Development and pilot evaluation of an educational programme on infection prevention and antibiotics with English and Scottish youth groups, informed by COM-B.

BACKGROUND: The UK 5-year antimicrobial resistance (AMR) National Action Plan highlights the need to prevent community infections through education of children. Activities around infection prevention (IP) and antibiotics were piloted by UK youth groups in 2016-2018, prompting Public Health England (PHE) to develop a standardised programme. The aim of the study was to develop and pilot an educational programme on IP and antibiotics for use by community youth groups in the UK. METHODS: A working group, including youth group volunteers interested in IP and AMR, agreed on the programme content through consensus, informed by the Capability, Opportunity, Motivation, Behaviour model (COM-B). The Antibiotic Guardian Youth Badge (AGYB) included learning through interactive e-Bug activities on IP and prudent antibiotic use, action setting through Antibiotic Guardian pledges and consolidation through poster development. The programme was piloted and evaluated with conveniently recruited youth groups in 2019, including quantitative and qualitative questionnaire feedback from community leaders and children. RESULTS: Fourteen youth group leaders and 232 children from uniformed Girlguiding/Scout groups in England and Scotland participated in the pilot evaluation, as well as two primary schools. Leaders reported alignment to the themes of their youth organisation, but struggled to teach antibiotics and antibiotic resistance. Children reported enjoyment and intentions to improve hygiene behaviour. CONCLUSION: Community youth groups are a suitable setting for IP and antibiotics education. The AGYB was officially launched in March 2020 and promoted for use with home-schooling children and remote youth group meetings to educate about IP during the coronavirus disease 2019 (COVID-19) pandemic.

Alternative approaches to managing respiratory tract infections: a survey of public perceptions.

BACKGROUND: Respiratory tract infections (RTIs) are a common reason for people to consult in primary care, and contribute to antibiotic overuse and antimicrobial resistance (AMR). Alternative approaches to supporting patients with RTIs may help, but it is important to understand public perceptions about these approaches before they are widely implemented. AIM: To describe public perceptions regarding finger-prick testing, back-up antibiotic prescriptions (BUPs), and alternatives to traditional consultations for RTIs, and identify factors associated with favouring these approaches. DESIGN & SETTING: Online national survey (HealthWise Wales) with linked primary care health record data. METHOD: Survey item response distributions were described. Associations between responses about consultation alternatives, BUP, and finger-prick point-of-care testing (POCT), and potential explanatory variables, were explored using logistic regression. RESULTS: A total of 8752 participants completed the survey between 2016 and 2018. The survey found 76.7% (n = 3807/4,966) and 71.2% (n = 3529/4,953) of responders with valid responses were in favour of being able to consult with a pharmacist or nurse in their GP surgery, or with a community pharmacist, respectively. It also showed 92.8% (n = 8034/8659) of responders indicated they would be happy to have a finger-prick test to guide antibiotic prescribing, and 31.8% (n = 2746/8646) indicated they would like to be given a BUP if their clinician thought immediate antibiotics were not required. In addition, 47.4% (n = 2342/4944) and 42.3% (n = 2095/4949) were in favour of having video and email consultations, respectively. Characteristics associated with different response options were identified. CONCLUSION: Consulting with pharmacists, using electronic communication tools, and finger-prick testing are widely acceptable approaches. BUP was described as acceptable less often, and is likely to require greater information and support when used.

"...they should be offering it": a qualitative study to investigate young peoples' attitudes towards chlamydia screening in GP surgeries.

BACKGROUND: Despite the known health and healthcare costs of untreated chlamydia infection and the efforts of the National Chlamydia Screening Programme (NCSP) to control chlamydia through early detection and treatment of asymptomatic infection, the rates of screening are well below the 2010-2011 target rate of 35%. General Practitioner (GP) surgeries are a key venue within the NCSP however; previous studies indicate that GP surgery staff are concerned that they may offend their patients by offering a screen. This study aimed to identify the attitudes to, and preferences for, chlamydia screening in 15-24 year old men and women attending GP surgeries (the target group). METHODS: We undertook 36 interviews in six surgeries of differing screening rates. Our participants were 15-24 year olds attending a consultation with a staff member. Data were analysed thematically. RESULTS: GP surgeries are acceptable to young people as a venue for opportunistic chlamydia screening and furthermore they think it is the duty of GP surgery staff to offer it. They felt strongly that it is important for surgery staff to have a non-judgmental attitude and they did not want to be singled out as 'needing' a chlamydia screen. Furthermore, our sample reported a strong preference for being offered a screen by staff and providing the sample immediately at the surgery rather than taking home a testing kit. The positive attitude and subjective norms demonstrated by interviewees suggest that young peoples' behaviour would be to accept a screen if it was offered to them. CONCLUSION: Young people attending GP surgeries have a positive attitude towards chlamydia screening and given the right environment are likely to take up the offer in this setting. The right environment involves normalising screening by offering a chlamydia screen to all 15-24 year olds at every interaction with staff, offering screening with a non-judgmental attitude and minimising barriers to screening such as embarrassment. The GP surgery is the ideal place to screen young people for chlamydia as it is not a threatening place for them and our study has shown that they think it is the normal place to go to discuss health matters.

