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

Impact of the ´Alforja Educativa' on Ecuadorian schoolchildren's knowledge of bacteria, antibiotics, and antibiotic resistance, a pretest-posttest study

BACKGROUND

Widespread use of antibiotics disrupts the balance in the microbial world and promotes development and spread of antibiotic resistant bacteria. Educational initiatives are important as part of strategies to mitigate antibiotic resistance. The Alforja Educativa is an innovative educational program developed in Ecuador with the aim to teach schoolchildren about antibiotic use and antibiotic resistance. The program places antibiotic resistance within a broader frame of health, well-being, and ecological awareness, highlighting the importance to maintain balance in the microbial world. The objective of this study was to evaluate the effect of the Alforja Educativa on knowledge about bacteria, antibiotics and antibiotic resistance amongst fifth and sixth grade Ecuadorian schoolchildren.

METHODS

This pretest-posttest intervention study was conducted between April and June 2017 and comprised fifth and sixth grade schoolchildren from 20 schools in Cuenca, Ecuador, recruited by purposeful sampling. The Alforja Educativa was implemented over twelve 80-minute sessions by trained university students. Schoolchildren's knowledge was assessed before and after participation in the educational program using a structured questionnaire. A mean total score, the proportion of correct responses for each individual knowledge-based question, as well as correct responses for each of the multiple-choice options of the knowledge-based questions were calculated for the pretest and posttest.

RESULTS

A total of 1,257 schoolchildren participated in the Alforja Educativa program, of which 980 (78%) completed both the pretest and posttest. Overall, the mean total knowledge score increased from pretest to posttest (2.58/7.00 vs. 3.85/7.00; CI = 0.5, p < 0.001). After participation in the program, the proportion of schoolchildren that correctly identified that bacteria can be both good and bad increased from 35.0 to 84.3%. In addition, scores increased for correctly identifying the meaning of antibiotic resistance (37.4-72.0%); how to prevent antibiotic resistance (63.2-74.6%); and for identifying the meaning of self-medication (46.3-54.3%).

CONCLUSION

The Alforja Educativa was effective in improving the knowledge of participating schoolchildren about concepts related to bacteria, antibiotics and antibiotic resistance. The holistic perspective taken to explain the complex relationship between humans and bacteria, as well as the effect of antibiotics on the microbial world, may help provide a foundation for more sustainable antibiotic use.

The impact of an online educational game on breast cancer awareness among university female students, Malaysia: a pilot study

BACKGROUND

Breast cancer is one of the world's most prevalent cancer and the most common type of cancer in Malaysia. Interestingly, breast cancer in young women is more aggressive compared to older women and the survival rate among these groups of individuals is poor. Thus, breast cancer awareness is essential among young women as early detection is possible and treatment will be effective during which the disease is curable. Hence, the purpose of this study is to design and evaluate the impact of an educational game on breast cancer awareness among female university students in Malaysia.

METHODS

This is a one-group pre-and post-intervention pilot study. It was conducted in Private and public higher education institutions around Malaysia. An online education game was created and used as the intervention. A self-administered questionnaire was administered to the participants during the pre-and post-intervention test to evaluate the online educational game on breast cancer awareness.

RESULTS

A total of 52 responses were collected. The mean age of the participants was 21.98 (SD = 1.896) years. The findings showed a statistically significant median increase (p < 0.05) in breast cancer knowledge scores among participants in the post-intervention. A median increase in breast cancer knowledge score of 6 was shown when participants were exposed to the online education game (24.00) compared to before they were exposed to it (17.00).

CONCLUSION

Using online educational games effectively raised awareness of breast cancer among university students. Online games can be used as a health educational tool to promote awareness of a topic of interest, as digital games can be accessed easily, game content can be tailored made or updated, and improve participant engagement in learning.

'If you want to go far, go together'-community-based behaviour change interventions to improve antibiotic use: a systematic review of quantitative and qualitative evidence

INTRODUCTION

A large proportion of the burden of infections with antibiotic-resistant bacteria is linked to community-associated infections. This suggests that interventions set in community settings are needed. Currently there is a gap in understanding the potential of such interventions across all geographies. This systematic review aimed to synthesize the evidence on the value of community-based behaviour change interventions to improve antibiotic use. These are any interventions or innovations to services intended to stimulate behaviour changes among the public towards correct antibiotic use, delivered in a community setting and online.

METHODS

Systematic searches of studies published after 2001 were performed in several databases. Of 14 319 articles identified, 73 articles comprising quantitative, qualitative and mixed-methods studies met the inclusion criteria.

