How can we engage publics in the prevention of antimicrobial resistance?

News media interest 1990-2019 (source: Davis et al., 2020b).

Context

This case study comes from AMR: Science, Communications and Public Engagements (AMR-scapes), based at Monash University in Melbourne, Australia. Global and national policy frameworks make reference to the need to involve members of the general public in efforts to reduce antimicrobial resistance, including close adherence to prescription guidelines for antibiotics. In addition, individuals in Australia can access antibiotics on prescription and funded by the government at low cost (Pharmaceutical Benefits Scheme, PBS), making antibiotic consumption highly regulated. Government data shows that use of antibiotics has somewhat declined since 2016 and 2017, the first drop since the 1990s (ACSQHC, 2019). In 2017, 41.5% of the population was dispensed an antibiotic under the PBS (ACSQHC, 2019). 

In 2019, Australia launched its second national strategy which focusses on ‘whole of society’ awareness and action, among other approaches (Australian Government, 2020). We analysed Australian news media and health communications on AMR alongside in-depth interviews with 99 socially diverse individuals in Melbourne about their experiences of using antibiotics and how they explained the concept of antimicrobial resistance. The research aimed to generate a new qualitative database to help inform Australian policy and communications on AMR (Davis et al., 2021). 

Promoting public awareness and action on AMR through policy and communications

Public understanding

Research, including that of AMR-scapes, shows that most individuals do not understand how they could contribute to the prevention of AMR, partly because they understand the management of infections in terms of immunity as bodily self-defence (Lohm et al., 2020; Davis et al., 2020a; Norris et al., 2013; Brooker-Howell et al., 2012). For this reason, individuals often say that their bodies become resistant to antibiotics. In addition, healthcare is often seen as an individual life project or a parental or carer’s responsibility (McNay, 2009). These understandings can interfere with messaging on the reduction of AMR which seeks collective effort to protect the healthcare of future generations. 

Communications and news media

In Australia since 2000, public health campaigns have attempted to correct mistaken beliefs and establish norms for compliant use, with limited impact (Price et al., 2018). International evidence shows that social media (Antibiotic Guardian; Twitter) used to prevent AMR tend to reach individuals employed in health care and AMR fields but not so much the rest of the general public (Newitt et al., 2019; Cumbraos-Sánchez et al., 2019). Less well understood is how AMR messaging could be integrated into online health information services, emerging online script services, and related digital health care products (Brown and Netleton, 2017).

AMR-scapes analyses of news media show that AMR is mostly depicted as a niche, science story, featuring the heroic efforts of scientists and medical professionals, and less often the tragic stories of superbug victims (Davis et al., 2020b). News media rarely depict the action that individuals can take to prevent AMR. This is problematic since it conveys the impression that science will solve AMR and that therefore there is little individuals need do (Davis et al. 2020b). 

Using antibiotics

Research often depicts members of the general public as misusing antibiotics and demanding them when they are not needed, in ways that have been attributed to their lack of understanding of microbiology (Pan et al., 2016). AMR-scapes found that individuals spoke of themselves as compliant with medical expertise, and made reference to medical practitioners who were too willing to prescribe antibiotics (Davis et al., 2020a). This polarised system of AMR blame – doctors blame patients; patients blame doctors – indicates that antibiotic use is loaded with moral judgement and norms of good health citizenship. AMR messaging that confers responsibility on publics, or medical professionals, is likely to further feed this polarised blame game and alienate audiences. 

AMR-scapes also showed that antibiotic use arises in response to infections in ways that depend on material and symbolic settings, including responding to the health needs of a pet; prophylactic use of antibiotics due to travel; caring for a child with an infection; early intervention for those with recurrent infections; and selfcare prior to consulting a medical practitioner. AMR-scapes data show that antibiotics have meanings beyond their impact on microbial pathogens. For individuals, these social properties of antibiotics solve the pressing practical challenges of life and social norms of selfcare. These practices reflect longstanding marketing of health care products as solutions and particularly the reputation of antibiotics as highly effective. The practical, situatedness of antibiotic use and its social properties may provide opportunities for tailored and targeted support for the promotion of appropriate antibiotic use decision-making. 