Is sharing the TARGET respiratory tract infection leaflet feasible in routine general practice to improve patient education and appropriate antibiotic use? A mixed methods study in England with patients and healthcare professionals.

BACKGROUND: Patient education on treatment choices for common respiratory tract infections (RTIs) is important to encourage appropriate antibiotic use. Evidence shows that use of leaflets about RTIs can help reduce antibiotic prescribing. TARGET leaflets facilitate patient-clinician communication in consultations. AIM: To explore patient, healthcare professional (HCP) and general practice (GP) staff views on the current Treating Your Infection (TYI)-RTI leaflet and proposed new 'antibiotic effect' column aimed at sharing information on the limited effect antibiotics have on the duration of RTIs. METHODS: Service evaluation underpinned by Com-B behavioural framework, using patient and HCP questionnaires, and GP staff interviews/focus groups. RESULTS: Patients completed 83 questionnaires in GP waiting rooms. A lack of patient understanding about usual illness duration influenced their use of antibiotics for some RTIs. Patients provided positive feedback about the leaflet, reporting it increased their capability to self-care, re-consult when necessary and increase understanding of illness duration. Patients indicated they would value information on the difference antibiotics can make to illness duration. In total, 43 HCP questionnaires were completed and 16 GP staff participated in interviews/focus groups. Emerging themes included: barriers and facilitators to leaflet use; modifications; and future dissemination of the leaflet. GP staff stated that the 'antibiotic effect' column should not be included in the leaflet. CONCLUSION: Patient education around usual illness duration, side effects of antibiotics and back-up prescriptions gives patients a greater control of their infection management. As GP staff opposed the extra information about benefits of antibiotics on illness duration, this will not be added.

Optimising management of UTIs in primary care: a qualitative study of patient and GP perspectives to inform the development of an evidence-based, shared decision-making resource.

BACKGROUND: Urinary tract infections (UTIs) are one of the most common bacterial infections managed in general practice. Many women with symptoms of uncomplicated UTI may not benefit meaningfully from antibiotic treatment, but the evidence base is complex and there is no suitable shared decision-making resource to guide antibiotic treatment and symptomatic care for use in general practice consultations. AIM: To develop an evidence-based, shared decision-making intervention leaflet to optimise management of uncomplicated UTI for women aged <65 years in the primary care setting. DESIGN AND SETTING: Qualitative telephone interviews with GPs and patient focus group interviews. METHOD: In-depth interviews were conducted to explore how consultation discussions around diagnosis, antibiotic use, self-care, safety netting, and prevention of UTI could be improved. Interview schedules were based on the Theoretical Domains Framework. RESULTS: Barriers to an effective joint consultation and appropriate prescribing included: lack of GP time, misunderstanding of depth of knowledge and miscommunication between the patient and the GP, nature of the consults (such as telephone consultations), and a history of previous antibiotic therapy. CONCLUSION: Consultation time pressures combined with late symptom presentation are a challenge for even the most experienced of GPs: however, it is clear that enhanced patient-clinician shared decision making is urgently required when it comes to UTIs. This communication should incorporate the provision of self-care, safety netting, and preventive advice to help guide patients when to consult. A shared decision-making information leaflet was iteratively co-produced with patients, clinicians, and researchers at Public Health England using study data.

What Resources do NHS Commissioning Organisations Use to Support Antimicrobial Stewardship in Primary Care in England?

