Social science research for understanding drug resistant infections

In this month’s guest blog post, Marco Haenssgen, Nutcha Charoenboon, and Yuzana Khine Zaw reflect on the problems of language entailed in describing and tackling AMR at a global level, drawing on their experience with a range of communities in northern Thailand. They point out that calls to agree a standardised AMR vocabulary don’t take account of situations where there is no direct equivalent in local language for ‘antibiotics’; and they suggest that attending to the social or economic drivers of medicine use may be more important than focusing on individual ‘awareness raising’.  

By Marco J Haenssgen, Nutcha Charoenboon, and Yuzana Khine Zaw

A comment in Nature recently highlighted that “antibiotic resistance has a language problem” (Mendelson et al., 2017), alluding to the ambiguity of terms like “stewardship,” lacking popular awareness of “antimicrobial resistance,” and the problematic translation of “antimicrobial resistance” (AMR) into other languages. The authors suggest that unambiguous umbrella terms like “drug-resistant infections” and “antibiotics” could support efforts to address the global health priority issue of antimicrobial resistance, although the local interpretation of these words may vary across and within countries. Drawing on our research on antibiotic-related behaviour in Southeast Asia with the Centre for Tropical Medicine and Global Health (University of Oxford), we agree that language is an important and locally specific facet of antimicrobial resistance, but we caution against championing globally standardised and awareness-centred approaches in light of deeper-rooted local understandings and behaviours involving antibiotic use.

Language does indeed matter, and it is an expression of how people think about medicine and illness. Take for instance our work in Chiang Rai in Northern Thailand (pictured). In interviews with fever patients, we have come across varied expressions of “antibiotics.” For example, antibiotics are often translated into “anti-inflammatory medicine” (“ยาแก้อักเสบ” or “yah kae ak seb”) (So & Woodhouse, 2014:84).ⁱ This notion of anti-inflammatory drugs resonates with local descriptions of illnesses as being caused by inflammations of the body (e.g. in the case of a sore throat), for which this “anti-inflammatory” medicine may be deemed appropriate.ⁱⁱ Moreover, some local ethnic groups in Chiang Rai (e.g. Akha) may not have an equivalent of the Thai term in their mother tongue and rather refer to antibiotics as “medicine that relieves the pain,” and yet other people would not actively distinguish between antibiotics and other kinds of medicine.ⁱⁱⁱ The literal translation of “antibiotic” (“ยาปฏิชีวนะ” or “yah pa ti chee wa na”) is a technical term with Pali roots (akin to Latin) that is hardly used or understood in rural Chiang Rai. Even seemingly unambiguous expressions like “drug resistance” (“ดื้อยา” or “due yah”)—literally translated into being “stubborn to [the effects of] medicine”—can be interpreted by non-native speakers or people without active conceptions of antibiotic resistance as meaning “stubborn to take medicine.”

Landscape in Chiang Rai
Photo credits: Nutcha Charoenboon

What does this teach us? On the one hand, a standard language to tackle antimicrobial resistance may reach its limits in contexts where there is no shared understanding of antibiotics or other antimicrobials, and where there is no clear distinction between antibiotics and other medicine. We thereby share Helen Lambert’s concern that simplistic and standardised messages that do not take account of local notions of illness and medicine could lead to unforeseen behaviours like scaring people off medicine when they in fact need it (Lambert, 2016). This is not a purely theoretical concern, as we have witnessed such cases first-hand in other studies involving non-verbal communication for AMR.

On the other hand, the common policy emphasis on education and “awareness raising” for AMR (Department of Health, 2013; Gelband et al., 2015; The Review on Antimicrobial Resistance, 2016:19-20; WHO, 2015) assumes that irrational choices are the main driver behind problematic antibiotic-related behaviour (e.g. over- or under-use of antibiotics), but not all medicine consumption is the result of active choice. Social, economic, and health system constraints may drive people into behaviours where they may be more likely to access antibiotics—knowingly or unknowingly. These broader determinants of behaviour require us to think out of the box. Consider for example the recent Thai “Antibiotic Smart Use” campaign to reduce antibiotic over-prescription for conditions like sore throats. This campaign has encouraged primary healthcare providers to prescribe traditional herbal medicines capsules to patients who might expect to receive medicine in return for a costly visit to the healthcare provider (So & Woodhouse, 2014:84). Poorer and more remote population groups might benefit from the “Antibiotic Smart Use” approach because their expectations  might be accentuated by higher costs and greater hardship to reach healthcare facilities (yet, not all are actually able to access public healthcare). But activities that influence antibiotic use may not stop at health policies and interventions: Might for instance sick leave, access to financial services like loans and savings accounts, or more efficient public transport alleviate some of the constraints that shape the antibiotic use among marginalised groups?

