Annotation of Qualitative Research ArticleTo Prepare: For this assignment, read the attached research article. Complete an
annotation of the article using the attached “Annotation Guideline” as a guide.
Paper Guidelines:
• Communication plan needs to be at minimum 2 pages with 4 references
• Paper is written in Double-Space
• Font size 12 & Times New Roman font
• Section headers in APA format
• Additional Reference page at the end with APA citations
Outline
Section headers, in APA format for each section below:
• Provide the reference list entry for this article in APA Style followed by a
three-paragraph annotation that includes:
o Summary
o Analysis
o An Application similar to the example in the attachment.
Annotation Guideline
Reference List: Common Reference List Examples
Article (With DOI)
Laplante, J. P., & Nolin, C. (2014). Consultas and socially responsible investing in Guatemala: A
case study examining Maya perspectives on the Indigenous right to free, prior, and
informed consent. Society & Natural Resources, 27, 231–248.
doi:10.1080/08941920.2013.861554
Toren, Z., & Iliyan, S. (2008). The problems of the beginning teacher in the Arab schools in
Israel. Teaching and Teacher Education, 24, 1041–1056. doi:10.1016/j.tate.2007.11.009
According to the Publication Manual of the American Psychological Association (6th ed.;
APA) guidelines for citing sources, cite the DOI number whenever one is available. The
DOI stands for digital object identifier, a number specific to this article that can help
others locate the source. Include an issue number for the article only if the journal is
paginated by issue rather than by volume. Although most journals are paginated by
volume, you may find it helpful to consult the APA Style Blog’s post, “How to Determine
Whether a Periodical is Paginated by Issue.”
Summary:
For each source listed, you will begin with a summary of the information you found in
that specific source. The summary section gives your reader an overview of the important
information from that source. Remember that you are focusing on a source’s method
and results, not paraphrasing the article’s argument or evidence.
The questions below can help you produce an appropriate, scholarly summary:
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What is the topic of the source?
What actions did the author perform within the study and why?
What were the methods of the author?
What was the theoretical basis for the study?
What were the conclusions of the study?
Remember, a summary should be similar to an abstract of a source and written in past
tense (e.g. “The authors found that…” or “The studies showed…”), but it should
not be the source’s abstract. Each summary should be written in your own words.
Critique / Analysis:
After each summary, your annotations should include a critique or analysis of each
source. In this section, you will want to focus on the strengths of the article or the study
(the things that would make your reader want to read this source), but do not be afraid to
address any deficiencies or areas that need improvement. The idea of a critique is that
you act as a critic—addressing both the good and the bad.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Was the research question well framed and significant?
How well did the authors relate the research question to the existing body of
knowledge?
Did the article make an original contribution to the existing body of knowledge?
Was the theoretical framework for the study adequate and appropriate?
Has the researcher communicated clearly and fully?
Was the research method appropriate?
Is there a better way to find answers to the research question?
Was the sample size sufficient?
Were there adequate controls for researcher bias?
Is the research replicable?
What were the limitations in this study?
How generalizable are the findings?
Are the conclusions justified by the results?
Did the writer take into account differing social and cultural contexts?
Application:
Finally, the last part of each annotation should justify the source’s use and address how
the source might fit into your own research. Consider a few questions:
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•
•
•
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How is this source different than others in the same field or on the same topic?
How does this source inform your future research?
Does this article fill a gap in the literature?
How would you be able to apply this method to your area of focus or project?
Is the article universal?
First person may be appropriate to use in an Application paragraph of the annotated
bibliography, but doing so will depend on what aspects of the article you are discussing
and faculty preferences. For example, if you are discussing how the article is applicable
to your research project, first person may be appropriate. If you are talking about how the
article relates to the literature or field as a whole, first person may not be appropriate. In
all cases, be sure to follow our guidance on appropriate use of first person.
Application Example:
The example annotation below includes the citation, a summary in the first paragraph, the
critique/analysis in the second paragraph, and the application in the third paragraph.
Gathman, A. C., & Nessan, C. L. (1997). Fowler’s stages of faith development in an honors
science-and-religion seminar. Zygon, 32(3), 407–414. Retrieved from
http://www.zygonjournal.org/
The authors described the construction and rationale of an honors course in
science and religion that was pedagogically based on Lawson’s learning cycle model. In
Lawson’s model, the student writes a short paper on a subject before a presentation of the
material and then writes a longer paper reevaluating and supporting his or her views.
Using content analysis, the authors compared the students’ answers in the first and second
essays, evaluating them based on Fowler’s stages of development. The authors presented
examples of student writing with their analysis of the students’ faith stages. The results
demonstrated development in stages 2 through 5.
The authors made no mention of how to support spiritual development in the
course. There was no correlation between grades and level of faith development. Instead,
they were interested in the interface between religion and science, teaching material on
ways of knowing, creation myths, evolutionary theory, and ethics. They exposed students
to Fowler’s ideas but did not relate the faith development theory to student work in the
classroom. There appears to have been no effort to modify the course content based on
the predominant stage of development, and it is probably a credit to their teaching that
they were able to conduct the course with such diversity in student faith development.
However, since Fowler’s work is based largely within a Western Christian setting, some
attention to differences in faith among class members would have been a useful addition
to the study.
Fowler’s work would seem to lend itself to research of this sort, but this model is
the only example found in recent literature. This study demonstrates the best use of the
model, which is assessment. While the theory claimed high predictive ability, the change
process that the authors chronicled is so slow and idiosyncratic that it would be difficult
to design and implement research that had as its goal measurement of movement in a
faith development continuum.
Lum et al. BMC Public Health (2017) 17:799
DOI 10.1186/s12889-017-4813-7
RESEARCH ARTICLE
Open Access
Australian consumer perspectives, attitudes
and behaviours on antibiotic use and
antibiotic resistance: a qualitative study
with implications for public health policy
and practice
Elaine P. M. Lum1*, Katie Page1, Lisa Nissen2, Jenny Doust3 and Nicholas Graves4
Abstract
Background: Consumers receive over 27 million antibiotic prescriptions annually in Australian primary healthcare.
