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

Optimization of Screening Media to Improve Antimicrobial Biodiscovery from Soils in Undergraduate/Citizen Science Research-Engaged Initiatives

Background/Objectives: Research-engaged academic institutions offer the opportunity to couple undergraduate education/citizen science projects with antimicrobial biodiscovery research. Several initiatives reflecting this ethos have been reported internationally (e.g., Small World, Tiny Earth, MicroMundo, Antibiotics Unearthed). These programs target soil habitats due to their high microbial diversity and promote initial screening with non-selective, nutrient media such as tryptic soy agar (TSA). However, evaluation of published outputs to date indicates that isolate recovery on TSA is consistently dominated by the genera Bacillus, Pseudomonas, and Paenibacillus. In this study, we evaluated the potential of soil extract agar to enhance soil isolate diversity and antibiosis induction outcomes in our undergraduate Antibiotics Unearthed research program. Methods: We comparatively screened 229 isolates from woodland and garden soil samples on both tryptic soy agar (TSA) and soil extract agar (SEA) for antimicrobial activity against a panel of clinically relevant microbial pathogens. Results: On one or both media, 15 isolates were found to produce zones of clearing against respective pathogens. 16S rRNA gene sequencing linked the isolates with three genera: Streptomyces (7), Paenibacillus (6), and Pseudomonas (2). Six of the Streptomyces isolates and one Pseudomonas demonstrated antimicrobial activity when screened on SEA, with no activity on TSA. Furthermore, incorporation of the known secondary metabolite inducer N acetyl-glucosamine (20 mM) into SEA media altered the pathogen inhibition profiles of 14 isolates and resulted in broad-spectrum activity of one Streptomyces isolate, not observed on SEA alone. In conclusion, SEA was found to expand the diversity of culturable isolates from soil and specifically enhanced the recovery of members of the genus Streptomyces. SEA was also found to be a superior media for antibiosis induction among Streptomyces isolates when compared to TSA. It was noted that Paenibacillus isolates' antibiosis induction demonstrated a strain-specific response with respect to the growth media used. Conclusions: The authors propose SEA inclusion of in soil screening protocols as a cost-effective, complementary strategy to greatly enhance outcomes in undergraduate/citizen science-engaged antimicrobial biodiscovery initiatives.

Hands On Biofilm! A multidisciplinary public engagement event using kombucha tea pellicle as an accessible example of biofilm

Public engagement with science has become increasingly important for the scientific community. There are many documented public engagement events that focus on aspects of microbiology, but relatively few utilise biofilms as a topic, despite their importance. Kombucha tea pellicles are easy to grow biofilms, facilitating their use within the public domain as examples of these complex communities. The aim of this work was to deliver a public engagement event that introduced visitors to general concepts about biofilm, and applications around sustainability, using kombucha. The event encouraged visitors to: build a biofilm using model clay; inoculate kombucha tea cultures using different incubation conditions, as part of a citizen science experiment to assess impact on pellicle biofilm yield; create garments and drapes on mini-mannequins using dried kombucha pellicle fabric, and demonstrate the range and importance of fermented foods (including kombucha tea), and 'good bacteria'. Quantitative and qualitative indicators of engagement were built into the activities. More than 1200 visitors, mainly in family groups, visited the event over a 4-h period. Knowledge of biofilms was low at the beginning of the event. Participation in all activities was high. Indicators of quantitative engagement were impressive, but it was difficult to obtain qualitative evidence other than observations from the delivery team (nineteen members) because of the intensity of the event and volume of visitors. The event was clearly successful in terms of fulfilment of aims, audience engagement and enthusiasm: the embedded evaluations helped to evidence the impact and reach of the event, enabling confidence in dissemination of good practice in the enhancement of public understanding of the importance of biofilm in general, and kombucha in particular.

