Background Antimicrobial Resistance Behaviour Change First informal technical consultation 6-7 November, 2017 Château de Penthes, Geneva Meeting Report The global action plan on antimicrobial resistance was adopted by Member States at the World Health Assembly in May 2015. The plan is a roadmap to tackle the increasing global threat of antimicrobial resistance (AMR). Strategic Objective 1 of the plan is to improve awareness and understanding of AMR through effective communication, education and training to address the widespread public misunderstanding about AMR. Under this objective WHO is conducting ongoing global activities to raise awareness of AMR and aims to provide the public, policymakers and professionals in the human health, animal health, food, agriculture and environment sectors with information about AMR and guidance on specific actions they can take to address it. The campaign continues to attract widespread media coverage and engagement on social media platforms as well as great interest from Member States and partners, particularly during the annual World Antibiotics Awareness Week. However, it is also important to catalyse shifts in behaviour towards more appropriate use of antimicrobials, including antibiotics, and reduce AMR. WHO recognizes that this is a complex, multi-stage process and that the Organization will need to draw on a wide range of expertise beyond its traditional partners in public health. Objectives and process The World Health Organization has brought together a regionally diverse, multidisciplinary group of experts to provide evidence-based guidance, on an informal basis, on the development of behaviour change policies and actions, with reference to examples of best practice and lessons learned. The AMR Secretariat will draw on this guidance and, in consultation with key stakeholders, identify the most appropriate way forward for the Organization to support Member States in the development of behaviour change programmes for appropriate antimicrobial use and where feasible, supplement with other interventions. The informal technical consultation group, comprising 16 external experts, met for the first time on Monday, 6 November and Tuesday, 7 November 2017 at the Château de Penthes, Geneva, convened by the WHO AMR Secretariat. The first meeting focused on identifying the most relevant target audiences together with the specific behaviour patterns that are driving misuse of antimicrobials. Discussions drew on lessons learned from other relevant behaviour 1
change programmes and explored how the principles of behavioural science could be applied to AMR. Selection process and composition of the informal expert consultation In identifying potential experts to join the informal technical consultation on behaviour change, the WHO AMR Secretariat sought recommendations from WHO regional offices, technical focal points within the AMR Secretariat and across WHO Headquarters and external stakeholders. Nominations received were evaluated against the selection criteria developed for this consultation. The experts selected all have advanced university degrees, and substantial experience in contributing to cross disciplinary guidance processes. In addition, candidates have a proven track record of publications, experience with behaviour change related initiatives, or country/regional level antimicrobial resistance related expertise. All were determined to have strong communication and inter personal skills, a willingness to consider innovative approaches, leadership skills and, through their international standing among their peers, the capacity to access and engage with other expert networks. Throughout the process, consideration was given to attaining a wide distribution of technical expertise, geographical representation and gender balance. Prior to the meeting, members of the informal consultation were requested to declare any interests they may have of relevance to the subject of the meeting. Declared interests were evaluated in advance of the consultation and none were deemed to pose any conflict that would prohibit any participant from fully engaging in the discussions and recommendations. The group currently comprises experts from behavioural sciences, health workforce, and those with direct experience on behaviour change programmes. A complete list of the consultation experts is attached (Annex 1). To ensure a One Health approach and enhance tripartite collaboration, colleagues from the World Organisation for Animal Health (OIE) and from the Food and Agriculture Organization of the United Nations (FAO) were fully involved in identifying individuals from their respective sectors and were present at the meeting. Meeting process The informal technical consultation on behaviour change was opened by Marc Sprenger, Director of WHO s AMR Secretariat, and was chaired throughout by Elizabeth Long. Following a brief round of introductions, the first day comprised a series of presentations that focused on behaviour change models and frameworks, country level examples of best practice and lessons learned from other health programmes. Specific attention was given to determining the evidence base for antimicrobial resistance behaviour change initiatives. These informative 2
