So now for something completely different, as Monty Python used to say. Good afternoon and welcome to the 2nd BVA sponsored webinar. And it's titled Social Science and Antibiotic Use on Farm.
Understanding behaviour and Encouraging Change. During my career, Goodrin's done an excellent job of reading out my biography. So I have worked as a mixed practise vet and a dairy vet, both in the UK and out in New Zealand, working quite closely with farmers and I became increasingly fascinated with the way that farmers were using or not using my advice.
The decisions they were making when we're not on the farm and the way that they use the medicines we prescribe, particularly the differences and similarities between farms of different sizes and management types and even between the countries. I knew that early on I was quite guilty as a vet of leaving a farm thinking, Yep, I've told them what needs to be done, so that's what they're now going to do. And I think, you know, that's a bit naive.
And as soon as you work as a vet for a few years, you realise that that doesn't happen. And I was soon proved wrong. I remember being quite frustrated by that, because I didn't really understand why my advice might not be being listened to.
I have heard that write farmers off as being hard to reach or impossible to teach, but the more I thought about it, the more I realised that perhaps I just wasn't ready to understand the reasons why my expert in inverted commas advice might not be going through. So after Emming and eyeing for a while and I was in a bit of a career crisis in my own head, I decided I'd write a PhD proposal, apply for some funding, and I was lucky enough to win a scholarship to study this very subject. Trying to understand the way in which, for me, I'm particularly interested in dairy farmers, so I'm trying to understand the way in which dairy farmers use prescription veterinary medicines in the UK.
I'm in the final year of my PhD now, so I'm just finalising analysis and writing up. But I've really found the journey from a quantitatively trained veterinary scientist to a qualitative researcher. Well, both difficult and really rewarding.
I'm hoping to share with you all a few of the insights I've gained, because it really has changed the way I think about the interactions we have daily with our farming clients, and I'm, I've become quite passionate about it. Oh, OK. I'm sorry, my slides aren't moving.
At the moment, are they, so it's good, are they moving at at your, oh dear. Once, Is there anything happening at your end? No, we don't seem, we're still on your front page.
Stacey, are you able to move them at all? Hi, sorry, no, I can't move them. It's on Gwen's screen.
Gwen, are the arrows at the bottom of the screen visible? Oh yes, sir. Thank you.
Sorry about that, bit of a rookie error. Right, I'll use the arrows from now on. OK, so this slide, it's quite busy, but it's just to introduce the stuff that the University of Bristol's been doing.
So I'm in this research group called AMR Force, and we're doing quite a lot of research into antimicrobial resistance. We've been working in many areas and with a huge number of key stakeholders in the UK and just a few of them are dotted around on this. On this slide.
And as you can see, some of the research that we're doing is purely quantitative, so we're studying the microbiology of resistance, the epidemiology and the effect of changing antimicrobial use on animal health. However, at least half of what we do these days is a qualitative research element. So we're looking to understand medicine use behaviours.
We're working with farmers, milk buyers and policymakers in order to promote responsible medicine use. We're using techniques such as motivational interviewing to bring about knowledge transfer and to hopefully encourage behaviour change on farm. I think the veterinary world really is moving on from the narrow view of science as requiring sample size calculations and P values in order to be valid.
And just flicking through the veterinary record these days, it's becoming more obvious that the use of social science methodologies is increasingly important and increasingly accepted. However, it's, it's not enough to just do the odd interview and say we've paid our dues to social science. I think we really need to be able to understand a little bit about the theory and to be able to critically appraise that research and involve social scientists in any research that we do from study design onwards.
So, that's what the thinking was really behind this webinar. I was asked to put a few learning objectives together for this webinar, which is largely aimed at veterinary surgeons who are in clinical practise and have maybe a bit of a limited understanding of social science and its app, the applicability of the research, really. And hopefully, by the end of this session, you'll be somewhat closer to being able to Distinguish between quantitative and qualitative research.
You'll be able to list some of the key methodologies of social science research. Explain how social science can help us to understand antibiotic use. Describe what's currently understood about the way antibiotics are being used on farm.
And hopefully, think about applying this understanding to facilitate some practical changes on farm. Hopefully this doesn't sound like too big of an ask, and we'll recap these objectives again towards the end of the presentation. So just an outline of the session, I'll begin just by setting the scene a little bit, emphasising why this topic is worthy of an hour's CPD and then we'll move on to look at qualitative research and social science in general, and some of the ways you might see it being used.
We'll have a look at what it is that we currently know and don't know about antimicrobial use behaviour. Then we'll have a look at some of the practical changes that maybe we can make on farm, and I'll briefly introduce you to the concept of motivational interviewing as a tool for engaging and eliciting behaviour change with your farming clients. So why is this subject even important?
It's not going to pass to any of you by that antimicrobial resistance is a massively hot topic. I'm sure we've all heard some of the sound bites about the antibiotic apocalypse that's heading our way. So, our Chief Medical Officer, Professor Dame Sally Davis, said this a few years ago.
We've reached a critical point, and we must act now on a global scale to slow down antimicrobial resistance. And notice that she says slow down. We really, we can't stop it.
The very nature of bacteria just dictates that resistance will inexorably develop with time, but we can slow it down, and it's everyone's responsibility to help do so. It's no use us blaming the human medics or blaming countries in Southeast Asia. We as UK vets must be seen to be doing our bit as well, and the time to act really is now.
