The international dimensions of antimicrobial resistance: Contextual factors shape distinct ethical challenges in South Africa, Sri Lanka and the United Kingdom.

Antimicrobial resistance (AMR) describes the evolution of treatment-resistant pathogens, with potentially catastrophic consequences for human medicine. AMR is driven by the over-prescription of antibiotics, and could be reduced through consideration of the ethical dimensions of the dilemma faced by doctors. This dilemma involves balancing apparently opposed interests of current and future patients, and unique contextual factors in different countries, which may modify the core dilemma. We describe three example countries with different economic backgrounds and cultures-South Africa, Sri Lanka and the United Kingdom. Then we discuss how country-specific factors impact on the prominence of various ethical dimensions of the dilemma (visibility and moral equality of future generations; Rule of Rescue; prescribing autonomy and conflicts of interest; consensus on collective action). We conclude that a nuanced understanding of national prescribing dilemmas is critical to inform the design of effective stewardship approaches.

Prosocial Behaviour and Antibiotic Resistance: Evidence from a Discrete Choice Experiment.

INTRODUCTION: The health of a community depends on the health of its individuals; therefore, individual health behaviour can implicitly affect the health of the entire community. This is particularly evident in the case of infectious diseases. Because the level of prosociality in a community might determine the effectiveness of health programmes, prosocial behaviour may be a crucial disease-control resource. This study aimed to extend the literature on prosociality and investigate the role of altruism in antibiotic decision making. METHODS: A discrete choice experiment was conducted to assess the influence of altruism on the general public's preferences regarding antibiotic treatment options. The survey was completed by 378 Swedes. Latent class analysis models were used to estimate antibiotic treatment characteristics and preference heterogeneity. A three-class model resulted in the best model fit, and altruism significantly impacted preference heterogeneity. RESULTS: Our findings suggest that people with higher altruism levels had more pronounced preferences for treatment options with lower contributions to antibiotic resistance and a lower likelihood of treatment failure. Furthermore, altruism was statistically significantly associated with sex, education, and health literacy. CONCLUSIONS: Antibiotic awareness, trust in healthcare systems, and non-discriminatory priority setting appear to be structural elements conducive to judicious and prosocial antibiotic behaviour. This study suggests that prosocial messages could help to decrease the demand for antibiotic treatments.

Understanding and reducing inappropriate antibiotic use in the context of delayed prescriptions.

OBJECTIVE: Antimicrobial resistance is a global health threat perpetuated by the overprescribing of antibiotics in primary care. One strategy to reduce antibiotic use in this setting is delayed prescribing. However, several psychological factors might undermine its effectiveness. The aim of the study was to test whether different interventions aiming at helping patients to manage diagnostic uncertainty in the period of watchful waiting promote appropriate antibiotic use. METHOD: We conducted a preregistered online experiment (N = 690 adult participants from the United Kingdom) in which we modeled delayed prescription in a decision task with behavior-contingent incentives. Participants had either a fictional viral or bacterial infection and received interventions that aimed at facilitating symptom monitoring (i.e., passive monitoring) and engaging participants in the task (i.e., active monitoring). RESULTS: Both interventions decreased antibiotic use when the disease was viral. Active monitoring was more efficient in decreasing antibiotic use than passive monitoring. CONCLUSIONS: The findings have practical implications for managing uncertainty and fostering appropriate antibiotic use in delayed prescribing situations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Reasons for COVID-19 vaccine hesitancy in ethnic minority groups: A systematic review and thematic synthesis of initial attitudes in qualitative research.

Despite being disproportionately affected by the COVID-19 pandemic, ethnic and racial minority groups show widespread vaccine hesitancy. Adherence to ongoing booster vaccine campaigns is required to contain future spread of the virus and protect health systems. This review aims to appraise and synthesise qualitative studies published from December 2021 to February 2022 addressing the issue for an in-depth exploration of initial COVID-19 vaccine hesitancy in minorities, including refugee, asylum seeker and migrant populations. A systematic literature search of five databases identified 15 eligible studies. Thematic synthesis identified three main themes of "institutional mistrust", "lack of confidence in vaccine and vaccine development process", and "lack of reliable information or messengers". Two minor themes included "complacency/perceived lack of need" and "structural barriers to vaccine access". "Institutional mistrust" permeated several other themes, demonstrating the need for culturally sensitive approaches. Applying our findings to the World Health Organisation's Three C Model of vaccine hesitancy, the "confidence" dimension appears to represent a disproportionately large barrier to vaccine uptake in ethnic minority groups. Indeed, nuanced adaptations of the model may be necessary to explain vaccine hesitancy in those groups. Further research is required to explore factors facilitating vaccine uptake to monitor changes in hesitancy over time.

