An educational initiative aimed at increasing antimicrobial resistance awareness among school-going Jordanian youth

Background

The World Health Organization (WHO) has recommended strategies and actions to enhance awareness and understanding of AMR. Gaps in AMR awareness remain in Jordan, particularly among the youth.

Aim

To describe our programmatic approach to AMR education across Jordanian governorates among school-aged children.

Methods

Our approach depicts the development of comprehensive health messages, pilot and expansion phases in schools, and pre- and post-session knowledge assessments.

Results

2,700 students across 30 schools reached with AMR health messages. Gained knowledge was assessed in 932 students, revealing significant improvements in understanding the importance of consulting a doctor before taking antibiotics, the relationship between nutrition and immunity, the dangers of sharing medicines, and proper handwashing techniques. The average expenditure was approximately $8.55 per student.

Conclusion

The intervention underscores the critical role of targeted educational initiatives in improving AMR awareness among youth, emphasizing the need for sustained and scalable approaches to combat AMR effectively.

Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review

BACKGROUND

Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health.

OBJECTIVE

In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools.

METHODS

We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively.

RESULTS

Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature.

CONCLUSIONS

Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts.

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.

Assessing the impact of a national social marketing campaign for antimicrobial resistance on public awareness, attitudes, and behaviour, and as a supportive tool for healthcare professionals, England, 2017 to 2019

BackgroundPrevious United Kingdom campaigns targeting antimicrobial resistance (AMR) recommended running multimedia campaigns over an increased timeframe. The 3-year-long Keep Antibiotics Working (KAW) campaign was a mass media campaign in England targeting the public and general practitioners (GPs).MethodsEvery year, pre- and post-campaign questionnaire data were collected from the public, whereas post-campaign interview data were obtained from GPs. Data were weighted to allow pre- and post-campaign comparisons between independent samples. Significant changes in nominal and ordinal data were determined using Pearson's chi-squared (X2) and Mann-Whitney U tests, respectively.ResultsPrompted campaign recognition was high, increasing by 6% from 2018 to 2019 (2017: data unavailable; 2018: 68% (680/1,000); 2019: 74% (740/1,000); X2 = 8.742, p = 0.003). Knowledge regarding declining antibiotic effectiveness when taken inappropriately improved following the campaign (net true: pre-2017 = 69.1% (691/1,000); post-2019 = 77.6%; (776/1,000); X2 = 5.753, p = 0.016). The proportion of individuals reporting concern for themselves or for children (≤ 16 years) about AMR increased by 11.2% (Z = -5.091, p < 0.001) and 6.0% (Z = -3.616, p < 0.001) respectively, pre- to post-campaign. Finally, in 2017, reported confidence to say no to patients requesting antibiotics differed significantly between GPs who were and were not aware of the campaign (net agree: 98.9% (182/184) vs 92.4% (97/105) respectively; X2 = 4.000, p = 0.045).ConclusionA high level of prompted campaign recognition was achieved. The KAW campaign improved aspects of AMR knowledge and certain attitudes towards appropriate antimicrobial use. It increased awareness of and concern about AMR, supporting GP confidence to appropriately prescribe antibiotics. Future determination of measurable behaviour changes resulting from AMR campaigns is important.

Insights from a Cross-Sectional Study on Knowledge, Attitudes and Behaviors Concerning Antibiotic Use in a Large Metropolitan Area: Implications for Public Health and Policy Interventions

The overuse and inappropriate use of antibiotics pose a grave threat to public health, contributing significantly to the accelerated development of antimicrobial resistance (AMR) and increased rates of morbidity and mortality, making it a leading cause of death globally. To examine the relationship between demographic variables and knowledge, attitudes, and behaviors concerning antibiotic use, a survey-based cross-sectional study was conducted involving 1158 individuals. The questionnaire included two sections: in the first section, participants' socio-demographic characteristics were analyzed; the second investigated knowledge, attitudes, and behaviors concerning antibiotics utilization using a total of 36 questions. Descriptive statistics were used, and then a multiple linear regression analysis (MLRA) using three models was carried out. In Model I, knowledge about antibiotics exhibited correlations with smoking habits and educational attainment. In Model II, attitudes were significantly associated with gender, smoking habits, age, education, relationship status, and knowledge. In Model III, behaviors related to antibiotics were correlated with educational attainment, having children, knowledge, and attitudes. Implementing tailored public health programs could be a cost-effective intervention to enhance behaviors associated with antibiotic use in the general population. This study offers valuable insights into the determinants of knowledge, attitudes, and behaviors regarding antibiotics in the general population.

Community Pharmacists' Knowledge, Attitude, and Nonprescription Dispensing Practices of Antibiotics: An Explorative Study in a Selected City of South India

Objective

This study aimed to assess the community pharmacists' knowledge of antibiotics, their attitude toward antibiotic usage and antibiotic resistance, and their nonprescription dispensing practices of antibiotics.

Methods

A cross sectional-questionnaire-based study was conducted among 75 community pharmacists practicing in a selected city of South India. Data on their age, years of experience, and educational qualifications were obtained. A modified, 33-items, prevalidated structured questionnaire was used to assess the community pharmacists knowledge, attitude, and nonprescription antibiotic dispensing practices knowledge, attitudes and practices (KAP). The responses obtained were expressed in descriptive statistics. The association between years of experience and their KAP was assessed using Pearson's correlation.

Findings

Most pharmacists (60%) agreed that antibiotics are used for bacterial infections, and 35% believed that antibiotics could be given for pain and inflammation. Fourty-one percentage of pharmacists agreed that dispensing antibiotics without prescription increases the risk of antibiotic resistance. Seventy-two percentage agreed that they are responsible for taking a prominent role in antimicrobial resistance and infection-control programs in healthcare. Only 46% of pharmacists stated that they always dispensed antibiotics only with a prescription, and 56% dispensed antibiotics for longer than the doctor prescribed. Amoxicillin, metronidazole, and cephalexin were the most commonly dispensed antibiotics without a prescription. The most common reason for dispensing antibiotics without a prescription was the fear of losing customers.

Conclusion

The study identified an average KAP interquartile range 1 among community pharmacists, indicating a lack of awareness of antibiotic resistance and dispensing antibiotics without a prescription.

How can behavioural science contribute to qualitative research on antimicrobial stewardship in primary care?

Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change 'tools': behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.

Impact of Educational Intervention to Promote Jordanian Community Pharmacists' Knowledge and Perception Towards Antimicrobial Stewardship: Pre-Post Interventional Study

OBJECTIVE

The aim of this study was to assess the impact of an online educational workshop on improving the knowledge, and perception of community pharmacists in Jordan towards the antimicrobial stewardship (AMS) and enhancing their ability to appropriately select correct antibiotic therapy.

METHODS

This is a pre-post study that was conducted in Jordan in December 2020. An electronic questionnaire was used to assess the awareness, perception of community pharmacists towards AMS, and their ability to appropriately select correct antibiotic before and after the educational workshop. The two-days' workshop was conducted on Zoom application. Analysis was conducted using Wilcoxon signed-rank test, McNemar's test using SPSS version 22.

RESULTS

During the study period, 100 community pharmacists attended the educational workshop. Pharmacists' knowledge was assessed prior to their participation which revealed a relatively good knowledge score with a median score of 6/10 (IQR = 4); their scores have improved significantly following the educational workshop with a median score of 7/10 (IOR = 2), p-value<0.001. Although one-third of the participants knew the definition of AMS prior to the workshop, almost half of the respondents (n = 56, 56%) knew the definition after the educational workshop. Regarding community pharmacist's ability to appropriately select correct antibiotic therapy, they showed a significant improvement in selecting the optimal antimicrobial for the virtual cases following the workshop (p-value < 0.05). Perceptions towards AMS were consistently positive before and after the workshop.