In summary, while we agree that antimicrobial resistance has a language problem, we do not believe that its solutions lie primarily in standardising terminology but rather in appreciating and responding to local conceptions, and in strategies beyond awareness raising that help to reduce antibiotic over-use without discouraging access to medical treatment and essential medicines for socially, economically, or spatially marginalised groups. Social research (including e.g. anthropology, sociology, economics, or political sciences) can help to learn the extent to which this argument holds. Our own research programme in Southeast Asia thereby studies the relationship between patients and the health system, focusing on the role of primary-care-level biomarker testing, the evolution of explicit and implicit antibiotic demand and supply, and the constraints and social dynamics that entail varied forms of antibiotic access.

Notes

ⁱ This mirrors for example reports from China (Fang, 2014; Lv et al., 2014; Yu et al., 2014).

ⁱⁱ Our point is not that this is a wonderful foreign context—antibiotic over-prescription e.g. for sore throat can also be observed in high-income Europe; see e.g. Dekker et al. (2015).

ⁱⁱⁱ These are not the only examples, and our informants also had a wide range of notions and descriptions for other medicines ranging from brand names (e.g. Tiffy) via generic descriptions (fever reliever) to visual descriptions (“the white pill”).

Contributors

Marco J Haenssgen has a background in development studies and is Postdoctoral Scientist – Health Policy and Systems at the Centre for Tropical Medicine and Global Health (CTMGH), University of Oxford, where he leads social research on antibiotic-related behaviour in Southeast Asia (including a Theme-4 grant of the Cross-council Initiative to Tackle Antimicrobial Resistance: http://gtr.rcuk.ac.uk/projects?ref=ES%2FP00511X%2F1). Nutcha Charoenboon is based at the Mahidol-Oxford Tropical Medicine Research Unit in Bangkok. She has a background in biology and works as research officer on these projects in Thailand, Myanmar, and Lao PDR. Yuzana Khine Zaw is an MSc candidate in International Health and Tropical Medicine at the CTMGH, where her thesis research compares local conceptions of illness and medicine in the context of biomarker testing in Myanmar and Thailand.

References

Dekker, A. R. J., Verheij, T. J. M., & van der Velden, A. W. (2015). Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients. Family Practice, 32(4), 401-407. doi: 10.1093/fampra/cmv019

Department of Health. (2013). UK five year antimicrobial resistance strategy: 2013 to 2018. London: Department of Health.

Fang, Y. (2014). China should curb non-prescription use of antibiotics in the community. BMJ : British Medical Journal, 348. doi: 10.1136/bmj.g4233

Gelband, H., Miller-Petrie, M., Pant, S., Gandra, S., Levinson, J., Barter, D., et al. (2015). State of the world’s antibiotics, 2015. Washington, DC: Center for Disease Dynamics, Economics & Policy.

Lambert, H. (2016). The rhetoric of resistance.  Retrieved from amrchamp.blogs.bristol.ac.uk/2016/09/21/the-rhetoric-of-resistance/

Lv, B., Zhou, Z., Xu, G., Yang, D., Wu, L., Shen, Q., et al. (2014). Knowledge, attitudes and practices concerning self-medication with antibiotics among university students in western China. Tropical Medicine & International Health, 19(7), 769-779. doi: 10.1111/tmi.12322

Mendelson, M., Balasegaram, M., Jinks, T., Pulcini, C., & Sharland, M. (2017). Antibiotic resistance has a language problem. Nature, 545(7652), 23-25. doi: 10.1038/545023a

So, A. D., & Woodhouse, W. (2014). Thailand: Antibiotic Smart Use Initiative. In M. Bidgeli, D. H. Peters & A. K. Wagner (Eds.), Medicines in health systems: advancing access, affordability and appropriate use (pp. 83-86). Geneva: World Health Organization.

