Sociology of Health & IllnessVolume 46, Issue 3 p. 570-571 BOOK REVIEW Gut Anthro: An experiment in thinking with microbes. By A. Benezra, Minneapolis: University of Minnesota Press. 2023. 266 pages (pbk). £21.99. ISBN: 978-1-5179-0130 (pbk); £90. ISBN: 978-1-5179-0129-5 (hbk) Catherine Will, Corresponding Author Catherine Will [email protected] University of Sussex, Brighton, UK Email: [email protected]Search for more papers by this author Catherine Will, Corresponding Author Catherine Will [email protected] University of Sussex, Brighton, UK Email: [email protected]Search for more papers by this author First published: 27 February 2024 https://doi.org/10.1111/1467-9566.13764Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume46, Issue3March 2024Pages 570-571 RelatedInformation

Antimicrobial Resistance is a threat to individual and to population health and to future generations, requiring “collective sacrifices” in order to preserve antibiotic efficacy. ‘Who should make the sacrifices?’ and ‘Who will most likely make them?’ are ethical concerns posited as potentially manageable through Antimicrobial Stewardship. Antimicrobial stewardship almost inevitably involves a form of clinical cost-benefit analysis that assesses the possible effects of antibiotics to treat a diagnosed infection in a particular patient. However, this process rarely accounts properly for patients – above and beyond assessments of potential (non)compliance or adherence to care regimes. Drawing on a vignette of a pregnant woman of colour and migrant diagnosed with Mycoplasma genitalium, a sexually transmissible bacterium, this article draws out some of the ethical, speculative, and practical tensions and complexities involved in Antimicrobial Stewardship. We argue that patients also engage in a form of cost-benefit analysis influenced by experiences of reproductive and social (in)justice and comprising speculative variables - to anticipate future possibilities. These processes have the potential to have effects above and beyond the specific infection antimicrobial stewardship was activated to address. We contend that efforts to practice and research antimicrobial stewardship should accommodate and incorporate these variables and acknowledge the structures they emerge with(in), even if their components remain unknown. This would involve recognising that antimicrobial stewardship is intricately connected to other social justice issues such as immigration policy, economic justice, access to appropriate medical care, racism, etc.

This paper addresses debates concerning the ‘participatory turn’ in healthcare. It focuses on the case of blood pressure self-monitoring, understanding this as a form of patient participation at the level of individual care. Drawing and expanding on the work of Marres and Wynne and their notions of material participation and of uninvited engagement, we examine how patients’ home blood pressure self-monitoring is incorporated into clinical care, how the materials of blood pressure self-monitoring mediate participation and how we might characterise the practices of participation found within everyday clinical care. Our analysis makes new conceptual links, suggesting that, in this context, invited participation appears to align with participation made easy, while uninvited participation involves more invested, more engaged participation. We offer two further developments of these concepts. First, we trouble characterisations of invited and uninvited participation as distinct and separate, observing movement between these. Second, through applying the logics of material participation in a new context, everyday clinical practice, we suggest that the logic of participation made easy might be extended beyond lay people, to apply to professionals as well. Our analysis illustrates how materials are mobilised to facilitate invited and uninvited participation within the context of the on-going asymmetries in doctor patient relationships.

With Microbes shows the diversity of human-microbe relationships and their dynamism, through detailed ethnographies of the relationships between humans, animals, plants, and microbes. The objective is to look at situated practices: categories mobilized by people to talk about their relationships with microbes, their practices and actions, stories people tell about microbes and materialities that are specific to them. Therefore, the volume is just as much on scientific practices of living-with-microbes as it about other ways of engaging with them. The introduction develops the notion of 'withnessing' to understand these relations. Ethnographic contributions of the book present diverse forms of microbial encounters that open up new perspectives, showing how humans and microbes compose common worlds together. Crucially, the authors and editors of this project put forward new vocabulary for describing the human-more-than-human nexus without dichotomizing between nature and culture, subject and object, human and other, etc. This is a move away from an approach that stresses on terms, entities, and individual organisms, to attend to the relationships between human-microbe entanglements, how they develop and by which they exist.

In this paper, we offer insights into practices of tracking as part of healthy living through talk about home blood pressure and weight from adults living in the UK. Drawing on theoretical resources from feminist ethics of care and Science and Technology Studies on care as socio-material practice, we build on interest in the relational dimensions of tracking and the potential for intimate surveillance and care using monitoring technologies. Our cases offer not only new perspectives in a field that has often focused on fitness tracking but also help go beyond a narrow focus on surveillance, showing how surveillance and care may be intertwined in the everyday negotiation of health-related tracking and other 'health practices' in family life. Using the diversity in our relatively large sample, and reflecting on the different types of interview completed, we highlight the varied ways in which adults engage with tracking blood pressure and weight (or body mass index) in the context of established relationships. The combination of attentiveness and appeals to responsibility for maintaining health as something owed to a partner can make tracking a very ethically sensitive area. In this paper we emphasise that reciprocity is one important way in which couples make tracking feel more like care. Tracking together or discussing it can take couples in this direction even if the actual practice remains somewhat difficult. On the other hand, responsiveness to someone else's feelings, including a desire to avoid the topic altogether, or avoid weight as a specific parameter, might all help move towards more caring tracking. We therefore develop a more sustained account of care in relation to tracking than in previous work, and a novel account of tracking as a (potential) care practice between adult partners.