Hence, consumers are a key group to engage in the fight against antibiotic resistance. There is a paucity of research
pertaining to consumers in the Australian healthcare environment. This study aimed to investigate the perspectives,
attitudes and behaviours of Australian consumers on antibiotic use and antibiotic resistance, to inform national
programs for reducing inappropriate antibiotic consumption.
Method: Semi-structured interviews with 32 consumers recruited via convenience and snowball sampling from a
university population in South East Queensland. Interview transcripts were deductively and inductively coded. Main
themes were identified using iterative thematic analysis.
Results: Three themes emerged from the analysis, to elucidate factors affecting antibiotic use: (a) prescription type;
(b) consumer attitudes, behaviours, skills and knowledge; and (c) consumer engagement with antibiotic resistance.
Consumers held mixed views regarding the use of delayed antibiotic prescriptions, and were often not made aware
of the use of repeat antibiotic prescriptions. Consumers with regular general practitioners were more likely to have
shared expectations regarding minimising the use of antibiotics. Even so, advice or information mediated by
general practitioners was influential with all consumers; and helped to prevent inappropriate antibiotic use
behaviours. Consumers were not aware of the free Return of Unwanted Medicines service offered by pharmacies and
disposed of leftover antibiotics through household waste. To engage with mitigating antibiotic resistance, consumers
required specific information. Previous public health campaigns raising awareness of antibiotics were largely not seen
by this sample of consumers.
Conclusions: Australian consumers have specific information needs regarding prescribed antibiotics to enable
appropriate antibiotic use behaviours. Consumers also have expectations for high quality general practice consults
conducted in a manner that increases consumer confidence in the treatment decision, regardless of whether an
antibiotic is prescribed. To reduce inappropriate consumption of antibiotics and to more fully engage Australian
consumers in mitigating antibiotic resistance, changes in health policy and practice are required.
Keywords: Consumer, Antibiotic use, Antibiotic resistance, Qualitative, Semi-structured interview, Perspective, Attitude,
Behaviour, Australia, Primary care
* Correspondence: elaine.lum@qut.edu.au
1
School of Public Health & Social Work, Faculty of Health, Queensland
University of Technology, Kelvin Grove Campus, 60 Musk Avenue, Kelvin
Grove, Brisbane, QLD 4059, Australia
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Lum et al. BMC Public Health (2017) 17:799
Background
Every dose of antibiotic used increases the likelihood of
antibiotic resistance [1]. Antibiotic resistance occurs
when bacteria change in ways that enable them to resist
the effects of antibiotics, to which they previously
succumbed [2]. Australia is contributing to the global
problem of antibiotic resistance with an antibiotic
consumption rate above the Organisation for Economic
Co-operation and Development (OECD) average [3].
Successful management of antibiotic resistance requires
partnerships and conscious participation of individuals
including every prescriber, health professional and
consumer.
In Australian primary healthcare over 27 million antibiotic prescriptions are issued annually [4]. Hence, consumers are a key group to engage in the fight against
antibiotic resistance. From the literature, known barriers
which prevent appropriate use of antibiotics by consumers
include: confusion as to whether viruses or bacteria
caused the infection [5]; the belief that antibiotics will
shorten illness duration [5–9]; seeking antibiotics despite
the self-limiting nature of the illness [5]; not being aware
of risks associated with antibiotic use [8, 10]; needing a
legitimate reason to be away from work [11]; and the
perception that antibiotic resistance is a problem
confined to hospitals caused by doctors who overprescribe antibiotics [12, 13].
Consumers are aware of the link between antibiotic
use and antibiotic resistance [14]. However, most
people misunderstood antibiotic resistance to mean
that the body becomes resistant rather than the
micro-organism acquiring mechanisms of resistance,
to antibiotics [12, 14, 15]. Despite public health
campaigns aimed at raising awareness of antibiotic
resistance, a considerable proportion of consumers incorrectly think that antibiotics are effective against
viral infections [16–18]. Sixty-five percent of Australian
workers believe that taking antibiotics for the common
cold hastens recovery and enables an earlier return to
work [6]. Consumer behaviours which potentially contribute to antibiotic resistance include: seeking antibiotics for
minor self-limiting illnesses e.g. acute respiratory tract
infections; self-medication with antibiotics; and nonadherence to prescribed antibiotics [19, 20].
To date, qualitative studies have predominantly been
conducted with consumers in Europe and the USA [7, 9,
12–15, 21–24], which have different governance, funding
structures and infrastructure to that in Australia. There
is a paucity of such research pertaining to the Australian
healthcare environment. As a signatory of the WHO
Global Action Plan [25], it is critical for Australia to
have current research pertinent to its primary healthcare
sector informing the implementation of its national antimicrobial resistance strategy designed to deliver an
Page 2 of 12
effective and sustainable response using a multi-sectoral
One Health approach [26, 27].
This study aimed to investigate the perspectives, attitudes and behaviours of Australian consumers recruited
from a university campus in South East Queensland in
May and June (early winter) 2015 about antibiotic use and
antibiotic resistance, to inform national programs for reducing inappropriate antibiotic consumption. The findings
of this study are pertinent to Objective 1 of Australia’s
national antimicrobial resistance strategy — to “increase
awareness and understanding of antimicrobial resistance,
its implications, and actions to combat it through effective
communication, education and training” [27].
Methods
Semi-structured interviews
Pragmatism, understood as a problem-driven approach,
was the underpinning philosophy for this study [28].
The one-on-one semi-structured interview was the
method selected to capture the lived meanings and views
of consumers, as it allowed: exploration of a main set of
questions while enabling flexibility for follow-up questions; flexibility of question sequence according to how
conversations unfolded; participant freedom to express
views without fear of being judged by fellow participants;
and minimised the likelihood that only what they
deemed socially acceptable or desirable was disclosed.