sessions were followed by discussions of the key priority behaviours and target audiences for potential behaviour change interventions, together with an impact and feasibility assessment of each of the priorities identified. The second day went on to consider potential tools and methodologies required for successful behaviour change programmes. The consultation concluded with a comprehensive mapping of the four identified key target audiences alongside the respective desired behaviour change, practical interventions, potential barriers to change, and discussions on timeline for implementation. The meeting concluded with consensus on a number of possible behaviour change interventions aimed at the target audiences that WHO might wish to pursue further. Individual comments made by participants are not attributed in this meeting report unless specifically relevant to the information provided. This report also uses the term antimicrobials as encompassing terminology to include antibiotics as well. Presentations and case studies Kama Garrison presented the key lessons learned from programmes that address behaviour change as part of malaria control. She stressed the importance of understanding the specific behaviour, context and audience that is being targeted and the need for data to identify risk and to measure impact and response. She noted that behaviour change programmes rarely succeed in isolation and frequently fail without a thorough analysis and understanding of the exact behaviour focus. Dongbo Fu outlined the multiple factors that can influence behaviour choices around tobacco use. These factors are operating at multiple levels including individual, interpersonal, organizational, policy and enabling environmental levels, all of which must be taken into account in designing comprehensive behaviour change programmes. He identified two categories of interventions, those with a practical approach and those based on established theories. Elizabeth Long and Michael Sanders together presented an overview of how advances in the field of behavioural economics can be applied to health promotion activities. Understanding the gap between knowledge, intention, and action, as well as how social norms, peer pressure and behaviour choices interact and influence actors at the point of decision-making is crucial. Using examples from a variety of settings, the presenters described successful interventions and addressed lessons from others that had failed. Clare Chandler presented findings from qualitative field research into levels of awareness and understanding of AMR among health professionals that has been undertaken by the London School of Hygiene and Tropical Medicine with the support of WHO. The study had concluded that knowledge and awareness are higher than expected but that other factors were contributing to decision choices. She also stressed the importance of considering the potential 3
unintended consequences of behaviour change. A full report of the study is expected in the first quarter of 2018 and will be shared with members of the technical consultation. Jeremy Knox and Dan Metcalfe provided an overview of the Wellcome Trust s interest and involvement in addressing AMR and in finding new policy tools for the stewardship of new antimicrobials. They emphasized the key role that the Wellcome Trust can play in bringing together interdisciplinary evidence from experts to enable policy makers and politicians to bring about policy changes. The Wellcome Trust is currently undertaking a literature review of evidence and interventions from low and middle-income countries which will be shared with the group in due course. Wang Yu described how knowledge and awareness of AMR had been raised among undergraduate medical students in China and presented an initiative to introduce AMR education to primary school children. The pilot project in schools had been underway for two years and would be scaled up nationwide. AMR ambassadors were playing key roles in reaching children and young adults through social media. Fatemeh Soleymani presented the impact of education courses in Iran on encouraging the rational use of antimicrobials. The programmes had used a variety of media including story books, lectures, plays, visual arts and workshops. Students are being followed over a five year period to identify trends in increasing understanding. The presenter stressed, however, that regulation and managerial interventions play a significant role in changing prescribing behaviour. Nithima Sumpradit focused on initiatives underway in Thailand aimed at changing the social norm that drives inappropriate behaviour. Nationwide campaigns on the smart use of antimicrobials were seeing significant results through low-tech interventions that were empowering patients to engage with health care providers and pharmacists to identify the correct diagnosis and seek the appropriate treatment. Tenaw Andualem Tadege presented FAO s work on AMR containment and the example of Ethiopia as a country that had been running an effective large-scale AMR awareness and understanding, empowerment and stewardship programme over recent years. The programme on awareness and understanding includes complementary interventions, such as: individual one-to-one antimicrobial treatment adherence counselling by providers; face-to-face group education at health facilities; mass media broadcasts through electronic and print media; and the use of social and behavioural change communications. Moreover, antimicrobial stewardship and auditing practices and feedback to health care providers in combination with other interventions had reduced the percentage of antimicrobials being prescribed, increased appropriate labelling of medicines and over years had improved knowledge among patients at the participating health facilities. 4