This paper is concerned with everyday data practices, considering how people record data produced through self-monitoring. The analysis unpacks the relationships between taking a measure, and making and reviewing records. The paper is based on an interview study with people who monitor their blood pressure and/or body mass index/weight. Animated by discussions of 'data power' which are, in part, predicated on the flow and aggregation of data, we aim to extend important work concerning the everyday constitution of digital data. In the paper, we adopt and develop the idea of curation as a theory of attention. We introduce the idea of discerning work to characterise the skilful judgements people make about which readings they record, how readings are presented, and about the records they retain and those they discard. We suggest self-monitoring produces partial data, both in the sense that it embodies these judgements, and also because monitoring might be conducted intermittently. We also extend previous analyses by exploring the broad set of materials, digital and analogue, networked and not networked, involved in record keeping to consider the different ways these contributed to regulating attention to self-monitoring. By paying attention to which data is recorded and the occasions when data is not recorded, as well as the ways data is recorded, the research provides specificity to the different ways in which self-monitoring data may or may not flow or contribute to big data sets. We argue that ultimately our analysis contributes to nuancing our understanding of 'data power'.

Background Home self-monitoring of blood pressure is widely used in primary care to assist in the diagnosis of hypertension, as well as to improve clinical outcomes and support adherence to medication. The National Institute for Health and Care Excellence (NICE) care pathways for hypertension recommend specific guidelines, although they lack detail on supporting patients to self-monitor. Aim To elicit primary care practitioners’ experiences of managing patients’ home blood pressure self-monitoring, across surgeries located in different socioeconomic areas. Design & setting A qualitative focus group study was conducted with a total of 21 primary care professionals. Method Participants were GPs and practice nurses (PNs), purposively recruited from surgeries in areas of low and high deprivation, according to the English indices of multiple deprivation. Six vignettes were developed featuring data from interviews with people who self-monitor and these were used in five focus groups. Results were thematically analysed. Results Themes derived in the thematic analysis largely reflected topics covered by the vignettes. These included: advice on purchase of a device; supporting home monitoring; mitigating patient anxiety experienced as a result of home monitoring; valuing patients’ data; and effect of socioeconomic factors. Conclusion The work provides an account of methods used by primary care practitioners in the management of home blood pressure self-monitoring, where guidance may be lacking and primary care practitioners act on their own judgement. Findings complement recent policy documentation, which recognises the need to adopt new ways of working to empower patients (for example, additional support from healthcare assistants), but lacks detail on how this should be done.

The worldwide COVID-19 crisis has highlighted perhaps more than ever before in the history of SHI the need for a critical sociological lens alongside the clinical, public health and organisational discussion of the current pandemic as it continues through 2020. In particular, debates around social inequalities in health and medicine have received new attention globally. A research note by one of us (Will, 1) suggested in the spring that sociologists should pause and reflect as the pandemic progressed but many of us have now been able to begin empirical research on the experience of and response to the coronavirus around the world. At the same time, only some of that research is ready for publication: other projects will take time. As a result, the editorial team of this journal hesitated to assemble a special issue on the pandemic too hastily. We began by making our previous 2013 Pandemic Monograph open access online, and then invited all the authors to contribute contemporary reflections or commentaries given their expertise on pandemics before COVID-19. We are now able to launch the SHI Virtual Special Issue (VSI) with some of the results alongside a research note making a call for sociological action from Lee Monaghan. Other pieces on COVID-19 are still welcome from authors who were not in our original monograph, and a number of papers are under review or being revised as we write. We therefore hope to be able to add more empirical work to this VSI, though we note that an enormous amount of medical and health sociology research is going to focus on COVID-19 for the foreseeable future. Each piece offers something different, but rather than summarise them here in turn, we hope to offer our own reflections on the process and on the role of the journal in relation to other platforms promoting sociological understanding of the pandemic, health care and health more generally. What have we learned from producing this VSI over summer 2020? It has yielded an enormously varied set of submissions, but perhaps first and foremost it has clarified for us that whilst immediate responses are important, some are not suitable for journals, which should we believe be a place for content that will be readable and interesting in the longer term. Our ambition to publish only peer-reviewed material has also made it difficult to get things out quickly, at a time when it is hard to find reviewers and we are all too aware of the pressures on those juggling caring responsibilities with demands to reimagine teaching and research work. For those wishing to publish fast, we would probably recommend that people consider writing for the various blogs that are active on COVID-19. Cost of Living is sponsored by the British Sociological Association (BSA) to discuss the politics, economics and sociology of health and health care. Discover Society, another BSA blog, offers a broader view of sociological topics of contemporary relevance. Somatosphere, which is perhaps most clearly associated with our colleagues in medical anthropology, is also willing to consider sociological work, especially but not exclusively when it has a geographical focus beyond the global north; and Sociology Lens is a platform hosted by our publishers Wiley. Writing in these – and indeed in the media more generally – is we believe vital work. We know there is a thirst for sociological critique and analysis as people are learning to appreciate the importance of behaviour, meaning, and social and political organisation in keeping populations safe. The mention of Somatosphere is instructive for other reasons. One of our disappointments in doing the VSI is that the voices and stories from the global South have been largely lacking. In part, this is about the material submitted, but not entirely. We have learned over the summer that the difficulties getting timely reviews are magnified when the piece addresses experiences outside what Marilyn Strathern calls the ‘Euroamerican’. We continue to seek this work out actively and hope to support authors as far as we can as an editorial team, building on manifest commitment to diversifying our community and reflecting different experiences here in the UK and elsewhere. COVID-19 comparisons have not always reflected well on the UK’s National Health Service and systems of public health, but they have reminded us that international comparisons can be instructive, and help develop better theories of global processes and events. In this case, it is clearly worth spending time not only on the national and nationalistic elements of the response to the pandemic, replete with military metaphors, but also the patchwork of different ‘public’ and ‘private’ initiatives across the world. There are some other gaps in the discussion that we feel able to draw attention to in part because we participated in the Cost of Living COVID-19 panel at the BSA Medical Sociologyonline conference in early September 2020. High among those would be the politics of trust and mistrust in expertise, the national and international dynamics affecting compliance or adherence to public health measures generally and vaccine debates and the emergence and flow of different forms of knowledge. As the pandemic continues to run, we think the discipline is well placed to draw attention to and defend lay attempts to make sense of governmental messages and of the virus itself, both in general and among particular groups with good reason not to trust in experts or state agencies. Running alongside the pandemic, the Black Lives Matter movement reminds us that ethnic minorities and other marginalised groups including migrants feel victimised and alienated from the police, that disabled people feel closed out of the workplace, and racialised groups feel discriminated against in health services. For us, then the inequalities of the pandemic are no surprise, even when we are hopefully quick to organise to help address and explain them. We can also take inspiration from the well-documented examples of political organising and mutual aid in different countries, not just as a bland celebration of ‘community’ but also through very practical examples like the QueerCare protocols for community support and transfeminist advocacy. At the same time, we need to build on the research done on HIV/AIDS mobilisations to explore how different ‘lay’ understandings and indeed practices link with institutionalised knowledge-making now and in the future. We look forward to reading more of the many studies that we know are underway with some of the rapid response funding already awarded or in the pipeline, and to participating in debates about the pandemic with our readers through the journal, including its social media activity, and the other platforms recommended above, which together help make up our medical sociology community.

