Exploring Antibiotic Resistance and the Effect of Antimicrobial Stewardship on Physicians’ and Non-Physician Prescribing Clinicians through Knowledge, Attitudes, Practices and Beliefs (KAPB) Utilizing the Social Cognitive Theory (SCT)

ABSTRACT Exploring Antibiotic Resistance and the Effect of Antimicrobial Stewardship on Physicians’ and Non-Physician Prescribing Clinicians through Knowledge, Attitudes, Practices and Beliefs (KAPB) Utilizing the Social Cognitive Theory (SCT) Tamika Carty Seton Hall University, 2021 Dissertation Chair: Genevieve Pinto Zipp, PT, EdD, FNAP Background: Antibiotics are one of the greatest medical discoveries, revolutionizing the field of medicine. However, antimicrobial and antibiotic over usage has become a prevalent issue among outpatients, leading to antibiotic resistance (AR) (Ventola, 2015). As a result of, its widespread usage and associated concerns, the World Health Organization (WHO) has cited AR as a growing concern for many nations (WHO, 2015). This in turn has led to the development of management programs such as stewardships which are often led by health professionals and clinicians to address this growing issue. One would argue that stewardship programs are only as effective if those leading them are adequately prepared. Therefore, it is imperative to identify physicians’ and prescribing non-physician practitioners’ knowledge, attitudes, practices, and beliefs regarding AR and the incorporation of Antimicrobial Stewardship Programs (ASPs) to combat AR. Purpose: The purpose of this study was threefold: first to create, validate and test the reliability of the novel instrument “Antibiotic Resistance & Antimicrobial Stewardship Assessment Tool (ABRASAT)”. The second purpose was to test the valid and reliable tool in physicians’ and non-physician prescribing practitioners. The final purpose was to use the valid and reliable tool in the population of interest to understand physicians’ and non-physician prescribing practitioners’ knowledge, attitudes, practices, and beliefs with regard to antibiotic resistance and ASPs as combative method for AR. Methods: This study employed a mixed methods research approach, utilizing specifically an explanatory mixed methods design. The study can also further be categorized as non-experimental, descriptive, cross sectional, correlational and explanatory. The study consisted of two practitioner groups (physicians’ and non-physician prescribing practitioners) in which their knowledge, attitudes, practices, and beliefs were explored utilizing the ABRASAT instrument which was rooted in the available “evidenced based” literature, KAPBs theory and the Social Cognitive Theory (SCT). The ABRASAT consisted of 10 demographic questions and 25 questions relating to KAPBs, expectations, suggestions and thoughts on AR and ASPs. Data Collection and Analysis: Data was collected from both practitioner groups. Participants were recruited via social media (Facebook, WhatsApp, Twitter, Reddit and LinkedIn) and research platform (Research Gate), in addition to convenience sampling. The PI utilized descriptive statistics in addition to statistical analysis tests (ANOVA, T-Test, MANOVA and Pearson’s Correlation) to analyze quantitative data. The PI employed an inductive approach utilizing descriptive and in vivo coding to analyze qualitative data. Both the quantitative and qualitative data helped to form an inclusive overview of KAPBs of physicians’ and non-physician prescribing practitioners. Results: A total of 234 participants completed the survey. The study results for both the quantitative and qualitative data for descriptive research questions (RQ) 1 -5 resulted in the following: for RQ1, the quantitative and the qualitative data shows overall both practitioner groups had high knowledge on AR. For RQ2, the quantitative and the qualitative data shows overall both practitioner groups had high knowledge on what ASPs were. For RQ3, the quantitative and the qualitative data shows overall both practitioner groups had favorable attitudes with regards to ASPs. For RQ4, the quantitative and the qualitative data shows overall both practitioner groups had good ASP practices. For RQ5, the quantitative and the qualitative data shows overall both practitioner groups had favorable beliefs with regards to ASPs. The study results for both the quantitative and qualitative data for relational research questions (RQ) and hypotheses 6 -13 resulted in the following: for RQs 6 & 7, there was no significant difference in practitioner groups on knowledge, resulting in failure to reject the null hypothesis. For RQs 8 - 11, there was a significant difference in practitioner groups on attitudes and beliefs resulting in rejection of the null hypothesis. Finally, for RQ 12 & 13, like RQs 6 & 7, there was no significant difference in practitioner groups on practices, resulting in failure to reject the null hypothesis. While the overall instrument had a high reliability of .843 and successfully measured attitudes, practices and beliefs, knowledge had a poor reliability. While knowledge had poor reliability, it did not affect the overall reliability of the tool. However, it will need to be reassessed for future use as an individual construct. Conclusion: Though knowledge scored poorer in reliability it does not dispute the fact that physicians’ and non-physician prescribing clinicians have knowledge of AR, and displayed positive attitudes and beliefs towards ASPs. As a result, practitioners are generally in favor of ASPs yet improvements should still be made to ensure maximum benefits, thus society must continue to implement and refine these programs

Raising awareness of antimicrobial resistance among the general public in the UK: the role of public engagement activities

In response to the accepted risk of emerging antimicrobial resistance, many organizations and institutions have developed and delivered events and activities designed to raise awareness of the issue and to change the behaviour of the intended audience. However, few of these events for a general public audience are documented or able to be sourced by those who might wish to repeat, adapt or modify, particularly those events that are successful. ‘Insider knowledge’ appears to be the best search tool. Moreover, evaluation of the success or impact of the event is rarely published. It would be useful if there were a ‘hub’ where descriptions of such activities could be deposited, enabling the building of a significant resource with real academic value

Antibiotic resistance: how did we get here and what can we do?

Executive summary Does antibiotic resistance exist? Yes. It is a worsening phenomenon seen all over the world, including Australia. What are the implications of antibiotic resistance? Infection with antibiotic-resistant bacteria is associated with longer length of stay in hospitals and higher death rates. This amounts to significant financial costs; the European Union, for example, spends €1.5 billion annually on antibiotic-resistant infections. Significant indirect costs can also arise from antibiotic-resistant infections when they adversely affect other areas of medicine, for example, transplant medicine, surgery and chemotherapy. How did we get here? Antibiotic resistance has many causes but the most important ones include: excessive and inappropriate antibiotic use among humans and animals (including ‘over-the-counter’ antibiotic use), global trade, global travel, medical tourism, environmental contamination with antibiotics, and a decline in new antibiotic development. What can we do? Because there are multiple causes, a multi-pronged solution is required. The ‘EVADES BUGS’ strategy seeks to address the core problems: Education, Vaccine development, Animal health, Diagnostics, Environmental controls, Surveillance, Better antibiotics, Universal infection control and hand hygiene, Government and political will, Stewardship of antibiotics in hospitals. Many superbugs arrive here from overseas as a consequence of global trade and global travel. As a result, Australia must play a global role in addressing the issue as well as a local one. Implementing the EVADES BUGS strategy would require activity across portfolios (for example, Health, Trade, Agriculture, Environment, Tourism, Customs). Therefore, it is worth considering the establishment of a single coordinating body, such as an Australian Centre for Disease Control, to take responsibility for the strategy as part of a broader focus on monitoring and responding to communicable diseases

The Adoption of Antimicrobial Stewardship Programmes in Ministry of Health Hospitals in Saudi Arabia

Aim: This thesis aims to explore and investigate the level and process of adoption of Antimicrobial Stewardship Programmes (ASPs) and factors influencing their implementation in Saudi Ministry of Health (MOH) hospitals. The findings of this study will provide hospitals and policy makers with evidence-based recommendations on how barriers to ASPs adoption can be overcome, which will ultimately improve antimicrobial use and reduce antimicrobial resistance (AMR). Method: A mixed method approach was carried out using both qualitative and quantitative research methods. Semi-structured interviews were conducted with healthcare professionals in three Saudi hospitals to explore the enablers and barriers to their adoption of ASPs. A survey was then developed based on these findings to investigate the level of hospitals’ adoption of ASPs and factors influencing their implementation at a national level. Further, a case study using in-depth interviews was utilised to understand the process of ASP adoption in a Saudi hospital, and how adoption challenges were addressed. Finally, a self-administered questionnaire was used to examine patients’ knowledge and perceptions of antimicrobial use and resistance, and to evaluate the institutional role of patient education on antimicrobial use in two Saudi hospitals. The overall methodology of the research is summarised in Figure I. Results: Despite the introduction of a national ASP strategy, adoption of ASPs in Saudi MOH hospitals remains low. Organisational barriers such as the lack of senior management support, lack of supportive IT infrastructure and the shortage of ASP team members hinder hospitals’ efforts to adopt ASPs. Further barriers relate to the lack of formal enforcement by MOH and the physicians fears of patients' complications and clinical liability. Patients admitted to Saudi hospitals lack knowledge and perceptions of AMR, and the adoption of ASPs may improve hospitals’ role in patients' education. Conclusions: Despite the established benefits of ASPs, their adoption in Saudi MOH hospitals remains low. Urgent action is needed to address the strategies priorities associated with AMR, including access to antimicrobials, antimicrobial stewardship and education and research. Policy makers are urged to consider making ASPs adoption in hospitals a regulatory requirement supported by national guidelines and surveillance programmes. It is essential to increase the provision of ID and infection control residency and training programmes to meet the extreme shortage of ID physicians, pharmacists, microbiologists and infection control practitioners. Higher education institutions and teaching hospitals are required to introduce antimicrobial prescribing and stewardship competencies into undergraduate Medical, Pharmacy, Dental, Nursing and Veterinary curriculum, as well as introduction of AMR topics in order to increase knowledge and awareness of ASPs and AMR. Collaboration between ASPs adopting and non-adopting hospitals is essential to share implementation experience, strategies and solutions to overcome barriers. Healthcare specialised associations are needed to be part of AMR conversation and guide healthcare professionals’ training and accreditation. Multiple stakeholders should be actively part of the conversations around tacking AMR. Primary care, secondary care, community pharmacies and policy makers should strive to create a shared culture of responsibility among all healthcare partners to improve antimicrobial therapy and reduce risks of AMR

