Challenging Dogma - Fall 2008

Monday, December 15, 2008

The Failure of Current Antimicrobial Resistance Campaigns to Affect a Wider Population – Lynn Tran


Antimicrobial resistance has been a persistent public health problem in recent years. As the development of antimicrobial agents evolve to allow for effective treatment of bacterial ailments, there has also been an evolution of misuse that has given opportunities for microorganisms to form a resistance, rendering the treatment ineffective. Medical advancement to develop new antibiotics cannot keep up with the rise of resistant bacterial strains, posing a significant issue to finding and maintaining effective treatments for bacterial illnesses.

Several reasons have been posed as to why antimicrobial resistance has been so difficult to address, many of which rely heavily on perceptions on how antibiotics should be prescribed and subsequently used. While these perceptions provide valuable insight into how people are contributing to this problem, they have been commonly misapplied in public health campaigns. The failure of current antimicrobial resistance campaigns will be addressed in the context of how relying on interventions based on individual and biomedical beliefs overlook higher level social factors that are more appropriate to address a larger audience.

The Reliance on the Health Belief Model and Other Individual Level Theories

A number of attempts aimed to reduce the development of antimicrobial resistance have relied on components of individual level theories. The most prevalent of these theories is the Health Belief Model (HBM). This model is comprised of four factors: perceived susceptibility, perceived severity, perceived benefits of action, and perceived barriers to taking that action (1). From these perceptions, the individual identifies his/her intentions to perform the behavior. The hallmark of the HBM is its assumption of rationality; that is, given a set of perceptions that has high benefits and minimal barriers, the individual would be expected to enact on this behavior.

While the HBM is among the most widely used theory for developing public health interventions, it is not always the most effective in reaching the general population. As will be demonstrated in the ensuing paragraphs, people often do not act rationally and that intention does not always translate into behavior.

In a study conducted by the UK Department of Health (DH) Standing Medical Advisory Committee on Antimicrobial Resistance (SMAC), the perception and attitude of the public towards antibiotics was assessed. The results of the household survey rejected the notion that people acted rationally, given that the majority were quite knowledgeable on the topic of antibiotics (2).

Overall, it was found that patients believed that antibiotics aided their recovery process and sought medical counsel for them and physicians were compelled to prescribe antibiotics due to the perception they had that patients wanted them. The DH-SMAC determined that it was necessary to break these perceptions by both patients and physicians in order to control the misuse of antibiotics (2). In this sense, the DH-SMAC modeled its study on the HBM by identifying the perceived susceptibility and perceived severity of the patients (i.e. patients’ perception that not having antibiotics would leave them susceptible to prolonged sickness or increased severity of sickness), coupled with the perceived barrier of not receiving antibiotics to outweigh perceived benefits (i.e. the decrease of antimicrobial resistance in the community).

The DH-SMAC, despite acknowledging that people were not acting rationally, added various caveats as to why this may have happened to essentially justify the place of the HBM as an effective model. First, McNulty et al. claimed that the number of survey respondents (of which there were over 7,000 people) were not sufficient enough to declare irrationality about antibiotic use. However, note that the survey identified 11.3% of respondents who did not finish their last antibiotic course as prescribed (with incomplete antibiotic courses being a factor in the development of antimicrobial resistance), with 87% of these respondents also saying that a course of antibiotic should always be completed (2). This suggests irrationality and that intention does not always lead to behavior, which the HBM assumes will occur. Instead of addressing this irrationality, the authors chose to counter that not enough people were assessed to make such an assumption.

Secondly, the authors claimed that the reason intention did not translate into behavior is that penetration of the current public health campaign was poor. The DH-SMAC had developed a program named the Andybiotic Campaign, where an animated character named Andybiotic introduced topics of the sensible use of antibiotics. Only 20% of English respondents and 25% of respondents prescribed antibiotics in the past year had seen or heard of the campaign. McNulty et al. suggested that with better funding and prolonged exposure, the campaign would have had a greater impact (2). However, they neglect to admit that the entire premise of the campaign was to inform the public on how to sensibly use antibiotics to influence their behavior, which from the survey results, it appears that most people actually are aware but they simply are not acting. Thus, the campaign fails to change behavior, but relies on the concepts of the HBM to change individual perceptions in hopes that it will lead to a change.