Our analyses also pointed to a schism between general publics and AMR experts. AMR is distinctive compared to other health problems because it lacks a ‘community of interest’, for example, cancer survivors, people with COPD, or people with HIV. AMR is also difficult to comprehend without some basic microbiological knowledge, as research has shown. The dominance of scientific discovery narrative on AMR in news media underlines this schism between lay and expert publics. A key challenge for AMR communications pertains to effective dialogue between lay and expert publics to fashion new alliances, messages and narratives for the prevention of AMR. 

Conclusion

Helping members of the general public endorse and assist with the careful and moderated use of antimicrobials will depend on close attention to the meanings loaded onto these pharmaceuticals and the social contexts and biographical circumstances within which they are sought out and consumed.  

Points of discussion

• Ask students to select one of the themes above (public understanding, communications, and news media, using antibiotics) and reflect on its implications for the prevention of AMR. 
• Ask students to consider how the topics (policy context, public understanding, communications, and news media, use of antibiotics) in the case study may be influenced by contexts where antibiotics are readily available off prescription.
• Ask students to focus on blame polarisation and how communications messaging could respond. 
• Ask students to focus on the expert/lay schism and how it could be addressed.

Pedagogical notes

For new students:

• Awareness and knowledge may not equal behaviour

• Students may need to be helped to understand that high AMR awareness and knowledge are likely to not be sufficient conditions for changes in behaviour. Antibiotic use is socially and temporally situated, and these conditions need to be acknowledged before interventions can be effective. 

• Medical paternalism

• AMR messaging can be construed as somewhat paternalistic in the sense that experts are seeking publics to change their behaviour, while individuals may not regard AMR as a personal problem and therefore not understand the imposition of newly required behaviours. Understanding AMR also requires considerable microbiological knowledge, which many individuals may not have due to their educational and cultural background. However, expecting everyone to acquire the required knowledge may not be reasonable, possible or have much impact. It may also deepen the demonisation of publics as ignorant. AMR prevention also requires individuals to forgo treatment in some circumstances. These effects can deepen medical paternalism and therefore may compromise public trust in expertise in the field of AMR and beyond, for example, in the arena of vaccines. 

• Media complexity

• Students will need to engage with the impact of media technologies on options for AMR message design, delivery, consumption, and interpretation. Social media bubbles, clickbait economics and consumer-led online media production need to be considered in relation to effective AMR communications. 

For advanced students:

• Manufactured risk

• AMR is a prime example of a health threat that has emerged, in part, through efforts to mitigate other ones. Antibiotics, for example, reduce the immediate threat of an infection, but use of them has also led to antimicrobial resistance and therefore new risks. AMR is therefore a ‘manufactured risk’, a key concept from risk society and social systems theory.  

• Possessive individualism and health consumerism

• AMR interventions need to be set into the context of consumer cultures and how they respond to and reinforce notions of the body and mind as personal possessions and related concepts of immunity and hygiene as forms of self-defence. These emphases run counter to the underlying AMR challenge of long-term altruistic and cooperative action to preserve and protect the health of future generations. Related challenges also pertain to One Health and the need to conserve antimicrobials for non-human animals and therefore collaboration across human and animal health care. 

• Affirmative biopolitics 

• Scholars have responded to the challenges of possessive individualism through the concept of ‘affirmative biopolitics’. This concept reveals how possessive individualism applied to health leads, by logical extension, into health approaches that deny the interdependence of the self on others, as AMR emphasises. Affirmative biopolitics seeks out policies and communications that emphasise communities of interest, collaboration and how individual health is always dependant on relationships with others. 

Authors

• Dr Mark Davis

Community Engagement and Policy Lead, Centre to Impact AMR and Associate Professor, School of Social Sciences, Monash University.