Shona Wynd presented the lessons learned from the response to HIV/AIDS. Of particular note was that interventions based solely on technical perspectives often fall short in the context of human behaviour and irrational decision-making. She stressed the importance of placing people at the centre of interventions and giving them a voice with which to be fully engaged. It was essential to identify all potential stakeholders and partners, provide a platform for interaction, and gather and share data of maximum granularity in order to make sense of blockages and give visibility to populations. Catherine Bertrand-Ferrandis provided an overview of OIE s approach to risk communication, which had not, up to now had an emphasis on behaviour change. The communication interventions were mainly focused on veterinary services to provide tools and messages to convey prudent use to their constituents. Channels are largely one-to-one and are technical in nature. OIE is now focused on gathering behaviour data among farmers and vets. Overarching themes In the discussions that followed the presentations, two recurring themes emerged that the technical consultation noted should be emphasized as overarching principles. Awareness alone does not intrinsically lead to behaviour change. Comprehensive effective behaviour change programmes require a combination of data to inform policy makers, regulation, tools for implementation, and strategies to correct misunderstanding among the public. The experts reiterated the importance of acquiring data; segmenting the target audience and analysing their current behaviour; considering the social and cultural context in which behaviour is taking place; utilizing multiple reinforcing channels and different message dosage; continually measuring pre-set input, output, outcome and impact indicators for the interventions; and anticipating and avoiding unintended consequences. The presentations provided valuable insight into behaviour change that contributed significantly to the AMR Secretariat s understanding of the complexity of behaviour change; concepts such as knowledge, intention, and behaviour not always being intrinsically linked and the hot-cold empathy gap, a cognitive bias in which visceral factors on attitudes and behaviours although pre-requisites, can distort rational decision-making. Priority audiences and interventions Following extensive discussion, the expert consultation defined and agreed on four, clear target audiences The Four P s on which to focus behaviour change interventions: public prescribers for humans and animals 5
pharmacists policy makers (across sectors e.g., public, animal and environment) For each of these target audiences, the experts considered key behaviours related to the use of antimicrobials that a programme would seek to change. Working in interchangeable groups, they considered the possible barriers that may impede change, practical interventions to encourage the behaviour, and means of measurement. Participants also considered feasibility and the timeframe within which WHO could implement the interventions. A table detailing the working group deliberations is attached to this meeting report (Annex 2); interventions receiving the most votes were deemed to be the highest priority per target audience. Public Case studies from China, Ethiopia, Iran, Thailand all exemplified the importance of empowering patients to engage in discussions with prescribers around appropriate antimicrobial use. The innovative example from Thailand of a self-diagnosis tool for upper respiratory tract infections in health care and pharmacy settings was particularly highlighted as an intervention that has successfully reduced the pressure on prescribers to prescribe unnecessary antimicrobials. Experts agreed that the development and implementation of self-monitoring/diagnosis tools that enhance patient/physician partnerships are a key priority. The group repeatedly focused on the messaging of antimicrobial use, particularly in education settings for children. Programmes that introduce AMR education in primary schools can also reach parents through their children, as seen in China and Iran, and offer insight into how best to implement AMR education in primary, secondary, professional, and continuing education programmes. It was noted that hygiene, sanitation, and infection prevention measures are vital to reduce the use of antimicrobials and efforts to implement related interventions should be considered where possible. Prescribers Pressure from patients is frequently cited as a strong motivation for health-care professionals to prescribe or dispense antimicrobials. As a result, the experts agreed that physicians could benefit from communication training to enhance their interpersonal communication skills and health care team work to mitigate patients anxiety and pressure for improved outcomes. Behaviour change science offers language that is aimed at streamlining decision-making processes which could be incorporated into training for prescribers, building on existing efforts to improve provider education on AMR. 6