Antimicrobial resistance as a super wicked problem: how do we engage the public to be part of the solution

Antimicrobial resistance (AMR) is now regarded as one of the greatest global challenges of the 21st century. The complexity, urgent timeframe, and lack of clear solution to AMR have contributed to its classification as a 'super wicked problem'. Yet knowledge surveys of the general public have found that they still harbour numerous misconceptions linked to both the sources and impact of AMR. This confusion is compounded by AMR being a One Health issue, and therefore a factor in not just human health but in other industries, such as farming. This can further inhibit understanding and knowledge transfer around AMR for those without a prior knowledge base. In order to address the escalating risk that AMR presents, however, it is essential to address this knowledge gap and engage with the public to support wide scale changes in behaviour and consumer choice. The WHO now requires national action plans tackling AMR to include patient and public involvement/engagement (PPI/E) to support changing the trajectory of AMR. Despite this, little detail is available as part of strategic plans on how PPI/E should be undertaken in order to aid implementation. This paper discusses a number of approaches to support the design and delivery of PPI/E in relation to AMR, including the different social behaviour models underlying successful PPI/E strategies, and key considerations linked to specific activity types. The framework produced includes features for steps from initial planning and design through to evaluation. The aim is to help improve the ability of scientists and healthcare professionals to produce high quality AMR PPI/E.

Participatory antimicrobial stewardship: fostering patient and public engagement to counter antimicrobial resistance

International governments defined antimicrobial stewardship (AS) as an essential ally against antimicrobial resistance (AMR). Patient and public engagement (PPE) in AS was pointed out as an imperative requirement to be embraced. We discuss PPE state of the art in AS and methodological reflections on how to achieve its effective implementation.

Knowledge and Attitudes about Antibiotics and Antibiotic Resistance of 2404 UK Healthcare Workers

Background: Using the COM-B model as a framework, an EU-wide survey aimed to ascertain multidisciplinary healthcare workers’ (HCWs’) knowledge, attitudes and behaviours towards antibiotics, antibiotic use and antibiotic resistance. The UK findings are presented here. Methods: A 43-item questionnaire was developed through a two-round modified Delphi consensus process. The UK target quota was 1315 respondents. Results: In total, 2404 participants responded. The highest proportion were nursing and midwifery professionals (42%), pharmacists (23%) and medical doctors (18%). HCWs correctly answered that antibiotics are not effective against viruses (97%), they have associated side effects (97%), unnecessary use makes antibiotics ineffective (97%) and healthy people can carry antibiotic-resistant bacteria (90%). However, fewer than 80% correctly answered that using antibiotics increases a patient’s risk of antimicrobial resistant infection or that resistant bacteria can spread from person to person. Whilst the majority of HCWs (81%) agreed there is a connection between their antibiotic prescribing behaviour and the spread of antibiotic-resistant bacteria, only 64% felt that they have a key role in controlling antibiotic resistance. The top three barriers to providing advice or resources were lack of resources (19%), insufficient time (11%) and the patient being uninterested in the information (7%). Approximately 35% of UK respondents who were prescribers prescribed an antibiotic at least once in the previous week to responding to the survey due to a fear of patient deterioration or complications. Conclusion: These findings highlight that a multifaceted approach to tackling the barriers to prudent antibiotic use in the UK is required and provides evidence for guiding targeted policy, intervention development and future research. Education and training should focus on patient communication, information on spreading resistant bacteria and increased risk for individuals.

Challenges and Lessons Learned in the Development of a Participatory Learning and Action Intervention to Tackle Antibiotic Resistance: Experiences From Northern Vietnam

Antibiotic use in the community for humans and animals is high in Vietnam, driven by easy access to over-the counter medicines and poor understanding of the role of antibiotics. This has contributed to antibiotic resistance levels that are amongst the highest in the world. To address this problem, we developed a participatory learning and action (PLA) intervention. Here we describe challenges and lessons learned while developing and testing this intervention in preparation for a large-scale One Health trial in northern Vietnam. We tested the PLA approach using community-led photography, and then reflected on how this approach worked in practice. We reviewed and discussed implementation documentation and developed and refined themes. Five main themes were identified related to challenges and lessons learned: understanding the local context, stakeholder relationship development, participant recruitment, building trust and motivation, and engagement with the topic of antibiotics and antimicrobial resistance (AMR). Partnerships with national and local authorities provided an important foundation for building relationships with communities, and enhanced visibility and credibility of activities. Partnership development required managing relationships, clarifying roles, and accommodating different management styles. When recruiting participants, we had to balance preferences for top-down and bottom-up approaches. Building trust and motivation took time and was challenged by limited study team presence in the community. Open discussions around expectations and appropriate incentives were re-visited throughout the process. Financial incentives provided initial motivation to participate, while less tangible benefits like collective knowledge, social connections, desire to help the community, and new skills, sustained longer-term motivation. Lack of awareness and perceived importance of the problem of AMR, affected initial motivation. Developing mutual understanding through use of common and simplified language helped when discussing the complexities of this topic. A sense of ownership emerged as the study progressed and participants understood more about AMR, how it related to their own concerns, and incorporated their own ideas into activities. PLA can be a powerful way of stimulating community action and bringing people together to tackle a common problem. Understanding the nuances of local power structures, and allowing time for stakeholder relationship development and consensus-building are important considerations when designing engagement projects.