The Review on Antimicrobial Resistance. (2016). Tackling drug-resistant infections globally: final report and recommendations. London: The UK Prime Minister.

WHO. (2015). Global action plan on antimicrobial resistance. Geneva: World Health Organization.

Yu, M., Zhao, G., Stålsby Lundborg, C., Zhu, Y., Zhao, Q., & Xu, B. (2014). Knowledge, attitudes, and practices of parents in rural China on the use of antibiotics in children: a cross-sectional study. BMC Infectious Diseases, 14(1), 112. doi: 10.1186/1471-2334-14-112

In this month’s blog post, Carolyn Tarrant reflects on the challenges and rewards of doing cross-disciplinary AMR research, drawing on her experience of participating in the workshop on ‘Interdisciplinary Research and AMR’ convened in Bristol by the ESRC AMR Research Champion in March 2017.

By Carolyn Tarrant

In March 2017 I travelled down to Bristol for a two day meeting on interdisciplinary research into antimicrobial resistance (AMR), organised by Helen Lambert (ESRC AMR Research Champion), University of Bristol. Around 50 researchers had come together for the workshop, and they were a diverse group – over coffee and dinner I spoke to lab-based researchers, economists, psychologists, sociologists, and clinical researchers. All were working on, or were interested in, infection, antibiotic use, and antimicrobial resistance, but all were looking at the problem in different ways. The workshop was part of an ongoing investment in an ambitious cross- research council initiative which has been running since 2015, with the aim of creating an infrastructure for interdisciplinary research into AMR.

Interdisciplinary research is becoming ubiquitous, but why is interdisciplinary research particularly important in the case of AMR? Antibiotic resistance is one of the pressing problems of our age, and a global risk. Through exposure to antibiotics bacteria can develop resistance, meaning that antibiotics that were previously effective in treating infections will no longer work. Some have predicted a catastrophic future scenario where people will be at risk of dying from even minor injuries and infections because we can no longer call on antibiotics to treat them.

There is no simple answer to the problem. Although scientific research into new ways of treating infection and better diagnostic tests will make an important contribution, the proliferation of antibiotic resistance is as much a social as a technical problem – it’s down to the ways we use (and over-use) antibiotics. Because behaviour around antibiotic use is so important for controlling the spread of resistance, social scientists have an important role to play, working alongside scientists, clinicians, and policymakers to better understand the nature of the problem and find ways to intervene. Interdisciplinary approaches to research offer exciting possibilities for novel solutions, but can also pose significant challenges, not least navigating the political, emotional, and practical aspects of working in interdisciplinary teams. The ESRC workshop was a valuable opportunity to reflect on these benefits and challenges in the context of work on infection control and AMR.

Among those presenting were Henry Buller and Kristen Reyher (Universities of Bristol and Exeter), who are working on interdisciplinary projects on antibiotic use in farming and who emphasised the challenges of developing a shared vocabulary, and the importance of engaging the wider community of farmers in their research. Marco Haenssgen (University of Oxford) drew on his experience as a social scientist of working on interdisciplinary research on AMR in India, China, and Thailand to highlight the challenges arising from people working within different paradigms and with different objectives, assumptions and expectations, but also to emphasise the value of interdisciplinary research in tackling problems more holistically, and not losing sight of the ‘big picture’.

What also became apparent, but is perhaps less often discussed, is the challenge of forming interdisciplinary teams in the first place. How do we meet people we might need to work with? How do we overcome our suspicions of others who may speak a different ‘language?’ We need more opportunities to meet and talk to others outside of our discipline. In my work I rarely come across farmers or vets, but from talking to researchers in these fields during the workshop I now understand much more about the range of stakeholders in this global problem, and appreciate the value of an integrative ‘One Health’ approach. We need to know who the important people for us to talk to and work with are, and have the opportunity to build some level of familiarity and trust, which are critical elements for the start of a good working relationship.