Creating digital materials for Antimicrobial Resistance One Health awareness and behaviour change for Rhodes University peer educators

Antimicrobial resistance (AMR) is an urgent, global health problem that stems from the inappropriate use of and poor adherence to antibiotics that treat diseases in human beings. It is further exacerbated by the proliferation of antibiotics into the food chain, particularly from the overuse and misuse of antibiotics in agricultural, meat, and dairy production. The recently developed World Health Organisation (WHO) One Health (OH) approach encompasses and acknowledges the various interconnected pathways that drive AMR between the human, animal, and environmental spheres. Until recently, AMR health challenges have been viewed primarily through a biomedical lens, but this study draws on the more holistic perspective that the One Health approach offers. AMR from food sources (AMR-OH) is an underrepresented topic of research. Creating digital health communication for low-literate end-users on this topic using the One Health approach is an emerging field of research. AMR-OH has not been extensively covered in health communication campaigns and requires developing context-specific digital educational materials, such as the ones this study presents. This study draws on Social Behaviour Change Communication (SBCC) theory elements to create a suggested approach to disseminate AMR-OH information. This intervention was aimed at low-health-literate end-users to accomplish two objectives. First, create awareness and improve knowledge about AMR-OH via a video. Second, offer feasible, easily implementable behaviour change actions in the form of an infographic comprising four food safety steps (Clean, Separate, Cook, and Chill). The study was conducted in three phases. First, recruit participants and conduct a literature review to identify the effective SBCC elements of health communication intervention design. Second, conduct a needs assessment to gauge the volunteering participants’ familiarity with digital media and their current health literacy on AMR-OH. Third, conceptualise and design the two AMR-OH digital educational materials (a video and accompanying infographic). The materials were first evaluated by the researcher using the Clear Communication Index (CCI) test, and then shared with the participants via WhatsApp to be evaluated by them, using two end-user tests: the Patient Education Material Assessment Tool (PEMAT) and the Suitability Assessment of Materials (SAM) test. These two tests assessed the materials’ readability, understandability, and actionability. A post-evaluation, semi-structured interview (SSI) was then conducted with the participants. Deductive thematic analysis was conducted on the SSI data and analysed using the five design benchmarks as themes: Ease of Use of Technology, Clarity of Content, Appropriate Format, Target Audience Resonance (Appropriate for target audience), and Clear calls to Action (Actionable). The rapid onset of COVID-19 restrictions forced the project to scale down and shift entirely online. The study could be conducted due to the active and enthusiastic virtual participation of two Rhodes University Peer Educators (PEs) whose contribution was vital to developing and evaluating the materials. The needs assessment showed that the PEs were comfortable using WhatsApp, had reliable internet connection when on campus, and used this social media platform for professional and personal communication. This assessment also showed that they had prior knowledge of AMR but only from the human health perspective. The video and infographic scored high on the Clear Communication Index, 93.3% and 94.4%, respectively. The PEs’ evaluation of the materials was also high on the PEMAT and SAM assessments: video narration (100%, 80% respectively), video (100%, 99% respectively), and infographic (86%, 90% respectively). This study produced an easy-to-use, accessible and appropriate online repository of AMR-OH information in a novel format with actionable steps. The post-evaluation SSI revealed that the materials and the channel of delivery were welcomed. The PEs expressed their confidence in receiving, using, and sharing this novel presentation of evidence and solutions-based information about AMR-OH. They further highlighted that this is the first time they have received and evaluated context-specific digital multimedia about AMR-OH and that this information equipped them to adopt the food safety behaviours – namely, the four food safety steps. This study demonstrates that the theory-informed creation of engaging digital media for AMR-OH is feasible and viable. Furthermore, it affirms that engaging digital media for AMR-OH can be created to enhance the knowledge of end-users about this health issue. The scaled-down approach created a blueprint to implement a more extensive intervention in the future, informed by this intervention’s methods and tools. Lastly, this blueprint for a particular conceptualisation of an AMR-OH digital media intervention provides effective and empowering tools with which the PEs can disseminate this information to the university's support staff.Thesis (MA) -- Faculty of Humanities, School of Journalism and Media Studies, 202

