource-poor countries as failing to take seriously the threat of AMR, or as being negligent in, for example, not prohibiting over-the-counter sales of antibiotics, is not only stigmatising; it is inaccurate.

In Europe, a generic focus on the need to reduce antibiotic use makes sense. Jim O’Neill’s comment (accurate or not) that people take antibiotics ‘like sweets’ was a media-friendly soundbite that drew attention to the problem of expectations in many high-income countries where antibiotics have long been prescribed routinely. But the assumption that widespread antibiotic use automatically indicates overuse is unwarranted.  India is the largest consumer of antibiotics for human health in the world; but fewer antibiotics are used per capita than in the UK, despite the fact that levels of morbidity and mortality from common bacterial infections are several magnitudes greater. One estimate puts the number of childhood deaths from pneumonia that would be averted by having prompt access to antibiotics in India alone at almost 170,000 a year.

In such circumstances, rising levels of antibiotic consumption may well be a good thing.  Even in the UK, while more antibiotics overall are prescribed in poorer areas of the country (as we should expect, given the greater burden of disease among the poor), fewer antibiotics are prescribed per consultation than in wealthier areas.  This suggests that GPs are limiting prescribing more in poorer than in wealthier areas. And the most plausible explanation for this is simply that, like all other forms of health care, better educated and more articulate patients are more likely to gain access to limited health care resources than poorer and less articulate ones (aka the ‘inverse care law’) – regardless of what is or isn’t wrong with them.  The pleasant consensus that unthinkingly translates ‘appropriate’ use into ‘restricting availability of antibiotics’ conceals the potential for real harm to the poorest and least powerful sections of every country upon whom generic restrictions will have the greatest impact.

To put it another way, equity is central to decision-making about which policies and measures will really contain AMR effectively – but this issue too is effectively masked by what is fast becoming an empty alliterative slogan, ‘excess versus access’.  In reality, the tension between these two poles will only be resolved by addressing the difficult, mundane, long-term problems of poorly resourced health systems that mean access to high quality clinical care and diagnostics is limited to a wealthy minority (and often, in the competitive private medical markets that characterise much of the developing world and lead to overprescribing, unnecessary testing and overdiagnosis, not even them).  There is, as yet, little evidence on which interventions will really be most effective in limiting AMR prevalence; given the extremely complex ways that environment, human and animal health are interlinked in the development and circulation of AMR, perhaps there never will be. But old-fashioned public health measures – better sanitation, clean water and childhood vaccination to prevent infections – and improved health systems that would bring quality primary health care and efficient referral mechanisms within reach to the bulk of the global population, hold at least as much promise as high-tech solutions of rapid diagnostic testing and new drug discovery mechanisms.  Yet pharmaceutical ‘innovation’ has consistently captured far more attention in both research and media forums than these relatively low-cost mechanisms for prevention.

When it comes to public awareness, too, the repeated claims that too many antibiotics are prescribed because of patients’ ‘irrational demands’ stigmatises the public. Within the AMR research community it goes without saying that ‘irrational’ is a technical term that refers to the use of antibiotics without microbiological or (in some versions) adequate clinical indication.  But in ordinary language, ‘irrational’ is a pejorative word that suggests lack of judgement, understanding or intelligence.  One of the policy components that WHO and various European countries are seeking to have adopted at the UNGA is that of ‘raising public awareness’. The rationale for this rests on two related assumptions. The first is that doctors prescribe antibiotics because of ‘irrational demand’ from patients – a canard that continues to be propagated in policy and media circles despite a wealth of research evidence showing that the problem is mostly to do with poor doctor-patient communication and the need for clinicians to avoid risk by prescribing ‘just in case’.  The second is that consumer pressure will help reduce prescribing by getting patients to refuse antibiotic prescriptions when they are not essential.  There may be some grounds for ‘public awareness’ campaigns in high income countries to generate such pressure, although the success of such campaigns in the past has been mixed. But the ‘public awareness’ component of proposed measures to contain AMR worldwide completely disregards the fundamental requirement for strategies to be context-appropriate if they are to be effective.  Under any circumstances, the notion of antibiotics as a generic class (spanning some types of pharmaceuticals but not others across a multitude of brand names and generics) is a complex one to grasp. The demand for campaigns to ‘raise public awareness’ or ‘educate the public’ about antibiotics skates over the risks of disseminating simplistic messages in low-literacy environments where access to antibiotics is already limited. At best, such messages are likely to cause misunderstandings and at worst, they may lead people who genuinely need antibiotics to avoid or refuse them. 

