Institutional review board approval

Iowa State University obtained approval and exempt status from the Institutional Review Board at Iowa State University (IRB# 22-089) for human subjects’ research prior to initiation of this study.

In-person focus group

A single in-person focus group was held at the National Institute for Animal Agriculture (NIAA) annual meeting in Kansas City, Missouri, on April 20, 2022. Recruitment for this focus group was through NIAA conference emails to both members and registered attendees. Hosting this focus group in association with the NIAA meeting was based on a desire to ensure involvement of all facets of animal agriculture, with a special emphasis on recruitment of livestock producers. Attendance was open to anyone who registered for the conference.

At the meeting, paper copies of response forms were distributed to attendees (Supplementary Material S2). Questions were posed verbally by the moderators, attendees were asked to share their initial responses on the paper form, and a group discussion of the responses was then facilitated. The meeting was not recorded and notes on the verbal discussion were collected. The completed forms were gathered at the end of the focus group, and the responses were compiled into a spreadsheet for subsequent data analysis. The focus group instrument initially developed for the in-person focus group was then adapted for the virtual sessions.

Virtual focus groups

A total of 9 virtual focus groups were held via Zoom (Zoom Video Communications Inc) from April 25 to May 24, 2022, and utilized PowerPoint software (Microsoft Corp) as an instrument of presentation (Supplementary Material S3). A moderator script was developed for these meetings to ensure consistency across focus groups and guide the discussion. Potential stakeholders were identified from a wide range of sources, and the final recruitment list totaled over 800 individuals (Supplementary Material S4). An invitation to join one of the 1.5-hour virtual focus groups was then sent via email by National Institute of Antimicrobial Resistance Research and Education leadership to the recruitment list. Individuals interested in the project were able to choose the category with which they best aligned (data providers [veterinarians, producers], VDL diagnosticians, government officials, or researchers) and were asked to participate in 1 of the 3 virtual focus groups held for each of the categories according to their availability.

Each virtual focus group began with an orientation to preserve participants’ anonymity.⁷ Participants were requested to keep cameras off and provided instructions on how to change their names according to the group they represented (eg, V for veterinarians, P for producers), animal species they worked with (eg, B for beef cattle, H for human), and a random number. During the focus groups, the primary participation was via the Annotate tool within Zoom using either the text or stamp function. In some cases, participants also provided opinions agreeing or disagreeing with other participants’ comments by placing a stamp near it. Screenshots were captured at the end of each activity. Stakeholders were also able to verbally share an opinion and use the chat function if desired. Video and audio (assuring anonymity) of each focus group were recorded for analysis. When clarification was needed during the focus group, occasional nonstandardized questions were asked by moderators.

Pre- and postmeeting surveys

Online surveys were developed using Qualtrics XM software (Qualtrics) and designed to be completed in 15 to 20 minutes to minimize the time commitment of participants. Premeeting surveys were sent to all registered participants of the virtual focus groups and to an email list maintained by NIAA of members and past conference attendees who had indicated interest in AMR. Postmeeting surveys were sent only to registered attendees of the focus groups. While participants were highly encouraged to submit both the pre- and postmeeting surveys, completion was not a requirement to join the focus groups, and response rates were not monitored.

Participant demographics

Premeeting surveys engaged 76 participants, but not all questions were fully completed. Attendees’ demographic data were collected (Supplementary Table S1), and participants were asked to identify their role by selecting all options that applied. They self-identified as veterinarians (40), academics (33), government employees (24), animal health professionals (16), part of the human health sector (2), livestock producers (2), and others (7) and represented all sectors of animal agriculture listed. Ten participants affirmed that they owned livestock, though only 2 identified themselves as livestock producers.

