Exploring barriers and enablers to the implementation of feasible interventions that address antibiotic resistance in Romania

Background: Antimicrobial resistance (AMR) is a major global public threat to human and animal health and sustainable development with significant economic and societal implications. The key drivers of AMR are numerous with one key one being non-prudent use (whether misuse or overuse) of antibiotics. Non-prudent use practices are: inappropriate prescribing, self-medication and antibiotic use without prescription, non-adherence to appropriate or recommended treatment. These may result from deficient patient-doctor interactions, treatment characteristics, access to treatment, storing of antibiotics at home, limited access to healthcare, and from intentions to self-medicate. A significant number of these factors are directly associated with human behavior and occur in a community setting. The Behavior Change Wheel (BCW), which proposes the identification of capabilities, opportunities and motivations that may dictate or change a certain behavior, is a useful framework to further understand different stakeholders’ behaviors that drive antibiotic consumption (ABC) and AMR as well as related interventions. Furthermore, while antibiotics are extensively used in the community, most interventions implemented thus far are set in health facilities and are delivered or are targeting healthcare professionals. This approach misses other community spaces and engagement opportunities. Romania has the highest total ABC for systemic use in the European Union (EU). Data on public knowledge on antibiotics in this country, shows a decline in knowledge compared to previous years. All these suggests that the Romanian setting would benefit from addressing related ABC and AMR issues through community-based interventions. Furthermore, the Romanian health and social systems are confronted with challenges that parallel or will be encountered by other countries.

Aim: The overall aim of the project was to construct an evidence base for developing and implementing community-based interventions to combat AMR and inform relevant policy documents, in view of combating AMR in Romania.

Methods: Two studies (study I and III) relied on qualitative methodology (content analysis), using semi-structured interviews to understand pharmacists and family doctors’ perceptions on related roles as well as ABC and AMR in Romania. Study I captured data from 18 interviews with pharmacists whereas study III from 12 family doctors’ interviews. Study III represented a quantitative and qualitative synthesis of evidence on the value of community-based educational interventions to improve antibiotic use. Seventy-three papers were included, ranging from quantitative, qualitative and mixed-methods studies. Study IV used a quantitative methodology to capture perceptions of future Romanian health professionals about antibiotic use. A total of 479 participants completed the study IV survey- 233 medical students from seven faculties and 246 pharmacy students from four faculties.

Key findings: Study I articulated three sub-themes that would describe pharmacists’ perceptions. The first one referred to their difficulties in ‘maintaining equilibrium between ethics, law and economy’. The second sub-theme characterized ‘antibiotic resistance problem as rooted in a low social capital environment’. This reflected the deep causes of antibiotic resistance that go beyond strictly antibiotic management. Lastly pharmacists were found to be ‘wanting to fulfil their educational role’, which is how they felt they could best contribute. The overarching theme ‘Undervalued medicines’ professionals struggling with agency related and structural barriers to meet their deontological duties’- reflects the way pharmacists perceive their current societal standing as well as how their roles are challenged by several barriers that impact their decision-making processes. Study II revealed advantages of community-based behavior change interventions in improving antibiotic use. Multifaceted interventions were found to provide the greatest benefits. Particularly, interventions that combined educational components with persuasion had a better impact across most outcomes (knowledge, attitudes, and beliefs; antibiotic adherence; antibiotic use) compared to interventions focused solely on education. The review also identified challenges in evaluating this type of research and emphasized the necessity for standardized approaches in study design and outcome measurements. While there is some emerging evidence on the cost-effectiveness of these interventions, it remains limited in scope. Study III identified the perceived factors affecting ABC and antibiotic prescribing by family doctors. Some factors pertained to the perceived behavior of family doctors or patients, others were associated with different systems, local contexts, and the COVID-19 pandemic. An overarching theme was articulated: ‘family doctors in Romania see their role differently when it comes to antibiotic resistance and perceive the lack of patient education or awareness as one of the major drivers of ABC’. All these perceived factors spanned the capability, opportunity, and motivational domains of the BCW and could be addressed through a mix of interventions. Study IV found that most students responded they felt prepared in at least 14 areas (covered by 14 questions) (out of 22 areas/questions for medical students, and 19 for pharmacy students). In terms of willingness to engage, a similar trend was observed among both medical and pharmacy students, with scores of 2 out of 4 (4 being the maximum score showing the maximum engagement willingness, considering there are 4 areas of engagement) and 3 out of 4, respectively. A significant proportion, approximately 53.5% (n=254), confirmed that they received sufficient training to ensure the appropriate use of antibiotics in their professional fields. Students who scored low on preparedness expressed a desire for additional education. Regarding their estimation on how antibiotic use will evolve in Romania, the highest number of responses from medical and pharmacy students (n=159, 33.5%), highlighted the view that the situation would worsen. Regarding the survey design, the factor structure identified through Exploratory Factor Analysis (EFA) could not be validated through Confirmatory Factor Analysis (CFA), indicating that further adjustments are required for the model and/or questionnaire.

Conclusions: Promising evidence supports the benefits of community-based interventions in enhancing antibiotic use, particularly multifaceted approaches. Considering the impact of the COVID19 pandemic, policymakers should consider these interventions alongside clinical-based approaches to rebuild trust. Inclusive participation in community-based interventions fosters public ownership and utilization of community channels. Romanian healthcare professionals hold diverse perceptions of AMR. Factors influencing appropriate antibiotic use and AMR in Romania include the behaviors of pharmacists, family doctors, patients, the health system, local contexts, and the pandemic's impact. Findings also have important implications for the education and training of future Romanian healthcare professionals, necessitating further research to establish standardized methods for monitoring and evaluating progress in preparedness, engagement willingness, and teaching preferences regarding antibiotic use.

List of scientific papers

I. Ghiga, I., Stålsby Lundborg, C. ‘Struggling to be a defender of health’ –a qualitative study on the pharmacists’ perceptions of their role in antibiotic consumption and antibiotic resistance in Romania. J of Pharm Policy and Pract. 9, 10 (2016).
https://doi.org/10.1186/s40545-016-0061-y

II. Ghiga I, Sidorchuk A, Pitchforth E, Stålsby Lundborg C, Machowska A. 'If you want to go far, go together'-community-based behaviour change interventions to improve antibiotic use: a systematic review of quantitative and qualitative evidence. J Antimicrob Chemother. 2023 May 6.
https://doi.org/10.1093/jac/dkad128

III. Ghiga I, Pitchforth E, Stålsby Lundborg C, Machowska A. Family doctors' roles and perceptions on antibiotic consumption and antibiotic resistance in Romania: a qualitative study. BMC Prim Care. 2023 Apr 10;24(1):93.
https://doi.org/10.1186/s12875-023-02047-z

IV. Ghiga I., Pitchforth E., Popescu GA., Fulop I., Stålsby Lundborg C., Machowska A. How do future Romanian health professionals feel about antibiotic use? Results from a cross-sectional survey in Romanian Universities of Medicine and Pharmacy. [Manuscript]