‘Superbugs’: raising public awareness of antimicrobial resistance through a pop-up science shop

‘Superbugs: A Pop-up Science Shop’ was a public engagement event in the school summer holidays of 2019, organised by members of Cardiff University’s School of Medicine. We transformed an empty retail unit in the centre of Wales’s largest shopping centre into an interactive and immersive microbiology experience. We facilitated two-way dialogue to impart positive impact on the awareness of antibiotic resistance, while concurrently evaluating the efficacy of an engagement strategy focused on the utilisation of public spaces to attract public demographics diverse to those who would normally engage with conventional science, technology, engineering and mathematics (STEM) outreach. Over the course of 14 days, we welcomed 6,566 visitors, with 67 per cent attending as part of the natural footfall of the shopping centre. We created 1,626 young Antibiotic Resistance Champions, located in over two hundred schools, across many of the most deprived areas in Wales. We imparted a positive impact to our stakeholders, with a significant increase in the knowledge and understanding of the subject of antimicrobial resistance (AMR); 91.7 per cent indicated that they had a better understanding after the event. In this article, we discuss the evolution of ‘Superbugs’ from concept, planning and design, to the logistics of delivering an engagement event of this scale. We focus in particular on the learning outcomes of the project, and on how this will shape the future of our ‘Superbugs’ project, and engagement events beyond.

Comparing public attitudes, knowledge, beliefs and behaviours towards antibiotics and antimicrobial resistance in Australia, United Kingdom, and Sweden (2010-2021): A systematic review, meta-analysis, and comparative policy analysis

BACKGROUND

Social and behavioural drivers of inappropriate antibiotic use contribute to antimicrobial resistance (AMR). Recent reports indicate the Australian community consumes more than twice the defined daily doses (DDD) of antibiotics per 1000 population than in Sweden, and about 20% more than in the United Kingdom (UK). We compare measures of public knowledge, attitudes and practices (KAP) surrounding AMR in Australia, the UK and Sweden against the policy approaches taken in these settings to address inappropriate antibiotic use.

METHODS

National antimicrobial stewardship policies in Australia, Sweden, and the UK were reviewed, supplemented by empirical studies of their effectiveness. We searched PubMed, EMBASE, PsycINFO, Web of Science and CINAHL databases for primary studies of the general public's KAP around antibiotic use and AMR in each setting (January 1 2011 until July 30 2021). Where feasible, we meta-analysed data on the proportion of participants agreeing with identical or very similar survey questions, using a random effects model.

RESULTS

Policies in Sweden enact tighter control of community antibiotic use; reducing antibiotic use through public awareness raising is not a priority. Policies in the UK and Australia are more reliant on practitioner and public education to encourage appropriate antibiotic use. 26 KAP were included in the review and 16 were meta-analysable. KAP respondents in Australia and the UK are consistently more likely to report beliefs and behaviours that are not aligned with appropriate antibiotic use, compared to participants in similar studies conducted in Sweden.

CONCLUSIONS

Interactions between public knowledge, attitudes and their impacts on behaviours surrounding community use of antibiotics are complex and contingent. Despite a greater focus on raising public awareness in Australia and the UK, neither antibiotic consumption nor community knowledge and attitudes are changing significantly. Clearly public education campaigns can contribute to mitigating AMR. However, the relative success of policy approaches taken in Sweden suggests that practice level interventions may also be required to activate prescribers and the communities they serve to make substantive reductions in inappropriate antibiotic use.

