The following sections consider important AMR-related aspects of the broad behavioural domain of interactions between vets and pet owners, firstly from the perspective of vets, then from the perspective of pet owners.
Vet perspectives on AMR-related interactions with pet owners
Vets gave their perspectives on their interactions with pet owners, and identified the behaviours, and barriers and facilitators they thought contributed to inappropriate antibiotic decision-making. These relate primarily to perceived pressures from pet owners and possible discussions around antimicrobial resistance.
Perceived pressures from pet owners that influence antibiotic decision making
Vets reported that their interactions with pet owners were complex when it came to their decision making concerning antibiotics. There was a common tension between an awareness of the need for AMR stewardship and the perceived satisfaction of the pet owner. The satisfaction of the pet owner, from a vet perspective, was dependent on a myriad of factors which extended beyond the appropriate use of an antibiotic relating to clinical need, including: payment for consultation and the expectation of active treatment; ease of administering the treatment; previous experiences with receiving antibiotics for their pets; and pet owners’ emotional connections with their animals. Vets commonly reported prescribing ‘just in case’ in response to their perceptions of client anxiety about pet health and welfare. From the vet’s point of view, clients appeared to expect the provision of a clearly defined treatment (i.e. an antibiotic prescription), as the following example indicates:
There's a pressure when an owner comes in and pays 35 or 40 pounds , for a consultation, because their animal is unwell, that they want to go home with a medication that in inverted commas “fixes” their animal, and even though the bill will be higher with that medication, so you sort of have that feeling that if you have an unwell animal and if you send it home with nothing then you'll get a raised eyebrow, or for example they will say to you, “Well, so and so , the senior partner gave my older dog antibiotics just last week for similar symptoms” so, you know whatever, but there is a sort of general expectation I think of owners, that you will treat their animal when they pay for a consultation. (Vet 10)
As this extract suggests, expectations from clients to prescribe antibiotics were often inferred rather than explicitly stated. Vets saw that pet owners appeared to perceive prescription as a binary of presence or absence of treatment and therefore action versus inaction. Prescription appeared to be received as a measurable, visible action taken for the health of the pet, whereas a lack of prescription meant nothing was being done to help the animal.
Tacit pressure was also framed by vets in terms of pet owners’ expectations for transaction, that is, payment exchanged for a tangible outcome in the form of medicine for the pet. This expectation was exacerbated by the fact that veterinarian practices are profit making enterprises, and seeking to keep customers loyal, sometimes against appropriate clinical action. This pressure was felt by vets because customers are able to go to other practices where they may get what they want:
Yeah, I mean these people are our customers and they are, what keeps the business going, so if we annoy them and there is another vet practice they can go to where they may just be handed out antibiotics, and [the vet] might take the opinion “well, here’s a client, if I give him a course of antibiotics, he’ll just take his dog to me from now on and I’ve gained a client” (Vet 1)
These market pressures can therefore be construed as potential drivers of inappropriate antibiotic prescribing among other mechanisms. Other vet accounts show that the AMR related consequences of over-prescription are not high on their agenda when acquiescing to pet owner pressure to provide treatment. Vets cited professional tendencies to prescribing, i.e., giving animals antibiotics as a quick and easy way to deal with an infection, even if that was not necessarily the best course of action:
So for example, if you’ve got a cat with cystitis and a lot of [vets] will give them antibiotics when actually a lot of them don't need antibiotics. So I think a lot of is through fear as well. You want to make the animal better, therefore you think oh sod it, I'll just give them a jag. (Vet 13)
As this quotation indicates, the risks involved in inappropriate use of an antibiotic were outweighed by the risk losing a client. Potential, ambiguous and non-present consequences of AMR for vets were not as salient as the present lived experiences of pressure from pet owners, and business pressures around client satisfaction.