So here are a few facts about antimicrobial use in the UK. The majority of antimicrobials are still being used in human medicine. And I think that's an important one to, to get across when Jude talks about, you know, our image and what we're portraying to the public.
That that is quite an important point, because a lot of the public would assume that animals are getting most of the antibiotics, I would say. Of the antibiotics that are used in animals, over 80% are used in the pig and poultry sectors. I mean, that makes sense.
It's unsurprising given the sheer numbers of these animals raised each year. And both of these industries have actually worked really hard recently to improve the situation and reduce their overall antimicrobial use. When it comes to the amounts of antimicrobials used in dairy cattle, beef cattle and sheep, we really don't know.
We don't have great data. It's getting better, but, it's a lot more difficult to find out what's happening. And this is multifactorial.
So, veterinary products and antimicrobials, they're licenced in multiple species or they're not licenced at all. The way in which the use is currently measured doesn't allow for us splitting out that species use. And even though farmers are required to keep really detailed medicine records of all treatments administered on their farms, this information's not really accessed or used in any way at the moment for monitoring purposes.
Clinically though, we're simply not seeing AMR when we're out on form. We may come across the odd mastitis pathogen, we'll culture it. It's resistant to some of the antibiotics we might want to use.
It's very rare that we'd have a refractory case due to antimicrobial resistance, and multi-drug resistant bacteria is predominantly a problem in human hospital settings. And this can make conceptualising AMR a bit of a problem and a bit difficult for vets and farmers. It doesn't affect us directly.
We give antibiotics to treat infections, they either work or we probably got the diagnosis wrong, to be honest. So even though around 35% of the antibiotics used in the UK go into animals. These animals make up 2.
2.4 times as much biomass as humans, making the relative proportions of yeast. Reps fairly favourable really compared with people.
As in human medicine, there's a lot of evidence to show that the use of medicines is really complex and multifactorial, and we really do lack a significant amount of knowledge in this area at the moment. We also don't truly understand how or by how much resistance mechanisms are transferred between animals and humans. Although there is currently a huge amount of research going on in this area.
Hopefully, you know, we'll know a bit more soon. What we do know, and what this study, on this slide illustrates quite well, is that if you increase the use of antimicrobials in veterinary medicine, you also increase the amount of resistant bacteria found in food producing animals. Now, correlation doesn't equal causation, so we can't really say that.
What, what exactly is happening in this relationship, only that there is a relationship there. But it does seem logical then to assume that decreasing the use of antimicrobials in veterinary medicine can only be a positive move. So this is a goal we should all be working towards in order to do our bit in the fight against AMR.
So what we've got is a paradox. You can, you only have to pick up a copy of the Daily Mail and as Jude said, please don't. To see that there is an increasing public concern about the transfer of AMR from animals to people.
This concern is really echoed in scientific circles as well. However, it's also known that the main driver for AMI in people is the use of antibiotics in people. While this means that there should be a huge focus on responsible use in humans, it doesn't let us off the hook, and it doesn't mean that veterinary use is unimportant.
In recent years, there's been, there has been increasing pressure of the vet on the veterinary profession to promote responsible use from many sources, and we've already done some sterling work with the BVA producing excellent guidelines for responsible use in order to support the profession in this endeavour. The agricultural industry is also subject to increasing pressures. So it's not just us vets who are feeling this pressure.
We've got various stakeholders really driving policy change in agriculture. In part, this is coming from government, but mostly it's coming in agriculture from, well, it's being driven by consumers, by milk buyers, by the supermarkets, the industry bodies, and research institutions. The use of antimicrobial use targets and benchmarking are becoming increasingly common and farm assurance schemes are beginning to shift their gears towards responsible medicine use too.
Some private veterinary practises have also been really proactive in this area actually, and they're working with their clients to measure, to benchmark, and ultimately to reduce the use of certain antimicrobials, particularly those that are classified by the WHO as the highest critical importance to human health. So here we're talking about the fluoroquinolons, the 3rd and 4th generation cephalosporins. So let's move on to have a look at some of the differences between quantitative and qualitative research.
As veterinary surgeons, we've all been trained in basic quantitative research methodologies, and we can all, I'm sure fondly recall our epidemiology lectures from vet school. So this kind of research is pretty familiar to us. It has many strengths, which is why it's always been relied on very heavily in the medical sciences.
And in the context of AMR, there are many things that quantitative research can do. So we can, we can measure antimicrobial use. We can benchmark and audit vets and farmers, measure and improve herd health parameters, develop new therapeutics or animal management strategies, and we can really define the mechanisms and pathways of resistance.
So obviously, the use of quantitative research is vitally important to the understanding of AMR and the Promotion of responsible use. But there are some things that Quantitative research simply can't do. It can't explain why a vet or farmer might choose to use one antibiotic instead of another.
It can't really define how decisions about treatment are being made or why a farmer might decide to use a double dose of antibiotic for their favourite cow. It can't explore what's motivating treatment decisions, what beliefs that some farmers have about antimicrobial resistance, or what values people hold as important. Quantitative research also can't explain the relationships between policy, actions, stakeholders, and advice pathways.
In order to answer these more sort of how and why questions, we really need to use a different approach and we need to look towards social science and qualitative research for this. So what is qualitative research? Well, for one thing, it can be filled with lots of off-putting jargon, and that was, quite a steep learning curve at the beginning of my journey.
But I'll try and introduce you to some of the more, basic stuff about qualitative research, and I'll explain as I go. So, it's interpretive rather than positivistic. And what this means is that look, it looks for meaning or explanation.