CONCLUSION

This study revealed the benefit of AMS-focused workshops for improving community pharmacists' knowledge and appropriate antibiotic prescribing. Thus, efforts are required to implement more AMS educational workshops for community pharmacists.

The utility of an AMR dictionary as an educational tool to improve public understanding of antimicrobial resistance

Background: Communicating about antimicrobial resistance (AMR) to the public is challenging.   Methods: We developed a dictionary of terms commonly used to communicate about AMR. For each term, we developed learning points to explain AMR and related concepts in plain language.  We conducted a pilot evaluation in 374 high school students in Ubon Ratchathani, Thailand. In three 50-minute sessions, students were asked to answer five true/false questions using a paper-based questionnaire. The first session assessed their understanding of AMR at baseline, the second after searching the internet, and the third after the provision of the printed AMR dictionary and its web address.    Results: We developed the AMR dictionary as a web-based application (www.amrdictionary.net). The Thai version of the AMR dictionary included 35 terms and associated learning points, seven figures displaying posters promoting AMR awareness in Thailand, and 66 recommended online videos. In the pretest, the proportion of correct responses to each question ranged from 10% to 57%; 10% of the students correctly answered that antibiotics cannot kill viruses and 57% correctly answered that unnecessary use of antibiotics makes them ineffective. After the internet searches, the proportions of correct answers increased, ranging from 62% to 89% (all p<0.001). After providing the AMR dictionary, the proportions of correct answers increased further, ranging from 79% to 89% for three questions (p<0.001), and did not change for one question (p=0.15). Correct responses as to whether taking antibiotics often has side-effects such as diarrhoea reduced from 85% to 74% (p<0.001). The dictionary was revised based on the findings and comments received. Conclusions: Understanding of AMR among Thai high school students is limited. The AMR dictionary can be a useful supportive tool to increase awareness and improve understanding of AMR. Our findings support the need to evaluate the effectiveness of communication tools in the real-world setting.

Antimicrobial stewardship in community pharmacies in Jordan: assessing current status

Objectives

The aim of this study was to assess knowledge and perceptions of the Jordanian community pharmacists towards antimicrobial resistance and antimicrobial stewardship programmes (ASPs).

Methods

A descriptive cross-sectional questionnaire-based study was conducted between August and September 2020. The validated questionnaire consisted of sections that measure participants’ demographics, knowledge and perceptions towards ASPs, and assess antibiotic prescribing practice. Questionnaires were distributed via social media to be filled by community pharmacists in Jordan. For knowledge questions, participants gained one point for each correct answer and zero point for each incorrect answer. Then, a knowledge score was calculated out of 10.

Key findings

During the study period, a convenience sample of 200 pharmacists were recruited and were asked to fill out the study questionnaire, with a majority claimed attending ASPs workshops previously (n = 162, 81.0%). The main sources of knowledge about antimicrobial resistance were university courses and books. With a median knowledge score of 6/10, participants knew that antimicrobials are not always safe. Although only less than 25% knew that ASPs does not necessarily increase treatment duration, most of the pharmacists had positive perceptions towards ASPs. Barriers against application of ASPs were mainly lack of training and lack of physicians’ cooperation (89.0% and 87.5%, respectively). It was agreed by 90.0% of the respondents that ASPs would boost public health confidence in community pharmacists, and 86.0% believed that ASPs would enhance their job satisfaction. Multivariate linear regression showed that female gender of pharmacist was significantly associated with higher knowledge score (P-value = 0.045).

Conclusions

This study highlighted that community pharmacists have a good knowledge in antibiotics and a positive perception regarding ASPs. Despite not being highly familiar with ASPs concept, pharmacists showed great support for involvement in ASPs. They also encouraged incorporating ASPs within community pharmacy level which is considered crucial to control antimicrobial resistance throughout the world.

Teaching young consumers in Europe: a multicentre qualitative needs assessment with educators on food hygiene and food safety

AIM

Foodborne illnesses have a significant global burden and can be life-threatening, with higher risk in vulnerable groups such as children. SafeConsume is an EU-funded, transdisciplinary project aiming to improve consumers' food safety behaviour. Developing educational resources on food safety for use in schools has potential to improve teaching of our young consumers. The aim of this study was to explore school educators' attitudes, behaviours and knowledge towards food hygiene, safety and education.

METHODS

Focus groups and interviews in England, France, Portugal and Hungary explored educator knowledge, skills, intentions and beliefs around educating young people (11-18 years) about food safety. Data were analysed using NVivo and emerging themes were applied to the Theoretical Domains Framework.

RESULTS

A total of 48 educators participated. Knowledge, confidence and skills to teach food safety to young people varied depending on background and training. Educators reported they had a role to teach food safety to young people, were positive about delivering education and optimistic they could improve students' food safety behaviour. Barriers to teaching included lack of national curriculum coverage, limited time and money, and lack of facilities. Educators reported that social influences (family, celebrity chefs, public health campaigns and social media) were important opportunities to improve young peoples' awareness of food safety and consequences of foodborne illness.

CONCLUSION

Educator food safety expertise varied; training could help to optimise educator knowledge, confidence and skills. Ministries of Health and Education need encouragement to get food safety incorporated further into school curricula across Europe, so schools will be motivated to prioritise these topics.

'The Mould that Changed the World': Quantitative and qualitative evaluation of children's knowledge and motivation for behavioural change following participation in an antimicrobial resistance musical

BACKGROUND

A primary school musical ("The Mould that Changed the World") was developed as a unique public engagement strategy to combat antimicrobial resistance (AMR) by engaging children in the story of the discovery of antibiotics, the risks of drug-resistant infections and the importance of prudent antibiotic use.

METHODS

The musical intervention was implemented in two UK primary schools by music specialists through a series of workshops, associated learning resources and performances to relatives. Participating children (n = 182), aged 9 to 11 years, were given an online questionnaire in the classroom before rehearsals began and at two weeks post-performance with a six-month evaluation in one school. The impact of the musical was analysed using generalised linear models to control for confounding factors. For the qualitative evaluation, fifteen participating children were selected randomly from each school to take part in semi-structured focus groups (n = 5 per group) before rehearsals began and two weeks post-performance.

FINDINGS

Knowledge gain was demonstrated with children being more likely to answer questions on key messages of the musical correctly at two weeks post- performance (response rate 88%, n = 161) compared with the pre-rehearsal questionnaire (response rate 99%, n = 180) (bacteria can become resistant to antibiotics OR 4.63, C.I. 2.46-9.31 p<0.0001, antibiotic resistant infections can be life threatening OR 3.26 C.I. 1.75-6.32 p = 0.0001, prudent use of antibiotics will slow the rise of antibiotic resistant infections OR 2.16, C.I. 1.39-3.38, p = 0.0006). Long term knowledge gain was demonstrated by a consistent level of correct answers on key messages between two weeks (response rate 95%, n = 89) and 6 months post musical (response rate 71%, n = 67). Following the musical children participating in the focus groups (n = 30) articulated a greater understanding of AMR and the risks of antibiotic overuse. They discussed motivation to minimise personal antibiotic use and influence attitudes to antibiotics in their family and friends.

INTERPRETATION

This study demonstrates that musical theatre can improve both short and long-term knowledge. It demonstrates a hitherto infrequently reported change in attitude and motivation to change behaviour in children at an influential age for health beliefs. This unique public health tool has the potential for high impact particularly if rolled out within national education programmes for primary school aged children.

