Table 4 Summary of key findings from studies assessing changes in knowledge, attitudes and or reported behaviour as key outcome measure

Mei Lin Ho et al. 2014

Hong Kong

Longitudinal

Six months of mass media messaging with key message ‘Abs do not help in cold and flu’. Information resources also available in hospitals and clinics. Promotional materials also provided to HCPs

n = 1569 (response rate 69.3%) in Nov 2010

n = 1527 (response rate 66.6%) in June 2011.

Random sample of members of the public aged > 18yrs

2011

Mainly public, some HCP education

National

Pre and post campaign

Knowledge and attitudes related to AMR and antibiotic use

27.7% of respondents could recall the campaign, 73.9% through TV advertising. Increase in number of individuals correctly identifying that antibiotics do not cure flu or viral infections (7, p < 0.001, and 4.1%, p = 0.002, increases respectively)

Formoso et al. 2013

Italy

Experimental

Social marketing information campaign between Nov 2011 and Feb 2012 in Moderna and Parma. Focused on the use of Abs in URTI.

600 citizens in the intervention and control areas were randomly selected. 500 were interviewed by phone, 100 by internet

2011 and 2012

Public

Community

Pre and post campaign survey

Knowledge, attitudes and reported behaviour about the campaign messages

Control and intervention groups had similar baseline scores. Following the campaign, only knowledge on the effectiveness of antibiotics against viruses changed significantly, worsening more in the intervention compared to the control area (‘Antibiotics are effective against viruses’ pre: intervention = 47%, control = 59%; post: intervention = 62%, control = 67%).

Redding and Cole, 2019

USA

Cross-sectional

Posters showing antimicrobial stewardship messages related to RTI in dogs and cats were placed in clinic exam rooms for a 6-month period

Five privately owned veterinary clinics. 111 participants, 91 completed a follow up survey with 83 providing a definition of antibiotic resistance

Unclear, paper published in 2019

Public

Local

NA

Survey assessed message recall and knowledge related to AMR.

51 (46.4%) of participants noticed the posters within the clinic. 15.7% (8/51) participants paraphrased the message and 5.9% (3/51) reproduced the message.

No significant difference in knowledge score between those who had and had not noticed the posters (p = 0.693)

van Rijn et al., 2019

Netherlands

Quasi-experimental

Educational video explaining what antibiotics are, how bacteria become resistant to antibiotics and the importance of prudent use of antibiotics. Study aimed to determine the effect of this information on the general awareness of antibiotic resistance.

Control group: n = 560

Intervention group: n = 1220

Unknown

Public

Community

Control group who was not shown the educational video

Level of knowledge. The number of correct knowledge-based questions for each individual was summed and categorised into three groups - Group 1: low knowledge < 4 correct answers (N = 332, 18.7%); group 2: moderate knowledge 4 to 7 correct answers (N = 1024, 57.5%); Group3: highest knowledge > 7 correct answers (N = 424, 23.8%).

Educational video raised general awareness of AMR in the intervention group (p = 0.048) with 67% of the intervention group had a better general awareness of antibiotic resistance.

Among the lowest knowledge group, those in the intervention group had a significantly higher mean score on the general awareness of the threat of antibiotic resistance than the control group (p < 0.001). 67% of the intervention group had a better general awareness of antibiotic resistance.

Mazinska et al., 2017

Poland

Longitudinal

EAAD campaign with intensive educational action aimed at the public. Activities included press conferences, posters, leaflets for patients, leaflets for children and parents, exhibition displayed nationwide (16 posters), 10 s. spot broadcast in public TV, 10 s, 30 s. spots in public TV, Facebook since 2011.

5004 respondents were recruited: 1000 in wave 1 (October 2009), 1002 in wave 2 (December 2009), 1001 in wave 3 (October 2010), 1000 in wave 4 (December 2010) and 1001 in wave 5 (December 2011). The response rates were 5.1 -11.3% (2009–2011).

2009 to 2011

Public and HCP

International

Pre and post data collected before and after the EAAD campaigns run in 2019 and 2010 and following the campaign in 2011.

