Abstract

High rates of antimicrobial prescribing for children, combined with widespread misunderstanding among the general public about the appropriate use of antibiotics, are major causes for concern. European Antibiotic Awareness Day (EAAD) is an annual event that aims to raise awareness of how to use antibiotics in a responsible way that will help keep them effective for the future. As part of EAAD 2013, this article provides an overview of some initiatives aimed at limiting the extent of inappropriate antibiotic use in children.

Introduction

There are few public health issues of potentially greater importance for society than antibiotic resistance. Professor Dame Sally Davies.1

European Antibiotic Awareness Day (EAAD), initiated by the European Centre for Disease Prevention and Control in 2008, is a Europe-wide annual event that aims to raise awareness of how to use antibiotics responsibly.2 On 18 November each year, Europe-wide activities are undertaken to publicize the risks associated with the inappropriate use of antibiotics and to advise the public that taking antibiotics for the wrong reasons is of no benefit and may cause more harm than good.3–5

There is general public misunderstanding on how to use antibiotics properly.6 Antibiotics are the most widely prescribed therapeutic agents, with rates of prescribing for children being particularly high.7,8 Within schools, respiratory and gastrointestinal infections are a major cause of childhood illness, with poor respiratory and hand hygiene contributing to increased spread. Throughout the 2011/12 academic year in England, ‘illness (not medical or dental appointments)’ accounted for the majority of student absenteeism.9 Secondary cases following spread to parents and school staff are common.10,11 This article provides an overview of some of the excellent antibiotic awareness initiatives aimed at children.12

School educational initiatives

School affords children the opportunity to learn about health, medicines and the underpinning science if teachers contribute to children's knowledge, beliefs and expectations about antibiotics in their teaching. School hygiene campaigns have been shown to reduce rates of infection in schoolchildren, staff and their families and this in turn may reduce antibiotic use.13,14

e-Bug school materials

Teachers find the topic of antibiotics and antibiotic resistance difficult to teach.15 The e-Bug teaching materials aim to fill this skill gap by providing free antibiotic and hygiene teaching resources for junior (7–11 years) and senior (12–15 years) schools across Europe. The resources are designed to raise awareness of the benefits of antibiotics and the importance of using them wisely.16

The e-Bug resource has been shown to improve students' knowledge of antibiotics and hygiene.17 Visits to the English language web site increased by 44.5% in the 2012/13 academic year and, since its launch in 2009, the number of other languages in which e-Bug resources are available has increased from 8 to 25, with extension outside the EU into Turkey and Saudi Arabia. Many of these countries utilize the e-Bug resources as part of their EAAD initiatives.

Peer education

Peer education is becoming an increasingly popular and trusted method for health education initiatives,18 in which both the ‘educators’ and the ‘students’ gain from the experience. Students feel that their peers can be a trusted and credible source of information, whilst the peer educator gains in terms of knowledge, skills, attitudes and confidence.19

Public Health England, in collaboration with the Environmental Health Department has piloted one such peer education initiative in Gloucestershire, encompassing the Marmot Review objective of ensuring a healthy standard of living for all and strengthening the role and impact of ill-health prevention.20 Year 8 students were trained to deliver to their peers a science roadshow consisting of five stands, including one on hygiene and prudent antibiotic use. Groups of three to five peer educators were trained on one of the five stands and given a take-home information booklet.

Peer educators expressed concern that antibiotic awareness was a particularly difficult topic, as they had received no previous education on the subject. During the intervention, however, it was evident that they adapted the suggested delivery of the materials to suit their own style and understanding, resulting in a successful, fun stand. One peer educator later said:

I think that it's more of a fun way of learning if you get someone like, from like your age, you can get across learning in your like, your way kind of thing. Student, Year 8.

The pilot was well received not only by the students but also by the school as a whole.

The reciprocal learning, from the team of Year 8 students, was really special. This made the event really stick in everyone's minds. The ‘waves will go out across the pond’, so to speak, about this, and such real life learning will not be forgotten. This was truly life changing. Head teacher.

This initiative is currently being taken forward as a joint research project between Public Health England and the Environmental Health Department, and is partially funded by the BSAC. Following completion of the research phase, the initiative will be rolled out to all national Environmental Health Departments for delivery to schools in September 2014.

Train the trainer

Public Health England is currently producing a series of ‘train the trainer’ materials aimed at informing school nurses and others about how to educate schoolchildren on hygiene, the spread of infection, vaccination uptake and prudent antibiotic use. This project will build on and extend the current e-Bug educational resources, which have been shown to improve student knowledge on key health messages.17 Focus groups of stakeholders will be qualitatively interviewed to identify their needs and the findings will be used to further develop a previously trialled pilot ‘train the trainer’ workshop.21 Participants will be able to access training resources and other tools via dedicated pages on the e-Bug web site.

Clinician resources

A recent review to identify online educational programmes on the optimal use of antibiotics in children demonstrates that there are limited educational resources currently available.22

The Antibiotic Resistance and Prescribing in European Children (ARPEC) project

Despite antibiotic prescribing rates being high in children, there is currently limited information on antimicrobial consumption and antibiotic resistance among children in Europe. Surveillance schemes such as ESAC (European Surveillance of Antimicrobial Consumption), and EARS-Net (European Antimicrobial Resistance Surveillance Network) currently have limited age-specific data. ARPEC,23 an initiative developed by the European Society of Paediatric Infectious Diseases, aims to improve the evidence base for antibiotic prescribing in children and translate this into long-term educational programmes for prescribers and trainee paediatricians.

The ‘When Should I Worry?’ booklet

‘When Should I Worry?’,24 a booklet developed by Cardiff University for use during primary care consultations, provides information for parents about respiratory tract infections in children. Use of the booklet has been shown to result in a two-thirds reduction in antibiotic prescribing without negatively affecting parental satisfaction.25

Discussion

Teaching children about antibiotic resistance should raise their awareness of the importance of prudent antibiotic use. Taking the message home to their parents should in turn raise awareness in the family environment. Children are the largest consumers of antibiotics, but research indicates that their knowledge of antibiotics is poor.17 It is therefore essential that we invest in their education to allow both children and their parents to make informed decisions. Indeed, research indicates that children with knowledge of medicine feel more in control of their own health,26 and that those who are the most knowledgeable about antibiotics behave more responsibly.27 Educating young people about antibiotics will also facilitate behaviour change in the long term through changes in social norms, which are an important determinant of behaviour.28

Parents have an influential voice in the medicines used by their children;29 however, it has been suggested that although the public are aware of the dangers of antibiotic misuse, their behaviour and practice do not always reflect this awareness.30 This may be because parental beliefs, fears and expectations play an important part in consulting behaviour. The 2010 Eurobarometer report27 concluded that messages on antibiotic use obtained from doctors are more effective than those from the media. Resources like the ‘Why should I worry?’ booklet used during consultation may not only help to increase parental knowledge about antibiotic use and resistance but also increase their confidence to self-care for the majority of infections that are self-limiting, without consulting their GP.

Research in the USA has noted that individuals have a higher awareness of prudent antibiotic use when exposed to two or more interventions.31 Whilst mass media campaigns are known to increase awareness and knowledge and reinforce existing attitudes,32 it has been suggested that interpersonal channels work better at changing attitudes and behaviour.33 Indeed, Huttner et al.34 concluded that multifaceted campaigns repeated over several years have the greatest effect. Taking this into consideration, it may be concluded that for campaigns to be truly successful, a focused multichannel approach should be adopted that combines mass media and interpersonal channels, including the education of young people. EAAD helps facilitate this approach whilst ensuring the delivery of consistent and united European key messages on prudent antibiotic use.

Transparency declarations

C.A.M. is a member of the Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections, is a member of the Prescribing Sub-Group, and is Chair of the Public Education Sub-Group. C.A.M. also leads the e-Bug Project. D.L. has previously been the e-Bug Project Manager and currently assists the project in the role of International Liaison Officer.

References

1
Sample
I
Antibiotic-resistant diseases pose ‘apocalyptic’ threat, top expert says. The Guardian. 23 January 2013
 
2
Earnshaw
S
Monnet
DL
Duncan
B
, 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
Euro Surveill
 , 
2009
, vol. 
14
  
pii=19280
3
European Antibiotic Awareness Day website
 
http://ecdc.europa.eu/en/EAAD/Pages/Home.aspx/ (8 August 2013, date last accessed)
4
Council of the European Union
Antimicrobial Resistance: Adoption of Council Conclusion
 , 
2008
 
Document 9637/08: Annex DG1
5
Finch
RG
Metlay
JP
Davey
PG
, et al.  . 
Educational interventions to improve antibiotic use in the community: report from the International Forum on Antibiotic Resistance (IFAR) colloquium, 2002
Lancet Infect Dis
 , 
2004
, vol. 
4
 (pg. 
44
-
53
)
6
McNulty
CAM
Boyle
P
Nichols
T
, et al.  . 
The public's attitudes to and compliance with antibiotics
J Antimicrob Chemother
 , 
2007
, vol. 
60
 
Suppl 1
(pg. 
i63
-
8
)
7
WHO
World Health Organization Report on Infectious Diseases 2000: Overcoming Antimicrobial Resistance
  
http://www.who.int/infectious-disease-report/2000/ (8 August 2013, date last accessed)
8
Spyridis
N
Sharland
M
The European Union Antibiotic Awareness Day: the paediatric perspective
Arch Dis Child
 , 
2008
, vol. 
96
 (pg. 
909
-
10
)
9
Department for Education
Pupil Absence in Schools in England, Including Pupil Characteristics: 2011/12
  
10
Bowers
T
McIver
M
Ill health, retirement and absenteeism amongst teachers
2000
Norwich
HMSO
 
Department for Education and Employment. Research Report 235
11
Heymann
A
Chodick
G
Reichmann
B
, et al.  . 
Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization
Ped Infect Dis J
 , 
2004
, vol. 
23
 (pg. 
675
-
7
)
12
Harris
D
Initiatives to improve appropriate antibiotic prescribing in primary care
J Antimicrob Chemother
 , 
2013
, vol. 
68
 (pg. 
2424
-
7
)
13
Lennell
A
Fredlund
H
Use of hand disinfection reduces absenteeism from day care centers
Euro Surveill
 , 
2008
, vol. 
13
  
pii=19006
14
Sandora
TJ
Shih
MC
Goldmann
DA
Reducing absenteeism from gastrointestinal and respiratory illness in elementary school students: a randomized, controlled trial of an infection-control intervention
Pediatrics
 , 
2008
, vol. 
121
 (pg. 
1555
-
62
)
15
Lecky
DM
McNulty
CAM
Adriaenssens
N
, et al.  . 
Development of an educational resource on microbes, hygiene and prudent antibiotic use for junior and senior school children
J Antimicrob Chemother
 , 
2011
, vol. 
66
 
Suppl 5
(pg. 
v23
-
31
)
16
McNulty
CAM
Lecky
DM
Farrell
D
, et al.  . 
Overview of e-Bug: an antibiotic and hygiene educational resource for schools
J Antimicrob Chemother
 , 
2011
, vol. 
66
 
Suppl 5
(pg. 
v3
-
12
)
17
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
)
18
Sriranganathana
G
Jaworsky
D
Larkin
J
, et al.  . 
Peer sexual health education: interventions for effective programme evaluation
Health Educ J
 , 
2010
, vol. 
71
 (pg. 
62
-
71
)
19
Phelps
FA
Mellanby
AR
Crichton
NJ
, et al.  . 
Sex education: the effect of a peer programme on pupils (aged 13–14 years) and their peer leaders
Health Educ J
 , 
1994
, vol. 
53
 (pg. 
127
-
39
)
20
Marmot
M
Fair Society, Healthy Lives. The Marmot Review
 , 
2010
 
London http://www.ncb.org.uk/media/42195/marmotreview_vssbriefing.pdf (29 August 2013, date last accessed)
21
Lecky
DM
Fettis
D
Pritchard
B
, et al.  . 
e-Bug: working in partnership with our local Environmental Health Department to further our joint public educational reach
2012
Poster presented at the Health Protection Agency Annual Conference
22
Dubos
F
Nicolini
GG
Sharland
M
Qualitative review of web-based professional education on antibiotic prescribing for children: 10 million hits—but only ten good websites
J Ped Infect Dis
 , 
2013
 
in press
23
European Society of Pediatric Infectious Diseases.
 
Antibiotic Resistance and Prescribing in European Children website www.arpecproject.eu (8 August 2013, date last accessed)
24
When Should I Worry? website
 
http://www.whenshouldiworry.com (8 August 2013, date last accessed)
25
Francis
NA
Butler
CC
Hood
K
, et al.  . 
Effect of using an interactive booklet about childhood respiratory tract infections in primary care consul-tations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial
BMJ
 , 
2009
, vol. 
339
 pg. 
b2885
 
26
Bush
PJ
Lannotti
RJ
Jones
CR
Battjes
RJ
The development of children's health orientations and behaviours: lessons for substance use prevention
Etiology of Drug Abuse: Implications for Prevention
  
NIDA Research Monograph 56, 1985; 45–74
27
European Commission
Special Eurobarometer 338: Antimicrobial Resistance
 , 
2010
Brussels, Belgium
European Commission
 
28
Ajzen
I
The theory of planned behaviour
Organ Behav Hum Decis Process
 , 
1991
, vol. 
50
 (pg. 
271
-
87
)
29
Bush
PJ
Hardon
AP
Towards rational medicine use: is there a role for children?
Soc Sci Med
 , 
1990
, vol. 
31
 (pg. 
1043
-
50
)
30
Emslie
MJ
Bond
CM
Public knowledge, attitudes and behaviour regarding antibiotics: a survey of patients in general practice
Eur J Gen Pract
 , 
2003
, vol. 
9
 (pg. 
84
-
90
)
31
Trepka
MJ
Belongia
EA
Chyou
P-H
, et al.  . 
The effect of a community intervention trial on parental knowledge and awareness of antibiotic resistance and appropriate antibiotic use in children
Pediatrics
 , 
2001
, vol. 
107
 pg. 
e6
 
32
Freimuth
V
Linnan
HW
Potter
P
Communicating the threat of emerging infections to the public
Emerg Infect Dis
 , 
2000
, vol. 
6
 (pg. 
337
-
47
)
33
Rogers
EM
Diffusion of Innovations
 , 
1983
3rd edn.
New York
The Free Press
34
Huttner
B
Goossens
H
Verheji
T
, et al.  . 
on behalf of the CHAMP consortium. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high income countries
Lancet Infect Dis
 , 
2010
, vol. 
10
 (pg. 
17
-
31
)