{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T05:09:04Z","timestamp":1772168944159,"version":"3.50.1"},"update-to":[{"DOI":"10.12688\/f1000research.26709.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2022,5,6]],"date-time":"2022-05-06T00:00:00Z","timestamp":1651795200000}}],"reference-count":33,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2022,5,6]],"date-time":"2022-05-06T00:00:00Z","timestamp":1651795200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns5:p>\n                    <ns5:bold>Background:<\/ns5:bold>\n                    Higher consumption of antimicrobials plays an important role in driving the higher prevalence of antimicrobial resistance in Southern compared to Northern Europe. Poor controls on corruption (CoC), high uncertainty avoidance (UA) and performance vs. cooperation orientation (POCO) of societies have been found to explain much of this higher consumption in Southern European countries.\u00a0 We hypothesized that these predictors were in turn influenced by the Protestant Reformation in the 16\n                    <ns5:sup>th<\/ns5:sup>\n                    century onwards.\n                  <\/ns5:p>\n                  <ns5:p>\n                    <ns5:bold>Methods:<\/ns5:bold>\n                    We used structural equation modelling (SEM) to assess the relationships between country-level proportions being Protestant, CoC, UA, POCO and four markers of antimicrobial consumption in the community (all antibacterials, cephalosporin, macrolides and fluoroquinolones).\n                  <\/ns5:p>\n                  <ns5:p>\n                    <ns5:bold>Results:<\/ns5:bold>\n                    The proportion of a country that was Protestant was negatively correlated with the consumption of all antibacterials. SEM revealed that UA predicted all antibacterial consumption (direct effect coef. 0.15, 95% Confidence Interval [CI] 0.04-0.26). The proportion Protestant exerted an indirect effect on consumption (coef. -0.13, 95% CI -0.21- -0.05). This effect was mediated predominantly via its effect on UA (direct effect coef. 0.15, 95% CI 0.04-0.26). The model explained 37% of the variation in consumption.\u00a0 Similar results were obtained for each of the other three classes of antimicrobials investigated.\n                  <\/ns5:p>\n                  <ns5:p>\n                    <ns5:bold>Conclusions:<\/ns5:bold>\n                    Our results are compatible with the theory that contemporary differences in antimicrobial consumption in Europe stem in part from cultural differences that emerged in the Reformation. These findings may explain the differential efficacy of similar antibiotic stewardship campaigns in Northern and Southern European populations.\n                  <\/ns5:p>","DOI":"10.12688\/f1000research.26709.2","type":"journal-article","created":{"date-parts":[[2022,5,6]],"date-time":"2022-05-06T10:45:08Z","timestamp":1651833908000},"page":"1200","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Thank Martin Luther that ciprofloxacin could cure your gonorrhoea? Ecological association between Protestantism and antimicrobial consumption in 30 European countries"],"prefix":"10.12688","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2557-8998","authenticated-orcid":false,"given":"Chris","family":"Kenyon","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6467-662X","authenticated-orcid":false,"given":"Geoffrey","family":"Fatti","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2022,5,6]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"579-87","DOI":"10.1016\/S0140-6736(05)17907-0","article-title":"Outpatient antibiotic use in Europe and association with resistance: a cross-national database study.","volume":"365","author":"H 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Ecological association between Protestantism and antimicrobial consumption in 30 European countries.","author":"C Kenyon","year":"2020","journal-title":"figshare."}],"container-title":["F1000Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/f1000research.com\/articles\/9-1200\/v2\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/9-1200\/v2\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/9-1200\/v2\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,20]],"date-time":"2023-11-20T23:26:38Z","timestamp":1700522798000},"score":1,"resource":{"primary":{"URL":"https:\/\/f1000research.com\/articles\/9-1200\/v2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,5,6]]},"references-count":33,"URL":"https:\/\/doi.org\/10.12688\/f1000research.26709.2","relation":{"has-review":[{"id-type":"doi","id":"10.5256\/f1000research.133783.r128893","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.133783.r128893","asserted-by":"object"}]},"ISSN":["2046-1402"],"issn-type":[{"value":"2046-1402","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,5,6]]},"assertion":[{"value":"Indexed","URL":"https:\/\/f1000research.com\/articles\/9-1200\/v2#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.5256\/f1000research.29490.r79088, Christoph M. Tang, Sir William Dunn School of Pathology, University of Oxford, Oxford, UK, 03 Mar 2021, version 1, 1 approved, 1 approved with reservations","URL":"https:\/\/f1000research.com\/articles\/9-1200\/v1#referee-response-79088","order":0,"name":"referee-response-79088","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.29490.r76564, Peter J Collignon, Infectious Diseases and Microbiology, Canberra Hospital, Australian National University, Acton, Australia, 04 May 2022, version 1, 1 approved, 1 approved with reservations","URL":"https:\/\/f1000research.com\/articles\/9-1200\/v1#referee-response-76564","order":1,"name":"referee-response-76564","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Chris Kenyon<\/b>; <i>Posted: 04 May 2022<\/i>; We thank the reviewer for their useful comments. We agree that we need to be very careful with the conclusions we draw from this study for all the reasons outlined by the reviewer. We acknowledge that the Collignon <i>et al<\/i>., paper referred to by the reviewer is one of the most definitive ecological analyses of the drivers of AMR globally. This is however different to our research questions which were: what are the determinants of antimicrobial consumption (AMC), is the percent of a countries population that is Protestant associated with AMC and if so is this association a direct or an indirect one (via UA, POCO or CoC)?&nbsp; As the reviewer notes, we find that there is a weak positive association and the effect is indirect- acting via UA and POCO. One parsimonious explanation for these findings is that an upstream determinant of UA and POCO is the percent of the population that is Protestant. As we note in the discussion, while we cannot prove that this is the causal pathway, this is at least a plausible way to interpret the data. To the best of our knowledge, this is the first time that statistical evidence has been produced to back up the percent Protestant-POCO\/UA-AMC pathway.&nbsp; Once again we have endeavoured in our discussion to make it very clear that whilst we find some statistical support for this pathway, this does not constitute strong evidence that this pathway played any role in the genesis of differential levels of AMC in European countries. To address the reviewer's valid concerns, we have added the Collignon <i>et al.<\/i> reference and the following text in the discussion (4th paragraph): <i>We also did not control for differences in environmental temperatures. Southern European countries tend to be both hotter and more Catholic than Northern European countries. A previous ecological study has found that environmental temperature is associated with the prevalence of certain types of antimicrobial resistance <sup>33<\/sup><\/i>","URL":"https:\/\/f1000research.com\/articles\/9-1200\/v2#referee-comment-8194","order":2,"name":"referee-comment-8194","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.133783.r128893, Harvey Morgan Scott, Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA, 17 May 2022, version 2, indexed","URL":"https:\/\/f1000research.com\/articles\/9-1200\/v2#referee-response-128893","order":3,"name":"referee-response-128893","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The author(s) declared that no grants were involved in supporting this work","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}