Sinead Duane

Systems-thinking social marketing: conceptual extensions and empirical investigations

ABSTRACT Systems thinking dominated the 2015 World Social Marketing conference with the premise that a more holistic approach takes into account all the issues at play for effective change. Augmenting the broadening social marketing literature, we contend that systems-thinking social marketing enhances the field’s conventional behavioural change with concepts of scale, causation, and iterative co-creating change processes for complex health and environmental problems. The results of our empirical Sea for Society study, a sustainable European marine ecosystem examination of what the barriers to change are and how they are interrelated, find systems-thinking social marketing offers the potential to strategically and critically reinforce, not replace, behavioural change campaigns. With systems-thinking social marketing, a coherent theory of change becomes a possibility. Orchestrating social change may become a reality.

Intervention to improve the quality of antimicrobial prescribing for urinary tract infection: a cluster randomized trial.

Background: Overuse of antimicrobial therapy in the community adds to the global spread of antimicrobial resistance, which is jeopardizing the treatment of common infections. Methods: We designed a cluster randomized complex intervention to improve antimicrobial prescribing for urinary tract infection in Irish general practice. During a 3-month baseline period, all practices received a workshop to promote consultation coding for urinary tract infections. Practices in intervention arms A and B received a second workshop with information on antimicrobial prescribing guidelines and a practice audit report (baseline data). Practices in intervention arm B received additional evidence on delayed prescribing of antimicrobials for suspected urinary tract infection. A reminder integrated into the patient management software suggested first-line treatment and, for practices in arm B, delayed prescribing. Over the 6-month intervention, practices in arms A and B received monthly audit reports of antimicrobial prescribing. Results: The proportion of antimicrobial prescribing according to guidelines for urinary tract infection increased in arms A and B relative to control (adjusted overall odds ratio [OR] 2.3, 95% confidence interval [CI] 1.7 to 3.2; arm A adjusted OR 2.7, 95% CI 1.8 to 4.1; arm B adjusted OR 2.0, 95% CI 1.3 to 3.0). An unintended increase in antimicrobial prescribing was observed in the intervention arms relative to control (arm A adjusted OR 2.2, 95% CI 1.2 to 4.0; arm B adjusted OR 1.4, 95% CI 0.9 to 2.1). Improvements in guideline-based prescribing were sustained at 5 months after the intervention. Interpretation: A complex intervention, including audit reports and reminders, improved the quality of prescribing for urinary tract infection in Irish general practice. Trial registration: ClinicalTrials.gov, no. NCT01913860

From restricted to complex exchange and beyond: social marketing’s change agenda

ABSTRACT The forward thinking body of social marketing knowledge, rooted in commercial marketing tools, suffers from two potentially interlinked crisis of identity. First, there is the question of behavioural change to address difficult social problems. This embraces the development of co-ordinated multi-domain approaches for large scale social transformation. Second, there is the concept of exchange, the defining characteristic of social marketing yet problematic and the least researched of its benchmark criteria. Recognising the centrality of exchange, we address the broadening social marketing discourse, suggesting a focus beyond restricted to complex exchanges. This paper presents the insights from the application of Interactive Management, a system-based methodology, embracing a systemic change and a complex exchange agenda. Our case study finds the contexts for restricted and complex exchanges through barriers as well as structural and influence maps. Understanding complex exchanges closes the gap between the theoretical and practical debates surrounding contemporary social marketing and the role and function of exchange theory.

Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections

Objectives The aim of this paper is to explore the culture of antibiotic prescribing and consumption in the community for urinary tract infections (UTI) from the perspective of the general practitioners (GPs) and community member. Design Indepth interviews were conducted with GPs, and focus groups were held with community members. Setting General practice and community setting. Participants 15 GPs practising in rural and urban locations in Ireland participated in the indepth interviews. 6 focus groups (n=42) with participants who had direct or indirect experiences with UTI were also undertaken. Results The decision to prescribe or consume an antibiotic for a UTI is a set of complex processes including need recognition, information search and evaluation processes governed by the relationship and interactions between the GP and the patient. Different GP and patient decision-making profiles emerged emphasising the diversity and variety of general practice in real-life settings. The GP findings showed a requirement for more microbiological information on antibiotic resistance patterns to inform prescribing decisions. Focus group participants wanted a conversation with the GP about their illness and the treatment options available. Conclusions Collectively, this research identified the consultation as a priority intervention environment for stimulating change in relation to antibiotics. This paper demonstrates how qualitative research can identify the interacting processes which are instrumental to the decision to prescribe or consume an antibiotic for a suspected UTI. Qualitative research empowers researchers to investigate the what, how and why of interventions in real-life setting. Qualitative research can play a critical and instrumental role in designing behavioural change strategies with high impact on practice. The results of this research were used to design a complex intervention informed by social marketing. Trial registration number NCT01913860; Pre-results.