To build on the concept set forth in the HBM, the Theory of Planned Behavior (TPB), which is based also on the idea that people act rationally, takes into account a person’s attitude towards a behavior and the person’s perception of social norms associated with this behavior (1). The TPB is also a commonly used model in public health and shares similar flaws seen with the HBM.

As briefly mentioned earlier, when patients do not complete the antibiotic course prescribed, they are aiding in antimicrobial resistance by allowing for these resistant traits to be selected and transferred to other bacteria to render the antibiotic ineffective. In a study by Jackson et al. based on the TPB, intentions were evaluated to determine whether a person would implement a particular behavior. The authors of this study focused on the element of perceived behavioral control as a potential aspect of the TPB to help develop interventions against antimicrobial resistance (3). Perceived behavioral control refers to the degree in which a person believes that they have control over a certain behavior and relies on two concepts, control beliefs and perceived power, of which would prompt an individual to change his/her behavior (1). To address this, they allowed participants the option of implementing their own plan, phrased on the questionnaire as, “You are more likely to carry out your intention to take these antibiotics as prescribed if you make a decision about when and where you will do so. Decide now when and where you will take these antibiotics. You may find it useful to take a tablet before or after something else that you do regularly, such as brushing your teeth in the morning in the bathroom. We now need to decide when and where you will take each dose of antibiotics.” (3, p.214) Unfortunately, even by empowering participants to develop their own implementation plan, there was no significance between implementation groups. Again, as with the McNulty et al. study, these authors rationalized their results, citing that perhaps students were not representative of the groups of people that need to take prescribed medicines and the good adherence seen by the control group was due to the fact that they knew that someone would follow up with participants at the end of the antibiotic course (3).

Both the McNulty et al. and Jackson et al. studies exemplify a common theme seen with campaigns using individual level theories: the need to rationalize flaws or failures instead of accepting them and find ways to improve rather than adapt to the model. Jane Ogden critically reviewed these individual level theories and came to a very similar conclusion, that researchers often claim that their models are useful, but always preface this statement with some caveats. Mainly, Ogden found that researchers often cited that perhaps the wrong variables were used in the model, certain sample characteristics explained the results (e.g. how Jackson et al. cited students as not a representative group), or simply that their model needs to be extended (4).

This is not meant to entirely discount the HBM and TPB as useless models, but to provide awareness that while these models provide an understanding of how a person approaches health, it does not provide an effective framework for how to affect behavioral change in all instances. This is especially true when the flaws of the model are not taken into consideration when developing and improving upon public health interventions.

Basing Interventions on Biomedical Beliefs and Academic Theory

The issues surrounding antimicrobial resistance are inherently medical in nature in regard to how microorganisms are developing these resistance mechanisms. Understanding that adhering to the complete antibiotic course prescribed, avoiding unnecessary antibiotic prescriptions for illnesses not bacterial in nature, and what the difference between bacteria and viruses are is essential to form the foundation for these public health campaigns. Nonetheless, biomedical beliefs and academic theories alone do not automatically translate into behavior change (2-3).

Realizing that antimicrobial resistance and the need to extend the life of antimicrobial drugs are becoming significant dilemmas, the Centers for Disease Control (CDC) has enacted a Public Health Action Plan to Combat Antimicrobial Resistance by an Interagency Task Force on Antimicrobial Resistance. This Interagency Task Force consists of several federal health agencies, but no social science or public health consultants were mentioned as participants. Some areas of focus for this group are ensuring patient adherence to an antibiotic regimen through directly observed therapy and to identify areas where rapid diagnostic tests and consultation are not readily available. The strong biomedical foundation of these antimicrobial resistance interventions ignore non-biomedical barriers to implementation to the public. For example, implementing directly observed therapy to ensure adherence by having a health care worker observe the patient take a dose of medication is unrealistic when taking into consideration cost, access, infrastructure, transportation, and other external factors that would prevent effective implementation (5).