It doesn't seek to establish facts as such. So instead of say of asking, is this black or is this white, it might ask, why is this a certain shade of grey? Social science is inductive, which means that instead of using theories to explain results, it'll often use results to create the theories.
So instead of starting out with a hypothesis and then testing it, you often start out with a question, and you'll generate theories that help to answer that question based on the data that you collect. And this can be a really powerful tool for identifying unknowns. So in cases where we don't know anything about the question, it's not limited in the way that hypothesis-driven quantitative research can be.
One criticism that's often levelled at qualitative research is that the sample sizes are so small. But to say that is kind of to miss the point a little bit. The focus of qualitative research is on the depth of the data rather than the breadth.
So we're looking at gathering extremely rich data from a smaller number of sources, rather than gathering a huge amount of narrow data to prove a statistical significance to answer 11 or two set hypotheses. Social science focus is much more wordy, so it's on words rather than numbers. It's very descriptive and narrative, and above all, it's flexible.
Its use is particularly powerful, where research is exploratory, as I said, So when little is known about a subject, it's impossible to generate an accurate hypothesis or guess of the significance in order to calculate a sample size. But it is possible to go in with an open mind, gather rich data, explore that data and analyse it, and then generate some theories from it. So while qualitative research can be very descriptive or involve transcripts of conversations, it's often not what is said or done that's quite as important.
It's the meanings and the interpretations of these things. So the context in which words have been said or behaviours have been carried out is vital to interpreting the data well, and the skills of a social scientists lie in this form of analysis, really. So social life is seen as an interlocking series of events and processes where nothing happens in isolation or in a vacuum.
There's always a context that must be taken into account. Social scientists are very aware of their own role within the data collection and the analysis and therefore must be reflexive. This means they must consider what effect their own presence, their own knowledge, and perhaps their own research agenda might be having on the data that they're collecting.
I'll touch really briefly on some of the more in-depth differences between the paradigms of quantitative and qualitative research. So as I said, quantitative research is positivistic, so when you're designing and conducting quantitative research, you assume that the world is composed of objective facts. That reality is independent completely of the researcher.
There are some qualitative social science methods. They're also positivistic. So when you see these sort of like it scale kind of surveys, which are asking you how strongly do you agree with the below statement, one very strongly, 2, slightly strongly, etc.
Etc. These are quite positivistic as well. So they assume that what you're saying is a fact.
These research methods, they seek to explain, to verify or to predict human behaviour, and begin with the development of hypothesis that will be tested, and they're often coming from a human psychology background. On the other hand, much of qualitative research is from a more interpretivist perspective, where reality is subjective, and it depends on the observer, suggests the fact that there is an observer there is changing reality. The researcher plays a role in this reality and can't be independent from it.
So the methods seen in interpretivist data collection are things like semi-structured in-depth interviews, participant observation, and focus groups. And they intend to discover new insights and understand human behaviour. So these methods are more theory generating and inductive and are often based in anthropology and human geography.
So we'll hear the terms sociology, and we hear the terms anthropology. Are they interchangeable? Do they mean the same thing?
Well, there is a little bit of a difference between the two. So, in the human medical field, medical sociology would be looking at the relationship between social structures and health. So maybe the influence of ethnicity, gender, age, or socioeconomic status on health and healthcare.
On risk-taking behaviours, looking at health beliefs and perceptions, health effects of socio-cultural changes, we're looking at the role of health institutions and health professionals in society. Medical anthropology, on the other hand, is more focused on healthcare culture and practises. So cultural interpretations of medicine and disease, perceptions of the body, cultural and economic disparities in health and healthcare provision.
Looking at organisational culture, so maybe the relationship between surgeons, anaesthetists and nurses, and that hierarchy in an operating theatre. And it's also looking at maybe engagement with and responses to new biomedical technologies. So they may sound quite similar, but they are exploring slightly different things in slightly different ways.
And in the human medical field, both medical sociology and medical anthropology are really well established. But in the veterinary sphere, veterinary anthropology and sociology is very much still in its infancy. There are a few people who've been out there doing it for quite a long time, but we're still pretty rare, really.
So we'll have a brief look at some of the major research methods that you might see used, particularly if you're picking up copies of the vet record more recently, these are becoming more common, as I said. So we've got semi-structured in-depth interviews. They're being used more frequently in the veterinary world.
And with these interviews, you have some broad research questions that you have in mind when you go and conduct an interview, and often you'll have a bit of a topic guide that you can use to keep the interview on track. But they're led in a large part by the interviewee. And this is in order to establish what their feelings and thoughts are on the subject, so not to impose limited questions on them.
They typically last around an hour per interview and they ideally occur face to face, so they're quite intense and intensive. You might see focus groups being used. They're used in order to stimulate conversation or to gather the views of several people at once on a topic.
There's something called participant observation, which is a powerful research method whereby the researcher will spend a prolonged period of time, and it's classically around a year, participating in day to day activities within a certain group of interest, and really observing, describing and analysing the behaviours, the social hierarchies and the contexts, and what's going on there. There's something called documentary analysis and you'll see this particularly where issues of policy are concerned. It might involve an analysing the language used in policy documents or in the press.
OK. So, when it comes to analysing this sort of qualitative research methodology, we've got 3 strategies for interpretation, broadly speaking, and they're all based on an incremental approach to analysis. So we've got something called ethnography, which comes from anthropology, mainly.