Discussion of AMR with pet owners that influence antibiotic decision making
Vets were asked to what extent they felt they could use the concept of AMR to negotiate with pet owners in the interactions described above, to improve overall antimicrobial stewardship. Vets identified that pet owner understanding and willingness to discuss antibiotics and AMR were important determinants of their eventual prescribing decisions. The majority of vets reported that their clients tended to have some knowledge of the importance of correct antibiotic use; particularly that partial use of a course of antibiotics, or using them unnecessarily, had some kind of negative effects concerning future treatment outcomes. However vets reported a general lack of knowledge of the wider and longer term, inter specifies effects of over- or mis-use of antibiotics, and an almost total lack of knowledge of about the phenomena of AMR. This was also borne out in data from pet owners. Vet accounts also reported that clients were often unaware of disease processes. The limits of pet owners’ knowledge about appropriate antibiotic use could lead them to believe that an antibiotic would be appropriate treatment when it would not be suitable, for example, for a viral infection:
They'll be a little bit annoyed that I haven't really given them anything, even though there's nothing that I could really give them that would improve their cat's position. And a lot of the time, they will sort of be like, well, what about some antibiotics, what about this, what about that, and I'll have to be, like, well, no, your cat doesn't need it and it's not going to help. But they sort of feel like I'm not really listening to their issue or that I'm not trying to help their cat because I'm not giving them this medicine that they perceive will be helpful to them, basically. (Vet 3)
Most vets in the sample perceived that whilst this lack of knowledge was an issue, awareness was improving, making it easier to carry out AMR negotiations without jeopardising pet owner satisfaction. However, some vets reported that there were still those who would not engage in discussion about appropriate use of antibiotics:
You can tell very quickly if someone’s going to be receptive to that [appropriateness of antibiotics] conversation or not, and if they’re not, then obviously sometimes you just have to accept that that’s what the client wants, and if we don’t do that then the animal is going to suffer anyway, so we just say, well, there’s no point even discussing this. (Vet 15)
This extract shows that vets are required to make judgements which balance outcomes for clients and pets, revealing prescribing decisions to be complexly embedded in management of the pet’s illness, the owner’s expectations and the reality of a competitive business environment. Antimicrobial stewardship does not easily factor into these complex deliberations.
Vets also reported that their professional experience played an important role in empowering them to be able to assert a more appropriate course of action, skills which took time to develop:
I think a lot of it boils down to communication, and it does get easier as you get older. As a younger vet - I'm kind of middle aged now, somewhere in the middle - as a younger vet, it's difficult, you often feel pressured from clients, you feel pressured to conform to what the older vets would do, if they would do something in a certain way. But now that I'm an established vet in my own right with my own ideas and opinions, as long as I get the time to actually communicate that with the client and talk effectively, I can usually talk them round to my point of view and they will see that's reasonable enough, yeah. And I think it depends where you work. If you're in a very busy practice or if you're a younger vet feeling pressure from clients or from senior staff, then it is going to be difficult, you're just going to grab the antibiotics, that's the easy option. (Vet 2)
This account reflects the social norms and dynamics which influence prescribing decisions and underlines that the development of communication skills was an important factor in being able to negate pressures from misinformed pet owners and, it seemed, other vets. Identifying and sharing these skills could be a useful tactic for the advancement of stewardship.
Pet owner’s perspectives on AMR-related interactions with vets
Pet owners also gave their perspectives on their interactions with vets, and identified the behaviours, and barriers and facilitators they thought contributed to antibiotic decision-making and antibiotic use for their pets. These relate primarily to pet owner expectations around antibiotic prescribing and discussions related to antimicrobial resistance.
Pet owners’ expectations of antibiotic use
In contrast to vet perspectives that pet owner satisfaction was the main source of inappropriate prescribing, pet owners, on the whole, denied that they would be dissatisfied if their pets were not prescribed antibiotics. The majority of our respondents indicated that they would follow the vet’s instructions because they perceived vets to have expertise in an area where they had little to no knowledge.