This note was written on 1 st April – April Fool ’ s Day - 2020 when we all vehemently wished that the global COVID-19 pandemic could be forgotten as a bad joke. I put the date because at this point it feels that no one knows where we are going over the next few weeks and months, and it is curiously exposing to write in the centre of the pandemic. Typically a research note for our journal is meant to cover ‘ a topical issue and/or an issue that has been neglected in some way, identifying research priorities ’ . It is not a form that has been much used in recent years, but I certainly do not think COVID-19 is being or likely to be neglected. Nor do I primarily want to map out research priorities for other sociologists. Some of this is being done through blogs - for example Discover Society 1 or Cost of Living 2 supported by the British Sociological Association – and sociologists have been prominent on social media offer-ing rapid responses to the crisis from different angles. While many see in COVID-19 evidence of the importance of solidarity or social protection, and threats to them from neoliberal practices, a huge swathe of other concerns and concepts in the sociology of health and illness also feel urgently relevant. However I want to start by insisting on the right not to rush to formu-late new research or draw conclusions. We have chosen as a journal not to solicit new material at this relatively early stage of the COVID-19 pandemic. No doubt numerous studies will be done but research can also take time. We suggest that our authors and readers ‘ breathe ’ when they can and research when it feels right.

Apps, websites and networked devices now offer to help consumers produce, access and share health knowledge, precipitating social scientific concern over the consequences of these so-called digital health platforms. This paper makes a novel contribution to this literature, taking up a recent call from Plantin et al. to adopt an infrastructural lens in exploring platforms. It argues, through empirical analysis of digital health platforms of different sizes, ages and nationalities, that this conceptual tool is necessary to surface the work entailed in creating and sustaining digital health platforms. Additionally, we suggest that the social scientific literature on platforms - and initial efforts to explore their infrastructural qualities - frequently focus too strongly on the dominant technology companies. Instead, we emphasise the value of drawing emergent companies' platforms into empirical purview through returning to some of the infrastructures literature that informs Plantin et al. - particularly Susan Leigh Star and colleagues. We demonstrate empirically the importance of looking at standards as part of infrastructure building, and the broader set of interconnections between different actors and materials within an infrastructure. In doing so, we demonstrate the value of an infrastructural lens for understanding the density of interconnections that characterise digital health and propose some orientating questions for further enquiry into the infrastructural qualities of platforms.

In the time of coronavirus disease 2019 (COVID-19) there are numerous attempts to compare across national boundaries and rank governments for their action against the virus. In this context the ‘universal’ ambition of the Wellcome Trust report on communicating antimicrobial resistance (AMR) is somewhat refreshing, and recalls some of the older ambition of the global health field. Though the report now feels some time ago – it was published in November 2019 - the pandemic does not mean AMR has gone away. Indeed, it may be worsened in the context of rescue prescribing, both for secondary infections following COVID-19 and other health conditions where antibiotics may stand in for scarce or compromised care. In this open letter we wish to respond to the Trust report – locating it in the field of social science work on AMR – and proposing some directions for further discussion. In particular, writing against the backdrop of the viral pandemic, we explore how both COVID-19 and AMR raise questions about our attachment to modern medicine, about the motivating value appeals to vulnerability and health inequality. We therefore call for the report and others to be the start of the further long-distance conversations and experimentation across different fields.