Supporting the improvement and management of prescribing for urinary tract infections (SIMPle): protocol for a cluster randomized trial

BackgroundThe overuse of antimicrobials is recognized as the main selective pressure driving the emergence and spread of antimicrobial resistance in human bacterial pathogens. Urinary tract infections (UTIs) are among the most common infections presented in primary care and empirical antimicrobial treatment is currently recommended. Previous research has identified that a substantial proportion of Irish general practitioners (GPs) prescribe antimicrobials for UTIs that are not in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The aim of this trial is to design, implement and evaluate the effectiveness of a complex intervention on GP antimicrobial prescribing and adult (18 years of age and over) patients’ antimicrobial consumption when presenting with a suspected UTI.Methods/designThe Supporting the Improvement and Management of Prescribing for urinary tract infections (SIMPle) study is a three-armed intervention with practice-level randomization. Adult patients presenting with suspected UTIs in primary care will be included in the study.The intervention integrates components for both GPs and patients. For GPs the intervention includes interactive workshops, audit and feedback reports and automated electronic prompts summarizing recommended first-line antimicrobial treatment and, for one intervention arm, a recommendation to consider delayed antimicrobial treatment. For patients, multimedia applications and information leaflets are included. Thirty practices will be recruited to the study; laboratory data indicate that 2,038 patients will be prescribed an antimicrobial in the study. The primary outcome is a change in prescribing of first-line antimicrobials for UTIs in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The study will take place over 15 months with a six-month intervention period. Data will be collected through a remote electronic anonymized data-extraction system, a text-messaging system and GP and patient interviews and surveys. The intervention will be strengthened by the implementation of a social marketing framework and an economic evaluation.Trial registrationThis intervention is registered at ClinicalTrials.gov, IDNCT01913860.

Tomorrow’s World: Collaborations, Consultations and Conversations for Change

Since their discovery in the 1940s, antibiotics have been heralded as a miracle drug saving millions of lives. Antibiotics have made the treatment of illnesses such as ear infections, pneumonia and pelvic inflammatory disease possible and when used correctly are an important part of our health system. Without effective antibiotics quality of life for individuals and communities will significantly change, making for example, the treatment of cancer or major surgery less safe (Tomson and Vlad 2014). Connected to antibiotics is Antibiotic Resistance (ABR), a phenomenon that causes bacteria to become resistant to antibiotics, making them less effective. ABR is not new and occurs naturally however, the intensity of the ABR spread and its impact on the effectiveness of treatments is of increasing concern (Levy and Marshall 2004). Our continued overuse and misuse of antibiotics has us moving into a post antibiotic era where ABR is one of the world’s most pressing public health problems threatening the quality of life for all mankind (Department of Health 2013).

Reconsultation and Antimicrobial Treatment of Urinary Tract Infection in Male and Female Patients in General Practice

