Title: Enabling antimicrobial prescribing reduction during urgent primary dental care in England: Developing a complex intervention for behaviour change of professionals and patients. [Short Title: APTiTUDE – Antimicrobial Prescribing: Towards a reducTion during Urgent Dental care in England.]
Funder: Department of Health and Social Care

Abstract: Scientific Rationale & Health Need:Professor Dame Sally Davies, UK Chief Medical Officer has highlighted the importance of antimicrobial resistance and the need to reduce its impact.10 My PhD proposal addresses this national priority by contributing to the UK five-year antimicrobial resistance strategy:-conserve and steward the effectiveness of existing treatments.11 Prescribing of antibacterials in primary dental care accounts for 5% of the NHS total.4 Aim Addressing antibacterial prescription rates during urgent appointments with NHS primary dental care services in England, through development of a complex intervention to change professional and patient behaviours. This will contribute to national antimicrobial stewardship goals and ultimately to reducing risks to patients and wider society from antimicrobial resistant infections. The MRC Guideline for complex interventions provides a structured framework for:-1) development; 2) evaluation (feasibility and definitive evaluation); 3) process evaluation.1 My PhD covers the development phase. An evidence-based logic model will be developed informed by evidence synthesis and qualitative enquiry, using the principles of interventional mapping.5 Whilst full evaluation of the complex intervention is beyond the scope of my PhD timeline, a specification for the evaluative phase will be developed using case-study review of the feasibility of the intervention.PhD Objectives [PRE-AWARD]-STAGE_1:-Evidence Synthesis OBJECTIVE_1:-Determine what is known from the published literature about the barriers and drivers for prescribing antibacterial medication in primary health care, in particular dentistry. Systematic review of the literature is identifying professional and patient behaviour relating to dental antibacterial prescribing(Section_4[4]). Thematic analysis is:-guiding selection of appropriate theoretical models of behaviour; and identifying issues for inclusion in the sampling framework/topic guides for [Stage_2]. STAGE_2:-Qualitative enquiry OBJECTIVE_2:- Identify the professional-related influences (individual, interpersonal and contextual) on members of the dental team that impact the decision whether to prescribe antibacterial medication. OBJECTIVE_3:- Identify how patients influence (encourage/discourage) antibacterial prescribing. A sampling framework will be established, considerate of high/low prescribing rates. Observations/audio-recording of the professional-patient interactions during urgent appointments in primary dental care settings (together with follow-up questionnaires and interviews) will help elucidate the factors which influence prescribing of antibacterials. Topic guides for the qualitative enquiries will be developed from the issues identified during [Stage_1], together with the findings of initial work with the Cheshire/Merseyside project. STAGE_3:- Intervention development OBJECTIVE_4:-Building from Stages_1&2, develop a logic model to provide a coherent theoretical framework for describing antibacterial prescribing behaviour during urgent appointments in the primary dental care setting. OBJECTIVE_5:-Develop an evidence-based complex intervention using the logic model (Objective_4) and intervention mapping, with knowledge transfer from the GP context, as appropriate. OBJECTIVE_6:-Explore acceptability of the intervention tool-kit amongst dental professionals and patients, and develop a detailed protocol for a feasibility Randomised Controlled Trial. Based on findings from the preceding stages, a complex intervention will be developed using the principles of intervention mapping, together with knowledge transfer from development of GP interventions. A specification for the follow-on evaluative phase will be produced informed by a case-study feasibility review of the intervention. Dissemination: This research is supported by high-profile supervisors and advisors from Public Health England(Dailey), NHS England(Howard); and a behavioural change psychologist with international standing in the area of GP antimicrobial prescribing(Tonkin-Crine). In addition, NHS Deputy Chief Dental Officer(Rooney) is a member of the Lancashire Dental Research network. Through these and other links, such as professional bodies(see Section_3), wide publicity will targeted, including conference presentations and posters. Standard publicity through academic publication is planned. Lay member Horsfield will assist production of public-facing material, including a plain English summary. More imaginative ways of disseminating research results are being explored with social media, the APTiTUDE website/app, local media/press and with Theatre of Debate.

