Reducing expectations for antibiotics in primary care: a randomised experiment to test the response to fear-based messages about antimicrobial resistance.

BACKGROUND: To reduce inappropriate antibiotic use, public health campaigns often provide fear-based information about antimicrobial resistance (AMR). Meta-analyses have found that fear-based campaigns in other contexts are likely to be ineffective unless respondents feel confident they can carry out the recommended behaviour ('self-efficacy'). This study aimed to test the likely impact of fear-based messages, with and without empowering self-efficacy elements, on patient consultations/antibiotic requests for influenza-like illnesses, using a randomised design. METHODS: We hypothesised that fear-based messages containing empowering information about self-management without antibiotics would be more effective than fear alone, particularly in a pre-specified subgroup with low AMR awareness. Four thousand respondents from an online panel, representative of UK adults, were randomised to receive three different messages about antibiotic use and AMR, designed to induce fear about AMR to varying degrees. Two messages (one 'strong-fear', one 'mild-fear') also contained empowering information regarding influenza-like symptoms being easily self-managed without antibiotics. The main outcome measures were self-reported effect of information on likelihood of visiting a doctor and requesting antibiotics, for influenza-like illness, analysed separately according to whether or not the AMR information was 'very/somewhat new' to respondents, pre-specified based on a previous (non-randomised) survey. RESULTS: The 'fear-only' message was 'very/somewhat new' to 285/1000 (28.5%) respondents, 'mild-fear-plus-empowerment' to 336/1500 (22.4%), and 'strong-fear-plus-empowerment' to 388/1500 (25.9%) (p = 0.002). Of those for whom the respective information was 'very/somewhat new', only those given the 'strong-fear-plus-empowerment' message said they would be less likely to request antibiotics if they visited a doctor for an influenza-like illness (p < 0.0001; 182/388 (46.9%) 'much less likely'/'less likely', versus 116/336 (34.5%) with 'mild-fear-plus-empowerment' versus 85/285 (29.8%) with 'fear-alone'). Those for whom the respective information was not 'very/somewhat new' said they would be less likely to request antibiotics for influenza-like illness (p < 0.0001) across all messages (interaction p < 0.0001 versus 'very/somewhat new' subgroup). The three messages had analogous self-reported effects on likelihood of visiting a doctor and in subgroups defined by believing antibiotics would 'definitely/probably' help an influenza-like illness. Results were reproduced in an independent randomised survey (additional 4000 adults). CONCLUSIONS: Fear could be effective in public campaigns to reduce inappropriate antibiotic use, but should be combined with messages empowering patients to self-manage symptoms effectively without antibiotics.

Reducing Primary Care Attendance Intentions for Pediatric Respiratory Tract Infections.

PURPOSE: The aim of this study was to evaluate a theory and evidence-based, parent-targeted online intervention, combining microbiological local syndromic surveillance data, symptom information, and home-care advice, to reduce primary care attendance for self-limiting, low-risk pediatric respiratory tract infections (RTIs). METHODS: The effect of this novel intervention on primary care attendance intentions was evaluated in an online experimental study. A representative sample of mothers (n = 806) was randomly assigned to receive the intervention material before (intervention) or after (control) answering questions concerning attendance intentions for an RTI illness scenario and mediating factors. Both groups provided feedback on the material. Group comparisons, linear regression, and path analyses were conducted. RESULTS: Intervention participants reported lower attendance intentions compared with control participants (d = 0.69, 95% CI, 0.55-0.83), an effect that remained when controlling for demographic and clinical characteristics (B = -1.62, 95% CI, -1.97 to -1.30). The path model highlighted that the intervention effect (B = -0.33, 95% CI, -0.40 to -0.26) was mostly indirect and mediated by infection and antibiotic knowledge, symptom severity concerns, and social norm perceptions concerning attendance. Information on when to attend was rated as the most important intervention component 227 times, followed by symptoms rated 186 times. Information on circulating viruses was rated as least important 274 times. CONCLUSIONS: The intervention was effective in reducing primary care attendance intentions by increasing knowledge, lowering attendance motivation, and reducing the need for additional resources. The contribution of individual intervention components and effects on behavioral outcomes requires further testing.

The Community Integration Questionnaire - Revised: Australian normative data and measurement of electronic social networking.

