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Antibiotic resistance: a multimethod investigation of individual responsibility and behaviour

PhD thesis
Mirko Ancillotti
Publication year: 2021

The rapid development of antibiotic resistance is directly related to how antibiotics are used in society. The international effort to decrease and optimise the use of antibiotics should be sustained by the development of policies that are sensitive to social and cultural contexts.

The overarching aim of the thesis was to explore and discuss the Swedish public’s beliefs, values and preferences influencing engagement in judicious antibiotic behaviour.

Study I explored through focus group discussions lay people’s perceptions and beliefs about antibiotics and antibiotic resistance. The Health Belief Model was used to identify factors that could promote or hinder engagement in judicious antibiotic behaviour. Participants found antibiotic resistance to be a serious problem but were not equally worried about being affected by it. There was a tension between individual and collective reasons for engaging in judicious behaviour.

Study II explored lay people’s views on the moral challenges posed by antibiotic resistance through focus group discussions. Participants identified in the decreasing availability of effective antibiotics a problem of justice, which involves individual as well as collective moral responsibility. Different levels of policy demandingness were discussed in light of these results.

Study III investigated, through an online Discrete Choice Experiment, public preferences regarding antibiotic treatment and the relative weight of antibiotic resistance in decisionmaking. Public behaviour may be influenced by concerns over the rise of antibiotic resistance. Therefore, stressing individual responsibility for antibiotic resistance in clinical and societal communication may affect personal decision-making.

Study IV clarified the notions of collective and individual moral responsibility for antibiotic resistance and suggested a virtue-based account thereof. While everyone is morally responsible for minimising his/her own contribution to antibiotic resistance, individuals do or do not engage in judicious antibiotic behaviour with different degrees of voluntariness.

The findings suggest that people could change their behaviour due to concerns over their own contribution to antibiotic resistance. Effective health communication should be developed from an appraisal of people’s attitudes, beliefs and social norms that influence antibiotic resistance related behaviours. Policy demandingness should take into account socioeconomic factors characterising local realities.

Preferences regarding antibiotic treatment and the role of antibiotic resistance: A discrete choice experiment

Mirko Ancillotti, Stefan Eriksson, Dan I Andersson, Tove Godskesen, Jessica Nihlén Fahlquist, Jorien Veldwijk
International Journal of Antimicrobial Agents, Vol 56, Issue 6, Art 106198
Publication year: 2020



To identify preferences of the Swedish public regarding antibiotic treatment characteristics and the relative weight of antibiotic resistance in their treatment choices.


A questionnaire including a discrete choice experiment questionnaire was answered by 378 Swedish participants. Preferences of the general public regarding five treatment characteristics (i.e., attributes) were measured: Contribution to antibiotic resistance, Cost, Side effects, Failure rate, and Treatment duration. Latent class analysis models were used to determine attribute-level estimates and the heterogeneity in preferences. Relative importance of the attributes and willingness to pay for antibiotics with a lower contribution to antibiotic resistance were calculated from the estimates.


All attributes influenced participants’ preferences for antibiotic treatment. For the majority of participants ‘Contribution to antibiotic resistance’ was the most important attribute. Younger respondents found contributing to antibiotic resistance relatively more important in their choice of antibiotic treatments. Choices of respondents with lower numeracy, higher health literacy and financial vulnerability were influenced more by the cost of the antibiotic treatment. Older respondents with lower financial vulnerability and health literacy, and higher numeracy found side effects to be most important.


All attributes can be considered as potential drivers of lay people’s use of antibiotics. Findings also suggest that the behaviour of lay people may be influenced by concerns over the rise of antibiotic resistance. Therefore, stressing individual responsibility for AR in clinical and societal communication has a potential to have an impact on personal decision making.


  • Antibiotic resistance
  • Discrete Choice Experiment
  • PreferencesSCImago Journal & Country Rank
  • Communication
  • Behaviour
  • Sweden


An effort worth making: A qualitative study of how Swedes respond to antibiotic resistance

Mirko Ancillotti, Stefan Eriksson, Tove Godskesen, Dan I Andersson, Jessica Nihlén Fahlquist
Public health Ethics, phaa033
Publication year: 2020


Due to the alarming rise of antibiotic resistance, medically unwarranted use of antibiotics has assumed new moral significance. In this paper, a thematic content analysis of focus group discussions was conducted to explore lay people’s views on the moral challenges posed by antibiotic resistance. The most important finding is that lay people are morally sensitive to the problems entailed by antibiotic resistance. Participants saw the decreasing availability of effective antibiotics as a problem of justice. This involves individual as well as collective moral responsibility. Yet, holding agents responsible for their use of antibiotics involves varying degrees of demandingness. In our discussion, these findings are related to the contemporary ethical debate on antibiotic resistance and two proposals for the preservation of antibiotic effectiveness are compared to and evaluated against participants’ views.


