Expansion of the 'Antibiotic Guardian' one health behavioural campaign across Europe to tackle antibiotic resistance: pilot phase and analysis of AMR knowledge

Assessment of global antimicrobial resistance campaigns conducted to improve public awareness and antimicrobial use behaviours: a rapid systematic review

INTRODUCTION

Public health campaigns with a well-defined outcome behaviour have been shown to successfully alter behaviour. However, the complex nature of antimicrobial resistance (AMR) creates challenges when evaluating campaigns aimed at raising awareness and changing behaviour.

AIMS

To determine what campaigns have been conducted and which reported being effective at improving awareness of antimicrobial resistance and changing behaviour around antimicrobial use in members of the public. It also sought to determine the outcome measures studies have used to assess campaign effectiveness.

METHODS

A systematic search of Ovid MEDLINE and Embase, was conducted in October 2022 using a predefined search strategy. Studies which were published between 2010 and September 2022 that outlined a campaign or invention aimed at the public and focusing on AMR or antibiotic usage were eligible for inclusion and studies which solely targeted healthcare professionals (HCP) were excluded.

RESULTS

Literature searches retrieved 6961 results. De-duplication and screening removed 6925 articles, five articles from grey literature and reference screening were included, giving a total of 41 studies and 30 unique interventions. There was a distribution of campaigns globally with the majority run in Europe (n = 15) with most campaigns were conducted nationally (n = 14). Campaigns tended to focus on adult members of the public (n = 14) or targeted resources towards both the public and HCPs (n = 13) and predominately assessed changes in knowledge of and/or attitudes towards AMR (n = 16). Campaigns where an improvement was seen in their primary outcome measure tended to use mass media to disseminate information, targeted messaging towards a specific infection, and including the use of HCP-patient interactions.

DISCUSSION

This review provides some evidence that campaigns can significantly improve outcome measures relating to AMR and antibiotic usage. Despite a lack of homogeneity between studies some common themes emerged between campaigns reported as being effective. However, the frequent use of observational study designs makes it difficult to establish causation between the campaign and changes seen in the studies outcome measures. It is important that clear evaluation processes are embedded as part of the design process for future campaigns; a campaign evaluation framework for use by campaign developers may facilitate this.

Barriers and Facilitators in Pricing and Funding Policies of European Countries That Impact the Use of Point-of-Care Diagnostics for Acute Respiratory Tract Infections in Outpatient Practices

Antimicrobial resistance is a major global health threat, which is increased by the irrational use of antibiotics, for example, in the treatment of respiratory tract infections in community care. By using rapid point-of-care diagnostics, overuse can be avoided. However, the diagnostic tests are rarely used in most European countries. We mapped potential barriers and facilitators in health technology assessment (HTA), pricing, and funding policies related to the use of rapid diagnostics in patients with community-acquired acute respiratory tract infections. Expert interviews were conducted with representatives of public authorities from five European case study countries: Austria, Estonia, France, Poland, and Sweden. Barriers to the HTA process include the lack of evidence and limited transferability of methods established for medicines to diagnostics. There was no price regulation for the studied diagnostics in the case study countries, but prices were usually indirectly determined via procurement. The lack of price regulation and weak purchasing power due to regional procurement processes were mentioned as pricing-related barriers. Regarding funding, coverage (reimbursement) of the diagnostic tests and the optimized remuneration of physicians in their use were mentioned as facilitators. There is potential to strengthen peri-launch policies, as optimized policies may promote the uptake of POCT.

Synthesis, Characterization and Antimicrobial Activity of Multiple Morphologies of Gold/Platinum Doped Bismuth Oxide Nanostructures