This is really immersing the researcher in a setting, and the researcher is examining the social structure. So maybe the local social organisation, like I said, the hierarchies, the arrangements of power, and also looking at the culture, the meanings behind behaviours. This approach is examining as much as possible.
So the research really includes context and environment, as well as individuals and sets of patterns. So for example, health seeking will be interpreted by reference to another set of patterns such as kinship structures or household organisations, something like that. It's highly reflexive and it acknowledges, and to a certain extent, it really embraces the presence and the role of the researcher in the information gathering.
And the second is a bit more sociological, so Glasser and Strauss developed a strategy for dealing systematically with data that they called grounded theory. In this information is interpreted through coding, through comparison, and a constant process of toing and froing within the data set. So.
The idea here is really to develop theoretical notions from the data itself. So when you develop theory, it's really grounded in the data, which is why they called it grounded theory. And a little bit similar to that, but more narrow in approach and scope is this framework method, which was developed by the National centre for Social Research and Richard Spencer.
And it's especially useful for interview and focus group material. So it's a content analysis method where you summarise and classify data within a matrix and hence a, a framework. It's favoured for policy analysis, and it tends to be a bit more deductive rather than inductive.
OK, so that was a bit of a whirlwind tour through some of the basics of social science. I hope some of you are still with me and still awake. Now on to the more clinically relevant stuff.
So we'll have a look now at how that might be useful to us and applying it to prescribing decisions. It's a big question, why do we prescribe what we prescribe? And, you know, are we being purely evidence-based or are there some other factors at play?
First, let's have a look at the clinical factors that might influence our decision to prescribe antimicrobials. As you can see, there are loads of clinical factors, lots of clinical questions that we should be asking ourselves. And when we're out on farm deciding to prescribe, it can feel a bit overwhelming.
And when, especially when you look at them written down, but we really should be asking ourselves all of these questions, and every time we think of prescribing antimicrobials, and we often are, however briefly or subconsciously. So if we think of an example, perhaps a coughing cough with a fever. If you ask yourself all of these questions, and we should only really be using antimicrobials if most or all of the answers support that decision.
Of course, in reality, most of the answers to these questions are unknowns, and we have to make the best educated guess we can. This isn't necessarily easy, but it is responsible and we're at least considering all of these questions and, as I said, making an educated guess. However, these are only the clinical factors, and there are a few more factors that might influence our prescribing decisions.
So alongside all of the clinical factors that need to be considered, there are a myriad of practical factors as well. So, is the drug even available in my car? How much does it cost?
Does the farmer have a particular preference? Do I have a particular preference? Does the milk buyer have a reg have any regulations minimising, say, the use of critically important antimicrobials?
Does it need to be a long-acting antibiotic because this crazy limousine steer is only going to be caught once. You know, there's a lot of things that are very context, context specific and These are all going on in our heads at the same time, and these external forces are often just as important to vets in clinical practise, but they can be forgotten by policymakers and academics, these sort of less clinical factors that are influencing our decisions. So there's plenty of evidence from human medicine that defensive prescribing is pretty common, by general practitioners.
And this is really understandable and simply a product of human nature. Where there's uncertainty, and this is very often when we're in clinical practise, and where the stakes are high, it's humans, it is human nature to hedge your bets. So this is.
The reason many vets will give a bottle of calcium under the skin as well as one in the vein or do a buona suture after a prolapse. Even though there's not really an evidence base for what we're doing and to say that it's warranted, we do it just in case. And we think that the potential benefits, which are often psychological, outweigh the potential risks.
So defensive prescribing isn't just a problem in human healthcare settings. And I'm afraid I don't really have an answer to the dilemma of defensive prescribing, but the, I mean, the human medics have also been struggling with this issue. And one of the most effective ways to tackle this feeling of uncertainty is to develop practise protocols for treatment of certain conditions.
And, this provides a form of psychological safety net, which has Proven beneficial within the NHS. I'm sure you've all heard of NICE, which is the National Institute for Clinical Excellence. They produced guidelines and protocols for treatments, which has helped to standardise decision making and remove some of this discomfort and uncertainty from prescribing decisions and therefore increase responsible prescribing practises.
Of course, the best way to deal with the issue of uncertainty is to completely eliminate that uncertainty. And that's where the development of fast, cheap, and accurate patient side diagnostics is imperative and hopefully in the future we'll have a lot more of that. So using an evidence-based approach to antimicrobial use is considered best practise prescribing, but is this really realistic in practise?
There are loads of barriers to using an EBVM approach. And compared to human medicine, we, we don't have much in the way of peer-reviewed evidence to answer a lot of our clinical questions. Where the evidence does exist, it can be difficult for the general practitioner to access it.
It'll often sit behind a paywall, and it's known that there's, there is bias towards publishing papers where a positive outcome was found. Many randomised controlled trials and veterinary medicine will be funded by pharmaceutical companies, and, you know, they might have a vested interest in showing that their drug works. So there, there are pitfalls with the EBVM approach and It does mean that anecdotal evidence does still really reign supreme for much of veterinary medicine.
More out of necessity due to a lack of evidence, but also because it's so psychologically powerful, and Jude touched a bit on some of this earlier as well. So we've got something called confirmation bias, and just as in human medicine, if we use a drug and then the patient gets better, we'll attribute it to that drug. Even though often self cure or getting better despite the drug is what's been happening, we'll then form this confirmation bias for the treatment.