BACKGROUND/AIM: Consideration of the relationship between meaningful participation, health and wellbeing underpins occupational therapy intervention, and drives measurement of community integration following acquired brain injury (ABI). However, utility of community integration measures has been limited to date by lack of normative data against which to compare outcomes, and none examine the growing use of electronic social networking (ESN) for social participation. This research had four aims: (i) develop and pilot items assessing ESN to add to the Community Integration Questionnaire, producing the Community Integration Questionnaire-Revised (CIQ-R); (ii) examine factor structure of the CIQ-R; (iii) collect Australian CIQ-R normative data; and (iv) assess test-retest reliability of the revised measure. SETTING: Australia. PARTICIPANTS: A convenience sample of adults without ABI (N = 124) was used to develop and pilot ESN items. A representative general population sample of adults without ABI aged 18-64 years (N = 1973) was recruited to gather normative CIQ-R data. DESIGN: Cross-sectional survey. MAIN MEASURES: Demographic items and the CIQ-R. RESULTS: The CIQ-R demonstrated acceptable psychometric properties, with minor modification to the original scoring based on the factor analyses provided. Large representative general population CIQ-R normative data have been established, detailing contribution of a range of independent demographic variables to community integration. CONCLUSION: The addition of electronic social networking items to the CIQ-R offers a contemporary method of assessing community integration following ABI. Normative CIQ-R data enhance the understanding of community integration in the general population, allowing occupational therapists and other clinicians to make more meaningful comparisons between groups.

Children's sun exposure and sun protection: prevalence in Australia and related parental factors.

BACKGROUND: Reducing childhood exposure to ultraviolet radiation is important to minimize lifetime skin cancer risk. OBJECTIVES: We sought to describe the prevalence of children's sun-related behaviors and associated parental and other factors. METHODS: In weekly cross-sectional telephone interviews during summer, 1140 parents/guardians of children aged 0 to 11 years were recruited. Parents provided proxy reports for one of their children. Key questions related to weekend sun protection and sunburn, parent's sun-related attitudes, and demographic characteristics. Potential predictors of children's sun protection and sunburn were analyzed adjusting for covariates including weather conditions on the previous weekend. RESULTS: On summer weekends, 73% of children spent longer than 15 minutes outdoors in peak ultraviolet radiation periods. Of these, 64% were protected by a hat and 58% by sun-protection factor 15 or higher sunscreen, 32% stayed under shade, and 18% wore three-quarter or long-sleeved tops. Overall, 8% of children had sunburn. Parental attitudes were typically supportive of children's sun protection. Parental use of hats (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.6-6.2), shade (OR 9.6; 95% CI 4.4-20.8), sunscreen (OR 12.6; 95% CI 5.2-30.4), longer leg cover (OR 10.3; 95% CI 4.4-24.0), and two or more protective behaviors (OR 5.7; 95% CI 2.8-11.9) increased the odds of their children practicing these behaviors, as did some parental attitudes. LIMITATIONS: We relied on cross-sectional parent reports. CONCLUSION: Although children's sun protection was favorable, there was room for improvement. Health promotion to improve sun-protection practices in adults may benefit children's sun-safe behaviors.

The role of overweight and obesity in perceived risk factors for cancer: implications for education.

Epidemiological evidence indicates that obesity plays an important role in cancer incidence. A telephone survey of 1,433 adults, aged 18+ years who reported their knowledge and beliefs regarding behavioral risk factors for cancer, was conducted. Most respondents believed that people can take steps to reduce cancer risk; however, many, particularly obese respondents, did not rate being overweight as a very important risk factor. A dedicated public education campaign focused on overweight and cancer is needed to address the significant gap in knowledge about the role of weight control in preventing cancer, particularly among those most afflicted.

Content and Mechanism of Action of National Antimicrobial Stewardship Interventions on Management of Respiratory Tract Infections in Primary and Community Care.

A major modifiable factor contributing to antimicrobial resistance (AMR) is inappropriate use and overuse of antimicrobials, such as antibiotics. This study aimed to describe the content and mechanism of action of antimicrobial stewardship (AMS) interventions to improve appropriate antibiotic use for respiratory tract infections (RTI) in primary and community care. This study also aimed to describe who these interventions were aimed at and the specific behaviors targeted for change. Evidence-based guidelines, peer-review publications, and infection experts were consulted to identify behaviors relevant to AMS for RTI in primary care and interventions to target these behaviors. Behavior change tools were used to describe the content of interventions. Theoretical frameworks were used to describe mechanisms of action. A total of 32 behaviors targeting six different groups were identified (patients; prescribers; community pharmacists; providers; commissioners; providers and commissioners). Thirty-nine interventions targeting the behaviors were identified (patients = 15, prescribers = 22, community pharmacy staff = 8, providers = 18, and commissioners = 18). Interventions targeted a mean of 5.8 behaviors (range 1-27). Influences on behavior most frequently targeted by interventions were psychological capability (knowledge and skills); reflective motivation (beliefs about consequences, intentions, social/professional role and identity); and physical opportunity (environmental context and resources). Interventions were most commonly characterized as achieving change by training, enabling, or educating and were delivered mainly through guidelines, service provision, and communications & marketing. Interventions included a mean of four Behavior Change Techniques (BCTs) (range 1-14). We identified little intervention content targeting automatic motivation and social opportunity influences on behavior. The majority of interventions focussed on education and training, which target knowledge and skills though the provision of instructions on how to perform a behavior and information about health consequences. Interventions could be refined with the inclusion of relevant BCTs, such as goal-setting and action planning (identified in only a few interventions), to translate instruction on how to perform a behavior into action. This study provides a platform to refine content and plan evaluation of antimicrobial stewardship interventions.