Understanding the social drivers of antibiotic use during COVID-19 in Bangladesh: Implications for reduction of antimicrobial resistance

Antimicrobial resistance (AMR) is a global public health crisis that is now impacted by the COVID-19 pandemic. Little is known how COVID-19 risks influence people to consume antibiotics, particularly in contexts like Bangladesh where these pharmaceuticals can be purchased without a prescription. This paper identifies the social drivers of antibiotics use among home-based patients who have tested positive with SARS-CoV-2 or have COVID-19-like symptoms. Using qualitative telephone interviews, the research was conducted in two Bangladesh cities with 40 participants who reported that they had tested positive for coronavirus (n = 20) or had COVID-19-like symptoms (n = 20). Our analysis identified five themes in antibiotic use narratives: antibiotics as 'big' medicine; managing anxiety; dealing with social repercussions of COVID-19 infection; lack of access to COVID-19 testing and healthcare services; and informal sources of treatment advice. Antibiotics were seen to solve physical and social aspects of COVID-19 infection, with urgent ramifications for AMR in Bangladesh and more general implications for global efforts to mitigate AMR.

Population knowledge and awareness of antibiotic use and antimicrobial resistance: results from national household survey 2019 and changes from 2017

Background

Lack of knowledge and awareness on antimicrobial resistance (AMR) can result in irrational use of antibiotics, which is one of the major drivers of AMR. One goal of the Thailand National Strategic Plan on AMR (2017-2021) is a 20% increase in public knowledge and awareness of antibiotic use and AMR by 2021. This study assesses antibiotic use, level of knowledge and awareness of antibiotic use and AMR and the factors associated with their knowledge and awareness in the Thai population in 2019. It compares findings with a similar national survey in 2017.

Methods

An AMR module was integrated into the Health and Welfare Survey, a biennial national household survey conducted by the National Statistical Office since 2017. The 2019 survey took place in March, through face-to-face interviews with 27,900 Thai adults aged 15 years or above who participated in the survey and compares 2019 findings with those from 2017.

Results

One month prior to the survey, 6.3% of population reported use of antibiotics (reduced from 7.9% to 2017), of which 98.1% received antibiotics through healthcare professionals and almost half (43.2%) for flu symptoms. During the last 12 months, 21.5% of Thai adults received information on the appropriate use of antibiotics and AMR (increased from 17.8% to 2017); mostly through health professionals (82.7%). On knowledge, 24.3% of adults gave correct answers to more than three out of six statements (three true and three false statements) (increased from 23.7% to 2017). The overall mean score of awareness of appropriate antibiotic use and AMR is 3.3 out of total score of 5.

Conclusions

Although progress was made on knowledge and awareness between 2017 and 2019, certain practices, such as use of antibiotics for flu symptoms and receiving information about antibiotic use and AMR, are inappropriate and inadequate. These findings require significant action, notably strengthening health professionals’ ability to prescribe and dispense antibiotics appropriately and effective communication with patients. The government should promote specific information on rational use of antibiotics and AMR to specific target groups.

Navigating sociocultural disparities in relation to infection and antibiotic resistance-the need for an intersectional approach

One of the key drivers of antibiotic resistance (ABR) and drug-resistant bacterial infections is the misuse and overuse of antibiotics in human populations. Infection management and antibiotic decision-making are multifactorial, complex processes influenced by context and involving many actors. Social constructs including race, ethnicity, gender identity and cultural and religious practices as well as migration status and geography influence health. Infection and ABR are also affected by these external drivers in individuals and populations leading to stratified health outcomes. These drivers compromise the capacity and resources of healthcare services already over-burdened with drug-resistant infections. In this review we consider the current evidence and call for a need to broaden the study of culture and power dynamics in healthcare through investigation of relative power, hierarchies and sociocultural constructs including structures, race, caste, social class and gender identity as predictors of health-providing and health-seeking behaviours. This approach will facilitate a more sustainable means of addressing the threat of ABR and identify vulnerable groups ensuring greater inclusivity in decision-making. At an individual level, investigating how social constructs and gender hierarchies impact clinical team interactions, communication and decision-making in infection management and the role of the patient and carers will support better engagement to optimize behaviours. How people of different race, class and gender identity seek, experience and provide healthcare for bacterial infections and use antibiotics needs to be better understood in order to facilitate inclusivity of marginalized groups in decision-making and policy.

Crowdsourcing to develop open-access learning resources on antimicrobial resistance

Objectives

Antimicrobial resistance (AMR) is a significant threat to global public health. Many medical curricula have limited clinical cases and materials focused on AMR, yet enhanced AMR education and training are needed to support antimicrobial stewardship programmes. We used crowdsourcing methods to develop open-access, learner-centred AMR resources. Crowdsourcing is the process of having a large group, including experts and non-experts, solve a problem and then share solutions with the public.

