Skip to content

Advertisement

You're viewing the new version of our site. Please leave us feedback.

Learn more

BMC Public Health

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Impact of a United Kingdom-wide campaign to tackle antimicrobial resistance on self-reported knowledge and behaviour change

  • Katerina Chaintarli1, 2Email author,
  • Suzanne M. Ingle2,
  • Alex Bhattacharya3,
  • Diane Ashiru-Oredope3,
  • Isabel Oliver1, 2 and
  • Maya Gobin1, 2
BMC Public HealthBMC series – open, inclusive and trusted201616:393

https://doi.org/10.1186/s12889-016-3057-2

Received: 20 January 2016

Accepted: 29 April 2016

Published: 12 May 2016

Abstract

Background

As part of the 2014 European Antibiotic Awareness Day plans, a new campaign called Antibiotic Guardian (AG) was launched in the United Kingdom, including an online pledge system to increase commitment from healthcare professionals and members of the public to reduce antimicrobial resistance (AMR). The aim of this evaluation was to determine the impact of the campaign on self-reported knowledge and behaviour around AMR.

Methods

An online survey was sent to 9016 Antibiotic Guardians (AGs) to assess changes in self-reported knowledge and behaviour (outcomes) following the campaign. Logistic regression models, adjusted for variables including age, sex and pledge group (pledging as member of public or as healthcare professional), were used to estimate associations between outcomes and AG characteristics.

Results

2478 AGs responded to the survey (27.5 % response rate) of whom 1696 (68.4 %) pledged as healthcare professionals and 782 (31.6 %) as members of public (similar proportions to the total number of AGs). 96.3 % of all AGs who responded had prior knowledge of AMR. 73.5 % of participants were female and participants were most commonly between 45 and 54 years old.

Two thirds (63.4 %) of participants reported always acting according to their pledge. Members of the public were more likely to act in line with their pledge than professionals (Odds Ratio (OR) =3.60, 95 % Confidence Interval (CI): 2.88-4.51). Approximately half of participants (44.5 %) (both healthcare professionals and members of public) reported that they acquired more knowledge about AMR post-campaign. People that were confused about AMR prior to the campaign acquired more knowledge after the campaign (OR = 3.10, 95 % CI: 1.36-7.09). More participants reported a sense of personal responsibility towards tackling AMR post-campaign, increasing from 58.3 % of participants pre-campaign to 70.5 % post-campaign.

Conclusion

This study demonstrated that the campaign increased commitment to tackling AMR in both healthcare professional and member of the public, increased self-reported knowledge and changed self-reported behaviour particularly among people with prior AMR awareness. Online pledge schemes can be an effective and inexpensive way to engage people with the problem of AMR especially among those with prior awareness of the topic.

Keywords

Public healthCampaign evaluationBehavioral medicinePledge schemeBehaviour changeHealth promotionHealth campaignImplementation intentionsAntibiotic resistance

Background

Antimicrobial resistance (AMR) is a major public health problem and is partly associated with high levels of antimicrobial use [13]. Prescribing practices in humans and animals have led to the overuse and misuse of antimicrobials and the development of AMR [47]. AMR remains an important issue for the United Kingdom (UK) despite a reduction in the total consumption of antibiotics in recent years [8, 9]. The World Health Organisation (WHO) Global Strategy for Containment of Antimicrobial Resistance provides a framework for interventions to slow the emergence and reduce the spread of AMR [10, 11]. One aim of the strategy includes actions to educate members of the public and healthcare professionals about AMR [11]. Similarly in the UK, the 5 year UK AMR strategy (2013) includes improving professional education, training and public engagement as one of its seven key areas [12].

Numerous educational campaigns have been implemented worldwide to help tackle AMR with differing levels of effectiveness [6, 1321]. The “European Antibiotic Awareness Day” (EAAD) was initiated by the European Centre for Disease Prevention and Control to raise awareness towards antibiotic use [22, 23]. The UK “Antibiotic Guardian Campaign” was launched in September 2014 to increase public and healthcare professionals engagement and change behaviour towards the rising threat of AMR [24]. It was also developed as a way to have, for the first time an ‘always on’ (available all year round) campaign for AMR. The campaign comprised an online pledge system (http://antibioticguardian.com/) and was available to everyone with access to the internet. People could select a single pledge from a list tailored for either members of the public or health care professionals (the third group “student or educator” was added in October 2015 - after the evaluation of the campaign had started) (Additional file 1). Online pledges were one of the recommended interventions from a recent behavioural analysis that identified key behaviours and drivers for antibiotic use in both the public and healthcare professionals [25, 26]. The Antibiotic Guardian pledges were subsequently designed to overcome the intention – behaviour gap through the formation of implementation intentions (or if – then plans) [27]. Implementation intention is a method of deciding in advance when, where and how a person will act on particular action to reach a particular goal or objective using If-then approach - If X happens, then I will do Y. For example, one of the Antibiotic Guardian pledges for members of the public states: ‘For infections that our bodies are good at fighting off on their own, like coughs, colds, sore throats and flu, I pledge to talk to my pharmacist about how to treat the symptoms first rather than going to the GP’ and for a general practitioner (GP) one of the pledges available to select from is ‘The next time I intend to prescribe antibiotics for a self-limiting infection to a patient with high expectations of antibiotic treatment, I will use a delayed/backup prescription’. Using implementation intentions have been shown through several meta-analyses to support individuals as well as groups in their intention-behaviour gaps [28, 29].

The initial concept for the website and logo was developed jointly with the British Society for Antimicrobial Chemotherapy, who also kindly provided the initial funding for the website. The campaign website was launched by Public Health England (PHE) alongside the release of digital resources such as posters, leaflets and social media graphics developed at no additional cost by PHE which were shared openly for use [30]. The AG website included a video produced by PHE which educated on the threat of antimicrobial resistance and linked to resources which described the importance of AMR [23]. All materials were made available via the English EAAD website and EAAD resources toolkit for health care professionals [23]. PHE wrote letters to leaders in primary and secondary care and professional organisations with the purpose of forming a network through which messages and materials could be promoted and disseminated [31]. Further promotion for the campaign by PHE took place at professional-facing conferences through donated exhibition space. The 182 organisations that registered participation for EAAD by 30th November were also invited to promote the AG campaign to staff and service users [23].

The main objective of that campaign was that by 30th November 2014 at least 10,000 healthcare professionals and members of the public would have committed to at least one pledge for prudent use of antimicrobials. The objective was met on the 19th November and by the end of November there were 11,833 Antibiotic Guardians.

The aim of this evaluation was to determine whether the AG campaign increased engagement and improved AMR knowledge and behaviour.

Methods

An online questionnaire was developed to determine if the campaign resulted in changes in self-reported knowledge/awareness and self-reported behaviour amongst Antibiotic Guardians (AGs) (Additional file 2). AGs who previously consented to follow up were sent the questionnaire via e-mail on 3rd February 2015, five months after the launch of the campaign. The questionnaire was available for completion for one month; a reminder was sent via e-mail a week after the launch of the survey. Before launching the survey, the questionnaire was reviewed by a wide range of healthcare professionals and members of the public who were members of the EAAD planning group.

Demographics of the pledge group (pledging as a health professional or a member of the public), age, sex, use of social media and whether working in a health related profession were collected (Questions 1–3 & 21–27). Closed multi-choice questions were used to ascertain the participant’s motivation for becoming an Antibiotic Guardian and the reason for choosing their specific pledge (Questions 4–6). Participants were asked to select the options that best described their behaviour in relation to the pledge (‘Pledge Behaviour’) and their general knowledge/awareness of AMR before and after becoming an Antibiotic Guardian (pre and post-campaign) (Questions 7–14).

The perceived effectiveness of the promotion of the campaign and quality of the promotional material were ascertained through a series of multiple choice questions (Questions 15–20). The questionnaire logic was designed such that some questions were skipped depending on whether the participant had pledged as a member of the public or as a healthcare professional.

The two primary outcomes “change in self-reported behaviour” and “change in knowledge” were assessed as the difference in reported frequency of pledge behaviour pre and post campaign and whether participants stated a positive acquisition of knowledge post-campaign respectively.

Statistical analysis

To assess bias in our sample, we compared the response rates of members of public and health care professionals among those who completed the survey with the total population that signed up as an AG.

To assess the outcome ‘change in behaviour’ after the campaign, we used an ordinal logistic regression model [32] to estimate associations with the ordered categorical outcome “acting in line with their pledge” (Question 7). The model was adjusted for variables describing whether participants acted according to their pledge before the campaign and whether they remembered their pledge (Questions 4 & 14). Multivariable analysis was conducted taking into account pledge group, age and sex as possible confounders.

To assess the outcome ‘knowledge of AMR after the campaign’ we used a logistic regression model to estimate associations with the outcome (Question 12). We looked for associations with knowledge before the campaign and whether people were confused about what AMR is before the campaign (Questions 10 & 11). Multivariable analysis was conducted taking into account pledge group, age and sex as possible confounders.

For all categorical variables, the group with the largest number of observations was used as the reference group for each variable.

Missing values

After assessing the amount of missing data from our models, we decided to perform some sensitivity analysis to assess whether our complete-case study could be biased. We assumed that data were missing at random, although this cannot be tested [33]. A multiple imputation model was developed using chained equations and the ice command in Stata. The model included all the covariates and outcomes of interest (as listed in Table 1) as well as a comprehensive (but not exhaustive) list of other variables collected. 20 imputed datasets were created and were analysed following Rubin’s rules.
Table 1

Baseline characteristics of survey participants, Number of observations (N) = 2478

Variable

N (%)

Pledge group

 

 Healthcare Professionals

1696 (68.4 %)

 Members of Public

782 (31.6 %)

 Missing

0 (0 %)

Age

 

 <35 years old

596 (24.1 %)

 35-64 years old

1548 (62.5 %)

 ≥65 years old

114 (4.6 %)

 Prefer not to say

10 (0.4 %)

 Missing

210 (8.5 %)

Sex

 

 Female

1657 (66.9 %)

 Male

598 (24.1 %)

 Prefer not to say

15 (0.6 %)

 Missing

208 (8.4 %)

Do you remember your pledge?

 

 Yes

1087 (43.9 %)

 Somewhat

1286 (51.9 %)

 No

105 (4.2 %)

 Missing

0 (0 %)

Act in line with pledge before campaign

 

 Strongly agree

761 (30.7 %)

 Agree

1021 (41.2 %)

 Tend to Agree

505 (20.4 %)

 Tend to Disagree

101 (4.1 %)

 Disagree

6 (0.2 %)

 Strongly Disagree

4 (0.2 %)

 Missing

80 (3.2 %)

Confusion on what AMR is before the campaign?

 

 Yes

34 (1.4 %)

 No

2399 (96.8 %)

 Missing

45 (1.8 %)

Prior knowledge on AMR?

 

 Yes

2386 (96.3 %)

 No

44 (1.8 %)

 Missing

48 (1.9 %)

Outcomes

 

Act in line with pledge after campaign

 

 Always

1571 (63.4 %)

 Most of the time

709 (28.6 %)

 Some of the time

96 (3.9 %)

 Occasionally

64 (2.6 %)

 Never

37 (1.5 %)

 Missing

1 (0.0 %)

Acquired more knowledge of AMR after campaign

 

 No

1316 (53.1 %)

 Yes

1103 (44.5 %)

 Missing

59 (2.4 %)

Data were analysed using Stata 13.1 [34].

Results

The questionnaire was completed by 2478 AGs; 27.5 % (2478/9016) of those that consented for follow up and received the questionnaire. Response rates in each pledge group were similar (20.7 % for healthcare professionals and 21.5 % for members of the public). Table 1 shows the baseline characteristics of the 2478 AGs. Two thirds of participants pledged as healthcare professionals (68.4 %). Of those AGs with valid data, the majority were females (73.5 %) and most participants were between 45 and 54 years old.

Of the 782 people who pledged as members of public, 134 (17.1 %) were healthcare professionals and 208 (26.6 %) were connected to the healthcare system (e.g., working in a healthcare organisation or health related professional body). Characteristics of the survey participants were similar to those of the total population of Antibiotic Guardians (Graph 1 shows job type for healthcare professionals and certain job types/family status for members of the public).

The majority of public participants (64.2 %) became Antibiotic Guardians because they knew the importance of antimicrobial resistance. For healthcare professionals the reason most commonly stated was professional experience of AMR (32.5 %). For both healthcare professionals and members of public, the majority of participants were able to remember their pledge either in part (51.9 %) or completely (43.9 %). Also, for both groups in total, most participants chose the specific pledge because it was the one they could commit to (57.5 %), or felt was most important (31.7 %). Almost all participants of both groups (91.3 %) felt that the AG campaign would contribute to the prevention of antibiotic resistance and they were part of a wider community of people working to keep antibiotics active (88.9 %).

Change in self-reported behaviour

Self-reported action in line with their pledge increased from 30.7 % pre-campaign to 63.4 % post-campaign. Pledge group, pre-campaign reported pledge behaviour and remembering the pledge were associated with post-campaign reported pledge behaviour in the multivariable analysis (Table 2). Members of the public were more likely to report positive post-campaign pledge behaviour (Adjusted Odds Ratio (aOR) = 3.60, 95 % Confidence interval (CI): 2.88-4.51). Participants without positive pre-campaign pledge behaviour were less likely to have positive post-campaign pledge behaviour (aOR = 0.23, 95 % CI: 0.16-0.34). AGs who remembered the pledge were more likely to have positive post-campaign behaviour (aOR = 1.96, 95 % CI: 1.63-2.36). Age and sex were not associated with post-campaign pledge behaviour.
Table 2

Crude and Adjusted Odds Ratios from ordinal logistic regression model for associations with Antibiotic Guardians acting according to their pledge, N = 2242

Covariate

N

Crude OR (95 % CI)

aOR (95 % CI)

Act according to pledge before becoming AG

   

 Yes

2141

1.0 (ref)

1.0 (ref)

 No

101

0.29 (0.20 – 0.43)

0.23 (0.16 – 0.34)

Remember the pledge

   

 Completely

994

1.63 (1.37 – 1.95)

1.96 (1.63 – 2.36)

 Somewhat

1163

1.0 (ref)

1.0 (ref)

 No

85

0.28 (0.18 – 0.46)

0.24 (0.15 – 0.38)

Pledge group

   

 Members of Public

708

3.09 (2.50 – 3.82)

3.60 (2.88 – 4.51)

 Healthcare Professionals

1534

1.0 (ref)

1.0 (ref)

Age

   

 <35 years old

592

0.94 (0.77 – 1.14)

0.86 (0.70 – 1.05)

 35-64 years old

1530

1.0 (ref)

1.0 (ref)

 ≥65 years old

110

1.63 (1.04 – 2.54)

1.11 (0.68 – 1.79)

 Prefer not to say

10

0.36 (0.11,1.16)

0.36 (0.10,1.24)

Sex

   

 Female

1641

1.0 (ref)

1.0 (ref)

 Male

591

0.99 (0.82 – 1.20)

1.09 (0.89 – 1.33)

 Prefer not to say

10

2.03 (0.43-9.66)

3.92 (0.61-25.11)

N number of observations, OR odds ratio, aOR adjusted OR for all variables listed in the table

Members of the public stated that lack of opportunity was the most common reason (60 %) for the absence of positive post-campaign pledge behaviour. For health professionals, the expectations of others (mainly patients) was the most common reason stated for not fulfilling their pledge (40.4 %).

Knowledge/awareness of AMR

Approximately half of participants (44.5 %) (both healthcare professionals and members of public) reported that they acquired more knowledge about AMR post-campaign. More participants reported a sense of personal responsibility towards tackling AMR post-campaign, increasing from 58.3 % of participants pre-campaign to 70.5 % post-campaign. Of the participants who had not acquired more knowledge post-campaign, the majority (99.3 %) reported having good knowledge/awareness of AMR pre-campaign.

Table 3 shows that participants were more likely to have more knowledge about AMR post-campaign if they did not have pre-campaign knowledge (aOR = 4.21, 95 % CI: 2.04 – 8.67) or had some knowledge but were confused about AMR (aOR =3.10, 95 % CI: 1.36 – 7.09). Members of the public were less likely to have acquired more knowledge post-campaign than healthcare professionals (aOR = 0.79, 95 % CI: 0.66 – 0.96). Age and sex were not associated with the acquisition of more knowledge post-campaign.
Table 3

Crude and Adjusted Odd Ratios from logistic regression model for associations with knowledge on antimicrobial resistance after the Antibiotic Guardian campaign, N = 2224

Covariate

N

Crude OR (95 % CI)

aOR (95 % CI)

Confused about AMR before the campaign

   

 Yes

29

3.21 (1.41 – 7.27)

3.10 (1.36 – 7.09)

 No

2195

1.0 (ref)

1.0 (ref)

Prior knowledge on AMR

   

 Yes

2182

1.0 (ref)

1.0 (ref)

 No

42

3.95 (1.93 – 8.07)

4.21 (2.04 – 8.67)

Pledge group

   

 Members of Public

700

0.83 (0.70 – 1.00)

0.79 (0.66 – 0.96)

 Healthcare Professionals

1524

1.0 (ref)

1.0 (ref)

Age

   

 <35 years old

585

1.13 (0.93 – 1.36)

1.12 (0.93 – 1.36)

 35-64 years old

1521

1.0 (ref)

1.0 (ref)

 ≥65 years old

108

0.78 (0.52 – 1.16)

0.88 (0.58 – 1.33)

 Prefer not to say

10

0.82 (0.23-2.91)

1.13 (0.29-4.41)

Sex

   

 Female

1629

1.0 (ref)

1.0 (ref)

 Male

585

0.92 (0.76 – 1.11)

0.89 (0.73 – 1.08)

 Prefer not to say

10

0.29 (0.06-1.38)

0.29 (0.06-1.43)

N number of observations, OR odds ratio, aOR adjusted OR for all variables listed in the table

Promotion

Over half of the participants for both healthcare professionals and members of public (61.7 %) thought the AG campaign was well promoted in terms of motivating them to take the pledge although more than half of them (60.6 %) had not seen some of the promotional materials such as the quiz or the crosswords. A greater proportion of members of the public had not seen the different promotional materials (43.2 %) as compared with healthcare professionals (33.9 %), possibly because the campaign was mainly promoted through healthcare settings. The majority of participants said they were or would be willing to actively promote the campaign to friends, family and colleagues.

Overall participants stated that information from a combination of sources influenced their decision to become AGs. Table 4 shows that age was associated with the type of information source with biggest impact (Chi2 tests P <0.001). Under 18 year olds were most influenced by social media and the website whereas older participants were most influenced by colleagues or a combination of resources.
Table 4

Sources that made the biggest impact on becoming an Antibiotic Guardian in relation to age and use of social media

 

Sources that made the biggest impact on becoming an Antibiotic Guardian (%)

Printed materials

YouTube

Social media

Website

Colleagues

Friends

Combination

None

Age

        

 12-17 years old

0.0

0.0

28.6

28.6

0.0

28.6

14.3

0.0

 18-24 years old

4.6

2.0

12.4

17.7

22.2

5.2

30.7

5.2

 25-34 years old

4.6

2.3

16.2

15.2

26.6

2.8

21.3

11.1

 35-44 years old

3.8

1.4

17.1

15.1

21.7

1.4

28.2

11.3

 45-54 years old

4.9

1.3

8.6

18.7

20.2

1.6

33.9

10.8

 55-64 years old

8.4

0.3

7.1

17.9

17.1

1.9

36.3

11.1

 65-74 years old

13.9

1.0

8.9

17.8

8.9

5.0

24.8

19.8

 75 years or older

15.4

0.0

0.0

7.7

7.7

7.7

46.2

15.4

 Total

5.6

1.4

12.2

16.9

20.8

2.4

29.8

11.1

Social Media User

        

 Yes

4.5

1.5

15.5

15.9

19.8

2.6

29.9

10.2

 No

9.3

1.0

0.2

19.9

23.6

1.8

29.5

14.8

 Total

5.6

1.4

12.1

16.8

20.7

2.4

29.9

11.3

Missing data analysis

Looking at the pattern of missing data, 89 % of the records have complete data on the variables of interest. The analysis was rerun using the imputed data and the results were compared to the results of the original dataset and were found to be similar.

Discussion

The AG campaign is the first published example of the use of an online pledge system to improve AMR related knowledge and behaviour amongst healthcare professionals and the general public. Our evaluation found that the AG campaign contributed to an overall increase in the personal commitment of healthcare professionals and members of the public to tackle AMR as well as improved self-reported AMR related behaviour and knowledge in both healthcare professionals and the general public who participated in the campaign.

There was a difference in the level of reported change in behaviour observed between healthcare professionals and members of the public. Healthcare professionals were less likely to act according to their pledge than members of the public. Literature shows that healthcare professionals’ perceptions about patient and professional expectations continue to influence their AMR related behaviour [3538]. The last is also reflected by the results of our survey where the expectations of others was the most common reason stated among healthcare professionals for not fulfilling their pledge. A recommendation for next campaigns would be to work with the relevant groups to ensure that the pledges are achievable and realistic.

Strengths and weaknesses of the campaign

The evaluation was conducted five months after the AG campaign and only provides an assessment of the short term impact of the campaign on self-reported behaviour. The campaign did not include reminding the AGs of their pledge and whilst a high proportion could remember their pledge in part less than half of the participants could remember their pledge completely. The launch of the AG campaign in the UK deliberately coincided with the 2014 European Antibiotic Awareness Day (EAAD) to move from awareness raising to increasing engagement and commitment and to provide an ‘always on’ AMR campaign that was available all year round. As part of the EAAD, European countries are provided with resources to inform people about AMR and on the prudent use of antibiotics although these resources were published later than the AG campaign.

We found the campaign contributed to increasing the personal commitment of healthcare professionals and members of the public as well as improvement in self-reported knowledge and awareness of AMR and was particularly effective for people who were previously confused about the subject. In general participants felt that the AG campaign was well promoted, however, our evaluation suggests that the campaign was less successful in engaging people without previous professional or personal experience of antimicrobial resistance. This likely to be due to the routes of promoting the campaign which relied on health and professional organisations rather than a public facing campaign using, for example, mass media.

The AGs who responded to the survey were similar in terms of pledge group to the total AG population. The current evaluation indicated that a pledge scheme can be an inexpensive and effective way of promoting knowledge, raising awareness and changing self-reporting behaviour on important public health issues especially among people with prior awareness of the topic.

However, certain caveats should be considered when reviewing the results. The majority of participants were female and aged between 44 and 54 years old, two demographic groups shown to be associated with better AMR related knowledge and behaviour [39, 40]. Details of the age and sex distribution of AGs were not available and comparison with the survey participants was not possible and non-responder bias cannot be excluded. However, it is known that there is a greater proportion of women between 35 and 54 years old among healthcare professionals [41, 42]. It is important for the next campaign to identify ways of engaging men and people of older age groups more effectively.

The evaluation was based on self-reported changes in behaviour and knowledge. It is possible that acquiescence bias was present as participants would have been aware of the desirability of a positive change in behaviour and knowledge around AMR. Recall bias may be considered but the majority of participants were able to remember their pledge either in part or completely five months after taking their pledge.

The online questionnaire used for our evaluation was a convenient and inexpensive way to quickly communicate with a large number of AGs but risks a lower response rate [43]. In addition, people who may have limited access to internet such as those from older age groups may be under-represented in such surveys. Other approaches may be needed to have an impact on those with limited internet access.

Overall, the survey was well completed; however, there was some missing information in questions pertaining to the promotion of the AG campaign and demographic characteristics of the participants. We have no reason to believe that these data are not missing at random (i.e., that men are less likely to answer the gender question) although this cannot be formally tested. Therefore, we imputed the missing data to reduce the chance of bias and improve power [33]. Analyses on the imputed data showed similar results to those reported here. In the paper, only the analysis of original data is reported.

Our evaluation provides the baseline characteristics of the participants and a high level assessment of the promotion of the campaign and impact on behaviour and knowledge. Qualitative methods will be applied to further investigate the results from the quantitative analysis.

Context

The discovery of new antibiotics has proved challenging [3] and a variety of different campaigns to help tackle AMR have previously been developed; however a recent summary of the campaigns in the UK highlight that although the campaigns have increased awareness, there has been limited impact on increasing knowledge and changing behaviour [13]. Multifaceted educational programmes and antimicrobial stewardship interventions targeting healthcare professionals are associated with improved antimicrobial use [44, 45]. Mass media interventions as part of a multimodal campaign can also play an important role in educating healthcare professionals and especially members of public about AMR [13, 21, 4548]. The AG campaign is the first published example of the use of a pledge system to engage, educate and encourage others towards positive behaviour change with regards to antibiotic prescribing, expectation and use [24].

Pledges have been used in a number of different contexts to effect behaviour change at an individual and organisational level [4953]. Pledges are employed primarily for four purposes: increase awareness, change behaviour, engage others and collect data on individuals [54]. Only a limited number of pledge schemes have been evaluated and the evidence of effectiveness of pledge schemes is inconsistent [54].

Factors that contribute to successful behaviour change include direct personal contact with pledgees and prior awareness of/engagement with the topic and reflect the findings from our evaluation [54]. Although the majority of participants could remember the general meaning of their chosen pledge, over half could not remember in full their pledge at five months. The last indicates the need for regular communication with pledgees via e-mails or newsletters to remind them of their pledge and provide information on the topic. We also found that the campaign was primarily adopted by people with prior awareness of the topic which suggests that similar pledge-based campaigns may not be the most appropriate intervention to engage people with no prior awareness. Identifying alternative promotional methods to reach members of the public would be an important next step for the campaign.

Any new or ongoing pledge campaigns should adopt the lessons learnt from our evaluation and the techniques that have been successfully implemented in other similar campaigns [55, 56]. These include allowing pledgees to create personalised pledges and getting individuals to make pledges in public [57, 58]. Finally our evaluation was developed after the campaign was delivered and we recommend that evaluations be built into the design of future campaigns to effectively capture pre and post-campaign effects on behaviour and knowledge [13]. The next goal for the AG campaign 2015 is to have 100,000 Antibiotic Guardians by the end of March 2016 and subsequently to assess the impact of the campaign on outcomes such as reduced antibiotic use or prescribing.

Conclusions

In conclusion, although there are limitations, we found that the Antibiotic Guardian campaign was effective in demonstrating engagement from healthcare professionals and members of the public to tackle antimicrobial resistance and also highlighted an increase in self-reported commitment of healthcare professionals and members of the public in their personal actions to tackle antimicrobial resistance. It was also effective for achieving positive changes in self-reported knowledge and behaviour amongst people with prior awareness of the topic. This approach could be developed further to engage with other groups including those without prior knowledge of AMR.

Ethics

The project was a service evaluation of intervention and no ethics approval was required.

Availability of supporting data

Data can be requested through Public Health England.

Abbreviations

AG: 

antibiotic guardian

AMR: 

antimicrobial resistance

aOR: 

adjusted odds ratio

CI: 

confidence interval

EAAD: 

European Antibiotic Awareness Day

OR: 

odds ratio

UK: 

United Kingdom

WHO: 

World Health Organisation

Declarations

Acknowledgements

We acknowledge the support of Dr Jo Kesten from the School of Social and Community Medicine of University of Bristol and Anna Sallis CPsycol from the Behaviour Insights team of Public Health England for their input; as well as the EAAD/AG planning group for their feedback on the study questionnaire. The study was partly supported by the NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or Public Health England.

Funding

The evaluation of the campaign was funded by the National Institute for Health Research through the Health Protection Research Unit in Evaluation of Interventions at University of Bristol.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Field Epidemiology Service, Public Health England
(2)
Health Protection Research Unit in Evaluation of Interventions, School of Social and Community Medicine, University of Bristol
(3)
Antimicrobial Resistance Programme, Public Health England

References

  1. Goossens H, Ferech M, Vander SR, Elseviers M, Project E. Outpatient antibiotic use in Europe and association with resistance : a cross-national database study. Lancet. 2005;365:579–87.View ArticlePubMedGoogle Scholar
  2. Lipsitch M, Samore MH. Antimicrobial use and antimicrobial resistance: a population perspective. Emerg Infect Dis. 2002;8(4):347–54.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Livermore DM. Discovery research: the scientific challenge of finding new antibiotics. J Antimicrob Chemother. 2011;66(9):1941–4. [cited 2015 Jun 30]: Available from: http://www.ncbi.nlm.nih.gov/pubmed/21700626.View ArticlePubMedGoogle Scholar
  4. Grigoryan L, Burgerhof JGM, Degener JE, Deschepper R, Lundborg CS, Monnet DL, et al. Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and the healthcare system. J Antimicrob Chemother. 2008;61(5):1172–9. [cited 2015 Jun 8]: Available from: http://www.ncbi.nlm.nih.gov/pubmed/18296694.View ArticlePubMedGoogle Scholar
  5. Hunter PA, Dawson S, French GL, Goossens H, Hawkey PM, Kuijper EJ, et al. Antimicrobial-resistant pathogens in animals and man: prescribing, practices and policies. J Antimicrob Chemother. 2010;65(Supplement 1):i3–17. [cited 2015 Jun 30]: Available from: http://www.jac.oxfordjournals.org/cgi/doi/10.1093/jac/dkp433.View ArticlePubMedGoogle Scholar
  6. Huttner B, Goossens H, Verheij T, Harbarth S. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis. 2010;10(1):17–31. [cited 2015 Jun 3]: Elsevier Ltd; Available from: http://www.ncbi.nlm.nih.gov/pubmed/20129146.View ArticlePubMedGoogle Scholar
  7. Plachouras D, Kavatha D, Antoniadou A, Giannitsioti E, Poulakou G, Kanellakopoulou K, et al. Dispensing of antibiotics without prescription in Greece, 2008: another link in the antibiotic resistance chain. Eurosurveillance. 2010;15(7):4–7.Google Scholar
  8. Fleming DM, Ross AM, Cross KW, Kendall H. The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing. Br J Gen Pract. 2003;2000(October):778–83.Google Scholar
  9. Public Health England. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) Report 2014 About Public Health England [Internet]. 2014. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/362374/ESPAUR_Report_2014__3_.pdf
  10. Shallcross LJ, Davies SC. The World Health Assembly resolution on antimicrobial resistance. J Antimicrob Chemother. 2014;69(11):2883–5. [cited 2015 Jun 12]: Available from: http://www.ncbi.nlm.nih.gov/pubmed/25204342.View ArticlePubMedGoogle Scholar
  11. WHO. WHO Global Strategy for Containment of Antimicrobial Strategy for Containment of Antimicrobial Resistance [Internet]. 2001. Available from: http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf
  12. Public Health England. UK Five Year Antimicrobial Resistance Strategy 2013 to 2018 [Internet]. 2013. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf
  13. Ashiru-Oredope D, Hopkins S. Antimicrobial resistance : moving from professional engagement to public action. J Antimicrob Chemother. 2015;7–10. doi:10.1093/jac/dkv297.
  14. Chazan B, Ben R, Turjeman Z, Frost Y, Besharat B, Tabenkin H, et al. Antibiotic consumption successfully reduced by a community intervention program. IMAJ. 2007;9(January):16–20.PubMedGoogle Scholar
  15. Formoso G, Paltrinieri B, Maria A, Gagliotti C, Pan A, Luisa M. Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: community level, controlled, non-randomised trial. BMJ. 2013;5391(September):1–10.Google Scholar
  16. Kardas-Sloma L, Boëlle P-Y, Opatowski L, Guillemot D, Temime L. Antibiotic reduction campaigns do not necessarily decrease bacterial resistance: the example of methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 2013;57(9):4410–6. [cited 2015 Jun 12]: Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3754303&tool=pmcentrez&rendertype=abstract.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Lambert MF, Masters GA, Brent SL. Can mass media campaigns change antimicrobial prescribing? A regional evaluation study. J Antimicrob Chemother. 2007;59(3):537–43. [cited 2015 Jun 12]: Available from: http://www.ncbi.nlm.nih.gov/pubmed/17283035.View ArticlePubMedGoogle Scholar
  18. Mcnulty CAM, Boyle P, Nichols T, Clappison P, Davey P, Centre HI, et al. The public’ s attitudes to and compliance with antibiotics. J Antimicrob Chemother. 2007;60 (suppl 1):i63-i68. doi:10.1093/jac/dkm161.
  19. Mcnulty CAM, Nichols T, Boyle PJ, Woodhead M, Davey P. The English antibiotic awareness campaigns: did they change the public’s knowledge of and attitudes to antibiotic use? J Antimicrob Chemother. 2010;65(7):1526-33. doi:10.1093/jac/dkq126. First published online: May 20, 2010.
  20. Plachouras D, Antoniadou A, Giannitsioti E, Galani L, Katsarolis I, Kavatha D, et al. Promoting prudent use of antibiotics: the experience from a multifaceted regional campaign in Greece. BMC Public Health. 2014.Google Scholar
  21. Sabuncu E, David J, Bernède-Bauduin C, Pépin S, Leroy M, Boëlle P-Y, et al. Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002–2007. PLoS Med. 2009;6(6):e1000084. [cited 2014 Dec 2]: Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2683932&tool=pmcentrez&rendertype=abstract.View ArticlePubMedPubMed CentralGoogle Scholar
  22. Dryden M, Johnson AP, Ashiru-Oredope D, Sharland M. Using antibiotics responsibly: right drug, right time, right dose, right duration. J Antimicrob Chemother. 2011;66(11):2441–3. [cited 2015 Jun 12]: Available from: http://www.ncbi.nlm.nih.gov/pubmed/21926080.View ArticlePubMedGoogle Scholar
  23. Earnshaw S, Monnet DL, Duncan B, O’Toole J, Ekdahl K, Goossens H, et al. European Antibiotic Awareness Day, 2008 – The first Europe - wide public information campaign on prudent antibiotic use: Methods and survey of activities in participating countries. Eurosurveillance. 2008;14(30):1–8.Google Scholar
  24. Ashiru-Oredope D, Hopkins S. Antimicrobial resistance: moving from professional engagement to public action. J Antimicrob Chemother [Internet]. 2015 Sep 16; Available from: http://jac.oxfordjournals.org/content/early/2015/09/15/jac.dkv297.abstract
  25. Public Health England. Behaviour change and antibiotic prescribing in healthcare settings Literature review and behavioural analysis About Public Health England About the Department of Health [Internet]. 2015. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/405031/Behaviour_Change_for_Antibiotic_Prescribing_-_FINAL.pdf
  26. Tonkin-crine S, Walker AS, Butler CC. Contribution of behavioural science to antibiotic. BMJ. 2015;350:h3413.Google Scholar
  27. Gollwitzer PM. Implementation Intentions. 1999;54(7):493–503.Google Scholar
  28. Rhodes R, Dickau L. Experimental evidence for the intention-behavior relationship in the physical activity domain: a meta-analysis. Heal Psychol. 2012;31(6):724–7.View ArticleGoogle Scholar
  29. Cooke R, Sheeran P. Moderation of cognition-intention and cognition-behaviour relations: a meta-analysis of properties of variables from the theory of planned behaviour. Br J Soc Psychol. 2004;43(2):159–86.View ArticlePubMedGoogle Scholar
  30. Public Health England. Antibiotic awareness resources: 2015 [Internet]. 2015. Available from: https://www.gov.uk/government/collections/european-antibiotic-awareness-day-resources
  31. Public Health England. European Antibiotic Awareness Day: letters to NHS, local authority and professional organisations [Internet]. 2015. Available from: https://www.gov.uk/government/publications/european-antibiotic-awareness-day-letters-to-nhs-and-local-authority-health-and-wellbeing-boards
  32. Armstrong BG, Sloan M. Ordinal regression models for epidemiologic data. Am J Epidemiol. 1989;129(1):191–204.View ArticlePubMedGoogle Scholar
  33. Sterne JAC, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ. 2009.Google Scholar
  34. StataCorp. Stata Statistical Software: Release 13. College Station TSL. TX: StataCorp LP; 2013.Google Scholar
  35. Calbo E, Alvarez-Rocha L, Gudiol F, Pasquau J. A review of the factors influencing antimicrobial prescribing. Enferm Infecc Microbiol Clin. 2013;31 Suppl 4:12–5. [cited 2015 Jul 27]: Available from: http://www.sciencedirect.com/science/article/pii/S0213005X13701277.View ArticlePubMedGoogle Scholar
  36. Dempsey PP, Businger AC, Whaley LE, Gagne JJ, Linder JA. Primary care clinicians’ perceptions about antibiotic prescribing for acute bronchitis: a qualitative study. BMC Fam Pract. 2014;15:194. [cited 2015 Sep 2]: Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4275949&tool=pmcentrez&rendertype=abstract.View ArticlePubMedPubMed CentralGoogle Scholar
  37. Karras DJ, Ong S, Moran GJ, Nakase J, Kuehnert MJ, Jarvis WR, et al. Antibiotic use for emergency department patients with acute diarrhea. Ann Emerg Med. 2003;42(6):835–42. [cited 2015 Jul 27]: Available from: http://www.sciencedirect.com/science/article/pii/S0196064403006024.View ArticlePubMedGoogle Scholar
  38. Paredes P, de la Peña M, Flores-Guerra E, Diaz J, Trostle J. Factors influencing physicians’ prescribing behaviour in the treatment of childhood diarrhoea: Knowledge may not be the clue. Soc Sci Med. 1996;42(8):1141–53. [cited 2015 Jul 27]: Available from: http://www.sciencedirect.com/science/article/pii/0277953695003878.View ArticlePubMedGoogle Scholar
  39. McNulty CAM, Boyle P, Nichols T, Clappison P, Davey P. Don’t wear me out--the public's knowledge of and attitudes to antibiotic use. J Antimicrob Chemother. 2007;59(4):727–38. [cited 2015 Sep 2]: Available from: http://www.ncbi.nlm.nih.gov/pubmed/17307770.View ArticlePubMedGoogle Scholar
  40. You JHS, Yau B, Choi KC, Chau CTS, Huang QR, Lee SS. Public knowledge, attitudes and behavior on antibiotic use: a telephone survey in Hong Kong. Springer Link. 2008;36(2):153–7.Google Scholar
  41. Yar M, Dix D, Bajekal M. Socio-demographic characteristics of the healthcare workforce in England and Wales-- results from the 2001 Census. Health Stat Q. 2006;32:44–56. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17165469.Google Scholar
  42. WHO. Spotlight on statistics [Internet]. 2008. Available from: http://www.who.int/hrh/statistics/spotlight_2.pdf?ua=1
  43. Hunter L. Challenging the reported disadvantages of e-questionnaires and addressing methodological issues of online data collection. Nurse Res. 2012;20(1):11–20.View ArticlePubMedGoogle Scholar
  44. Butler CC, Simpson SA, Evans J, Moore L. Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. BMJ. 2012;8173(63355948):1–13.Google Scholar
  45. Kaki R, Elligsen M, Walker S, Simor A, Palmay L, Daneman N. Impact of antimicrobial stewardship in critical care: a systematic review. J Antimicrob Chemother. 2011;66(6):1223–30. [cited 2015 Jun 30]: Available from: http://www.jac.oxfordjournals.org/cgi/doi/10.1093/jac/dkr137.View ArticlePubMedGoogle Scholar
  46. Bauraind I, Lopez-Lozano J-M, Beyaert A, Marchal J-L, Seys B, Yane F, et al. Association between antibiotic sales and public campaigns for their appropriate use. JAMA. 2004;292(20):2465–70.Google Scholar
  47. Campaign L, Locaal A. Doctors and local media: a synergy for public health information?: a controlled trial to evaluate the effects of a multifaceted campaign on antibiotic prescribing (protocol). BMC Public Health. 2011;11(1):816. [cited 2015 Jun 12]: BioMed Central Ltd; Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3212824&tool=pmcentrez&rendertype=abstract.View ArticleGoogle Scholar
  48. Goossens H, Guillemot D, Ferech M, Schlemmer B, Costers M, van Breda M, et al. National campaigns to improve antibiotic use. Eur J Clin Pharmacol. 2006;62(5):373–9.View ArticlePubMedGoogle Scholar
  49. Donovan RJ, Fisher DA, Armstrong BK. “Give it away for a day”: An evaluation of Western Australia’s first smoke free day. Community Health Stud. 2010;8(3):301–6.View ArticleGoogle Scholar
  50. Heiskanena E, Johnson M, Robinsonb S, Vadovicsc E, Saastamoinena M. Low-carbon communities as a context for individual behavioural change. Energy Policy. 2010;38(12):7586–95.View ArticleGoogle Scholar
  51. Hillier FC, Batterham AM, Nixon CA, Crayton AM, Pedley CL, Summerbell CD. A community-based health promotion intervention using brief negotiation techniques and a pledge on dietary intake, physical activity levels and weight outcomes: lessons learnt from an exploratory trial. Public Health Nutr. 2011;15(8):1446–55.View ArticlePubMedGoogle Scholar
  52. Petticrew M, Eastmure E, Mays N, Knai C, Durand MA, Nolte E. The public health responsibility deal: how should such a complex public health policy be evaluated ? J Public Health (Bangkok). 2013;35(4):495–501.View ArticleGoogle Scholar
  53. Raju S, Rajagopal P, Gilbride TJ. Marketing healthful eating to children: the effectiveness of incentives, pledges, and competitions. J Mark. 2010;74(3):93–106.View ArticleGoogle Scholar
  54. Cotterill S, John P, Richardson L. Pledge campaigns to encourage charitable giving: a randomised controlled trial [Internet]. Political Studies Association. 2010. Available from: https://www.researchgate.net/profile/Peter_John4/publication/228979043_Pledge_campaigns_to_encourage_charitable_giving_a_randomised_controlled_trial/links/02e7e517aac28a66f7000000.pdfGoogle Scholar
  55. Edgar T, Boyd SD, Palamé MJ. Sustainability for behaviour change in the fight against antibiotic resistance: a social marketing framework. J Antimicrob Chemother. 2009;63(2):230–7. [cited 2015 Jul 13]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19095680.View ArticlePubMedGoogle Scholar
  56. Davey P, Garner S. Professional education on antimicrobial prescribing: a report from the Specialist Advisory Committee on Antimicrobial Resistance (SACAR) Professional Education Subgroup. J Antimicrob Chemother. 2007;60 Suppl 1:27–32. [cited 2015 Jun 30]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17656378.View ArticleGoogle Scholar
  57. Cotterill S, Richardson L. Can pledging increase civic activity? A literature review on developing community Pledgebanks [Internet]. 2009. Available from: https://www.escholar.manchester.ac.uk/api/datastream?publicationPid=uk-ac-man-scw:66966&datastreamId=FULL-TEXT.PDF
  58. Burgess D, Haney B, Snyder M, Sullivan J, Transue J. Rocking the vote: using personalized messages to motivate voting among young adults. Public Opin Q. 2000;64(1):29–52.View ArticlePubMedGoogle Scholar

Copyright

© Chaintarli et al. 2016

Advertisement