Advocacy for Increased International Efforts for Antimicrobial Stewardship Actions in Low-and Middle-Income Countries on Behalf of Alliance for the Prudent Use of Antimicrobials (APUA), Under the Auspices of the International Society of Antimicrobial Chemotherapy (ISAC)

Antimicrobial stewardship (AMS) is a set of coordinated strategies to improve the use of antimicrobials, to enhance patient outcomes, reduce antimicrobial resistance, and decrease unnecessary costs. The pioneer years of AMS were restricted to high-income countries (HIC), where overconsumption of antibiotics was associated with emergence of multidrug-resistant (MDR) bacteria. AMS in low- and middle-income countries (LMIC) is also necessary. However, programs effective in HIC may not perform as well in LMIC, because (i) While decreased consumption of antibiotics may be an appropriate target in overconsuming HIC, this may be dangerous in LMIC, where many patients die from the lack of access to antibiotics; (ii) although AMS programs in HIC can be designed and monitored through laboratory surveillance of resistance, surveillance programs are not available in many LMIC; (iii) the heterogeneity of health care systems implies that AMS programs must be carefully contextualized. Despite the need to individually tailor AMS programs in LMIC, international collaborations remain highly valuable, through the dissemination of high-quality documents and educational material, that may be shared, adapted where needed, and adopted worldwide. This process, facilitated by modern communication tools, combines many benefits, including: (i) saving time, a precious dimension for health care workers, by avoiding the duplication of similar works in different settings; (ii) taking advantage of colleagues skills, and initiatives, through open access to the work performed in other parts of the world; (iii) sharing experiences, so that we all learn from each others' successes and failures.

Teaching about antibiotic resistance to a broad audience: a multidisciplinary approach

Education for the general public about antibiotic resistance is advocated as a key component of our response to this crisis. Since this is a multidisciplinary problem encompassing natural, medical and social sciences, it is an educational challenge as both students and lecturers will have vastly different backgrounds in the topics. Here we describe an online multidisciplinary course on antibiotic resistance spanning topics as diverse as chemistry and practical philosophy. The target group was any post-secondary school student and the participating students had different occupations and educational experience. Although as many as 38% of the students were currently studying natural sciences at university, the course included a diverse group with medical professionals (16%) and teachers (6%) making up a significant fraction of the class. The outcomes based on examination and the course evaluations were very positive and we have indications that the information students gained from this course has been spread to others. Unlike other online courses addressing antibiotic resistance, this course is both accessible to a wide range of students and covers a broad range of topics. We advocate courses like ours as an effective tool in educating the public about this crisis.

Teacher and Student Views on the Feasibility of Peer to Peer Education as a Model to Educate 16-18 Year Olds on Prudent Antibiotic Use-A Qualitative Study

Peer education (PE) has been used successfully to improve young peoples' health-related behaviour. This paper describes a qualitative evaluation of the feasibility of university healthcare students delivering PE, covering self-care and antibiotic use for infections, to biology students in three UK schools (16-18 years), who then educated their peers. Twenty peer educators (PEds) participated in focus groups and two teachers took part in interviews to discuss PE feasibility. Data were analysed inductively. All participants reported that teaching students about antibiotic resistance was important. PE was used by PEds to gain communication skills and experience for their CV. PEds confidence increased with practice and group delivery. Interactive activities and real-life illness scenarios facilitated enjoyment. Barriers to PE were competing school priorities, no antibiotic content in the non-biology curriculum, controlling disruptive behaviour, and evaluation consent and questionnaire completion. Participation increased PEds' awareness of appropriate antibiotic use. This qualitative study supports the feasibility of delivering PE in schools. Maximising interactive and illness scenario content, greater training and support for PEds, and inclusion of infection self-care and antibiotics in the national curriculum for all 16-18-year olds could help facilitate greater antibiotic education in schools. Simplifying consent and data collection procedures would facilitate future evaluations.

Evaluation of an Educational Health Website on Infections and Antibiotics in England: Mixed Methods, User-Centered Approach

Background

e-Bug, an educational health website for teachers and students, aims to help control antibiotic resistance by educating young people about microbes, hygiene, and antibiotic resistance, reducing the incidence of infection and, therefore, the need for antibiotics. The teachers’ section of the e-Bug website has not been evaluated since it was launched in 2009, and worldwide page views have been steadily decreasing since 2013.

Objective

This study aimed to apply GoodWeb, a comprehensive framework utilizing methodologies and attributes that are relevant to the digital era, to evaluate and suggest improvements to the e-Bug website.

Methods

Electronic questionnaires and face-to-face completion of task scenarios were used to assess content, ease of use, interactivity, technical adequacy, appearance, effectiveness, efficiency, and learnability of the teachers’ section of the e-Bug website.

Results

A total of 106 teachers evaluated the e-Bug website; 97.1% (103/106) of them reported that they would use e-Bug, and 98.1% (104/106) of them reported that they would recommend it to others. Participants thought that there was a niche for e-Bug because of the way the resources fit into the national curriculum. Suggestions for improvements included changing the menu indication by highlighting the current page or deactivating links, improving home page indication, and providing a preview of resources when hovering the mouse over hyperlinks. Additional features requested by users included a search function and access to training opportunities.

Conclusions

This paper reports that the GoodWeb framework was successfully applied to evaluate the e-Bug website, and therefore, it could be used to guide future website evaluations in other fields. Results from this study will be used to appraise the current quality and inform any future changes, modifications, and additions to e-Bug.

Effectiveness and Efficiency of Persuasive Space Graphics (PSG) in Motivating UK Primary School Children's Hand Hygiene

Good hand hygiene is necessary to control and prevent infections, but many children do not adequately wash their hands. While there are classroom communications targeted at children, the toilet space, the location of many hand hygiene activities, is neglected. This paper describes an initial evaluation of “123” persuasive space graphics (images and messages integrated within an architectural environment that encourage specific actions). The effectiveness (whether hand hygiene improves) and efficiency (the ease with which a setting can adopt and implement an intervention) is evaluated in three UK schools and one museum. Five evaluations (participant demographic, handwashing frequency, handwashing quality, design persuasiveness, stakeholder views) were conducted. In the school settings, persuasive space graphics increased the quality and frequency of handwashing. In the museum setting, frequency of handwashing slightly increased. In all settings children found the graphics persuasive, and stakeholders also believed them to be effective. Stakeholders considered persuasive space graphics a low-cost and time-efficient way to communicate. It can be concluded that persuasive space graphics are effective in increasing hand hygiene, particularly in school settings where children have a longer exposure to the graphics. Persuasive space graphics are also an efficient low-cost means of communicating hand hygiene.

Peer-Education as a Tool to Educate on Antibiotics, Resistance and Use in 16-18-Year-Olds: A Feasibility Study

Peer education (PE) interventions may help improve knowledge and appropriate use of antibiotics in young adults. In this feasibility study, health-care students were trained to educate 16-18 years old biology students, who then educated their non-biology peers, using e-Bug antibiotic lessons. Knowledge was assessed by questionnaires, and antibiotic use by questionnaire, SMS messaging and GP record searches. Five of 17 schools approached participated (3 PE and 2 control (usual lessons)). 59% (10/17) of university students and 28% (15/54) of biology students volunteered as peer-educators. PE was well-received; 30% (38/127) intervention students and 55% (66/120) control students completed all questionnaires. Antibiotic use from GP medical records (54/136, 40% of students' data available), student SMS (69/136, 51% replied) and questionnaire (109/136, 80% completed) data showed good agreement between GP and SMS (kappa = 0.72), but poor agreement between GP and questionnaires (kappa = 0.06). Median knowledge scores were higher post-intervention, with greater improvement for non-biology students. Delivering and evaluating e-Bug PE is feasible with supportive school staff. Single tiered PE by university students may be easier to regulate and manage due to time constraints on school students. SMS collection of antibiotic data is easier and has similar accuracy to GP data.

