Public attitudes towards bacterial resistance: a qualitative study

Abstract

Objectives

Behaviour of members of the public contributes to bacterial resistance. For behavioural change to occur, individuals need to perceive the issue as important to them and feel able to make a valuable contribution. Public campaigns have, so far, not been informed by detailed understanding of public attitudes to the problem. We therefore set out to explore the attitudes of members of the public to bacterial resistance.

Methods

A qualitative grounded theory interview study was undertaken. A purposive maximum variation sample included 32 (70%) women and 14 (30%) men, aged from 18 to 89 years, from areas of high, average and low deprivation.

Results

Participants were uncertain about bacterial resistance and their explanations were generally incongruent with prevailing biomedical concepts. Perceived importance and personal threat were low. The media was the main information source and it left the impression that dirty hospitals are the main cause. Some participants dreaded hospitalization because they feared resistant infections. Few recognized resistant infections as a problem in the community. Less than a quarter indicated that they could positively influence the situation by expecting antibiotic prescriptions less often, or taking antibiotics according to instructions, and even fewer through their own hand washing behaviour.

Conclusions

Although members of the public can contribute to containing bacterial resistance, most do not feel that they have a personal role in either the problem or its solution. Campaigns should identify bacterial resistance as both a hospital and a community problem that individuals have the power to influence through specific actions.

Introduction

The public are being increasingly engaged in efforts to contain bacterial resistance. They can positively contribute to controlling bacterial resistance by lowering their expectation for antibiotics for common infections,¹ by adhering to antibiotic regimes² and by helping reduce the spread of resistant organisms through behaviour such as hand washing.³ Public campaigns have had a mixed response,^4,5 perhaps because they are often based on broad non-specific messages, for example, ‘Antibiotics: don't wear me out’,⁶ and are not adequately developed from an appraisal of the public's attitudes towards bacterial resistance. Behavioural change is unlikely unless people have a clear sense of its importance, value the change and believe in their ability to make a positive contribution through feasible action.^7–9

Although previous studies have explored lay perceptions of common infections and antibiotic treatment,¹⁰ public attitudes to bacterial resistance are under-researched. Understanding the attitudes of the public may be vital in enabling health professionals and health education programmes to develop and frame messages in specific and meaningful ways.

Methods

We defined attitudes as having three aspects: affective (evaluative feelings), cognitive (opinions and beliefs) and behavioural (overt actions).¹¹ Qualitative methods were chosen because they enable in-depth exploration of perceptions while avoiding researchers merely quantifying responses to pre-conceived notions. Grounded theory methods were chosen as a way of revealing participants' views, feelings, intentions and actions within the context and structures of their lives.¹²

Subjects

We initially selected a purposive sample aimed to capture maximum variation in views and hypothesized that these would vary according to age, level of social deprivation and geographical context. We therefore recruited participants from three unitary authorities: Cardiff (urban), Blaenau Gwent (post-industrial, former coal mining area) and Monmouthshire (rural). We identified one deprived, one average and one ward of low deprivation, based on the Townsend scores of the census data, in each of these three areas.¹³ We aimed to recruit participants with a range of ages and to include a meaningful gender balance. One additional electoral ward with high levels of deprivation within Caerphilly was also targeted because of recruitment difficulties in Blaenau Gwent. The characteristics of the sample are described in Table 1.

Participants were recruited through community groups. A study team member visited a meeting of each group, following initial discussion with community group leaders. Verbal explanations of the study were given and all attendees were provided with an information pack. Those willing to participate returned a signed reply form using a self-addressed envelope.

N. J. H. conducted in-depth interviews with participants in their own homes or at local community centres. Interviews were semi-structured using an interview guide (see Table 2 for questions relevant to this report). Open questions were used, followed by prompts when there was no response to initial questions. For example, when participants indicated that they had not heard of bacterial resistance, they were asked whether they had any ideas about methicillin-resistant Staphylococcus aureus (MRSA) or ‘super bugs’. The data generated during interviews were, thus, either spontaneous, the result of open questioning, or prompted and were coded as one of these three possibilities. Different ways of data generation were taken into account in our analyses.