Methods

We organised a global crowdsourcing contest soliciting AMR-related multiple-choice questions, infographics, and images. First, we convened a diverse steering committee group to finalise a call for entries. Second, we launched the contest and disseminated the call for entries using social media, blog posts, email, and an in-person event. Partner institutions included two digital healthcare platforms: Figure 1^® and Ding Xiang Yuan. Both organizations serve as online communities for healthcare specialists and professionals to report and comment on clinical information. At the end of the call, solicited entries were screened for eligibility and judged on merit and relevance to AMR learning and education. Exceptional entries were recognised, awarded prizes, and further reviewed for sharing with the public via open-access platforms.

Results

We received 59 entries from nine countries. These included 54 multiple-choice questions, four infographics, and one image. Eligible entries (n = 56) were reviewed and assigned a score on a 1–10 scale. Eight entries received mean scores greater than 6.0 and were selected as finalists. The eight finalist entries consisted of three infographics and five multiple-choice questions. They were disseminated through open-access publications and online medical communities. Although we launched a global call, we relied heavily on medical student groups and the entries received were not entirely globally representative.

Conclusions

We demonstrate that crowdsourcing challenge contests can be used to identify infectious disease teaching materials. Medical educators and curriculum developers can adapt this method to solicit additional teaching content for medical students.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06628-0.

Analysis of university student responses to the pandemic in a formal microbiology assessment

During the coronavirus pandemic, second-year students on the B.Sc. molecular biology and genetics degree at Istanbul Technical University sat an open-ended online exam for a microbiology course in which one of the compulsory questions asked how the course had helped them during the first phase of the pandemic (April–July 2020). Fifty of 69 students gave consent for their (anonymous) responses to be analysed in order to discern any key ways in which their knowledge had been applied. The aim of the study was to investigate whether taking an advanced microbiology course increases understanding of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic and has a positive impact on student behaviours with respect to public health practices. Findings were divided into four major themes: course content (information), application of course content to behavioural change (practice), professionalism and their ‘audience’ whilst at home in lockdown (family and friends). Social distancing, wearing face masks, and hand and surface hygiene were described as important behaviours, with this practice informed by their basic microbiology knowledge. This paper describes a scenario where rote assessment can be used to assess wider scientific literacy with respect to application in society, providing students with an opportunity to incorporate and apply their learning into real-life situations, whilst tutors can assess constructivist learning, conceptual understanding and impact on student behaviour.

Microbial Resistance Movements: An Overview of Global Public Health Threats Posed by Antimicrobial Resistance, and How Best to Counter

Antibiotics changed medical practice by significantly decreasing the morbidity and mortality associated with bacterial infection. However, infectious diseases remain the leading cause of death in the world. There is global concern about the rise in antimicrobial resistance (AMR), which affects both developed and developing countries. AMR is a public health challenge with extensive health, economic, and societal implications. This paper sets AMR in context, starting with the history of antibiotics, including the discovery of penicillin and the golden era of antibiotics, before exploring the problems and challenges we now face due to AMR. Among the factors discussed is the low level of development of new antimicrobials and the irrational prescribing of antibiotics in developed and developing countries. A fundamental problem is the knowledge, attitude, and practice (KAP) regarding antibiotics among medical practitioners, and we explore this aspect in some depth, including a discussion on the KAP among medical students. We conclude with suggestions on how to address this public health threat, including recommendations on training medical students about antibiotics, and strategies to overcome the problems of irrational antibiotic prescribing and AMR.

Biofilm Control Strategies: Engaging with the Public

There are few peer-reviewed publications about public engagement with science that are written by microbiologists; those that exist tend to be a narrative of an event rather than a hypothesis-driven investigation. However, it is relatively easy for experienced scientists to use a scientific method in their approach to public engagement. This short communication describes three public engagement activities hosted by the authors, focused on biofilm control: hand hygiene, plaque control and an externally applied antimicrobial coating. In each case, audience engagement was assessed using quantitative and/or qualitative methods. A critical evaluation of the findings enabled the construction of a public engagement 'tick list' for future events that would enable a hypothesis-driven approach with more effective communication activities and more robust evaluation.