An interview guide for the semi-structured interviews
was developed using upper respiratory tract infections as
a point of conversation, as consumer misconceptions
around antibiotic use for such illnesses remain [6, 12,
14–20]. Pilot interviews conducted with three consumers to refine the interview guide were not included
in the data analysis. The main questions in the interview
guide are shown in Table 1.
Sampling and recruitment
Eligible participants were consumers between 18 and
54 years of age, residing or working within a 1 h drive
from the Brisbane Central Business District. This age
range was specified as it represents the peak years of the
Australian workforce [29]; and 65% of Australian
workers believe antibiotics would hasten recovery from
the common cold enabling an earlier return to work [6].
Convenience and snowball sampling were used in the
recruitment of participants via an email sent to
university staff and students, as well as via Twitter®.
Participants were recruited until no new relevant
information was obtained.
Interview procedure
Individual interviews were conducted face-to-face and
audio-recorded in May and June 2015, either at participants’ workplace or in a university meeting room. The
Lum et al. BMC Public Health (2017) 17:799
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Table 1 Main questions in the interview guide
Sub-topics
Indicative phrasing of main questions
Self-care strategies in managing an upper
respiratory tract infection
When you get a common cold or cough, what would you normally do to manage it?
Triggers for and expectations of the GP
consultation
What would lead you to decide to see a GP?
Views on repeat and delayed antibiotics
What is your view on repeat prescriptions? [an explanation of repeat antibiotic
prescription was given]
If you did go to the GP, what would be your expectations for that visit?
What is your view on delayed prescriptions? [an explanation of delayed antibiotic
prescription was given]
What do you normally do with these prescriptions?
Views on the use of antibiotics
What information or advice did the GP give you about the antibiotics?
What information or advice did the pharmacist give you about the antibiotics?
How much does the risk of side effects of antibiotics worry you? [examples of side
effects provided if required]
Many people find it hard to remember to take antibiotics as prescribed. What is
your own experience of this?
What do you do with leftover antibiotics?
Views on antibiotic resistance
When you hear the phrase “antibiotic resistance”, what comes to mind?
Can you tell me in your own words what antibiotic resistance is?
In your view, is antibiotic resistance an issue that would affect the community at large?
What do you think can be done to manage antibiotic resistance?
Can you think of things that you can do as a private individual that can help reduce
antibiotic resistance?
length of interviews was between 30 and 59 min (average, 43 min). Ethics approval was granted by the
Queensland University of Technology. Informed written
consent from participants was obtained prior to the
interview. Participants were not paid for their time, but
were offered appropriate incentives in line with university guidelines. Participants were also offered a summary
report of research interviews.
Interviews were conversational following Rubin and
Rubin’s responsive interviewing technique [30]. Paraphrasing was used throughout the interview to clarify
and confirm accurate interpretation of the intended
meaning. Researcher self-reflections (EL) were documented immediately after each interview using an
adapted template [31]. The interview process and content, observations of non-verbal communication, and
any new concepts/themes that could be explored with
subsequent participants were noted.
The quality of the co-created knowledge in an interview is contingent on the skill of the researcher (EL);
where co-creation invokes the deliberate practice of the
researcher in leading and being led by the participant as
a conversation partner. Previous experience as a clinical
pharmacist, skills in educational visiting, and active
listening were used in the preparation and conduct of
these interviews. The co-creation of knowledge via interviews minimises researcher bias as the backgrounds and
worldviews of both researcher and participants, shape
the research.
Data analysis
Interviews were transcribed verbatim from the audio
recording, using an adaptation of the Jeffersonian
Transcription Notation [32]. De-identified transcripts
were uploaded to NVivo (Version 11.3.1.777) for
coding and analysis [33].
Deductive and inductive coding were used to identify
categories and themes. A codebook was developed a
priori for deductive coding based on the main interview
questions. An eclectic combination of coding methods
was used for inductive coding: descriptive, initial, In
Vivo, and theming the data [34]. To test the reliability of
codes, three transcripts (1%) were randomly selected
using the Microsoft Excel® random number function, for
coding confirmation by another researcher (KP). The
level of agreement between both researchers was high;
some inductive codes were refined collaboratively.
Results
Recruitment yielded 49 expressions of interest; 32
consumers were interviewed. Fig. 1 shows recruitment
and participant characteristics.
Three themes comprising nine sub-themes elucidate
factors linked to the perspectives, attitudes and behaviours
Lum et al. BMC Public Health (2017) 17:799
Page 4 of 12
Fig. 1 Recruitment yield, attrition, and participant characteristics
of Australian consumers, affecting antibiotic use and antibiotic resistance (Table 2). Each theme and its corresponding sub-themes are presented in this section.
Theme 1: Prescription type
This theme covers consumer perspectives and the resulting influence on antibiotic use behaviours linked to the
use of two types of antibiotic prescriptions — delayed
and repeat antibiotic prescriptions.
Delayed antibiotic prescriptions
A delayed antibiotic prescription is an antibiotic prescription given by a general practitioner (GP) to a patient with instructions to use it only if symptoms
worsen or do not improve in a few days. Consumers
were divided on the issue of delayed antibiotics and
Table 2 Themes and sub-themes
Themes
Sub-themes
1. Prescription type
Delayed antibiotic prescriptions
Repeat antibiotic prescriptions
2. Consumer attitudes, behaviours,
skills and knowledge
Patient expectations
Antibiotic use behaviours
Self-care strategies for
respiratory tract infections
Antibiotic risks
3. Consumer engagement with
antibiotic resistance
Information needs and
consumer education
Views on antibiotic resistance
Mitigating antibiotic resistance
whether this was a preferable course of action for
GPs to take in instances where the need for antibiotics is uncertain. Many consumers had been given a
delayed antibiotic prescription under such circumstances. Those in favour of a delayed antibiotic
prescription cited personal convenience as the overriding factor. In that, they did not have to return for
reassessment should their symptoms worsen, especially in proximity to an important event such as
university exams, a wedding, or travel.