Another popular tool for assessing the effectiveness of antimicrobial resistance interventions is the use of mathematical modeling. The benefits of using mathematical models are that they are cost effective and produce rapid results. And while additional factors can be added to models to address the complexity of the environment in which microorganisms live, it will never be on par with direct, participatory observations in a community. Discrepancies have been identified with the reliance on mathematical models, particularly that these models often have important variables missing and make incorrect assumptions. One of these assumptions is that a community is generally regarded as homogeneous, which it is certainly not. One community can encompass a range of diverse situations that, at the same time, can both promote and reduce antimicrobial resistance and these community traits are not readily transferable to other communities (6).

Part of the reason why interventions are heavily theory based is the historically academic nature of the epidemiological studies of which these interventions are relying on to identify which factors to focus its attention. Carl Shy stated in his commentary on this topic that “epidemiologists have failed to provide the public health community with scientifically tested choices among alternative community actions for promoting health.” (7, p.480). He further elaborates that academic epidemiology has limited itself to a narrow biomedical perspective of disease, neglecting to incorporate upstream factors to understand population behavior (7). These upstream factors oftentimes provide more insight into behavior than academic theory or biomedical concepts can provide, as will be discussed in further detail in the following section.

Neglecting to Acknowledge Societal Factors in Addressing Antimicrobial Resistance

While the emphasis on theory and mathematical modeling has allowed for conceptualizing how different factors may play into devising an effective intervention, it does so at the expense of realizing higher level circumstances that potentially have a larger role in why people are not changing their behavior for the betterment of the public.

To help aid in realizing the implications of understanding societal factors in a group setting, further analysis will be performed on survey results assessing knowledge on antimicrobial resistance. In the household survey conducted by McNulty et al., the issue of left-over antibiotics was addressed. Thirty-one percent of survey respondents indicated that they had kept left-over antibiotics in case they needed them again and 8% in case the same infection occurred. Another survey question had asked if participants agreed with the statement, “A course of antibiotics should always be completed,” of which only 3% of respondents disagreed with. Looking at these survey questions in conjunction, it is evident that people are knowledgeable about the situation, so merely educating the public will not rectify this issue. One must look beyond the facts of the situation to social factors that may be driving why people are saving their left-over antibiotics at the cost of losing efficacy and promoting resistance in the future (2).

A possible explanation is that antibiotics can be costly and if one does not have health insurance, the cost is even greater, so it might drive a person to ration their drug supply to save money. Compound this with the fact that many bacterial illnesses are recurring and that within a family structure, the illness can be readily transmitted from one person to another. Also add to this that once a person feels better, he/she can decide that the treatment is no longer necessary, further rationalizing keeping the antibiotic for future use. So in this instance, current educational campaigns would be rendered ineffectual.

It is necessary to study the characteristics of populations to better affect behavioral change. By looking beyond the immediate causes, as Shy suggested, interventions can communicate a broader perspective instead of the narrow biomedical, individualistic viewpoint expressed today. Regularly, studies are performed where societal context is either completely omitted or superficially mentioned. For instance, the CDC has indicated that antimicrobial resistance will require the assistance of behavioral scientists and health communications experts, but these experts are absent as members of the Interagency Task Force to address this issue. Also, the CDC expressed interest in identifying interventions that are effective in decentralized, heterogeneous environments, but current CDC campaigns are quite homogeneous itself in nature, making it difficult to imagine how it could affect a greater population (5,7).

Another unique aspect of antimicrobial resistance is the increase in global movement and international travel. This has allowed for more rapid emergence of new resistant bacterial strains that not only is easily spread from person to person, but environment to environment. Globalization of trade and increased prevalence of developing countries and their contributions to the market have greatly influenced the proliferation of resistant bacterial microorganisms (8). So, not only should interventions consider societal factors, but global factors also.