Responses associated with AMR

Level of agreement with belief statements—The level of agreement with several belief statements regarding AMR was assessed, and belief statements were separated into positive and negative statements (Table 1). Results show that there was a strong agreement about “AMR being a serious concern for human health” (85.3%) and “animal agriculture” (66.2%) and demonstrates the acknowledgment among stakeholders that “sharing AMR data into a centralized database is important to combating development of future AMR” (71.6%). Opinions from all 68 participants were divided regarding the possibility of “personal information being compromised by sharing AMR data” (35.3% strongly/somewhat agreed and 41.1% strongly/somewhat disagreed) and about the “chances of negative effects for animal agriculture due to government storing AMR data” (33.8% strongly/somewhat agreed and 45.6% strongly/somewhat disagreed). In addition, most participants did not believe that “government having specific AMR data from a farm is an invasion of privacy” (67.2% strongly/somewhat disagreed). When analyzing government and nongovernment employees separately, only 4.5% of participants who self-identified as government employees strongly/somewhat agreed that this was “an invasion of privacy”; however, this percentage was higher for participants that self-identified as nongovernment (26.7% strongly/somewhat agreed).

In contrast, participants were concerned with the idea that “AMR data might be released under a Freedom of Information Act [FOIA] request” (55.9% strongly/somewhat agreed) and either somewhat or strongly agreed with the beliefs that “centralized collection of AMR data could be used against animal agriculture” (64.2%) and “against an individual commodity” (55.8%). Participants who self-identified as government employees were more concerned about “AMR being released under FOIA requests” (65.2% strongly/somewhat agreed) compared to those who did not self-identify as government (51.1% strongly/somewhat agreed). Nongovernment participants primarily selected “neither agree nor disagree” with this statement (42.2% of responses), which suggests that a lack of understanding of the FOIA process may have influenced their response as compared to those of governmental employees, who would have a more complete understanding of the process.

Level of comfort sharing specific AMR data items—Stakeholders were asked to share their level of comfort related to specific data items that might be shared by VDLs (Figure 2). Participants demonstrated extreme comfort sharing information on type of “AST panel test used,” “bacterial species” and “animal species,” “body site from which bacteria were isolated,” and “AST results from bacterial species that only cause disease in animals” (> 70% extremely comfortable answers, little to no discomfort with sharing). Most participants were also extremely comfortable sharing “AST result data from bacterial species that affect both animals and humans,” “laboratory sample identification number,” and “region of country” or “state where animal was located” (> 50% extremely comfortable answers); however, a level of concern with sharing these items was noted by some participants. From the data items that were not related to geospatial location, the item with the highest level of concern for sharing was “previous antibiotic use” (26.2% somewhat/extremely uncomfortable); however, most participants were still at least somewhat comfortable sharing this information (58.4% extremely/somewhat comfortable). While sharing “the county where animal is located” also showed an overall positive level of comfort (> 50% extremely/somewhat comfortable answers), when geospatial data sharing was more limited and specific, stakeholders demonstrated increasing concern. The item with the most concern noted was “veterinarian’s name and address” (only 20% extremely/somewhat comfortable answers); there was also concern with sharing the “zip code where the animal tested is located,” although not as great (44.6% extremely/somewhat comfortable).

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Premeeting survey results on data sharing, listed in order of comfort level (n = 65). AST = Antimicrobial susceptibility testing.

Citation: Journal of the American Veterinary Medical Association 262, 2; 10.2460/javma.23.07.0426

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Concerns about sharing AMR and AMU data from animal agriculture—Participants were asked to rank topics in the order of highest concern to least concern regarding sharing of AMR and antimicrobial use (AMU) data from animal agriculture (Table 2). For both questions, the biggest concern was “harm to the public perception of animal agriculture.” Concern regarding FOIA requests was also noted, similar to other answers observed (Table 1). For both questions, the “loss of export markets” was identified as the least concern.

Additional questions—Specific questions to livestock owners and non–livestock owners were also asked (Supplementary Table S2). Although there was a low participation rate from livestock owners, a considerable number of responses were collected from non–livestock owners (n = 59) and revealed that 83% either strongly or somewhat agreed that “[an AMR] database could help producers, animal owners, and veterinarians to detect more rapidly outbreaks of animal pathogens,” indicating support for the use of an AMR database for this purpose. Moreover, all participants were asked whether they would be supportive of efforts to develop statutory data protections for personally identifiable information (PII; somewhat analogous to the Health Insurance Portability and Accountability Act [HIPAA])⁹ for AMR and AMU data from animals (Supplementary Table S3). A total of 65 responses were obtained, and the percentage of answers that were “maybe” and “yes” combined was 92.3% for AMU and 86.2% for AMR, respectively, denoting that most participants approve the establishment of such efforts.

