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Health, Risk & Society
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/chrs20
Role crisis, risk and trust in Australian general
public narratives about antibiotic use and
antimicrobial resistance
Davina Lohm , Mark Davis , Andrea Whittaker & Paul Flowers
To cite this article: Davina Lohm , Mark Davis , Andrea Whittaker & Paul Flowers (2020): Role
crisis, risk and trust in Australian general public narratives about antibiotic use and antimicrobial
resistance, Health, Risk & Society, DOI: 10.1080/13698575.2020.1783436
To link to this article: https://doi.org/10.1080/13698575.2020.1783436
Published online: 24 Jun 2020.
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Role crisis, risk and trust in Australian general public narratives
about antibiotic use and antimicrobial resistance
Davina Lohm
,
a
*, Mark Davis
a
, Andrea Whittaker
a
and Paul Flowers
b
a
Monash University Melbourne;
b
School of Psychological Sciences and Health, University of
Strathclyde, Glasgow, UK
As antibiotics have become increasingly ineffective against bacteria, antibiotic stew-
ardship has been introduced across a variety of settings world-wide. Members of the
public have been entreated to use antibiotics strictly as prescribed. We interviewed
ninety-nine participants who shared their understandings of antibiotics and reflections
on antibiotic resistant bacteria. Some participants were eager consumers of antibiotics
whilst others sought to avoid them. Overall, the participants expressed their desire to
act in a responsible manner in relation to antibiotic usage. However, we also found
considerable confusion regarding responsible action linked with risk management and
trust in expert advice. Despite the encouragement of personal responsibility for health
decisions, sick individuals are urged to enact a Parsonian-like sick role that abdicates
personal decision-making powers and invests trust in the expertise of prescribers. We
find this assumption of a responsible, knowledgeable patient and expert clinician is
disrupted by 1) patients’ contingencies when circumstances force them to seek and
use antibiotics despite their misgivings, 2) patients’ own embodied knowledge and
assessment of their vulnerability and progression of infections and 3) doubts in the
expert knowledge of clinicians, as considered in light of scientific debate.
Accordingly, lay publics are left entangled in contrary expectations of responsibility
and trust regarding the use of antibiotics with significant implications for antimicro-
bial stewardship.
Keywords: risk; antibiotics; antimicrobial resistance; responsibility; trust
Introduction
Antimicrobial resistance epitomises the risk society notion of manufactured risk (Beck,
2011; Giddens, 1997, p. 124) with particular implications for public engagements with
biomedicine. The post-World War Two global pharmaceutical industry delivered access
to antibiotics that quickly dealt with common and life-threatening infections. Yet, by the
end of the twentieth century, the emergence of bacteria able to resist antibiotics had
become a central challenge for biomedicine. While it is natural for bacteria to mutate
when challenged by naturally occurring antibiotic substances, such mutation has been
accelerated by human overuse and misuse of pharmaceutical antibiotics. The loss of
antibiotic effectiveness will impact many routine procedures such as surgery and che-
motherapy due to increased risks associated with untreatable health-care acquired infec-
tions, where antibiotics may be used prophylactically to minimise the danger of infection
or to treat any infection that may arise post-surgery (Teillant et al., 2015, p. 1429).
*Corresponding author. Email: davina.lohm@monash.edu
Health, Risk & Society, 2020
https://doi.org/10.1080/13698575.2020.1783436
© 2020 Informa UK Limited, trading as Taylor & Francis Group
Antibiotics that were once welcomed as ‘miracle’ drugs, now present a world-wide threat
(Ekberg, 2007, p. 348) whereby the actions of one hospital, farm, or individual, ‘misus-
ing’ antibiotics has the potential, in principle, to harm ‘everyone in society’ (Spellberg
et al., 2013, p. 129).
Concomitant with this historical shift towards the proliferation of risks associated
with antibiotic consumption is increased emphasis on the role of the individual in
antibiotic prescription acquisition and adherence, referred to as antimicrobial stewardship
(AMS). Individuals are expected to participate in the management of antimicrobial
resistance (AMR) risks, reduce supposed demand for antibiotics, and adhere to prescrip-
tion requirements (Terrie, 2004). They are expected to accept and enact advice provided
by experts and therefore set aside previous expectations and practices. As we will show,
this dilemma comes to the fore in light of scientific debate about optimal prescription
adherence. A key element of manufactured risk, therefore, is not only the risk of
antimicrobial resistance itself but the challenges posed by rupturing traditional patterns
of patient trust in expert knowledge and trust in the patients’ compliance with prescrip-
tion requirements.
In this paper we report on how members of the general population in Australia
contend with the threat of antimicrobial resistance and their role in AMS. In what follows
we focus on the growth in antimicrobial resistant bacteria, global, local and personal
responses to this threat, and the significance of the attrition of trust in combatting this
increasing risk.
Background
The biosocial production of antimicrobial resistance
Prior to the discovery of antibiotics, bacterial infections were responsible for an esti-
mated thirty percentof deaths in America (Fair & Tor, 2014, p. 25). Sir Alexander
Fleming’s discovery of penicillin in 1928 marked the end of the tyranny that bacterial
infections held over people. From 1928 a range of antibiotics, often referred to as
‘miracle drugs’ (Lushniak, 2014, p. 314) were developed which radically altered the
health and well-being of people across the world. Bacterial infections which had pre-
viously been life-threatening, or debilitating, could be effectively treated leading to great
optimism about humanity’s ability to conquer illness.