Antibiotic resistance



SCImago Journal & Country Rank

Public awareness and individual responsibility needed for judicious use of antibiotics: a qualitative study of public beliefs and perceptions

Mirko Ancillotti, Stefan Eriksson, Jorien Veldwijk, Jessica Nihlén Fahlquist, Dan I Andersson, Tove Godskesen
BMC Public Health, Vol 18, Art 1153
Publication year: 2018



High consumption of antibiotics has been identified as an important driver for the increasing antibiotic resistance, considered to be one of the greatest threats to public health globally. Simply informing the public about this consequence is insufficient to induce behavioral change. This study explored beliefs and perceptions among Swedes, with the aim of identifying factors promoting and hindering a judicious approach to antibiotics use. The study focused primarily on the medical use of antibiotics, also considering other aspects connected with antibiotic resistance, such as travelling and food consumption.


Data were collected through focus group discussions at the end of 2016. Twenty-three Swedes were recruited using an area-based approach and purposive sampling, aiming for as heterogeneous groups as possible regarding gender (13 women, 10 men), age (range 20–81, mean 38), and education level. Interview transcripts were analyzed using qualitative content analysis. The Health Belief Model was used as a theoretical framework.


Antibiotic resistance was identified by participants as a health threat with the potential for terrible consequences. The severity of the problem was perceived more strongly than the actual likelihood of being affected by it. Metaphors such as climate change were abundantly employed to describe antibiotic resistance as a slowly emerging problem. There was a tension between individual (egoistic) and collective (altruistic) reasons for engaging in judicious behavior. The individual effort needed and antibiotics overprescribing were considered major barriers to such behavior. In their discussions, participants stressed the need for empowerment, achieved through good health communication from authorities and family physicians.


Knowledge about antibiotic consumption and resistance, as well as values such as altruism and trust in the health care system, has significant influence on both perceptions of individual responsibility and on behavior. This suggests that these factors should be emphasized in health education and health promotion. To instead frame antibiotic resistance as a slowly emerging disaster, risks diminish the public perception of being susceptible to it.


  • Antibiotic resistanceSCImago Journal & Country Rank
  • Health Belief Model
  • Health behavior
  • Qualitative research


Uncritical and unbalanced coverage of synthetic biology in the Nordic press

Mirko Ancillotti*, Niklas Holmberg*, Mikael Lindfelt, Stefan Eriksson (*shared first author)
Public Understanding of Science, Vol 26, Issue 2, Pages 235-250
Publication year: 2017


Synthetic biology will probably have a high impact on a variety of fields, such as healthcare, environment, biofuels, agriculture, and so on. A driving theme in European research policy is the importance of maintaining public legitimacy and support. Media can influence public attitudes and are therefore an important object of study. Through qualitative content analysis, this study investigates the press coverage of synthetic biology in the major Nordic countries between 2009 and 2014. The press coverage was found to be event-driven and there were striking similarities between countries when it comes to framing, language use, and treated themes. Reporters showed a marked dependence on their sources, mainly scientists and stakeholders, who thus drives the media agenda. The media portrayal was very positive, with an optimistic look at future benefits and very little discussion of possible risks.


  • Media representation
  • Public participation
  • Science attitudes and perceptions
  • Science communicationSCImago Journal & Country Rank
  • Synthetic biology


Challenges and opportunities for ELSI early career researchers

Jessica Bell, Mirko Ancillotti, Victoria Coathup, Sarah Coy, Tessel Rigter, Travis Tatum, Jasjote Grewal, Faruk Berat Akcesme, Jovana Brkić, Anida Causevic-Ramosevac, Goran Milovanovic, Marianna Nobile, Cristiana Pavlidis, Teresa Finlay, Jane Kaye
BMC Medical Ethics, Vol 17, Art 37
Publication year: 2016



Over the past 25 years, there has been growing recognition of the importance of studying the Ethical, Legal and Social Implications (ELSI) of genetic and genomic research. A large investment into ELSI research from the National Institutes of Health (NIH) Human Genomic Project budget in 1990 stimulated the growth of this emerging field; ELSI research has continued to develop and is starting to emerge as a field in its own right. The evolving subject matter of ELSI research continues to raise new research questions as well as prompt re-evaluation of earlier work and a growing number of scholars working in this area now identify themselves as ELSI scholars rather than with a particular discipline.

Main text

Due to the international and interdisciplinary nature of ELSI research, scholars can often find themselves isolated from disciplinary or regionally situated support structures. We conducted a workshop with Early Career Researchers (ECRs) in Oxford, UK, and this paper discusses some of the particular challenges that were highlighted. While ELSI ECRs may face many of the universal challenges faced by ECRs, we argue that a number of challenges are either unique or exacerbated in the case of ELSI ECRs and discuss some of the reasons as to why this may be the case. We identify some of the most pressing issues for ELSI ECRs as: interdisciplinary angst and expertise, isolation from traditional support structures, limited resources and funding opportunities, and uncertainty regarding how research contributions will be measured. We discuss the potential opportunity to use web 2.0 technologies to transform academic support structures and address some of the challenges faced by ELSI ECRs, by helping to facilitate mentoring and support, access to resources and new accreditation metrics.


As our field develops it is crucial for the ELSI community to continue looking forward to identify how emerging digital solutions can be used to facilitate the international and interdisciplinary research we perform, and to offer support for those embarking on, progressing through, and transitioning into an ELSI research career.


