Antimicrobial resistance (AMR) is a global menace. If no effective action is taken, decades of medical progress risk being undone. AMR happens when microorganisms, such as bacteria, viruses, fungi and parasites, no longer respond to antimicrobial medicines. This means infections become harder to treat and diseases spread. In the face of this serious global health threat, every potential avenue for promoting more effective approaches must be explored.
Using behavioural and cultural insights (BCI) offers an innovative, evidence-based and people-centred approach to reshape how we address AMR. Health ministers and delegates from WHO/Europe’s 53 Member States have recently endorsed a new roadmap on AMR for the WHO European Region, which recognizes BCI as a “high-impact intervention” to be integrated into bigger efforts to tackle AMR.
An underutilized tool
BCI uses methods from social and behavioural sciences to systematically map individual and contextual factors that influence health behaviours. Various factors affect behaviours contributing to AMR: hospital standard operating procedures; social norms among doctors; fears of malpractice; habits related to doctors’ prescription of antibiotics; and availability of diagnostic tests. Understanding these behaviours paves the way for tailored and more effective interventions that, in turn, improve behavioural and health outcomes.
“BCI can be a game-changer in addressing global health threats like AMR,” says Robb Butler, Director of the Division of Communicable Diseases, Environment and Health at WHO/Europe. “It’s high time we scaled-up the use of this tool and supported public health authorities in integrating BCI effectively into health systems.”
BCI in practice
Evidence, theoretical frameworks and practical methods exist to help public health authorities use a BCI approach to identify and implement interventions to tackle AMR. WHO/Europe developed the Tailoring Antimicrobial Resistance Programmes (TAP) and the more broadly applied Tailoring Health Programmes (THP) approaches as step-by-step tools for guiding health authorities in applying BCI, from problem definition to intervention design and evaluation.
These guides have proven pivotal in, for example, understanding the role of health worker (HW) behaviours in addressing AMR.
Studies conducted by WHO/Europe between 2020 and 2023, related to routine and COVID-19 vaccines, underscore the importance and complexity of HW behaviours and their underlying factors.
A wide range of BCI pilot projects have already been performed and are underway to tackle AMR, including in Sweden on social orientation, in the United Kingdom on changing antibiotic prescribing behaviours, in Hungary on paediatric antibiotic prescribing, in Kazakhstan on pharmacists’ behaviour regarding over-the-counter sale of antibiotics, and in Georgia on a surgical antimicrobial stewardship programme in hospitals.
Several models can be used to explore the behaviours of HWs, including the so-called COM-B model which pinpoints four key factors that should be considered for the implementation and evaluation of AMR-related interventions:
- capability: refers to the proficiency of HWs in effectively and responsibly selecting, dosing and monitoring antibiotics (e.g., knowledge skills, professional judgement, training);
- motivation: integrates HWs’ confidence in their capabilities and awareness of the consequences of their decisions, as well as emotional responses (e.g., fear, habits, reactions to situational pressures);
- social opportunity: related to interpersonal and group dynamics, and organizational structures (e.g., peer norms and values, interaction with managers); and
- physical opportunity: refers to the tangible and environmental factors influencing prescribing behaviours (e.g., easy access to necessary equipment, readily available protocols and guidelines).
Using BCI to address AMR in Ukrainian hospitals
At present, these insights are playing a pivotal role in guiding a situation analysis in three Ukrainian hospitals to address the rise of resistant infections, especially among individuals with war-related injuries, and the longer-term need to reduce AMR through appropriate antibiotic prescribing and use.
“AMR is a problem in our institution … For a long time, antimicrobials have been prescribed uncontrollably without direct indications and without confirmation by bacteriological testing,” explains Nataliia Balaniuk, Head of the Infection Control Department at Khmelnytskyi City Hospital. “Behavioural science can substantiate how to change staff behaviour in general towards infection control and in particular towards AMR.”
The knowledge and evidence that a BCI approach can offer is critical for infection prevention and control and for reducing the inappropriate use of antibiotics in Ukraine, with the goal to generate insights that can be scaled nationally.
It is clear that the fight against AMR is a complex one that requires everyone’s commitment. In the wake of World AMR Awareness Week, we can commit to ending this silent pandemic with the help of BCI.