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Identifying and Prioritising Behaviours to Slow Antimicrobial Resistance

Identifying and Prioritising Behaviours to Slow Antimicrobial Resistance

What should behaviour change interventions target to slow antimicrobial resistance?

Antimicrobial resistance (AMR) refers to the ability of bacteria, viruses, fungi, parasites - and other microorganisms - to withstand the effects of drugs that are designed to kill or inhibit their growth. Over time, this can lead to the development of strains that are resistant to antimicrobial drugs. This poses a significant threat to global public health. Thus, it is important that we understand the behaviours we need to change to slow this process.

Australia is in a unique position with relatively low levels of antimicrobial resistance (AMR). This is due to its low population density, stringent biosecurity measures, community and agricultural stewardship and its geographical isolation. Nonetheless, the authors in this recently published article argue that this advantage is slowly eroding.

BehaviourWorks Australia researchers Fraser Tull, Liam Smith, and Denise Goodwin, and Monash University’s Rebecca Bamert and Karen Lambert argue that we must consider the role of behaviour change in slowing Australian AMR.

Behavioural science can play a crucial role achieving this goal through driving lasting change in how we engage with antimicrobials. But what behaviours are relevant in slowing AMR? How do you determine which ones will make a lasting impact?

First step is to figure out who needs to do what differently to slow AMR 

Some actors and the actions they take play a more important role than others in behaviour change interventions. In a football game, for example, the coach is the most important actor due to their significant influence on the team’s performance, strategy, and therefore, success.

The researchers conducted an online behaviour identification workshop, with 12 AMR experts across Australia and New Zealand, to identify the key players and their associated behaviours in slowing AMR. The expertise of the participants' included sociology, microbiology, public health, and government. 

A system mapping exercise was used to identify the people and their behaviours. The key actors considered were consumers (i.e. general public), rather than providers (i.e. doctors). However, it was recognised that some actors fit into both roles (i.e. farmer). The workshop found:

  • 3 connections to human use of antibiotics; not ‘pressuring’ doctors for antibiotics, only taking antibiotics when prescribed, and returning unused antibiotics to a pharmacy.
  • 5 connections to antimicrobial marketing on cleaning products; choosing to not use products with antimicrobial agents (personal and household products), encouraging others to not use these products, asking workplace procurement to avoid these products, and contacting the local council to find out where they can dispose of these products safely.
  • 3 connections to lobbying for change; lobbying against antimicrobial marketing, lobbying to remove antimicrobial agents from cleaning products, and lobbying supermarkets to sell antibiotic free meat products.
  • 1 connection to stopping the spread of bacteria; in particular, hand-washing.

Secondly, find out which behaviours have the biggest impact on slowing AMR

Next, to rank the above 12 behaviours from most impactful to least, 21 AMR experts across academia, government, and industry were surveyed. The experts concluded that some of the more impactful behaviours included:

  • Do not pressure your doctor for antibiotics.
  • Contact the council to find out where you can safely dispose of products with antimicrobial marketing.
  • Lobby to remove antimicrobial agents from cleaning products.

There were some behaviours that didn’t make the cut (were noted to be the least impactful),  including choosing personal cleaning products without antimicrobial marketing.

Then they ask the public which behaviours are currently (and most likely to be) adopted

Understanding behavioural adoption is crucial when creating behaviour change interventions. It helps identify the factors that influence an individuals' acceptance and incorporation of new behaviours into their daily lives.

The researchers asked the public to vote, via a survey, on the identified behaviours. The aim was to understand the current and likelihood of future behaviour adoption. 285 people participated in the survey.

Results on current behaviours varied considerably, with only 2.46% already engaging in lobbying to remove antimicrobial agents from cleaning products whilst 85.6% currently only take antibiotics when prescribed. Those behaviours that are already being adopted by the majority of people offer little room for improvement.

The next issue was the likelihood of future changes to behaviour. The top behaviours that had the highest chances of being adopted, include washing hands regularly and only taking antibiotics when prescribed. Four behaviours were seen to be unlikely to be adopted by the general public. These included: 

  • Lobby to remove antimicrobials from cleaning products.
  • Lobby against antimicrobial marketing on cleaning products.
  • Asking procurement at your workplace to choose products without antimicrobial marketing. 
  • Encourage the people close to you to choose products without antimicrobial marketing.

Finally, they determine the behaviour(s) that are the better targets for a behaviour change interventions

Developed by BehaviourWorks Australia’s Dr Sarah Kneebone, the Impact-Likelihood Matrix is a tool that can help identify the behaviours that have the highest likelihood of driving change.

The researchers were able to conclude with a list of the top four behaviours to target through interventions. The results were based on the impact of the behaviour - as determined by the group of AMR experts - and the likelihood of adoption by the public - as indicated by the surveyed general public. Using this approach the researchers determined the following behaviours were the best targets:

  1. Do not pressure your doctor for antibiotics.
  2. Contact the council to find out where you can safely dispose of products with antimicrobial marketing.
  3. Return unused antibiotics to a pharmacy.
  4. Lobby supermarkets to only sell antibiotic-free meat products.
A screenshot of the Impact-Likelihood Matrix taken from the original article. Circle sizes indicate the level of behaviour adoptions (bigger circles = higher adoption). Green circles denote direct antibiotic use behaviours, yellow circles lobbying behaviours, blue circles are marketing/purchasing behaviours and grey is hand hygiene.

From behaviours in personal hygiene, to lobbying, purchasing and advocacy, changing behaviours to slow the spread of AMR needs to happen from multiple angles.

Encouragingly, there seems to be a high level of interest to learn more about AMR. It was not the main focus of the research, however, this study found that almost 40% of the general public surveyed would be interested to learn more about the topic.

This is great news and helps map a way forward in slowing AMR in Australia.

Read the full published article:

Identifying and Prioritising Behaviours to Slow Antimicrobial Resistance

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