Abstract

The high rates of antibiotic prescriptions and antimicrobial resistance in France motivated its participation in the European e-Bug school project concerning microbes, and infection transmission, prevention and treatment. The prospect of raising awareness among children, helping them to adopt suitable attitudes and behaviour towards infection transmission and treatment starting from childhood, generated enthusiastic support from relevant national educational and health institutions throughout the Project. France was actively involved in every stage: background research showed that the subject matter was best suited to the national science curricula of the fourth and fifth forms in junior schools, and the sixth and ninth forms in senior schools; a focus group study with junior and senior teachers elicited teachers’ needs concerning teaching resources; and a qualitative and quantitative evaluation, after translation and pack review, enabled further adaptation of the packs. This evaluation showed an overall enthusiastic reception by teachers and their students in France, and reassured teachers on the ease of use of the Project's resources and students’ progress. The e-Bug Project was launched through a national institutional implementation plan in September 2009 and orders for e-Bug tools increased rapidly. By the end of October, 57% of all senior science teachers and 16% of all junior school teachers had ordered the pack. France is one of the most frequent users of the e-Bug web site. The collaboration with both educational and health partners was particularly helpful to implementing the Project, and this was confirmed by the favourable reception and participation of teachers and students in the field.

Introduction

France is notorious for its high rates of antibiotic prescriptions and antimicrobial resistance.1 Studies investigating potential determinants of antibiotic prescriptions identified sociocultural factors2 and these have been taken into account when plans to reverse the situation were developed.

Various local and national interventions to promote appropriate antibiotic use have been launched since 2000, such as ‘Antibios quand il faut’3 and ‘Antibiotiques c'est pas automatique’.4 These appear to have been effective, as analysis of the National Health Insurance (CNAMts) database shows a 26.5% decrease in community-based antibiotic prescribing between 2002 and 2007.4 However, public health campaigns need to be sustained to remain effective over time and strategies must be developed to attain this goal.5

One advantage of school interventions is that they provide the opportunity to reach a large proportion of children in their normal learning surroundings. Such interventions could help facilitate cultural changes and prolong the effects of public health campaigns. The e-Bug pack addresses several relevant public health issues regarding the situation in France. Besides respiratory tract infections, gastroenteritis is generally epidemic during the wintertime in France and together these conditions account for >40% of the 20 most frequent diagnoses in general practice in France.6 The threat of an influenza pandemic also encouraged support for the e-Bug Project, with a view to improving hand and respiratory hygiene.

Vaccination rates, such as that against hepatitis B, could be further improved in France, in particular among schoolchildren, and relevant education could help broaden coverage.7

Sexual activity begins early (27% of school pupils declare being sexually active before the age of 15) and sexual education, including sexually transmitted infections, is therefore important for this age group.8

Educational structure and curriculum

Number of teachers, schools and their structure

There are 7010 senior schools and 56 158 junior schools (63 168 schools in total) targeted by the e-Bug Project in France, among which 88% are public and 12% are private.

Among the private schools, 97% have a contract with the Ministry of Education (MoE) and follow the same national curriculum as public schools. There are 367 462 junior school teachers, of whom 25% teach the junior age groups covered by the e-Bug Project, and 14 400 science teachers in senior schools. In total, 106 266 teachers in France were targeted by the Project. Scientific skills are not compulsory for junior school teachers. Almost all schools are equipped with computers and Internet connection.

Curriculum

The background research in collaboration with the MoE and local school authorities (LSAs) in Nice showed that the subject matter covered by the e-Bug Project was best suited to the following national science curricula:

  • Junior schools: fourth and fifth forms (9–10 year olds)

    • Unity and diversity within the living world

    • Health education and the human body

    • Environmental education

  • Senior schools:

    • Sixth form (11–12 year olds)

      1. Diversity, interdependency and unity of the living world

      2. Practices related to human food

    • Ninth form (14–15 year olds)

      1. Human responsibility: health and environment

      2. Infection risk and protection of the human body

French partners, stakeholders and endorsement

A team from the Public Health and Infectious Diseases Departments at Nice University Hospital (CHU de Nice) was contacted because of their experience gained from organizing a pilot public health campaign3 concerning appropriate antibiotic use. This team accepted coordinating the e-Bug Project in France. Partnership was sought at an early stage of the Project from relevant national educational and health institutions: the MoE; the Ministry of Health (MoH); the National Institute for Prevention and Health Education (INPES); CNAMts (responsible for the national media campaign ‘Antibiotiques c'est pas automatique'); and a national association of senior school science teachers (APBG). No association of junior school teachers could be identified. All these partners agreed to take part at different stages of the Project, according to their abilities, skills and motivations, which facilitated the implementation of the Project in France. The Project was approved from the start by the MoH, who in turn requested endorsement by the MoE. This was officially obtained in September 2006. The Project was officially integrated in 2007 into the National Plan to Preserve the Effectiveness of Antibiotics, coordinated by the MoH. The institutional implementation plan confirmed these commitments.