Sources of knowledge

Knowledge and impact of the campaign on attitudes towards the use of antibiotics

One third of the respondents (29%) declared that they received information about antibiotics.

Fewer of the respondents had used antibiotics to treat colds (2009: 30%, 2011: 21%, p = 0.008), sore throats (2009: 24%; 2011: 12%, p < 0.001) and flu (2009: 16%; 2011: 13%,p = 0.124).

More respondents declared they had taken the full dose of antibiotic prescribed (2009: 75%, 2011: 81%, p = 0.063)

Fewer respondents expected a prescription for antibiotics because of colds (2009: 19%; 2011: 15%, p = 0.019) and flu (2009: 43%; 2011: 32%, p < 0.001). More respondents declared a change in behaviour after receiving EAAD campaign information (2009: 38%; 2011: 48%, p = 0.012). More respondents who came across the campaign indicated they have limited the use of antibiotics (2009: 27%; 2011: 43%, p = 0.009) and they have become more cautious regarding the use of antibiotics (2009: 4%: 2011: 16%, p = 0.001)

UKHSA., 2021

England

Longitudinal

National, mass media, social marketing campaign. The direct-to-public communications were supplemented with resources that prescribers could download and customise for their surgeries.

Random sample of the public. December 2017: n = 1201; December 2018: n = 1352; December 2019: n = 1350. Purposive sampling in target groups (mothers of children aged 0–16 and adults over 50). GPs: 2017, n = 189; 2018, n = 172; 2019, n = 207

2017 to 2019

Public

National

Pre and post campaign comparison for each year the campaign was run.

Campaign recognition

Knowledge, attitudes and reported behaviour

Campaign recognition increased each year (56%, 65% and 71%). Knowledge increased for AMR specific questions including ‘Antibiotics will stop working if taken for the wrong things’: 2017, 29%; 2018, 33% and 2019, 35% answered definitely true; ‘Taking antibiotics when you don’t need them puts you and your family at risk of antibiotic resistant infections’: 2017, 36%; 2018, 45 and 2019, 48% answered definitely true). Concern increased for self and for child with percentage very unlikely to ask for AB for self (2017, 53%; 2018, 53%; 2019, 48%) or for child (2017, 38%; 2018, 34%; 2019, 33%) decreasing each year.

McNulty et al., 2010

England

Longitudinal

Public campaign using posters and patient advice leaflets to disseminate information

1706 English and 182 Scottish adults in January 2008; 1707 English and 123 Scottish adults in January 2009. Random location sampling and non-random quota sampling used.

2008

Public

National

Pre and post comparison

Publics knowledge, attitudes and behaviour (reported AB use) with respect to AB use.

Increase in percentage of individuals that recalled any of the three campaign posters (19.2 to 23.7%). Absolute change from baseline (including both England and Scotland response) was 2.3%. Respondents were more likely to agree with the statement ‘Resistance to ABs is a problem in British hospitals’ (37% vs. 30%, p = 0.03).

Reported antibiotic use did not improve. A similar percentage of English respondents reported being prescribed an antibiotic between 2008 and 2009 (34 vs. 35%) or reported asking their GP for an antibiotic between 2008 and 2009 (28 vs. 29%). The percentage of English respondents retaining leftover ABs from their last course increased following the campaign (2.2 vs. 7.0%, p < 0.001).

Thong et al., 2021

Malaysia

Longitudinal

Educational intervention tool developed after reviewing knowledge gaps. Each educational session was conducted by trained pharmacists and lasted approximately 15 min for each participant.

300 recruited and 234 respondents who completed the study were included in the final analysis.

Unknown

Public (patients)

Community

Pre and two weeks post intervention comparison

Knowledge on antibiotic resistance and use. Perception of antibiotic use.

Knowledge of antibiotic resistance: number of respondents answering the statement “Taking leftover antibiotics from previous infection may cause antibiotic resistance” increased by 26.1% after the intervention (64.1 to 90.2%, p < 0.001). Correct responses to “Using antibiotics without consulting doctor or purchasing directly from the pharmacy without a prescription may cause antibiotic resistance” increased by 19.2% (69.7 to 88.9% p < 0.001).

Knowledge on antibiotic use: increase in number of respondents that understood antibiotics cannot treat viral infections (25.6 vs. 80.3%, p = 0.004). Improvement in the number of respondents who could correctly identify conditions treatable with ABs (9.8% vs. 43.2%, p = 0.022).

Perception of antibiotic use: Improvement in respondents’ belief they had a role to play in stopping AMR (26.5 to 69.2%, p < 0.001). Increase in concern about the impact of AMR on their health and their family (66.2 vs. 86.8%, p < 0.001). Improvement in all correct responses to questions relating to respondents’ perception on antibiotic use was seen following the intervention (p < 0.001).

Shehadeh et al., 2016

Jordan

Longitudinal

Participant was verbally educated on one-to-one basis using educational card contained information based on the published educational materials by the Centre for Disease Control and Prevention. Additionally, the educational card included further information outlined in the previously published recommendations

271 adults completed both questionnaires (purposive sampling)

April to July 2012

Public

Local

Pre and post questionnaire

Knowledge about appropriate antibiotics use and resistance.

Knowledge scores improved following the intervention (pre: 59.4; post: 65.9% p < 0.001). Knowledge of appropriate use (i.e. not effective against viral infections) improved (Pre: 45.8%; post: 75.9%, p = 0.035). Awareness regarding antibiotic use by pregnant, lactating mothers and young children increased (pre: 17.6, post: 81.3%; pre: 31.1, post: 77.9%; pre: 52.7, post: 63.7%). The knowledge score (SD) for safe use of antibiotics increased (pre: 23.8% (9.7), post: 76% (26.7), p = 0.017).

Ngadimon et al., 2016

Malaysia

Longitudinal

20-30 min antibiotic education session delivered verbally to students based on education content from the National Pharmaceutical Control Bureau, Ministry of Health, Malaysia.

510 secondary school students (13 to 17 years). Schools were randomly selected.

Unknown

Public (students)

National

Pre and post comparison

Antibiotics knowledge and attitude toward antibiotics

Mean knowledge (Pre: 3.2 ± 1.8 vs. post: 6.8 ± 2.1, p < 0.001) and attitude scores (Pre: 3.3 ± 1.7 vs. post: 5.4 ± 1.9, p = 0.003) increased significantly following the intervention. Positive correlation between attitude and knowledge scores (0.4, p < 0.001).

Kandeel et al., 2019

Egypt

Pilot

Campaign aimed to raise awareness of HCP and the public of the importance of rational antibiotic prescribing for RTIs. Social media campaign targeted youths. Training course provided to HCP and fact sheets on RTI management guidelines. Posters displayed in GP waiting areas, pharmacies, community areas, schools and universities.

Randomly selected patients from acute care hospitals and a sample of primary healthcare centres in Minya. Pre- intervention: n = 113; post-intervention: n = 277

2011

Both

Community

Pre and post comparison

Clinician and public attitudes and knowledge

Self-reported antibiotic prescribing practices

Overall knowledge and attitude scores increased among caregivers and adult patients after the intervention (from 2.3 to 2.5 and from 2.4 to 2.6, respectively).

Self-reported prescribing practices: the percentage of physicians who reported prescribing antibiotics most of the time for colds, bronchitis, sinusitis decreased following the intervention (9.3 to 2.1%, 65.8 to 28.4% and 43.5 to 17.0% respectively). Percentage of pharmacists prescribing antibiotics or recommending antibiotics for RTI (83.6 to 57.7%, 57.8 to 24.8%) and in the percentage of pharmacists prescribing antibiotics for colds declined (67.5 to 28.0%).

Khoshgoftar et al., 2021

Iran

Quasi-experimental

Educational campaign using informative and persuasive style messaging developed to disseminate info on resting during colds, ineffectiveness of Abs at treating viruses, the effects of arbitrary antibiotic use and the need to prescribe medication.

Random sampling in ten urban areas (n = 708)

Unknown

Public

Community

Pre and post comparison

Knowledge, attitude and self-reported antibiotic consumption (behaviour change).

Mean knowledge (23.27 vs. 38.96) and attitude (15.00 vs. 25.61) increased after the intervention (p < 0.001).