The presentations and discussions resonated with my own experience of working on the interdisciplinary project: ‘Antimicrobial resistance as a social dilemma’. The project involves social scientists from different disciplines and methodological backgrounds, along with clinicians in microbiology/infection control, and this has thrown up both benefits and challenges.

First the positives: the big benefit of interdisciplinary working is the stimulation of new ways of thinking. Clearly, there are potential benefits from using social science theory to help us understand how to tackle the important but seemingly intractable problem of AMR. But as social scientists, working on a new, applied problem also brings opportunities to develop within our disciplines. One of my co-investigators is particularly excited about how working on AMR will help take things forward in his field; he feels he would not have thought about working on AMR if we had not put together this interdisciplinary team. The clinician role in our project is critical, and the social scientists in the group have learned a lot from the clinicians. As social scientists we can theorise but we don’t have that insight into important aspects of day-to-day clinical practice – the decisions that have to be made, the risks that have to be balanced, the challenges that arise, and the way that behaviour is shaped by the context in which they practice. This insight is so critical in ensuring that theorising is anchored in the realities of the clinical world.

But it hasn’t all been plain sailing! I’ve found there are different expectations in the team of the goals of the research and what the outputs might be. Perhaps not unexpectedly, the clinicians are more interested in interventions – they want to know what can be done differently to optimise prescribing. The academic social scientists have a strong slant towards theory development, but different theoretical perspectives can pull the research in different directions. Within this project we’ll need to keep the dialogue going about expectations goals, and end outputs from this particular project. But at the same time, as it’s a pump priming grant, we’re keen to explore how we can develop ideas for future research together.

At our second meeting, one of the team bravely admitted that they didn’t understand anything about agent-based modelling, an approach we plan to use in the project. We all recognised similar gaps in our knowledge and expressed anxieties about this – some team members didn’t really understand qualitative research methods, or how antibiotic resistance comes about. I’ve reassured the team that the value of interdisciplinary research is that everyone brings different and valuable expertise and perspectives to the problem. We don’t all need to be experts in everything, instead we need to recognise where we each are experts, and be aware of the extent and limits of our knowledge. But, if we’re going to be able to bring these different perspectives together we all need some level of shared understanding to orient towards the problem. My ‘crib sheet’ folder of key, accessible resources, which has been shared with the team, is one way of trying to help us develop this shared understanding.

What’s also helpful is having someone who can act as a lynchpin – with a broad level of understanding of the different disciplines or perspectives, and with the interactional expertise to orchestrate cooperation between people from different worlds. I’m cognisant of the need for me to play that role; as project lead, managing relationships and interactions within the team will be as important as project management.

We’ve also faced practical challenges of getting the team together for a meeting – so far our meeting plans have been disrupted by a Tube strike, Storm Doris, and the need to avoid the Sri Lankan monsoon season!

Perhaps the strongest message that I took away from the workshop and from beginning work on our project is that tackling antimicrobial resistance will be impossible without interdisciplinary research, but we also need to recognise that we have to work hard at building strong cooperative relationships and maintaining open communication in order to help make it work.

Contributor

Carolyn Tarrant is a Senior lecturer in SAPPHIRE, Department of Health Sciences, University of Leicester. Social scientist and qualitative researcher. Interested in ethnography, evaluation, patient safety, quality improvement, acure care, healthcare associated infections.

by Christie Cabral and Helen Lambert

Anti-microbial resistance (AMR) is a ‘wicked problem’ leading to drug resistant infections.  The evidence is incomplete or contradictory, there are many different interest groups with different needs and views, and the ‘solution’ depends on how the ‘problem’ is framed and vice versa.  Like other ‘wicked problems’ (e.g. climate change, species conservation, pandemic influenza) that result from the complex interaction of a huge range of influences, there is no single, simple solution and so our response needs to be multifaceted.

Leonardo Da Vinci, one of the best known polymaths, excelled in different artistic and scientific fields long before we had separated these activities out into the numerous disciplines we have today.  This boundary-crossing approach is what is called for by the Cross-Council Initiative to tackle antimicrobial resistance.

Inter-disciplinary research is often under-funded and poorly regarded but it is essential “to solve the grand challenges facing society”.  The Cross-Council Initiative is a rare call for everyone from Artists to Veterinary Scientists to work together on the problem of AMR.