Customization for a French audience

Pack development

Prior to developing the school packs, as in the UK, a focus group study was conducted among junior and senior school teachers from the Nice area to explore teachers’ needs and criteria of choice concerning teaching resources for the themes concerned, as well as ideas for approaching students.9

France was one of the three countries participating in the initial pack evaluation. The resource was first translated and reviewed from a teaching, educational, scientific and sociocultural perspective by a committee comprising representatives from the MoE, INPES and CHU de Nice. The committee's comments were communicated to the European coordination team before the evaluation and led to an initial adjustment of the packs.

Evaluation

This qualitative and quantitative evaluation was very important for the success of e-Bug in France. Although the reception was globally enthusiastic among teachers and students, the evaluation enabled further adjustment of the packs according to the national legislation and science-teaching context in France, and reassured teachers on the ease of use and the improvement of students’ knowledge.10

Special features of the French packs

Comments from the pack-review committee resulted in modification of certain sections that were tailored to comply with French educational aspects, school safety standards, scientific content and presentation of the subject matter. As an example, because microbe culture is forbidden in schools, an alternative activity to the senior hand hygiene activity, based on photographic material, was developed.

With the approval of the French national partners, the ‘sneeze in the sleeve’ message was highlighted in the hygiene sections and an alternative activity was added for senior students, encouraging them to understand the advantages of this new health educational advice.

According to the qualitative evaluation in France, the yogurt-making activity in the senior section on useful microbes was considered too complicated and time consuming. An alternative activity for seniors based on yeast was developed, observing the factors that make the dough rise, demonstrating the gas produced during the fermentation process as well as microscopic observation of yeast cells.

Implementation

Pack printing

Based on the number of schools and teachers in the background research survey, it was decided to print approximately one pack per targeted teacher and key person. This goal was achieved thanks to the financial contribution of the MoH and the CNAMts, and to the choice of stapled packs, which reduced costs. Thus, 134 000 copies were printed (116 000 junior packs and 18 000 senior packs) and delivered to the distribution department of INPES.

An institutional implementation plan

All French partners agreed to launch the e-Bug Project through a national institutional implementation plan, as is usually the case for institutional health educational tools.

Thus, an information letter was sent in September 2009 by the MoE and INPES to school principals of all concerned schools and key persons within all 27 different local school authorities (headmasters, general inspectors, junior school inspectors, senior school science inspectors, school practitioners, nurses and school library staff).

This information letter describes the Project and the content of the packs, highlighting the advantages of using this resource when teaching public health subjects concerning how to preserve the effectiveness of antibiotics and prevent infection transmission.

Taking into account the then contemporary context of pandemic influenza, hand and respiratory hygiene activities were highlighted in the information letter and on the French start page of the e-Bug web site, with a link to national official, regularly updated influenza information. Promotion of e-Bug can currently also be found on key health educational web sites, such as INPES. Orders can be made online, and packs are distributed accordingly and continually by INPES (http://www.inpes.sante.fr). A reminder is planned for key persons (junior school inspectors, senior school science inspectors, school practitioners and nurses). The resource is also promoted through teachers’ web sites.

Reception by French schools

Orders for e-Bug tools increased rapidly following the launch in early September 2009. By the end of October 2009, 57% of all senior science teachers and 16% of all junior school teachers had ordered the tool, which was considered a good score compared with that of usual health educational tools. The difference between junior and senior schools can probably be explained by the difficulty in reaching the junior schools, due to their large number and organizational differences. The orders are ongoing and a new institutional information letter is planned for September 2010. The e-Bug web site web log report for 2009 shows that France is among the most frequent users, with a peak following the implementation letter sent to the schools. These users are evenly spread across the country. The web site was also used by French-speaking countries not involved in the Project, such as Algeria, Morocco, Tunisia, Switzerland, Lebanon and Canada. The most visited page was that for the junior hand hygiene activity.

Communication

Information concerning e-Bug was presented on various occasions during scientific national meetings, workshops and in the national scientific press,11 as well as through the local and national media (press, radio and television). A press release from the MoH for the 2009 Antibiotic Awareness Day included information about the e-Bug Project.

