Behaviour Change for Antibiotic Prescribing

1 Behaviour Change and Antibiotic Prescribing in healthcare settings Literature review and behavioural analysis Behaviour Change for Antibiotic Prescribing About Public Health England Public Health England exists to protect and improve the nation's health and wellbeing, and reduce health inequalities. It does this through world-class science, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. PHE is an operationally autonomous executive agency of the Department of Health. About the Department of Health The Department of Health helps people to live better for longer.

2 We lead, shape and fund health and care in England, making sure people have the support, care and treatment they need, with the compassion, respect and dignity they deserve. Public Health England Wellington House 133-155 Waterloo Road London SE1 8UG Tel: 020 7654 8000 Twitter: @PHE_uk For queries relating to this document, contact: Crown copyright 2015 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence To view this licence, visit OGL or email Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

3 Published February 2015 PHE publications gateway number: 2014719 2 Behaviour Change for Antibiotic Prescribing Authors Dr Richard Pinder1,2 Department of Health and Public Health England Anna Sallis1 C Psychol, Public Health England Dan Berry2 Department of Health Dr Tim Chadborn1 Public Health England 1 Public Health England behavioural insights team 2 Department of Health behavioural insights team Contributors Dr Diane Ashiru-Oredope, Public Health England Nick Beavon, Wandsworth Clinical Commissioning Group Amanda Bunten, Public Health England Dr Constance Chen, Central Manchester Clinical Commissioning Group Dr Alexa Dean, Ashford and St Peter s Hospitals NHS Trust Michael Hallsworth, the Behavioural Insights Team Dr Kieran Hand, University Hospital Southampton NHS Foundation Trust Hugo Harper, the Behavioural Insights Team Dr Susan Hopkins, Public Health England Dean Ironmonger, Public Health England Dr Lorenz Kemper, Oxfordshire Clinical Commissioning Group Prof Cliodna McNulty, Public Health England Dr Nichola Raihani, University College London Dr Joanna Wilde.

4 Warwick Business School and British Psychological Society 3 Behaviour Change for Antibiotic Prescribing Contents About Public Health England 2 About the Department of Health 2 Authors 3 Contributors 3 Contents 4 Executive summary 5 Abbreviations 8 Introduction 9 Aim and objectives 13 Methodology 14 Literature review of behaviours that drive resistance 16 Literature review of interventions to promote antimicrobial stewardship 30 Antibiotic stewardship monitoring and guidance in England 42 Proposed behavioural pathways 45 Behavioural analysis of patient use of antibiotics 47 Behavioural analysis of Antibiotic Prescribing in primary care 51 Behavioural analysis of Antibiotic Prescribing in secondary care 56 Intervention opportunities 61 Conclusion 75 Appendix 1.

5 Literature search methodology 76 Appendix 2. List of published NICE guidance involving antimicrobial therapies 78 Appendix 3. Drivers of patient Behaviour categorised by the theoretical domains framework 79 Appendix 4. Drivers of Prescribing Behaviour in primary care categorised by the theoretical domains framework Error! Bookmark not Appendix 5. Drivers of Prescribing Behaviour in secondary care categorised by the theoretical domains framework Error! Bookmark not Appendix 6. Glossary of interventions 90 References 94 4 Behaviour Change for Antibiotic Prescribing Executive summary The Annual Report of the Chief Medical Officer published in March 2013 highlighted the threat posed by Antibiotic resistance to the UK.

6 This report is part of the response to that call to action. It proposes new and enhanced interventions that have the potential to reduce the risk of Antibiotic resistance. These interventions are grounded in behavioural science, underpinned by a thorough review of the evidence, and have robust theoretical foundations for their mechanism of action. We undertook a literature search to identify more than 150 scientific articles to review. Few of them took a behavioural science approach. From these we assessed the available evidence about key behaviours that support Antibiotic stewardship across three important constituencies: the public and patients; primary care; and secondary care.

7 We subsequently carried out a behavioural analysis using the theoretical domains framework17 and COM-B18 model. The theoretical domains framework distils a range of Behaviour Change theories into domains explaining common influences on Behaviour . COM-B is an associated model of Behaviour . These analyses identified the key behaviours and, importantly, drivers for those behaviours that may be amenable to Change . From this we were able to identify a series of potential new or enhanced interventions that may mitigate Antibiotic resistance. We are sharing this behavioural analysis for two reasons.

8 First, so it can be used by any interested parties working to develop policies, strategies, interventions or campaigns to reduce Antibiotic resistance. It is already informing actions in Public Health England (PHE) and the Department of Health (DH). Second, as an example for behavioural or implementation scientists who are interested in the application of a theoretical behavioural framework to address the factors relevant to a pressing policy challenge. This report is not a statement of government policy, nor does it commit DH or PHE to a particular course of action. Rather, the behavioural insights teams in DH and PHEwill continue to work alongside our colleagues and other experts to consider whether, and how, the proposed interventions could be tested and implemented.

9 Others are also encouraged to use these strategically-identified opportunities to contribute to the fight against antimicrobial resistance. behaviours that drive Antibiotic resistance Primary care: about four-fifths of antibiotics are prescribed in primary care. There are substantial barriers to improving antimicrobial stewardship in this setting. There is considerable local variation in Prescribing rates that is not explained by case-mix and may be attributed to behavioural factors. Many primary care prescribers admit that even some of their own Prescribing will not be clinically beneficial.

10 This is because it is the norm, because they fear 5 Behaviour Change for Antibiotic Prescribing what might happen should they withhold antibiotics, and because they perceive that their patients will be dissatisfied. Patient Behaviour : public understanding is mixed. Misconceptions include that resistance will only affect patients who over-consume antibiotics. Considerable efforts in educating the public have been made, but with varying degrees of success. Patient pressure for antibiotics is not reported as frequently by patients as it is by clinicians, but more so on behalf of children.