Friday, December 08, 2006

A Better Approach to Address Antibiotics in the USA Would Consider Social and Environmental factors - Jun Liu

Since penicillin was first discovered by Alexander Fleming in 1927, antibiotics have been used world wide to treat infectious diseases. They have transformed medical care and reduced illness and deaths dramatically. After more than 50 years of widespread use, however, many antibiotics are not as effective as they used to be. The bacteria and other microbes have become resistant to the effects of antibiotics. The term “antibiotic resistance” is used to describe these microbes.

Antibiotic resistance is an emerging public health crisis facing the world. There are numerous reports showing that resistant bacteria are increasing (3). Over the last decade, almost every type of bacteria has become stronger and less responsive to antibiotic treatment. These antibiotic-resistant bacteria can quickly spread to family members, schoolmates, and co-workers—threatening the community with a new strain of infectious disease that is more difficult to cure and more expensive to treat. People infected with antibiotic-resistant organisms are more likely to have longer hospital stays and require treatment with second- or third-choice medicines that may be less effective, more toxic, and more expensive. Although scientists are developing new antibiotics every day to fight the antibiotic resistant microbes, this has not kept up with the development of resistant bacteria.

It is now clear that the primary cause of antibiotic resistance is the consistent misuse and overuse of antibiotics (3). These behaviors include using antibiotics in a viral infection, stopping antibiotics too early, taking antibiotics prescribed for someone else, pressuring the physician to prescribe an antibiotic, etc. This is especially true among parents with young children.

In order to address antibiotics resistance, there have been some public health programs aiming at reducing or eliminating the behaviors described above. The typical approaches used in these programs are individual educations. In this paper, I’m going to critique one of the programs as an example applying the theories of social behavior science.

Critiques of Current Intervention Approaches

Failure of Health Belief Model

One intervention program was launched in two pediatric primary care clinics located in an urban and suburban setting in the Boston area (2). In this program, parents were randomly assigned to the intervention or control groups. Parents in the intervention group were asked to view a 20-minite video, specifically developed for this project, over a 2-month period, and given a brochure about antibiotics. They contained information about common viral infections, how to use antibiotics, and a statement that antibiotics are effective only against bacterial infections. At the end of the study, the parents’ behavior regarding appropriate use of antibiotics were assessed by filling out questionnaires about the frequency with which they adhered to a prescribed regimen or followed appropriate or inappropriate antibiotic practice. Unfortunately, the results showed that there was essentially no significant difference of self-reported behavior between the intervention group and control group.

The rationale of this program is based on the traditional Health Belief Model (HBM). The HBM is a psychological model that attempts to explain and predict health behaviors (5). This is done by focusing on the attitudes and beliefs of individuals. The HBM is based on the understanding that a person will take a health-related action if that person has a desire to avoid illness and believe that a specific health action will prevent illness. There are four constructs in this model: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. This model has been applied to a broad range of health behaviors.

This intervention program is based on the HBM model. Applying the four constructs in the model, first the patient must perceive that he/she is susceptible to develop antibiotics resistance if he/she misuses or overuses the antibiotics. Second, he /she must also perceive the serious consequence of antibiotics resistance. He/she should know that once he/she develops resistance, there will be no effective treatment of infectious disease any more. This may lead to a serious condition even death. Third, he/she must also perceive that if they follow the instruction in the video about appropriate use of antibiotics, the development of antibiotics resistance will be slowed down. That’s the perceived benefits. Finally he/she needs to identify personal barriers to using antibiotics appropriately.
I believe that this educational video and brochure program had covered all these contents. After viewing this video, patients should have the knowledge that if they misuse or overuse the antibiotics, they will be susceptible to antibiotic resistance and this will lead to a serious medical condition in case of infectious disease. They should also know that as long as they follow the instructions in this video program and brochures, the development of antibiotics resistance can be stopped or slowed down.