Perceived addiction to smoking and associations with motivation to stop, quit attempts and quitting success: A prospective study of English smokers.

AIMS: Some argue that perceived addiction to smoking (PAS) might undermine motivation to stop. We examined the association of PAS with motivation to stop in a population sample and assessed its association with past and future quit attempts and future quit success. METHOD: 12,700 smokers in England were surveyed between September 2009-March 2012 as part of the Smoking Toolkit Study. 2796 smokers were followed up after 6 months. PAS was assessed at baseline by a single self-report item. The outcome variables were ratings of motivation to stop and reports of past-year quit attempts at baseline, and quit attempts in the past 6 months and smoking status at follow-up. Baseline covariates were sex, age, social grade and daily cigarette consumption. RESULTS: In adjusted analyses, PAS was positively associated with at least some degree of motivation to stop versus no motivation (ORs = 1.97-2.96, all p's < 0.001). PAS was also positively associated with past-year quit attempts (OR = 1.43, 95% CI = 1.32-1.55, p < 0.001), but not with future quit attempts (OR = 1.17, 95% CI = 0.99-1.39, p = 0.064) or quit success (OR = 1.04, 95% CI = 0.73-1.47, p = 0.83). CONCLUSION: In smokers in England, perceived addiction to smoking is positively associated with motivation to stop and having recently made a quit attempt but is not clearly associated with future quit attempts or success. These findings provide no grounds for believing that increasing smokers' perceived addiction through promotion of stop-smoking support has undermined motivation to stop.

Weekend sun protection and sunburn in Australia trends (1987-2002) and association with SunSmart television advertising.

BACKGROUND: The Australian state of Victoria has run a population-based skin cancer prevention program called SunSmart since 1988, incorporating substantial public education efforts and environmental change strategies. Trends over 15 years in behavioral risk factors for skin cancer were examined in a population exposed to the SunSmart program. Whether outcomes were associated with extent of SunSmart television advertising was then assessed. METHODS: In nine cross-sectional surveys from 1987 to 2002, 11,589 adults were interviewed by telephone about their sun exposure and sun protection during outdoor activities on summer weekends. Analyses completed in 2007 adjusted for ambient temperature and ultraviolet radiation. RESULTS: Sun protection and sunburn show substantial general improvement over time, but have stalled in recent years. Use of hats and sunscreens significantly increased over time and peaked during the mid to late 1990s, compared with the pre-SunSmart baseline. The mean proportion of unprotected skin was reduced and was lowest in the summer of 1997-1998. Summer sunburn incidence declined over time and was 9.1% in 2002, almost half baseline (OR=0.53; 95% CI=0.39-0.73). Higher exposure to SunSmart advertising in the 4 weeks before the interview increased: (1) preference for no tan, (2) hat and sunscreen use, and (3) proportion of body surface protected from the sun. CONCLUSIONS: The general improvement in sun-protective behaviors over time highlight that a population's sun-protective behaviors are amenable to change. Population-based prevention programs incorporating substantial television advertising campaigns into the mix of strategies may be highly effective in improving a population's sun-protective behaviors.

Prevalence and determinants of Australian adolescents' and adults' weekend sun protection and sunburn, summer 2003-2004.

BACKGROUND: Reducing people's exposure to ultraviolet radiation is the primary strategy for skin cancer prevention. OBJECTIVE: We sought to provide comprehensive national data on preventive behaviors and risk assessment for Australia. METHODS: A national survey was conducted in summer 2003-2004. In 8 weekly cross-sectional surveys, adults and adolescents were interviewed about their sun protection and sunburn on the previous summer weekend. Adjustments were made for specific weather and ultraviolet radiation conditions relevant to time and location. RESULTS: Adolescents were relatively homogeneous in their low compliance with sun protection (significantly less use of hats, covering clothing, shade, and sunglasses than adults) on weekends, and consequently were more likely to be sunburned than adults (25% compared with 18%; odds ratio=1.80, P<.001). Temperature was a significant predictor of sun-protective behaviors and a strong determinant of sunburn, as was ultraviolet radiation for adults' sunburn. Using shade, spending less time outdoors, and, for adults, wearing clothing covering were associated with reduced odds of sunburn. LIMITATIONS: The study relied on self-reported behaviors and sunburn. CONCLUSIONS: Further improvement in Australians' sun-protective behaviors is needed.