Yet within bacteria was the mechanism that would enable them to become immune to
antibiotics. When Fleming gave his acceptance speech for his Nobel Prize in 1945, he
foresaw that the efficacy of penicillin could be extinguished if the drugs were not
judiciously managed (Podolsky, 2015). He noted that if bacterial infections were not
totally eliminated by penicillin, any surviving bacteria would ‘educate’ themselves ‘to
resist penicillin’. It would appear that Fleming’s warnings were not heeded by those
Table 1. Participants according to purposive selection criteria (cell numbers do not total 99 as the
individuals can appear in more than one selection criteria).
Experience of chronic respiratory
and/or immunity related illness
Experience of
surgery (since
2008)
Carers (for children
and the elderly)
No chronic
illness
identified
9 – self
3 – family members
52 46 53
2 D. Lohm et al.
marketing and prescribing antibiotics. Antibiotics were used extensively for a raft of
ailments, including infections for which they were deemed ineffective or unnecessary.
Exposure to unwarranted antibiotics through their widespread use in agriculture and
medicine and subsequent accumulation in waste waters have all enabled bacteria to
accelerate their adaptions to antimicrobicides (Larsson, 2014, p. 109) and develop
resistance to antibiotics, resulting in the current situation where their effectiveness is
no longer assured (Lushniak, 2014, p. 314).
AMS, which emphasises the clinically-justified prescription of antibiotics and pre-
scription adherence to protect the efficacy of known antibiotics for future treatments
(Dyar et al., 2017, p. 793), has been widely promoted by the World Health Organisation
(World Health Organisation, 2017), and state and national governments in Australia
(Australian Commission on Safety and Quality in Health Care, 2018). AMS among the
general population, however, faces some challenges. Poor knowledge of AMR is found
in general populations (Bakhit et al., 2019; Gualano et al., 2015). Consumers are said to
place unwarranted demands on prescribers for antibiotics (Pan et al., 2016), though
medical practitioners may too readily prescribe them (Broom et al., 2014), views echoed
in our research, as we will see. Complicating this picture, McNulty and colleagues found
that only eight percent of UK antibiotics consumers recalled having been given advice
about AMR and AMS by their prescriber (McNulty et al., 2016). AMS in hospitals,
general practice and aged care is closely monitored (Australian Commission on Safety
and Quality in Health Care, 2018), but less is known about AMS in domestic settings. In
Portugal forty five percent of patients were found to not adhere to their prescriptions
(Fernandes et al., 2014), whilst in Sweden nine and a half percent were non-adherent
(Axelsson, 2013). Australians from Chinese communities reported sharing and self-
prescribing of antibiotics (Hu & Wang, 2015). Our analysis, therefore, provides impor-
tant new knowledge of how members of the general public access and use antibiotics
from their own points of view.
The role of the public in AMS
Public engagement in AMS is a key element of public policy. For example, the Centre
for Disease Control (CDC, 2017) advocates that members of the public speak with their
medical practitioner about the types of infections for which antibiotic treatment is
suitable and about antibiotic resistance. The CDC (2017) focuses on the avoidance of
infections, relief of symptoms and limiting antibiotics for use as a last resort. They also
encourage that when antibiotics are used, they be taken exactly as prescribed, so that no
antibiotic doses are omitted, saved for later use, or shared (CDC, 2017). Similarly,
Australian doctors are encouraged to give their patients the message that they should
not expect antibiotics for an infection, that when given them they should be taken for as
long as advised, that antibiotics should never be stored or shared, and that any leftover
antibiotics should be returned to the pharmacy (Australian Commission on Safety and
Quality in Health Care, 2018, p. 184).
This renewed focus on patient compliance with medical advice, however, is unlikely
to be a simple matter of fewer drugs prescribed and increased adherence. In part, the
compliance emphasis in many considerations of patient participation in AMS recalls the
Parsonian sick role where a medical practitioner confers patienthood upon a person and
the only duty of the patient is to adhere to the treatment regime established by the doctor
and seek to regain health. Williams (2005, pp. 133–134) notes that this relationship
Health, Risk & Society 3
between patient and doctor is ‘asymmetrical’ as only doctors have ‘real know how’ and
there are limitations to public’s knowledge. In some contrast to this, initiatives including
the UK Expert Patients Programme (Rogers et al., 2008) and the Australian Charter of
Healthcare Rights (Australian Commission on Safety and Quality in Healthcare, N.D.)
encourage people to share responsibility for their own health with health professionals.
These approaches to prescribing depend on concordance; the notion that patients and
medical practitioners should together decide upon medical treatments (Stevenson &
Scambler, 2005, p. 13). Concordance acknowledges that many patients have knowledge
about their illness and so should be involved in decision making. Thus, AMS expecta-
tions of patient compliance may sit awkwardly with notions of patients as reflexive
agents collaborating with experts and making informed choices about their own health
and well-being.