Every time we then give it and the patient gets better, that adds to our confirmation bias and we think, yep, it's because the drug works. But every time we use it and the patient doesn't get better, we might think, oh, it's because of another reason that the farmer wasn't compliant or I made the wrong diagnosis. So that is really quite psychologically powerful.
Equally important to the way that we make our prescribing decisions is the way in which those medicines are actually being used on farm. And this is what I'm really fascinated by. Farm vets are in a bit of a unique situation, really, where we're generally not present when the when the medicines that we prescribe are being used.
We prescribe the medicine for the farm to these animals who are under our care. We tend to review this quite intensively once a year within the herd or the flock health planning. But in the meantime, farmers happily buying these antimicrobials, storing them on his or her in his or her medicine cupboards for use at a later date.
We then don't really know what's happening after that point, and finding that out has been the main aim of my PhD really. So as we've already discussed, legally, the vets are the res are responsible for the medicines that get used on a farm. But practically, we're rarely there when these medicines are being used, and we're only involved in these prescribing decisions from a distance.
And that's both a physical distance and a temporal distance. It's often happening at a different time to when we made the decision. Compliance is really complex and multifactorial.
And we looked at a list of clinical and some more practical reasons when you're making decisions that you might make one decision or another. Farmers have just as long a list, and just as Many factors influencing their choices of medicine as the vets do. But they are going to be slightly different questions because they do have different priorities to us.
So, yeah, it's what do I have in the parlour? Do I have anything that needs using up? That's quite a common one.
Do I care if it's out of date? Is this my favourite cow? Do I need, do I have the time to give 3 injections, and can I even afford to treat in the first place?
There's a lot of work again in human medicine studying patient compliance with prescribed medicines, and it shows that patients will use medicines in many weird and wonderful ways, not originally intended by the prescribing practitioner. So it's important to bear that in mind, and while our farmers tend to be better educated in animal health than the lay public, misunderstandings and misconceptions are still pretty common, and we should never assume that just because a farmer's always been using pen and strap, they actually know when or how best to use it. So there was a recent, quite interesting study in the journal of Rural Studies, That it came out of Nottingham, I think, and it was studying UK press coverage of antibiotic use in agriculture.
It found that there were 3 themes that emerged from the articles that were being analysed, and it really depended on who had written those articles as to which themes they fell under. So the first, which was sort of articles by the Alliance to save our antibiotics, or from the Soil Association, so organic kind of publications, was that it's a system failure. Agriculture's using antibiotics because of the way that animals are kept, and the current farming systems are using them as a prop, basically.
So that was one theme that was coming out in the press coverage. But then when we looked at farming press, veterinary press, and some policy documents, there was an uncertainty about responsibility for the development of AMR at all. So it's sort of not really being sure whether we should do something because we're not sure if we are part of the problem.
But particularly in the farming press, they found that farmers, despite this uncertainty, were keen to take voluntary action to preserve public image. So farmers are really on board with responsible medicine use, and they, they do realise that it's, that it's important. And I think we need to sort of keep up with them on that.
There was a recent survey conducted for the Royal Association of British Dairy Farmers, and it found that 97% of farmers surveyed. Believed that they needed to play their part in tackling AMR. 85% believed they could refine and reduce their own use of antimicrobials, and they were talking about being able to realistically make an average reduction of 30% of dryotherapy, 20% in clinical mastitis cases, or 15% of antibiotics that are used in their calves.
These are really exciting findings, I think. And there, there are some issues with the survey in that, you know, you're gonna get the more proactive farmers who are receiving and responding to these surveys, but it does show that our farmers, they don't just want to do something. They believe they can actually do it and that they can make significant reductions in their antimicrobial use.
It's all too easy for us to assume that farmers won't be happy if we talk about reducing their antimicrobial use or restricting the use of certain types of antimicrobials. In reality, we would be facilitating changes that the farmers are already asking for and that they want. Values, perceptions and behaviours surrounding veterinary medicine use.
There's a huge knowledge gap at the moment in this area, and a deaf refunded report fairly recently from Exeter and Bristol universities did find that, When it comes to veterinary medicines, the behaviours of farmers are really, really poorly understood, and it recommended that in order to better understand these decisions, we needed to use a n a combination of quantitative and qualitative research. It's all very well knowing exactly what's being used on a farm, but it doesn't help to explain why. So to answer those questions, we need to understand the context, to ask what it is that's influencing these decisions and the social and cultural factors that are involved.
By using some of the research methods that I described earlier in this presentation, it is possible to begin to explain why certain treatment decisions are being made, and importantly, to identify areas for possible intervention and behaviour change. OK, so here are just a few quotes that were in that report. They're from pig farmers and poultry vets and farmers.
And they interviewed a number of these farmers and vets about their views on antimicrobial use within the industry. And it does show that there really is a mixture of views out there. So one pig farmer felt that the overuse of antibiotics in humans was the greatest danger.
So, you know, it's kind of shirking responsibility a little bit there. You've got a poultry farmer, a poultry vet, sorry, who believed that if you reduce the use, then you might increase the efficacy. Of the drug, and we had another one who believed it was possible to be drug free, although I'm not sure that that's really our ultimate aim in the industry, for myriad reasons.
So, I thought I'd talk to you a little bit now, just about the research that I've been doing for the past couple of years. So I've been looking at understanding veterinary medicine use on UK dairy farms as a free year full-time PhD which I'm now in the final year of and beginning to write up my findings. Farms were purposeively selected, so I selected farms in order to represent varying cow numbers, different management types and different production goals to try and reflect the UK sort of dairy population in general.