This article offers a critical account of efforts to engage people with the issue of antimicrobial resistance (AMR). It analyses how public health workers encourage what they understand as responsible antibiotic use or antibiotic stewardship, and how their efforts are shaped by different theories of ‘behaviour’ or social action. Discourse analysis of all major UK campaigns and their evaluations over the last two decades reveals how different versions of the citizen jostle for attention in a public health that draws on sociology, psychology, and increasingly behavioural economics. Rejecting an explanation which focuses solely on the appeal of emotion in new forms of governance, I deploy theories of expert and lay ignorance to show how public health is pushed towards new approaches as it struggles with an apparently recalcitrant public in the case of AMR. Here ignorance is both problematic and productive, prompting a shift to campaigns based on unreflective action, that are accompanied by decisions to work with potential misunderstandings about antibiotics and their effects. I suggest the term ‘shrug’ as a provocative counterpart to the ‘nudge’ of behavioural economics, drawing attention to the ways in which behavioural interventions may be linked to strategic retreats from engagement, when policy makers feel unable to affect or predict the understanding and views of non-experts. The article thus contributes to sociological and political critique of narrow forms of behavioural thinking and their effects on relations between governments and their citizens.

In the time of coronavirus disease 2019 (COVID-19) there are numerous attempts to compare across national boundaries and rank governments for their action against the virus. In this context the ‘universal’ ambition of the Wellcome Trust report on communicating antimicrobial resistance (AMR) is somewhat refreshing, and recalls some of the older ambition of the global health field. Though the report now feels some time ago – it was published in November 2019 - the pandemic does not mean AMR has gone away. Indeed, it may be worsened in the context of rescue prescribing, both for secondary infections following COVID-19 and other health conditions where antibiotics may stand in for scarce or compromised care. In this open letter we wish to respond to the Trust report – locating it in the field of social science work on AMR – and proposing some directions for further discussion. In particular, writing against the backdrop of the viral pandemic, we explore how both COVID-19 and AMR raise questions about our attachment to modern medicine, about the motivating value appeals to vulnerability and health inequality. We therefore call for the report and others to be the start of the further long-distance conversations and experimentation across different fields.

Commercial actors play a key role in promoting public health agendas as they move into space previously occupied by the state-sponsored health sector and welfare state. This paper examines how marketing of digital self-monitoring devices promotes public health. Existing self-monitoring research often separates or compares positions of commercial actors and users, using a discourse lens to examine commercial actors' 'expectations' and 'promises', and user research focusing on 'practices'. The research on which this paper is based moves beyond this divide, examining commercial and user worlds through a practice lens. We draw on the research's first stage which examined self-monitoring device marketing, arguing that marketing can be understood as constituting self-monitoring practices. Much literature on self-monitoring focuses on novel networked devices, resulting in potential over-emphasis on change and innovation. Taking cases of well-established bodily monitoring (weighing and blood pressure), we set self-monitoring within a longer history. We draw on Shove's practice theory which attends to histories of practices and evolutions in practices required elements materials, meanings and competences. Commercial companies are shown to rework well-embedded practices as they constitute the practice elements of self-monitoring. They thus keep in play continuities and novelty, maintaining connections to health while moving away from clinical associations. We argue that, in constituting self-monitoring practices as 'aesthetic', 'enjoyable', and 'shared', commercial actors address implicit resistances to negative connotations of 'individualised', 'responsibilised' consumer citizens implied in neo-liberal health-promotion agendas, widening the self-monitoring market and promoting public health by creating more desirable 'lifestyle' practices.

The growing consumer market in health monitoring devices means that technologies that were once the preserve of the clinic are moving into spaces such as homes and workplaces. We consider how one such device, blood pressure monitors, comes to be integrated into everyday life. We pursue the concept of 'care infrastructure', drawing on recent scholarship in STS and medical sociology, to illuminate the work and range of people, things and spaces involved in self-monitoring. Drawing on a UK study involving observations and interviews with 31 people who have used a consumer blood pressure monitor, we apply the concept beyond chronic illness, to practices involving consumer devices - and develop a critical account of its value. We conclude that the care infrastructure concept is useful to highlight the socio-material arrangements involved in self-monitoring, showing that even for ostensibly personal devices, monitoring may be a shared practice that expresses care for self and for others. The concept also helps draw attention to links between different objects and spaces that are integral to the practice, beyond the device alone. Care infrastructure draws attention to the material, but ensures that analytic attention engages with both material and social elements of practice and their connections.