AMS, therefore, mobilises tensions linked with the reflexive management of health
risks and trust in abstract systems that have been shown to be less than trustworthy
(Giddens, 1997, p. 90). In this paper we adopt the definition of trust as a feature of social
relationships that involve an expectation that the other person and or the social institution
they represent will be competent and act in one’s best interests (Ommen et al., 2011: 319;
Rolfe et al., 2014: 3) particularly under conditions of uncertainty and in times of
vulnerability (Simpson, 2007, p. 265). However, when there is doubt that the other is
willing and able to act in one’s interests, trust may be weakened. Moreover, Ward (2018,
p. 718) argues that the time when people were expected to blindly trust those in positions
of power no longer exists. Rolfe et al. (2014, p. 4) suggest that trust in the medical
profession may be declining partly due to the post-modern perspective that knowledge is
‘always provisional and contingent on context and power’ (Hodgkin, 1996, p. 1568). In
this view, the rise of antimicrobial resistance potentially undermines antibiotics as
manifestations of biomedicine’s curative powers. To admit this situation may accentuate
the degradation of trust relations or, at least, trouble the foundations of the patient-doctor
relationship within which antibiotics are prescribed.
Whilst there may exist a reduction in trust of expert opinion (Hodgkin, 1996; Ward,
2006) research suggests that trust in medical doctors remains strong. Blind and unques-
tioning trust in doctors may be less pervasive but publics, who lack comprehensive
medical knowledge can be understood as negotiating ‘impressions and ideas to arrive at
a temporary “fix” for the context they find themselves in’ (Walls et al., 2004, p. 147),
thus accepting the need to trust when unwell and reliant upon medical expertise. For
example, surveys indicate that most Australians trust medical practitioners, especially
general practitioners (Hardie and Critchley 2008, p. 210) and believe that doctors tell the
truth (Feriman, 2001, p. 694). It is also suggested that general prescription compliance is
positively associated with trust in the medical profession (Ommen et al., 2011, p. 319).
Research about AMR shows that consumers place a high degree of trust in their
prescribers (Ancillotti et al., 2018; Brookes-Howell et al., 2014). McNulty and collea-
gues report that eighty eight percent of UK antibiotics consumers ‘trust’ their medical
practitioners (McNulty et al., 2016). Also in the UK, van Hecke and colleagues (Van
Hecke et al., 2019) found that parents felt morally responsible for antibiotic use in their
children, accentuating the importance of trust in the prescriber.
4 D. Lohm et al.
Scientific debate and paradoxical trust
The relationship between doctors and patients particularly in relation to AMR-risk and
trust is also subject to further troubles tied to the provisionalities and debates that arise in
the biosciences. A key example, that as we will see has direct relevance for the narratives
we analyse below, was the publication in 2017 in the British Medical Journal of research
that argued against the prevailing practice of prescription completion (Llewelyn et al.,
2017). The researchers argued that the belief in the need to complete a course of
antibiotics is not based upon sound medical research, that it is not always necessary to
complete a long course of antibiotics, and that taking antibiotics for longer than neces-
sary may actually contribute to antibiotic resistance. This contention was, in turn,
contested by an editorial in Nature Microbiology (editorial, 2017). Government websites
(Health Direct, 2018) appear to offer advice that glosses over the emergent scientific
uncertainty. This example points to the paradoxical nature of risk and trust in relation to
AMR (Crawford, 2004, p. 510). Patients obtaining antibiotics are expected to comply
with advice provided by their medical practitioner when they may be aware that other
experts disagree. This fragmentation of expertise is an important factor for the patient
enactment of AMS. As we will see, many of our research participants were aware of this
situation and discussed it with us.
The emergence of opposing expert opinion about safe medicines use, as with many
aspects of risk in everyday life, is also accompanied by a view – though strongly opposed
(see Nichols, 2017) – that the opinion of anyone appears to now carry similar worth and,
as such, the voices of experts are being obscured by ‘loud’ out-spoken lay people. Ward
(2006, p. 144) notes that ‘claims to “expertise” around health, illness and medicines are
no longer the sole province of medical practitioners’ as many other voices, even those
with limited medical expertise, contend to express their interpretations of medical issues.
If all opinions are deemed to be of equal worth (Hodgkin, 1996, p. 1568), or at least of
equal volume, and those of experts are no longer respected for the knowledge and
research which supports them, then an element loss of trust in the medical profession
is not unexpected. Increasing the predicament of trust is the dramatic rise in fake news
(Brennen, 2017, p. 180), whereby fabricated information is presented as truth (Speed &
Mannion, 2017, p. 250), leaving publics uncertain about what information to believe.
Such factors can contribute to public reservations about AMR and AMS messages.
In the analysis presented below, we aim to shed light upon publics’ engagements with
the messages from public health authorities that they enact AMS. In particular we
examine participants’ risk management pathways taken to acquire antibiotics, their
trust in doctors and medical expertise, their adherence to doctors’ instructions about
antibiotic use, and the various narratives by which our participants described attempting
to act in a responsible manner when faced with infection.
Methods
After receiving ethics approval from The Monash University Human Ethics Committee
(MUHREC) 91 interviews were conducted with 99 participants (40 males, 58 women
and 1 who identified as other) in Melbourne between December 2017 and June 2019.