Bismuth oxides were synthesized from bismuth carbonate using the sol-gel method. Studies have described the formation of Bi2O3, as a precursor of HNO3 dissolution, and intermediate oxides, such as BixOy when using H2SO4 and H3PO4. The average size of the crystallite calculated from Scherrer's formula ranged from 9 to 19 nm, according to X-ray diffraction. The FTIR analysis showed the presence of specific Bi2O3 bands when using HNO3 and of crystalline phases of "bismuth oxide sulphate" when using H2SO4 and "bismuth phosphate" when using H3PO4. The TG curves showed major mass losses and specific thermal effects, delimited in four temperature zones for materials synthesized with HNO3 (with loss of mass between 24% and 50%) and H2SO4 (with loss of mass between 45% and 76%), and in three temperature zones for materials synthesized with H3PO4 (with loss of mass between 13% and 43%). Further, the thermal stability indicates that materials have been improved by the addition of a polymer or polymer and carbon. Confocal laser scanning microscopy showed decreased roughness in the series, [BixOy]N > [BixOy-6% PVA]N > [BixOy-C-6% PVA]N, and increased roughness for materials [BixOy]S, [BixOy-6% PVA]S, [BixOy-C-6% PVA]S, [BixOy]P, [BixOy-6% PVA]P and [BixOy-C-6% PVA]P. The morphological analysis (electronic scanning microscopy) of the synthesized materials showed a wide variety of forms: overlapping nanoplates ([BixOy]N or [BixOy]S), clusters of angular forms ([BixOy-6% PVA]N), pillars ([BixOy-6% PVA]S-Au), needle particles ([BixOy-Au], [BixOy-6% PVA]S-Au, [BixOy-C-6% PVA]S-Au), spherical particles ([BixOy-C-6% PVA]P-Pt), 2D plates ([BixOy]P-Pt) and 3D nanometric plates ([BixOy-C-6% PVA]S-Au). For materials obtained in the first synthesis stage, antimicrobial activity increased in the series [BixOy]N > [BixOy]S > [BixOy]P. For materials synthesized in the second synthesis stage, when polymer (polyvinyl alcohol, PVA) was added, maximum antimicrobial activity, regardless of the microbial species tested, was present in the material [BixOy-6% PVA]S. For the materials synthesized in the third stage, to which graphite and 6% PVA were added, the best antimicrobial activity was in the material [BixOy-C-6% PVA]P. Materials synthesized and doped with metal ions (gold or platinum) showed significant antimicrobial activity for the tested microbial species.

A Process Evaluation of the Isfahan Antibiotic Awareness Campaign: Developing Engagement on Antimicrobial Resistance

Background

One of the most prominent global health threats is antibiotic resistance, leading to infection treatment failure. The first Iranian antibiotic awareness week campaign was initiated to improve the prudent use and wise prescription of antibiotics.

Materials and Methods

The Isfahan antibiotic awareness campaign was held from November 30 to December 6, 2019, among two targeted populations; the general population and health-care workers by Isfahan University of Medical Sciences. In this campaign held in the main squares, streets, and a city's referral hospital, various educational methods were used to aware and sensitize the general population and medical staff about antibiotics and microbial resistance. These methods include face-to-face training, brochures, advertisement posters and billboards around the city, educational videos, social media messages, retraining for medical doctors and medical specialists, and interviewing in the Islamic Republic of Iran Broadcast.

Results

Two hundred and twenty general practitioners, medical specialists, and residents participated in two retraining educational conferences in Al-Zahra Hospital, Isfahan, Iran. The mean score satisfaction of the two conferences was three from four. Nearly 2000 of the general population were under face-to-face educational programs whom after that, 83.6% had the correct answer to the questions around antimicrobial awareness.

Conclusions

This campaign was an excellent experience as a pilot study with appealing issues. Further, activities are required to improve engagement with the target population and determine the impact of this campaign on antibiotic consumption and prescription behavior among the public and health-care professionals.

A qualitative investigation of perceptions towards antibiotics by members of the public after choosing to pledge as an Antibiotic Guardian

INTRODUCTION

Antimicrobial resistance is one of the biggest threats facing global humanity. In 2014, Public Health England (now the UK Health Security Agency) launched the Antibiotic Guardian (AG) campaign as a national health promotion initiative to increase public and health professionals' commitment to reducing the threat of antibiotic resistance (ABR). The aim of this research study was to gain a snapshot of public AG attitudes towards antibiotic use, the AG campaign and illness postpledge.

METHODOLOGY

This research used an exploratory study design using thematic and framework analysis of semistructured, in-depth interviews. A purposive convenience sampling strategy was used to recruit 10 participants; adults in the general population who had registered with and chosen an AG pledge via the AG online platform during November 2020 were eligible for inclusion. Interviews were conducted via Zoom.