Written consent was obtained prior to all interviews. All interviews were audio-recorded, apart from two where the recording device failed. In these two cases, additional detailed field notes were made immediately following the interviews. All data were anonymized on transcription.

After 21 interviews, category development left us convinced that we had insufficient data from young men from areas of high deprivation. We therefore made particular efforts to recruit from this group. We considered this theoretical sampling because the cases were selected on the basis of their potential to facilitate the development of categories.¹² Consistent with a grounded theory approach, data collection stopped when ‘theoretical saturation’ was reached in that no new properties emerged from the data.¹²

Data were analysed using techniques of open, axial and theoretical coding, constant comparison and searching for deviant/unusual cases. Data collection and analysis proceeded in tandem using a cyclical process whereby analysis informed further data collection.¹² Codes, categories and themes were developed. Emerging theoretical hypotheses were repeatedly re-evaluated through subsequent interviewing. During open coding, concepts were named and their properties and dimensions identified. Axial coding related categories to subcategories and linked properties with dimensions. As initial hypotheses were formed, data were searched for disconfirming evidence falsifying initial hypotheses. Unusual (deviant/negative) cases were identified and early theoretical conclusions modified in the light of such evidence. Finally, during theoretical coding, concepts were integrated and the theory refined.¹²

The organization and retrieval of data were supported by qualitative data analysis software (NUD-IST). Reliability was explored through dual coding of 20% of the data by two researchers (N. J. H. and F. W.). Lack of concordance was resolved through discussion.

Results

We approached 37 community groups and gave out 283 information packs. Interviews were conducted between March 2005 and March 2006. Although we aimed to achieve a balance of men and women across locations and socio-economic groups, women were over-represented in the sample, and we were not able to interview people from rural areas of high deprivation or post-industrial areas of low deprivation. Twenty-four participants had undergone post-compulsory education (Table 1). Most of the data were the result of direct questioning and the use of prompts. Prompts were used more often when interviewing those who did not have a science background (professional training/qualifications within the fields of either biomedicine or health science). Analysis of data revealed two key themes:

(i) Uncertainty about the causes and consequences of bacterial resistance

‘I really don't know the cause of them’

Data from our initial interviews led us to hypothesize that many members of the public shared ideas about bacterial resistance, which are broadly congruent with current biomedical thinking. Eleven (24%) participants with a science background, four middle class mothers and an unusual case of a father from a deprived urban area described the adaptation and mutation of bacteria in association with antibiotic use. Some of these participants also blamed general practitioners for over prescribing antibiotics (n = 10, 22%). However, following theoretical sampling, our early hypotheses were modified. Most participants, in fact, had little awareness of the causes and consequences of bacterial resistance (Table 3). Most were unable to respond to questions about the nature of bacterial/antibiotic resistance. Following prompts, however, most did acknowledge that they had heard of MRSA and/or super bugs.

P34: I really don't know the origin of them; they talk about cleaning hospitals better. I do not have a clue, whether it's airborne or whatever. I'm not sure. I just know it's severe (60 year old man, rural area).

P21: I don't actually know very much about it. But having been into hospital and everyone was talking about it and there must be something in place to prevent it, perhaps? It can be carried by people. I know that because some hospitals actually test you for it. But I don't know what it is. I just know that it is serious (57 year old woman, rural area).

None of the participants had personal experience of resistant infection, but several knew of others who had suffered from resistant infections while in hospital. Young adults (18–26 years of age) from areas of high deprivation expressed most uncertainty about the causes and consequences of the problem. Most participants associated resistant infection only with severe life-threatening infection and death.

Source of beliefs

Most respondents reported that their main source of information about bacterial resistance was television and to a lesser extent, newspapers and radio reports.

P44: Nothing, I don't know nothing but what I hear on the telly and they say that people go into hospital and end up worse than they did when they went in there but other than that I don't know a lot really (46 year old man, post-industrial area).