Sociology of Health & IllnessVolume 40, Issue 3 p. E1-E9 EditorialFree Access Editorial: Beyond behavior? Institutions, interactions and inequalities in the response to antimicrobial resistance Catherine M. Will, Catherine M. Will School of Law, Politics and Sociology, Freeman Building G44, University of Sussex, BN1 9QESearch for more papers by this author Catherine M. Will, Catherine M. Will School of Law, Politics and Sociology, Freeman Building G44, University of Sussex, BN1 9QESearch for more papers by this author First published: 25 March 2018 https://doi.org/10.1111/1467-9566.12735Citations: 19AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Antimicrobial resistance (AMR) has come to prominence as a priority for policy makers and a subject for media debate, following advocacy by the Chief Medical Officer (Davies 2015). The concept refers to the emergence and spread of strains of common infections that can no longer be treated by existing antibiotic classes, as bacteria change in response to exposure to antibiotics. The concept is known to many, not least due to the work of Dubos (1959) which informed early critical accounts of biomedicine and its claims. Resistance is becoming increasingly clinically important because of the lack of new classes of antibiotics and the spread of resistance to older drugs through transfers of genetic material as well as inheritance. Recent work in sociology and science and technology studies has examined different framings of this ‘social problem’ (Brown and Crawford 2008; Brown and Nettleton forthcoming; Morris, Helliwell and Raman 2016), however sociology has not often been seen as part of the solution. In this virtual special issue, I draw attention to relevant work within the Sociology of Health and Illness and call for further research to inform policy and practical responses. Currently policy in the UK mainly draws on research data from clinical psychologists and theories popularized as part of behavioural economics or ‘nudge’. A ‘behavioural insights’ report for the Department of Health (2015) drew from these two fields, and made only one explicit reference to sociology, though some other sociological work was cited (e.g. Britten and Ukoumunne 1997; Stivers 2006). The report primarily focused on a particular type of behaviour - prescribing in primary care - seeing reducing prescribing as a type of ‘antibiotic stewardship’. Little reference was made to questions that might arise if we look at prescribing in secondary care, or indeed the experience and management of infection and medication beyond the clinic. These omissions are corrected in Fiona Wood's much broader discussion of ‘Antimicrobial Resistance and Medical Sociology’ (2016) – prepared for the ESRC – which makes numerous interesting suggestions about sociological concepts that might inform research, including theories of risk and illness beliefs and professional identity and power. However, the document mainly cites work with an explicit focus on antibiotics or invokes very general theory to suggest resources for further work. This special issue aims to take a path between behavioural analysis as the policy ‘dish of the day’ and the broad conceptual menu offered by Wood, introducing work in medical sociology that is relevant to AMR even where it does not start from questions about antibiotic prescription and use. In particular I argue for more research on the meaning of and response to different infections, building on the recent argument that the concept of resistant infections is a more intuitive starting point for public health messages than explaining ‘resistance’ as a characteristic of bacteria (Wellcome Trust 2016). For those seeking to reduce antibiotic use and the spread of infections that prompt it, research on healthcare institutions and clinical interactions also has much to offer, especially when it looks beyond prescriber behaviour alone. Finally, I suggest that reviving and extending previous sociological work on health inequalities may be important to provide evidence on the distribution of ‘need’ for antibiotics and prevent worsening inequalities through reductions in prescribing mandated by national policy. As an issue, AMR can be posed as invoking a tension between an individual with current health problems and collective, future needs that demand that we seek to preserve the efficacy of antibiotic drugs. However current health problems arise and are treated within social settings, including the family, primary and secondary health care organisations and communities. Consequently the meanings of infections and their treatment are negotiated in a web of relationships between people and technologies. Health-seeking by professionals or lay people is also balanced against other priorities and pressures. Providing information about the risks of particular actions like over-prescribing of antibiotics is not enough – often risks are known but do not shift embedded routines and ways of thinking, especially where there is a shortage of time or money (for discussion of this in relation to professional practice see Broom et al 2014). For lay people the unequal distribution of such pressures also helps explain social patterns of harmful practices like smoking and medicine use in ways that are tackled only briefly in analysis that starts from individual behaviour (Calnan and Williams 1991, Cohn 2014). In the rest of this introduction to the special issue I set out some of the ways in which our field's social and situated understandings can help inform research and practical action to conserve the efficacy of current antibiotics and reduce the spread of infections. Infections Antibiotics are an important part of the image and practice of modern medicine (Calnan and Williams 1992) and are used to counter a wide range of bacterial infections through direct treatment and prevention (prophylactic use around surgery or chemotherapy when the body is compromised). Work by Brown and colleagues helps consider the meaning of such infections, drawing attention to the wider awareness of bacterial resistance. For example, one paper shows how media reporting of the threat of methicillin-resistant staphylococcus aureus (MRSA) represented bacteria as ‘clever’ and versatile, outwitting antibiotics through mutation (Brown and Crawford 2008). The same authors consider the experience of those who had surgical site infections. Brown et al (2014) show how patients might make sense of infections acquired after surgery (known as Health Care Acquired Infections or HCAIs) and adopt their own practices for wound management, based on a complex set of beliefs about the body, threats to its health, and medical treatment. Though neither paper is directly concerned with antibiotic use these authors demonstrate how ways of framing the problem of resistant infections imply particular solutions and responsibilities. For example, they express concern that talk of ‘vulnerable groups’ and hygiene failures in institutions outside healthcare, such as care homes and schools ‘mitigates the responsibilities of hospitals and statutory healthcare providers and turns the risk back towards the individual as a responsible actor in an ecology of mutation’ (Brown and Crawford 2008 p520), and then show that