The application of the Necessity-Concerns Framework in understanding inappropriate demand for antibiotics in upper respiratory tract infections and COVID-19 vaccine hesitancy

Abstract

The National Institute for Health and Care Excellence (NICE) Medicines Adherence Guidelines recommend personalised support to address both practical issues, enhancing patients’ abilities and perceptions that influence motivation to engage with, and adhere to treatment. The perceptions and practicalities approach (PaPA) operationalises key adherence-related beliefs through the Necessity-Concerns Framework (NCF). The NCF proposes that adherence is influenced by patients’ perceptions of their personal need for medication relative to concerns about adverse consequences. Studies across diseases, cultures, and healthcare systems have demonstrated the validity of the NCF in explaining variation in treatment engagement. This PhD thesis aims to examine the application of the NCF to address two behavioural challenges related to respiratory illnesses: vaccine hesitancy and demand for antibiotics to treat upper respiratory tract infections (URTIs). The research includes a scoping review of determinants influencing patients’ demand for antibiotics, a qualitative study involving patients with URTIs, a cross-sectional survey investigating beliefs about antibiotics and AMR, a review of COVID-19 vaccine hesitancy literature, a cross-sectional cohort survey examining differences in beliefs between COVID-19-vaccinated and unvaccinated individuals, and an exploratory analysis of the antecedents of beliefs about COVID-19 vaccine necessity and concerns. The scoping review identified patient demand as an important driver of unnecessary antibiotic prescriptions, influenced by factors that shape the perceived need for antibiotics and are associated with low concerns regarding their use. The qualitative study (n=32) identified determinants influencing perceived need for antibiotics (e.g., type and severity of symptoms) and concerns (e.g., frequent administration of antibiotics), impacting inappropriate demand for and unnecessary use of antibiotics. The cross-sectional study (n=1105) found that intention to request antibiotics was significantly predicted by beliefs about antibiotic necessity (β=0.475, p<0.001), and concerns (β=-.133, p<0.001). The COVID-19 vaccine hesitancy literature review was suggestive of the applicability of the NCF as an effective framework to understand and address this public health issue. The following cohort cross-sectional survey (n = 1012) reported that beliefs about vaccine necessity outweighed concerns about the vaccine and strongly predicted vaccination decisions [OR=1.616, 95% CI (3.001, 8.440)]. This research highlighted the adaptability of the NCF as a theoretical framework for comprehending inappropriate demand for antibiotics and COVID-19 vaccine hesitancy. The findings indicate the potential applicability of a reverse NCF approach in understanding and addressing inappropriate antibiotic demand. It further identified that COVID-19 vaccine hesitancy demonstrated patterns commonly observed in medication non-adherence, specifically characterised by low perceived necessity and increased concerns regarding treatment. The thesis findings potentially laid the foundation that the NCF can effectively inform the design of interventions targeting vaccine hesitancy and patients’ inappropriate demand for antibiotics in the management of URTIs.