Addressing antibiotic use: insights from social science around the world

Antimicrobial resistance (AMR) is a major threat to global health and economies, the harmful effects of which are disproportionately experienced by those living in Low- and Middle-Income Countries (LMICs). Tackling this complex problem requires multidisciplinary and multisectoral responses. In the last few years, there has been a growing acknowledgement of the vital role of social science in understanding and intervening on antibiotic use, a key driver of AMR. Existing reviews summarise evidence of specific aspects of antibiotic use and specific intervention types. The growing concern that our off-the-shelf toolkit for addressing antibiotic use is insufficient in the face of rising use across humans, animals and plants, requires that we take a fresh look at the ways we are understanding this problem and possibilities for solutions. The ambition of this report is to provide a timely intervention into this global debate, by formulating a conceptual map of the insights from the growing body of social science research on addressing antibiotic use conducted in a diverse range of economic, social, and health system settings around the world. A series of panel presentations and discussions was held in 2020 with leading social scientists working on antibiotic use in different settings. Analysis of the proceedings of these panels, together with a literature review which snowballed from the work of the 76 researchers profiled through the antimicrobialsinsociety.org community of practice, led to a grouping of the key points of entry for recommendations to act on antibiotic use. The report identifies three main areas of focus of social science recommendations to address antibiotic use: Practices, Structures and Networks. The Practices grouping, in which the majority of the social research on antibiotic use has been carried out over the years, focuses on addressing end user antibiotic use. It shows how scholarship has moved away from knowledge deficit models to embracing an ‘ecological’ approach and to considering practice as embedded in lives and livelihoods. This body of work emphasizes the centrality of the local context to identify possible targets for intervening to change practice. The Structures grouping assembles the growing body of work that understands antibiotic use as a product of economic and political conditions. This research draws from political economical perspectives to identify the ways antibiotics have taken on critical roles in modern societies. Based on research investigating water, hygiene, sanitation (WASH), health systems and the political economy, the report considers how interventions that target these societal structures might reduce recourse to antibiotics as a ‘quick fix’. The Networks grouping collates recent work that draws attention to the mundane networks of logics, classifications and flows within which antibiotics are entangled. Research exploring agricultural and development imperatives, global health architectures, and circulating discourses has revealed the material and meaningful connections between human and non-human actors – animals, medicines, microbes, technologies, for example – that extend through time and space far beyond the moment of antibiotic use. These studies help render visible for action the apparatus such as clinical guidelines, delivery chains and models of care that have previously been overlooked when studying and addressing antibiotic use. The domains for action on antibiotic use presented in this report raise important questions for the AMR community. First, how can we move from standardised approaches to developing, refining, and monitoring impacts of interventions locally? Second, what time horizons should we set for interventions that aim to address AMR, and what other impacts should we expect of efforts to optimise antibiotic use? Third, what forms of evidence are most relevant, and what professional and infrastructural investment is required for this to support meaningful and responsive evaluation? The analysis in this report suggests new forms of transnational and intranational engagements to address this pressing bio-social-political issue could provide a platform for widening the options for addressing antibiotic use and its associated challenges

Understanding Antibiotic Use in Companion Animals: A Literature Review Identifying Avenues for Future Efforts.

Addressing antibiotic use is essential to tackle antimicrobial resistance, a major human and animal health challenge. This review seeks to inform stewardship efforts in companion animals by collating research insights regarding antibiotic use in this group and identifying overlooked avenues for future research and stewardship efforts. The development of population-based methods has established that antibiotics are frequently used in companion animal care. Research insights are also contributing toward an in-depth comprehension of the contexts to antibiotic use. Qualitative approaches, for example, have enabled a nuanced understanding in four key areas: interactions with owners, clinical and financial risk management, time pressures, and clinic dynamics. This review identifies that much of the existing research frames antibiotic use as the result of choices made by the individuals at the interface of their use. Future research and policy endeavours could look beyond the moment of prescribing to consider the societal structures and networks in which companion animal antibiotic use is entangled. A diversification in research approaches and frameworks through which antibiotic use is understood will facilitate the identification of additional targets for stewardship initiatives beyond providing information and awareness campaigns

Parental expressed emotion toward children: prediction from early family functioning

Expressed emotion (EE), an index of family member criticism and emotional overinvolvement, predicts outcome among adults and children with mental disorders. However, limited research exists on factors contributing to EE. Aims of the current study were to (a) examine EE in mothers of young children; (b) assess relationships between demographic factors and EE in a diverse sample; and (c) investigate whether family stress and functioning, including quality of marital relationship, life events, maternal stress, and family environment, predict EE. In the current study, 276 mothers completed questionnaires when their children were between 1 and 3 years of age and a measure of EE when their children were in kindergarten. Results indicated that family expressiveness was the most consistent predictor of EE. Further research seems warranted to better delineate associations between family functioning and EE. Keywords: predictors of EE in families, family environment expressiveness, expressed emotion and the family environment, family stress and expresed emotio