patients may indeed be ready to shoulder this responsibility by narrating wound infections as their fault (Brown et al 2014). These studies offer some support for the argument that the risks of resistant infections are being discussed outside the medical profession and may be used in stewardship messages, even when the mechanisms of AMR are not well understood (Wellcome 2016). At the same time, they remind us that calling for action from particular groups risks making them feel or appear responsible – it introduces moral and political questions as well as purely practical ones. This issue is particularly clear in hospitals, when difficulties in changing the practice of senior medical professionals have sometimes led to efforts to add antibiotic stewardship to the duties of less powerful actors. Sociological work on infection management as part of hospital safety helps elaborate some of the issues here with an organizational or institutional perspective. Institutions An awareness of the difficulty of changing professional behaviour is by no means exclusive to sociology. In a study cited by the Department of Health Behavioural Insights report, Charani et al (2013) rehearse understanding that prescribing is shaped by numerous factors, including doctors’ sense of their own individual responsibility for their patient and professional hierarchies. They use the concept of ‘prescribing etiquette’ (see Armstrong and Ogden 2006) to argue that senior doctors may value prescribing autonomy highly, leading them to pay little attention to guidelines and making it difficult for more junior staff to challenge decisions. Similar and stronger pressures are felt by other healthcare practitioners. In reporting on their project on superbugs, Crawford and Brown (2008) noted that though the modern matron was expected to play a key role in infection control, matrons themselves talked of their limited power, especially in trying to achieve greater cleanliness of the ward environment. Other work has since been published based on research in Australia that explored nurses as brokers of antibiotic prescribing (Broom, Broom, Kirby and Scambler forthcoming) and accounts of the problem from pharmacists and managers (Broom, Broom, Kirby and Scambler 2015; Broom, Gibson, Broom, Kirby, Yarwood and Post, 2016). Such research does not simply raise questions of whether a particular occupational group has ‘power’ to reduce prescribing or infections in a particular institution, but requires an understanding of organizational practice that can account for the negotiation of work within and between different actors and teams. Numerous sociological pieces on broader questions of patient safety help elaborate on the social organization of clinical work and safety, including the distributed or diffuse nature of much decision making and accountability (Goodwin 2013, Aveling et al 2015) and the need to attend to the play of power and control between different actors (Waring et al 2015). Even when not directly addressing the case of antibiotic prescribing, this work also offers important lessons about the fate of new ‘artefacts or tools to bring about behavioural change in the workplace’ (Allen et al 2015). These tools may include guidelines, protocols or decision support aids (Berg 1997a and 1997b) and softer technologies that spread injunctions to ‘speak up’ about potential breaches of infection control in secondary care settings (Szymczak 2015). As new work in organizational sociology suggests, it is rare that guidelines either fail entirely or change practice as expected by the designers, but rather may succeed to the extent that they are incorporated into local accommodations between professionals and managers (Martin et al 2017). At the same time, more might be done to investigate the practice and effects of infection control, safety measures and changing practice in other institutions, for example care homes or prisons. Interactions One of the advantages of looking outside the hospital, is that we are able to bring back into view patient or lay practices. In considering patients, sociology demands attention to the ‘clinical interaction’ as a negotiated order rather than looking at the behaviour of a particular group separately. Though patients may be conceived of as having different priorities and strategies from doctors, studies of clinical interaction help understand how these are negotiated and shape clinical practice, and well as identify variations between different members of the two groups. Work by Britten (1995) is widely cited for the argument that patients consulting a general or family practitioner may approach the consultation with the hope and expectation of an antibiotic prescription – and that this affects the outcome – but this should not be taken to mean that patients simply get what they want. Research using conversation analysis shows that clinical interaction involves active work by both patients (or their representatives) and practitioners. Focusing on the question of antibiotic prescription in the United States, Stivers (e.g.2002, 2007) documents parents of children trying to get or (sometimes) avoid antibiotics for their children. Conversation analysis of this kind allows for better understandings of the ways in which an option preferred by patients before the consultation can become the outcome. For example Gill (2010) describes how people pre-emptively name possible accounts for their symptoms, ‘pressing for and against particular interpretations’. Public health messages that offer simple rules of thumb for antibiotic use – such as telling people about the average length of viral or bacterial respiratory tract infections – may be co-opted in such strategies by patients and not close the conversation or help avoid an antibiotic script. Qualitative research can help explore these emergent effects of interventions as they are made sense of by reflexive social actors. Much behavioural science in this area has focused on the case of respiratory illness as an area where there may be ‘unnecessary’ antibiotic prescribing for viral infections or self-limiting bacterial illness (e.g. Francis et al 2008). More could be done to examine what are called ‘interaction sequences’ (Pilnick et al 2009) for different symptoms and kinds of infections, showing how the interaction covers the work of opening the encounter; presenting the complaint; completing an examination; offering evaluation or diagnosis; and treatment. Each of these sequences may well vary in different health systems and locations, and may be sensitive to whether people are consulting about themselves or a child (as in the work of Stivers). Studies in the conversational analysis tradition use sound or video recordings to account for the nuances of language use, silence and movement that make up negotiations about appropriate medical action. This is important because in interviews about their preferences or expectations of medicine people commonly draw themes of ‘resisting’ or ‘avoiding’ certain medications as part of particular moral discourses and performances (e.g. Murdoch et al 2012), talk which fits with the idea of minimizing antibiotic use but may not be a good source of evidence on practice. Studies of this kind also point to