It is time to give social research a voice to tackle antimicrobial resistance?

Exploring medical and veterinary student perceptions and communication preferences related to antimicrobial resistance in Ontario, Canada using qualitative methods

BACKGROUND

Antimicrobial resistance (AMR) threatens our ability to treat and prevent infectious diseases worldwide. A significant driver of AMR is antimicrobial use (AMU) in human and veterinary medicine. Therefore, education and awareness of AMR among antimicrobial prescribers is critical. Human and animal health professionals play important roles in the AMR issue, both as contributors to the emergence of AMR, and as potential developers and implementers of effective solutions. Studies have shown that engaging stakeholders prior to developing communication materials can increase relevance, awareness, and dissemination of research findings and communication materials. As future antimicrobial prescribers, medical and veterinary students' perspectives on AMR, as well as their preferences for future communication materials, are important. The first objective of this study was to explore medical and veterinary student perceptions and understanding of factors associated with emergence and spread of AMR. The second objective was to identify key messages, knowledge translation and transfer (KTT) methods, and dissemination strategies for communication of AMR information to these groups.

METHODS

Beginning in November 2018, focus groups were conducted with medical and veterinary students in Ontario, Canada. A semi-structured format, using standardized open-ended questions and follow-up probing questions was followed. Thematic analysis was used to identify and analyze patterns within the data.

RESULTS

Analyses showed that students believed AMR to be an important global issue and identified AMU in food-producing animals and human medicine as the main drivers of AMR. Students also highlighted the need to address society's reliance on antimicrobials and the importance of collaboration between different sectors to effectively reduce the emergence and transmission of AMR. When assessing different communication materials, students felt that although infographics provide easily digestible information, other KTT materials such as fact sheets are better at providing more information without overwhelming the target audiences (e.g., professional or general public).

CONCLUSION

Overall, the study participants felt that AMR is an important issue and emphasized the need to develop different KTT tools for different audiences. This research will help inform the development of future communication materials, and support development of AMR-KTT tools tailored to the needs of different student and professional groups.

Understanding antibiotic use: practices, structures and networks

In this article, we consider how social sciences can help us to understand the rising use of antibiotics globally. Drawing on ethnography as a way to research how we are in the world, we explore scholarship that situates antibiotic use in relation to interactions of pathogens, humans, animals and the environment in the context of globalization, changes in agriculture and urbanization. We group this research into three areas: practices, structures and networks. Much of the public health and related social research concerning antimicrobial resistance has focused on antibiotic use as a practice, with research characterizing how antibiotics are used by patients, farmers, fishermen, drug sellers, clinicians and others. Researchers have also positioned antibiotic use as emergent of political-economic structures, shedding light on how working and living conditions, quality of care, hygiene and sanitation foster reliance on antibiotics. A growing body of research sees antibiotics as embedded in networks that, in addition to social and institutional networks, comprise physical, technical and historical connections such as guidelines, supply chains and reporting systems. Taken together, this research emphasizes the multiple ways that antibiotics have become built into daily life. Wider issues, which may be invisible without explication through ethnographic approaches, need to be considered when addressing antibiotic use. Adopting the complementary vantage points of practices, networks and structures can support the diversification of our responses to AMR.

Antibiotic stories: a mixed-methods, multi-country analysis of household antibiotic use in Malawi, Uganda and Zimbabwe

BACKGROUND

As concerns about the prevalence of infections that are resistant to available antibiotics increase, attention has turned toward the use of these medicines both within and outside of formal healthcare settings. Much of what is known about use beyond formal settings is informed by survey-based research. Few studies to date have used comparative, mixed-methods approaches to render visible patterns of use within and between settings as well as wider points of context shaping these patterns.

DESIGN

This article analyses findings from mixed-methods anthropological studies of antibiotic use in a range of rural and urban settings in Zimbabwe, Malawi and Uganda between 2018 and 2020. All used a 'drug bag' survey tool to capture the frequency and types of antibiotics used among 1811 households. We then undertook observations and interviews in residential settings, with health providers and key stakeholders to better understand the stories behind the most-used antibiotics.

RESULTS

The most self-reported 'frequently used' antibiotics across settings were amoxicillin, cotrimoxazole and metronidazole. The stories behind their use varied between settings, reflecting differences in the configuration of health systems and antibiotic supplies. At the same time, these stories reveal cross-cutting features and omissions of contemporary global health programming that shape the contours of antibiotic (over)use at national and local levels.

CONCLUSIONS

Our findings challenge the predominant focus of stewardship frameworks on the practices of antibiotic end users. We suggest future interventions could consider systems-rather than individuals-as stewards of antibiotics, reducing the need to rely on these medicines to fix other issues of inequity, productivity and security.