Consumers not in favour of a delayed antibiotic
prescription were overwhelmingly uncomfortable that
the final decision whether to use antibiotics fell on
them, rather than the GP. Although highly educated,
these consumers did not want such responsibility.
They were concerned that GPs did not, or were not
able to, provide precise and definitive instructions on
when to use the delayed antibiotic prescription:
“… sometimes they’re [GP] just like, ‘Oh just keep it in
case you need it [delayed prescription].’ I’m like, what((makes an incredulous face)) … Well, how will I
know if I need it?” (CS06, female, 38 years old)
Some consumers interpret the provision of a delayed
prescription to mean that the GP was leaning towards
the judgment that antibiotics were warranted. In such
cases, consumers reported that they filled the prescription immediately (thus negating the GP’s intent
for the delayed prescription) and commenced treatment without delay; unless the GP had given explicit
instructions not to do so.
Lum et al. BMC Public Health (2017) 17:799
Repeat antibiotic prescriptions
A repeat antibiotic prescription enables a patient to obtain another course of antibiotics without having to consult a GP. Repeat antibiotic prescriptions are authorised
by the GP when issuing the original antibiotic prescription. These prescriptions are usually only issued if: (a)
the GP intentionally prescribes a duration of treatment
which requires more than one course of antibiotics, (b)
when the dosage required means a repeat prescription is
needed to obtain the correct quantity of tablets/capsules
for a course of treatment, or (c) when a standby antibiotic prescription is needed in the event of an acute relapse/exacerbation e.g. patients suffering from chronic
obstructive pulmonary disease.
When GPs do not explicitly discuss what to do with
repeat antibiotic prescriptions — assuming one was
given intentionally, let alone those issued unintentionally
due to default settings in computer-generated prescriptions — consumers are left to decide for themselves how
to act. Undesirable consequences may ensue, such as
truncated treatment or an unintended gap in treatment.
“I finish[ed] one [prescription] and I thought that’s all
over you know, but I see that I’ve got a repeat. And
so, you know, ‘Oh wait, do I need to do this?’ [fill the
repeat prescription and take the antibiotics]. And then
you call up [the clinic] and then by the time you get
to the pharmacy again, sometimes you’ve lost time.
To me, that was kind of annoying, when that
happened. … I ended up getting the repeat. But it
wasn’t until about three days [later], so there was a
3-day gap.” (CS02, female, 27 years old).
Unused repeat prescriptions create a problematic “reservoir” of antibiotics accessible to consumers, much like unused delayed antibiotic prescriptions. Many consumers
retained these prescriptions for future use, discarding
them only when the prescription can no longer be dispensed. Antibiotic prescriptions are currently valid for dispensing within 12 months from the date of prescribing.
Theme 2: Consumer attitudes, behaviours, skills, and
knowledge
This theme groups together key sub-themes related to consumer attitudes, behaviours, skills and knowledge which
influence antibiotic consumption: expectations for antibiotics, how consumers use antibiotics, self-management
strategies for respiratory tract infections, and consumer
perception of risks associated with antibiotic use.
Patient expectations
Consumers who have regular GPs tend to have shared
expectations regarding overall management of their
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health and health outcomes. Informed consumers with
established doctor-patient relationships reported having
had preliminary conversations regarding their preference
to avoid antibiotic use where possible. Although it was
not apparent whether these conversations were GP or
consumer initiated, it provided a basis for future GP
consultations whenever the need for antibiotic use came
into question:
“But if you’re going to miss more than 1 day [of work]
then I’ll go and see a doctor to get a medical
certificate. … I’ll say to them to make clear that I
don’t want antibiotics or anything. I don’t need to say
that if I see my GP. Because she knows that.”
(CS06, female, 38 years old)
Overwhelmingly, when describing what they expected
from a GP consultation, consumers said they wanted to
be listened to. Consumers also expected the GP to
conduct a thorough clinical examination, explain their
findings, treatment options, and decisions, and to answer any questions. These elements of the consultation
taken together, increased consumer confidence in the
professionalism, competence and trustworthiness of the
GP. Most consumers would accept the GP’s decision not
to prescribe an antibiotic if it was clearly explained:
“I’d be disappointed that it couldn’t be treated [with
antibiotics]. But I also understand that there’s no
point in treating some things with antibiotics. … So if
that was clearly explained, I think I’d be less
disappointed in the care that I receive from the
doctor. But of course, I would always be disappointed
in the fact that you just have to like, tough it out
through a sickness, because there’s no easy fix.”
(CS05, female, 29 years old)
Antibiotic use behaviours
Consumers struggled to adhere to prescribed antibiotics.
The most common behaviour was not completing the
course of antibiotics, either due to a conscious decision
to cease taking, or forgetting to take when they felt better as the main driver of adherence (feeling ill) is lost.
Given that most consumers rely on GPs’ instructions to
guide them on appropriate use of antibiotics, GPs who
omit to provide clear advice may inadvertently contribute to misuse. For example, omission to provide advice
on the duration of treatment led to non-completion of
the prescribed course of antibiotics for this consumer:
“… [the] doctor doesn’t comment much about when
you stop it ((taps table twice with palm of hand for
emphasis)). So, the assumption is, you stop when you
feel good.” (CS16, male, 26 years old)
Lum et al. BMC Public Health (2017) 17:799
Middle-of-the-day doses were especially challenging to remember for antibiotics requiring a dosing frequency of
three or more times a day. Some handled missed doses by
working it in within the same 24-h period, doubling the
antibiotic dose for their next dose, or skipping the missed
dose resulting in taking longer to complete the course:
“… I have no idea what effect that has, but I figured- I
guess it’s better to finish it.” (CS06, female, 38 years old)
Others were proactive in anticipating the likelihood of
forgetting doses and implemented strategies, such as
phone apps as reminder systems.