As it is, a worried mother seeking help for her ailing baby who is recommended to buy two capsules at the medicine shop, after finding the nearest rural health post locked up (again) because the health worker has not turned up, is not acting irrationally when she uses scarce cash to buy that precious medicine. What other choice does she have?

Posted in Uncategorized | Tagged , , , | Leave a comment

What can Leonardo Da Vinci teach us about tackling drug resistant infections?

by Christie Cabral and Helen Lambert

Anti-microbial resistance (AMR) is a ‘wicked problem’ leading to drug resistant infections.  The evidence is incomplete or contradictory, there are many different interest groups with different needs and views, and the ‘solution’ depends on how the ‘problem’ is framed and vice versa.  Like other ‘wicked problems’ (e.g. climate change, species conservation, pandemic influenza) that result from the complex interaction of a huge range of influences, there is no single, simple solution and so our response needs to be multifaceted.

LeonardoLeonardo Da Vinci, one of the best known polymaths, excelled in different artistic and scientific fields long before we had separated these activities out into the numerous disciplines we have today.  This boundary-crossing approach is what is called for by the Cross-Council Initiative to tackle antimicrobial resistance.

Inter-disciplinary research is often under-funded and poorly regarded but it is essential “to solve the grand challenges facing society”.  The Cross-Council Initiative is a rare call for everyone from Artists to Veterinary Scientists to work together on the problem of AMR.

 

So far, a lot of attention has focussed on possible technological solutions (such as new antibiotics and rapid diagnostic tests), but key work by the O’Neill Review team has rightly highlighted the importance of understanding economic processes.  These underline the ‘wicked’ nature of this problem, as the needs and views of stakeholders are not aligned.  Pharma companies want to maximise profits, but governments want to restrict the use of new antibiotics to preserve their effectiveness – so the pharmaceutical industry cannot recoup the costs of developing them through sales. The O’Neill Review recommends other financial mechanisms to encourage the pharmaceutical industry to develop new drugs that can be reserved for use when current ‘last resort’ antibiotics become ineffective.

But improving the likelihood of future technological innovations can only ever be part of a solution. When, how and why people use existing antibiotics unnecessarily – for themselves or their animals – are problems that can’t be tackled through drug or diagnostics development.  For many people around the world, especially in lower and middle income countries, the problem is not so much too many antibiotics as insufficient access to them.  The tension between access and excess is another dimension of the ‘wickedness’ of the problem; seemingly obvious solutions, like banning over-the-counter antibiotics sales in low-income countries, risk denying essential life-saving drugs to the poor, who lack easy access to decent medical care where they can be prescribed appropriate antibiotics when needed. Here social science is needed to understand the complexities of human behaviour and the cultural, social, institutional and political forces that shape it, as well as individual psychology. This way we can gain insights into ways to ensure that people get access to these life-saving drugs when they need them, while not using them unnecessarily so that infections become resistant to them.

The ESRC-led Theme 4 of the Cross-Council Initiative is entitled ‘Behaviour within and beyond the health care setting’.  As we saw at our recent Social Science and AMR workshop (#amrchamp), potentially relevant research covers a broad range of topics.  When social scientists get together, some interesting questions get asked: what types of drug resistance are a problem, in which contexts and for whom?  Issues of justice and future security are highlighted by international relations researchers looking at the unequal balance between access to antibiotics and the development of drug resistant infections across the globe.  Geographers, sociologists, environmental and veterinary scientists are looking at how our environments are entangled and the poorly understood microbiological pathways and social networks by which resistance is spread, without which we cannot know which ‘human and animal behaviours’ it might be sensible to target.  Artists and engineers are exploring how to design infection control into our world and how to communicate important messages to the wider community.