Lay abstract: What's the health problem? Antibiotics are important medicines for preventing and treating infections caused by bacteria. The overuse of antibiotics has led to a worrying rise in resistant infections which can be very difficult to treat. These infections cause patients to be sicker for longer and can be life-threatening. Professor Dame Sally Davies, the UK Chief Medical Officer has issued serious warnings about the global health problem faced if the threat of antibiotic resistance is not tackled. One way to slow the spread of resistant bacteria is by using antibiotics more carefully and reducing the number of prescriptions.Dentists in England prescribe more antibiotics than any other medication. In 2014, 1-in-20 of all antibiotic prescriptions issued in the NHS were from dentists, totalling 3.7 million prescriptions per year from NHS dentistry alone; with additional from private dental care. We know that dental antibiotic prescriptions are more often linked to urgent primary dental treatment. Dentists clearly have an important role to play in safeguarding the threat of antibiotic resistance by acting to reduce prescription numbers. Aim of the research: The aim is to develop an effective way to reduce antibiotic prescribing by NHS dentists in England, by addressing the behaviour of dental team members and patients during urgent dental appointments. How am I approaching it? We know that antibiotic prescribing by General Practitioners (GPs) can best be achieved by altering the behaviours, concerns and expectations of both GPs and their patients; education alone is not sufficient for lasting changes. As this needs more than one thing to change, it is known as a complex intervention. Such toolkits for changing the behaviours of doctors and patients are available for use by GPs and in hospitals, but not for dentists. I will develop a toolkit for use by those providing urgent dental care, to support a reduction in antibiotic prescribing. This will be based on identifying what drives high prescribing rates and what encourages low prescribing rates in dentistry. It will also use knowledge and experience from the previous development of a similar toolkit for GPs. What will be done? My research will be delivered in three stages: Stage 1 - a review of published research to identify what factors affect antibiotic prescribing in primary health care, with a focus on dentistry; Stage 2 - research to identify the barriers, drivers and patient-related influences on antibiotic prescribing using observations/recording of urgent dental appointments, questionnaires and interviews with patients and dentists; Stage 3 - the information gathered in Stages 1 and 2 will be used to develop a complex intervention or toolkit (possibly including an interactive website or app) to reduce antibiotic prescribing. Who will be involved? In Stage 2, I will recruit dentists from emergency out-of-hours' dental clinics and general dental practices with known high or low prescribing rates in Yorkshire and Lancashire. Patients attending those practices for urgent care will be invited to join the study. Urgent appointments will be observed/audio-recorded and I will follow up with telephone interviews with patients and dental professionals to gain richer insight into their thoughts, feelings and behaviours with regard to their appointment and the prescription (or otherwise) of an antibiotic. These patients and dentists will also be invited to contribute, during Stage 3, to the development of the complex intervention or toolkit. What will be the outcome? New understanding of what encourages and discourages dental prescribing of antibiotics will be an important addition to the scientific knowledge base in this area. From these findings, I will design a toolkit to help dentists reduce antibiotic prescribing during urgent dental appointments. This is just the first step, as further, rigorous testing will be needed to check that the range of tools reduce antibiotic prescribing in practice without causing harm. I will also develop a detailed plan in collaboration with the Dental Translational Clinical Research Unit describing how the testing/trial will take place. This will be the basis for a future funding application. Publicity: Antibiotic resistance from over-prescribing is a national research priority. This research benefits from the strong support of eminent specialists, who will ensure that the research receives the necessary publicity nationally and beyond. They encompass: NHS England, Public Health England; British Dental Association; International Association of Dental Research and an internationally-known behavioural change psychologist. Lay members will help produce a plain English summary for the public. Standard publicity is planned through publications in the relevant scientific literature. More imaginative routes are being explored, including through APTiTUDE's website, social media and with Theatre of Debate.

Research activity codes: 6.1 PHARMACEUTICALS
Health categories: INFECTION