Consumers reported the following undesirable behaviours: using leftover antibiotics from the last unfinished
course the next time they were unwell with similar
symptoms, sharing unused medications with other
people, and disposing of expired unused/leftover antibiotics as part of household waste:
“Just keep [the leftovers]. Like next time somebody
gets sick you start with that, you don’t even go to the
doctor ((chuckles)).” (CS16, male, 26 years old)
” … like when I was taking them [antibiotics] all
the time, I would keep them [leftovers] because I
would expect to take them very soon. … and then
they run out of date … and I just had a big clean
out last year ((chuckles)) and I just chucked them
all out. And I probably should have taken them to
the pharmacy but I didn’t, I just chucked it.”
(CS04, female, 31 years old)
Antibiotic mixtures/syrups were disposed of in household sinks. Most consumers were not aware of the
Return of Unwanted Medicines (RUM) program for safe
destruction of medicines offered at no charge by community pharmacies.
Social influences were important in shaping consumer
approach and behaviours in antibiotic use. Influences
from family — parents (while growing up), friends and
partner/spouse, were cited.
“He [husband] would just say- ‘coz I guess he’s
very against all the antibiotics and everything, and I
think that’s probably another influence on me that
I have shifted from that, because … I would come
back from [name of country, visiting family
overseas] with a big sack of medication ((smiles)).
And he said, ‘Oh you shouldn’t be doing this you
know, you have to go and see the doctor’ … and
he said, ‘you know the more you take [antibiotics],
it’s not going to work anymore…’ ”
(CS04, female, 31 years old)
Page 6 of 12
The GP was another important influence, particularly
for consumers who had established good doctor-patient
relationship with a regular GP. For example, consumers
reported that they were more likely to complete the
course of antibiotics if the GP had explicitly instructed
them to do so. Another consumer recounted that patient
education from her GP, enabled her to recognise and resist inappropriate behaviours i.e. not accepting shared
antibiotics from family and not using her own leftover
antibiotics.
The relatively higher cost of products for symptomatic
management of coughs and the common cold may motivate some consumers to seek antibiotic treatment,
which costs less. This was true of consumers for whom
costs of healthcare was a key concern. For example,
these consumers would prefer to use bulk-billing clinics
as far as possible to reduce out-of-pocket costs.
“Because often I guess, those types of remedies like
nasal sprays and … you know all those other types,
they can … be a lot of them and they can be
expensive [to purchase]. So whereas, antibiotics can
just be quite affordable, in terms of treatment options
… Like even just like cold and flu tablets are more
expensive than antibiotics themselves.”
(CS05, female, 25 years old)
Self-care strategies for respiratory tract infections
Consumers used the following strategies for symptomatic
management of respiratory tract infections: home remedies, commercially available natural remedies, immune
boosters, over-the-counter cough and cold products,
increased rest and increased fluids. Consumers with
underlying respiratory conditions such as asthma were especially mindful of following their asthma management
plan during periods of intercurrent illness.
Workplace culture can shape self-care behaviours.
Some workplaces expect staff to “power through” minor
illnesses such as coughs and the common cold, whereas
other organisations deem it acceptable for staff to take a
few days off to recuperate at home, and to minimise the
spread of infections to colleagues.
Consumers were realistic about feeling miserable and
unwell during a common cold or cough, and would
tolerate their symptoms for up to 3 weeks before seeking
a GP consult. Self-care and self-management strategies
were used in the meantime to alleviate their symptoms.
Consumers were more likely to seek a GP consult if:
they were unable to take time off work/study to recover,
they had to maintain a high level of functionality (both
work and family commitments), they have an important
upcoming event, they need a medical certificate to take
time off work to recover, and persistence or worsening
of symptoms.:
Lum et al. BMC Public Health (2017) 17:799
“… so it would depend on my symptoms, but also
what I have to do [life context]. So if I’m going
through a period where I don’t have a lot on, then I
wouldn’t mind so much suffering through symptoms.
But if I have something that I need to do like a run
[athletic event] or something important job-wise or
something [like that], then I might seek out healthcare
earlier. … I’ll just say persistence of the symptoms.”
(CS05, female, 29 years old)
Antibiotic risks
Many consumers perceived antibiotics to be safe medicines; and hence, would lean toward taking the antibiotic if a delayed prescription was given. Others
expressed their preference to avoid antibiotics where
possible due to being unsure how the antibiotics
worked, unwanted effects it could have on the body,
and being concerned about becoming “resistant”.
Many of these consumers considered themselves low
users of medicines overall.
“I’m pretty hesitant to take them [antibiotics], only
because of the lack of information that I have received
about what they actually do. And I prefer to find an
alternative method to fixing what ails me
((chuckles)).” (CS02, female, 27 years old)
Cultivating a healthy immune system was another
reason cited by consumers who were mindful of using
antibiotics only when required:
“… from a while ago I got the idea in my head that in
order to build up your immune system well, you need
to give it a chance to fight things on its own. It’s only
if it’s clearly going to lose the battle that you should
really help it with medication.”
(CS10, female, 23 years old)
Consumers who had negative experiences with antibiotics were more reluctant to use them unless necessary. They reported experiencing side effects such as:
adverse impact to digestive system for a prolonged
period, feeling physically tired, and vaginal thrush.
Consumers who had neutral experiences with taking
antibiotics, for example those with no troublesome
side effects and recovered with the treatment, were
open to using antibiotics.
Theme 3: Consumer engagement with antibiotic
resistance
This theme comprises three sub-themes which has an
impact on consumer engagement with the fight against
antibiotic resistance.
