Depreciación del Proyecto

There have only been a few studies exploring lay perceptions of resistant infections, but some evidence can be gleaned from studies exploring antibiotic use more generally and is included here where relevant. Although there are many different types of resistant infection, most studies explore lay beliefs about MRSA. Studies of hospital patient populations in the UK and North America have reported

considerable patient awareness of MRSA (43-84%) (Collett et al 1999; Hamour et al, 2003; Gill et al, 2005; Duncan and Dealy, 2007). High levels of public awareness of MRSA are confirmed by a recent population survey in which 79% of public agreed with the statement ‘antibiotic resistance is a problem in British hospitals’

(McNaulty et al, 2007a). Patient groups appear to be generally aware that MRSA is a pathogenic micro-organism: when provided with a number o f pre-defined options, 68% (n= l 13) correctly identified MRSA and superbugs as a ‘multi-resistant

bacterium’ (Hamour et al, 2003). However, there appears to be some public uncertainty about the characteristics o f the microbe involved. MRSA has been described by the public as a ‘bug’, ‘germ’, ‘virus’, ‘bacteria’ and as ‘a nit’ (Newton et al, 2001; Gill etal2006).

MRSA has been associated with unhygienic hospitals and to a lesser extent, with poor standards o f care, inadequate hand washing, surgical procedures, and in particular surgical wounds (Newton et al 2001; Hamour et al, 2003; Duncan and

Dealy, 2007). Beliefs about MRSA are not, however, entirely confined to hospital settings. Hamour et al (2003) reported that 44% o f the informants surveyed believed that MRSA could exist in the wider community. These findings, however, need to be considered in light o f its limitations of a small convenience sample of hospital patients (n=113) which is unlikely to be generalisable to the wider population.

Despite public awareness of MRSA, previous studies fail to specify whether lay beliefs systems recognise that MRSA is not the only resistant micro-organism but one of many resistant microbes threatening public health.

Although poor hospital hygiene and other health care related factors (listed above) are perceived as the main causes of MRSA, a number of individual factors are also believed to contribute to contracting a MRSA infection. The risk o f contracting MRSA infection is believed to be increased if the individual’s immunity is

compromised in some way. Interestingly, consistent with the fatalistic views of infection described by Mabry (1967) and Helman (1978), contracting a resistant infection is considered by some to be just ‘bad luck’ ( Newton et al, 2001).

There have been no detailed studies examining the link between public awareness of antibiotic use and resistant infections. Pechere et al, (2001) reported that no

respondents mentioned antibiotic resistance as a negative consequence o f taking antibiotics, but other studies (Emslie and Bond, 2003; Eng et al, 2003; McNulty et al, 2007b) have demonstrated that some members of the public are aware that the use of antibiotics can contribute to the occurrence of resistant infections. Cals et al (2007) reported that 92% agreed with the statement “bacteria become less susceptible (resistant) to antibiotics” (p 944). McNulty et al (2007 b) asked respondents whether they agree or disagree to 11 statements related to bacterial resistance and antibiotic use. Most respondents knew that overuse of antibiotics increased resistance and considered resistant infections a growing concern. Little is known about the nature o f public understanding of the connection between antibiotic use and the occurrence o f bacterial resistance. In addition, lay meaning of the term

‘resistance’ has not been clearly described. Researchers appear to assume that the public attach the same meaning to the word resistance as they do themselves.

Public concerns about resistant infections have been reported (Palmer and Bauchner, 1997, Esmile and Bond, 2003). Newton et al's (2001) qualitative study reported that half of their hospital patient population sampled perceived MRSA as serious (n=9), and were fearful about contracting MRSA infection. Patient populations have a

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number o f concerns about MRSA including reduction in the effectiveness of antibiotic treatment, contagion, prolonged hospital admission, and recurrent

infection (Newton et al, 2001). Although the findings o f Newton et al (2001) are not statistically generalisable, other studies have confirmed patients concerns about MRSA (Hamour et al, 2003). Despite reports of concerns about bacterial resistance in hospital samples, studies sampling community populations have reported low levels of personal concern and a sense that bacterial resistance was unlikely to affect them personally. Emslie and Bond’s (2003) indicate that almost half (45%) of respondents did not feel that MRSA mattered to them personally and McNaulty et al (2007) reported that 19% of respondents did not know or disagreed with the

statement ‘antibiotic resistance could affect me or my family’. The reasons for the belief that bacterial resistance is something that is unlikely to effective individuals in the community are not, however, clear.