References

• Australian Commission on Safety and Quality in Health Care (ACSQHC) (2019). AURA 2019: Third Australian Report on Antimicrobial Use and Resistance in Human Health. Sydney: ACSQHC.
• Australian Government. (2020). Australia’s National Antimicrobial Resistance Strategy: 2020 & Beyond. Canberra: Department of Health and Department of Agriculture, Water and the Environment.
• Australian Commission on Safety and Quality in Health Care (ACSQHC) (2019). AURA 2019: Third Australian Report on Antimicrobial Use and Resistance in Human Health. Sydney: ACSQHC.
• Brookes-Howell, L., Elwyn, G., Hood, K., Wood, F., Cooper, L., Goossens, H., Ieven, M., and Butler, C.C. (2012). ‘The Body Gets Used to Them’: Patients’ Interpretations of Antibiotic Resistance and the Implications for Containment Strategies. Journal of General Internal Medicine 27(7), p. 766-772.
• Brown, N., and Nettleton, S. (2017). Bugs in the blog: Immunitary moralism in antimicrobial resistance (AMR). Social Theory & Health 15(3), p. 302-322.
• Cumbraos-Sáncheza, M., Hermoso, R., Iñiguez, D., Paño-Pardo, J.R., Allende Bandres, M.A., and Latorre Martinez, M.P. (2019). Qualitative and quantitative evaluation of the use of Twitter as a tool of antimicrobial stewardship. International Journal of Medical Informatics 131, 103955.
• Davis, M.D.M., Lohm, D.B., Whittaker, A., and Flowers, P. (2020a). ‘Willy nilly’ doctors, bad patients, and resistant bodies in general public explanations of antimicrobial resistance. Sociology of Health & Illness 42(6), p. 1394-1408.
• Davis, M., Lyall, B., Whittaker, A., Lindgren, M., Djerf-Pierre, M., and Flowers, P. (2020b). A year in the public life of superbugs: News media on antimicrobial resistance and implications for health communications. Social Science & Medicine 256, 113032.
• Davis, M., Lohm, D.B., Lyall, B., Schermuly, A.C., Rajkhowa, A., Flowers, P. et al. (2021). Promoting Australian general public awareness and action on antimicrobial resistance. Sydney: Monash University School of Social Sciences. 
• Lohm, D., Davis, M., Whittaker, A., and Flowers, P. (2020). Role crisis, risk and trust in Australian general public narratives about antibiotic use and antimicrobial resistance. Health, Risk & Society 22 (3-4).
• McNay, L. (2009). Self as Enterprise: Dilemmas of Control and Resistance in Foucault’s The Birth of Biopolitics. Theory, Culture & Society 26(6), p. 55-77.
• Newitt, S., Oloyede, O., Puleston, R., Hopkins, S., and Ashiru-Oredope, D. (2019).  Demographic, Knowledge and Impact Analysis of 57,627 Antibiotic Guardians Who Have Pledged to Contribute to Tackling Antimicrobial Resistance. Antibiotics 8(1), 21.
• Norris, P., Chamberlain, K., Dew, K., Gabe, J., Hodgetts, D., and Madden, H. (2013). Public Beliefs about Antibiotics, Infection and Resistance: A Qualitative Study. Antibiotics (Basel) 2(4), p. 465-476.
• Pan, X., Slater, M., Beacco, A., Navarro, X., Bellido Rivas, A.I., Swapp, D., Hale, J., Forbes, P.A.G., Denvir, C., de C. Hamilton, A.F., and Delacroix, S. (2016). The Responses of Medical General Practitioners to Unreasonable Patient Demand for Antibiotics – A Study of Medical Ethics Using Immersive Virtual Reality. PLoS ONE 11(2), e0146837.
• Price, L., Gozdzielewska, L., Young, M., Smith, F., MacDonald, J., McParland, J., Williams, L., Langdridge, D., Davis, M., and Flowers, P. (2018). Effectiveness of interventions to improve the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review. Journal of Antimicrobial Chemotherapy 73, p. 1464-1478.