And these farms were nominated by their veterinary surgeons and were served by 9 different veterinary practises in 6 counties across the southwest of England and South Wales. It's really a sort of truly mixed methods, approach to research. So I enrolled 26 farms on a purely, purely quantitative 12 month medicine bin audit.
Where I was comparing their medicine use as recorded by Veterinary sales data with their own farm medicine records and with the contents of these medicine waste bins that I placed on farm. So I spent 12 months being a glorified bin man, essentially, and counting all the waste of these farms. And in parallel to that quantitative work to try and measure and sort of assess how accurate record keeping was, I've been conducting ethnographic research.
And that's seeking to understand why farmers use the medicines the way they do. So I've been collecting semi-structured in-depth interviews with these farmers and looking at exploring their values, their beliefs and motivations. I've also conducted a 12 month intensive participant observation across 3 different dairy farms of different sizes and management types, gathering over 150 hours of data on their veterinary medicine use.
So some of the quotes I thought I'd just put up that have come out and illustrate some of the findings that I've got. So I was asking a little bit about the use of critically important antimicrobials, and views really were quite varied. So we did have one farmer who is using safety for as much as he can before it's taken away from him, which is not really what we wanted to hear.
But the other farmer says that he stopped using CIA's ages ago, and the only thing that's changed is that his bills got smaller. As with vets, risk averse behaviour is quite common among farmers, and they have an equal dislike of uncertainty. So we've got one farmer talking about, I was talking with him about the dry his dryotherapy while I was with him in the pit drying off cows, and I asked him whether they'd considered using selective dryotherapy on the farm.
And he was really wasn't keen, and he thought, you know, using these dry cow tubes is cheaper than a dead cow. And he just believed that the risks of selective dry co therapy outweighed the benefits. So for him, it just wasn't gonna happen.
Another farmer believed that farmers simply aren't taught enough about which antibiotics to use and when. So she has actually seen her dad in the cupboard, as she says, literally picking up different bottles of antibiotics and thinking, hm, which one today, which again, I probably wouldn't say fits within our definition of responsible use. Some other themes that emerged are the tensions that are present on most farms.
This was really interesting because it was tensions between the different people who work on that farm, so the different members of the team, so be they staff or family members. And the only farms where this wasn't an issue was one man bands where there were no other staff. The term power and agency are quite popular among social scientists.
It basically describes whether a person believes they have the power to make decisions and to take action. And this is a common tension on farms, either because there are issues with succession planning and decision making, who's making the decisions and a bit of a power struggle, or because of perceived poor management. This is coupled then with whether the farm manager or key decision maker actually trusts in their staff.
Do they believe that they'll carry out their wishes and administer the treatments correctly? Surprisingly, there's often quite a lack of trust there, which leads to decisions on treatments being made differently depends on, depending on who's making them. It does really all come down to trust, and this is trust in the vet.
It's trust in the staff on the farm, and it's also trust in the drug and whether the drug's gonna work. So there's mounting evidence to show that farmers Don't do what the vets expect with their medicines. And there have been several studies that show this, coming out of Europe, mostly.
I was often guilty when I was a vet of assuming that when I left medicines on medicines on farm, they'd be being used as I intended, as I said, but it's just not the case, a lot of the time. So there's evidence already out there that farmers will regularly exceed data sheet guidelines when treating mastitis. And in pigs, they're often both underdosing and overdosing.
Within my study, it's emerged that extending mastitis treatments to 5 or 6 tubes is very common. And also that some farmers are doing something called double tubing, but I had not heard of when I was in clinical practise, where they're putting 2 tubes into the affected quarter at the first treatment to, to get her kickstarted, as they say. And I really genuinely didn't have any idea that that was happening.
And when I asked the farmers about it, they said, oh yeah, I don't think the vet knows I do it. I just think, you know, it's such a small tube and she's giving 40 litres and it's such a big udder that it makes sense in his mind. So what are farmers actually doing?
From my research, these are some of the ways that farmers are using medicines in ways that maybe we don't realise or haven't measured. And sometimes it's because the vet has advised them to, but sometimes the vet has no idea that this is happening. So, like I said, we've got exceeding data sheet guidelines being really common, as is using expired medicines.
So using expired antibiotics. Is a really common practise, and I think we probably knew that that was going on. We don't really know how, what, how that has an effect because there are no studies to show whether expired antibiotics are less efficacious, but we kind of assume that's probably the case.
As I mentioned, we've got the double tubing with mastitis. We've got a lot of medicines being used off licence, especially these poultry antimicrobials that are used for foot baths. And when it comes to vaccine storage, my study really backs up another recent project that was led by Paul Williams from MSD, and that showed that they're commonly stored incorrectly and therefore are going to be very, a very questionable efficacy by the time they're being used in the cows.
So what is it the farmers actually want from us, want from their vets? They've explicitly stated in my study that they, they have a preference for simple set protocols for treatment. If there's more than one member of staff, this is what they want on their farms.
Laminated posters in the dairy are quite popular, but farmers really believe it's important that these are specifically tailored for their farm and that they're not gene generic protocols. If they think it's a generic protocol, they don't, they're not interested in it. They agree that they've probably already got these protocols in their herd health plans, but that their herd health plans are on a shelf somewhere.
So it's maybe printing these things off and laminating them for the farmers, and I know a lot of vet practises are doing that already. They do enjoy health planning, from what they're telling me anyway, when it's seen as practical. So health planning simply for farm assurance sake is often seen as a box ticking exercise.