RESULTS

Findings showed positive emerging evidence of the benefits of community-based behaviour change interventions to improve antibiotic use, with multifaceted interventions offering the highest benefit. Interventions that combine educational aspects with persuasion may be more effective than solely educational interventions. The review uncovered difficulties in assessing this type of research and highlights the need for standardized approaches in study design and outcomes measurements. There is emerging, but limited, indication on these interventions' cost-effectiveness.

CONCLUSIONS

Policy makers should consider the potential of community-based behaviour change interventions to tackle antimicrobial resistance (AMR), complementing the clinical-based approaches. In addition to the direct AMR benefits, these could serve also as a means of (re)building trust, due to their inclusive participation leading to greater public ownership and use of community channels.

Digital Marketing: A Unique Multidisciplinary Approach towards the Elimination of Viral Hepatitis

New technologies are supported by the global implementation of the internet. These improvements have deeply affected various disciplines of sciences and consequently changed services such as daily business, particularly health sectors. Innovative digital marketing strategies utilize the channels of social media and retrieved user data to analyze and improve relevant services. These multidisciplinary innovations can assist specialists, physicians and researchers in diagnostic, prophylaxis and treatment issues in the health sector. Accordingly, compared to recent decades, health decision makers are more accurate and trustful in defining new strategies. Interestingly, using social media and mobile health apps in current pandemics of SARS-CoV-2 could be an important instance of the key role of these platforms at the local and global level of health policies. These digital technologies provide platforms to connect public health sectors and health politicians for communicating and spreading relevant information. Adding influencers and campaigns to this toolbox strengthens the implementation of public health programs. In 2016, the WHO adopted a global program to eliminate viral hepatitis by 2030. Recent constructive measures that have been used in the battle against COVID-19 could be adopted for the elimination of viral hepatitis program. The presented evidence in our narrative review demonstrates that the application of digital marketing tools to create campaigns on social media, armed with professional influencers, can efficiently consolidate this program. The application of different strategies in using these popular tools will raise the public awareness about viral hepatitis. Subsequently, the availability of an effective vaccine for HBV and antiviral medication for HCV can motivate the audience to take steps towards prophylaxis and screening methods against these infectious illnesses. The encouragement of health policy makers to apply digital communication technologies and comprehensive roadmaps to implement this global program will certainly decrease the burden of viral hepatitis worldwide.

Public Health Interventions to Improve Antimicrobial Resistance Awareness and Behavioural Change Associated with Antimicrobial Use: A Systematic Review Exploring the Use of Social Media

Introduction: Over the years there have been several interventions targeted at the public to increase their knowledge and awareness about Antimicrobial Resistance (AMR). In this work, we updated a previously published review by Price et al. (2018), on effectiveness of interventions to improve the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials to identify which interventions work best in influencing public behaviour. Methods: Five databases—Medline (OVID), CINAHL (EBSCO), Embase, PsycINFO, and Cochrane Central Register of Controlled Trials (CENTRAL-OVID)—were searched for AMR interventions between 2017 and 2021 targeting the public. All studies which had a before and after assessment of the intervention were considered for inclusion. Results: In total, 17 studies were found to be eligible for inclusion in the review. Since there was a variety in the study interventions and in particular outcomes, a narrative synthesis approach was adopted for analysis. Whereas each study showed some impact on awareness and knowledge, none measured long-term impact on behaviours towards antibiotic use, awareness, or knowledge. Engagement was higher in interventions which included interactive elements such as games or videos. Social media was not used for recruitment of participants or as a mode of communication in any AMR interventions included in this review.

Development of and User Feedback on a Board and Online Game to Educate on Antimicrobial Resistance and Stewardship

Antimicrobial resistance (AMR), particularly antibiotic resistance, is one of the most challenging global health threats of our time. Tackling AMR requires a multidisciplinary approach. Whether a clinical team member is a cleaner, nurse, doctor, pharmacist, or other type of health worker, their contribution towards keeping patients safe from infection is crucial to saving lives. Existing literature portrays that games can be a good way to engage communities in joint learning. This manuscript describes an educational antimicrobial stewardship (AMS) game that was co-created by a multidisciplinary team of health professionals spanning across high- and low- to middle-income countries. The online AMS game was promoted and over 100 players across 23 countries registered to participate on 2 occasions. The players were asked to share feedback on the game through a short online form. Their experiences revealed that the game is relevant for creation of awareness and understanding on antimicrobial stewardship in both high- and low-to-middle income settings worldwide.