Criteria were established to guide the recruitment of participants: these included, those
groups thought to more frequently use antibiotics (carers of children and older people,
those with respiratory illnesses, and those who had recently undergone surgery or
hospitalisation), and healthy (infrequent antibiotics users) people. (See Table 1) Efforts
Health, Risk & Society 5
were made to include participants from a range of cultural backgrounds, from
a widespread of educational backgrounds from higher university qualifications to those
who had not completed secondary schooling, as well as a balance of ages and genders.
Strategies used to recruit participants, included, speaking to and emailing community
groups, placing flyers in public locations and promoting the research on community face-
book sites, and social networking.
The interviews were semi-structured and explored knowledge and use of antibiotics,
awareness of AMR and understandings of health and infection. During the interview,
a short television news clip on AMR was used to stimulate discussion about media
representations. All interviews were digitally recorded with the permission of the parti-
cipants. In order to maintain participant anonymity no names were recorded at the time
of the interview and participants were assigned pseudonyms during analysis. Interview
recordings were transcribed verbatim. The interview material was analysed using critical
thematic analysis focussed on social complexity and theory-building (Squire et al.,
2014). NVivo was used to code the interviews using an iterative, team-based procedure.
Findings
In the following presentation of findings, we explore how questions of reflexivity, risk
and trust emerged in narrative on antibiotics and considerations of antimicrobial resis-
tance. The findings are organised according to three themes. These themes emerged from
the responses provided by participants and accord with the temporal and risk manage-
ment aspects of antibiotic use reported by them:
1. Deciding to seek antibiotics/waiting to determine the seriousness of the ailment
before deciding to seek medical treatment
2. Narrative on trust and expert knowledge of AMR and AMS
3. Following the prescribed dosing.
Seeking antibiotics
Very few participants stated that they had never used antibiotics, and some were heavily
reliant upon them due to the nature of their chronic illness whilst for others antibiotics
were rarely sought or taken (see below). When confronted with an infection, participants
said that they either sought immediate medical treatment or waited to decide if the
infection warranted a visit to the doctor. These responses were directed by complex
reasoning and an acute awareness of the circumstances in which they found themselves,
and knowledge of their own bodies.
Seeking medical treatment as quickly as possible
Some participants reported that it was imperative that they sought medical attention and
a prescription for antibiotics as soon as they became aware of symptoms. Past experi-
ences of the speedy progression of illness prompted them to avoid future episodes. For
example, Dana, an asthma sufferer spoke about how she monitored symptoms to best
manage her health:
Interviewer: So you obviously have asthma. How does that impact your everyday
life?
6 D. Lohm et al.
Dana: Like, as when I’m sick, it impacts it a lot. I have a cold. I do rely
heavily on my Ventolin and I can get chest infections a lot more
easily. I have to be very careful. That’s why, if I know that I’ve
gotten to the point where I can’t shake the cough, I go to the doctor
straight away to get antibiotics ’cause I know I’ll end up with
bronchitis or worse. (Dana, 18- 30 years old, asthma)
Byron also suffered from asthma and relied on antibiotics if he felt he was developing
a chest infection.
Byron: Yeah. I’m possibly a little bit more prone [to chest infections] I think.
Like, if I get a bad cold, I might be slightly more prone to getting a chest
infection … I just know when I do get ’em it hurts, you know. It really …
they’re not fun. It hurts to breathe … and I won’t muck around. I never,
ever muck around. If I feel that pain, I go straight to the doctor. And it
doesn’t take me long to think … work out I’ve got a chest infection.
(Byron, 31-40 years old, asthma)
Both Dana and Byron, in part due to chronic asthma and a focus on reducing their
vulnerability to infections, depict themselves as active agents in their health care. Dana
and Byron are representative of the participants who suffered from chronic illness or who
were susceptible to severe infections who described enacting self-surveillance. From
their perspectives, any early symptoms were likely to escalate into illness resulting in
long periods of feeling unwell, ongoing treatment regimens, and time off work. Due to
their previous infection histories they regarded themselves as being particularly ‘at risk’
(Davis et al., 2015, p. 5) and this status led them to act as described above. Whilst these
respondents readily sought professional assistance to treat infection, this was not simply
a blind turn towards medical expertise. Rather, their turn to medical authority combined
a Parsonian endorsement of the authority of the medical expert with reflexive risk
management, therefore establishing a hybrid and relational prescribing practice of the
‘responsible, knowledgeable patient and expert clinician’ (Rogers et al., 2008, p. 21)
managing a known risk. The manner in which they described monitoring their own
bodies for signs of infection, their extensive experience of past infections, and the final
decision to act early and decisively instead of allowing their health to deteriorate,
highlights how the management of infection for these participants depended on their
conduct attuned to personal risks.
For others, the motivation to immediately seek antibiotics was based upon their life
circumstances at the time. For example, Gayle was on holiday abroad with her two
children when her daughter became ill with a severe ear infection. Given that they had
planned to fly home that day, Gayle described feeling compelled to seek medical advice
and antibiotics to treat the infection, as she was concerned that her daughter would be
unable to fly with such an infection.