Page 7 of 12
Information needs and consumer education
Consumers interviewed recognised that individuals
can contribute to the fight against antibiotic resistance through responsible use of antibiotics. To help
them do this, consumers wanted the following types
of information: how the antibiotic worked; the rationale for selection of an antibiotic (quote 1); the duration of treatment, including when or whether the
repeat antibiotic prescriptions (if issued) should be
used; whether they can have alcohol while on antibiotics (quote 2); and the rationale for finishing the
course of antibiotics or the consequences of not
doing so, to encourage adherence to the treatment.
Consumers noted that their information needs were
often not voluntarily met by GPs or community
pharmacists.
Quote 1: “But it seems to be the same one that’s
prescribed. So it would just be good if they [the GP]
could provide the information of how that actually
helps an ear infection and chest infection. You know
… because they’re completely different. To me they’re
completely different areas [the infections].”
(CS09, female, 31 years old)
Quote 2: “And so I looked it up because I have heard
competing information. … And all of the information
that I could find said, most antibiotics, doesn’t really
do anything when you drink alcohol [not necessary to
avoid alcohol], but these particular like, maybe two
strains or something … stop you from processing
alcohol properly … so … you only need to have one
drink or less, and you can start vomiting and fainting
and be really sick ((chuckles)). So the doctor didn’t
tell me that much detail. He just said, don’t drink
alcohol.” (CS18, female, 29 years old)
Consumers interviewed were largely not aware of the public campaigns, whether current or past, run by Government or Commonwealth funded agencies. Some were
generally sceptical about news reported in mainstream
media, and assumed that the issue of antibiotic resistance
had been sensationalised. However, consumers were consistent in acknowledging that antibiotic resistance is a difficult topic with which to engage the public, as it is
“invisible” and inconsequential for most people currently:
“It’s tough to convince people about that [the
importance of addressing antibiotic resistance]. It’s
invisible … And it is real, but it’s invisible. So it’s very
difficult to push the message across, people don’t see
it you know. They think like, it doesn’t matter, I’m
better today, that’s all that matters to me.”
(CS16, male, 26 years old)
Lum et al. BMC Public Health (2017) 17:799
Views on antibiotic resistance
Consumer understanding of antibiotic resistance was
conceptualised in four ways: (a) as a property of the
body — body becomes resistant to antibiotics; (b) as
a property of the medication — antibiotic is no longer effective; (c) as a property of the bacteria — bacteria is resistant to the antibiotic; and (d) as a
property of a collective — society is immune to antibiotics. The following quotes illustrate the different
ways consumers described antibiotic resistance.
Expressing antibiotic resistance as both a property of
the body and of the antibiotic:
“… it’s [the antibiotic] just not effective for the body
anymore. That’s obviously, you know, it’s like the
body’s built up this immunity to it [the antibiotic]
actually working.” (CS03, female, 27 years old)
Expressing antibiotic resistance as a property of the
bacteria:
“… bacteria … is getting stronger. … People don’t
finish the doses … so … the first part of the treatment
there are more weak bacteria [that] died, and then the
stronger ones live and as you don’t finish [the course
of antibiotics], only the stronger ones [survive] and
genetically would be the best bacteria, and that’s
what’s happened.” (CS12, male, 25 years old)
Expressing antibiotic resistance as a property of a
collective:
“… if it’s [antibiotics] prescribed for reasons which
aren’t very serious, then as a society we get immune
to the effects of those drugs [antibiotics].” (CS10,
female, 23 years old)
Other misconceptions about antibiotics and antibiotic
resistance gleaned from this consumer sample were:
(a) many were not aware that antibiotic resistance
could occur at both an individual and societal level,
having assumed it was one or the other, (b) a few
were unaware that using antibiotics inappropriately
for the common cold and/or coughs can contribute
to antibiotic resistance, and in time cause these antibiotics to be ineffective for the treatment of other
more serious infections; and (c) most were unaware
that resistant bacteria could be transferred from
person to person or from food-producing animals to
people.
Consumers were concerned as to whether antibiotic
resistance could be adequately addressed in a timely
manner; pointing out that preventing/reducing antibiotic
resistance is preferable to having to find ways to resolve
Page 8 of 12
it. A well-informed minority were very concerned about
the issue:
“I’m actually quite worried. ‘Coz even healthy people,
when you travel around, one of the main reasons for
spread of all these drug resistant strains has been
human movement. … people can carry them [resistant
strains of bacteria] with them, and not- [be sick], just
a carrier. And then, you know, you go to a region
that’s endemic for … these drug resistant bacteria,
pick them up and you come back, and you
disseminate it. And that’s how it spread[s]. So, yeah,
I’m, I’m quite worried. And I hope if I do get a
bacterial infection, it’s not drug resistant.”
(CS15, female, 28 years old).
On the other hand, some consumers were optimistic
and confident that medical technologies to address or
overcome resistant bacteria would soon be found:
“I guess medicine and technology is advancing so
quickly that they may be able to stamp them [resistant
bacteria] all out …” (CS09, female, 31 years old); and
“Scientists out there will come up with something and
they’re really clever, so I don’t worry too much
because I think somebody’s solving the problem.”
(CS23, female, 28 years old)
Consumers who had lived and/or worked overseas felt
that Australia had been managing the issue of antibiotic resistance rather well. They note that antibiotics are regulated prescription medicines in
Australia; they surmised and were optimistic that GPs
acted as effective gatekeepers for antibiotic use in the
community. There was also a sense of complacency,
of being safe in a “first-world” country which conferred a false sense of impermeability to issues such
as antibiotic resistance.
Mitigating antibiotic resistance
Many consumers felt that GPs should play a more
proactive role e.g. prescribe less antibiotics, educate
patients when antibiotics are not required, and not
succumb to patient demands for antibiotics. However,
they acknowledged that consumers needed to be part
of the solution. At the personal/individual level, consumers felt that by avoiding unnecessary antibiotics
they were not worsening the problem of antibiotic resistance. When antibiotics were prescribed, consumers
recognised that socially responsible behaviour on their
part would constitute completing the course of antibiotics, so as not to encourage the growth of resistant
bacteria. At the societal level, consumers reported
Lum et al. BMC Public Health (2017) 17:799
attempting to influence their social and familial circle,
albeit with mixed results.