Unfortunately, this program turned out to be a failure. After 2 months of education, there is no significant reduction of self-reported antibiotics misuse and overuse rate among the intervention group compared with the control group. The ineffectiveness of this approach indicated that HBM is not the best model to be applied in addressing this public health issue. Just believing the consequences of bad behaviors and the benefits of changing behaviors is not enough. The limitation of this model is that it ignores other factors that may heavily influence health behavior practices. These factors may include: special influences, cultural factors, socioeconomic status, and previous experiences, etc.

Applying Social Ecological Model to Intervention

Since a simple method is not enough, multifaceted approaches should be used. As a result, a model called “Social Ecological Model” is more appropriate in addressing this issue. This model attempts to direct interventions by identifying personal and environmental components from which to focus the intervention. It recognizes that behaviors are influenced by interpersonal, social, cultural, and physical environment variables. It also recognizes the necessity of addressing variables at multiple levels to understand and change health behaviors. There are five levels in the social ecological model: individual, interpersonal, organizational, community, and public policy (6).

Individual Level

The intervention at individual level should be focused on the education of patients. Although the video program failed, it doesn’t mean education is not needed. Knowledge is the first step. Only when the patients have the knowledge, they are likely to take actions. So we need to educate them about what antibiotics resistance is, what cause antibiotics resistance, what the serious consequences are and how to prevent them.
At the individual level, physicians should be targeted as well, because they are where the patients obtain the antibiotics from and have a great impact on patients. There is significant research about physicians’ overzealous prescribing habits. Approximately 50% of prescriptions for children written by community-based practitioners are unnecessary. So for intervention, first, physicians should be educated to stop over-prescribing antibiotics. There are multiple reasons for physicians’ over-prescribing, some of which are at organizational level and will be discussed in the later section. Second, physicians should play a role in educating patients. Actually since patients trust their physicians most, especially when they are sick, their physicians should be the best message providers. If physicians can educate patients about how to appropriately use antibiotics when they are seeing patients, this would be the most effective way. The current practices of physicians are that physicians usually don’t explain adequately about the drugs they prescribed. Patients rely on the instructions written on the drug bottles. This is especially harmful when taking antibiotics. Patients may stop antibiotics when they feel better. This is an important cause of antibiotics resistance. So physicians have the responsibilities to instruct patients about the proper use of antibiotics, especially emphasize the importance of completing the full course.

Interpersonal Level

The intervention at interpersonal level will be based on the approach that family support must be an integral part of education to impact patients’ behavior. To accomplish this, family members should be educated and aware of the antibiotics resistance as well.
The ways family members may impact patient’s behaviors are various. Sometimes patients don’t want to see a doctor when they are sick. They make diagnosis by themselves based on previous experience. Then they would use the antibiotics leftover from last time or prescribed for other family members. Sharing antibiotics is an important factor for developing antibiotics resistance. As a result, we should not only target patients, family members should be educated too. Family support is another contributing factor. Elderly patients and children are the most frequent users of antibiotics. But they are also the most susceptible to inappropriate use of antibiotics. They may stop antibiotics too early when they feel better, take family member’s antibiotics, etc. As a result, family support is especially important for these populations. They need to be reminded to take antibiotics as instructed, throw away the unused antibiotics, and see a doctor when they are sick.

Organizational Level

As discussed above, physicians over-prescribing behavior has a huge contribution to antibiotics resistance. The reasons for physicians’ over prescribing behaviors are complicated. Physicians have been receiving repeated messages to curtail antibiotics use from the biomedical literature, medical and public media, health insurance companies, key opinion leaders. So lack of knowledge is not the primary reason. The demand for antibiotics has been hypothesized to have occurred for several reasons, including physicians’ and patients’ shared dependence on antibiotics for mild illness, coercion by patients, time constraints, fear of litigation after a missed or delayed diagnosis, treatment-oriented physician competitors, concern over excessive return visits for persistent “untreated” viral illness, and parent dissatisfaction (7).