We come back to the ‘wicked’ nature of the issue.  The way the ‘problem’ is framed is important to how we tackle it: excessive use, or lack of access; public demand, or market-led health systems that incentivise medical practitioners to overprescribe; international travel, or locally occurring ‘pockets’ of resistance; lack of incentives for commercial pharmaceutical production or lack of non-profit making alternatives for developing new drugs; medical/veterinary overuse, or environmental contamination?

The Theme 4 call is an opportunity for truly interdisciplinary research involving biological, medical and social scientists, engineers and artists.  Thinking and acting collaboratively is perhaps the only way we might truly be able to tackle this wickedly complex problem.

Posted in Uncategorized | Leave a comment

Social Science Research on Antimicrobial Resistance

Social scientists from all over the British Isles came together to talk about antimicrobial resistance (AMR) at our workshop on Friday 22nd April.

The focus was on research which might be relevant to the forthcoming call for the cross council AMR Theme 4: behaviour within and beyond the health care setting.  To receive updates on this and similar funding opportunities, register an interest here.

Here are some of the highlights recorded by participants on Twitter #amrchamp

Helen Lambert introduces workshop

At Bristol zoo for day on social science research on AMR – looks like it will be an interesting day

Ian Donald: Social Sciences & AMR

  

Ian Donald: five questions we need to answer about behaviour and

Ian Donald says AMR research coming of age – needs a broad view of what social sciences can bring to AMR research

Matthew Avison on microbiology of AMR

Matthew Avison – when we distrupt our normal microflora we go around “sucking up new bugs like a hoover”

 Matthew Avison (@MutantBug) worth checking out if only for cat with hoover picture!

Gina Pinchbeck Vetinary Sciences and AMR

Gina Pinchbeck – what’s really happening with guidelines for antibiotic use in animals

Alasdair MacGowan: Infections and public health


Alasdair MacGowan: how can we measure the impact of antibiotic resistance

Alisdair MacGowan – takes a long time for patients with resistant infections to get the right treatment

Clare Chandler: a view from anthropology

Clare Chandler – there’s lot more to than changing behaviour to fix a single problem

Clare Chandler asking classic anthropological questions – AMR what is resisting what, where & why?

Jo Coast: a view from economics

we have really limited evidence on the cost of antibiotic resistance, need to change this

 Jo Coast – should we tax antibiotics?

Hayley Macgregor: a view from development studies

@PatriciaJLucas

Hayley mcgregor on the complex relationships between formal and informal health sectors. Fascinating

Import to rememb that many lack access to antibiotics, and informal unregulated access may be saving lives

 

Steve Hinchcliffe – antimicrobials are part of out (food) production infrastructure.

Stephan Elbe – Need to learn from past examples of health problems being thought of as security issues e.g. bird flu – pros & cons

Sujatha Raman: a view from sociology/science and technology studies

on how science & tech studies can help us to understand discourse of amr

Great meeting emphasising the key role of Soc Sci in the fight against AMR

 AMR is a ‘wicked’ problem – we need to find way to act despite inevitable uncertainty

Naomi Beaumont from ESRC chairs expert panel Q&A

@EmmaJ_Roe

Super expert presentations from these social scientists on AMR. A taster for future conferences.

Afternoon discussion sessions


Fantastic discussion at

Bristol Zoo Gardens – excellent venue!

