Exploring barriers and enablers to the implementation of feasible interventions that address antibiotic resistance in Romania

Background: Antimicrobial resistance (AMR) is a major global public threat to human and animal health and sustainable development with significant economic and societal implications. The key drivers of AMR are numerous with one key one being non-prudent use (whether misuse or overuse) of antibiotics. Non-prudent use practices are: inappropriate prescribing, self-medication and antibiotic use without prescription, non-adherence to appropriate or recommended treatment. These may result from deficient patient-doctor interactions, treatment characteristics, access to treatment, storing of antibiotics at home, limited access to healthcare, and from intentions to self-medicate. A significant number of these factors are directly associated with human behavior and occur in a community setting. The Behavior Change Wheel (BCW), which proposes the identification of capabilities, opportunities and motivations that may dictate or change a certain behavior, is a useful framework to further understand different stakeholders’ behaviors that drive antibiotic consumption (ABC) and AMR as well as related interventions. Furthermore, while antibiotics are extensively used in the community, most interventions implemented thus far are set in health facilities and are delivered or are targeting healthcare professionals. This approach misses other community spaces and engagement opportunities. Romania has the highest total ABC for systemic use in the European Union (EU). Data on public knowledge on antibiotics in this country, shows a decline in knowledge compared to previous years. All these suggests that the Romanian setting would benefit from addressing related ABC and AMR issues through community-based interventions. Furthermore, the Romanian health and social systems are confronted with challenges that parallel or will be encountered by other countries. Aim: The overall aim of the project was to construct an evidence base for developing and implementing community-based interventions to combat AMR and inform relevant policy documents, in view of combating AMR in Romania. Methods: Two studies (study I and III) relied on qualitative methodology (content analysis), using semi-structured interviews to understand pharmacists and family doctors’ perceptions on related roles as well as ABC and AMR in Romania. Study I captured data from 18 interviews with pharmacists whereas study III from 12 family doctors’ interviews. Study III represented a quantitative and qualitative synthesis of evidence on the value of community-based educational interventions to improve antibiotic use. Seventy-three papers were included, ranging from quantitative, qualitative and mixed-methods studies. Study IV used a quantitative methodology to capture perceptions of future Romanian health professionals about antibiotic use. A total of 479 participants completed the study IV survey- 233 medical students from seven faculties and 246 pharmacy students from four faculties. Key findings: Study I articulated three sub-themes that would describe pharmacists’ perceptions. The first one referred to their difficulties in ‘maintaining equilibrium between ethics, law and economy’. The second sub-theme characterized ‘antibiotic resistance problem as rooted in a low social capital environment’. This reflected the deep causes of antibiotic resistance that go beyond strictly antibiotic management. Lastly pharmacists were found to be ‘wanting to fulfil their educational role’, which is how they felt they could best contribute. The overarching theme ‘Undervalued medicines’ professionals struggling with agency related and structural barriers to meet their deontological duties’- reflects the way pharmacists perceive their current societal standing as well as how their roles are challenged by several barriers that impact their decision-making processes. Study II revealed advantages of community-based behavior change interventions in improving antibiotic use. Multifaceted interventions were found to provide the greatest benefits. Particularly, interventions that combined educational components with persuasion had a better impact across most outcomes (knowledge, attitudes, and beliefs; antibiotic adherence; antibiotic use) compared to interventions focused solely on education. The review also identified challenges in evaluating this type of research and emphasized the necessity for standardized approaches in study design and outcome measurements. While there is some emerging evidence on the cost-effectiveness of these interventions, it remains limited in scope. Study III identified the perceived factors affecting ABC and antibiotic prescribing by family doctors. Some factors pertained to the perceived behavior of family doctors or patients, others were associated with different systems, local contexts, and the COVID-19 pandemic. An overarching theme was articulated: ‘family doctors in Romania see their role differently when it comes to antibiotic resistance and perceive the lack of patient education or awareness as one of the major drivers of ABC’. All these perceived factors spanned the capability, opportunity, and motivational domains of the BCW and could be addressed through a mix of interventions. Study IV found that most students responded they felt prepared in at least 14 areas (covered by 14 questions) (out of 22 areas/questions for medical students, and 19 for pharmacy students). In terms of willingness to engage, a similar trend was observed among both medical and pharmacy students, with scores of 2 out of 4 (4 being the maximum score showing the maximum engagement willingness, considering there are 4 areas of engagement) and 3 out of 4, respectively. A significant proportion, approximately 53.5% (n=254), confirmed that they received sufficient training to ensure the appropriate use of antibiotics in their professional fields. Students who scored low on preparedness expressed a desire for additional education. Regarding their estimation on how antibiotic use will evolve in Romania, the highest number of responses from medical and pharmacy students (n=159, 33.5%), highlighted the view that the situation would worsen. Regarding the survey design, the factor structure identified through Exploratory Factor Analysis (EFA) could not be validated through Confirmatory Factor Analysis (CFA), indicating that further adjustments are required for the model and/or questionnaire. Conclusions: Promising evidence supports the benefits of community-based interventions in enhancing antibiotic use, particularly multifaceted approaches. Considering the impact of the COVID19 pandemic, policymakers should consider these interventions alongside clinical-based approaches to rebuild trust. Inclusive participation in community-based interventions fosters public ownership and utilization of community channels. Romanian healthcare professionals hold diverse perceptions of AMR. Factors influencing appropriate antibiotic use and AMR in Romania include the behaviors of pharmacists, family doctors, patients, the health system, local contexts, and the pandemic's impact. Findings also have important implications for the education and training of future Romanian healthcare professionals, necessitating further research to establish standardized methods for monitoring and evaluating progress in preparedness, engagement willingness, and teaching preferences regarding antibiotic use