A Co-Design Process to Elaborate Educational Materials to Promote Appropriate Use of Antibiotics for Acute Lower Respiratory Tract Infections in Primary Healthcare in Catalonia (Spain)

PURPOSE

Co-design processes with patients allow developing health education materials, that are adapted to the population's knowledge and use of language, to reduce inappropriate antibiotic use.

PATIENTS AND METHODS

This study presents a co-design process of educational material with patients (over 18 years old) with a previous diagnosis of acute lower respiratory tract infection. The co-design was framed within a qualitative study (Phase I, interviews; Phase II, focus group) conducted in Barcelona between April and September 2019.

RESULTS

Twenty-nine semi-structured interviews were conducted. Six people participated in the focus group. Based on participants' narratives, educational materials can be useful to support healthcare consultations. Materials should be designed to be accessible in terms of the content and language used.

CONCLUSION

The co-design of educational materials is essential for health promotion. This study presents an example of how materials can be co-developed with patients. The material elaborated in this study is being used for the ISAAC-CAT project and may be useful for future research, practice in health services and health policy.

The effects of gamification on antimicrobial resistance knowledge and its relationship to dentistry in Saudi Arabia: a randomized controlled trial

Background

Antimicrobial resistance (AMR) has reached alarming levels and is considered to be a worldwide public health problem. One of the most significant factors contributing to the spread of AMR is the lack of proper knowledge about the use of antibiotics, which are being used more frequently in dentistry. Recent studies have found that gamification shows promising results for helping the average person improve their knowledge about health and may also be used to boost knowledge about AMR among the public. This study aimed to assess the effects of gamification on AMR awareness, using a board game to promote knowledge about AMR among the public in Saudi Arabia.

Methods

Using a single-blinded parallel group randomized controlled trial design, 94 volunteers were recruited and randomized into two groups. The study group received information about AMR by playing a board game, while the control group received the same information given in a conventional lecture. The participants were evaluated three times: (T1) before the intervention, (T2) immediately after the intervention, and (T3) one month after the intervention for follow-up to evaluate their retention of the information.

Results

Results showed that there were significant improvements (p <  0.05) in knowledge scores for T2 and T3 in comparison to the T1 baseline scores in both groups. However, the knowledge scores also relapsed significantly from T2 to T3 in both groups. Nevertheless, the difference in knowledge score T1 to T3 was significantly higher in the study group in comparison to the control group, and the participants had higher mean scores to use the game as health promotion method.

Conclusions

Gamification using a board game can significantly improve AMR knowledge, with better retention than conventional lecture. It is a promising method for boosting public knowledge about AMR and its relationship to dentistry.

Trial registration

ISRCTN registry: ISRCTN15884410 (retrospectively registered 26-October-2019).

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.

Design Features Associated with User Engagement in Digital Games for Healthy Lifestyle Promotion in Youth: A Systematic Review of Qualitative and Quantitative Studies

User engagement in digital (serious) games may be important to increase their effectiveness. Insights into how to create engaging games for healthy lifestyle promotion are needed, as despite their potential, not all digital (serious) games are highly engaging. This study systematically reviewed game features that were associated with higher user engagement among youth. A systematic search was conducted in PubMed, Web of Science, CINAHL, and PsycARTICLES databases. Qualitative and quantitative studies were included, if they documented game features associated with youth engagement. Coding of game features was performed using the mechanics-dynamics-aesthetics (MDA) framework. A total of 60 studies met the inclusion criteria and were included in the registered systematic review (No. CRD42018099487). Results showed that various game features were associated with user engagement in digital (serious) games: an attractive storyline, adaptable to gender and age, including diverse (antagonist) characters the user may identify with, high-end realistic graphics, well-defined instructions, which can be skipped, in combination with clear feedback and a balance of educational and fun content. This review underpinned the relevance of investigating engaging game features specifically for youth, as deviations were found with characteristics that are engaging for other populations.

AntibioGame®: A serious game for teaching medical students about antibiotic use

INTRODUCTION

Measures for controlling antimicrobial resistance are urgently required. We describe here AntibioGame®, a serious game for improving the training of medical students in antibiotic use in primary care.

OBJECTIVE

We aimed to design a serious game for antibiotics teaching and to evaluate its usability and playability by medical students.