‘It's a hospital problem’

The majority of participants believed that bacterial resistance was a problem within hospitals caused by poor environmental hygiene (Table 3). Dirt and germs were closely associated as were dirty hospitals and resistant infections. No participants expressed a belief that bacterial resistance was a common community problem or that resistant infections could affect those who were not in hospital. Few talked about the important role of hand washing in response to questions about how resistant infections could be controlled, although they were not specifically probed about hand washing per se.

P33: I thought that was just to do with the basic hygiene because um, people aren't being cared for properly like they used to be in hospitals. I mean wards aren't clean, you know, floors aren't washed, toilets aren't cleaned (34 year old woman, urban area).

P14: I think it was obvious in a place like that (hospitals) with all the dirt around that it was going to cause a problem (36 year old woman, rural area).

P37: The standards of hygiene and I'm not just blaming cleaning staff. I am blaming nurses as well because the standards of nursing these days I think is absolutely outrageous. I mean years ago wards were scrubbed from head to foot. Now what do they do? Give the bed a quick wipe over and shove the next body in it, its disgusting (63 year old woman, post-industrial area).

Consequences of resistant infections

Six (13%) connected bacterial resistance with potential treatment failure. However, these participants generally related treatment failure to the body's response to repeated antibiotic use and not to changes in resistance characteristics of bacterial populations. They believed that antibiotics become less effective with repeated use because the body (and not bacteria) becomes ‘used to’ or ‘immune’ to them.

P24: I think that if you take too many antibiotics that they are not going to do the job they are supposed to do when you really need them because your body does build up an immunity to them, doesn't it ? (29 year old woman, rural area).

Not receiving antibiotics for long enough or antibiotics that were not strong enough, or of the wrong type, were also cited as reasons for treatment failure. Beliefs about the role of the immune system in combating infection were underdeveloped. Most participants overestimated the effect of antibiotics, independent of their own immune system.

(ii) Lack of individual ownership for the control of resistant infections and fear of hospital admission

‘I don't worry about it’

Participants initially appeared to have few concerns about resistant infections. They did not feel that they had a role in either the cause or the control of bacterial resistance.

P31: Um worries me in terms of um, am I anxious about it? No, but only because I don't think there is very much I can do about it. I do think it's um, compared to global warming, its concerning, definitely, and it should be acted on and researched (36 year old man, urban area).

Dual coding, however, highlighted an initial discrepancy between coders. Following further scrutiny of data and discussion among the coders, the code ‘lack of concern’ was renamed and redefined as two separated but inter-related issues, ‘perceptions of importance’ and ‘personal risk’. Participants' lack of concern was then coded as a low sense of importance for some and/or as low personal risk of contracting resistant infections for others.

P10: I can't say that I lose, I haven't lost any sleep over it. In general, terms, yes, you're aware of the problem; you know that the problem exists but its generally vague and not a cause for immediate concern (37 year old man, urban area).

However, following examination of an unusual case, it became clear that perceptions of risk were related to the likelihood of the participant needing hospitalization. When hospitalization was considered likely or possible, the perceptions of risk increased. This is not surprising as most respondents believe that resistant infections were caused by and contained within hospitals.

P26: I would worry about going into hospital but I don't worry about it every day but I would if I had to go into hospital for an operation, I would be very scared of getting MRSA (33 year old woman, rural area).

P17: Don't think it affects us on a day-to-day basis so we don't think about it. Well not a lot really. It's quite a scary one isn't it? But superbugs, I'm not quite sure about that. I've heard things on the news and in the newspaper and things like that but MRSA, I'm quite concerned about that myself because of having the baby soon and possibly going to have a caesarean. Is it like the wound stays; is it like the wound stays infected? (34 year old woman, urban area).

Fear of resistant infections was consistent with respondents' attitudes to germs as hostile invaders. Anxiety about hospitalization led some to refuse admission.

P30: I begged them last time that they wanted to take me into hospital not for me to go because I am afraid of going into hospital now. I am terrified of it (talking about MRSA) and everyone feels the same (58 year old woman, post-industrial area).