Raising awareness of antimicrobial resistance among the general public in the UK: the role of public engagement activities

In response to the accepted risk of emerging antimicrobial resistance, many organizations and institutions have developed and delivered events and activities designed to raise awareness of the issue and to change the behaviour of the intended audience. However, few of these events for a general public audience are documented or able to be sourced by those who might wish to repeat, adapt or modify, particularly those events that are successful. 'Insider knowledge' appears to be the best search tool. Moreover, evaluation of the success or impact of the event is rarely published. It would be useful if there were a 'hub' where descriptions of such activities could be deposited, enabling the building of a significant resource with real academic value.

International promotion of e-Bug, an infection prevention and control educational intervention: survey of partners across 14 countries

BACKGROUND

Antimicrobial resistance (AMR) is a global threat to public health. e-Bug is an educational resource developed and promoted by a network of international partners. e-Bug seeks to reduce the spread of infection and use of antimicrobials in young people and the community, so helping to control AMR. This study aimed to explore how e-Bug is promoted by international partners and observe barriers to promotion, including the extent of education about antibiotics in schools.

METHODS

A total of 29 e-Bug partners were invited to complete online questionnaires on (i) methods they use to promote e-Bug; and (ii) antibiotic topics covered in the national curriculum in their countries.

RESULTS

Fourteen and 15 of 29 e-Bug partners across Europe and Palestine completed the promotional activities and curriculum questionnaires respectively. The most frequently reported methods of promotion included endorsement and collaboration with government and non-government sectors and involvement in national and global health awareness campaigns. Barriers to promotion included a lack of time and funding. The curriculum survey data showed variation in antibiotic education across Europe and Palestine, lack of antibiotic education for children under 11 years of age and little change in antibiotic topics included in the curriculum since 2006.

CONCLUSIONS

Future and existing e-Bug partners should be encouraged to follow promotional activities reported in this paper, including ministry endorsement, educator training, international campaigns and youth programmes. We encourage all countries to increase antibiotic topics in the school curriculum across all ages.

Factors associated with sufficient knowledge of antibiotics and antimicrobial resistance in the Japanese general population

We conducted two online surveys about antibiotics targeted at the Japanese general population in March 2017 and February 2018. In total, 6,982 participants completed the questionnaire. Factors associated with knowledge of antibiotics, knowledge of antimicrobial resistance (AMR) and appropriate behavioural changes were evaluated by a machine learning approach using DataRobot. Factors strongly associated with three dependent variables in the model were extracted based on permuation importance. We found that the strongest determinant of knowledge of antibiotics and AMR was education level. Knowledge of antibiotics was strongly associated with the frequency of internet use. Exposure to primary information was associated with motivation for appropriate behavioural changes. Improving the availability of primary information would be a beneficial intervention. Individuals lacking higher education and without opportunities to obtain primary information should be considered a target population for effective interventions.

Students' Practices and Knowledge on Antimicrobial Usage and Resistance in Split, Croatia: The Education of Future Prescribers

Aims: To evaluate the effect of biomedical students' ongoing education, we assessed their knowledge and attitudes toward antimicrobial use. Study Design: A cross-sectional study was carried out among the students of four study programs: Medicine in Croatian, Medicine in English, Dental medicine, and Pharmacy. The anonymous questionnaire was distributed to students who attended classes from April to May 2018. Results: A total of 947 (86%) out of 1,107 students enrolled at the University of Split School of Medicine participated in this study. A third of dental students (51/159) and a quarter of medical (113/458) and pharmacy students (32/130) believed that paracetamol was an antibiotic that reduces pain. However, the percentage significantly decreased from the first to the final years. Only 31% of the final year dental medicine students (5/16) named a correct guideline for the usage of antimicrobial drugs, 23% of medical students (18/78), and none in the English program. Pharmacy students were the most informed, since 76% of the final year students (16/21) named Intersectoral Coordination Mechanism for the Control of Antimicrobial Resistance (ISKRA) guidelines. Conclusion: The students showed poor knowledge on the use of guidelines for antibiotic use, highlighting the need for changes in the existing curricula, including a more effective course on antimicrobial prescribing.

Using debate to educate young people in schools about antibiotic use and resistance: A before and after evaluation using a questionnaire survey

Introduction

The use of debating as an educational tool is increasing in popularity. Students who take part in debates can develop a range of skills such as confidence and communication as well as gaining a greater understanding of the topic discussed. Within this study we have evaluated an antibiotic-resistant debate kit, assessing the ability of the debate lesson to improve student knowledge and awareness around antibiotics.

Methods

The debate lesson was delivered in seven schools across South West England to 235 students aged 13-16 years. Change in student knowledge was measured using before and after knowledge questionnaires. Student and teacher feedback and suggestions for improvements for the lesson were also collected through questionnaires and interviews.

Results

Quantitative questionnaires found a significant improvement in knowledge for most areas covered in the debate, particularly around the use of antibiotics to treat colds and bacteria developing resistance. Teachers felt their students engaged well with the debate session and made suggestions for minor modifications that could improve the lesson.

Conclusions

The results suggest that the e-Bug antibiotic resistant debate kit is able to improve knowledge in young people around antibiotics and antibiotic resistance. Furthermore, the lesson was enjoyed by students and therefore this resource should be promoted more widely to teachers and schools.

Public understanding and use of antibiotics in England: findings from a household survey in 2017

OBJECTIVES

To describe public understanding and use of antibiotics.

DESIGN

Ipsos MORI Capibus survey of randomly-selected households.

SETTING

England, January-April 2017.

PARTICIPANTS

2283 adults (≥15 years) including 777 parents of children <5 years old.

DATA COLLECTION AND ANALYSIS

The main survey was undertaken in January 2017 (n=1691); data from an additional sample of parents were collected in April 2017 (n=592). Analyses were weighted to obtain estimates representative of the population.

MAIN OUTCOME MEASURES

Responses to questions about antibiotics (awareness and perceptions), recent illness (expectations and experience), delayed and leftover antibiotics, and child illness stratified by demographic and socioeconomic characteristics.

RESULTS

Most respondents (83% (1404/1691)) recognised that antibiotics kill bacteria/treat bacterial infections, but a sizeable minority (35% (592/1691)) thought that antibiotics kill viruses/treat viral infections. Overall levels of understanding have not changed substantially since similar surveys in 2003 and 2008/2009. One sixth of respondents who were prescribed antibiotics reported having leftovers (14% (64/498)) and 33% (22/64) kept these for possible future use. 1.3% of all respondents (23/1691) reported taking left-over antibiotics in the past year and 1.6% (26/1691) reported taking antibiotics obtained without a prescription. Higher social grade and educational qualifications were strongly positively associated with antibiotic knowledge; youngest (15-24 years), oldest (65 +years) and black, Asian and minority ethnic adults were less knowledgeable. Among 1319 respondents who had an infection or antibiotics within the past year, 43% (568/1319) said that they had not received any advice or information about antibiotics.

CONCLUSIONS

Despite many campaigns, public understanding of antibiotics in England continues to combine correct basic knowledge held by most people with less prevalent but persistent and potentially harmful misunderstandings. These could be addressed through active provision of advice and information during primary and secondary care consultations and more effective public health interventions.