METHODS

We used various gamification techniques (e.g. use of mascots, avatars, rewards, leader board) and cartoon graphics in the design of AntibioGame®. This game implements clinical case templates built from a list of learning goals defined by a medical team through an analysis of clinical practice guidelines. The game was evaluated by asking medical students to rate their satisfaction and the usability and playability of the game on an electronic form and through group discussions. The electronic form was derived from the MEEGA + scale, a five-point Likert scale including 32 items for assessing both usability and playability.

RESULTS

AntibioGame® is a case-based game in which students play the role of a doctor meeting patients in consultation and helping other health professionals to solve their problems, as in real life. The scenarios are realistic and cover situations frequently encountered in primary care. The 57 medical students enrolled found the game attractive, usable, fun, and appropriate for learning. Game quality was considered "good" (score = 60 on the MEEGA + scale). All the students said they would recommend the game, 96 % liked it and 81 % would use it for revision.

CONCLUSION

AntibioGame® is a promising tool for improving knowledge in antibiotic prescription that could easily be included in multifaceted programs for training medical students.

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.

Usability of Health Information Websites Designed for Adolescents: Systematic Review, Neurodevelopmental Model, and Design Brief

BACKGROUND

Adolescence is a unique developmental period characterized by biological, social, and cognitive changes, as well as an interest in managing one's own health care. Many adolescents use the internet to seek health care information. However, young people face barriers before they can understand and apply the health information that they access on the web. It is essential that usability of adolescent health websites on the internet is improved to help adolescents overcome these barriers and allow them to engage successfully with web-based health care content.

OBJECTIVE

The aim of this review was to synthesize the usability of specific health information websites. These findings were mapped onto the adolescent neurodevelopmental profile, and a design brief based on the findings was developed to tailor future websites for specific adolescent requirements.

METHODS

A systematic search conducted using PubMed, PsycINFO, and Education Resources Information Center (ERIC) identified 25 studies that assessed the usability of health information websites. Adolescent feedback was collected by a mixture of surveys, focus groups, interviews, and think-aloud procedures.

RESULTS

A majority of the information websites were developed for specific health issues that may be relevant to adolescents. The most preferred website features were interactive content such as games and quizzes, as well as videos, images, audio clips, and animations. Participants also preferred communicating with other adolescents with similar conditions or learning about their experience through real stories and testimonials. Adolescents found it difficult to use health information websites if they contained too much text, were too cluttered, or had features that made it difficult to access. The findings are considered in the context of adolescent social processes, low tolerance of delayed gratification, and attraction to novelty and mapped onto a neurodevelopmental model of adolescence.

CONCLUSIONS

Young people's feedback can determine usability and content that make a health information website easy or informative to use. Neurodevelopmental profiles and the users' specific preferences and skills should be addressed in future development of health information websites for adolescents.

Young People's Knowledge of Antibiotics and Vaccinations and Increasing This Knowledge Through Gaming: Mixed-Methods Study Using e-Bug

Background

e-Bug, led by Public Health England, educates young people about important topics: microbes, infection prevention, and antibiotics. Body Busters and Stop the Spread are 2 new e-Bug educational games.

Objective

This study aimed to determine students’ baseline knowledge, views on the games, and knowledge improvement.

Methods

Students in 5 UK educational provisions were observed playing 2 e-Bug games. Before and after knowledge and evaluation questionnaires were completed, and student focus groups were conducted.

Results

A total of 123 junior and 350 senior students completed the questionnaires. Vaccination baseline knowledge was high. Knowledge increased significantly about antibiotic use, appropriate sneezing behaviors, and vaccinations. In total, 26 student focus groups were conducted. Body Busters was engaging and enjoyable, whereas Stop the Spread was fast-paced and challenging but increased vaccination and health behavior intentions.

Conclusions

e-Bug games are an effective learning tool for students to enhance knowledge about microbes, infection prevention, and antibiotics. Game-suggested improvements should help increase enjoyment.

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.

Bacterial Survivor: An Interactive Game that Combats Misconceptions about Antibiotic Resistance

The growing threat of antibiotic resistant infections remains a huge public health concern. While many people are aware of “superbugs”, the vast majority of the general public does not understand how antibiotic resistance arises in a population of bacteria, and how exactly over use or misuse of antibiotics contributes to this problem. We developed an active learning exercise called “Bacterial Survivor” in order to combat misconceptions about antibiotic resistance in a large undergraduate non-majors microbiology course. The game models the random nature of genetic change, the impact of environment on survival, and illustrates the basic principles of evolution. This hands-on approach has been effective in counteracting student misconceptions about this important topic.