Decision Challenges for Managing Acute Paediatric Infections: Implications for Antimicrobial Resistance.

Overprescribing of antibiotics in paediatrics accounts for a significant proportion of inappropriate antibiotic use in human healthcare, thereby contributing to the global health emergency of antimicrobial resistance. Antimicrobial stewardship efforts are complicated by the unique social dynamics in paediatric healthcare, with a specific challenge being the prominent role of parents and carers who act as intermediaries between prescribers and paediatric patients. In this Perspective article concentrating on healthcare of the United Kingdom, we describe this complicated interplay of different decision stakeholders (patients, parents and prescribers), outline four dimensions of decision challenges (social, psychological, systemic and specific diagnostic and treatment challenges) and provide a number of theory-based strategies for supporting different stakeholders during the decision process, ultimately with the aim of improving antimicrobial stewardship. Key decision challenges for patients and carers include limited knowledge and experience of managing infections, which were exacerbated during the COVID-19 pandemic and frequently result in health anxiety and inappropriate health-seeking behaviours. Challenges for medical prescribers span societal pressures from prominent patient litigation cases, cognitive biases, and system pressures to specific diagnostic problems (e.g., age limitations of current clinical scoring systems). Strategies for mitigating decision challenges in paediatric infection management will need to include a range of context- and stakeholder-specific actions, including improvements of integrated care and public health education as well as better clinical decision tools and access to evidence-based guidelines.

Existing terminology related to antimicrobial resistance fails to evoke risk perceptions and be remembered.

BACKGROUND: Antimicrobial resistance (AMR) is a global healthcare threat promoted by all use of antibiotics. Hence, reducing overuse of antibiotics is essential. The necessary behaviour change relies on effective public health communication, but previous information campaigns-while showing some successes-have fallen short in generating a lasting increase of public awareness. A potential reason for this is AMR-related terminology, which has been criticised as inconsistent, abstract and difficult to pronounce. We report the first empirical test of word memorability and risk association for the most frequent AMR-related health terms. METHODS: Across two surveys sampling 237 US and 924 UK participants, we test people's memory for and the risk they associate with six AMR-related terms and thirty-four additional health risk terms (e.g., cancer). Participants also rate the terms on different linguistic dimensions including concreteness, familiarity, processing fluency and pronounceability. RESULTS: Our findings suggest that existing AMR-related health terms-particularly "AMR" and "Antimicrobial resistance"-are unsuitable for public health communication, because they score consistently low on both memorability and risk association. Out of the AMR terms, "Antibiotic resistance" and-to a lesser extent-"Drug-resistant infections" perform best. Regression analyses suggest that linguistic attributes (e.g., familiarity, processing fluency, pronounceability) are predictors of the terms' risk association. CONCLUSIONS: Our findings highlight an urgent need to rename AMR with a memorable term that effectively signals the existential threat of AMR and thereby motivates a change in antibiotic use. The success of the revised term is likely to depend, at least partially, on its linguistic attributes.

Antimicrobial resistance (AMR) is a serious public health risk. It means that microorganisms, such as bacteria, change in a way that existing medicines, such as antibiotics, no longer kill them. As a result, it may be impossible to treat even common infections. Increasing the public's understanding of AMR could help avoid its development, but to date, awareness campaigns have not been very successful in changing behaviour. Here, we aimed to understand why, by investigating the language used to communicate about AMR. Participants rated how much health risk they associated with different words (i.e., cancer, Ebola, AMR). People generally found it difficult to remember words associated with AMR and did not think they sounded risky compared to other health risk words. Future risk communication might benefit from renaming AMR to better signal the severity of the problem and motivate behaviour change.

Prosociality in the social dilemma of antibiotic prescribing.

Antibiotic prescribing can be conceptualised as a social dilemma in which the overuse of antibiotics, to minimise immediate risks to individual patients, results in a sub-optimal outcome for society (antimicrobial resistance) and increased risks to all patients in the long run. Doctors face the challenge of balancing the interests of individual patients against the collective good when prescribing antibiotics. While evidence suggests that doctors tend to prioritise individual interests over those of the collective, the conventional interpretation of such decisions as selfish may be inappropriate because most doctors are motivated by prosocial concerns about their patients. This review of antibiotic decision research provides a more nuanced understanding of prosociality in the context of the social dilemma of antibiotic prescribing.

Scoping Review of National Antimicrobial Stewardship Activities in Eight African Countries and Adaptable Recommendations.

Antimicrobial resistance (AMR) is a global health problem threatening safe, effective healthcare delivery in all countries and settings. The ability of microorganisms to become resistant to the effects of antimicrobials is an inevitable evolutionary process. The misuse and overuse of antimicrobial agents have increased the importance of a global focus on antimicrobial stewardship (AMS). This review provides insight into the current AMS landscape and identifies contemporary actors and initiatives related to AMS projects in eight African countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, and Zambia), which form a network of countries participating in the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme. We focus on common themes across the eight countries, including the current status of AMR, infection prevention and control, AMR implementation strategies, AMS, antimicrobial surveillance, antimicrobial use, antimicrobial consumption surveillance, a one health approach, digital health, pre-service and in-service AMR and AMS training, access to and supply of medicines, and the impact of COVID-19. Recommendations suitable for adaptation are presented, including the development of a national AMS strategy and incorporation of AMS in pharmacists' and other healthcare professionals' curricula for pre-service and in-service training.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-Saharan Africa: A Co-Creation Consensus Approach.

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa, as well as to implement the checklist in health institutions in four African countries. The AMS checklist tool was developed using a modified Delphi approach to achieve local expert consensus on the items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, Ghana and the UK were invited to review, score and comment on items from a published global AMS checklist. Following their feedback, 8 items were rephrased, and 25 new items were added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites. The final tool comprised 54 items. Across the 14 sites, the completed checklists consistently showed improvements for all the AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). The elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing the quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions. Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist, which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. This study extends the existing AMS materials for low- and middle-income countries and provides empirical evidence for successful use in practice.

Attitudes towards influenza and uptake of the flu vaccine: A survey of pharmacy staff working in English hospitals.

OBJECTIVES: Pharmacy staff working in hospitals are at risk of contracting and disseminating influenza. Previous research focuses on community pharmacists' attitudes towards influenza and vaccination. This survey investigates the beliefs and attitudes of pharmacists and other pharmacy staff working in English Hospitals regarding influenza and the vaccine and how this relates to vaccine uptake. METHODS: A self-administered survey was provided to pharmacy staff at three hospitals in the East Midlands of England. Job role, age and vaccination status (vaccinated, intended to be vaccinated, and not vaccinated) were collected alongside ratings of agreement with 20 statements regarding influenza and vaccination using a Likert scale. RESULTS: 170 pharmacy staff responded; 50.6% had been vaccinated, 17.1% intended to be vaccinated and 32.4% were not vaccinated. Increasing age showed a significant (p = 0.017) positive correlation with increased vaccine uptake as did the beliefs that vaccination protects the individual from influenza (p = 0.049) and that vaccination should be mandatory for NHS staff (p = 0.006). Fear of needles and believing their immune system is strong enough to protect against influenza were negatively correlated with vaccine uptake (p = 0.016 and p = 0.010, respectively). Job role was also strongly correlated with vaccine uptake (p = 0.001), with those holding a pharmacy degree more likely to report being vaccinated or intending to be vaccinated compared to all other pharmacy staff groups. CONCLUSIONS: This is the first survey to focus on vaccine behaviours of all pharmacy staff groups working in hospitals. Current uptake of the influenza vaccine may be increased through engagement of senior pharmacy colleagues and providing education on influenza, vaccines, and vaccination. Similar studies should be undertaken on a larger scale to fully interrogate the differences between pharmacy staff groups.

Modelling collective action to change social norms around domestic violence: social dilemmas and the role of altruism.