Assessing National Antimicrobial Resistance Campaigns Using a Health Equity Assessment Tool (HEAT)

It has been widely recognised that a significant proportion of the world’s population suffer inequalities in accessing high quality healthcare and wider services. Within healthcare, antimicrobial resistance (AMR) is a global threat to public health affecting all healthcare systems and growing at an alarming pace. To ensure that national AMR campaigns developed by Public Health England are inclusive of all populations within the target audience a health equity assessment tool (HEAT) was used. The project leads for each campaign completed the HEAT independently with a follow up meeting with the study team to discuss and clarify the responses. A trend analysis was carried out with common themes being used to provide recommendations. The campaigns have demonstrated equality and diversity based on the requirements of the Equality Act 2010, particularly age, sex, and race protected characteristics. Some notable results include the translation of website materials in over 30 languages and reaching individuals in 122 countries. It was however noted that several of the protected characteristics were not applicable. The continuous development of resources with collaboration from a variety of diverse user groups would be advantageous towards aiding future campaign reach. The use of the HEAT has demonstrated the ease and cost-effective way to assess any health inequalities and would be a useful addition to antimicrobial stewardship and public health campaigns.

Knowledge Assessment of E-Bug Assisted Antimicrobial Resistance Education Module in Class VII School Students of South Indian Coastal Town of Manipal

Antimicrobial resistance (AMR) is a recognized public health threat today globally. Although many active and passive stewardship strategies are advocated to counter AMR clinically, educating school going children on AMR could be a cost-effective measure to minimize AMR development in the future. We implemented NICE’s e-bug as a module to educate class VII school students on AMR determinants. A prospective quasi-experimental study on 327 students from nine different schools of class VII around Manipal town, Udupi district, Karnataka state, India were included in the study. Ten questions on AMR determinants from the e-bug program were used in written pre-test. After an education intervention, a post-test was conducted. Descriptive statistics to estimate epidemiological characteristics, Wilcoxon Signed Ranks and Kruskal–Wallis tests were applied to analyze statistical significance of pre/post-test performance scores and between schools. Students had inadequate knowledge on seven AMR determinants (antimicrobial indication, its course, hand hygiene, fermentation, spread of infection, microbial multiplication and characteristics of microbe) as analyzed from the post-test performance (p < 0.05). Comparison of post-test performance between schools showed significant improvement in scores (p < 0.05) for three questions (definition on antimicrobial, cover while cough/sneezing and microbial characteristics). Although students exhibited sub-optimal knowledge on some AMR determinants, they showed keenness to learn, which was evident by their post-test performance. Our findings and previous similar studies from Europe are suggestive of early pedagogic interventions on AMR through inclusion of such education modules in the regular school curriculum could be a potential tool for AMR prevention.

A mixed methods pilot of Beat the Bugs: A community education course on hygiene, self-care and antibiotics

Background

e-Bug is an international health education resource which support World Health Organization (WHO) public health recommendations by educating young people about microbes, hygiene and antibiotics use. The e-Bug team collaborated with Kingfisher Treasure Seekers to develop a six-session course for community groups called Beat the Bugs covering: microbes; hygiene; antibiotic use; and self-care. A pilot was used to inform further development and evaluation.

Methods

Pilot courses with 9-12 adults with learning difficulties and young parents were delivered by community leaders and observed by researchers. Participants completed before and after knowledge questionnaires. Two participant focus groups and two course leader interviews explored views on the course and retention of knowledge.

Results

Completed questionnaires and qualitative results showed an improvement in participant knowledge in each session; microbes and antibiotics sessions showed the greatest knowledge improvement. Self-care showed the greatest knowledge retention and participants reported behaviour change including an increase in appropriate hand-washing and tooth-brushing.

Conclusion

The Beat the Bugs course is a useful intervention for communities to give individuals the knowledge and confidence to manage their own infection and change behaviour around hygiene, self-care and antibiotics. Beat the Bugs is freely available to download.

Fitting the message to the location: engaging adults with antimicrobial resistance in a World War 2 air raid shelter

AIMS

There are many different initiatives, global and local, designed to raise awareness of antimicrobial resistance (AMR) and change audience behaviour. However, it is not possible to assess the impact of specific, small-scale events on national and international outcomes-although one might acknowledge some contribution to the individual and collective knowledge and experience-focused 'science capital' As with any research, in preparation for a public engagement event, it is important to identify aims, and appropriate methods whose results might help satisfy those aims. Therefore, the aim of this paper was to develop, deliver and evaluate an event designed to engage an adult audience with AMR.

METHODS AND RESULTS

The venue was a World War 2 air raid shelter, enabling comparison of the pre- and postantibiotic eras via three different activity stations, focusing on nursing, the search for new antibiotics and investigations into novel antimicrobials. The use of observers released the presenters from evaluation duties, enabling them to focus on their specific activities. Qualitative measures of audience engagement were combined with quantitative data.

CONCLUSIONS

The evaluation revealed that adult audiences can easily be absorbed into an activity-particularly if hands-on-after a brief introduction.

SIGNIFICANCE AND IMPACT OF THE STUDY

This research demonstrates that hands-on practical engagement with AMR can enable high-level interaction and learning in an informal and enjoyable environment.

A mixed-method evaluation of peer-education workshops for school-aged children to teach about antibiotics, microbes and hygiene

Background

Delivering health topics in schools through peer education is known to be beneficial for all students involved. In this study, we have evaluated a peer-education workshop that aims to educate primary and secondary school students on hygiene, the spread of infection and antibiotics.

Methods

Four schools in south-west England, in a range of localities, took part in peer-education workshops, with students completing before, after and knowledge-retention questionnaires. Mixed-effect logistic regression and mixed-effect linear regression were used to analyse the data. Data were analysed by topic, region and peer/non-peer-educator status. Qualitative interviews and focus groups with students and educators were conducted to assess changes in participants' skills, confidence and behaviour.

Results

Qualitative data indicated improvements in peer-educator skills and behaviour, including confidence, team-working and communication. There was a significant improvement in knowledge for all topics covered in the intervention, although this varied by region. In the antibiotics topic, peer-educators' knowledge increased in the retention questionnaire, whereas non-peer-educators' knowledge decreased. Knowledge declined in the retention questionnaires for the other topics, although this was mostly not significant.

Conclusions

This study indicates that peer education is an effective way to educate young people on important topics around health and hygiene, and to concurrently improve communication skills. Its use should be encouraged across schools to help in the implementation of the National Institute for Health and Care Excellence (NICE) guidance that recommends children are taught in an age-appropriate manner about hygiene and antibiotics.

Knowledge of community pharmacists about antibiotics, and their perceptions and practices regarding antimicrobial stewardship: a cross-sectional study in Punjab, Pakistan

Objective

To evaluate the knowledge of community pharmacists about antibiotics, and their perceptions and practices toward antimicrobial stewardship (AMS) in Punjab, Pakistan.

Materials and methods

A descriptive cross-sectional study was conducted among community pharmacists in Punjab, Pakistan from April 1, 2017 to May 31, 2017. A self-administered and pretested questionnaire was used for data collection. A simple random-sampling method was used to select community pharmacies. Independent-sample Mann-Whitney U tests, independent sample Kruskal-Wallis tests, and logistic regression analysis were performed with SPSS version 21.0.