As a result, the intervention at physicians’ level is multifaceted. First, continuing education of physicians is important. Physicians need to be convinced that antibiotics are not for viruses, antibiotics do not affect retention or return visit rates, and overuse of antibiotics brings about unnecessary costs. Faced with worried patients and their family members, most often the right thing is reassurance, symptomatic therapy, and availability for follow-up--not antibiotics. Second, to reduce the pressure from patients, education of patients as discussed at individual level is needed. Third, we should improve the communication between physicians and patients. There is evidence that parents were often misinformed on what antibiotics could effectively treat. Finally, we need to change the policies to promote the judicious use of antibiotics by physicians (discussed below).

Community Level

Unlike other public health issues, the individual’s inappropriate use of antibiotics will have an impact on other’s health as well. Once resistant strains have been developed, they are resistant to antibiotics for all human beings. As a result, public awareness is important. Interventions should not only be targeting patients, but healthy persons as well.
A community wide campaign is needed. Besides the health care provider education, patients, family members and public education is an integral part. This should involve local public health agencies, parents groups, community organizations, pharmacies, and child care providers. Communication of information can be through television, radio, newspaper coverage and public service announcement. Since children are the greatest users of antibiotics, child care providers should be included in the campaign. Effective child care interventions may require repeated educational presentations for staff members and frequent reinforcement of key messages to parents.

Public Policy Level

Since the antibiotic resistance is on the rise, imposing a huge cost on economics and society, policy makers should create economic incentives to encourage patients, physicians and drug manufactures to consider the societal cost of using antibiotics.
On the physician’s side, the high cost of malpractice lawsuits may induce physicians to use stronger and broader spectrum antibiotics. This would increase the antibiotics resistance at community levels. But the impact on each individual prescription is so small that the benefit perceived by the doctor of prescribing antibiotics often outweighs the small uncertain costs caused by increasing resistance. One solution would be to design guidelines that use community data to minimize the overall total cost of treatment and future resistance. In addition, policymakers may want to consider redesigning prescription drug insurance programs to reduce physicians’ over-prescribing of antibiotics.

On the patients’ side, they usually make decisions based on two factors: the benefits of quickly recovering from an infection and the cost, not aware of the risk of acquiring a resistant infection. The education at individual level is one solution. On the other hand, such economic instruments as taxes, subsidies should also be considered to guide patients to use antibiotics appropriately.
On the drug manufacturer’s side, adjusting the drug’s effective patent life could be an effective tool. Policy makers may want to extend the patent life to increase incentives for a company to minimize resistance, since the company would enjoy a longer period of monopoly benefits from its antibiotic’s effectiveness.

Summary

Antibiotics resistance is public health problem influenced by multiple factors. A simple method of HBM targeting only patients would not be successful. Based on the social ecological model, we have to consider multiple variables for intervention including intrapersonal, social, cultural, and physical environment.

References

1. http://www.cdc.gov/drugresistance/index.htm
2. Howard Bauchner, Stavroula Osganian, Kevin Smith, Randi Triant. Improving parent knowledge about antibiotics: a video intervention. Pediatrics 2001; 108; 845-850
3. Neu HC. The crisis in antibiotic resistance. Science. 1992; 257:1064-1073
4. American Academy of Pediatrics. Principles of judicious use of antimicrobial agents, a compendium for the health care professional. Elk Grove Village, IL: American Academy of Pediatrics; 1998;
5. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
6. Glanz K, Rimer BK (1997). Theory at a glance—a guide for public health promotion practice. National Institutes of Health. 249-262
7. Michael E Pichichero. Dynamics of antibiotic prescribing for children. JAMA 2002 (287); 3133-3135

2 Comments:

Blogger Michael Siegel said...

This is a great demonstration of the limitations of the health belief model (which, unfortunately, guides the majority of public health interventions) and the advantages of a broader social ecological model, which considers multiple levels of influence. Through your example of antibiotic use, you have demonstrated how a broader view of the determinants of health behaviors can contribute to the development of a much better informed and much more effective campaign. You have shown how the implications of the choice of guiding behavioral change model for the development of an intervention are enormous.

11:13 AM  
Blogger christyjames said...

This post was really properly written, and it also incorporates a lot of valuable facts.
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11:03 PM  

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