An Alternative Approach to Public Health Interventions

Current interventions targeted at reducing antimicrobial resistance have failed due to the pervasiveness of individual level theory based on biomedical beliefs that dominate the field of public health. By ignoring sociocultural factors that drive people to behave the way they do, we are essentially ignoring innovative methods that could be implemented to more profoundly affect behavioral change in the general population. Until we can learn to break from the norm and begin to incorporate more comprehensive methodologies from social sciences, we will always be lacking in truly affecting the public in the campaign against decreasing antimicrobial resistance.

An alternative approach using marketing and social learning theory is proposed in to address some of the inherent flaws seen in current public health campaigns.

An Intervention Aimed at Marketing Antimicrobial Resistance Prevention

Instead of approaching the intervention using conventional public health theories, this proposed intervention draws on theories from marketing and social learning. Posing a general framework for this intervention, several aspects must be addressed to ensure program effectiveness:

1. Identifying the target population and interviewing people within this community to identify how to better market the behavior.

2. Consider the barriers that might exist, within a social context.

3. Identify what aspect of antimicrobial resistance should be marketed, e.g. knowledge of bacteria, outcome of not following through with a prescribed antibiotic regimen.

4. Identify what the type of media is most appropriate to transmit the message.

5. Conceptualize a brand to solidify the message.

6. Putting it all together to aid in people forming new linkages to the behavior where it becomes a social and cultural norm (9-11)

How would this new intervention to antimicrobial resistance address the flaws of current campaigns? This will be discussed in further detail in the following sections.

Addressing the Current Reliance on Individual Level Public Health Theories: How to Address a Message to the Masses vs. Individuals

Relying on how an individual may perceive a situation or why a person acts the way s/he does ignores the fact that they live in an environment affected by others. Individual level factors provide great insight into attitudes and perceptions, but not into how to affect a wider population to change behavior. These individual factors are related to the issue at hand, but do not get to the root of the problem upstream. Instead, the intervention must be aimed at groups of people, whole societies, a culture, essentially to the masses to effect a change.

Theories that take into account societal norms and factors need to be considered instead. Social learning theory provides an excellent framework to base an intervention on; it states that, “how individuals observe other people’s actions and how they come to adopt those patterns of action as personal modes of response to problems, conditions, or events in their own lives.” (11, p.212) By influencing groups of people, others begin to respond to the new behavior and adopt it as their own.

Aspects of marketing theory using these social perceptions can be used to mass market a public health message to a broad population base. The goal is to affect as many people as possible, in a mass, rather than individually. The next question would be, what public health message needs to be addressed? Ideally, there needs to be a connection made between antibiotic usage and the prevention of resistance. People are already well aware of the consequences of improper antibiotic use, so bombarding them with more information would be counterproductive. A review by Evans et al. stressed how potent public health branding can be to change behavior. Branding creates a symbol that is used as a tool to communicate a message to an audience, building a relationship and encouraging execution of the health behavior. There needs to be a creation of a brand for preventing antimicrobial resistance. The effectiveness of branding has been shown in brands such as Nike, but also in public health such as the Truth campaign to stop smoking (10). For antimicrobial resistance, the brand created would communicate the message to foster an understanding of when antibiotics should be used and when how to properly use them, rather than telling the public information such as what the difference between bacteria and viruses are (9-10).

Moving Away from Academic Theory to Create a More Effective Intervention

As mentioned, people are quite knowledgeable about the consequences of improper antibiotic use. However, current interventions are still focused on the transmission of knowledge and information that is already well known. Goossens et al. used as an example how many campaigns tended to emphasize the distinction between viral and bacterial respiratory tract infections. Instead of educating people, this type of information may cause confusion and promote the perception that all bacterial infections must be treated with antibiotics. They suggest that instead, a message to foster an understanding of when antibiotics should be used and encouragement to consult with health professionals would be more effective (9).

Reliance on statistics, scientific theory, and medical theory has its place, but not when speaking to the public in a way to change their behavior. Using the fact that people are not finishing their prescribed antibiotic course, the proposed intervention would look within the social context of why people might be doing this. A possible reason might be that mothers are saving some of the medication for future use for their children due to the high cost of the drugs or because they cannot afford to make frequent visits to their physicians. There are a myriad of other reasons that may not have to do with cost: what is the cultural perception of antibiotics, are people basing the incompletion of their antibiotic course on how they feel, etc. Realizing how health behaviors are motivated by social context is important in developing an effective intervention, rather than relying on statistics and the mechanics behind how bacteria develop into a resistant strain.