Current antimicrobial prescribing guidelines indicate that male and female patients with urinary tract infections (UTIs) should be treated with same antimicrobials but for different durations. The aim of this study was to explore the differences in reconsultations and antimicrobial prescribing for UTI for both males and females. A total of 2557 adult suspected UTI patients participating in the Supporting the Improvement and Management of Prescribing for urinary tract infection (SIMPle) study from 30 general practices were analyzed. An antimicrobial was prescribed significantly more often to females (77%) than males (63%). Nitrofurantoin was prescribed more often for females and less often for males (58% vs. 41%), while fluoroquinolones were more often prescribed for males (11% vs. 3%). Overall, reconsultation was 1.4 times higher in females, and if the antimicrobial prescribed was not the recommended first-line (nitrofurantoin), reconsultation after empirical prescribing was significantly higher. However, the reconsultation was similar for males and females if the antimicrobial prescribed was first-line. When a urine culture was obtained, a positive culture was the most important predictor of reconsultation (Odds ratio 1.8 (95% CI 1.3–2.5)). This suggests, when prescribing empirically, that male and female UTI patients should initially be treated with first-line antimicrobials (nitrofurantoin) with different durations (50–100 mg four times daily for three days in females and seven days for males). However, the consideration of a culture test before prescribing antimicrobials may improve outcomes.

Protocols for Stakeholder Participation in Social Marketing Systems

Stakeholder participation is the systematic mapping of potentially influential actors who can affect or be affected by intervention(s). Literature to date acknowledges the presence and interrelatedness of multiple stakeholders but is extremely limited in its approach on how to systematically identify and encourage stakeholder participation in social marketing systems. To address this limitation, this article responds to Buyucek et al.’s call for “stakeholders to be systematically identified and managed throughout the intervention design, planning and implementation.” This research proposes stakeholder participation as important to social marketing, regardless of whether it is for a single intervention or systems. We describe and demonstrate seven protocols for stakeholder participation in social marketing systems. We apply an illustrative participatory research context that follows the seven protocols of stakeholder participation and their related sets of tasks, tools, and activities and designed to identify, classify, and map stakeholders across marine environmental social marketing domains. The participatory research context illustrates that working “with” stakeholders rather than “on” their behalf can build bridges and transform societies. We then discuss the implications of embedding a stakeholder participation orientation in social marketing systems—for example, the complexities associated with multilevel stakeholder identification, partnership formation, ownership, conflict and continuity, and the value derived from interlocking co-creation and participatory processes for change.

Exploring Experiences of Delayed Prescribing and Symptomatic Treatment for Urinary Tract Infections among General Practitioners and Patients in Ambulatory Care: A Qualitative Study

“Delayed or back up” antibiotic prescriptions and “symptomatic” treatment may help to reduce inappropriate antibiotic prescribing for Urinary Tract Infections (UTI) in the future. However, more research needs to be conducted in this area before these strategies can be readily promoted in practice. This study explores General Practitioner (GP) and patient attitudes and experiences regarding the use of delayed or back-up antibiotic and symptomatic treatment for UTI. Qualitative face to face interviews with General Practitioners (n = 7) from one urban and one rural practice and telephone interviews with UTI patients (n = 14) from a rural practice were undertaken. Interviews were analysed using framework analysis. GPs believe that antibiotics are necessary when treating UTI. There was little consensus amongst GPs regarding the role of delayed prescribing or symptomatic treatment for UTI. Delayed prescribing may be considered for patients with low grade symptoms and a negative dipstick test. Patients had limited experience of delayed prescribing for UTI. Half indicated they would be satisfied with a delayed prescription the other half would question it. A fear of missing a serious illness was a significant barrier to symptomatic treatment for both GP and patient. The findings of this research provide insight into antibiotic prescribing practices in general practice. It also highlights the need for further empirical research into the effectiveness of alternative treatment strategies such as symptomatic treatment of UTI before such strategies can be readily adopted in practice.

Social marketing partnerships: Evolution, scope and substance

The popularity and benefits of social marketing partnerships accord partnerships as the 5th ‘P’ of the social marketing mix and an essential element of interventions. Yet the scope and substance of partnerships within social marketing remains ambiguous and is an underutilized marketing mix tool. This article critically examines over 50 years of social marketing academic literature to uncover and unpack the full potential of social marketing partnerships and the various forms taken. Periodization is applied as a lens and method for modelling partnership evolution over time. Three dominant eras of social marketing partnerships are evident; the period of transaction, the period of formalization and the period of integrated systems, each with different partnership understandings and characteristics. By examining social marketing partnerships as an evolving entity, this article identifies a ‘constant flux’ trajectory, with partnerships continuing to respond and react to broadening environmental and theoretical catalysts with the development of a model of social marketing partnerships in sight.