Impact of the ´Alforja Educativa' on Ecuadorian schoolchildren's knowledge of bacteria, antibiotics, and antibiotic resistance, a pretest-posttest study.

BACKGROUND: Widespread use of antibiotics disrupts the balance in the microbial world and promotes development and spread of antibiotic resistant bacteria. Educational initiatives are important as part of strategies to mitigate antibiotic resistance. The Alforja Educativa is an innovative educational program developed in Ecuador with the aim to teach schoolchildren about antibiotic use and antibiotic resistance. The program places antibiotic resistance within a broader frame of health, well-being, and ecological awareness, highlighting the importance to maintain balance in the microbial world. The objective of this study was to evaluate the effect of the Alforja Educativa on knowledge about bacteria, antibiotics and antibiotic resistance amongst fifth and sixth grade Ecuadorian schoolchildren. METHODS: This pretest-posttest intervention study was conducted between April and June 2017 and comprised fifth and sixth grade schoolchildren from 20 schools in Cuenca, Ecuador, recruited by purposeful sampling. The Alforja Educativa was implemented over twelve 80-minute sessions by trained university students. Schoolchildren's knowledge was assessed before and after participation in the educational program using a structured questionnaire. A mean total score, the proportion of correct responses for each individual knowledge-based question, as well as correct responses for each of the multiple-choice options of the knowledge-based questions were calculated for the pretest and posttest. RESULTS: A total of 1,257 schoolchildren participated in the Alforja Educativa program, of which 980 (78%) completed both the pretest and posttest. Overall, the mean total knowledge score increased from pretest to posttest (2.58/7.00 vs. 3.85/7.00; CI = 0.5, p < 0.001). After participation in the program, the proportion of schoolchildren that correctly identified that bacteria can be both good and bad increased from 35.0 to 84.3%. In addition, scores increased for correctly identifying the meaning of antibiotic resistance (37.4-72.0%); how to prevent antibiotic resistance (63.2-74.6%); and for identifying the meaning of self-medication (46.3-54.3%). CONCLUSION: The Alforja Educativa was effective in improving the knowledge of participating schoolchildren about concepts related to bacteria, antibiotics and antibiotic resistance. The holistic perspective taken to explain the complex relationship between humans and bacteria, as well as the effect of antibiotics on the microbial world, may help provide a foundation for more sustainable antibiotic use.

Antibiotic Use before, during, and after Seeking Care for Acute Febrile Illness at a Hospital Outpatient Department: A Cross-Sectional Study from Rural India.

Antibiotic resistance is a naturally occurring phenomenon, but the misuse and overuse of antibiotics is accelerating the process. This study aimed to quantify and compare antibiotic use before, during, and after seeking outpatient care for acute febrile illness in Ujjain, India. Data were collected through interviews with patients/patient attendants. The prevalence and choice of antibiotics is described by the WHO AWaRe categories and Anatomical Therapeutic Chemical classes, comparing between age groups. Units of measurement include courses, encounters, and Defined Daily Doses (DDDs). The antibiotic prescription during the outpatient visit was also described in relation to the patients' presumptive diagnosis. Of 1000 included patients, 31.1% (n = 311) received one antibiotic course, 8.1% (n = 81) two, 1.3% (n = 13) three, 0.4% (n = 4) four, 0.1% (n = 1) five, and the remaining 59.0% (n = 590) received no antibiotics. The leading contributors to the total antibiotic volume in the DDDs were macrolides (30.3%), combinations of penicillins, including ß-lactamase inhibitors (18.8%), tetracyclines (14.8%), fluoroquinolones (14.6%), and third-generation cephalosporins (13.7%). 'Watch' antibiotics accounted for 72.3%, 52.7%, and 64.0% of encounters before, during, and after the outpatient visit, respectively. Acute viral illness accounted for almost half of the total DDDs at the outpatient visit (642.1/1425.3, 45.1%), for which the macrolide antibiotic azithromycin was the most frequently prescribed antibiotic (261.3/642.1, 40.7%).

Utilisation of diagnostics in India: a rapid ethnographic study exploring context and behaviour.

OBJECTIVES: To explore factors that influence behaviour in the utilisation of diagnostics by caregivers of sick children. Utilisation is defined as a caregiver assisting a child to get diagnostic tests done and return for follow-up of results. Understanding these experiences may help inform the development of interventions and implementation strategies to improve the use of diagnostics, thereby target treatment and optimise antibiotic use. DESIGN: A rapid ethnographic qualitative study using 3 months of unstructured observations, 1 month of structured observations of diagnostic utilisation and 43 semi-structured interviews. Transcripts were coded and analysed using inductive thematic analysis. Findings were explored from a behavioural perspective through the lens of the 'Capability, Opportunity, Motivation and Behaviour' (COM-B) model for understanding behaviour. The multiple methods of investigation applied allowed for triangulation and cross-validation of the findings. SETTING: The paediatric outpatient department of a teaching hospital in rural, central India. PARTICIPANTS: Caregivers of sick children attending the paediatric outpatient department who were sent for one or more diagnostic test. RESULTS: Three key themes were identified that influenced caregivers' behaviour. Caregivers trusted and understood the importance of diagnostics but their acceptance wavered depending on the severity of illness and preference to treat their child directly with medicines. Caregivers struggled to access diagnostics, describing delays in testing, receiving results and follow-up, further complicated by travel time, distance and competing priorities such as work. Diagnostics were relatively cheap compared with other healthcare facilities however, the cost of the test, travel expenses and wages lost for missing work, were barriers to getting the tests done and returning for follow-up. CONCLUSIONS: Diagnostics are generally accepted and their purpose understood, however, the organisation of diagnostic services, direct and indirect costs hinder caregivers from using diagnostics. Improvements in accessibility and affordability may increase caregiver motivation to use diagnostics and return for follow-up.