They value the time it takes to talk with their vet, and they'll often utilise time when the vet's doing other things on the farm. So we have to be really good at multitasking because when we're doing routine fertility work or TB testing, that, that's when they really want to be picking our brains about this stuff. They do really want consistency between vets, and they have stated more than once that sometimes you'll get different vets out on farm and they'll give them completely different drugs and different advice.
And again, this is, this causes some stress for the farmers and some ambiguity around prescribing, and we could be alleviating this by using practise protocols for, so not just having farm-based protocols, but having practice-based ones too. And at the end of the day, farmers want healthy cows and smaller bills. They are intrinsically motivated towards health planning and responsible use, so don't underestimate that motivation.
So can we change behaviour? Should we change behaviour? We have to consider the context and what will work for some farms might be impossible for others.
And there are many different pressures on farmers. Press of time, resources, money. We need to be empathetic and to try and understand the context that the farmers working within.
The traditional paternalistic approach of the vet, telling a farmer what to do just doesn't really work. There's a lot of evidence for that. And we need to create a partnership approach to this where We can work out how a farmer can come up with their own solutions that work within their own context.
And in all of this, the vet farmer relationship, it really is special and it's key, so we need to be quite proud of that. So just a little bit now at the end about what methods maybe can be used to to encourage change and behaviour change, improving our relationships with our farmers and encouraging their participation and engagement. This list shows a few of the successful methods employed by a fellow researcher at the University of Bristol, Lisa Morgans, to reduce antimicrobial use on dairy farms.
She's, running a project where she's Facilitating farmer groups where around 5 farmers are meeting monthly to 6 weekly on each other's farms. And they're having facilitated sessions, which include farm walks, mapping exercises, developing antibiotic reduction plans, and reviewing the antimicrobial use through benchmarking. And what's really important here is that it's facilitated, so someone's there to help guide the conversation, but no one's telling them how to do it.
They're coming up with the changes that they're making themselves, and it's proving to be It's proven to be really popular and successful and the engagement with the process has been excellent. So if this is something you want to know more about, then you can get in touch, I can put you in touch with Lisa about that. There's another quite exciting tool for encouraging encouraging behaviour change, and it's a technique some of you might have heard of called motivational interviewing.
So this describes itself as a person centred, goal-oriented methodology for eliciting and strengthening intrinsic motivation for positive change. As you can tell, it is very American based when they came up with that. But It's a technique that was originally developed to help medical clinicians who are working with people suffering from drug and alcohol addiction.
It brings about behaviour change by helping people examine their own ambivalence to change. So it really is an evidence-based approach because there are over 500 controlled trials, most of which showing positive outcomes, and it's recently being studied in the in the veterinary context here in the UK. So why does it work?
Well, I'm not actually an expert on this methodology by a long way, but I do share an office with someone who is, Alison Bard, and she lent me these slides and she says that the technique's been so widely adopted in human medicine for these reasons that, It's compatible with most consultation-based conversations. The techniques is quite simple, the changes are observable, and they're measurable, so it's quite easy to trial. But what do we mean by ambivalence?
Well, it's basically when you're stuck on the fence. So if we're thinking about a conversation we're having with a dairy farmer, we're suggesting that maybe more regular foot trimming would be of benefit. The farmer might be ambivalent to carrying out this change.
So on the one hand, I want to reduce my lameness, but on the other hand, I'm just too busy to fit it in. So here we have an example of change talk, I want to reduce my lameness and sustain talk. Well, I'm but I'm too busy to do it.
This is quite a busy slide again, but it's, it's required, it's just showing that what motivational interviewing requires is for us to communicate with our clients in a way where we're invoking this change talk and we're softening and minimising the sustained talk. So it's partnership, empathy and acceptance. It's about strategic listening, reflective listening, seeking collaboration, asking open evocative questions while maintaining a focus and summarising what's already been said.
And it really shapes the client's confidence in their ability to change. So, what we're seeking to do is to emphasise the farmers' control on decisions and change, to seek their permission, either implicitly or explicitly, and to really affirm their strengths, abilities and behaviours, and be quite generous in that. So flattery does go quite a long way.
What we need to avoid and what vets have occasionally been guilty of is persuading farmers using compelling arguments or facts. That actually just entrenches the farmer further in their sustained talk. So arguing, disagreeing with, blaming or criticising farmers is simply not gonna work.
Giving opinions or solutions to problems without, you know, putting context there that the farmer has a choice, again, isn't really something that is gonna be a good thing to do. So, Thank you very much for your attention for the last 50 minutes or so. Hopefully, you do now feel a little bit more able to achieve these learning objectives.
And we've looked at the differences, we've looked at some of the key methodologies, how it can help us to understand use and how it can help us. Well, apply this understanding to facilitate some practical changes on farms. So in conclusion, just quickly, because I feel like I'm probably running over, it's vitally important to use social science and qualitative research.
Prescribing and use is really complex and multifactorial. Behaviour change, it is possible and it is plausible where it's informed by research. And using participation, motivational interviewing, they can be really powerful tools for changing antimicrobial use and behaviours.
So just an acknowledgement slide there, thank you again very much to the BVA, the webinar at Bristol, my supervisors and you guys for all listening. Thank you very much, and I think there's some time for questions, hopefully. Yes, there is, and thank you very much, Gwen.
It's always really satisfying. It's sort of ending a, a, a Friday, a long week on some really good learning, actually, that is really affecting the veterinary profession. And very interesting to hear what you're working on and get those views out there.