Participants’ demographics

From a total preregistration pool of 22, 9 participants attended the in-person focus group, which lasted 3 hours. Participants were asked to select all options that applied, and they self-identified as veterinarians (7), government employees (3), livestock producers (3), others (3), academicians (2), and animal health professionals (1) (Supplementary Table S4). For the virtual focus groups, 49 out of 90 persons who registered participated in the 9 sessions, and based on which focus group they attended, the roles of participants were as follows: researchers (20), government employees (13), VDL representatives (8), and data providers (8) (Supplementary Table S5).

Responses associated with AMR

NVivo analysis of the open-ended responses identified perceived benefits and concerns associated with a centralized AMR database and dashboard. A total of 247 statements were related to benefits and then divided into 14 themes (Table 3; Supplementary Material S5). Regarding perceived concerns, the analysis identified 161 comments that were then divided into 7 themes (Supplementary Material S6).

Benefits—The top 2 themes (Table 3) corresponded to 50% of all opinions related to benefits. The first theme was that an AMR dashboard could serve as a valuable “resource of information [on AMR] and AMU guidance” and included comments on helping establish dosing regimens, filling research gaps, correcting assumptions, identifying risk factors and drivers of resistance, and enabling better treatment options. Also, participants commented that such a tool would contribute to obtaining more accurate AMR data to support and guide AMU and help gather funding to improve animal health. The second most cited them was “surveillance, trends, and emerging AMR,” where participants noted that such a tool would increase the ability to monitor AMR trends, recognize patterns, understand changes over time, and identify emerging issues. The possibility of tracking emerging resistance genes was also mentioned. A predetermined list of potential benefits that a centralized AMR repository could provide to veterinarians, producers, researchers, and government was also presented to participants to assess their level of agreement with each topic. The results indicate that most participants agreed there are numerous clear benefits to a centralized AMR repository (Supplementary Table S6).

Concerns—The top 3 themes (Table 3) corresponded to 61.8% of all concern-related opinions and included “unintentional misuse and misinterpretation,” “malicious use of data and fear of government actions,” and “data privacy and security”; some examples of statements include fear of data being inappropriately interpreted, fear of having biased data and skewed results depending on where the data are coming from or due to the lack of representativeness, and concerns about how use of breakpoints in veterinary medicine could lead to a misinterpretation of resistance due to differences between human and animal breakpoints. Also, within those main themes, concerns about data privacy and security, suffering retaliation, lawsuits, and having data used against them, in addition to government setting inconvenient rules about AMU based on data collected, were mentioned.

Participants were then asked to provide comments regarding alleviation of their concerns, and 3 main themes emerged, corresponding to 52.2% of all concern-alleviation statements (Supplementary Table S7). The most mentioned theme was “education and training” (21.0%), which included the need of tutorials, guidelines, and training of providers and users in addition to the need of increasing knowledge of the public, data users, and providers. “Privacy and security” (19.3%) was the second most mentioned theme, indicating that participants would like to have guaranteed confidentiality to avoid repercussions. The third was “standardized, curated, and accurate data” (11.9%), which reflected the need of data curation and harmonization to provide accurate information (Supplementary Material 7).

Geospatial data—A question related to the level of geospatial data participants were willing to share versus what is needed to reap the desired benefits was asked in the virtual focus groups only. While most participants of virtual focus groups agreed that the level of geospatial data needed to provide benefits would be county- or zip code–level data, most participants were not comfortable sharing data below the state level (Supplementary Table S8). Also, participants in virtual focus groups pointed out that the level of geospatial data needed and available depends on the animal species and type of industry. It was frequently mentioned that in some regions of the country, some counties are bigger than some states, so regional differences might affect an individual’s preference for county level if the county is over a certain size. Some participants also commented that “VDLs do not often have this kind of information” and that therefore gathering geospatial data may represent additional steps that will have to be undertaken by the VDLs.