Patient experience of home and waiting room blood pressure measurement: a qualitative study of patients with recently diagnosed hypertension

Background Out-of-office blood pressure (BP) measurement is advocated to confirm hypertension diagnosis. However, little is known about how primary care patients view and use such measurement.Aim To investigate patient experience of out-of-office BP monitoring, particularly home and practice waiting room BP measurement, before, during, and after diagnosis.Design and setting A cross-sectional, qualitative study with patients from two UK GP surgeries participating in a feasibility study of waiting room BP measurement.Method Interviewees were identified from recent additions to the practice hypertension register. Interviews were recorded, transcribed, and coded thematically.Results Of 29 interviewees, 9 (31%) and 22 (76%) had used the waiting room monitor and/or monitored at home respectively. Out-of-office monitoring was used by patients as evidence of control or the lack of need for medication, with the printed results slips from the waiting room monitor perceived to improve ‘trustworthiness’. The waiting room monitor enabled those experiencing uncertainty about their equipment or technique to double-check readings. Monitoring at home allowed a more intensive and/or flexible schedule to investigate BP fluctuations and the impact of medication and lifestyle changes. A minority used self-monitoring to inform drug holidays. Reduced intensity of monitoring was reported with both modalities following diagnosis as initial anxiety or patient and GP interest decreased.Conclusion Home and practice waiting room measurements have overlapping but differing roles for patients. Waiting room BP monitors may be a useful out-of-office measurement modality for patients unwilling and/or unable to measure and record their BP at home

Direct access cancer testing in primary care: a systematic review of use and clinical outcomes.

BACKGROUND: Direct access (DA) testing allows GPs to refer patients for investigation without consulting a specialist. The aim is to reduce waiting time for investigations and unnecessary appointments, enabling treatment to begin without delay. AIM: To establish the proportion of patients diagnosed with cancer and other diseases through DA testing, time to diagnosis, and suitability of DA investigations. DESIGN AND SETTING: Systematic review assessing the effectiveness of GP DA testing in adults. METHOD: MEDLINE, Embase, and the Cochrane Library were searched. Where possible, study data were pooled and analysed quantitatively. Where this was not possible, the data are presented narratively. RESULTS: The authors identified 60 papers that met pre-specified inclusion criteria. Most studies were carried out in the UK and were judged to be of poor quality. The authors found no significant difference in the pooled cancer conversion rate between GP DA referrals and patients who first consulted a specialist for any test, except gastroscopy. There were also no significant differences in the proportions of patients receiving any non-cancer diagnosis. Referrals for testing were deemed appropriate in 66.4% of those coming from GPs, and in 80.9% of those from consultants; this difference was not significant. The time from referral to testing was significantly shorter for patients referred for DA tests. Patient and GP satisfaction with DA testing was consistently high. CONCLUSION: GP DA testing performs as well as, and on some measures better than, consultant triaged testing on measures of disease detection, appropriateness of referrals, interval from referral to testing, and patient and GP satisfaction

The Commercial Determinants of Health and Evidence Synthesis (CODES): methodological guidance for systematic reviews and other evidence syntheses

Abstract Background The field of the commercial determinants of health (CDOH) refers to the commercial products, pathways and practices that may affect health. The field is growing rapidly, as evidenced by the WHO programme on the economic and commercial determinants of health and a rise in researcher and funder interest. Systematic reviews (SRs) and evidence synthesis more generally will be crucial tools in the evolution of CDOH as a field. Such reviews can draw on existing methodological guidance, though there are areas where existing methods are likely to differ, and there is no overarching guidance on the conduct of CDOH-focussed systematic reviews, or guidance on the specific methodological and conceptual challenges. Methods/results CODES provides guidance on the conduct of systematic reviews focussed on CDOH, from shaping the review question with input from stakeholders, to disseminating the review. Existing guidance was used to identify key stages and to provide a structure for the guidance. The writing group included experience in systematic reviews and other forms of evidence synthesis, and in equity and CDOH research (both primary research and systematic reviews). Conclusions This guidance highlights the special methodological and other considerations for CDOH reviews, including equity considerations, and pointers to areas for future methodological and guideline development. It should contribute to the reliability and utility of CDOH reviews and help stimulate the production of reviews in this growing field