Interviewer: You talked about ear infection in Bali. What happened there?
Gayle: So probably the day we were to fly home … she just was, you know,
crying and in pain … So we actually called the doctor to the room,
Health, Risk & Society 7
and she said, “Yep, it’s a nasty ear infection,” and we ended up not
being able to fly home for two days. So she had to have the
antibiotics to try and calm the ear infection down, and she said,
“No, you can’t fly,” ’cause there was a chance of her eardrum
bursting. So we stayed an extra two days. (Gayle, 51-60 years old)
Gayle spoke of acting quickly in recognition of her responsibility for her daughter’s
health. She noted that her hasty turn to antibiotics was not her usual response to illness,
but she found herself in a situation that was not usual since it included consideration of
the risk of flying with an ear infection and that the option to wait and try other treatments
or see if the infection resolved itself was not feasible. Like other participants, Gayle
spoke of her response in terms of an unusual intersection of events – her daughter’s ear
infection and a scheduled flight – underlining how individuals adjusted their manage-
ment of an infection to particular out-of-the-ordinary circumstances. Gayle’s example
demonstrates a contingent, episodic management of infection risks, with this contrasting
with Dana and Byron whose approach to infection was situated in their long-term status
as asthma patients. These contrasting ways of managing infection risk show how patients
in our study tended to narrate themselves as rational and responsible managers of their
health care, working in partnership with expert professionals.
Waiting to determine the seriousness of the ailment
A more common response from participants was for them to wait for some time before
making the decision to see a doctor and being prescribed antibiotics. Most said that they
preferred to use their own remedies and ‘tough out’ the illness where possible, for
reasons that included: a dislike of taking pharmaceutical products; a desire to enhance
their own immunity by overcoming an infection without resorting to antibiotics, and;
concerns about the overuse of antibiotics:
Carol: I’m wary of antibiotics. I would only use them in extreme circumstances
because I do think they’re overused in our community. And because my
gut’s weak, I know they have a serious impact on it which takes me quite
a long time to get over. (Carol, 71+ years old)
Helena noted how she preferred to use natural remedies and so avoided antibiotics
whenever possible:
Helena: And then even I feel like if she (daughter) is going to get a cold or
something I try to give those [herbal remedies] things first. So normally
she ends up not having a big, bad cold. So we haven’t had the need for
her getting antibiotics after that. So, and for Hanny [4-year-old daughter]
also it’s an ear infection and temperature, so that time we gave antibiotics
but she was fine; she didn’t have diarrhoea or anything. Yeah. I think
that’s it. Even sometimes even doctor prescribes antibiotics we try to wait
a little and see how she goes. And maybe get a second opinion, especially
with kids. I try to take a second opinion with another doctor … So I come
to conclusion, yeah, the good food, rest and sleep – really helps to get
through the illnesses [better] than antibiotics. (Helena, 31-40 years old)
8 D. Lohm et al.
These participants, like most in our study, acknowledged the efficacy of antibiotics –
Carol referred to them as ‘fantastic’ – but noted that they did not immediately seek
them. Rather, they reported that they relied upon their own skills and knowledge to
manage their own illnesses and those of their children. It seemed that Carol and Helena
were reluctant to transfer all responsibility for health care to medical experts. Carol
reported having faith in her knowledge of her body and was reluctant to hand over
responsibility to someone she felt may not know it so well. Apparent here were two
perspectives which are at odds with each other: the doctor’s biomedical expertise and
Carol’s appreciation of the idiosyncrasies of her own body. Helena tapped into alter-
native ‘knowledges’ such as herbal treatments and her motherly experience. Her deci-
sions to seek alternative opinions and wait before administering prescribed antibiotics
suggests that the pedestal of expertise upon which doctors were previously perceived to
sit has been eroded. Many participants referred to seeking their advice, but this was then
weighed against her own evaluation of her children’s health. Carol and Helena’s
narratives typify the ways in which many participants spoke of their relationships
with their doctors: they generally trusted the doctors’ advice and expertise, but this
was tempered with an element of doubt and a desire to maintain an active role in their
health management. Participants thus described negotiating a path between these rival
perspectives to fashion treatments that they could trust and accept, as we discuss in the
next section.
Trust and expert knowledge of AMR and AMS
Although it is up to the individual to determine when or even if they will consult
a medical practitioner about a perceived infection, the final decision about whether
antibiotics are provided rests with the doctor, because, in Australia, as with many
countries, a prescription is required to purchase antibiotics (Therapeutic Goods
Association, nd). Patients are expected to be responsible citizens, but their agency is
constrained to help preserve the increasingly limited number of effective antibiotics.
Fundamentally they depend on their doctor as the provider or with-holder of antibiotics,
as was apparent in our data.