Antibiotics and toothache: a social media review

Objectives Antibiotics are inappropriate for the treatment of toothache, yet many seek them. Social media allows users to express their opinions, share experiences and offer support. This study used social media to investigate the public’s experiences of, and attitudes towards, antibiotics for toothache. Methods A systematic search of posts on Facebook and Twitter was undertaken. Eligibility criteria were applied to select relevant social media posts for thematic analysis of word content. An inductive descriptive coding system was developed from the data and exemplary quotes were identified to illustrate the themes and subthemes identified. Key findings Searches identified 174 posts, of which 144 were selected for analysis. Five themes were identified: experience and expectations, self-care and professional treatment, access to dental care, quality of life and coping strategies. The belief that antibiotics are an appropriate treatment for a toothache was widespread. Antibiotic-seeking behaviour was related to access to professional dental care, including avoiding dental appointments due to dental anxiety and the perceived affordability of dentistry. A range of strategies to cope with the severe impact toothache was having on people’s quality of life were identified, from prayer to antibiotics. Conclusions Social media is used extensively to seek antibiotics, avoid dental treatment and provide support to people with toothache. A general belief that antibiotics are an appropriate and necessary treatment for toothache exists. This improved understanding about the factors driving antibiotic-seeking behaviour provides new targets for the development of approaches to tackling antibiotic resistance, by reducing unnecessary antibiotic use in dental clinics and beyond

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

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

Transatlantic Taskforce on Antimicrobial Resistance : progress report

The Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was created in 2009 with the goal of improving cooperation between the US and the EU in three key areas: appropriate therapeutic use of antimicrobial drugs in medical and veterinary communities, prevention of healthcare- and community-associated drug-resistant infections, and strategies for improving the pipeline of new antimicrobial drugs. TATFAR identified and adopted 17 recommendations for future collaborations between the US and the EU. The implementation of the recommendations has been carried out through increased communication; regular meetings and joint workshops; and exchange of information and approaches, best practises and methods.This report summarises the progress and the outcomes of the implementation of the 17 recommendations, as well as the decision about the future of each recommendation. In addition, it also includes one new recommendation.Based on the promise shown by our early cooperation, we decided to renew TATFAR in 2013 for another two-year term. In addition, we agreed to transfer the Secretariat from the European Centre for Disease Prevention and Control (ECDC) to the US Centers for Disease Control and Prevention (CDC) for the renewal term. As TATFAR moved into its two-year renewal period, this report reviews the progress that has been made for each recommendation and feedback to determine whether work toward the recommendation should continue in the future. Work on 15 of the original TATFAR recommendations and one new recommendation will continue into 2015, a strong testament to the benefits of the cooperation between the US and EU.tatfar-progress_report_2014.pdfForeword -- Executive summary -- Introduction -- Recommendations -- Key Area I. Appropriate therapeutic use of antimicrobial drugs in medicine -- Key Area II. Prevention of drug resistant infections -- Key Area III. Strategies to improve the pipeline of new antibacterial drugs for use in human medicine -- Conclusions -- Acknowledgement -- Annex A: Abbreviations and acronyms -- Annex B: TATFAR members -- Annex C: Scope and term of reference of TATFAR -- Annex D: The TATFAR recommendations for future collaboration -- Annex E: Timeline of the TATFAR, 2009-2013 -- Annex F: Ongoing activities: joint, EU, and US