RESULTS

Six main themes were identified: campaign awareness, motivators to pledge (uncertainty about the future of ABR, personal gratification, personal responsibility, moral obligation and COVID-19), perceptions of personal responsibility (and patient perspectives of moral obligation in clinicians), the impact of the campaign and campaign promotion. Pledging appeared to solidify existing perceptions AGs held. Behavioural motivations for responsible antibiotic behaviours stemmed from perceptions of personal responsibility, moral obligation and concerns about ABR. AGs attributed responsibility to variable patterns in overprescribing. Perceptions towards COVID-19, coinciding with the previously established study period, appeared mixed. AGs were keen to promote responsible perceptions in relation to antibiotics, resistance and the AG campaign. However, poor social acceptability of ABR concern was raised as a barrier to campaign promotion.

DISCUSSION

The AGs' longstanding commitment to antimicrobial resistance demonstrates the importance of a pre-existing interest in the public's self-reported judicious behaviours and decision to pledge to an ABR-focused campaign. Presenting the local and global threat to human mortality and morbidity in a more relatable format in public messaging should be considered in future strategies promoting ABR awareness and shifts in public perceptions. More frequent messaging to existing AGs is further recommended to propagate positive behaviour change among a wider audience.

PATIENT OR PUBLIC CONTRIBUTION

This study was based on interviews with adult members of the public who had pledged to be AGs via the website www.AntibioticGuardian.com. Interviews were based on the public's perceptions of the AG campaign, antibiotic use and ABR.

Antibiotic use and resistance in Belgium: the impact of two decades of multi-faceted campaigning

Objective: To present an overview of almost two decades of multi-faceted campaigning by the Belgian Antibiotic Policy Coordination Committee (BAPCOC) and partners, and its impact on public and prescribers' awareness, outpatient antibiotic use, its cost and antimicrobial resistance in Belgium.Methods: Awareness of both public and prescribers was assessed through pre- and post-campaign interviews and surveys. Outpatient antibiotic use was evaluated using national reimbursement data expressed in number of defined daily doses and packages (a good proxy for treatments) per 1000 inhabitants per day (DID and PID, respectively) from July 1997 to June 2018. Its cost was studied using the same data expressed in number of euros per 1000 inhabitants per day. Antimicrobial resistance was evaluated between 1986 and 2017 using national data on the proportion of Streptococcus pneumoniae isolates not susceptible to penicillins, macrolides and tetracyclines.Results: Antibiotic awareness improved significantly, with general practitioners preferred by 87.5% of respondents as source of information. The Belgian outpatient antibiotic use has decreased by 12.8% in DID and by 42.8% in PID in the 2017-2018 winter compared to the winter before the start of its public awareness campaigns (1999-2000). This evolution coincided with decreasing costs for antibiotics and decreasing antimicrobial resistance. Despite multi-faceted campaigning, outpatient antibiotic use and use of broad-spectrum antibiotics, especially fluoroquinolones and amoxicillin with clavulanic acid, are still high in Belgium.Conclusion: Almost two decades of multi-faceted campaigning coincide with improvements in antibiotic awareness among the public and prescribers, outpatient antibiotic use and resistance. Nevertheless, additional efforts are needed to reach the targets set in BAPCOC's national action plan 2014-2019. Therefore, a new national action plan was developed for 2020-2024 using a One Health approach.

Healthcare workers' knowledge, attitudes and behaviours with respect to antibiotics, antibiotic use and antibiotic resistance across 30 EU/EEA countries in 2019

Background

While several studies have assessed knowledge, attitudes and behaviours of the public, physicians and medical students in a number of EU/EEA countries with respect to antibiotic use and antibiotic resistance, there is a paucity of literature for other healthcare workers. This survey aimed to fill this gap.

Methods

A 43-item online questionnaire was developed, validated and pilot-tested through a modified Delphi consensus process involving 87 Project Advisory Group (PAG) members, including national representatives and members of European health professional groups. The survey was distributed by the PAG and via social media to healthcare workers in 30 EU/EEA countries.

Results

Respondents (n = 18,365) from 30 EU/EEA countries participated. Knowledge of antibiotics and antibiotic use was higher (97%) than knowledge of development and spread of antibiotic resistance (75%). Sixty percent of respondents stated they had received information on avoiding unnecessary prescribing, administering or dispensing of antibiotics. Among respondents who prescribed, administered or dispensed antibiotics, 55% had provided advice on prudent antibiotic use or management of infections to patients, but only 17% had given resources (leaflets or pamphlets). For community and hospital prescribers, fear of patient deterioration or complications was the most frequent reason (43%) for prescribing antibiotics that were considered unnecessary. Community prescribers were almost twice as likely as hospital prescribers to prescribe antibiotics due to time constraints or to maintain patient relationships.