Protocol for an interdisciplinary cross-sectional study investigating the social, biological and community-level drivers of antimicrobial resistance (AMR): Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA)

INTRODUCTION

Antimicrobial resistance (AMR) is a global health threat that requires urgent research using a multidisciplinary approach. The biological drivers of AMR are well understood, but factors related to treatment seeking and the social contexts of antibiotic (AB) use behaviours are less understood. Here we describe the Holistic Approach to Unravel Antibacterial Resistance in East Africa, a multicentre consortium that investigates the diverse drivers of drug resistance in urinary tract infections (UTIs) in East Africa.

METHODS AND ANALYSIS

This study will take place in Uganda, Kenya and Tanzania. We will conduct geospatial mapping of AB sellers, and conduct mystery client studies and in-depth interviews (IDIs) with drug sellers to investigate AB provision practices. In parallel, we will conduct IDIs with doctors, alongside community focus groups. Clinically diagnosed patients with UTI will be recruited from healthcare centres, provide urine samples and complete a questionnaire capturing retrospective treatment pathways, sociodemographic characteristics, attitudes and knowledge. Bacterial isolates from urine and stool samples will be subject to culture and antibiotic sensitivity testing. Genomic DNA from bacterial isolates will be extracted with a subset being sequenced. A follow-up household interview will be conducted with 1800 UTI-positive patients, where further environmental samples will be collected. A subsample of patients will be interviewed using qualitative tools. Questionnaire data, microbiological analysis and qualitative data will be linked at the individual level. Quantitative data will be analysed using statistical modelling, including Bayesian network analysis, and all forms of qualitative data analysed through iterative thematic content analysis.

ETHICS AND DISSEMINATION

Approvals have been obtained from all national and local ethical review bodies in East Africa and the UK. Results will be disseminated in communities, with local and global policy stakeholders, and in academic circles. They will have great potential to inform policy, improve clinical practice and build regional pathogen surveillance capacity.

A decade of antimicrobial resistance research in social science fields: a scientometric review

Background

Though social sciences are expectedly instrumental in combating antimicrobial resistance (AMR), their research on AMR has been historically lacking.

Objectives

This study aims to understand the current academic literature on AMR within the social science field by investigating international contributions, emerging topics, influential articles, and prominent outlets, to identify research gaps and future directions.

Methods

Bibliometric data of 787 peer-reviewed journal articles published in the period of 2010 to 2019 were extracted from the Social Science Citation Index in the Web of Science database. Bibliographic networks of the extracted articles were examined.

Results

Social science research on AMR has grown rapidly in the past 5 years. While western developed countries contributed the most to the field in the past decade, research within developing regions such as Asia and Africa have increased in the last 2 years. Social sciences have been contributing to AMR research in several different domains from surveillance and risk assessment of AMR, to promotions of appropriate use of antimicrobials in primary care and clinical settings. Though the idea of one health has been incorporated into research on AMR within the medical and microbial science fields, it has not been well recognized by social sciences.

Conclusion

Social science research on AMR is a new, while rapidly developing, research area that requires continued and intense global efforts from an interdisciplinary and one health approach. Research on social issues surrounding AMR transmissions between human, animal, and environments should be emphasized in the future.

The 'Drug Bag' method: lessons from anthropological studies of antibiotic use in Africa and South-East Asia

Understanding the prevalence and types of antibiotics used in a given human and/or animal population is important for informing stewardship strategies. Methods used to capture such data often rely on verbal elicitation of reported use that tend to assume shared medical terminology. Studies have shown the category 'antibiotic' does not translate well linguistically or conceptually, which limits the accuracy of these reports. This article presents a 'Drug Bag' method to study antibiotic use (ABU) in households and on farms, which involves using physical samples of all the antibiotics available within a given study site. We present the conceptual underpinnings of the method, and our experiences of using this method to produce data about antibiotic recognition, use and accessibility in the context of anthropological research in Africa and South-East Asia. We illustrate the kinds of qualitative and quantitative data the method can produce, comparing and contrasting our experiences in different settings. The Drug Bag method produce accurate antibiotic use data as well as provide a talking point for participants to discuss antibiotic experiences. We propose it can help improve our understanding of antibiotic use in peoples' everyday lives across different contexts, and our reflections add to a growing conversation around methods to study ABU beyond prescriber settings, where data gaps are currently substantial.

Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion

BACKGROUND

Antimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people's antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients' healthcare-seeking pathways?RQ2: Will people's exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities?

METHODS

We apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1-3), social network analysis (RQ2) and latent class analysis (RQ3).

DISCUSSION

Social research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour.

TRIAL REGISTRATION NUMBER

NCT03241316; Pre-results.