So far, a lot of attention has focussed on possible technological solutions (such as new antibiotics and rapid diagnostic tests), but key work by the O’Neill Review team has rightly highlighted the importance of understanding economic processes.  These underline the ‘wicked’ nature of this problem, as the needs and views of stakeholders are not aligned.  Pharma companies want to maximise profits, but governments want to restrict the use of new antibiotics to preserve their effectiveness – so the pharmaceutical industry cannot recoup the costs of developing them through sales. The O’Neill Review recommends other financial mechanisms to encourage the pharmaceutical industry to develop new drugs that can be reserved for use when current ‘last resort’ antibiotics become ineffective.

But improving the likelihood of future technological innovations can only ever be part of a solution. When, how and why people use existing antibiotics unnecessarily – for themselves or their animals – are problems that can’t be tackled through drug or diagnostics development.  For many people around the world, especially in lower and middle income countries, the problem is not so much too many antibiotics as insufficient access to them.  The tension between access and excess is another dimension of the ‘wickedness’ of the problem; seemingly obvious solutions, like banning over-the-counter antibiotics sales in low-income countries, risk denying essential life-saving drugs to the poor, who lack easy access to decent medical care where they can be prescribed appropriate antibiotics when needed. Here social science is needed to understand the complexities of human behaviour and the cultural, social, institutional and political forces that shape it, as well as individual psychology. This way we can gain insights into ways to ensure that people get access to these life-saving drugs when they need them, while not using them unnecessarily so that infections become resistant to them.

The ESRC-led Theme 4 of the Cross-Council Initiative is entitled ‘Behaviour within and beyond the health care setting’.  As we saw at our recent Social Science and AMR workshop (#amrchamp), potentially relevant research covers a broad range of topics.  When social scientists get together, some interesting questions get asked: what types of drug resistance are a problem, in which contexts and for whom?  Issues of justice and future security are highlighted by international relations researchers looking at the unequal balance between access to antibiotics and the development of drug resistant infections across the globe.  Geographers, sociologists, environmental and veterinary scientists are looking at how our environments are entangled and the poorly understood microbiological pathways and social networks by which resistance is spread, without which we cannot know which ‘human and animal behaviours’ it might be sensible to target.  Artists and engineers are exploring how to design infection control into our world and how to communicate important messages to the wider community.

We come back to the ‘wicked’ nature of the issue.  The way the ‘problem’ is framed is important to how we tackle it: excessive use, or lack of access; public demand, or market-led health systems that incentivise medical practitioners to overprescribe; international travel, or locally occurring ‘pockets’ of resistance; lack of incentives for commercial pharmaceutical production or lack of non-profit making alternatives for developing new drugs; medical/veterinary overuse, or environmental contamination?

The Theme 4 call is an opportunity for truly interdisciplinary research involving biological, medical and social scientists, engineers and artists.  Thinking and acting collaboratively is perhaps the only way we might truly be able to tackle this wickedly complex problem.

Social scientists from all over the British Isles came together to talk about antimicrobial resistance (AMR) at our workshop on Friday 22nd April.

The focus was on research which might be relevant to the forthcoming call for the cross council AMR Theme 4: behaviour within and beyond the health care setting.  To receive updates on this and similar funding opportunities, register an interest here.

Here are some of the highlights recorded by participants on Twitter #amrchamp

Helen Lambert introduces workshop

Joanna Coast ‏@joclarkecoast

Ian Donald: Social Sciences & AMR

Matthew Avison on microbiology of AMR

Gina Pinchbeck Vetinary Sciences and AMR

 @iandonald_psych

Alasdair MacGowan: Infections and public health

 @SKGTonkinCrine

Clare Chandler: a view from anthropology

‏@ChristieCabral

Clare Chandler asking classic anthropological questions – AMR what is resisting what, where & why?

