WHO Collaborating Centre on Patient Safety The University of Geneva Hospitals and Faculty of Medicine 4, Rue Gabrielle Perret-Gentil 1211 Geneva, Switzerland Evaluation of antibiotic awareness campaigns Report prepared by Mirko Saam, Benedikt Huttner and Stephan Harbarth1 for World Health Organization Expert Committee on the Selection and Use of Essential Medicines Policy, Access and Use (PAU) Department of Essential Medicines and Health Products 20, Avenue Appia 1211 Geneva 27, Switzerland 1 [email protected]; [email protected]; [email protected] 1 SUMMARY 1 INTRODUCTION 2 KEY FINDINGS OF THE SURVEY 3 OUTLINE OF SURVEYED CAMPAIGNS 3 TARGET AUDIENCES 5 INFECTIONS TARGETED 7 KEY MESSAGES AND ESSENTIAL PUBLIC SLOGANS 8 GLOBAL VERSUS LOCAL KEY MESSAGES 11 “NEW” KEY MESSAGES IDENTIFIED 12 INTERVENTIONS USED IN THE CAMPAIGNS 13 EVALUATION OF THE CAMPAIGNS 14 OBSTACLES FACED WHILE IMPLEMENTING A PUBLIC AWARENESS CAMPAIGN 15 POTENTIAL FOR EXPANSION IN NEW DIRECTIONS 15 ACKNOWLEDGMENTS 17 APPENDIX I - METHODOLOGY I APPENDIX II - SUMMARY TABLE I APPENDIX III - QUESTIONNAIRE USED FOR THE SURVEY I REFERENCES 18 2 SUMMARY ● Between September and November 2016, we conducted an online survey to review the characteristics of public awareness campaigns targeting antibiotic use conducted since 2010. We identified 60 campaigns implemented on a national (n=42, 70%), regional (14, 23%) or both levels simultaneously (2, 2%), across 16 low- and middle- income countries (LMICs), and 31 high-income countries. Respondents from another 8 countries (5 LMICs and 3 high-income countries) either stated they were not sure, or that there was no such campaign in their country. Among the 93 countries that were contacted, 38 (40%) did not respond at all. ● All but 12 (20%) campaigns targeted the general public and physicians simultaneously, with wide variations among the specifically targeted groups in the population (e.g. parents of young children, caregivers, etc.) and among the healthcare professionals (e.g. GPs, paediatricians, etc.). ● There were no major differences between middle-income and high-income countries in the type of key messages used in the campaigns. "Misuse/overuse of antibiotics causes resistance” (n=47, 78%) and "If we use antibiotics incorrectly we will lose them / they will become ineffective" (43, 72%) were the most commonly used key messages, followed by "Hand washing can reduce the spread of infection / Wash your hands", "Judicious / prudent / responsible / appropriate / adequate use of antibiotics is important" and "Antibiotics do not work against colds / flu" (used in 41 (68%) campaigns each). ● In the context of this survey we tried to identify and categorize messages which could be used by future campaigns. In general, it seems essential to base the campaigns messages more rigorously on scientific evidence and behavioral change concepts, while considering the particular context of each country. New key messages identified through this survey reveal, to a certain extent, the increasing prominence of the One Health approach in antibiotic awareness campaigns. ● The distribution or dissemination of education and communication material (either offline (87% of the campaigns) or online (77%)) was the intervention most frequently implemented. Other types of interventions included public relation activities, press conferences, training sessions for prescribers, and active promotion or distribution of guidelines. ● According to this survey, respondents reported that both human and financial constraints have posed significant barriers to implementing campaigns or to achieving a clinical or public health impact. Lack of political support, and an enduring 1 gap between common practices and suggested actions, are potential major obstacles to translating campaigns into concrete results. ● Evaluation of the impact of antibiotic awareness campaigns is still suboptimal, with 36 of 60 campaigns (60%) reporting no formal evaluation. Most of the campaigns that were formally evaluated (n=24, 40%) relied on the monitoring of antibiotic use to assess their impact (17, 28%), and/or surveillance of antibiotic resistance rates (13, 22%). The most effective messages and interventions remain unclear. The lack of thorough evaluation, the absence of prospectively determined control groups and the multifaceted nature of most campaigns makes any formal conclusions difficult. It seems, however, that some campaigns were associated with a reduction in overall antibiotic use. ● More research is required to better understand which key messages and which types of interventions work best in different setting. Nevertheless, based on the results of this survey, recommendations can already be made to enhance the deployment of communication activities