Will and Lance noted that this dependence necessitated trust in the integrity and
expertise of their doctor:
I believe what the doctor’s telling me and I go on his word. (Will, 51–60)
I’m not gonna doubt him, no. So, yeah, whatever they told me to do I do, yeah. That’s why
I go back. (Lance: 61 – 70)
Yet this talk of trust was ambiguous, perhaps due to twenty-first century patient reflex-
ivity, involving an awareness of the disagreements and provisionalities that can char-
acterise biomedical knowledge (Rolfe et al., 2014, p. 4). As revealed in the following
story told by Diana about her daughter’s spider bite, patients can be compelled to trust
because they have no other option:
Diana: She would have been bitten at least 24 hours before we thought there was
anything wrong …
Health, Risk & Society 9
Also because we were planning to stop overnight almost in the middle of nowhere and kind
of where the, you know, the chemists aren’t open 24 hours there or the doctors aren’t gonna
be available. So we just wanted to make sure it was okay.
Interviewer: Yeah. And so what happened at the hospital? What did they say
there?
Diana: She was admitted and treated, and, yeah, he said it was probably the
bacteria from the spider’s mouth that was causing a reaction in her
toe. And, no, actually, on her leg. I can’t remember now. And it,
yeah, she had to have the antibiotics to get it, get it away, otherwise it
would end up as a secondary infection and it’d get worse and
worse. Yep.
Interviewer: So did he do any tests on it at all [No] to see what it was? [No]
Diana: And I wasn’t, to be, I don’t know if I guess you wanna hear every-
thing. I wasn’t all that, I wasn’t all that confident in his diagnosis and
I don’t like to, especially with kids, I don’t like them to go on
antibiotics unnecessarily. But it, in the end, you kind of had to trust
him and, when we got back here, the bite was still quite inflamed.
Three days later I took her to the local doctor and he said, “Yep, the
antibiotics are likely to do and she needs to keep going for a little
bit.” So yeah. That validated it a bit but, yeah, I wasn’t totally sure
I was doing the right thing. But, yeah, I was left without really
a choice. (Diana, 41 – 50 years old)
Diana’s depiction of these particular circumstances, and the obligation to trust that
transpires, was an important dimension of manufactured risks that shape lived experience
(Giddens, 1997). Similarly, Ursula and Trevor spoke of how they were required to trust
their doctor’s advice when their daughter had an ear infection. Like Diana they felt that
they did not have a choice:
Trevor: So, I’m more inclined to believe when the doctor says, “You should
give your child antibiotics for this particular ailment,” because, you
know, it’s the cost benefit analysis of, you know, there could be
a very substantial cost if I don’t give the child antibiotics. And the
damage antibiotics will cause to them and to increased antibiotic
resistance is small compared to the benefit and small compared to the
potential damage I could do them by making a bad choice as
a parent, you know. Damaging, like you were saying about hearing
infection. If you don’t give them antibiotics, then you know it’s
a precautionary measure. I mean you don’t know … Like you said,
I don’t think I’ve been over-prescribed but you don’t really know
where the line is. It’s not like the doctor gives you a whole lot of
information and goes, “Well, if you don’t give them antibiotics,
there’s a 30 per cent chance that, or there’s a 10 per cent chance
there’ll be a problem.” And so, you know …
10 D. Lohm et al.
Interviewer: Yeah. So you trust.
Ursula: Yeah.
Trevor: Yeah. You kind of have to I guess, you know.
(Ursula: 31 – 40 years old and Trevor: 41 – 50 years old)
Diana, Ursula and Trevor described themselves as cautiously compliant parents/patients.
They forewent their personal inclination to avoid antibiotics and agreed to treatment for
their children. However, this was described as not a simple decision. The immediate fear
of allowing their children to suffer and/or face potential long-term health risks, accom-
panied by the stark awareness of the limitations of their own knowledge, drove them to
acquiesce to the doctors’ advice, despite their concerns about the future repercussions of
antibiotic resistant bacteria and the risk this may later pose to their children. This
dilemma highlights another tension in manufactured risk since it is awareness of AMR
that seemingly led these parents to speak about their reluctant use of antibiotics. As
parents, they carried the burden of responsibility for their child’s wellbeing, an onerous
burden previously chiefly imposed upon women (Mackendrick, 2014, p. 709; Shaw,
2008, p. 690; Lupton, 2011, p. 638) but increasingly shared with fathers (Shaw, 2008,
p. 691). This burden was amplified by notions of the child as being ‘vulnerable’ (Lupton,
2011, p. 637) and thus in particular need of protection. These factors intersected with
participants’ own restricted medical expertise, interacting with caution about antibiotics.
The use of antibiotics – especially in the context of AMS and AMR – required parents
and patients to place trust in medical practitioners despite anxieties (Van Hecke et al.,
2019). That Diana, Ursula and Trevor referred to ambivalence when faced with this
dilemma is not surprising as they were caught between responsibility for vulnerable
children, AMR risk, biomedical authority and the exigencies of everyday life.
Following prescriptions
When patients are prescribed antibiotics, they are provided with information about how
to take them, including the usual advice on the importance of completing the course
(Health Direct, 2018). The necessity of completing antibiotic courses was widely under-
stood by participants. Tamara’s account of consistent completion of all courses of
antibiotics is typical of about half of the respondents. She explains:
Interviewer: And did you get any instructions with them? [Yes] So what were
they?
Tamara: It was like a little while ago but obviously like finish the whole
course and, yeah, take them at a certain time. Yeah.
Interviewer: So did you finish the course?
Tamara: Of course, yeah, yeah.