The experts agreed that using and adhering to standard treatment guidelines and categorization of Access, Watch and Reserve that has been established for specific classes of antibiotics should be embedded into policy, implemented and, wherever possible, enforced. This could entail the introduction of additional approval steps before prescribing watched or reserved antibiotics, or Member States establishing antimicrobial stewardship programmes that monitor and reduce the use of critical antibiotics. The experts also discussed the possibility of introducing a feedback system based on comparisons among peer countries where prescriber data are available. It was noted that this intervention had proved successful at changing the behaviour of prescribers in England. And indeed, noted that auditing practices and feedback to prescribers and other health care providers have shown an improvement in the use of antimicrobials in Ethiopia. The particular role that pharmaceutical sales representatives play in influencing prescription decisions was frequently noted. Here government policy and legislation could help to limit the interaction between pharmaceutical sales representatives and prescribers, however, it was recognized that, addressing this issue lay beyond the scope of WHO s remit towards behaviour change under objective 1 of the global action plan. Pharmacists The experts acknowledged that globally not all pharmacists receive extensive training before they are employed in this role. The consultation considered the possibility of developing training on appropriate dispensing of antimicrobials. It was suggested that it would be useful to map existing resources available in this area and to consider how best to incorporate or develop training materials specific to AMR. The experts also agreed that pharmacists, as well as physicians, would benefit from interpersonal training in communication to improve their ability to handle patients demands for unnecessary antimicrobials. Training could also include behavioural insights on how best to communicate these messages and to offer counselling in alternative treatment. It was noted that the success seen in the malaria programme with pharmacy branding and accreditation, might be replicated to ensure appropriate medications based on prescriptions are provided with the right information and adherence counselling at the right time, possibly adding a financial return for pharmacies that follow recommended best practices. Independent assessment would determine whether the pharmacy is providing good quality medications that correspond to the right medical conditions and would provide a 5 star rating that can be placed at the entrance to the pharmacy. The increased recognition for the quality of the pharmacy s services would serve as an incentive for the pharmacies to sustain the quality of care to their customers. It was noted, however, that a significant challenge rests in developing and sustaining this type of accreditation programme. 7
Policy makers The experts recognized that policy makers frequently struggle with misinformation, limited access to technical expertise or evidence to weigh the impact of AMR, and a lack of information on available options, all of which impede the development of critical policies to support investments and actions to combat AMR. The experts agreed that evidence-based and datadriven policy briefs could be developed to present a politically and economically attractive case. It was urged that these briefs would be most effective if they were written to be both context and country specific. The experts discussed the potential value of clear guidance or checklists to support the policy landscape for AMR. They agreed that professional bodies could assist in developing the tools for policy makers to ensure that actions would lead to the desired behavioural changes. Moving forward During the first quarter of 2018, it is anticipated that there will be regional consultations (conducted remotely) to discuss the priority audiences and interventions that were tabled during the expert consultation. It is anticipated that there will be a second in-person informal consultation in the second quarter of 2018 that will bring together the expert members of the group and a larger group of external stakeholders and partners, with additional regional colleagues involved in AMR behaviour change. The aim of the second consultation will be for the group to put forward recommendations on appropriate mechanisms and policy tools to move target groups along the behaviour change continuum and to assess progress. The AMR Secretariat will then determine where best it can initiate, pilot or contribute to the development of interventions identified as priorities by the experts, by maximizing its comparative skill sets and tools, while acknowledging its resource limitations. The priorities identified by the expert consultation will be shared throughout the relevant teams across WHO to determine their feasibility, the resources required and the most appropriate technical area within which to advance the work; and how corresponding behaviour change can be mainstreamed. Acknowledgements The AMR Secretariat would like to express its gratitude and commend Elizabeth Long for her leadership as Chair of the technical consultation on behaviour change. In addition, the AMR Secretariat would like to thank all members of the expert consultation who gave their time in advance of the meeting to contribute to background documents and to develop presentations and to all participants for an active and engaging consultation that resulted in an array of potential interventions for consideration. 8