Consumers maintained a realistic view of having to
tackle antibiotic resistance from multiple angles,
highlighting the need for conservation of antibiotics now
through individual efforts, while at the same time pursuing innovative approaches:
“… So we need to look after what we have, and not
just hope that the next breakthrough is just around
the corner. I certainly hope that it is. But … where
does it stop? You might find a new antibiotic, well
that one becomes resistant … so I think it’s a
continual thing.” (CS19, female, 31 years old)
Discussion
This study adds to current literature in the field the
perspectives, attitudes and behaviours of Australian
consumers toward antibiotic use and antibiotic resistance. In particular, consumer information needs regarding prescribed antibiotics, consumer expectations
and perceived trustworthiness of a GP consult, the
importance of GP-mediated advice on antibiotic use
behaviours, and consumer views and behaviours in
relation to delayed antibiotic prescriptions.
Australian consumers expect to be given information regarding prescribed antibiotics which would
enable appropriate use and motivate adherence. Consumers want information on how the antibiotic
worked; the GP’s rationale for antibiotic selection;
treatment duration; the rationale for completing the
course of treatment or the consequences of not doing
so; and advice regarding alcohol consumption while
on antibiotics. Consumers sought other avenues of information when not enough detail was provided as
evidenced by a retrospective analysis of an Australian
medicines helpline where over 40% of antibiotic-related
calls were due to inadequate information provision [35].
Community pharmacists are well-placed to provide medicines information to consumers, and should proactively
seek to do so when consumers present an antibiotic
prescription for dispensing [36]. However, consumers
interviewed in this study reported that while they did not
ask, detailed information was not voluntarily provided by
either the GP or community pharmacist apart from the
product information sometimes included with the antibiotic. An in-depth exploration of consumer perception of
the role of community pharmacists in mitigating antibiotic
resistance was not part of the scope of this study.
The expectations of Australian consumers of a GP
consult are made explicit in this study. Consumers want
to be listened to; to be given a thorough clinical examination; to have the GP explain their findings, treatment
options, and decisions including the decision not to treat
Page 9 of 12
with antibiotics when it is not warranted; and to have
their questions answered. These elements of the consultation, when present, increased consumer confidence in
the professionalism, competence and trustworthiness of
the GP. Most consumers would accept the GP’s decision
not to prescribe an antibiotic if it was clearly explained,
which complements findings from other studies where
patient satisfaction with clinic visits were not necessarily
related to getting antibiotics [21, 37]. Many simply
wanted reassurance that they did not have a more
serious illness requiring treatment, were seeking information, or required pain relief [21]. Consumers who
have an established doctor-patient relationship with a
GP tend to have shared expectations regarding the overall management of their health, including avoiding antibiotics where possible.
GP-mediated advice exerted an important influence in
encouraging desirable antibiotic use behaviours in consumers and preventing inappropriate behaviours, even
as consumer behaviours in self-care and antibiotic use
were shaped through the social influences of significant
others (partner and family), friends, and workplace
culture. Hence, GPs need to be empowered and skilled
to communicate confidently and unambiguously to patients, especially when conveying the decision that an
antibiotic is not warranted and discussing other management options. Public health campaigns can be used to
support GPs in their antibiotic stewardship role, by
reframing public perception as to what constitutes a
“good” GP, contextualised for conservation of antibiotics.
In this study, consumer expectations of a GP consult
outlined earlier, mirrored the qualities of a “good” GP
reported by Australian GPs — someone who: has the
skills to deal with uncertainty; practices evidencebased medicine where evidence is available; has good
communication skills; has the ability to establish rapport to build robust doctor-patient relationships; and
makes treatment decisions in the best interest of the
patient [38]. Hence, when antibiotics are not warranted, “… good GPs talk to you about not using
antibiotics” [38].
Regarding delayed antibiotic prescriptions, consumers
had mixed views on the use of this strategy when there
was uncertainty in diagnosis. While some welcomed the
convenience of this avenue of accessing antibiotics,
others did not want the responsibility of being the final
decision maker. Overall, if such prescriptions were issued consumers wanted specific instructions from GPs
on when/whether to use the prescription; a finding
which corroborates that of a recent Australian study
focussed on delayed antibiotic prescribing [39].
Consumer interpretation of the GP’s intention through
the provision of delayed antibiotic prescriptions led
some to assume that the GP was leaning towards the
Lum et al. BMC Public Health (2017) 17:799
judgment that antibiotics were warranted. Such interpretation prompted consumers to immediately fill the
prescription. This behaviour highlights the differences
between consumer and GP interpretation and tolerance
of clinical uncertainty; and negates the GP’s intent to
take a “watch and wait” approach. Hence, while there is
evidence that delayed antibiotic prescriptions could
reduce antibiotic consumption [40], policy failure is foreseeable unless mismatched interpretations are resolved
through clear communication.
Unused antibiotic prescriptions create a problematic
“reservoir” of antibiotics in the community, which could
potentially be misused. Consumers reported retaining
unused antibiotic prescriptions for future use, discarding
them only when the prescription can no longer be
dispensed. Hence, regulatory changes to the national
medicines subsidy scheme to remove oral antibiotic repeats and to reduce the period of prescription validity
should be enacted [41]; while ensuring accessibility of
antibiotics where there is a proven clinical need.