Interviewer: You said ‘of course’. Why did you say ‘of course’.
Health, Risk & Society 11
Tamara: Yeah, because I studied antibiotics at uni[versity] and I know the
detrimental effects of not finishing a course. Like it might look like
it’s better but then give it a little while and the bacteria that are still
left there will mutate and become resistant to the antibiotic. And so
I didn’t want that to happen. That’s not good for anyone. (Tamara,
18 – 30 years old)
Tamara’s response reflects orthodox thinking about the use of antibiotics that if the
course is not completed and any residual pathogenic bacteria exist, they are likely to
build their resistance to the antibiotic (CDC, 2017). Whilst Tamara had a sound under-
standing of bacteria this was not the case for most participants. Reasons for completing
the course of antibiotics varied from practical-economic ones, for example, ‘because you
paid for them’ (Geoff), to simple notions of the need complete the course ‘even if the
symptoms clear up, they can, the bacteria can still be there. And if you, if you finish too
early, they can start growing again’ (Marcia) to simply ‘listen(ing) to the doctors’
(Quang). This interview fragment, and others like it, are examples of responsible patient-
hood whereby the interviewees described adhering to expert advice through the respon-
sible use of antibiotics. Yet, whether the advice to complete the course of antibiotics
stands up to scrutiny appears to be questionable:
Walter: That’s the thing. I don’t know whether it is important to finish them.
I think the media I guess has been sort of quite vocal about needing to
finish. Well, actually, doctors in general usually tell you that you need to
finish the entire course of antibiotics I guess to prevent resistance. But
I guess I have heard more recently that that doesn’t have strong evidence
behind it. I haven’t looked further into it, which is why I’m not gonna
judge either way. But, yeah, ‘I’m not sure either way’ is my answer.
(Walter, 31-40 years old)
As discussed previously, an article in the British Medical Journal reported on new
research that queried the long-held doctrine that patients must always complete a course
of antibiotics (Llewelyn et al., 2017). Australian media reported on this publication, for
example, in the online version of Melbourne’s broadsheet, The Age (Cha, 2017) and the
Australian Financial Review (AFR, 2015). In 2015, a similar story had been carried in
Medical Journal Australia (Gilbert, 2015a) and The Conversation (Gilbert, 2015b). Such
reporting illuminates the contestability of medical knowledge, intensifying confusion
about the importance of adhering to medical advice about completing antibiotic courses.
Walter expressed some confusion about what these media reports implied for how he
should approach prescription compliance. His account indicates that some members of
the general public have become aware that expert knowledge about prescription com-
pliance is dynamic and contested, with possible ramifications for how lay publics per-
form their role in AMS. This situation adds further complexity to the risk management
and trust considerations noted in the previous section where interviewees spoke of their
reservations about expert advice and the obligation to place trust in experts due to their
circumstances.
Rebecca was also aware of such media reporting and made similar comments to
Walter:
12 D. Lohm et al.
Rebecca: I always finish the course only because that’s what you’re instructed to
do but I know that, I know that they’ve started, in the press I’ve heard
a little bit that maybe that’s not necessary anymore. So I’ve sort of heard
something a while ago and I thought, “Oh okay.” But whether I’d be
brave enough to not to, like to go against the normal consensus just yet
I don’t think … ’Cause I, you know, I don’t need to have a reinfection.
But I’m not sure, I still don’t quite understand the whole philosophy
beside having, along, like the reasoning of why you need to have
a course. I understand you’ve gotta kill off the bacteria but to me, if
my symptoms have improved, I’d prefer to stop if I could. (Rebecca,
41 – 50 years old)
In this fragment, Rebecca referred to being reflexive with the risks that were linked to
the use of antibiotics. She spoke of an established practice of compliance thrown into
some question due to the changing expert opinion and her own lack of knowledge.
The establishment of AMS on the part of members of the general public requires that
they adopt the role of the compliant patient, as Rebecca spoke of doing, yet the changing
knowledge that informs AMS appeared to confuse some patients and destabilised their
role in the AMS system, as both Walter and Rebecca suggested. That expert information
is not always in agreement may contribute to confusion and anxiety experienced by
members of the public who seek to act in a manner which is responsible for their own
health and the preservation of antibiotics for the wider community.
Conclusion
Our analysis of antibiotic use narratives provided by members of the general public
reveals the complex interplay of biographical and situational context, the reflexive
management of health risks and considerations of trust and the changing expert knowl-
edge systems that inform antibiotic prescribing. We have argued that AMR is a highly
apposite case of manufactured risk, in the historical sense that it has arisen due to the
widespread use of antibiotics to manage infection risk, but also because of the risk
management issues the enactment of AMS produces in everyday lived experiences. Our
participants reported that while they readily consult medical practitioners, and none
rejected biomedicine completely, they did not all immediately turn to their doctors
when confronted with an infection, and even when they did consult a doctor they did
not unreservedly comply with instructions. This picture of diverse public engagement
with antibiotics contrasts with that provided by research using clinical samples and
focussing on prescription demand and compliance.