Professional education and public engagement are fundamental components of any antimicrobial stewardship (AMS) strategy. The National Institute for Health and Care Excellence (NICE), Public Health England (PHE), Health Education England (HEE) and other professional organisations, develop and publish resources to support AMS activity in primary care settings. The aim of this study was to explore the adoption and use of education/training and supporting AMS resources within NHS primary care in England. Questionnaires were sent to the medicines management teams of all 209 Clinical Commissioning Groups (CCGs) in England, in 2017. Primary care practitioners in 168/175 (96%) CCGs received AMS education in the last two years. Respondents in 184/186 (99%) CCGs reported actively promoting the TARGET Toolkit to their primary care practitioners; although 137/176 (78%) did not know what percentage of primary care practitioners used the TARGET toolkit. All respondents were aware of Antibiotic Guardian and 132/167 (79%) reported promoting the campaign. Promotion of AMS resources to general practices is currently excellent, but as evaluation of uptake or effect is poor, this should be encouraged by resource providers and through quality improvement programmes. Trainers should be encouraged to promote and highlight the importance of action planning within their AMS training. AMS resources, such as leaflets and education, should be promoted across the whole health economy, including Out of Hours and care homes. Primary care practitioners should continue to be encouraged to display a signed Antibiotic Guardian poster as well as general AMS posters and videos in practice, as patients find them useful and noticeable.

Using debate to educate young people in schools about antibiotic use and resistance: A before and after evaluation using a questionnaire survey.

INTRODUCTION: The use of debating as an educational tool is increasing in popularity. Students who take part in debates can develop a range of skills such as confidence and communication as well as gaining a greater understanding of the topic discussed. Within this study we have evaluated an antibiotic-resistant debate kit, assessing the ability of the debate lesson to improve student knowledge and awareness around antibiotics. METHODS: The debate lesson was delivered in seven schools across South West England to 235 students aged 13-16 years. Change in student knowledge was measured using before and after knowledge questionnaires. Student and teacher feedback and suggestions for improvements for the lesson were also collected through questionnaires and interviews. RESULTS: Quantitative questionnaires found a significant improvement in knowledge for most areas covered in the debate, particularly around the use of antibiotics to treat colds and bacteria developing resistance. Teachers felt their students engaged well with the debate session and made suggestions for minor modifications that could improve the lesson. CONCLUSIONS: The results suggest that the e-Bug antibiotic resistant debate kit is able to improve knowledge in young people around antibiotics and antibiotic resistance. Furthermore, the lesson was enjoyed by students and therefore this resource should be promoted more widely to teachers and schools.

Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines.

OBJECTIVE: To evaluate the duration of prescriptions for antibiotic treatment for common infections in English primary care and to compare this with guideline recommendations. DESIGN: Cross sectional study. SETTING: General practices contributing to The Health Improvement Network database, 2013-15. PARTICIPANTS: 931 015 consultations that resulted in an antibiotic prescription for one of several indications: acute sinusitis, acute sore throat, acute cough and bronchitis, pneumonia, acute exacerbation of chronic obstructive pulmonary disease (COPD), acute otitis media, acute cystitis, acute prostatitis, pyelonephritis, cellulitis, impetigo, scarlet fever, and gastroenteritis. MAIN OUTCOME MEASURES: The main outcomes were the percentage of antibiotic prescriptions with a duration exceeding the guideline recommendation and the total number of days beyond the recommended duration for each indication. RESULTS: The most common reasons for antibiotics being prescribed were acute cough and bronchitis (386 972, 41.6% of the included consultations), acute sore throat (239 231, 25.7%), acute otitis media (83 054, 8.9%), and acute sinusitis (76 683, 8.2%). Antibiotic treatments for upper respiratory tract indications and acute cough and bronchitis accounted for more than two thirds of the total prescriptions considered, and 80% or more of these treatment courses exceeded guideline recommendations. Notable exceptions were acute sinusitis, where only 9.6% (95% confidence interval 9.4% to 9.9%) of prescriptions exceeded seven days and acute sore throat where only 2.1% (2.0% to 2.1%) exceeded 10 days (recent guidance recommends five days). More than half of the antibiotic prescriptions were for longer than guidelines recommend for acute cystitis among females (54.6%, 54.1% to 55.0%). The percentage of antibiotic prescriptions exceeding the recommended duration was lower for most non-respiratory infections. For the 931 015 included consultations resulting in antibiotic prescriptions, about 1.3 million days were beyond the durations recommended by guidelines. CONCLUSION: For most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. Substantial reductions in antibiotic exposure can be accomplished by aligning antibiotic prescription durations with guidelines.

Improving the appropriateness of laboratory submissions for urinalysis from general practice.

BACKGROUND: Urine is the most common microbiology laboratory specimen. Submissions increase annually by 5-10%, and many specimens may be unnecessary. OBJECTIVES: To assess the impact of guidance, implemented by interactive workshops and reinforced with modified request forms, on specimen submission. METHODS: This was a prospective randomized controlled study with modified Zelen design. The study population comprised five primary care trusts (PCTs) in Gloucestershire/County Durham/Darlington, containing 82 general practices in six geographical clusters. The six clusters were randomly assigned to urine workshop covering submission in the elderly, adults and children or a control workshop. Within these groups, half the practices were randomized to receive modified laboratory forms emphasizing the workshop messages. Practices were not aware of the study. RESULTS: Workshops lead to a 12% reduction in urine submissions from 16- to 64-year olds, which persisted for the 15 months but had no effect on bacteriuria rate. Workshops had no significant effect in the elderly or children. Modified forms were not associated with any reduction in submissions but were associated with an 11% reduction in detection of significant bacteriuria in 16- to 64-year olds. CONCLUSIONS: The 12% decrease in urine submissions from 16- to 64-year olds, attained with workshops, may help counter relentlessly rising test submissions. Modified forms are currently not worth pursuing. When educational workshops are used across PCTs to change practice, the change in test submission is smaller than attained in educational initiatives involving volunteers. Workshops may be more effective if they also discuss urine submissions from asymptomatic patients and are directed at high testing practices and care homes.

Interactive workshops increase chlamydia testing in primary care--a controlled study.

BACKGROUND: Primary care clinicians suggest that staff education is needed to increase chlamydia testing appropriately. OBJECTIVES: To determine if interactive workshops and modified laboratory request forms could increase testing and case detection. STUDY DESIGN: Prospective cluster randomized controlled study, using modified Zelen's design, examining the effect of workshops and modified request forms on primary care clinicians' chlamydia specimen submission and case positivity rate. STUDY POPULATION: 82 general practices in six geographical clusters within five primary care trusts (PCTs) in Gloucestershire and County Durham and Darlington. INTERVENTION: Practices within geographical clusters were randomly assigned to workshops on chlamydia or a control consisting of comparable workshops on the management of urinary symptoms, held in PCT-protected learning time. Half the practices were randomized to receive modified laboratory request forms. Staff were unaware that they were part of a study. RESULTS: Interactive workshops increased chlamydia testing in 16- to 24-year-old women by 33% in intervention practices compared to controls with effect persisting at 10 months (P = 0.003). No associated rise in the number of chlamydia infections was detected (P = 0.91), suggesting that increased testing may have occurred in a lower risk population. Modified forms did not change test submission (P = 0.75). CONCLUSIONS: Interactive workshops for general practices can be used to successfully increase chlamydia-testing rates. Chlamydia detection rates will need to be monitored as this type of educational programme may not increase absolute numbers of chlamydia infections detected, if patients at lower risk of infection are inappropriately tested. Other interventions may need to be combined with the workshops, to reach sufficiently high chlamydia screening rates to significantly reduce prevalence of chlamydial infection.

Qualitative impact assessment of an educational workshop on primary care practitioner attitudes to NICE HIV testing guidelines.

BACKGROUND: In 2013, Public Health England piloted the '3Cs (chlamydia, contraception, condoms) and HIV (human immunodeficiency virus)' educational intervention in 460 GP surgeries. The educational HIV workshop aimed to improve the ability and confidence of staff to offer HIV testing in line with national guidelines. AIM: To qualitatively assess the impact of an educational workshop on GP staff's attitudes to NICE HIV testing guidelines. DESIGN & SETTING: Qualitative interviews with GP staff across England before and after an educational HIV workshop. METHOD: Thirty-two GP staff (15 before and 17 after educational HIV workshop) participated in interviews exploring their views and current practice of HIV testing. Interview transcripts were thematically analysed and examined, using the components of the theory of planned behaviour (TPB) and normalisation process theory (NPT) as a framework. RESULTS: GPs reported that the educational HIV workshop resulted in increased knowledge of, and confidence to offer, HIV tests based on indicator conditions. However, overall participants felt they needed additional HIV training around clinical care pathways for offering tests, giving positive HIV results, and current treatments and outcomes. Participants did not see a place for point-of-care testing in general practice. CONCLUSION: Implementation of national HIV guidelines will require multiple educational sessions, especially to implement testing guidelines for indicator conditions in areas of low HIV prevalence. Additional role-play or discussions around scripts suggesting how to offer an HIV test may improve participants' confidence and facilitate increased testing. Healthcare assistants (HCAs) may need specific training to ensure that they are skilled in offering HIV testing within new patient checks.

Attitudes and behaviours of adolescents towards antibiotics and self-care for respiratory tract infections: a qualitative study.

BACKGROUND: To understand attitudes and behaviours of adolescents towards antibiotics, antimicrobial resistance and respiratory tract infections. DESIGN: Qualitative approach informed by the Theory of Planned Behaviour. Semi-structured interviews and focus groups were undertaken. We aimed to inform the development of an intervention in an international setting to improve antibiotic use among adolescents; therefore on completion of thematic analysis, findings were triangulated with qualitative data from similar studies in France, Saudi Arabia and Cyprus to elucidate differences in the behaviour change model and adaptation to diverse contexts. SETTING: 7 educational establishments from the south of England. PARTICIPANTS: 53 adolescents (16-18 years) participated in seven focus groups and 21 participated in interviews. RESULTS: Most participants had taken antibiotics and likened them to other common medications such as painkillers; they reported that their peers treat antibiotics like a 'cure-all' and that they themselves were not interested in antibiotics as a discussion topic. They demonstrated low knowledge of the difference between viral and bacterial infections.Participants self-cared for colds and flu but believed antibiotics are required to treat other RTIs such as tonsillitis, which they perceived as more 'serious'. Past history of taking antibiotics for RTIs instilled the belief that antibiotics were required for future RTIs. Those who characterised themselves as 'non-science students' were less informed about antibiotics and AMR. Most participants felt that AMR was irrelevant to them and their peers. Some 'non-science' students thought resistance was a property of the body, rather than bacteria. CONCLUSION: Addressing adolescents' misperceptions about antibiotics and the treatment of RTIs using a behaviour change intervention should help improve antibiotic awareness and may break the cycle of patient demand for antibiotics to treat RTIs amongst this group. Schools should consider educating all students in further education about antibiotic usage and AMR, not only those taking science.

Monitoring Web Site Usage of e-Bug: A Hygiene and Antibiotic Awareness Resource for Children.

BACKGROUND: e-Bug is an educational resource which teaches children and young people about microbes, hygiene, infection, and prudent antibiotic use. The e-Bug resources are available in over 22 different languages and they are used widely across the globe. The resources can be accessed from the e-Bug website. OBJECTIVE: The objective of this study was to analyze the usage of the e-Bug website in order to understand how users access the website, where and when they access the site, and to review variation in use across the different areas of the site. METHODS: The usage statistics for the e-Bug website were monitored by Google Analytics between September 2010 and August 2013. RESULTS: The statistics show the website had over 324,000 visits during the three years, from just under 250,000 visitors, with the number of visitors increasing year after year. Visitors accessed the website from 211 different countries, with more than 267,000 documents downloaded. The majority of visitors were from the United Kingdom and visited the English website, although countries such as France and Portugal were also frequent visitors. CONCLUSIONS: These website statistics confirm that e-Bug is frequently used across Europe and highlight that e-Bug use has expanded across the world. The findings from this report will be used to inform future modifications or updates to the materials, as well as the development of new educational resources.

Management of suspected infectious diarrhoea by English GPs: are they right?

BACKGROUND: The criteria used when GPs submit stool specimens for microbiological investigation are unknown. AIM: To determine what criteria GPs use to send stool specimens, and if they are consistent with national guidance, and whether GPs would prescribe an antibiotic before they receive a result. DESIGN AND SETTING: Questionnaire survey of 974 GPs in 172 surgeries in England. METHOD: GPs were sent a questionnaire (23 questions) based on national guidance. RESULTS: Questionnaires were returned by 90% (154/172) of surgeries and 49% (477/968) of GPs. GPs reported sending stool specimens in about 50% of cases of suspected infectious diarrhoea, most commonly because of individual symptoms, rather than public health implications. Fewer considered sampling with antibiotic-associated diarrhoea post hospitalisation, or children with acute, painful, bloody diarrhoea; only 14% mentioned outbreaks as a reason. Nearly one-half of GPs reported they would consider antibiotics in suspected cases of Escherichia coli O157, which is contraindicated. Only 23% of GPs would send the recommended three specimens for ova, cysts, and parasites (OCP) examination. Although 89% of GPs gave some verbal advice on how to collect stool specimens, only 2% of GPs gave patients any written instructions. CONCLUSION: GPs need more education to address gaps in knowledge about the risks and diagnosis of different infections in suspected infectious diarrhoea, especially Clostridium difficile post-antibiotics, E. coli O157, and requesting OCPs. Advice on reports, tick boxes, or links to guidance on electronic request forms may facilitate this.