AMR policy priorities and planning

1. General public awareness and action is a policy priority but implementation plans require development.

Public policy statements on AMR incorporate the need to address public awareness and consumer behaviour (see Table 1). These policy statements and others like them confirm that there is policy support for attention to be given to members of the general public, their awareness of AMR and the action they can take to assist its reduction.

Less obvious in these policy framings is guidance on what action publics need to take and how best to assist them to do so. This information is needed to specify behaviours that contribute to AMR and that need to be altered, and which groups need specific kinds of advice and support. For example, are publics simply expected to endorse efforts to reduce AMR, and comply with expert advice? Or are they expected to learn about and understand AMR, and make changes in their healthcare practices, including hand hygiene, coughing and sneezing etiquette, or delay use of antibiotics?

These documents also do not remark on which members of the general public ought to get what support. This lack of specificity shows up in surveys of knowledge (McCullough et al., 2015), and our research (see below), which find that publics, for example, continue to muddle bacteria and viruses, misconstrue antimicrobial resistance as a property of their immune systems, and are unsure what is expected of them.

Policy extracts

1. A massive global public awareness campaign.

We need to improve global awareness of AMR across the board, so that patients and farmers do not demand, and clinicians and veterinarians do not prescribe, antibiotics when they are not needed, and so that policy makers ensure that policies to tackle AMR are taken forward now. The cost of running a sustained public awareness campaign across the world would depend on its nature and scope. Based on estimates we have considered, it could cost between 40 and 100 million USD a year. It could be met by a mix of existing public health programmes in high income countries, support for programmes in low and middle income countries and corporate sponsorship for major events.

➡︎ UK Review on Antimicrobial Resistance, 2016, p. 4

3. Greater engagement in the combat against resistance

Priority areas for action

3.1) Develop and implement a coordinated, One Health communication strategy, as well as monitoring and   evaluation, to support whole-of-society awareness and behavioural change

3.2) Strengthen public and political awareness to champion and improve the understanding of the importance of combatting antimicrobial resistance

3.3) Create new and different key antimicrobial resistance messages that resonate with society

3.4) Drive education and training initiatives across all relevant sectors and increase accessibility to evidence-based best practice information

➡︎ Australia’s National Antimicrobial Resistance Strategy: 2020 & Beyond, p. 9.

2. The general public contribution to AMR incidence and prevalence not yet understood in ways that could lead to intervention priorities.

There is little policy guidance on which groups among the general population could be addressed to increase the impact of antimicrobial stewardship. Surveillance data gives some direction for the identification of priority groups for policy on public awareness and action. Data shows that people under the age of 5 years and those over 65 (Australian Commission on Safety and Quality in Health Care, 2019), use antibiotics more than other age groups, mostly for acute respiratory infections, though it is not clear how much of this use is not clinically-justified or how much of it contributes to AMR. Initiatives such as the Global Antimicrobial Resistance Surveillance System (GLASS) (https://www.who.int/glass/en/), are attempting to generate evidence to help set priorities and monitor impacts.

3. Goals and targets for public awareness and action are not clear or specified in implementation plans.

The lack of priority groups is coupled with some fuzziness with regard to behavioural targets and the general public. Evidence reviews (Burstein et al., 2019, Catalan-Matamoros et al., 2019, Cross et al., 2017, Fletcher-Miles et al., 2019, Price et al., 2018), document how public awareness and action on antimicrobial use is defined using somewhat variable and imprecise concepts (‘prudent’, ‘appropriate’, ‘improving’, ‘judicious’, ‘good’, ‘responsible’, ‘correct’, ’careful’), or defined in the negative (‘misunderstanding’, ‘misuse’, ‘in-adherence’, ‘imprudent’). Lack of clarity also hampers research and evaluation as the markers of awareness and action cannot be monitored properly if they are not agreed and robustly operationalised in surveillance methods.

AntibioticGuardian.com, is an awareness and action intervention that, uniquely, does specify what is expected of the general public. It demonstrates behaviour change techniques (behavioural contract and goal setting) and specifies what individuals can do to help reduce AMR in the form of pledges (see Table 2). AntibioticGuardian pledges may help to clarify what is expected of general public awareness and action. Significantly, these pledges locate awareness and action in the context of the quotidian management of infections and compliance with prescriber and dispenser advice.

AntibioticGuardian.com pledges for the general public

For infections that our bodies are good at fighting off on their own, like coughs, colds, sore throats and flu, I pledge to try treating the symptoms for five days rather than going to the GP

For infections that our bodies are good at fighting off on their own, like coughs, colds sore throats and flu, I pledge to talk to my pharmacist about how to treat the symptoms first rather than going to the GP

It is vital we prevent antibiotics from getting into the environment. I pledge to always take any unused antibiotics to my pharmacy for safe disposal

If the NHS offers me a flu vaccination, I pledge to accept

If I’m prescribed antibiotics, I will take them exactly as prescribed and never share them with others

4. The communications and behaviour theory base for public awareness and action is weak and as yet not fully articulated with social science concepts from sociology, anthropology and media studies.

Reviews of evidence (Burstein et al., 2019, Catalan-Matamoros et al., 2019, Cross et al., 2017, Fletcher-Miles et al., 2019, Price et al., 2018), reveal that public facing campaigns, if they do reflect on their assumptions, most commonly assume that communication is the transmission of information and advice (Andersen et al., 2019, Dyar et al., 2014, Gennimata et al., 2011) (Kendra et al., 2015). This assumption needs to be reconsidered in light of digital media and social interaction (Davis et al., 2017, Lupton, 2018), audience fragmentation (Jenkins, 2006), and the economic rationality of media production (Webster, 2014).

The evidence reviews show that various models of behaviour change are used in the field, including ‘implementation intention strategy’ ‘intention behaviour gap’, ‘cognitive appraisal’ ‘accountability’. Researchers (McParland et al., 2018), reviewed the evaluation literature on public facing campaigns to identify behaviour change techniques used to design interventions, and found that 4/20 articles made explicit reference to behaviour change concepts. It is also not clear how well these models – mostly developed in health psychology for vaccine uptake and tobacco smoking cessation – will help to realise the policy aspiration of ‘whole-of-society awareness and behavioural change.’ Langdridge et al. (2018), reviewed the evaluation literature to consider how AMR messages convey emotion and culpability, dimensions of interventions that need to be further researched and theorised to enhance effectiveness and avoid counterproductive effects.

An emerging literature is also drawing attention to the drawbacks of over-reliance on behavioural economics and nudging, since these do not augur well for civil society trust in public health expertise and may intensify practices that advantage some parts of the population but leave others behind (Will, 2016, Will, 2020).