And, and as you said, it's something that the British Veterinary Association is, is working hard on as well. So brilliant that you can bring all that to everyone who's listening today. We do have some questions.
And somebody has asked around when, I think when You were talking about a farmer picking off the shelf, which one today. Is that the result of the UK's laissez-faire attitude to farm antibiotics and Scandinavian POMs are very much more precisely prescribed. So I suppose this question around, do you feel that is there a model in another country that's doing it better?
Or do you think that from what you've seen going forward, regulation has to be part of this as well? Well, I mean, that's an excellent question, and it's really pertinent, and it's something that we've all been asking ourselves. I think it's quite dangerous to compare our sort of prescription sort of system to that of some of the Scandinavian countries because our the veterinary profession is very different and their agricultural landscape's very different.
So. In those countries, dairy farms are really quite small. If you've got a vet having to go out and make prescription decisions every single time that there's a sick animal in this country, that's simply not going to work.
So we do have to work within the constraints that we have. And I'm not, I don't think anyone's advocating that we remove the choice and, the ability to administer treatments from farmers. I think what I would say that it shows is that there needs to be more education of farmers out there.
Most of the farmers on my study had at least an MBQ in agriculture. But they all said that they didn't get taught anything about responsible medicine use during these agricultural sort of college degrees and MBQs and things. It's, it's not being taught and there there is a real appetite to know more about it.
So I think, I think that's where I'd put the emphasis with, with that particular quote that came out of my study. Yeah, thank you. And I think the education pieces come up a few times in questions that are coming through, and a little bit on the, the other side where it doesn't go quite so well, and somebody's mentioning around country file where a farmer presenter was shown giving their, their animals a jab of something and a jab of antibiotics, and actually it wasn't explained in the media there.
So I think there was a concern around education. On that. And another question coming in around, when you were talking about herd health planning, how do we, how do we get it so that the herd health planning is more meaningful, etc.
Rather than relying on being on farms when we're TB testing, etc. To try and, and, and use that as a way of educating, etc. How do we get these herd health plans embedded in practise?
And somebody's, saying on here around in other sectors, particularly in the more intensive sectors around poultry, where vets are very integrated into the business, that kind of herd health planning is, is an absolutely key part of the, the structure of the business. So how do we get that on, on dairy farms? Well, yeah, that's a really good point and really good question again.
I think it will become increasingly important to farmers as well, this more intensive and more practical herd health planning. So we're, we're moving in the right direction. I think as vets, one way to improve the sort of practicality of it is maybe to take that herd health plan away from the kitchen table and away from that cup of tea, sorry, but to take it out and do a farm walk while you're talking about stuff.
It really, it it it It helps to encourage the farmer to engage and to maybe explain the constraints that they have when you're saying, I think you should do this. They can point out the reason that maybe they can't, and it it makes it a bit less paternalistic. It's more of a conversation.
It's more participatory, and it's a lot more practical. So you're gonna see things and do things and spend more time and develop that relationship with that farmer. If you just take it outside, I I'd probably say that that's one small step.
Yeah, thank you. And, and actually make it important in its own right. Someone's saying, what, what do you feel about the, World Health organisation in alluding that vets contribute to antimicrobial resistance in humans?
I, I think this is alluding to it, the most recent, WHO paper that came out around the critically important antimicrobials. Yeah, I think, again, we have to be careful. There is, there is still such a lack of research in this area, but the research is showing that there is a link between the use of antimicrobials in agriculture and the amounts of AR that's being found in humans as well, so they're not wrong in saying that we have ear responsibility, but perhaps the wording can be a little, well, not inflammatory, but just a little bit blame gamey sometimes.
So I think it's very easy to be defensive as vets and feel like we're under fire. But we do need to take some responsibility because we do have some responsibility in this area really. Thank you.
And again, I think when we talk to. Jude before, it was asking, you know, what would be your sort of three top tips to take away when discussing with farmers around antimicrobial microbial usage on the farm. Yeah, that's a really good question actually.
. Just asking them what they think they can do. So like I said, it's this stuff that comes out of the multifacial interviewing and from communication skills, and it's not something that I feel like I was particularly taught well at uni or it was very much in its infancy, but it's, it's seeing what is the, what is it that the farmer wants, not just what your agenda is when you walk on the farm and think, yes, I can change this, that or the other. What does, what's the priority for the farmer?
What are the sort of low hanging fruits? So is it moving to selective dry? Therapy, is it stopping using antibiotic foot baths.
So go for the low hanging fruit always first, because it's an easy win. And yeah, just a really participatory approach. I'm not sure if that was 3, but that's no, that's great.
Thank you. I, I'm with time for one last question. We've talked quite a lot about, the farmer and vet relationship, but what about when a vet down the road is selling antimicrobials that another practises is saying shouldn't be used?
How do we deal with that as a profession? That is the million dollar question, isn't it? Yeah, that's obviously a really difficult one, and it is something that.
I, I've heard said and does happen, definitely, but there are a lot of practises, particularly in the Southwest because that's where I, where I'm sort of based, so that's where I know who have successfully reduced their antimicrobial use and their farmers have stayed with them. They've As I've shown in my presentation, farmers are on board with this. They, they want to be doing something about it.
You might have some farmers that you lose, but you'll gain others for being a proactive practise that looks like it's really doing something about it. So I think overall, it, it shouldn't have too great an effect, hopefully. Well, thank you very much.
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