Future of e-Bug in France

Follow-up of the e-Bug Project will be on-going and complementary activities, such as further development of the web site, online evaluation (including student knowledge and behaviour, and teachers’ comments) and a virtual and/or touring exhibition, will be developed according to the availability of funding.

Conclusions

Considering the high antibiotic consumption and resistance rates in France, it was important for this country to participate in this school project in the hope of raising awareness among children, helping them to adopt suitable attitudes and behaviour towards infection transmission and treatment, starting from childhood. France was actively involved in every stage of the Project, which resulted in a particularly well-adapted final French version of the packs. The enthusiasm and collaboration from both educational and health partners was particularly helpful in implementing the Project, and this was confirmed by the favourable reception and participation of teachers and students in the field.

Funding

The European project was supported by European Commission DG SANCO (2005211). Additional staff costs were met by the CHU de Nice and the MoH. Funding of printing costs was equally shared between the MoH and the CNAMts. Distribution costs were endorsed by the INPES.

Transparency declarations

This article is part of a Supplement sponsored by the European Commission Health and Consumer Protection Directorate-General DG SANCO (grant number 2005211).

Acknowledgements

We would like to thank the following persons for their enthusiastic contribution: the LSAs of Nice and Bordeaux for participating in the evaluation (Nice: Mrs Daeden, Dr Azuelos-Flamm, Dr Bertolissio, Dr Pittaluga, Mr Deverre, Mrs Adam, Mrs Vial and Mr Salvadori; Bordeaux: Mr Blanc and Mrs Perez); the schools, teachers and their students; and the Association of Science Teachers (APBG; Mr Ulysse, Mr Lacassie, Mrs Ferry and Mrs Faure).

References

1
Goossens
H
Ferech
M
Vander Stichele
R
, et al.  . 
ESAC Project Group
Outpatient antibiotic use in Europe and association with resistance: a cross-national database study
Lancet
 , 
2005
, vol. 
365
 (pg. 
579
-
87
)
2
Harbarth
S
Albrich
W
Brun-Buisson
C
Outpatient antibiotic use and prevalence of antibiotic-resistant pneumococci in France and Germany: a sociocultural perspective
Emerg Infect Dis
 , 
2002
, vol. 
8
 (pg. 
1460
-
7
)
3
Pradier
C
Dunais
B
Touboul
P
, et al.  . 
Campagne “Antibios quand il faut” mise en place dans le département des Alpes-Maritimes
Médecine et Maladies Infectieuses
 , 
2003
, vol. 
33
 (pg. 
9
-
14
)
4
Sabuncu
E
David
J
Guillemot
D
, et al.  . 
Significant reduction of antibiotic use in the community after a nationwide campaign in France 2002–2007
PLoS Med
 , 
2009
, vol. 
6
 pg. 
e1000084
 
5
Goossens
H
Guillemot
D
Ferech
M
, et al.  . 
National campaigns to improve antibiotic use
Eur J Clin Pharmacol
 , 
2006
, vol. 
62
 (pg. 
373
-
9
)
6
Observatoire de la Médecine Générale de la Société Française de Médecine Générale; Most Frequent Diagnoses in General Practice in France
  
http://omg.sfmg.org/ (19 July 2010, date last accessed)
7
Balinska
MA
Hepatitis B vaccination and French society ten years after the suspension of the vaccination campaign: how should we raise infant immunization coverage rates?
J Clin Virol
 , 
2009
, vol. 
46
 (pg. 
202
-
5
)
8
Godeau
E
Arnaud
C
, et al.  . 
La santé des élèves en France de 11 à 15 ans/2006
 
www.inpes.sante.fr (19 July 2010, date last accessed)
9
Lecky
DM
McNulty
CAM
Farrell
D
, et al.  . 
on behalf of the e-Bug working group
An overview of e-Bug: an antibiotic and hygiene educational resource for schools
J Antimicrob Chemother
 , 
2011
, vol. 
66
 
Suppl 5
(pg. 
v3
-
12
)
10
Lecky
DM
McNulty
CAM
Touboul
P
, et al.  . 
Evaluation of e-Bug, an educational pack, teaching about prudent antibiotic use and hygiene, in the Czech Republic, France and England
J Antimicrob Chemother
 , 
2010
, vol. 
65
 (pg. 
2674
-
84
)
11
Dellamonica
P
Touboul
P
Dunais
B
Le projet éducatif scolaire e-Bug
Le quotidien du médecin
 , 
2009
, vol. 
8675
 pg. 
8