I would say ultimately it’s my decision but the vet is the expert… I mean if they tell me it’s needed, I’ll not, I’m not going to, I might try and ask sensible questions… but I’m not going to dispute that. (Laura, dog owner).
However, some participants reported that they thought it was vets who promoted antibiotics unnecessarily:
But I have been to the vet before and got antibiotics and questioned it and asked why they were taking them, when, where… they said right we’ll put them on antibiotics and I said I’m not really sure that they need them and do we really need to go ahead with them and they said to me, yes we really, really, need to go ahead, then I would go ahead with it. But there has been instances where I’ve said, I don’t, I’m not sure that we need them, are you absolutely sure? And they said OK, no. We’ll wait a while. (Andrea, dog owner).
Andrea’s account of questioning the prescription was rare in our interviews as most reported that they had not had any disagreements with vets over their expectations that antibiotics would be prescribed. Some pet owners reported assuming that antibiotics were required and had those assumptions negated by the expertise of the vet. However, in contrast to vet perceived risks of not keeping the client satisfied, there were no cases where pet owners had major disagreements which resulted in moving to other vets. These accounts indicate that pet owners may differ markedly from vets regarding their experiences of interactions and that there was a shared tendency among pet-owners and vets to externalise the drivers of inappropriate prescribing. This understandable self-protecting bias among both vets and owners is an important consideration for the development of effective stewardship, as we discuss below.
Pet owners’ understanding of AMR
As with vets, being able to understand and discuss AMR was seen by pet owners as an important factor for their own enactment of stewardship principles.
The majority of pet owners reported that they did not know about AMR, particularly in relation to their pets, confirming the reports of vets described above. While most pet owners did not know about AMR, the majority of participants did have an awareness of “superbugs”, which they described as being primarily hospital-based resistant infections such as MRSA. This awareness was mainly credited to news media. Only a few spoke in specific terms about AMR, for example, the mechanisms through which it might develop and what impact improper use of antibiotics might have on its development. It was usually discussed in more general terms:
“I think we’re just reaping the [consequences] of maybe people having antibiotics unnecessarily.” (Maura, dog and cat owner).
Even fewer pet owners had an understanding that AMR was an issue for animals and a very small minority knew about interspecies transmission. When participants were prompted about AMR specifically in animals, the large majority referred to antibiotic use in farming:
I'm sure there was something on the BBC news about pigs, I'm sure there was pig farming because I was just tuning in and out of it. I wondered why they had pigs and then they had people in a hospital bed and I was getting them confused. I know it was something about pigs being prescribed antibiotics and that is somehow having a knock on effect for us [laughter] but the steps on that chain I'm not sure about. (Rosemary, Dog owner)
This lack of awareness of AMR in pets, let alone interspecies transmission risks, implied that it was highly unlikely that pet owners would be able to broach the topic with vets, take AMR into account in the treatment of their pets, and participate in decision making concerning antibiotics. These perspectives indicate that AMR literacy and scaffolding of antibiotic decision making may be important for pet owners.
Another challenge for pet-owners was the long term and collective nature of AMR which was not easily related to their own immediate predicament with their pet in the present:
I suppose with any of these future problems, problems are easily described as being something that’ll affect us in the distant future, there’s an issue with knowing how serious a risk is this, how much needs to be done now (Dave, Dog Owner)
As in this example, for most pet owners, AMR was perceived as distant, future problem, with many ambiguous and unknown dimensions. Some participants contrasted the seemingly distant threat of AMR with the immediacy of their pets’ health, which was more directly experienced as part of their everyday lives, and therefore of a bigger influence on decision-making processes about antibiotics. AMR was of such negligible concern, due to its abstract, complex and temporally distant nature, that it did not influence decisions about the immediate concern of pet health and wellbeing. In contrast, the suffering of the animal that many considered to be “part of the family” was a visceral, potently experienced phenomenon that pushed individuals to make financial and other sacrifices to ensure their pet got better.
Figure 1 summarises results influences on pet owner and vet behaviours.