related to antibiotics. INTRODUCTION Tackling the global spread of antibiotic resistance is a high priority for the World Health Organization (WHO). On the one hand, as part of the implementation of Objective 1 of the Global Action Plan on Antimicrobial Resistance, WHO is coordinating a global campaign to raise awareness and encourage best practices among the public, policymakers, as well as health and agriculture professionals.1 On the other hand, the list of “Critically Important Antimicrobials” has been established as a reference to help formulate and prioritise strategies for containing antibacterial resistance, and is intended for public health and animal health authorities, practicing physicians and veterinarians, and policymakers. The appropriate application of the “Critically Important Antimicrobials List” supports the implementation of the Global Action Plan’s Strategic Objective 1 -- to improve awareness and understanding of antimicrobial resistance -- as the list is an important component to assure the responsible use of antibiotics and for controlling the potential spread of resistant microbes through the food chain. There is good evidence that public campaigns promoting responsible antibiotic use may be associated with reductions in overall antibiotic use. The individual impact of various public campaigns in Europe between 1997 and 2007 has been estimated to be equivalent to a 6.5– 28.3% drop in the mean level of overall antibiotic use.2 Factors leading to successful awareness campaigns include carefully designed and simple key messages; targeting a wide audience such as patients, their families and healthcare workers; engaging physicians and other healthcare professionals early in the campaign and designing the key messages with them; using mass media and social media; and continuously repeating key messages.3 4 The latter is of outmost importance, as experiences in Belgium and France have shown. In 2 these two countries national campaigns have reduced overall antibiotic consumption, but it has been difficult to sustain successes over time. Experience from other public health campaigns shows that repeated exposure of the targeted public over long periods of time is often necessary to exert a sustained effect.5 6 In its “Worldwide country situation analysis: response to antimicrobial resistance” report published in 2015, WHO stated that there are large variations across regions in the percentages of Member States that have conducted campaigns to educate the public about the appropriate use of antibiotics (e.g. 2% of countries in the WHO African Region vs. 42% in the WHO European Region). A multi-country public awareness survey on antibiotic resistance performed by WHO in 2015 highlighted that levels of knowledge around the appropriate use of antibiotics — including how and when to use antibiotics and what they should be used for — are mixed, but rather low in all regions. This is an alarming situation, particularly in countries where antimicrobial medicines are readily available over the counter without a prescription. In this context, WHO has mandated a team of researchers at the WHO collaborating center at the Geneva University Hospitals (Mirko Saam, Benedikt Huttner and Stephan Harbarth) to conduct an international survey of antibiotic awareness campaigns in order to fill some of the knowledge gaps and help the planning of future initiatives. The survey captured information on the design of campaigns in different contexts; this report compiles the data in an effort to facilitate information sharing and learning across countries. KEY FINDINGS OF THE SURVEY Outline of surveyed campaigns2 In mid-October 2016, invitations to participate in the survey were sent by email to a total of 93 countries, through WHO Regional offices and National Focal Points, and to persons in charge of antibiotic awareness campaigns; the countries to be contacted were identified through a preliminary review of the scientific literature and previously established contacts of the survey team. Consolidated answers represent a total of 60 campaigns, implemented in 16 low- and middle-income countries, and 31 high-income countries (12 countries reported more than one campaign); 47 countries contacted (51%) provided positive answers, 8 (9%) stated there was no campaign implemented in their country and 38 (40%) did not provide any answer, despite several reminders. 2 The methodology is detailed in APPENDIX I and a summary table highlighting the main characteristics of the campaigns is provided in APPENDIX II. 3 Map of countries included in the survey. Blue: antibiotic campaign conducted since 2010 (LMICs = light blue / high-income countries = dark blue). Red: answered “no campaign” OR “not sure” to have had a campaign