A complementary question about level of comfort on sharing specific geospatial data was asked in virtual and in-person focus groups (Supplementary Table S9). The proposed use of 3-digit zip codes (ie, aggregated at the level of the first 3 zip code digits) for data analysis was discussed, as it is currently considered an acceptable practice for the Safe Harbor method of de-identification of human health-care statistical data under HIPAA.⁹ Given this information, most participants were quite comfortable sharing a 3-digit zip code (62.6% extremely/somewhat comfortable answers). However, some stakeholders stated a few concerns (eg, “It might not give valuable information,” “There still may be a potential risk of site reidentification depending on size of the operation and kind of commodity,” and “There could be differences between environments within a 3-digit zip code area”). Concerning 5-digit zip codes, participants were shown a deidentified heat map (Supplementary Figure S1) to demonstrate that data could be collected and used without direct association to the actual data. Given this information, attendees agreed that this would be much preferred compared to generation of actual maps (70.3% extremely/somewhat comfortable answers); however, some remained concerned with data security and reidentification risks, and others questioned whether the information would be useful if there is no map or scale associated.

Additional questions—Finally, participants were also asked to select the top 3 data types that they were least comfortable sharing (during virtual focus groups) or any item that they were either somewhat or extremely uncomfortable sharing (during in-person focus group; Supplementary Table S10). Results were similar to pre-meeting surveys and identified that “laboratory sample number” and “previous AMU” were the primary items of concern. In addition, this set of questions specifically asked about sharing “genetic test results” and revealed that WGS was the third least preferred data to be shared because its clinical and public health meaning could be misinterpreted, leading to erroneous linkage to outbreaks.

Participant demographics

From the 58 stakeholders that participated in the in-person and virtual focus groups, 35 completed at least a portion of the postmeeting surveys (60.3% completion rate). Overall, participant demographics were similar to those reported in the premeeting surveys and represented a wide range of stakeholders (Supplementary Table S11). Participants were asked to select all that applied, and they self-identified as veterinarians (19), academicians (19), government employees (11), others (4), animal health professionals (3), human health sector (3), and livestock producer (1) and represented all sectors of animal agriculture listed. Only 1 participant self-identified as a livestock producer; however, 4 affirmed that they own livestock.

Responses associated with AMR

The postmeeting survey was designed to focus on assessing the changes in the perception related to the topics discussed during the focus group. Therefore, attendees were specifically asked if their perception of benefits and concerns associated with a centralized repository of AMR data from animals had changed. While more than 63.6% responded that their “opinions about concerns had not changed” and 76.5% kept the “same opinion on benefits,” 23.5% stated that they are “more likely to believe that there are significant benefits to this project,” and 36.4% mentioned that they are “less concerned overall about the risks to themselves or industry.” No participants stated that they were “less likely to believe in the benefits” nor that they were “more concerned about the risks.” Some participants added written comments that their opinion has not changed because they already saw benefits and minimal concerns or that, after the focus groups, they had fewer concerns because discussing the positive aspects made them realize the importance of such an initiative. Additional comments were centered around concerns associated with data confidentiality/privacy and security, data misuse, and the need of harmonization to provide an accurate and reliable database.

Attendees were then asked to report their level of comfort on sharing specific data related to AMR, and answers obtained in premeeting surveys were compared with answers from postmeeting surveys (Table 4). Comfort perception improved in all areas except for 3 items: “county where animal was tested” maintained almost the same percentage, while “laboratory sample identification number” and “zip code in which the animal tested is located” had the level of comfort decreased. Sharing zip code information was a concern highly mentioned in all focus groups and surveys due to the perceived risk of tracing AMR source back to farm/individual. Concerns regarding sharing of laboratory sample identification number and risk of reidentification of site of origin were shared in many of the focus groups, which may have influenced postmeeting perceptions. While decreased, the data show that more than 50% of people still felt some level of comfort sharing this data.