Interventions promoting collective action have been used to prevent domestic violence in a range of settings, but their mechanisms of operation remain unclear. We formalise and combine feminist theoretical approaches to domestic violence into a game-theoretic model of women's collective action to change gendered social norms and outcomes. We show that social norms create a social dilemma in which it is individually rational for women to abstain from action to prevent domestic violence among neighbours, but all women suffer negative consequences if none take action. Promoting altruism among women can overcome the social dilemma. Discouraging women from tolerating domestic violence, imposing additional external punishment on men for perpetrating violence, or lowering costs to women of taking action against violence may not work or even backfire. We invite researchers on community mobilisation to use our framework to frame their understandings of collective action to prevent domestic violence.

Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts-A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa.

Antimicrobial stewardship programs focus on reducing overuse of broad-spectrum antibiotics (BSAs), primarily through interventions to change prescribing behavior. This study aims to identify multi-level influences on BSA overuse across diverse high and low income, and public and private, healthcare contexts. Semi-structured interviews were conducted with 46 prescribers from hospitals in the UK, Sri Lanka, and South Africa, including public and private providers. Interviews explored decision making about prescribing BSAs, drivers of the use of BSAs, and benefits of BSAs to various stakeholders, and were analyzed using a constant comparative approach. Analysis identified drivers of BSA overuse at the individual, social and structural levels. Structural drivers of overuse varied significantly across contexts and included: system-level factors generating tensions with stewardship goals; limited material resources within hospitals; and patient poverty, lack of infrastructure and resources in local communities. Antimicrobial stewardship needs to encompass efforts to reduce the reliance on BSAs as a solution to context-specific structural conditions.

Nomen est omen: why we need to rename 'antimicrobial resistance'.

The naming of diseases is a critical aspect of public health communication. In light of the recent renaming of the 'Wuhan novel coronavirus' to COVID-19, the names of other health threats must be reviewed. In particular, a new name is urgently needed for the global challenge typically referred to as 'antimicrobial resistance'. The current name is inconsistently used, difficult to pronounce and lacks meaning for lay audiences. It also fails to express the magnitude of the phenomenon's potential consequences for human medicine. This article reviews and evaluates key findings from several cross-disciplinary streams of research on the psycholinguistic properties of names. These include early psychology literature pertaining to the concept of 'word attensity', recent cognitive research on 'processing fluency' in the context of word recognition, and relevant marketing literature examining the components of successful branding strategies. Three key criteria-pronounceability, meaningfulness and specificity-are found to influence the perception of names and these are discussed in the context of antimicrobial resistance. The article demonstrates that the current term of 'antimicrobial resistance' falls short with regard to all three criteria and concludes with specific recommendations for the creation of a new name. Only the strategic choice of a single term that is (i) short and easy to pronounce; (ii) intuitively meaningful to lay audiences and indicative of the existential threat linked to antimicrobial resistance; and (iii) uniquely associated with the topic of antimicrobial resistance is likely to bring about overdue change in the global discussion of antimicrobial resistance.

The Need for Ongoing Antimicrobial Stewardship during the COVID-19 Pandemic and Actionable Recommendations.

The coronavirus disease (COVID-19) pandemic, which has significant impact on global health care delivery, occurs amid the ongoing global health crisis of antimicrobial resistance. Early data demonstrated that bacterial and fungal co-infection with COVID-19 remain low and indiscriminate use of antimicrobials during the pandemic may worsen antimicrobial resistance It is, therefore, essential to maintain the ongoing effort of antimicrobial stewardship activities in all sectors globally.

Moral and Contextual Dimensions of "Inappropriate" Antibiotic Prescribing in Secondary Care: A Three-Country Interview Study.