Annex 1 Meeting Participant List: Antimicrobial Resistance Behaviour Change First informal technical consultation 6-7 November, 2017 Château de Penthes, Geneva Catherine Bertrand-Ferrandis: World Organisation for Animal Health (OIE), Head of Communications Unit Clare Chandler: London School of Hygiene and Tropical Medicine, Director of Antimicrobial Resistance Centre Sabiha Essack: University of KwaZulu-Natal, South African Research Chair in AMR and One Health Katherine Fleming-Dutra: U.S. Centers for Disease Control & Prevention (CDC), Office of Antibiotic Stewardship Kama Garrison: USAID, Senior Social and Behaviour Change Advisor Jeremy Knox: Wellcome Trust, Drug-resistant Infections Programme; Policy and Advocacy Lead Anja Leetz: Health Care Without Harm Europe, Executive Director Elizabeth Long: DTA Innovation, Founder; Behavioural Consultant at GRID Impact; Senior Advisor ICAAD Caline Mattar: World Medical Association, Chair, Junior Doctors Network Dan Metcalfe: Wellcome Trust, Head of Brand and Campaigns Michael Sanders: Behavioural Insights Team, Chief Scientist Fatemeh Soleymani: Tehran University of Medical Sciences, Assistant Professor; Director of National Committee on Rational Use (Ministry of Health and Medical Education) Nithima Sumpradit: Food and Drug Administration, Ministry of Public Health, Thailand, Senior Pharmacist Tenaw Andualem Tadege: Food and Agricultural Organization of the United Nations (FAO), Ethiopia, National Antimicrobial Resistance Containment Coordinator Peter Yeboah: Christian Health Association of Ghana (CHAG), Executive Director Wang Yu: Beijing University, Department of Global Health, Assistant Professor 9
Annex 2: Table Summary of Discussions per Audience Target Target Audience (1) Public * Interventions with no votes ** Interventions with some votes *** Interventions with most votes Wanted Behaviour Barriers Interventions Measurement Refrain from demanding antimicrobials when they are unnecessary Seek advice and treatment from a qualified healthcare provider Only take antimicrobials when prescribed Do not store unused antimicrobials or share them with others Follow antimicrobial treatment duration as prescribed Cost of and access to medicine Availability of medicines through unregulated market Availability of cheap and ubiquitous antibiotics Influence of advertising for antimicrobials Lack of sick leave and need to find a rapid cure Lack of understanding of linkage between diagnosis and treatment prescribed Lack of trust and confidence in the health care system Misunderstanding on virus/bacteria differentiation Misinformation Ignorance about negative effects of antimicrobials Lack of health literacy Over-reliance on selfdiagnosis Peer group and social norm influencing attitude towards antimicrobials Self-monitoring tool to support patient/physician partnership with incentives to report. e.g. Booklet for flu in Thailand *** Education for children aimed at changing social norms sustainably and embedding in school curriculum *** National self-diagnosis tools ** Legislation to control circulation and sale through unregulated market ** Platform for sharing experiences ** Awareness campaigns and messages at global level, such as WAAW ** Information made available on expected trajectory of common illnesses ** Reimbursement of costs of official medicines * Incentives to buy official medicines * Awareness raising of adverse events due to use of substandard medicines * Accreditation for community leaders * Number of communication campaigns References to AMR within curricula, number of tools developed, number of organizations, schools and youth groups involved. Champions and goodwill ambassadors actively engaged Data from social media reflecting dissemination of understanding and messages Number of self-diagnosis tools developed
Target Audience (2) Prescribers * Interventions with no votes ** Interventions with some votes *** Interventions with most votes Wanted Behaviour Barriers Interventions Measurement Maintain a clean environment Follow treatment guidelines and prescribe antimicrobials accordingly if needed Undertake secondary follow-up diagnosis, mid-treatment Complete continuing education on guideline compliance Provide patients with thorough diagnosis and treatment explanation Be familiar with and comply with best practices for infection prevention and control (IPC), such as hand hygiene and waste management Lack of access to information on susceptibility and available lines of treatment Fear of poor outcomes, patient dissatisfaction, loss of clients Experienced clinicians may have inherent biases/less willingness to change methods Entrenched prescribing habits Confidence in