Despite the consumer sample being highly educated,
there was variation in the level of knowledge, awareness and concerns regarding antibiotic use and antibiotic resistance; some of which were erroneous
indicating that consistently clear messages from health
professionals, public health campaigns, and media are
needed. Australian consumers conceptualised antibiotic resistance in four ways. Three conceptualisations are similar to consumers in Europe [14, 15] and
the fourth is new: antibiotic resistance understood as
a property of a collective — society is immune to antibiotics. Despite conceptualising antibiotic resistance
as a property of a collective, several “blind spots” in
antibiotic awareness related to this concept were
found — being unaware of the individual and societal
consequences of using antibiotics inappropriately for the
common cold/cough, and that resistant bacteria could be
transferred from person to person. It is sobering to realise
that consumers with perhaps less formal education and/or
less awareness of the topic may hold more misconceptions
about antibiotic use and antibiotic resistance. In beginning
to generally address consumer misconceptions, future
public health campaigns should adopt clearer terminology
— using “antibiotic resistant infections” or “antibiotic resistant bacteria” rather than simply “antibiotic resistance”;
and include key messages that highlight the interdependence of individual action and societal consequences. For
example, clarify that inappropriate use of antibiotics for
minor self-limiting illnesses would in time cause these
antibiotics to be ineffective for the treatment of more
serious infections; that antibiotic resistance occurs at
both an individual and societal level; and that resistant bacteria can be passed to others, potentially
harming those with frail health.
Page 10 of 12
Future research
Given the findings of this study, questions remain on the
efficacy and cost-effectiveness of public health campaigns
in influencing consumer behaviour; and the extent of
behaviour change possible through the re-engineering of
social and cultural memes. Research in these areas should
be supported.
Strengths and limitations
Semi-structured interviews captured participants’ knowledge, lived experience and views, in their own words;
which helped overcome potential researcher bias and resulted in the co-creation of knowledge [30, 42]. Interviews
were conducted one-on-one which allowed participants to
engage in unfettered commentary and removed any social
pressure to conform to other views being expressed.
The use of convenience and snowball sampling meant
that only respondents with interest in the topic volunteered
to participate. Other consumers may hold different views.
Recruitment was limited to the university population which
is not likely to be representative of the general population
in terms of educational levels achieved. However, the
university is a microcosm of diversity as demonstrated by
the consumer sample i.e. multi-ethnic, multi-cultural, and
includes people from rural/regional areas, ensuring that a
variety of views were captured. This study is relevant to the
Australian context; and as is the case with other qualitative
studies, generalisability of the findings was not intended.
Conclusions
Australian consumers expect information on prescribed
antibiotics which enable appropriate use, and a GP consult
conducted in a manner that increases consumer confidence in the treatment decision. To more fully engage
consumers as partners in mitigating antibiotic resistance,
consumer information needs regarding prescribed antibiotics must be addressed; shared expectations between
consumers and GPs in avoiding the use of antibiotics
should be encouraged; resources such as the Return of
Unwanted Medicines service should be widely promoted;
and the use of clearer terminology and the development
of new emphases suggested by this study for public health
campaigns should be supported. Regulatory changes to
the national medicine subsidy scheme to remove oral antibiotic repeats and to reduce the period of validity for oral
antibiotic prescriptions should be enacted. This study provided useful insight into the perspectives, attitudes and behaviours of Australian consumers towards antibiotic use
and antibiotic resistance, and presented pertinent suggestions for Australian public health policy and practice.
Abbreviations
GP: General practitioner; OECD: Organisation for Economic Co-operation and
Development; WHO: World Health Organization
Lum et al. BMC Public Health (2017) 17:799
Page 11 of 12
Acknowledgements
Not applicable.
5.
Authors’ contribution
EL designed the study with input from KP, LN, JD, and NG. EL conducted the
research including the analysis. KP conducted the coding check. EL drafted
the manuscript. All authors contributed to revisions of the manuscript and
approved the final manuscript.
6.
Availability of data and materials
Metadata for the semi-structured interviews will be made available in the
QUT research dataset e-repository [https://researchdatafinder.qut.edu.au/dataCollections]. The dataset generated by this study is not available as that
would constitute a breach of the Ethics approval.
Funding
This study was conducted under the auspices of the Centre of Research
Excellence in Reducing Healthcare Associated Infections (CRE-RHAI) funded
by the Australian National Health and Medical Research Council (NHMRC
grant number APP1030103). EL was supported by the Queensland University
of Technology Post-Graduate Research Award (QUT PRA), a CRE-RHAI Top-Up
Scholarship, and an Australian Centre for Health Services Innovation (AusHSI)
Post Graduate Top-Up Scholarship 2014/2015. Funders did not have direct
involvement in the research including manuscript preparation.
Ethics approval and consent to participate
Ethics approval was obtained from the Queensland University of Technology
Human Research Ethics Committee (Approval number: 1500000190).
Informed written consent was given by participants prior to being
interviewed.
Consent for publication
Not applicable.
Competing interests
All authors have completed the ICMJE uniform disclosure form at
www.icmje.org/coi_disclosure.pdf and declare that: EL, KP and NG had
financial support from the Australian National Health and Medical Research
Council (NHMRC grant number APP1030103) for the submitted work; all
authors have no financial relationships with any organisations that might
have an interest in the submitted work in the previous 3 years; and no other
relationships or activities that could appear to have influenced the submitted
work.
Publisher’s Note
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Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
22.
Author details
1
School of Public Health & Social Work, Faculty of Health, Queensland
University of Technology, Kelvin Grove Campus, 60 Musk Avenue, Kelvin
Grove, Brisbane, QLD 4059, Australia. 2School of Clinical Sciences, Faculty of
Health, Queensland University of Technology, Gardens Point Campus, 2
George Street, Brisbane, QLD 4000, Australia. 3Centre for Research in
Evidence Based Practice, Bond University, 14 University Drive, Robina, QLD
4226, Australia. 4The Australian Centre for Health Services Innovation,
Queensland University of Technology, 60 Musk Avenue, Kelvin Grove,
Brisbane, QLD 4059, Australia.
23.
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Received: 17 May 2017 Accepted: 2 October 2017
28.
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