Reducing Expectations for Antibiotics in Primary Care: A Randomised Experiment to Test the Response to Fear-Based Messages About Antimicrobial Resistance

Abstract

Background: Public health campaigns often provide fear-based information about antibiotic-use and antimicrobial-resistance (AMR). This study aimed to test the likely impact of fear-based messages on patient consultations/antibiotic-requests for influenza-like-illnesses. Methods: We hypothesised that fear-based messages containing empowering information about self-management without antibiotics would be more effective, particularly in a pre-specified subgroup with low AMR awareness. Respondents from an online research panel, representative of United Kingdom adults, were randomised to receive three different messages about antibiotic-use and AMR, designed to induce fear about AMR to varying degrees. Two messages (one 'strong-fear', one 'mild-fear') also contained empowering information regarding influenza-like-symptoms being easily self-managed without antibiotics. The main outcome measures were self-reported effect of information on likelihood of visiting a doctor, and requesting antibiotics, for influenza-like-illness; analysed separately according to whether the AMR information was very/somewhat new to respondents, pre-specified based on a previous non-randomised survey. Findings: The 'fear-only' message was very/somewhat new to 285/1,000(28·5%) respondents; 'mild-fear-plus-empowerment' to 336/1,500(22·4%); and 'strong-fear-plus-empowerment' to 388/1,500(25·9%) (p=0·002). Of those for whom the respective information was very/somewhat new, only those given the 'strong-fear-plus-empowerment' message said they would be less likely to request antibiotics if they visited a doctor for an influenza-like-illness (p<0·0001; 182/388(46·9%) 'much less likely'/'less likely', versus 116/336(34·5%) with 'mild-fear-plus-empowerment' versus 85/285(29·8%) with 'fear-alone'). Those for whom the respective information was not very/somewhat new said they would be less likely to request antibiotics for influenza-like-illness (p<0·0001) across all messages (interaction p<0·0001 versus very/somewhat new subgroup). The three messages had analogous self-reported effects on likelihood of visiting a doctor, and in subgroups defined by believing antibiotics would definitely/probably help an influenza-like-illness. Interpretation: Fear could be effective in public campaigns aimed at reducing antibiotic-use, but should be combined with messages empowering patients to self-manage symptoms effectively without antibiotics. Funding Statement: The research was funded by the National Institute for Health Research Health Protection Research Units (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford [grant number HPRU-2012-10041] and at Imperial College London [grant number HPRU-2012–10047], and the NIHR HPRU in Evaluation of Interventions at the University of Bristol [grant number HPRU-2012-10026], all in partnership with Public Health England (PHE). Michele Peters is an Associate Professor supported by the Department of Health funded Policy Research Unit on Quality and Outcomes of Person Centred Care (QORU), a collaboration between the London School of Economics and Political Science (LSE) and the Universities of Kent and Oxford. Tim Peto and A. Sarah Walker are NIHR Senior Investigators. Enrique Castro-Sanchez was supported by a Wellcome ISSF Faculty Fellowship at Imperial College London. Laurence S.J. Roope, Derrick Crook, Tim Peto, A. Sarah Walker, and Sarah Wordsworth are supported by funding from the NIHR Oxford Biomedical Research Centre (BRC). Declaration of Interests: All authors declare: no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could have influenced the submitted work. Ethical Approval Statement: This study is based on data from three surveys. The first survey data existed prior to this study, having been developed separately,24 on attitudes to antibiotics and awareness of AMR. This and the second survey (first wave of this study) were not submitted for ethical approval based on previous similar surveys, since they were undertaken outside the NHS setting and did not request personal health information, only views about health. Respondents had volunteered to receive information about such surveys from SSI. Completion of the survey was considered as indicating consent and respondents were able to refuse to participate in the survey at any stage in the process. The third survey (second wave of this study), which is identical to the second survey (first wave of this study), was approved by the University of Oxford’s Central University Research Ethics Committee – reference number R49463/RE001. Following approval of the third survey, the original and second survey were retrospectively considered by the same committee (reference number R57213/RE001) who deemed that “it is probable that, had the documentation and a full application been submitted for ethical opinion at the correct time, the committee would have granted ethical approval (perhaps subject to some amendments of the documentation).” Respondents gave informed consent before taking part. We attest that we have obtained appropriate permissions and paid any required fees for use of copyright protected materials.