Does consistent motivation to stop smoking improve the explanation of recent quit attempts beyond current motivation? A cross-sectional study.

AIMS: In seeking to provide more accurate models of population quit attempt rates, this study assessed whether a single self-report measure of consistent motivation to stop smoking adds useful explanatory power over and above an established measure of current motivation to stop. METHOD: Data from 16,657 current smokers in England were collected between October 2012 and June 2017 using cross-sectional household surveys. Smokers were asked whether they had made a serious quit attempt in the past year and they answered two questions on motivation to stop (current motivation and consistent motivation to stop smoking). Having made at least one quit attempt in the past year was regressed in logistic models onto current motivation to stop and consistent motivation to stop individually and then together, with both models adjusting for sociodemographic variables and a measure of nicotine dependence. RESULTS: The addition of consistent motivation to stop smoking added substantially to the fit of the model over and above the established measure of current motivation to quit (χ2(1, N = 16,657) = 901.7, p < 0.001) with an adjusted odds ratio of 4.1 (95% CI = 3.7-4.5, p < 0.001). CONCLUSION: Consistent motivation to stop smoking substantially improves the modelling of recent smoking cessation attempts over and above current motivation to stop. The consistency of smokers' motivation to quit may be a useful explanatory and target variable in future intervention studies.

Assessing population-wide behaviour change: concordance of 10-year trends in self-reported and observed sun protection.

OBJECTIVES: Increases in socially desirable responses in self-reports might occur in the context of ongoing public education. We examine concordance of trends in two long-term studies monitoring population impact for SunSmart. METHODS: One study employed telephone interviews of Melbourne residents; the other entailed observations at public recreation venues across Melbourne. The studies assessed people's sun protection on identical weekend dates (Nw = 33 dates). Data from five summers between 1992 and 2001 (n ~ 23,000 individuals) were analysed. A body cover index score was calculated for participants on each date. Outcomes were aggregated separately for Saturdays and Sundays by date and year. Regression analyses tested whether these trends differed by survey method. RESULTS: The pattern of change in body cover over time was similar for both surveys. Self-reported body cover was consistently higher than observed body cover, suggesting that social desirability bias may be present. Regression analyses showed no divergence between self-reported and observed trends in mean body cover, suggesting no evidence of significant increased social desirability bias in self-reporting over time. CONCLUSION: Findings suggest that self-report offers a valid means of assessing change in a population's sun protection compliance over time, at least when self-reports are precisely focussed for time and activity context.

The natural history of quitting smoking: findings from the International Tobacco Control (ITC) Four Country Survey.

AIMS: To describe the long-term natural history of a range of potential determinants of relapse from quitting smoking. DESIGN, SETTING AND PARTICIPANTS: A survey of 2502 ex-smokers of varying lengths of time quit recruited as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, United Kingdom, United States) across five annual waves of surveying. MEASUREMENTS: Quitters were interviewed by telephone at varying durations of abstinence, ranging from 1 to 1472 days (about 4 years) post-quitting. Smoking-related beliefs and experiences (i.e. urges to smoke; outcome expectancies of smoking and quitting; and abstinence self-efficacy) were included in the survey. FINDINGS: Most theorized determinants of relapse changed over time in a manner theoretically associated with reduced risk of relapse, except most notably the belief that smoking controls weight, which strengthened. Change in these determinants changed at different rates: from a rapidly asymptoting log function to a less rapidly asymptoting square-root function. CONCLUSIONS: Variation in patterns of change across time suggests that the relative importance of each factor to maintaining abstinence may similarly vary.

Predictors of smoking relapse by duration of abstinence: findings from the International Tobacco Control (ITC) Four Country Survey.

AIM: To explore predictors of smoking relapse and how predictors vary according to duration of abstinence. DESIGN, SETTING AND PARTICIPANTS: A longitudinal survey of 1296 ex-smokers recruited as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, United Kingdom and United States). Measurements Quitters were interviewed by telephone at varying durations of abstinence (from 1 day to approximately 3 years) and then followed-up approximately 1 year later. Theorized predictors of relapse (i.e. urges to smoke; outcome expectancies of smoking and quitting; and abstinence self-efficacy) and nicotine dependence were measured in the survey. FINDINGS: Relapse was associated with lower abstinence self-efficacy and a higher frequency of urges to smoke, but only after the first month or so of quitting. Both these measures mediated relationships between perceived benefits of smoking and relapse. Perceived costs of smoking and benefits of quitting were unrelated to relapse. CONCLUSIONS: Challenging perceived benefits of smoking may be an effective way to increase abstinence self-efficacy and reduce frequency of urges to smoke (particularly after the initial weeks of quitting), in order to reduce subsequent relapse risk.