empiric experience having stronger influence than abstract data Lack of knowledge of shifting peer practices due to isolation and lack of resources Heavy workload/decision fatigue Inability to adhere to IPC guidelines Uncertainty over diagnostic results Limited range of antibiotics available Influence of drug sales representatives on prescribers Assumption that patients are expecting/demanding antimicrobials Lack of access to pharmacovigilance data and patient records related to antimicrobial use Restriction on direct drug marketing to clinicians from drug representatives *** Implementation of Access, Watch and Reserve for antibiotic classes, restrictions on use of specific drugs *** Audit with feedback and peer comparison *** Training in interpersonal communication *** Commitment posters for stewardship and IPC ** Stewardship training for clinicians ** In service training/education ** Distribution of hygiene enhancing equipment for IPC e.g. alcohol gel ** Champions for momentum ** Standardization of protocols, treatment and pathways ** Visible SOPs for IPCS at health care centres* Incentives encouraging wellfunctioning prescribing practice* Data on local prescribing, susceptibility and pharmacovigilance* Integrated patient records system * Data indicating reduction in resistance levels Number of antimicrobials prescribed per population Ratio of distribution of antimicrobials by class Patient outcomes Levels of satisfaction among patients Level of satisfaction among clinicians Number of nosocomial infections
Target Audience (3) Pharmacists * Interventions with no votes ** Interventions with some votes *** Interventions with most votes Wanted Behaviours Barriers Interventions Measurements Engage and communicate with public Adhere to treatment guidelines Adhere to counselling guidelines Stock and supply only quality approved medication Comply with regulation concerning sales of over the counter treatment Conflicting priorities between business profit and provision of appropriate treatment Competitive environment between pharmacists Poor knowledge of treatment guideline No supply of appropriate drug diagnostics No enforcement of regulations Lack of knowledge of regulations Need to increase price, turnover and sales revenue Desire to see patient satisfaction and to meet demand for specific services/medicines Accreditation with branding for pharmacies, including offering guidance and financial reimbursement *** Stewardship training and empowerment for pharmacist, curriculum toolkit *** Improved counselling, interpersonal communication *** Establish links to insurance reimbursement ** Incentive/recognition for adhering to regulations ** In-service education about treatment guidelines and regulation ** Online training tools ** Pharmacy audits/anonymous shopping reports Knowledge survey (KAP) of pharmacies Quality rating Client surveys Undue pressure through incentives and advertising by pharmaceutical industry
Target Audience (4) Policy Makers * Interventions with no votes ** Interventions with some votes *** Interventions with most votes Wanted Behaviour Barriers Interventions Measurements Facilitate compliance with international commitments such as AMR Global Action Plan, International Health Regulations and UN Political Declaration on AMR Facilitate multi-sectoral, crossministry consultation and coordination to mobilize a One Health approach to AMR Enable a social compact Collaborate with regional and global partners Enable the development and implementation of effective, practical policies Establish and empower accreditation bodies Ensure up to date AMR & IPC knowledge is disseminated among health workers in human and animal sectors Encourage release of implementation guidelines by national professional bodies Complexity of AMR in the One Health context Higher priority placed on antimicrobial use in humans than with animals Enforcement of regulation Resource constraints and prioritization Capacity and capability constraints related to infrastructure, management and levels of regulation to implement change Lack of recognition of the importance of the issue to ensure prioritization and political action Incentives/disincentives within countries: recognition and peer benchmarking *** Professional bodies develop guidelines for desired behaviour expectations *** Development of clear policy briefs that are evidence based, data driven and country/context specific *** Increased investment in medical systems and personnel ** Champions/advocates for AMR in both human and animal health ** Global governance and accountability commitment mechanisms. e.g. league tables, UN/WHA feedback ** Mandatory AMR specific continuing professional education activities for prescribers * Funding strategies/mechanism development* Progress in meeting global commitments (GAP, IHR etc.) National champions/advocates actively on mainstream and social media Number of audits Number of policy briefs developed Data on use of last resort drugs in human and animal health Number of health workers who complete AMR continuing professional education requirements Number of vets completing antibiotic prescribing module for animal health per country Reduction and phase out use of last resort drugs in animal health Number of antimicrobials prescribed for animal health and agriculture per country