General public explanations of AMR

1. Interviewees were willing to talk about antibiotics and AMR

A key finding was that we found it easy to recruit interviewees who wanted to talk about antibiotics and AMR. Interviewees were generous with their time and story-telling, indicating that the topics covered were significant for them. Moreover, interviewees attempted to explain AMR, even when they were aware that they were not sure about the biological and medical concepts that underpin antibiotics and resistance. This commitment on the part of the research participants underlined that there is, in general, considerable good will in the general population for efforts to address AMR.

2. Interviewees had general awareness and partial knowledge of AMR

Though interviewees had heard of AMR/superbugs and accepted the AMR challenge, many showed surprise at the extent of the problem. AMR, in general, is not well understood or easily explained. Interviewees accepted the concept of AMR, though ability to talk about it was somewhat limited.

AMR-scapes findings echoed previous research. Surveys demonstrate: beliefs that bacteria are the same as viruses; not understanding that antibiotics are used for bacterial infections; endorsing prescription sharing; low awareness of AMR (McCullough et al., 2015, McNulty et al., 2016). A persistent finding is that many individuals have the view that the body and not microbes resist antibiotics (Brookes-Howell et al., 2012a, McCullough et al., 2015). Qualitative research shows that Australians have indicated the need for more precise information to enable them to act on their use of antibiotics (Lum et al., 2017). New Zealanders focussed on the management of infections, not AMR, and were concerned about the impact of antibiotics on the ‘body’s ‘balance’ (Norris et al., 2013, page 465).

3. Interviewee awareness, knowledge and healthcare shaped by education, science literacy and Cultural and Linguistic Diversity (CALD)

The interviews demonstrated that explanations of AMR were moderated by social factors including education, awareness and acceptance of science, and cultural backgrounds (Whittaker et al., 2019, Davis et al., 2020a, Lohm et al., 2020). It is likely that effective policy and communications will need to acknowledge these differences.

Most interviewees attempted to explain AMR when we asked them to do so. Few were capable of creating an orthodox, scientific explanation, and even those were partial. In general, those with more years of education were more willing to attempt explanations of AMR using scientific concepts, i.e., bacterial resistance. This pattern in the data foregrounds the science literacy needed to decode AMR messages.

Table 4. Interview narratives on ‘bicultural’ use of antibiotics

People from CALD backgrounds provided ‘bicultural’ narratives of AMR, infection and antibiotics, i.e., they spoke of their experiences using antibiotics in Australia and countries of origin and/or heritage and reflected on differences in terms of ease of access, use of alternative medicines and safety of health systems (See Table 4). For example, the Australian system of prescription regulated access to antibiotics is not the case in all countries. For people not born in Australia this difference, along with different customs in the ways that drugs (including antibiotics) are used at times resulted in participants discussing actions that were not consistent with antimicrobial stewardship. It is relevant that participants did not report taking such transgressive actions themselves but spoke of others’ behaviours (perhaps as a means of representing themselves as responsible antibiotic-using citizens).

Supporting CALD communities needs to extend beyond simply providing information in various languages, as the reduction in the use of clinically-unjustified antibiotics entails the modification of well-established consumer practices.

4. Self-defence immunity and habituation were the prevailing AMR explanatory models

As Table 5 demonstrates, individuals admitted that they did not understand AMR, or attempted to explain it using concepts that included evolution, ecological changes, agriculture, population mobility, and the hygiene hypothesis. Some interviewees attempted to explain AMR using orthodox, scientific explanations of changes in bacterial resistance to antimicrobials, and notions of over- and misuse of antibiotics.

These explanations, however, often coexisted with a notion that one’s body comes to resist antibiotics, as has been identified in previous research (Brookes-Howell et al., 2012a), and echoing common understandings of immunity as a self-defence system (Cohen, 2009), and/or habituation theory (Erblich, 2019).

5. Interviewees were not sure what was expected of them with regard to antibiotic use

Interviewees were in general aware of the need to use antibiotics carefully, but were not clear on how this should be done and if it applied to them. They expressed confusion about what action they should take.

Some interviewees were unaware of how antibiotics were different to medications used to reduce the symptoms of illness. For example, Panadol was readily understood to be used for headaches and that when the headache was gone, medication ceased. This accepted pattern led to some confusion about how to ‘correctly’ use antibiotics.

As much research has shown (McCullough et al., 2015, McNulty et al., 2016), there existed a lack of clarity about the difference between bacteria and viruses along with the knowledge that antibiotics are only effective for bacterial infections. This led to some confusion about when and why antibiotics may or may not be appropriate.

There was also some confusion about how to use prescriptions and manage remaining antibiotics. Some interviewees spoke of second prescriptions given in case symptoms did not clear up after one course. Some participants filled antibiotic prescriptions prior to travel for use should they become unwell. Thus, there were likely to be unfilled prescriptions and unused antibiotics in community settings, that may increase likelihood of off-prescription use.