‘There's nothing I can do’

Few participants talked about the individual's potential contribution to controlling bacterial resistance through adherence to medication regimes or by working with clinicians to limit antibiotics to essential indications. Most of those who mentioned the importance of finishing a course of antibiotics in relation to bacterial resistance had a science background. Interestingly, few participants acknowledged the importance of taking antibiotic doses at the correct intervals.

‘It's not my responsibility’

Attitudes towards infections influenced attitudes towards bacterial resistance. ‘Germs’ were perceived as something one caught from someone or something else, outside the individual's ability to control and closely associated with dirt. Participants perceived themselves as having little individual responsibility for the control of bacterial resistance, not only because they considered germs as being outside their control, but also because the standards of hygiene and resources within healthcare services were outside their field of influence. The majority of participants believed that the responsibility for tackling issues relating to bacterial resistance rested with the government and/or National Health Service (NHS) managers (n = 33, 72%). Blame was often placed with the NHS at policy and institutional levels, as cuts in funding and resources were believed to be responsible for poor hospital hygiene.

P37: I blame the government for cutting back. I can think of a number of people who have gone into hospital and they got MRSA. Where did they get it from? They didn't take it in with them (63 year old woman, post-industrial area).

P39: it's very common in hospitals at the moment, um, it's down to lack of cleaning and what have you, isn't it a lack of staffing, that's what I would put it down to (21 year old man, post-industrial area).

N. J. H.: Who has responsibility for sorting these ‘superbugs’ out?

P35: Well I would say the government first and foremost. They have got the power to enforce legislation on the rest of us and they've got money and resources to do things about it, whereas no one else in the country really has. So the responsibility, kind of, lands on their table (43 year old man, post-industrial area).

In contrast, participants with science backgrounds described responsibility for controlling resistant infections as residing not just with governmental authorities but also with society as a whole; i.e. among the general public, health service providers and the scientific community. However, five middle class mothers and a father from a deprived urban area (all of whom had completed post-compulsory education), despite expressing some uncertainty, also felt that responsibility for resolving the problem rested with members of the public, albeit led by government agencies.

P10: Well I think that there is personal responsibility but I also think that governments have responsibility as well; they have to lead the way (37 year old man, urban area).

Discussion

To the best of our knowledge, this is the first in-depth qualitative exploration of members of the public's attitudes towards bacterial resistance. We developed a grounded theory of attitudes to bacterial resistance through interviews with participants from a range of ages, gender and living in a wide range of geographical settings with a spread of deprivation. Most participants were uncertain about what bacterial resistance was and their explanations were generally incongruent with prevailing biomedical concepts. There was a low sense of perceived importance and personal threat. Bacterial resistance was not identified as a community problem. Rather, it was considered an issue of poor hospital hygiene. The media was the main source of information; its portrayal of resistant infections contributed to participants' fears of hospitalization. Participants generally felt that they had no role to play either in the cause or in the solution of the problem. Less than a quarter indicated that they could influence the situation through their own use of antibiotics and even less volunteered the importance of reducing the spread of resistant infections through their own hand washing behaviour.

Our findings are consistent with quantitative surveys reporting hospital patients' awareness of MRSA.^14–16 Previous studies, however, have not explored the nature of informants' understandings of bacterial resistance including beliefs about aetiology and responsibility. Our participants demonstrated limited understanding of biomedical concepts, with the exception of those with a science background.

The media acts as a conduit between medical and lay knowledge and, consistent with other studies, is the main source of public information about resistant infections.¹⁶ It was not surprising, therefore, that participants' attitudes were consistent with the social representations recently presented by the media. Such representations portray MRSA as a potentially lethal infection contained within hospitals and caused by poor hygiene, the responsibility for which lay with the NHS and politicians.¹⁷

National strategies to contain bacterial resistance have focused mainly on reducing community antibiotic prescribing and improving infection control within hospitals.¹⁸ Indeed, some participants blamed general practitioners for over prescribing, but most described dirty hospitals as the primary cause of the problem.