Getting a break from AMR discussions…

Last session of Bristol AMR workshops. Interesting, engaging, productive & worth the 4.45 alarm-clock

Posted in Uncategorized | Leave a comment

Reducing antibiotic prescriptions for children with coughs: who to target?

head shot  By Christie Cabral

Do parents want antibiotics when a child has a cough?  I’ve spoken to a lot of parents over the past five years and pretty well all of them say they would really rather not give their child any kind of drug treatment.  Yet the belief that parent demand for antibiotics is an important driver of antibiotic over-prescription is very persistent among clinicians and policy makers.

Over-prescription of antibiotics is a serious issue as it contributes to the problem of rising drug-resistant infections.  Considerable effort is going into trying to reduce over-prescription of antibiotics.  However, figuring out where best to target that effort is not always that straightforward.  The TARGET research programme and related Conker project investigated what influences antibiotic prescribing for children with coughs.

The parents we talked to in our study worry about the impact of any kind of medication on their child.  Many express fears around overdosing with child paracetamol and ibuprofen and believe that antibiotics should only be given if really needed.  All of this supports a general preference for not giving children any pharmaceutical treatment at all.

So that sounds like good news – parents don’t want antibiotics, problem solved; right?  Well of course the reality is messier than that.  Parents do want antibiotic treatment if they think it’s going to make a difference, to help their child to get better or to suffer less.   The key influence on parental expectation of antibiotic treatment is experience of antibiotics being prescribed for something similar in the past.  Often when antibiotics are prescribed, there is little explanation of the reasons, leaving parents to develop their own ideas about what symptoms indicate a need for antibiotic treatment.  These ideas are shared and reproduced within communities.  We have created an animation which shows how this happens.

The animation also illustrates a doctor’s point of view.  The doctor’s main concern is making sure they don’t miss a child with a potentially life threatening infection.  I think we would all agree that this is a good top priority.  However, because there is currently no definitive way of identifying children who may develop a serious illness from those who are poorly but will get better, doctors have to use their judgement to decide which ones to treat.  Most of the time, clinicians are able to judge confidently, but in a minority of cases there remains some uncertainty.   This is where the problem lies.  Faced with clinical uncertainty, many doctors will prescribe antibiotics in the belief that not only is it safer for the child in front of them but it also protects the doctor from the potentially serious medico-legal consequences of ‘missing a sick child’.

Reducing over-prescription of antibiotics for children with a cough is a challenging problem. Our research found that current antibiotic prescribing practices by doctors are a key influence on parental expectations (rather than the other way around).  Enabling doctors to change their practice will be a key part of the solution.  There is a need for basic science to help reduce clinical uncertainty, but we are still a long way from eliminating this.  In the meantime, there is a role for social science research in understanding how clinicians deal with uncertainty and how a different balance might be struck between the immediate risks to the patient and doctor and the wider risks to all of us from drug resistant infections.

Posted in Uncategorized | Leave a comment

Newton Fund: Opportunity for China-UK research collaboration on AMR

Helen Lambert, ESRC Research Champion, attended image012
the UK-China joint workshop in Shanghai to discuss the recently announced call for collaborative research on AMR.

UK research councils (ESRC, MRC & BBSRC) together with the National Natural Science Foundation of China (NSFC) announced the call for photo1research into antibacterial resistance in China just before Christmas (details below if you missed it).  The funds for this call will be channeled through the Newton Fund which aims to promote the economic development and social welfare of partner countries. Applicant teams will need to include partner institutions from both the UK
and China which are eligible for funding from their respective country funding bodies new iPhone photos Jan 2016 532
(ESRC, MRC or BBSRC in the UK or NSFC in China).

Key Deadlines:

Expression of Interest: 15th January 2015

Full proposals: 1st March 2016new iPhone photos Jan 2016 448

Further information

new iPhone photos Jan 2016 502 new iPhone photos Jan 2016 480

Posted in Uncategorized | Leave a comment

Why social scientists are needed to address the challenge of drug resistant infections

helen

By Helen Lambert

ESRC AMR Research Champion

Reader in Medical Anthropology
School of Social and Community Medicine

The global health problem of drug-resistant infections has been identified as a key issue for the UK, and the threat posed has been likened to terrorism or global warming.  To date, many of the proposed solutions have focussed on new technologies, such as the £10 million Longitude prize to develop a new diagnostic test for bacterial infections. Yet the phenomenon of antimicrobial resistance is largely a consequence of human action and both its drivers and its consequences are socially patterned.