Results

Of the 414 pharmacists, 400 responded to the survey (response rate 96.6%). The participants had good knowledge about antibiotics. They showed positive perceptions, but poor practices regarding AMS. All of the participants were of the view that AMS program could be beneficial for health care professionals for improvement of patient care, and 78% (n=312) of participants gave their opinion about incorporation of AMS programs in community pharmacies. Collaboration was never/rarely undertaken by pharmacists with other health care professionals over the use of antibiotics (n=311, 77.8%), and a significant proportion of participants (n=351, 87.8%) never/rarely participated in AMS-awareness campaigns. Logistic regression analysis revealed that male sex (OR 0.204, 95% CI 0.104-0.4; P<0.001), age 20-29 years (OR 0.172, 95% CI 0.05-0.595; P=0.005), and <1 year of experience (OR 0.197, 95% CI 0.083-0.468; P<0.001) were the factors associated with poor practices regarding AMS.

Conclusion

Pharmacists had good knowledge about antibiotics. There were some gaps in perceptions and practices of community pharmacists regarding AMS. In the current scenario, it will be critical to fill these gaps and improve perceptions and practices of community pharmacists regarding AMS by developing customized interventions.

Qualitative interviews with healthcare staff in four European countries to inform adaptation of an intervention to increase chlamydia testing

OBJECTIVE

To determine the needs of primary healthcare general practice (GP) staff, stakeholders and trainers to inform the adaptation of a locally successful complex intervention (Chlamydia Intervention Randomised Trial (CIRT)) aimed at increasing chlamydia testing within primary healthcare within South West England to three EU countries (Estonia, France and Sweden) and throughout England.

DESIGN

Qualitative interviews.

SETTING

European primary healthcare in England, France, Sweden and Estonia with a range of chlamydia screening provision in 2013.

PARTICIPANTS

45 GP staff, 13 trainers and 18 stakeholders.

INTERVIEWS

The iterative interview schedule explored participants' personal attitudes, subjective norms and perceived behavioural controls around provision of chlamydia testing, sexual health services and training in general practice. Researchers used a common thematic analysis.

RESULTS

Findings were similar across all countries. Most participants agreed that chlamydia testing and sexual health services should be offered in general practice. There was no culture of GP staff routinely offering opportunistic chlamydia testing or sexual health advice, and due to other priorities, participants reported this would be challenging. All participants indicated that the CIRT workshop covering chlamydia testing and sexual health would be useful if practice based, included all practice staff and action planning, and was adequately resourced. Participants suggested minor adaptations to CIRT to suit their country's health services.

CONCLUSIONS

A common complex intervention can be adapted for use across Europe, despite varied sexual health provision. The intervention (ChlamydiA Testing Training in Europe (CATTE)) should comprise: a staff workshop covering sexual health and chlamydia testing rates and procedures, action planning and patient materials and staff reminders via computer prompts, emails or newsletters, with testing feedback through practice champions. CATTE materials are available at: www.STItraining.eu.

Can Gaming Increase Antibiotic Awareness in Children? A Mixed-Methods Approach

BACKGROUND

e-Bug is a pan-European educational resource for junior and senior school children, which contains activities covering prudent antibiotic use and the spread, treatment, and prevention of infection. Teaching resources for children aged 7-15 years are complemented by a student website that hosts games and interactive activities for the children to continue their learning at home.

OBJECTIVE

The aim of this study was to appraise young people's opinions of 3 antibiotic games on the e-Bug student website, exploring children's views and suggestions for improvements, and analyzing change in their knowledge around the learning outcomes covered. The 3 games selected for evaluation all contained elements and learning outcomes relating to antibiotics, the correct use of antibiotics, and bacteria and viruses.

METHODS

A mixed methodological approach was undertaken, wherein 153 pupils aged 9-11 years in primary schools and summer schools in the Bristol and Gloucestershire area completed a questionnaire with antibiotic and microbe questions, before and after playing 3 e-Bug games for a total of 15 minutes. The after questionnaire also contained open-ended and Likert scale questions. In addition, 6 focus groups with 48 students and think-aloud sessions with 4 students who had all played the games were performed.

RESULTS

The questionnaire data showed a significant increase in knowledge for 2 out of 7 questions (P=.01 and P<.001), whereas all questions showed a small level of increase. The two areas of significant knowledge improvement focused around the use of antibiotics for bacterial versus viral infections and ensuring the course of antibiotics is completed. Qualitative data showed that the e-Bug game "Body Busters" was the most popular, closely followed by "Doctor Doctor," and "Microbe Mania" the least popular.

CONCLUSIONS

This study shows that 2 of the e-Bug antibiotic educational games are valuable. "Body Busters" effectively increased antibiotic knowledge in children and had the greatest flow and enjoyment. "Doctor Doctor" also resulted in increased knowledge, but was less enjoyable. "Microbe Mania" had neither flow nor knowledge gain and therefore needs much modification and review. The results from the qualitative part of this study will be very important to inform future modifications and improvements to the e-Bug games.

School Nurses' perspectives on the role of the school nurse in health education and health promotion in England: a qualitative study

Background

The role of the school nurse is complex with many possible elements identified by previous research. The aim of this study is to understand perceptions of the role of the school nurse in order to support school nurses in the delivery of health education.

Methods

The study used an inductive, qualitative research design involving semi-structured interviews and focus groups. Participants were recruited from four NHS trusts across England and final sample size was thirty one school nurses. Three focus groups and two interviews took place in person, and three interviews were over the phone. Data was thematically analysed.

Results

School nurses described six main themes. Four themes directly related to the school nurse role: the main roles of a school nurse, school nurses' role in health education, prioritisation of workload and activities, and community work. A further two other themes related to the delivery of health education: the school nursing system and educational resources.

Conclusions

The role of the school nurse in England is very diverse and the school nurse role in health education is primarily to advise and support schools, rather than to directly deliver education. The study identified that tailored public health educational resources are needed to support school nurses.

Bacterial resistance to antimicrobial agents and its impact on veterinary and human medicine

BACKGROUND

Antimicrobial resistance has become a major challenge in veterinary medicine, particularly in the context of bacterial pathogens that play a role in both humans and animals.

OBJECTIVES

This review serves as an update on acquired resistance mechanisms in bacterial pathogens of human and animal origin, including examples of transfer of resistant pathogens between hosts and of resistance genes between bacteria.

RESULTS

Acquired resistance is based on resistance-mediating mutations or on mobile resistance genes. Although mutations are transferred vertically, mobile resistance genes are also transferred horizontally (by transformation, transduction or conjugation/mobilization), contributing to the dissemination of resistance. Mobile genes specifying any of the three major resistance mechanisms - enzymatic inactivation, reduced intracellular accumulation or modification of the cellular target sites - have been found in a variety of bacteria that may be isolated from animals. Such resistance genes are associated with plasmids, transposons, gene cassettes, integrative and conjugative elements or other mobile elements. Bacteria, including zoonotic pathogens, can be exchanged between animals and humans mainly via direct contact, but also via dust, aerosols or foods. Proof of the direction of transfer of resistant bacteria can be difficult and depends on the location of resistance genes or mutations in the chromosomal DNA or on a mobile element.

CONCLUSION

The wide variety in resistance and resistance transfer mechanisms will continue to ensure the success of bacterial pathogens in the future. Our strategies to counteract resistance and preserve the efficacy of antimicrobial agents need to be equally diverse and resourceful.