Jo Coast: a view from economics

Hayley Macgregor: a view from development studies

‏@PatriciaJLucas

Hayley mcgregor on the complex relationships between formal and informal health sectors. Fascinating

Import to rememb that many lack access to antibiotics, and informal unregulated access may be saving lives

 Ian Donald ‏@iandonald_psych

Steve Hinchcliffe – antimicrobials are part of out (food) production infrastructure. #amrchamp#AntibioticResistance

Christie Cabral ‏@ChristieCabral

Stephan Elbe – Need to learn from past examples of health problems being thought of as security issues e.g. bird flu – pros & cons #amrchamp

Sujatha Raman: a view from sociology/science and technology studies

 ‏@PatriciaJLucas

@sujatharaman2 on how science & tech studies can help us to understand discourse of amr

Claire Lawrence ‏@aggresslab

Naomi Beaumont from ESRC chairs expert panel Q&A

‏@EmmaJ_Roe

Afternoon discussion sessions

 ‏@ChristieCabral

Bristol Zoo Gardens – excellent venue!

Joanna Coast ‏@joclarkecoast

 ‏@iandonald_psych

  By Christie Cabral

Do parents want antibiotics when a child has a cough?  I’ve spoken to a lot of parents over the past five years and pretty well all of them say they would really rather not give their child any kind of drug treatment.  Yet the belief that parent demand for antibiotics is an important driver of antibiotic over-prescription is very persistent among clinicians and policy makers.

Over-prescription of antibiotics is a serious issue as it contributes to the problem of rising drug-resistant infections.  Considerable effort is going into trying to reduce over-prescription of antibiotics.  However, figuring out where best to target that effort is not always that straightforward.  The TARGET research programme and related Conker project investigated what influences antibiotic prescribing for children with coughs.

The parents we talked to in our study worry about the impact of any kind of medication on their child.  Many express fears around overdosing with child paracetamol and ibuprofen and believe that antibiotics should only be given if really needed.  All of this supports a general preference for not giving children any pharmaceutical treatment at all.

So that sounds like good news – parents don’t want antibiotics, problem solved; right?  Well of course the reality is messier than that.  Parents do want antibiotic treatment if they think it’s going to make a difference, to help their child to get better or to suffer less.   The key influence on parental expectation of antibiotic treatment is experience of antibiotics being prescribed for something similar in the past.  Often when antibiotics are prescribed, there is little explanation of the reasons, leaving parents to develop their own ideas about what symptoms indicate a need for antibiotic treatment.  These ideas are shared and reproduced within communities.  We have created an animation which shows how this happens.

https://www.youtube.com/watch?v=GgapMUN222Q&feature=youtu.be

The animation also illustrates a doctor’s point of view.  The doctor’s main concern is making sure they don’t miss a child with a potentially life threatening infection.  I think we would all agree that this is a good top priority.  However, because there is currently no definitive way of identifying children who may develop a serious illness from those who are poorly but will get better, doctors have to use their judgement to decide which ones to treat.  Most of the time, clinicians are able to judge confidently, but in a minority of cases there remains some uncertainty.   This is where the problem lies.  Faced with clinical uncertainty, many doctors will prescribe antibiotics in the belief that not only is it safer for the child in front of them but it also protects the doctor from the potentially serious medico-legal consequences of ‘missing a sick child’.

Reducing over-prescription of antibiotics for children with a cough is a challenging problem. Our research found that current antibiotic prescribing practices by doctors are a key influence on parental expectations (rather than the other way around).  Enabling doctors to change their practice will be a key part of the solution.  There is a need for basic science to help reduce clinical uncertainty, but we are still a long way from eliminating this.  In the meantime, there is a role for social science research in understanding how clinicians deal with uncertainty and how a different balance might be struck between the immediate risks to the patient and doctor and the wider risks to all of us from drug resistant infections.

Helen Lambert, ESRC Research Champion, attended 
the UK-China joint workshop in Shanghai to discuss the recently announced call for collaborative research on AMR.

UK research councils (ESRC, MRC & BBSRC) together with the National Natural Science Foundation of China (NSFC) announced the call for research into antibacterial resistance in China just before Christmas (details below if you missed it).  The funds for this call will be channeled through the Newton Fund which aims to promote the economic development and social welfare of partner countries. Applicant teams will need to include partner institutions from both the UK
and China which are eligible for funding from their respective country funding bodies
(ESRC, MRC or BBSRC in the UK or NSFC in China).

Key Deadlines:

Expression of Interest: 15th January 2015

Full proposals: 1st March 2016

Further information