Our data indicate that there was a low sense of personal ability to help contain the problem, because infections were perceived as outside the influence of individuals. Such beliefs are not new. Helman's seminal study in suburban London found that fevers were perceived to be caused by microbes and as such were outside individuals' control. The individual could not be proportioned with any blame or responsibility for these illnesses.¹⁹ Few participants expressed ideas that responsibility for resistant infections lies with society more broadly. Ideas about individual and social responsibilities were largely confined to participants with similar occupations and social class. Middle class parents and those with a science background were more likely to express beliefs that the control of bacterial resistance was an issue not just for government agencies. This finding is consistent with studies of health beliefs in the UK, which reported that working class mothers' hold more fatalistic views of ill health and lower levels of perceived personal responsibility when compared with middle class mothers, i.e. middle classes felt responsible.²⁰

Some believed that the repeated use of antibiotics has a negative impact, because of changes in the individuals' response to the antibiotic (their bodies ‘got used to’ antibiotics). Some informants of a quantitative pan-European survey indicated similar beliefs.¹⁰

Few participants in our study were aware of the importance of adherence to the optimal timing between doses as a way of reducing the risk of bacterial resistance. Adherence to the optimal intervals between doses has, however, only relatively recently been emphasized and depends on the nature of the infective microorganisms and the class of antibiotic.²

The ease with which resistant organisms are transmitted has made a major contribution to the problem of bacterial resistance. Hands are the primary mode for the transmission of some infections. The actual mutation of microbes, in comparison, is rare.² Reducing the spread of resistant infections is a national objective.¹⁸ However, very few participants volunteered the importance of simple hand washing in reducing the spread of infection, either in the home or while admitted to, or visiting, hospitals.

Participants did not perceive themselves at risk of contracting resistant infections in the community, despite emerging evidence that resistant infection in the community is common and increases morbidity. For example, antibiotic-resistant Escherichia coli urinary tract infections are common in the community and are associated with increased duration of symptoms and increased workload of general practitioners.²¹

Despite expressing few concerns about bacterial-resistance in general, some participants anticipated hospitalization with intense fear because of the threat of antibiotic-resistant infection while admitted. Public fear of hospitalization may now resemble anxieties during the 18th and 19th centuries, when hospitals were associated with death.²² Social historians tracing the development of modern medicine described how public views on hospitals were transformed through generations from suspicion to general acceptance, but recently, reports have indicated a growth in dissatisfaction with healthcare services in the UK.²³

Studies sampling people admitted to hospitals, however, have demonstrated relatively low levels of perceived vulnerability to resistant infections. A small quantitative survey of patients and visitors of a single hospital in the north of England reported that about a third felt that they might contract MRSA if admitted.¹⁶ Levels of perceived vulnerability are important as they influence health action and may motivate behavioural change and adherence.^8–10 Realistic and appropriately channelled public concerns may have the potential to act as a powerful motivating force for engaging the public in the fight against resistant infections.

Health promotion campaigns focusing on other public health issues have found that simple practical advice influences public attitudes.^24,25 Recent campaigns have aimed to reduce the use of antibiotics in minor respiratory tract infections by using simple messages.⁶

Conclusions and implications

Many participants in this study demonstrated misconceptions about resistant infections and a lack of individual ownership both of the cause and of the control of bacterial resistance. Although simple advice may influence knowledge, behavioural change is unlikely unless people have a clear sense of the importance of the change, value it and believe that they can make feasible, positive contributions. Campaigns aiming to engage the public in the fight against bacterial resistance could focus on three key elements: improving public understanding of the causes and consequences of resistance infections; raising the importance of bacterial resistance as a community issue and convincing individuals, with specific messages, that they can feasibly make a valuable positive contribution.

Acknowledgements

We wish to thank the members of the public who participated in the study.

Professor R. Pill provided additional methodological guidance. Research costs were met by the Department of General Practice, Cardiff University. Contributors: C. C. B. conceived of the study and led the study team. All authors contributed to the study design, analysis and report writing. N. J. H. led the data collection and acts as guarantor. The South East Wales LREC confirmed that the study raised no ethical concerns and that a full ethical application was not required for this study.

Transparency declarations

None to declare.

References