Title: Optimising knowledge mobilisation surrounding antibiotic utilisation in the community setting.
Funder: Department of Health and Social Care

Abstract: Background: In highly professionalised organisations, knowledge mobilisation (KM) impacts only once knowledge of what is acceptable' practice is developed and negotiated collectively within and across professional groups, teams, or organisations. Structural and cultural environments mediate this process. Whilst the societal threat of antimicrobial resistance is recognised, to date, KM activities targeted at GP teams, community pharmacists and patients have not been evaluated from a systems perspective. Empirical research reports that up to 30% of antibiotic prescribing by GPs may be inappropriate, and roles of other healthcare professionals, public and patients in the community setting remain unexploited. Aim: To develop and pilot a user modifiable process mapping tool to refine existing, and develop new initiatives for knowledge mobilisation amongst actors that influence antibiotic use in the community setting. Research question: how to optimise knowledge mobilisation between and across the core triad (GP teams, community pharmacy, patient) involved in antibiotic utilisation in the community setting? Plan of investigation: A three phased project to develop and apply a novel software based method of systems mapping to KM processes: Phase 1: Two mixed method case studies to explore within context, KM activities that surround the triad described. Purposive sampling for level of integration of KM activities across sectors is proposed: Case study A (Manchester): vertically integrated KM activity across secondary and community care via a dual formal antibiotic specialist pharmacist - role across an acute NHS trust and Clinical Commissioning Group. Case study B (London): horizontally integrated knowledge mobilisation activity within community care. Quantitative data of demographics, process and outcome quality indicators will establish areas of sub-optimal prescribing of antibiotics to provide context for the interventions assessed. Qualitative interviews with healthcare professionals will be used to assess extent of uptake, knowledge retention and application of national level capacity building interventions for GPs [Royal College of GPs toolkit] and Pharmacists [Centre for Postgraduate Pharmacy Education programme ]. The role of local KM initiatives, technologies including electronic decision aids and near-patient testing will be examined. Phase 2: Two patient workshops (case study B) consisting of group interviews and discreet choice methods to evaluate perceived need, demand and experience of community care based antibiotic use. A dynamic systems map of sources of advice and patient health-seeking behaviour between GPs, practice nurses and community pharmacists will be developed. Extreme case' sampling of patients with a special interest in antimicrobial resistance/patient safety (via the Patients' Association) will capture variance in behaviour when health literacy of patients matches or exceeds that of healthcare professionals. Phase 3: The modifiable process map (using ithink software) which can test what-if' scenarios, based on the findings of phase 1& 2, will be piloted to refine existing KM activities and develop new initiatives with participants from the continuum of: public, patients, healthcare professional students/practitioners , educators, in the community and secondary care settings. Theoretical approaches to analysis: A deductive-inductive process using: a. the Resource Based View, that competencies confer competitive advantage to examine if/how NHS policy structures, performance measures, and definitions of success support this approach. Essential to determine differential drivers for individual and organisational learning in GP teams compared to community pharmacists. b. a sensemaking perspective ( micro-level ) to optimise KM activities particularly for public/patients. Whilst pharmacists may be physically present and more accessible than GPs (particularly in areas of high deprivation) understanding public trust and confidence in different healthcare professionals and teams is needed. Benefits to patients/NHS: This project will provide timely actionable insights and tools as NICE guidance recommends that community sector staff promote and monitor use of antimicrobials ahead of further guidelines aimed at the public.

Lay abstract: Knowledge mobilisation refers to the process of production, dissemination, and exchange of research. Knowledge mobilisation is important in healthcare because research, if fully utilised, has the potential to improve the health of people using the national health service. Knowledge mobilisation can also ensure that the health service provides care in the best possible and efficient way. Knowledge mobilisation is particularly important when the information about the best medical treatment is clear but this treatment has not been universally accepted or practiced upon yet. Antibiotics (medicines used to treat infections) are a good example of such area where practice often does not follow recommended guidelines the underuse because of delays in treatment for some health problems, and over use for other illnesses that do not respond to antibiotics, encourages the rise of micro organisms which can not be treated (ie, they are resistant') with available medicines. The danger from these organisms to our society is fast becoming a national and global problem. Pressures on GPs coupled with patient demands do impact on inappropriate use of antibiotics. This project will look at how knowledge transfer happens between patients, GPs teams and community pharmacists to understand how we can improve the use of antibiotics. The project will look at the different ways that are currently used to help GP teams and community pharmacists to make the best treatment choices for treating different infections. These methods include: a specialist pharmacist from hospitals working and advising GPs (Manchester); continuing education and training and guides to prescribing (for example in the form of internet tools or smartphone/tablet apps' London). The researcher will use interviews, and observation of meetings and training events alongside indicators associated with different GP practices to understand how antibiotics are prescribed and the underlying reasons that may explain such prescription. Examples of working across GP and pharmacy teams will be of particular interest. Perhaps most importantly, the behaviour of patients and the general public will be explored through workshops with them. The result of this research will use a computer program to create a map' of the behaviours of healthcare professionals and patients, which will help understand the influence of research and education. The map will be designed so that it can be easily modified to try out different alternative scenarios. For example, what ifGPs are restricted in choice of antibiotic' will this bring about most appropriate use or what ifmore time is invested in helping the public know almost as much as healthcare professionals about which antibiotic and when?' Of course the scenarios will have to be based on what we know from research but the process will create new ideas and make best use of how we exchange knowledge. Also, previous studies within healthcare have shown that the public and patients have different levels of confidence and trust in different healthcare professionals. So this project will build our knowledge about the importance of the source of the knowledge. This is also relevant in knowledge exchange between healthcare professionals. The approach we propose is highly original and the software has not been used before to study knowledge mobilisation. This proposal will also allow a highly experienced researcher to learn new skills to competently carry out the work. The tool will be tested with a wide range of users, including people in primary and hospital care, which will be helpful for policy makers to consider the different barriers use antibiotics in the best possible way. This work will take the perspectives and behaviours of the three main groups of people which influence the use of antibiotics in the community setting in ONE system map.

Research activity codes: 8.4 RESEARCH DESIGN AND METHODOLOGIES (HEALTH SERVICES);7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE