Abstract
For inappropriate antibiotic prescribing to be reduced, education of the public in addition to the medical profession is essential, so that antibiotics are not the expected outcome of every medical consultation. This article summarizes the steps taken by the Specialist Advisory Committee on Antimicrobial Resistance to educate both adults and children. These steps provide a firm foundation for future efforts in what will need to be a continuing campaign.
Introduction
Until quite recently, the medical profession and the public have increasingly seen antibiotics as a harmless panacea for ills of many sorts, whether bacterial in origin or not. This has led to a public expectation of antibiotic prescription at medical consultation.1,2 This may be especially so where young children are concerned and to stop a cold ‘going on to the chest’. Issuing a script for an antibiotic is often easier and quicker than a discussion about why an antibiotic should not be used.
Inappropriate and excessive antibiotic prescription leads to bacterial antibiotic resistance. It therefore follows that selective pressure for the development of bacterial resistance is likely to be lowered by a reduction in antibiotic prescribing. However, if this approach is promoted by the medical profession without public education, consultations are likely to be prolonged and patients are likely to be dissatisfied by the consultation process, leading to loss of confidence in the prescriber. Appropriate antibiotic therapy for bacterial infection remains of critical importance for bacterial illnesses that have high morbidity and mortality such as pneumonia and meningitis. Attempts to reduce antibiotic consumption carry the risk of reducing appropriate prescribing as well. Any public education campaign has to tread a fine line if it is not to inadvertently stop members of the public taking antibiotics for an appropriate illness and hence suffer harm. Indeed, studies have suggested an association between both hospital admissions and mortality and reduced antibiotic prescription.3,4 A causal link has not been established, but prudence in public education is essential.
Public campaigns
A public campaign with key messages to patients not to expect antibiotics for trivial illnesses, to cherish normal bacterial flora, and to learn that unnecessary use of antibiotics may be harmful was recommended in ‘The Path of Least Resistance’.5 This then became one theme of the UK Antimicrobial Resistance Action Plan.6
Against this background, the Public Education Subgroup of the Specialist Advisory Committee on Antimicrobial Resistance (SACAR) sought to advise the Department of Health (DH) in its ongoing campaign to promote prudent prescribing. A first step was to investigate what information was already in the public domain and to identify specific target groups within the general population where the impact of such a campaign might have most benefit. In parallel with this, an investigation of similar campaigns in other countries was undertaken.7
The ‘Andybiotic’ campaign
The Andybiotic campaign (Figure 1) was first run in autumn 1999, before the formation of SACAR, to persuade target audiences that antibiotics do not work on colds, coughs, sore throats or flu. It featured an illustrated cartoon character symbolizing antibiotics and gave the message ‘Don't wear me out’. The campaign included press and magazine advertising with postcards and leaflets distributed to GP's surgeries. GPs were provided with a ‘non-prescription’ pad, which could be used to explain to the patient why an antibiotic was not being prescribed. It was run again in 2000, 2002, February 2003 and 2006. Lack of funding prevented significant campaigns after 1999.
‘Andybiotic’ from 2002 NHS education campaign.
The impact of the Andybiotic campaign was assessed before and after it was run. It was found to be associated with a small increase in the overall antibiotic awareness, with a small reduction in the expectation of antibiotic prescription for ‘bad sore throat’, ‘bad cold’, ‘bad cough’ and ‘flu’. However, the campaign had limited funding, was not run intensively every year, the most successful medium (television) was not able to be used, and the campaign's timing was not always optimally targeted before the cold and flu season, all of which may have limited its actual impact.
The ‘Bug Investigators’ school resource pack
In parallel with this initiative aimed principally at adults, and in support of the inclusion of a microbiology teaching element in the National Curriculum by the Healthy Schools Programme, a project was developed to target junior schoolchildren called the Bug Investigators school resource pack. This encompassed classroom, homework and optional web-based educational elements (www.buginvestigators.co.uk). It teaches about infections, how they are spread, and raises awareness about the appropriate use of antibiotics and the drawbacks of overuse. It aims to educate children about the effect of antibiotics on pathogenic microorganisms and our body's natural flora. Six thousand copies were issued free, on request, to primary schoolteachers in the UK. After use of the pack, an evaluation of eight schools showed that children's knowledge improved in all topic areas. This was most significant for what antibiotics do and how to use them and the value of our own good bugs (27%, 31% and 16% improvement, respectively). Knowledge about how bugs spread and hand hygiene was excellent (88% and 90%) before the education, but there was still 4% improvement in these topics. This project is currently being modified for use in senior schools as well as being rolled out across Europe with support from a grant from DG SANCO.
Other campaigns
In 2006, SACAR also collaborated with the Royal Pharmaceutical Society of Great Britain in the production of an ‘Ask about your antibiotics’ leaflet with distribution funded by the DH. SACAR has, in addition, been active in its support and advice to ‘Bugs and Drugs on the Web’ the antimicrobial resistance web site (www.antibioticresistance.org.uk) of the National electronic Library of Infection. The site provides information on antibiotic resistance, its relevance to common illnesses and its prevention. It also provides links to other relevant web sites such as SACAR. In the 2005–6 and 2006–7 winter seasons the site received on average 21 000 hits per month. This is well above the average monthly traffic and indicates the rise of interest in the site in winter when common viral infections are most prevalent (P. Kostkova, personal communication).
The effectiveness of public campaigns
Experience from public education initiatives in other countries confirms that these approaches work, at least, in the short term.8 Long-term studies over a series of years have not been conducted. Effective campaigns target all relevant groups and use clear and consistent, usually positive, messages, via multifaceted interventions with television being most effective.3,7,8 Cost saving has been demonstrated in at least one country.8 There is an unknown limit below which reduction in antibiotic prescribing will cause more harm than benefit. However, even when this is reached, prudent antimicrobial prescribing will continue to need promotion to both the prescribers and the public.
Comment
We have provided a structured basis for future public education initiatives. Campaigns will need to avoid the limitations of the Andybiotic campaign and the way that it was promoted. Knowledge about antibiotics is least in the most deprived and those with no formal qualifications.9 In contrast, the more knowledgeable and well educated have a higher frequency of keeping leftover and standby antibiotics.10,11 The public do not understand the difference between viruses and bacteria; future campaigns should concentrate on giving positive messages about clinical syndromes. A matrix of strategies including the targeting of specific groups, the education of children, and the use of a multimedia approach is likely to be most effective.
Transparency declarations
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