Overuse of broad-spectrum antibiotics in secondary care is a key contributor to the emergence and spread of antimicrobial resistance (AMR); efforts are focused on minimizing antibiotic overuse as a crucial step toward containing the global threat of AMR. The concept of overtreatment has, however, been difficult to define. Efforts to address the overuse of medicine need to be informed by an understanding of how prescribers themselves understand the problem. We report findings from a qualitative interview study of 46 acute care hospital prescribers differing in seniority from three countries: United Kingdom, Sri Lanka and South Africa. Prescribers were asked about their understanding of inappropriate use of antibiotics. Prescriber definitions of inappropriate use included relatively clear-cut and unambiguous cases of antibiotics being used "incorrectly" (e.g., in the case of viral infections). In many cases, however, antibiotic prescribing decisions were seen as involving uncertainty, with prescribers having to make decisions about the threshold for appropriate use. Decisions about thresholds were commonly framed in moral terms. Some prescribers drew on arguments about their duty to protect public health through having a high threshold for prescribing, while others made strong arguments for prioritizing risk avoidance for the patients in front of them, even at a cost of increased resistance. Notions of whether prescribing was inappropriate were also contextually dependent: high levels of antibiotic prescribing could be seen as a rational response when prescribers were working in challenging contexts, and could be justified in relation to financial and social considerations. Inappropriate antibiotic use is framed by prescribers not just in clinical, but also in moral and contextual terms; this has implications for the design and implementation of antibiotic stewardship interventions aiming to reduce inappropriate use of antibiotics globally.

Harnessing the wisdom of crowds can improve guideline compliance of antibiotic prescribers and support antimicrobial stewardship.

Antibiotic overprescribing is a global challenge contributing to rising levels of antibiotic resistance and mortality. We test a novel approach to antibiotic stewardship. Capitalising on the concept of "wisdom of crowds", which states that a group's collective judgement often outperforms the average individual, we test whether pooling treatment durations recommended by different prescribers can improve antibiotic prescribing. Using international survey data from 787 expert antibiotic prescribers, we run computer simulations to test the performance of the wisdom of crowds by comparing three data aggregation rules across different clinical cases and group sizes. We also identify patterns of prescribing bias in recommendations about antibiotic treatment durations to quantify current levels of overprescribing. Our results suggest that pooling the treatment recommendations (using the median) could improve guideline compliance in groups of three or more prescribers. Implications for antibiotic stewardship and the general improvement of medical decision making are discussed. Clinical applicability is likely to be greatest in the context of hospital ward rounds and larger, multidisciplinary team meetings, where complex patient cases are discussed and existing guidelines provide limited guidance.

Improving shared health decision making for children and adolescents with chronic illness: A narrative literature review.

OBJECTIVE: This review aims to increase understanding of health decision-making by children and adolescents with chronic illnesses and offer suggestions for improving shared decision-making with healthcare professionals. METHODS: Using cross-disciplinary publication databases, we surveyed literature on children's and adolescents' health decision-making from psychology, health sciences, and neuroscience. RESULTS: Several factors influencing health decision-making were identified. Considering neurobiological aspects, children lack functionality in the frontal lobe resulting in lesser cognitive control and higher risk-taking compared to adults. Additionally, adolescents' generally higher arousal of socioemotional systems demonstrates neurological underpinnings for reward-seeking behaviours. Psychological investigations of children's health decision-making indicate important age-dependent differences in risk-taking, locus of control, affect and cognitive biases. Furthermore, social influences, particularly from peers, have a large, often negative, effect on individual decision-making due to desire for peer acceptance. CONCLUSION: Acknowledging these factors is necessary for optimising the process of shared decision-making to support minors with chronic illnesses during healthcare consultations. PRACTICE IMPLICATIONS: Doctors and other healthcare professionals may need to counteract some adolescents' risk-taking behaviours which are often spurred by peer pressure. This can be achieved by highlighting the patient's control over health outcomes, emphasising short-term benefits and long-term consequences of risky behaviours, and recommending peer support networks.

Medical prescribing and antibiotic resistance: A game-theoretic analysis of a potentially catastrophic social dilemma.

The availability of antibiotics presents medical practitioners with a prescribing dilemma. On the one hand, antibiotics provide a safe and effective treatment option for patients with bacterial infections, but at a population level, over-prescription reduces their effectiveness by facilitating the evolution of bacteria that are resistant to antibiotic medication. A game-theoretic investigation, including analysis of equilibrium strategies, evolutionarily stability, and replicator dynamics, reveals that rational doctors, motivated to attain the best outcomes for their own patients, will prescribe antibiotics irrespective of the level of antibiotic resistance in the population and the behavior of other doctors, although they would achieve better long-term outcomes if their prescribing were more restrained. Ever-increasing antibiotic resistance may therefore be inevitable unless some means are found of modifying the payoffs of this potentially catastrophic social dilemma.