By Christie Cabral, Senior Lecturer, Centre for Academic Primary Care , University of Bristol

As a social anthropologist, I’ve been investigating why antibiotics are overused for over a decade and using the insights gained to develop antibiotic stewardship interventions. For World Antimicrobial Resistance (AMR) Awareness Week, I am writing about three key insights from my research.

1. The role of ‘Explanatory Models’ for illness and treatment: the influence on consulting and prescribing behaviours

Explanatory models are the set of linked ideas or theories that we each have in our minds about an illness and the possible treatments. These inform what we do as a patient, deciding whether to consult, or as a clinician deciding whether to prescribe.

The (simplified) biomedical model for the infections is of two types: viral or bacterial. Antibiotics treat bacterial infections but are ineffective for viral infections. So, it’s simple, no one should be prescribing or taking antibiotics for viral infections, and doing so is described as unnecessary or irrational.

Except in practice, it’s quite hard to tell the difference between infections caused by viruses and those caused by bacteria when all you can observe is the symptoms.

“There is uncertainty. I mean is it viral, is it bacterial? You don’t know.” (GP)

In the face of this uncertainty, primary care clinicians must decide when prescribe antibiotics.

“I don’t have to know if it’s viral or bacterial: I have to know whether they need treatment or don’t need treatment.” (GP)

I did many interviews with primary care clinicians about their decision making for children with respiratory tract infections. We know that this is a group with high antibiotic prescribing rates.

“80% of the children you see are well or it’s a mild infection … 5% of them are really unwell, and … 10–15% [in] kind of [a] grey area.” (GP)

This quote captures clinicians’ explanatory model, which has two key groups of patients. Most of the children they see are “well” – by which they mean it’s an infection that is not dangerous, mostly likely caused by a virus, and the child will recover without treatment. There are a small number of children who are very unwell and need medical treatment. This is sometimes antibiotics but sometimes a child may have a serious viral infection, such as RSV, and will be referred to hospital.

Then there is a third group for whom there is uncertainty: will they recover or will they become seriously ill. A useful analogy for this group might be Schrodinger’s cat in a box – with a hidden potential for being either well or very ill. To protect these children from the possibility of becoming very ill, clinicians prescribe antibiotics “just in case”.

Parents know that when their child has the symptoms of an infection (cough, fever etc.), they will usually recover on their own but that sometimes the illness can be serious and need treatment. Crucially, they believe that clinicians can tell the difference between these two types of illness by examining their child. Parents are usually hoping for reassurance when they consult the doctor for their child.

“It’s just peace of mind, you know deep down in your heart that it’s probably only going to be a virus, but you just want for it to be double checked to make sure” (Mother)

Parents’ explanatory models are heavily influenced by what is done and said in the consultation. In their understanding, children either have “just a virus” or they have an infection that “needs antibiotics”. Whenever clinicians prescribe antibiotics, it creates the perception that the associated symptoms signal a need for antibiotics, which triggers future consultations and antibiotic expectations for similar symptoms.

2. Social construction of vulnerability and safety within our society: the influence on antibiotic prescribing and use

In our society, children are seen as more vulnerable than adults and therefore there is a social duty to protect them from harm. This was frequently mentioned by both parents and clinicians as influencing their consulting and prescribing decisions.

“with children you can’t be too careful really.” (Mother)

“it’s your biggest fear … missing something in a child” (GP)

This need to ensure the child’s safety leads to both ‘just in case’ consulting and ‘just in case’ prescribing, which together lead to the overuse of antibiotics for children. But none of this is irrational. These are well intentioned people trying to do their best to care for a child with an infection. Parents and clinicians are seeking safety for this child in the face of uncertainty.

There is added pressure because of the social norms around our duty to keep children safe from harm. Parents and clinicians both avoided actions they felt would be judged to be socially or professionally unacceptable.

“if they were, as a result of that not taking it [antibiotics], … to become more unwell, it’s very difficult to justify having held it back.” (GP)

3. Socially patterned experiences: the link to infection and AMR health inequities

Parents from all backgrounds were similarly worried by their early experiences of childhood infections in their first child. However, with repeated experiences of their child recovering and reassurance from their GP, over time parents become less worried by common infection symptoms.

“Unless they can produce a temperature, a high temperature. I would go away and ignore it [cough] completely.” (Mother)

However, not all parents have this reassuring experience, some children do have serious infections and this experience leads parents to view all infections as potentially more dangerous.

“I never even thought that children could get pneumonia…. now I know that it’s possible, … I wouldn’t hesitate to take her to the doctor (Mother)
Serious infections, like most health outcomes, are more frequent in deprived communities. This means that parents in these communities are more likely to have experience of a serious childhood infection, either themselves or within their social network.

“I wouldn’t trust anything, as soon as he got a cough I’d rather go to A&E … because I know what state he was in last time.” (Mother of child who had near fatal case of pneumonia)

Parents in poorer households also feel more pressure to demonstrate they are doing what is necessary to keep their child safe, more vulnerable to social censure and less confident they will be listened to. All of this contributes to higher consulting rates.

What does this mean for antimicrobial stewardship (AMS) interventions?

Messaging needs to speak to explanatory models. Advice not to take antibiotics for viral infections or ‘when you don’t need them’ does not seem relevant if you believe that you only take antibiotics because a doctor has prescribed them for a bacterial infection that they have definitively diagnosed.

Messaging that helps people interpret the embodied experience of the symptoms of infections is more useful. For example, that a normal viral cough can last as long as 4 weeks.

AMS interventions which aim to support parents and patients to feel safer to wait before consulting and support clinicians to feel safer to delay prescribing have also helped. Tools include better decision aids and safety-netting information for both patients and clinicians, but also messaging around social norms, particularly with respect to antibiotic prescribing.

AMS interventions tend to be ‘one size fits all’ but we know that infection frequency and severity differs with deprivation level. Poorer communities have worse health outcomes and higher rates of antibiotic prescribing and AMR. Tailored, co-designed interventions are needed to address not just individual behaviours but also the underlying structural issues that contribute to these inequities.