A variety of beliefs about how MRSA can be controlled have been reported. Patient populations have described hand washing (54%) as ‘important’ in reducing the spread of resistant infections and to a lesser extent the use of gloves, aprons and isolation rooms (Hamour et al, 2003). A more recent study has reported even greater levels (91%) o f the public believe that hand washing is the most effective way to reduce resistant infections (Duncan and Dealy, 2007). However MRSA has also incorrectly been believed to be spread in the air (Duncan and Dealy, 2007).

Although patients may be aware that isolation reduces the spread of infection, their actual understanding o f the modes of transmission and prevention are limited (Newton et al, 2001). Perceptions of the controllability and curability o f MRSA are

therefore ‘not highly developed’ (Newton et al, 2001). Although public awareness o f the role of antibiotics in resistance are reported along with a number of factors influencing resistant infections (previously discussed), public beliefs about the mechanisms by which antibiotic consumption can lead to antimicrobial resistance are at present under-researched.

2.5 Sum m ary

Studies undertaken from anthropological and sociological perspectives have consistently indicated that lay explanatory models of respiratory tract infection combine ideas consistent with traditional and biomedical belief systems. Within dominant cultures and health care systems in developed Western countries, lay beliefs systems recognise exposure to extremes o f temperature, disruption of the homeostasis o f the body and exposure to microbes as causing a variety of respiratory tract infections. Recent biomedically oriented studies have increasingly focused on eliciting beliefs about the microbial causes o f URTI. Misconceptions have been described where the beliefs expressed do not match the biomedical model of illness, for example when confusion between bacterial and viral aetiology is identified.

There are a number of illness behaviours adopted by sufferers of URTI. People most commonly treat their own illness using a number of self care tactics ranging from resting to using a variety o f home remedies and over the counter medicines.

Medicine use, in particular the use of OTCMs, is the main way in which URTIs are dealt with in the community. Although most would not consult a clinician in typical cases of URTI, some members of the public may consult a clinician in some

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circumstances. Patients may consult a clinician because of concerns about their children, specifically out of fear that if left untreated, the illness may develop into something worse, and when they experience symptoms which they perceive as indicating the need for antibiotics, such as a productive cough. Patients’

inappropriately high expectations for antibiotics for URTI are reported by studies sampling clinicians, and these expectations influence clinician prescribing

decisions. However, there is incongruence about the level of expectations between studies from the clinicians’ perspective and studies reporting patient’s perspectives.

Some researchers found that clinicians overestimate patients’ expectations for antibiotics, claiming that patients’ desire for reassurance and advice are more important reasons for consulting.

Public attitudes to antibiotics vary. Some reports indicate that antibiotics are highly revered medicines, with many members of the general public believing that

antibiotics are safe and effective in treating URTIs. There is, however, an important public view that indicates reservations about antibiotic use.

The body of literature exploring adherence to antibiotic therapy comes primarily from the USA and Europe. Reviewing literature relating to adherence presents some challenges as problems o f social-desirability bias and varying operational definitions and different ways of measuring adherence makes direct comparison between studies difficult. Reported levels of antibiotic adherence vary but recent surveys

demonstrate that sub-optimal adherence is common both nationally and internationally.

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Sub-optimal adherence takes several forms: not starting a course of therapy, altering the dose or dosage intervals, not finishing the full course o f therapy and self-

medication with incomplete courses. A large number of factors influence adherence including memory, age, concerns about side effects, and declining symptoms. A number o f patient and clinician factors influence behaviour including the patient’s knowledge and beliefs about the illness and antibiotics, the clinician-patient relationship, and characteristics of the course o f treatment.

Although the body of evidence surrounding public knowledge and opinions of MRSA is small, and the lay meaning of the term ‘resistance’ generally unexplored, reports indicate that the public are familiar with the term ‘MRSA’ and the term

‘superbugs’. However, studies also suggest little public understanding o f the causes or consequences of MRSA or bacterial resistance. In the UK, MRSA is almost exclusively associated with hospitals. Public concern about MRSA and resistant infection vary from extreme worry to ambivalence and minimal concern. In UK hospital based populations, confusion and lack of knowledge about the cause and severity of MRSA and the relationship between bacterial resistance and antibiotic use is widespread. Only a few studies have reported public awareness o f the link between antibiotic use and resistance. Crucially, few studies have explored public understandings of antibiotic resistance beyond hospital acquired MRSA. The impact of the use o f antibiotics in the home, or awareness of how the public can contribute to the cause and control of bacterial resistance, has not yet been adequately

addressed.

Chapter 3: Methods