Indeed, most interviewees expressed an eagerness to avoid turning to antibiotics
straightaway when unwell, perhaps a reflection of growing awareness of AMR risk and
knowledge of how antibiotics may affect their bodies, as others have noted (Bagnulo
et al., 2019; Chlabicz et al., 2019). Informants who have a history of severe infection and
understanding of how their bodies respond to infection reported that they visited the
doctor without hesitation to seek antibiotics. These participants – whether holding back
or readily seeking antibiotics – were exemplary of engaged, agential health subjects who
shaped how antibiotics are sought and used.
However, a number of participants also spoke of the challenging expectation that in
some situations they felt obliged to lay aside their doubts and concerns and place trust in
Health, Risk & Society 13
expert knowledge about antibiotic prescribing. These participants noted that experts were
not in agreement about how best to manage antibiotic treatments, raising questions about
the efficacy of following certain guidelines when taking antibiotics. Challenged trust in
abstract systems of knowledge can leave individuals in a state of angst (Giddens, 1997,
p. 100). Yet the importance of trust was often apparent in the interview narratives,
perhaps most keenly in situations where participants’ children were in distress.
Rather than ‘pure’ or unquestioning trust willingly granted based upon a belief in the
expertise and good-will of another, antibiotics use is subject to ‘obligatory’ trust that is
negotiated when people have little option but to trust in others’ expertise. The option to
not trust can be seen as untenable as it can only give rise to heightened stress and anxiety
(Brown & Meyer, 2015, p. 76), particularly when combined with potential condemnation
should an outcome be adverse and medical advice not followed. This situation is
accentuated, since governmental regulations and the limits of the individuals’ own
knowledge mean that they have no choice but to trust since individuals cannot obtain
antibiotics without the authorisation of a doctor. These shades of trust in the context of
risk management is a perspective that contrasts with the typical representation of patients
in the literature as more or less trusting of doctors (Hardie & Critchley, 2018, p. 213).
Our findings show that, while experts are focussed on the use of antibiotics, lay publics
are focussed on managing the various risks entailed in treating infections. Antibiotic use
is not a hydraulic system of more or less compliance; rather it is situated and reflexive
risk management is imbued with questions of trust. Individuals reveal themselves to not
be unreflexively compliant with public health messages, not because they are irrespon-
sible but because the environment in which they live sends contradictory messages about
how best to enact AMS. The central message of AMS is to comply with expert advice
(CDC, 2017). With regard to our data, however, the AMS binary of compliance and non-
compliance is too stark and unhelpful given the nuanced risk management concerns of
which our participants spoke.
Parents’ discussions about their decision making in relation to antibiotics palpably
highlighted the burden of responsibility they experienced in caring for their children’s
health. Wider cultural perceptions that children are particularly ‘vulnerable’ (Cabral
et al., 2015, p. 158; Casiday, 2007, p. 1068; Frankenberg et al., 2000, p. 587) appeared
to accentuate the burden on parents who take care of those who are unable to make
decisions for themselves, deemed to be more susceptible and have effectively placed
their trust in them. Parents described being confronted with the immediacy of an unwell
child and this immediacy, along with their emotional attachment to the child, is the
foundation of their decision making (Zinn & Taylor-Gooby, 2006, p. 65). This overrides
concerns they may have for future risks, whether they be AMR or the long-term impact
of antibiotics upon their child and uncertainties about trust in doctors. We argue, there-
fore, that AMR risk management is not a simplistic calculation of potential costs and
benefits but comprises the impact of heightened emotions, cultural expectations and
amplified awareness of one’s own knowledge deficit.
We have also shown that trust in medical expertise is further challenged by the
emergence of conflicting scientific advice, such as debate over when to cease the use of
antibiotics staged in international news media. Such reporting exposes publics to the
provisionalities of scientific knowledge and that, given further investigation, the opi-
nions of experts may be proven to be mistaken or at least modifiable. This adds another
burden of complexity for publics as they are expected to adhere to advice that they
realise may be temporary and open to adjustment. This challenge to handling risk is also
14 D. Lohm et al.
faced by health systems as they work to provide clear and accurate messages about how
publics can play effective roles in AMS, when the advice may, at any time, require
amendment.
It seems to us therefore that AMS messages need to accommodate better the reflexive
risk management of diverse publics, including those, as in our research, who have fewer
educational advantages. It may be helpful to bring AMS into closer connection with concepts
of prescribing concordance, alliances and collaborations. In this way, AMS may provide
a basis for dealing with biographical and situational complexity and enlarging scope for the
development of pure, volitional trust as opposed to the obliged and enforced trust of current
approaches to prescribing. AMS focusses predominantly on limiting the use of antibiotic
treatments to only those cases where their effectiveness is certain and to safeguarding that
they are only used as explicitly directed by medical practitioners. Such strategies may, on the
surface, appear to be simple and unproblematic yet our findings suggest that there are
complex reasons why such a policy may face difficulties in implementation.
Acknowledgements
This research was supported by an Australian Research Council Discovery Project grant
(DP170100937). The authors are grateful for the contribution of the participants to this project.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by the Australian Research Council Discovery Project grant
[DP170100937].
ORCID
Mark Davis http://orcid.org/0000-0003-4075-0466
Andrea Whittaker http://orcid.org/0000-0002-2616-9651
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