  • Early career researcherSCImago Journal & Country Rank
  • ELSI
  • Interdisciplinary
  • Web 2.0
  • Collaboration
  • Networks
  • Mentoring


An update of public perceptions of synthetic biology: still undecided?

Mirko Ancillotti, Virgil Rerimassie, Stefanie B Seitz, Walburg Steurer
NanoEthics, Vol 10, Issue 3, Pages 309-325
Publication year: 2016


The discourse on the fundamental issues raised by synthetic biology, such as biosafety and biosecurity, intellectual property, environmental consequences and ethical and societal implications, is still open and controversial. This, coupled with the potential and risks the field holds, makes it one of the hottest topics in technology assessment today. How a new (bio)technology is perceived by the public influences the manner in which its products and applications will be received. Therefore, it is important to learn how people perceive synthetic biology. This work gathers, integrates and discusses the results of three studies of public perceptions of synthetic biology: (1) an analysis of existing research on how media portray synthetic biology across 13 European countries and in the USA, (2) the Meeting of Young Minds, a public debate between prospective politicians and synthetic biologists in the Netherlands and (3) the experiences of citizen panels and focus groups in Austria, the UK and the USA. The results show that the media are generally positive in their reports on synthetic biology, rather unbalanced in their view of potential benefits (emphasized) and risks (downplayed), and also heavily influenced by the sources of the stories, namely scientists and stakeholders. Among the prospective Dutch politicians, there were positive expectations as well as very negative ones. Some of these positions are also shared by participants in public dialogue experiments, such as not only the demand for information, transparency and regulation but also a sense of resignation and ineluctability of scientific and technological progress.


  • Synthetic biology
  • Public perception
  • Technology assessmentSCImago Journal & Country Rank
  • Media
  • Public engagement


Synthetic Biology in the Press - Media Portrayal in Sweden and Italy

Book Chapter
Mirko Ancillotti, Stefan Eriksson
In: Hagen K., Engelhard M., Toepfer G. (eds) Ambivalences of Creating Life. Ethics of Science and Technology Assessment. Springer
Publication year: 2015


Synthetic biology is a rapidly evolving field which potentially can change how we live in and understand the world. Given its potential impact it is important to inform and involve the public so that it gains a proper understanding of synthetic biology and is in a position to assess its future applications and implications. This study investigates through qualitative content analysis the synthetic biology press coverage in Sweden and Italy between 2009 and 2013. The three major newspapers of each country were considered a good example of what was offered to the public in a period which witnessed important scientific advancements of the field and consequent media resonance. The framing of the articles was analyzed in the light of the idea that mass media not only inform the public but also contribute to the shaping of ideas. Language was analysed and found to be generally adequate. The topics were presented in an overall positive and optimistic tone, which was reflected also in the benefits and risks envisioned. The two countries can be considered rather different in many social and cultural respects, yet besides a few differences (mainly quantitative), striking similarities were found, probably related to a marked dependence on the common sources of the articles and the lack of critical scrutiny on the behalf of the media.


  • Synthetic Biology
  • Public Engagement
  • Press Coverage 

The Value of the Pre-Person: Potentiality, Person-Maker Criteria, and Social Dimension

Mirko Ancillotti
Journal of Philosophy of Life, Vol 3, Issue 3, Pages 190-201
Publication year: 2013


There is a sense in distinguishing persons from other beings. Persons are forms of life towards
whom an agent should feel morally responsible to the highest degree. The aim of this paper is to try
and respond to the question: what line of conduct should we adopt with regard to those beings that
are not persons but that we have well-founded reasons for thinking may be so in the future? The
pre-persons are not, neither should they be considered as they were, persons. If we decide to
guarantee their existence or well-being this decision must be based on considerations that are
independent of their ontological constitution, of their actual biological status, and of the concept of
potentiality. This decision can be taken only accounting for social aspects involved in the
consideration of what a person is.


  • Person
  • Potentiality
  • Pre-Person
  • Person-Maker Criteria

John Harris. Persona, potenzialità e pre-persona

Mirko Ancillotti
Sintesi Dialettica, Vol 6, Issue 1
Publication year: 2013

Abstract (in Italian)

Secondo la nozione sviluppata da John Harris è da considerare persona l’individuo che dimostri la capacità di concepire se stesso in differenti tempi e luoghi e che sia capace di desiderare di fare esperienza di una vita a cui assegna un valore. Tale concezione viene analizzata ricostruendone la genesi, chiarendo quali criteri sottendono le scelte effettuate. L’elaborazione teorica di Harris viene posta a confronto con altre due formulazioni contemporanee, sviluppate rispettivamente da Peter Singer e Vittorio Possenti. Nell’ultima parte sono stati approfonditi criticamente due concetti che emergono dalla descrizione di Harris della persona e che sono ad essa collegati, ossia i concetti di potenzialità e pre-persona.

John Harris: un approccio razionale in bioetica

Master thesis
Mirko Ancillotti
Univeristà di Pisa. Supervisor: Sergio Bartolommei
Publication year: 2012