Conclusion

It is important to move from raising awareness about prudent antibiotic use and antibiotic resistance among healthcare workers to designing antimicrobial stewardship interventions aimed at changing relevant behaviours.

The Role of the Private Sector in Advancing Antimicrobial Stewardship: Recommendations from the Global Chief Medical Officers' Network

Antimicrobial resistance (AMR) occurs when microorganisms develop the ability to defeat the drugs designed to kill them. If allowed to increase at the current rate, AMR could kill an estimated 10 million people per year and cost society approximately 100-200 trillion USD globally by 2050. The slow development of novel antimicrobials further exacerbates the problem. Most human antibiotic use occurs in homes and workplaces, where antibiotic-resistant infections may contribute to diminished performance and loss of work productivity. Employers in the private sector have the ability to reach large populations of employees and their families, raise awareness about AMR, and promote antimicrobial stewardship (AMS) among their workforce. The authors describe 4 steps a company can take to help advance AMS: (1) sign the AMR Pledge, (2) perform a gap analysis, (3) implement and/or modify standard practices, and (4) measure and report outcomes. Real-world examples are provided, including barriers faced, in order to successfully implement initiatives to promote better AMS. Behavioral methods to influence change in the workplace are also presented. Both large and small companies can make a difference to support responsible use of antibiotics and improve the health and well-being of their employees.

A scoping review to assess the impact of public education campaigns to affect behavior change pertaining to antimicrobial resistance

BACKGROUND

Years of global antibiotic misuse has led to the progression of antimicrobial resistance (AMR), posing a direct threat to public health. To impact AMR and maintain antimicrobial viability, educational interventions toward fostering positive AMR behavior change have been employed with some success.

METHODS

This scoping review sought to identify research-supporting use of public educational AMR campaigns, and their efficacy toward informing positive AMR behaviors to inform current debate. To enable credible and reflexive examination of a wide variety of literature, Arksey and O'Malley's (2005) methodological framework was used.

RESULTS

Three primary themes were identified: (1) behavior change and theoretical underpinnings, (2) intervention paradigm, and (3) educational engagement. From 94 abstracts identified, 31 articles were chosen for review. More attention is required to identify elements of intervention design that inform and sustain behavior change, and the impact of how an intervention is delivered and targeted is needed to limit assumptions of population homogeneity, which potentially limits intervention efficacy. Moreover, research on the impact of hospital-based inpatient interventions is needed.

CONCLUSIONS

The existing body of research fails to provide robust evidence to support sound evidential interventions supported by theoretical justifications. Furthermore, interventions to ensure long-term sustained behavior change are unclear and not addressed.

Demographic, Knowledge and Impact Analysis of 57,627 Antibiotic Guardians Who Have Pledged to Contribute to Tackling Antimicrobial Resistance

In 2014, Public Health England (PHE) developed the behavioural change Antibiotic Guardian (AG) campaign to tackle antimicrobial resistance (AMR). This included an online pledge system aimed at healthcare professionals (HCP) and the public. Demographics of AGs were collected when pledging online and analysed by pledge group, type, geography, and source of hearing of the campaign between 24/07/2014–31/12/2017. Website visitors and acquisition routes were described using Google analytics data. From November 2016, five questions assessed AMR knowledge which was compared to published Eurobarometer AMR survey results for UK. Behaviour change of AGs was also assessed through an impact questionnaire, evaluating the effect of the campaign on self-reported behaviour around AMR. Overall there were 231,460 unique website visitors from 202 countries resulting in 57,627 English and 652 foreign language pledges. Website visitors increased each year with peaks during European Antibiotic Awareness Day and (EAAD) World Antibiotic Awareness Week (WAAW). Self-direction was the largest acquisition route (55%) with pledges more likely via this route than social media (OR 2.6, 95% CI 2.5–2.6). AGs (including the public) were more likely to answer questions correctly than the Eurobarometer UK group (OR 8.5, 95% CI 7.4–9.9). AG campaign engagement has increased over the four years with particular increases in the student group. AGs had greater knowledge compared to the Eurobarometer UK population. The latest impact evaluation of the online pledge scheme highlights that it continues to be an effective and inexpensive way to engage people with the problem of AMR especially among those with prior awareness of the topic.