Helen Rickard: Antimicrobial resistance as a super wicked problem: how do we engage the public to be part of the solution
Despite these implications for human health the behaviour change required to prevent escalation within both healthcare workers and in the general population is proving difficult to achieve. Global antibiotic consumption is increasing exponentially with poor public understanding of what AMR is and its potential impact , with one study reporting only 9% of participants understanding that AMR occurs in bacteria not the host .
One obstacle to addressing AMR as an increasingly serious issue, is that it is a ‘super wicked problem’. Super wicked problems typically combine inherent complexity, with numerous interrelated biological and social drivers. Multiple stakeholders impede a single agency taking charge, with limited time available to reduce potential impact . AMR is also a One Health engagement challenge: with key stakeholders existing beyond the area of human health, including within the farming and veterinary sectors.
Within human health, usage of antimicrobials is influenced by the knowledge, attitudes, and beliefs of both healthcare workers and the public . It is estimated that historic public AMR campaigns between 1997 and 2007 across Europe led to the equivalent of a 6.5–28.3% drop in the mean level of antibiotic use . The WHO has therefore acknowledged the importance of including members of the public within strategic planning in order to change the trajectory of AMR, with a requirement to include public engagement within all national action plans (NAPs). Although many NAPs recognise that public education raises awareness of AMR, few include strategic pathways for implementation.
Undertaking patient and public involvement/engagement (PPI/E) is a recognised key pathway to improving education and awareness, but also in supporting behaviour change within the public and healthcare professionals. The National Institute of Health Research defines patient and public involvement (PPI) as research done with or by patients and the public, not to, about, or for them. Involvement aims to work collaboratively with patients and the public including them in shared decision-making. Meanwhile, patient and public engagement (PPE) focuses on raising awareness and sharing research knowledge and findings; to tackle AMR as a ‘super wicked problem’, both approaches are required.
Published approaches to PPI/E
Published evaluated examples of PPI/E activities and interventions encompass material or meetings delivered in various ways. Common examples include: face to face training, brochures, advertisements and billboards, educational videos, social media messaging, media engagement via interviews or films/TV, and educational conferences or science festivals .
Several high-profile approaches to AMR engagement have been evaluated and published including the Antibiotic Guardian Campaign and European Antibiotic Awareness Day. The Antibiotic Guardian campaign launched in 2014 using a One Health approach to change behaviour through collective action via the use of pledges . The first European Antibiotic Awareness Day was launched in 2008 and consisted of 32 European countries sharing content distributed in 25 languages, with the first World Antibiotic Awareness week launched in 2015. These have demonstrated a focus on social media dissemination of material designed by focus groups  with campaigns targeting large scale distribution of information; which may require individuals to have a pre-existing interest in order to trigger engagement with either webpages or social media strategies.
Science, technology, engineering, arts and mathematics (STEAM) approaches, such as comic books, gamification or theatre, have become increasingly common . While these have different advantages, the use of STEAM can support some of the more difficult conversations linked to AMR, such as managing individual versus community-level need, as they engage with emotion-based drivers in a way that allows participants to interact with information without obstacles such as fear from the apocalyptic aspects, or blame linked to prior personal choices . Emotion has previously not been widely considered when designing or evaluating interventions; its growing use acknowledges that people are not driven by facts alone, but also by patterns of emotional response and ideological factors or beliefs .
Cognisant selection of the most appropriate approach for the outcome sought in conjunction with these factors should be undertaken (Figure 1). The PPI/E approach selected also drives the choice of evaluation tool to determine success and impact, and so evaluation methods should be derived from the activity selected.