Influence of Immunology Knowledge on Healthcare and Healthy Lifestyle

Completing a course in Immunology is expected to improve health care knowledge (HCK), which in turn is anticipated to influence a healthy lifestyle (HLS), controlled use of health care services (HCS) and an awareness of emerging health care concerns (HCC). This cross-sectional study was designed to determine whether these interrelationships are empirically supported. Participants involved in this study were government servants from two ministries in Malaysia (n = 356) and university students from a local university (n = 147). Participants were selected using the non-random purposive sampling method. Data were collected using a self-developed questionnaire, which had been validated in a pilot study involving similar subjects. The questionnaire items were analyzed using Rasch analysis, SPSS version 21 and AMOS version 22. Results have shown that participants who followed a course in Immunology (CoI) had a higher primary HCK (Mean = 0.69 logit, SD = 1.29 logits) compared with those who had not (Mean = -0.27logit, SD = 1.26 logits). Overall, there were significant correlations among the HLS, the awareness of emerging HCC, and the controlled use of HCS (p <0.001). However, no significant correlations were observed between primary HCK and the other variables. However, significant positive correlation was observed between primary HCK and controlled use of HCS for the group without CoI. Path analysis showed that the awareness of emerging HCC exerted a positive influence on controlled use of HCS (β = 0.156, p < .001) and on HLS (β = 0.224, p < .001). These findings suggest that having CoI helps increase primary HCK which influences controlled use of HCS but does not necessarily influence HLS. Hence, introducing Immunology at various levels of education and increasing the public awareness of emerging HCC might help to improve population health en masse. In addition, further investigations on the factors affecting HLS is required to provide a better understanding on the relationship between primary HCK and HLS.

Knowledge and perceptions on antibiotic use and resistance among high school students and teachers in New Delhi, India: A qualitative study

OBJECTIVE

To explore the perceptions and knowledge of school teachers and students about antibiotic use, resistance, and suggestions for practical interventions for the rational use of antibiotics.

METHODOLOGY

Five focus group discussions (FGDs) with high school students (Class: 9-11) and five with teachers were conducted in two private and three public schools (one teacher and one student FGD per school) in five municipal wards of Delhi. Qualitative data on antibiotic knowledge, resistance, and behaviors with respect to antibiotics use were collected. There were 4-8 persons per teacher FGD and 15-20 persons per student FGD. FGDs were analyzed using "thematic analyses."

RESULTS

Students had poor knowledge regarding antibiotics and antibiotic resistance, while only some teachers had a basic understanding. Four broad themes needing attention emerged: definition of antibiotic and antibiotic resistance, antibiotic use behavior, doctor-patient relationship, and interventional strategies suggested to curtail the misuse of antibiotics and to spread awareness. In order to tackle these problems, both groups suggested a multipronged approach including robust public awareness campaigns also involving schools, better doctor-patient relationships, and stronger regulations.

CONCLUSIONS

Although students and teachers exhibited poor knowledge about antibiotic use and resistance, they were keen to learn about these issues. School education programs and public education could be used to shape correct perceptions about antibiotic use among all stakeholders including children. This may help in the containment of antibiotic resistance and thus preservation of antibiotics for future generations.

Monitoring Web Site Usage of e-Bug: A Hygiene and Antibiotic Awareness Resource for Children

Background

e-Bug is an educational resource which teaches children and young people about microbes, hygiene, infection, and prudent antibiotic use. The e-Bug resources are available in over 22 different languages and they are used widely across the globe. The resources can be accessed from the e-Bug website.

Objective

The objective of this study was to analyze the usage of the e-Bug website in order to understand how users access the website, where and when they access the site, and to review variation in use across the different areas of the site.

Methods

The usage statistics for the e-Bug website were monitored by Google Analytics between September 2010 and August 2013.

Results

The statistics show the website had over 324,000 visits during the three years, from just under 250,000 visitors, with the number of visitors increasing year after year. Visitors accessed the website from 211 different countries, with more than 267,000 documents downloaded. The majority of visitors were from the United Kingdom and visited the English website, although countries such as France and Portugal were also frequent visitors.

Conclusions

These website statistics confirm that e-Bug is frequently used across Europe and highlight that e-Bug use has expanded across the world. The findings from this report will be used to inform future modifications or updates to the materials, as well as the development of new educational resources.

The Ethical Significance of Antimicrobial Resistance

In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the context of antimicrobial resistance (AMR), which includes an introduction to the contributions to the symposium in this issue. We begin by discussing why AMR is a distinct ethical issue, and should not be viewed purely as a technical or medical problem. In the second section, we expand on some of these arguments and argue that AMR presents us with a broad range of ethical problems that must be addressed as part of a successful policy response to emerging drug resistance. In the third section, we discuss how some of these ethical challenges should be addressed, and we argue that this requires contributions from citizens, ethicists, policy makers, practitioners and industry. We conclude with an overview of steps that should be taken in moving forward and addressing the ethical problems of AMR.

The Potential Role of Social Media Platforms in Community Awareness of Antibiotic Use in the Gulf Cooperation Council States: Luxury or Necessity?

The increasing emergence and spread of antimicrobial resistance (AMR) is a serious public health issue. Increasing the awareness of the general public about appropriate antibiotic use is a key factor for combating this issue. Several public media campaigns worldwide have been launched; however, such campaigns can be costly and the outcomes are variable and difficult to assess. Social media platforms, including Twitter, Facebook, and YouTube, are now frequently utilized to address health-related issues. In many geographical locations, such as the countries of the Gulf Cooperation Council (GCC) States (Saudi Arabia, United Arab Emirates, Kuwait, Oman, Qatar, and Bahrain), these platforms are becoming increasingly popular. The socioeconomic status of the GCC states and their reliable communication and networking infrastructure has allowed the penetration and scalability of these platforms in the region. This might explain why the Saudi Ministry of Health is using social media platforms alongside various other media platforms in a large-scale public awareness campaign to educate at-risk communities about the recently emerged Middle East respiratory syndrome coronavirus (MERS-CoV). This paper discusses the potential for using social media tools as cost-efficient and mass education platforms to raise awareness of appropriate antibiotic use in the general public and in the medical communities of the Arabian Peninsula.

Educational effectiveness, target, and content for prudent antibiotic use

Widespread antimicrobial use and concomitant resistance have led to a significant threat to public health. Because inappropriate use and overuse of antibiotics based on insufficient knowledge are one of the major drivers of antibiotic resistance, education about prudent antibiotic use aimed at both the prescribers and the public is important. This review investigates recent studies on the effect of interventions for promoting prudent antibiotics prescribing. Up to now, most educational efforts have been targeted to medical professionals, and many studies showed that these educational efforts are significantly effective in reducing antibiotic prescribing. Recently, the development of educational programs to reduce antibiotic use is expanding into other groups, such as the adult public and children. The investigation of the contents of educational programs for prescribers and the public demonstrates that it is important to develop effective educational programs suitable for each group. In particular, it seems now to be crucial to develop appropriate curricula for teaching medical and nonmedical (pharmacy, dentistry, nursing, veterinary medicine, and midwifery) undergraduate students about general medicine, microbial virulence, mechanism of antibiotic resistance, and judicious antibiotic prescribing.

Antibiotic use: a cross-sectional survey assessing the knowledge, attitudes and practices amongst students of a school of medicine in Italy

Background

Since antibiotic resistance has become a worldwide public health concern and is in part related to physicians’ lack of knowledge, it is essential to focus our attention on healthcare profession students. The present study aims at evaluating the knowledge and attitudes of the School of Medicine’s students towards antibiotic usage and antibiotic resistance.

Methods

In December 2013, a cross sectional study was conducted amongst medical, dental, nursing and other health care profession students of the School of Medicine at the University of Torino. Students of all the academic years took part in this study. Questionnaires were submitted during regular lectures (only students who attended courses on one specific day were surveyed) and the data collected was analyzed using StataMP11 statistical software.