Table 5. Explanatory models of AMR. Source: Davis et al., 2020a

6. Antibiotic prescribers regarded as trustworthy, with some exceptions

No-one reported dissatisfaction with medical practitioners and antibiotics, though some spoke of those ‘others’ who too readily prescribed them and patients who too readily sought them out. Interviewees focussed foremost on their bodies and practical healthcare solutions. When doctors were consulted, participants said that they were happy to wait or not receive antibiotics if the reason was explained. Participants also spoke of seeking information and relief from symptoms, and not necessarily antibiotics, echoing previous research (Van Driel et al., 2006, Del Mar et al., 2012, Knottnerus et al., 2013).

7. Little evidence of consumer pressure on prescribers

The common depictions of the patient as expecting or demanding of prescription (Biezen et al., 2017, Brookes-Howell et al., 2012b, Cabral et al., 2015), were not supported by the interviews, though interviewees may have been unwilling to disclose in ways that could lead to moral jeopardy. The interviews were in keeping with other research that argues patients expect solutions that do not necessarily include antibiotics, they seek symptom and pain relief, and show willingness to delay the use of antibiotics (Van Driel et al., 2006, Del Mar et al., 2012, Knottnerus et al., 2013).

Some ‘I have a friend … …’ stories were related of people who did seek out antibiotics against medical advice. Perhaps more significantly, no-one spoke of being refused treatment or of mistrust and unhappiness with their GPs. This finding is doubly significant because our sample was recruited through community settings and not general practice clinics. In addition, interviewees spoke of antibiotic prophylaxis for travel, on occasion supported by a GP, and also use of antibiotics off-prescription overseas.

8. Digital media appear to be a significant source of information for healthcare and AMR

We asked participants about their sources of information about AMR and media use, which sources they trusted, and how they used them (See Table 6). Most participants reported that they were aware of AMR/superbugs and attributed their awareness to media sources, but without specific recollection. In addition, AMR was depicted as a distant risk that was not personally resonant.

Notably, several interviewees recalled debate in the media about whether or not to complete a course of antibiotics following on from news items on new findings from the BMJ (Llewelyn et al., 2017).

Sources of AMR awareness nominated in the interviews comprised: medical practitioners, media in general, digital media (Google search, wikis, Facebook), printed news, television news, and social networks. No-one mentioned Antibiotic Awareness Week or any public facing AMR campaigns.

Table 6. Sources of AMR information

9. Antibiotics use contexts include, pet care, travel, parenting, early intervention and self-care

A key finding was that antibiotic use was context specific, that is, the occurrence of symptoms and risks for infection, seeking care, and taking a prescription were tied to life events for the interviewee or their loved ones (including companion animals). Moreover, these contexts were shaped by factors, some of which, were not under volitional control. This aspect of antibiotic use gave it an emergent, responsive quality imbued with some uncertainties. The key ‘contexts’ we have identified comprise (See Table 7):

• Pet care
• Travel
• Parenting
• Early intervention
• Self-care

Pet care

Participants were directly asked if they had pets and whether they had been treated with antibiotics. Most pet owners acknowledged that at some time their pet had been treated with antibiotics. Talk of their pets’ antibiotic treatment was starkly different to general talk about their own, or even their children’s, use of antibiotics. For pets, there appeared to be no hesitation to administer antibiotics, even among participants who spoke of trying to avoid the unnecessary use of antibiotics for the humans in their household.

Travel

Antibiotic use is also somewhat context dependent and can be markedly emergent. For example, illness during international travel was at times linked with unusual antibiotic use. Tamara’s story (See Table 7) and others like it demonstrated how life circumstances shape how antibiotics are used. Other examples in our interviews included, antibiotic prescription for use PRN during international travel, and childhood illness and travel.

Parenting

Both male and female participants spoke about making decisions relating to their children’s health including giving them antibiotics. Whilst more female participants provided this information it was evident that many of the fathers under the age of 50 shared in decision making.

Early intervention

Another important context for the use of antibiotics was chronic illness or other biographical circumstances that led to early intervention. In this context, previous experience with serious infections and/or diagnosis with respiratory illness and similar conditions, was the basis for seeking medical advice as soon as possible. In part, this approach was also predicated on knowing the body and how symptoms could progress. Early intervention was also somewhat dependent on a pre-existing relationship with a medical practitioner due to chronic illness.

Self-care

A further antibiotics context pertained to avoiding them and/or adopting over the counter treatments, home remedies and traditional medicines to manage symptoms while the supposed infection took its course. Like early intervention, this approach was based on prior knowledge of the body and a degree of trust in its innate capacity to heal.

Table 7. Key contexts of antibiotic use

These contexts – pet care, travel, parenting, early intervention and self-care – provided a picture of the myriad ways in which antibiotics might be used in everyday life. A key feature of these narratives was time. For example, antibiotic use was linked with specific events in time, such as an infection in a companion animal, travelling or a child’s illness. For those seeking early intervention, their approach was to minimise the time between symptoms and treatment. For those embarking on self-care, their approach included allowing the body time to heal. These perspectives are important as they situate prescribing in life worlds that extend beyond the clinical encounter and that are temporally organised. Figure 2 (below) summarises these contexts and the reasons and factors interviewees used to explain them.