The effectiveness of community-based social innovations for healthy ageing in middle- and high-income countries: a systematic review

Objectives: Community-based social innovations (CBSIs) are one type of intervention that may help to address the complex needs of ageing populations globally. The aim of this research was to assess evidence for the effectiveness and cost-effectiveness of CBSIs involving in such contexts. Methods: We conducted a systematic review of CBSIs for healthy ageing in middle- and high-income countries, including any CBSI that aimed to empower people aged 50 and over by motivating them to take initiative for their own health and wellbeing. The protocol was registered with Prospero (CRD 42016051622). A comprehensive search was conducted in 15 academic databases and advanced search in Google. We included published studies from 2000 onwards in any language. Exploratory meta-analysis was conducted for quantitative studies reporting similar outcomes, and qualitative studies were analysed using thematic analysis. Narrative synthesis was conducted. Searches yielded 13,262 unique hits, from which 44 papers met the inclusion criteria. Results: Most studies reported interventions having positive impacts on participants, such as reduced depression, though the majority of studies were classified as being at medium or high risk of bias. There was no evidence on costs or cost-effectiveness and very little reporting of outcomes at an organization or system level. CBSIs have the potential for positive impacts, but with nearly half of studies coming from high-income urban settings (particularly the United Kingdom and the United States of America), there is a lack of generalizability of these findings. Conclusions: Our research highlights the need to improve reporting of CBSIs as complex interventions, and for improved conceptualization of these interventions to inform research and practice

Framework for managing the COVID-19 infodemic : Methods and results of an online, crowdsourced WHO technical consultation

Background: An infodemic is an overabundance of information—some accurate and some not—that occurs during an epidemic. In a similar manner to an epidemic, it spreads between humans via digital and physical information systems. It makes it hard for people to find trustworthy sources and reliable guidance when they need it. Objective: A World Health Organization (WHO) technical consultation on responding to the infodemic related to the coronavirus disease (COVID-19) pandemic was held, entirely online, to crowdsource suggested actions for a framework for infodemic management. Methods: A group of policy makers, public health professionals, researchers, students, and other concerned stakeholders was joined by representatives of the media, social media platforms, various private sector organizations, and civil society to suggest and discuss actions for all parts of society, and multiple related professional and scientific disciplines, methods, and technologies. A total of 594 ideas for actions were crowdsourced online during the discussions and consolidated into suggestions for an infodemic management framework. Results: The analysis team distilled the suggestions into a set of 50 proposed actions for a framework for managing infodemics in health emergencies. The consultation revealed six policy implications to consider. First, interventions and messages must be based on science and evidence, and must reach citizens and enable them to make informed decisions on how to protect themselves and their communities in a health emergency. Second, knowledge should be translated into actionable behavior-change messages, presented in ways that are understood by and accessible to all individuals in all parts of all societies. Third, governments should reach out to key communities to ensure their concerns and information needs are understood, tailoring advice and messages to address the audiences they represent. Fourth, to strengthen the analysis and amplification of information impact, strategic partnerships should be formed across all sectors, including but not limited to the social media and technology sectors, academia, and civil society. Fifth, health authorities should ensure that these actions are informed by reliable information that helps them understand the circulating narratives and changes in the flow of information, questions, and misinformation in communities. Sixth, following experiences to date in responding to the COVID-19 infodemic and the lessons from other disease outbreaks, infodemic management approaches should be further developed to support preparedness and response, and to inform risk mitigation, and be enhanced through data science and sociobehavioral and other research. Conclusions: The first version of this framework proposes five action areas in which WHO Member States and actors within society can apply, according to their mandate, an infodemic management approach adapted to national contexts and practices. Responses to the COVID-19 pandemic and the related infodemic require swift, regular, systematic, and coordinated action from multiple sectors of society and government. It remains crucial that we promote trusted information and fight misinformation, thereby helping save lives.peer-reviewe