Results

Overall, 1,050 students were interviewed. The response rate was 100%. Around 20% of the sample stated that antibiotics are appropriate for viral infections and 15% of the students that they stop taking those drugs when symptoms decrease. Results of the multivariate analyses showed that females were more likely than males to take antibiotics only when prescribed (OR 1.43, 95% CI 1.04–1.98). Interestingly, students with a relative working in a health-related field, as well as those who took at least one course of antibiotics in the last year, had a lower probability of taking those drugs only under prescription (OR = 0.69 95% CI: 0.49–0.97 and OR = 0.38 95% CI: 0.27–0.53, respectively).

Conclusion

The present paper shows how healthcare profession students do not practice what they know. Since those students will be a behavioral model for citizens and patients, it is important to generate more awareness around this issue throughout their studies. It would be advisable to introduce a specific course and training on antibiotics in the core curriculum of the School of Medicine.

European survey on principles of prudent antibiotic prescribing teaching in undergraduate students

We surveyed European medical schools regarding teaching of prudent antibiotic prescribing in the undergraduate curriculum. We performed a cross-sectional survey in 13 European countries (Belgium, Croatia, Denmark, France, Germany, Italy, Netherlands, Norway, Serbia, Slovenia, Spain, Switzerland, United Kingdom) in 2013. Proportional sampling was used, resulting in the selection of two to four medical schools per country. A standardized questionnaire based on literature review and validated by a panel of experts was sent to lecturers in infectious diseases, medical microbiology and clinical pharmacology. In-depth interviews were conducted with four lecturers. Thirty-five of 37 medical schools were included in the study. Prudent antibiotic use principles were taught in all but one medical school, but only four of 13 countries had a national programme. Interactive teaching formats were used less frequently than passive formats. The teaching was mandatory for 53% of the courses and started before clinical training in 71%. We observed wide variations in exposure of students to important principles of prudent antibiotic use among countries and within the same country. Some major principles were poorly covered (e.g. reassessment and duration of antibiotic therapy, communication skills). Whereas 77% of the respondents fully agreed that the teaching of these principles should be prioritized, lack of time, mainly due to rigid curriculum policies, was the main reported barrier to implementation. Given the study design, these are probably optimistic results. Teaching of prudent antibiotic prescribing principles should be improved. National and European programmes for development of specific learning outcomes or competencies are urgently needed.

Tackling antibiotic resistance in India

Infectious diseases are major causes of mortality in India. This is aggravated by the increasing prevalence of antimicrobial resistance (AMR) both in the community and in hospitals. Due to the emergence of resistance to all effective antibiotics in nosocomial pathogens, the situation calls for emergency measures to tackle AMR in India. India has huge challenges in tackling AMR, ranging from lack of surveillance mechanisms for monitoring AMR and use; effective hospital control policies; sanitation and non-human use of antimicrobial. The Ministry of Health and Family Welfare of Govt. of India has taken initiatives to tackle AMR. Extensive guidelines have been drafted and a model worksheet has been developed as a roadmap to tackle AMR.

Using interactive family science shows to improve public knowledge on antibiotic resistance: does it work?

The public plays an important role in controlling the emergence and spread of antibiotic resistance. A large British survey showed that there is still public misunderstanding about microbes and antibiotics. e-Bug, a European DG Sanco sponsored project, aims to disseminate a school antibiotic and hygiene educational pack and website across Europe. Interactive science shows based on the e-Bug educational packs were developed to take the key health and hygiene messages from the e-Bug school resources to families. The science show was evaluated to assess public knowledge and understanding of antibiotics and antibiotic resistance pre and post intervention. An interactive stall comprised of a 3×2 m backing stand with background information, an interactive activity and discussions with a trained demonstrator was on display at a family holiday resort. Pre-piloted knowledge questionnaires were completed by parents and children pre and post intervention. Adult (≥19 years) baseline knowledge regarding antibiotics and antibiotic resistance was high although significant knowledge improvement was observed where baseline knowledge was low. Children's (5–11 years) knowledge around antibiotics and antibiotic resistance was significantly improved for all questions. The science show can be viewed as a success in improving parents' and children's knowledge of antibiotic use thereby highlighting the importance of educating the public through interaction.

An overview of current and potential use of information and communication technologies for immunization promotion among adolescents

Information and communication technologies (ICT), such as the Internet or mobile telephony, have become an important part of the life of today's adolescents and their main means of procuring information. The new generation of the Internet based on social-networking technologies, Web 2.0, is increasingly used for health purposes by both laypeople and health professionals. A broad spectrum of Web 2.0 applications provides several opportunities for healthcare workers, in that they can reach large numbers of teenagers in an individualized way and promote vaccine-related knowledge in an interactive and entertaining manner. These applications, namely social-networking and video-sharing websites, wikis and microblogs, should be monitored in order to identify current attitudes toward vaccination, to reply to vaccination critics and to establish a real-time dialog with users. Moreover, the ubiquity of mobile telephony makes it a valuable means of involving teenagers in immunization promotion, especially in developing countries.

Fun on the farm: evaluation of a lesson to teach students about the spread of infection on school farm visits

Background

School visits to farms are a positive educational experience but pose risks due to the spread of zoonotic infections. A lesson plan to raise awareness about microbes on the farm and preventative behaviours was developed in response to the Griffin Investigation into the E. coli outbreak associated with Godstone Farm in 2009. This study evaluated the effectiveness of the delivery of the lesson plan in increasing knowledge about the spread of infection on the farm, amongst school students.

Methods

Two hundred and twenty-five 9–11 year old students from seven junior schools in England participated. Two hundred and ten students filled in identical questionnaires covering microbes, hand hygiene, and farm hygiene before and after the lesson. Statistical analysis assessed knowledge change using difference in percentage correct answers.

Results

Significant knowledge improvement was observed for all sections. In the ‘Farm Hygiene’ section, girls and boys demonstrated 18% (p<0.001) and 11% (p<0.001) improvement, respectively (girls vs. boys p<0.004). As girls had lower baseline knowledge the greater percentage improvement resulted in similar post intervention knowledge scores between genders (girls 80%, boys 83%).

Conclusions

The lesson plan was successful at increasing awareness of microbes on the farm and infection prevention measures and should be used by teachers in preparation for a farm visit.

Current initiatives to improve prudent antibiotic use amongst school-aged children

High rates of antimicrobial prescribing for children, combined with widespread misunderstanding among the general public about the appropriate use of antibiotics, are major causes for concern. European Antibiotic Awareness Day (EAAD) is an annual event that aims to raise awareness of how to use antibiotics in a responsible way that will help keep them effective for the future. As part of EAAD 2013, this article provides an overview of some initiatives aimed at limiting the extent of inappropriate antibiotic use in children.

Strategies to minimize antibiotic resistance

Antibiotic resistance can be reduced by using antibiotics prudently based on guidelines of antimicrobial stewardship programs (ASPs) and various data such as pharmacokinetic (PK) and pharmacodynamic (PD) properties of antibiotics, diagnostic testing, antimicrobial susceptibility testing (AST), clinical response, and effects on the microbiota, as well as by new antibiotic developments. The controlled use of antibiotics in food animals is another cornerstone among efforts to reduce antibiotic resistance. All major resistance-control strategies recommend education for patients, children (e.g., through schools and day care), the public, and relevant healthcare professionals (e.g., primary-care physicians, pharmacists, and medical students) regarding unique features of bacterial infections and antibiotics, prudent antibiotic prescribing as a positive construct, and personal hygiene (e.g., handwashing). The problem of antibiotic resistance can be minimized only by concerted efforts of all members of society for ensuring the continued efficiency of antibiotics.