In high-income settings such as the UK for example, social science research has revealed the complex processes that influence clinician decision-making around prescription of antibiotics.  Qualitative research conducted by my colleagues in the infections team at Bristol University on the perceptions and practices of GPs and parents seeking treatment for children’s respiratory infections, shows that doctors often prescribe antibiotics in the belief that their patients expect them, while parents in the main are simply seeking reassurance. These studies indicate that prescribing antibiotics occurs, at least in part, because both parties are trying to reduce the perceived risks of harm associated with failing to prescribe them in cases of serious illness. For doctors, the small risk of mis-diagnosing a seriously unwell child has major adverse reputational and potentially legal consequences. For parents, the potential negative social as well as health consequences of not seeking healthcare for their ill child outweighs the individually insignificant risk of over-treatment.  Differences in how clinical and lay communities understand infections and drug resistance, as well as subtle misunderstandings of meaning between doctors and patients, can hinder effective communication about these issues.

From my experience of conducting anthropological research in India over many years, I know that the realities of antibiotic use in low- and middle-income settings are also determined less by clinical necessity than by complex social, cultural and economic influences. Antibiotics can readily be bought over the counter without prescription and out-of-pocket expenses count for 80% of all health care costs, which means there is both over- and under-treatment of infections.  If new rapid diagnostic tests for use at the point of care do come on the market in such an environment, they will most likely be taken up selectively by private facilities serving wealthier patients who can bear the cost of the tests.  In turn the use of such tests may simply provide further grounds for offering novel treatment with the latest high-end antibiotics – a trend found in private hospitals that, according to Dr. Abdul Ghafur, is a key driver for antibiotic resistance in India.  Poorer patients, meanwhile, will still have to rely on underfunded government health facilities where cost will prohibit use of rapid diagnostic tests and only a limited range of increasingly ineffective antibiotics are provided, or on private practitioners who offer demand-driven, symptom-based treatment and often rely on pharmaceutical sales representatives as their main source of medical information. In this scenario, new technologies such as point-of-care tests to establish the identity of the disease-causing pathogen are unlikely to have much effect on the rise of AMR.  The selective availability of such tests may even widen health inequities, by making access to appropriate and effective treatment for bacterial infections even more dependent on families’ financial means.

My own discipline of social anthropology has long been recognised as centrally concerned with translation, that is, with the attempt to render knowledge and practices that are self-evident within one culture explicable within the terms of another. Thus anthropological insights have obvious potential in relation to ‘translation’ as a metaphor for rendering research results within one disciplinary field utilisable elsewhere. As the example of rapid diagnostic tests for limiting AMR suggests, social science research offers possibilities for gaining insight into possible ‘sticking points’ in translational pathways between new scientific developments and real people’s lives.  It can also shed light on how far scientific knowledge can be deliberately formulated to ‘travel’ beyond its initial community of discovery, including by consideration of how language itself can not only facilitate but also sometimes limit new discovery and understanding.

I have taken on the role of ESRC AMR Research Champion in order to advocate the involvement of social scientists in this field and over the next year I will be reaching out to researchers in a wide range of social science disciplines.  Some have already taken up the call to arms. In the next twelve months I will be inviting colleagues across the social sciences to post to this blog and to help compile accessible research briefings on the state of play in their field that will be made freely available on our website.  I will be looking for ways to forge links between social scientists and biomedical and life scientists so that together, they can find effective ways to address the challenge of drug-resistant microbes.  I believe that social science research is a crucial component in this endeavour.

 

Posted in Uncategorized | Leave a comment