What do we know about grant peer review in the health sciences? [version 2; referees: 2 approved]

Background: Peer review decisions award an estimated >95% of academic medical research funding, so it is crucial to understand how well they work and if they could be improved. Methods: This paper summarises evidence from 105 papers identified through a literature search on the effectiveness and burden of peer review for grant funding. Results: There is a remarkable paucity of evidence about the efficiency of peer review for funding allocation, given its centrality to the modern system of science. From the available evidence, we can identify some conclusions around the effectiveness and burden of peer review. The strongest evidence around effectiveness indicates a bias against innovative research. There is also fairly clear evidence that peer review is, at best, a weak predictor of future research performance, and that ratings vary considerably between reviewers. There is some evidence of age bias and cronyism. Good evidence shows that the burden of peer review is high and that around 75% of it falls on applicants. By contrast, many of the efforts to reduce burden are focused on funders and reviewers/panel members. Conclusions: We suggest funders should acknowledge, assess and analyse the uncertainty around peer review, even using reviewers’ uncertainty as an input to funding decisions. Funders could consider a lottery element in some parts of their funding allocation process, to reduce both burden and bias, and allow better evaluation of decision processes. Alternatively, the distribution of scores from different reviewers could be better utilised as a possible way to identify novel, innovative research. Above all, there is a need for open, transparent experimentation and evaluation of different ways to fund research. This also requires more openness across the wider scientific community to support such investigations, acknowledging the lack of evidence about the primacy of the current system and the impossibility of achieving perfection

The Association between Various Lifestyle Patterns and the Body Mass Index in Adolescents

Objective: The study aims to analyze obesogenic behavioral patterns of adolescents living in Mureş County, Romania, as well as to establish a relationship between these behaviors and their Body Mass Index (BMI), in an attempt to provide effective prevention strategies for obesity

The Relationship between Psychological Suffering, Value of Maternal Cortisol during Third Trimester of Pregnancy and Breastfeeding Initiation

Background and Objectives: Cortisol, the stress hormone, is an important factor in initiating and maintaining lactation. Maternal suffering during pregnancy is predictive for the initiation and shorter duration of breastfeeding and can also lead to its termination. The aim of this study is to evaluate the relationship between the level of salivary cortisol in the third trimester of pregnancy and the initiation of breastfeeding in the postpartum period in a cohort of young pregnant women who wanted to exclusively breastfeed their newborns during hospitalization. Materials and Methods: For the study, full-term pregnant women were recruited between January and May 2022 in the Obstetrics and Gynecology Clinic of the Mureș County Clinical Hospital. Socio-demographic, clinical obstetric and neonatal variables were collected. Breastfeeding efficiency was assessed using the LATCH Breastfeeding Assessment Tool at 24 and 48 h after birth. The mean value of the LATCH score assessed at 24 and 48 h of age was higher among mothers who had a higher mean value of salivary cortisol measured in the third trimester of pregnancy (p Results: A quarter of pregnant women had a salivary cortisol level above normal limits during the third trimester of pregnancy. There is a statistically significant association between maternal smoking, alcohol consumption during pregnancy and the level of anxiety or depression. Conclusions: The most important finding of this study was that increased salivary cortisol in the last trimester of pregnancy was not associated with delayed initiation/absence of breastfeeding