Newitt et al., 2018

International

Cross-sectional

Behaviour change and engagement campaign - Antibiotic guardian. Online pledge-based system designed to improve knowledge and behaviours regarding AB prescribing and use among HCP and the public. 2-min video aimed at the public, promotion of key messages via social media, resource development and toolkits for HCP, development of an interactive quiz.

Antibiotic guardian website visitors. Members of the public: n = 885

Ongoing

Both

International

Pre- post translation comparison.

Antimicrobial resistance knowledge

94.2% of questions were answered correctly (16,918/17,965). Russian pages had the lowest proportion of correct responses (78.5%, n = 208) compared to Dutch (93.9%, n = 1179) and English pages (94.4%, n = 15,531). A higher proportion of Antibiotic Guardians answered all four Eurobarometer survey questions correctly compared to the published results of the EU group (80.9% vs. 24%, P < 0.001). AG’s who were members of the public were also more likely to answer all four questions correctly compared to the published results of the EU group (70.2% vs. 24%, P < 0.001).

Newitt et al., 2019

International

Cross-sectional

Behaviour change and engagement campaign - Antibiotic guardian. Online pledge-based system designed to improve knowledge and behaviours regarding AB prescribing and use among HCP and the public. 2-min video aimed at the public, promotion of key messages via social media, resource development and toolkits for HCP, development of an interactive quiz.

3289 Antibiotic Guardian pledgers answered questions on AMR knowledge and 1940 AG’s completed online survey on self-reported behaviours

Ongoing

Both

International

Euro-barometer survey data on AMR knowledge

Self-reported knowledge and behaviour change

80% of Antibiotic Guardians answered all 5 questions correctly. For individual questions, the percentage that were correctly answered ranged from 91.1–98%. HCP answered more questions correctly than the public (96.5 vs. 91.2%, p < 0.001). Antibiotic Guardians answered more questions correctly when compared to UK (OR 8.5) and EU (OR 13.9) public. Antibiotic Guardians answered an average of 3.8 questions correctly compared to 2.8 and 2.5 for UK and EU public respectively.

McKay et al., 2011

Canada

Longitudinal

Do Bugs Need Drugs (DBND) programme had two main arms. Public component which included annual media campaigns, print material distribution, and audience-specific education curricula targeting children. The HCP education offered

accredited courses to physicians and pharmacists, with a focus on antibiotic use, resistance, and strategies to prescribe appropriately

63 physicians who completed the accredited continuing education

course for physicians in 2008

2005

Both

National

Pre and post analysis

Public knowledge and attitudes assessed via telephone survey before and after the initial launch of the programme. Physician and pharmacist knowledge of resistance trends, aetiology of respiratory infections and treatment options assessed via pre- and post-course learner assessments.

Assessment of public knowledge not evaluated due to low response rates (pre: 14.9% and post: 18.3)

GP knowledge - knowledge scores for bronchitis (70.35 vs. 81.43%), otitis media (66.84 vs. 85.16%), sinusitis (67.46 vs. 70.85%) and pharyngitis (73.33 vs. 90.16%) increased. An assessment of general knowledge about antibiotics and resistance showed an improvement in correct responses after the course (mean increase 11.2%; P = 0.013)

Maor et al., 2011

Israel

Longitudinal

Educational intervention aimed at parents accompanying children to participating clinics. Aimed to enhance knowledge regarding antibiotic resistance and it major determinant, non-judicious antibiotic use and decrease parents expectations to receive an antibiotic prescription.

1556 parents, 868 pre-campaign (control group) and 688 post campaign.

2002

Public (parents)

Community

Pre and post comparison

Knowledge of appropriate antibiotic use

Individuals who noticed the campaign has higher odds for low expectation for antibiotics (OR 1.51, p < 0.001). Intervention group had good knowledge (classed as scoring > 50% on test) about AB treatment compared to parents in the control group (45.1 vs. 36.8%, p = 0.005). Intervention group had a stronger tendency to avoid unnecessary AB treatment compared to the control group, (53.2% vs.59.9%). Similarly, higher proportion of intervention group did not expect antibiotic treatment on the survey day (48.6% vs. 56.7%, p = 0.001).