possible limits of asking patients to take responsibility for antibiotic stewardship, even if their preferences do appear to relate to the outcome. For example, Parry (2009) points out that patients are unlikely to ask ‘why’ questions in case they appear to challenge professional expertise (see also Pilnick and Dingwall 2011). Ongoing work on different clinical interactions may also document the evolution of consultation styles and offer important pointers for efforts to create new negotiations and practices around antibiotics. Drawing on data from neurological consultations, Torien et al (2013) suggests that contemporary doctors use the strategy of ‘option listing’ to appear to share the decision and relinquish some authority. Systematic investigation of this strategy in other settings could be valuable to understand the effectiveness of antibiotic stewardship interventions such as delayed prescription, and possible developments of this approach. Referring to the prescription as an object also helps remind us that these encounters are not only ‘conversational’ but happen in specific spaces using particular tools. Here sociological understanding may help inform and evaluate the use of delayed prescription sheets or patient information leaflets, while the conversation analysis methodology in particular can help understand what elements make different stewardship interventions successful or limit their effectiveness. Other more obviously technological interventions are those offering near-patient diagnosis (without the time and expense of a seeking laboratory culture away from the clinic). It is hoped this will help avoid the use of antibiotics for viral infections and of broad spectrum drugs when a more ‘narrow’ prescription would be effective. While this is clearly possible from a biomedical perspective, there is more to do to understand what inserting new diagnostic tools might do to the interaction and the clinical relationship. A good historical example comes from a study of ‘cystitis’ and the management of lower urinary tract infections. Pill (1987) points out that cystitis is a rather vague term for the symptom of burning pain in the urinary tract, but that a diagnosis of infection is by no means assured, making for uncertainty about an antibiotic prescription. She argues that when general practitioners had limited access to microbiology they were often inclined to treat people without a firm diagnosis. Indeed Berg (1992) argues this is not unusual but that work in general practice is often focused on deciding what to do – the clinical disposal – rather than looking for a diagnosis. Pill suggests that ‘it could be argued that a greater use of urine testing [in the clinic] would provide hard clinical evidence of infection and thus improve the care given in general practice by rationalizing the diagnosis. However, paradoxically, routine use of this test [in the 1970s] seems to bring further problems’ (1987, p278). For patients, getting a negative test that conflicted with their experience of painful symptoms worried and upset many women, a problem exacerbated when doctors reacted to the certainty promised by the test by reducing the time spent discussing other possible causes. These responses created the possibility of ‘increasing disenchantment’ between patients and doctors over repeated consultations. Sociology would suggest that such unintended consequences of near-patient diagnostics should be considered alongside their effects on antibiotic prescribing and that the effects might need studying beyond of a single consultation and its immediate aftermath. Like studies of interventions as resources in interactions, more research should be done on the way in which the anticipated consequences of particular diagnoses are important in the decision making of practitioners, who reflexively process the likely effects of the labels they give patients (Rasmussen 2017). Inequalities An important challenge for those doing controlled studies of stewardship interventions is translating effectiveness outside the special setting of the trial and into the wider world; the so-called implementation gap. This has a social and spatial element because prescribing surveillance suggests that there are quite significant differences in antibiotic prescribing according to deprivation and locality. For example, it has been proposed that general practitioners are more likely to prescribe antibiotics to those with lower socio-economic status (e.g. Covvey et al 2014, Cope et al 2015). Explaining such variation or inequalities appears an important site for a sociological contribution, not only through comparative studies of clinical interactions – perhaps using Rasmussen's (2017) concept of ‘diagnosing with anticipation’ – but also research exploring the distribution of infections and of practices of self-care (or neglect) that translate to need for antibiotics and their use. In their classic paper, Calnan and Williams (1991) explore the salience of health and health practices in different households and argue that working class respondents appeared more likely to accept an antibiotic prescription than middle class respondents, especially women, who might resist medication. There is more to do to explore this finding and patterns of acceptance, use, non-use, resistance and retention especially given more recent survey data suggesting that younger people and in particular educated younger women are more likely to ‘stockpile’ antibiotics for use without professional sanction (McNulty et al 2007, Populus 2014). Focus groups with different age groups, family forms and urban, rural or post-industrial settings in Wales (Hawkings et al 2012) imply that while some affluent young families do ‘resist’ antibiotics along with other forms of medication, antibiotics are particularly useful resources for families with young children or people in insecure jobs who cannot afford to take time at home while an illness runs its course – though the same groups may experience problems in taking as prescribed. Work by Vuckovic (1999) is suggestive here by conceptualizing medication as a ‘time saving device’. I have noted above that interviews and focus groups are particularly at risk of encouraging moral work by respondents to distance themselves from the stereotype of the ‘pill popper’ (Will and Eborall 2011). Research using observations, object-centred interviews or walkarounds outside the clinical interaction could explore other meanings for antibiotics and their place in family or domestic medication practices (Dew et al 2014). Theoretically studies of this kind could also elaborate the ‘medication practice’ or ‘adherence work’ that shapes the use of antibiotics just as other medicines (see McGoy's 2009 work on anti-retroviral therapy). It would also be sensitive to what Lehoux et al (2009) identify as ‘local contingencies associated with the heterogeneity of users’ in work combining interviews and observations to identify the distance between patient manuals and patient use of technologies including intravenous antibiotics. Such heterogeneity would need to include gender and socio-economic status or employment and their intersections with other factors such as ethnicity (see Mangione-Smith et al 2004 on this issue