Incorporating Knowledge of Societal Influences into an Intervention

As alluded to throughout this discussion, people are greatly influenced by the society in which they live. The norms, culture, and views all play into how people behave. These cannot be neglected, but have been in traditional public health campaigns. People make deliberate choices in adopting certain behaviors and this must be taken into account when developing an intervention. More importantly, people make these choices based on language and symbols.3 This is why branding of the antimicrobial resistance message is essential to the intervention. DeFleur et al. cites Bandura, when he states that “through verbal an imagined symbols people process and preserve experiences in representational forms that serve as guides for future behaviors.” (11, p.215)

Once the brand and message are created, it needs to be communicated. Typically, antimicrobial resistance campaigns have been distributed in print media. A more effective medium to use would be television advertising, which proved to be successful in France and Belgium antimicrobial resistance campaigns (9). Visual symbolism is very powerful, and can be easily used to convey the importance of proper antibiotic use. For example, imagery involving children would be very effective. One could show how using only some of the antibiotics does not entirely kill the microorganisms by visually showing, by use of color and imagery, survival of the bacteria in a child’s body. Subsequent proliferation of the bacteria into resistant strains could be shown by a change in color and size of the bacteria. Then, the child can be shown to be ill with the same symptoms, be prescribed the same antibiotic, but it does not work (shown by none of the bacteria being killed off). More visits to the doctor to receive alternative antibiotics can either show how the new treatment can be somewhat effective, but that continuing the bad health behavior will lead to more resistant strains until no medication is left to help the child. Various commercials in this vain would be shown to different markets, adapted to fit the views of that particular society, with the specified branding and message repeated along with the visual imagery.


Public health campaigns rooted in traditional behavioral theories view people as singular entities living in a vacuum. It is necessary to break free from this mindset in order to create more innovative and effective interventions. In regards to antimicrobial resistance campaigns, populations need to be addressed in masses with a strong message as to how misuse of antibiotics can lead to harm. After this general message is addressed, specific interventions need to be developed in the same manner, through interviews with the target population that would better be able to identify root problems dealing with poverty and related societal issues.


1. Edberg M. Chapter 4: Individual Health Behavior Theories. Essentials of Health Behavior: Social and Behavioral Theory in Public Health 2007; 35-49.

2. McNulty CAM, Boyle P, Nichols T, Clappison P, Davey P. The public’s attitudes to and compliance with antibiotics. Journal of Antimicrobial Chemotherapy 2007; 60(Suppl.1):i63-i68.

3. Jackson C, Lawton RJ, Raynor DK, Knapp P, Conner MT, Lowe CJ, Closs SJ. Promoting adherence to antibiotics: a test of implementation intentions. Patient Education and Counseling 2006; 61:212-218.

4. Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003; 22(4): 424-428.

5. Bell DM. Promoting appropriate antimicrobial drug use: perspective from the Centers of Disease Control and Prevention. Clinical Infectious Diseases 2001; 33(Suppl.3):S245-250.

6. Kristinsson KG. Mathematical models as tools for evaluating the effectiveness of interventions: a comment on Levin. Clinical Infectious Diseases 2001; 33(Suppl.3): S174-179.

7. Shy CM. The failure of academic epidemiology: witness for prosecution. American Journal of Epidemiology 1997; 145(6): 479-484.

8. Williams RJ. Globalization of antimicrobial resistance: epidemiological challenges. Clinical Infectious Diseases 2001; 33(Suppl. 3): S116-117.

9. Goossens H, Guillemot D, M Ferech et al. National campaigns to improve antibiotic use. Eur J Clin Pharmacol 2006; 62:373-379.

10. Evans WD, Blitstein J, Hersey JC, Renaud J. Systematic Review of Public Health Branding. Journal of Health Communication 2008; 13:721-741.

11. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

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