in the United States). In considering the importance of childcare and work pressures it is also tempting to return to older work in medical sociology, which often started from questions about variation in illness and care and might support an argument that different ‘needs’ as well as choices are governing prescribing variations from a national perspective (e.g. Antibiotics Research UK 2015). This may be a factor in prescribing for dental infections in primary care, where people cannot afford to see a dentist (see Cope et al 2015), but there is a need for further research on this issue to disentangle the efforts of the distribution of infection, access to routine care, and use of general practice. A paper by Williams and Gabe (1987) shows wide variations in childhood infectious disease in the 1980s, where children from poorer groups had more, and more severe, bronchiolitis, bronchitis and otitis media. Lauritzen (1997) and Reading (1997) both explored continued inequalities in childhood infection in the 1990s, and Bartley (1998) studied the interconnected contributions of poor housing, low incomes and job insecurity or unemployment on health. Such research raises critical questions about the different pressures on people to be ‘present’ at work in the contemporary setting, and the influence of poor nutrition, housing and stress on patterns of infection and should inform studies of antibiotic use among precarious workers, those suffering poverty and their doctors. Though relatively little has been published that directly references the problem of antimicrobial resistance as it is now being framed in policy and public health we hope this Virtual Special Issue shows how existing work in the sociology of health and illness may well be able to contribute. Moving beyond behaviour, efforts to intervene in professional practice need to be sensitive to embedded routines and logics and could build on existing efforts to shape hospital work in the name of safety. We suggest that the ‘meanings’ of different infections will be highly relevant to patient engagement with AMR and influence the transmission of infections. A better understanding of people's sense of responsibility and the causes and effects of infection may help avoid tensions or misunderstandings between professionals tasked with antibiotic stewardship and patients with symptoms that worry them. Having started with examples from hospital acquired infections in surgical wounds, I ended with the management of suspected urinary tract infections and dental health in primary care. Studies of the experience and management of these and other infections may help elaborate opportunities and risks for stewardship interventions beyond the case of respiratory tract infections, and perhaps explain some of the difficulties and dangers of translating interventions from trials into routine practice. Returning to an older sociological tradition of exploring variations in illness and healthcare practice according to socio-economic status, employment type, and region, may be particularly important to avoid creating new inequalities if antibiotic stewardship policies are enacted without reference to the social and economic pressures on patients, and efforts by general practitioners to respond. CONTENTS Allen, D., Braithwaite, J., Sandall, J. and Waring, J. (2016) Towards a sociology of healthcare safety and quality, Sociology of Health & Illness, 38, 2, 181– 197. Armstrong, D. and Ogden, J. (2006) The role of etiquette and experimentation in explaining how doctors change behaviour: a qualitative study, Sociology of Health & Illness, 28, 7, 951– 968. Aveling, E.-L., Parker, M. and Dixon-Woods, M. (2016) What is the role of individual accountability in patient safety? A multi-site ethnographic study, Sociology of Health & Illness, 38, 2, 216– 232. Barton, J., Dew, K., Dowell, A., Sheridan, N., Kenealy, T., Macdonald, L., Docherty, B., Tester, R., Raphael, D., Gray, L. and Stubbe, M. (2016) Patient resistance as a resource: candidate obstacles in diabetes consultations, Sociology of Health & Illness, 38, 7, 1151– 1166. Berg, M. (1992) The construction of medical disposals Medical sociology and medical problem solving in clinical practice, Sociology of Health & Illness, 14, 2, 151– 180. Brown, B. and Crawford, P. (2008) ‘Post antibiotics apocalypse’: discourses of mutation in narratives of MRSA, Sociology of Health & Illness, 31, 4, 508– 24. Brown, B., Tanner, J. and Padley, W. (2014) ‘This wound has spoilt everything’: emotional capital and the experience of surgical site infections, Sociology of Health & Illness, 36, 8, 1171– 1187. Calnan and Williams (1991) Style of life and the salience of health: an exploratory study of health related practices in households from differing socio-economic circumstances, Sociology of Health & Illness, 13, 4, 506– 529. Calnan, M. and Williams, S. (1992) Images of scientific medicine, Sociology of Health & Illness, 14, 2, 233– 254. Cohn, S. (2014) From health behaviours to health practices: an introduction, Sociology of Health & Illness, 36, 2, 157– 162. Crawford, P. and Brown, B. (2008) Soft authority: ecologies of infection management in the working lives of modern matrons and infection control staff, Sociology of Health & Illness, 30, 5, 756– 771. Dew, K., Chamberlain, K., Hodgetts, D., Norris, P., Radley, A. and Gabe, J. (2014) Home as a hybrid centre of medication practice, Sociology of Health & Illness, 36, 1, 28– 43. Gill, V.T., Pomerantz, A. and Denvir, P. (2010) Pre-emptive resistance: patients’ participation in diagnostic sense-making activities, Sociology of Health & Illness, 32, 1, 1– 20. Lauritzen, S.O. (1997) Notions of child health: mothers’ accounts of health in their young babies, Sociology of Health & Illness, 19, 4, 436– 456. Lehoux, P., Saint-Arnaud, J. and Richard, L. (2004) The use of technology at home: what patient manuals say and sell vs. what patients face and fear, Sociology of Health & Illness, 26, 5, 617– 644. Martin, G.P., Kocman, D., Stephens, T., Peden, C.J. and Pearse, R.M. (forthcoming) Pathways to professionalism? Quality improvement, care pathways, and the interplay of standardisation and clinical autonomy. Sociology of Health & Illness. McCoy, L. (2009) Time, self and the medication day: a closer look at the everyday work of ‘adherence’, Sociology of Health & Illness, 31, 1, 128– 146. Murdoch, J., Salter, C., Cross, J., Smith, J. and Poland, F. (2013) Resisting medications: moral discourses and performances in illness narratives, Sociology of Health & Illness, 35, 3, 449– 464. Parry, R. (2009) Practitioners’ accounts for treatment actions and recommendations in physiotherapy: when do they occur, how are they structured, what do they do?, Sociology of Health & Illness, 31, 6, 835– 853. Pill, R. (1987) Models and management: the case of ‘cystitis’ in women, Sociology of Health & Illness, 9, 3, 265– 285. Pilnick, A., Hindmarsh, J. and Gill, V.T. (2009) Beyond ‘doctor and patient’: developments in the study of healthcare interactions, Sociology of Health & Illness, 31, 6, 787– 802. Rasmussen, E.B. (forthcoming) Balancing medical accuracy and diagnostic consequences: diagnosing medically unexplained symptoms in primary care. 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