The English antibiotic awareness campaigns: did they change the public s knowledge of and attitudes to antibiotic use?

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1 J Antimicrob Chemother 2010; 65: doi: /jac/dkq126 Advance Access publication 20 May 2010 The English antibiotic awareness campaigns: did they change the public s knowledge of and attitudes to antibiotic use? Cliodna A. M. McNulty 1 *, Tom Nichols 2, Paul J. Boyle 3, Mark Woodhead 4 and Peter Davey 5 1 Health Protection Agency Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK; 2 Health Protection Agency Centre for Infections, Statistics Unit, 61 Colindale Avenue, London NW9 5EQ, UK; 3 School of Geography & Geosciences, University of St Andrews, North Street, St Andrews KY16 9AL, UK; 4 Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; 5 University of Dundee, Health Informatics Centre, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK *Corresponding author. Tel: ; Fax: ; cliodna.mcnulty@hpa.org.uk Received 17 February 2010; returned 1 March 2010; revised 22 March 2010; accepted 24 March 2010 Objectives: To determine the effect of the English public antibiotic campaigns. Methods: English and Scottish (acting as controls) adults aged 15 years were questioned face to face about their attitudes to and use of antibiotics, in January (1888) before and in January (1830) after the antibiotic campaigns. Results: Among English respondents, there was a small increase in recollection of campaign posters ( 23.7% versus 19.2%; P¼0.03), but this increase was only 2.3% higher in England than in Scotland. We did not detect any improvement in either England or Scotland, or any differences between England and Scotland in the understanding of the lack of benefit of antibiotics for coughs and colds, and we found no improvement in antibiotic use. We detected a significant increase in respondents retaining leftover antibiotics. Over 20% reported discussing antibiotics with their general practitioner (GP) or nurse in the year to January. The offer of a delayed antibiotic prescription was reported significantly more often by English respondents (19% versus 8% Scottish in ; P¼0.01), and English respondents were advised to use other remedies for coughs and colds significantly more often in the year to January (12.7% in versus 7.4% in ; P,0.001). Conclusions: There is little evidence that the public antibiotic campaigns were effective. The use and visibility of future campaign materials needs auditing. A carefully planned approach that targets the public in GP waiting rooms and through clinicians in consultations may be a more effective way of improving prudent antibiotic use. Keywords: resistance, questionnaire, education Introduction In the European Health Council stressed that antimicrobial resistance is still a growing health problem which increases morbidity and mortality and leads to a diminution in the quality of life, as well as additional health and medicinal costs. 1 Resistance is an increasing therapeutic problem in the community. In this setting, primary care clinicians and the public play a pivotal role in the control of resistance through prudent antimicrobial use. 2,3 Recent European surveys have shown that there is still public misunderstanding about the activity of antibiotics against microbes and their prudent use. 4,5 Thus, the WHO has stressed the importance of both professional and public involvement in the control of antibiotic resistance 6 and this has been echoed by the Chief Medical Officer in England in. 7 England, in common with other European countries, 8 has undertaken campaigns to encourage the public to ask for fewer antibiotics. In February the campaign featured three posters displayed in magazines and newspapers (Figure 1). The key message was: The best way to treat most colds, coughs or sore throats is plenty of fluids and rest. For advice talk to your pharmacist or doctor. 9 A copy of the posters and some copies of an A5 patient advice leaflet (to be given to patients instead of antibiotic prescriptions) were sent, by post, to English (not Scottish) general practice surgeries and independent pharmacies. An accompanying letter from the Inspector of # The Author Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please journals.permissions@oxfordjournals.org 1526

2 Did the English antibiotic campaign work? JAC Poster 1 Poster 2 Poster 3 Figure 1. Posters and leaflet used in the February campaign. Microbiology and the Chief Pharmaceutical Officer indicated that extra copies could be ordered free of charge via phone, fax or from the order line web site. A copy of this letter was also sent electronically to acute hospital trusts and health promotion units. In November the European Union (EU) launched the first annual European Antibiotic Awareness Day (EAAD), and England and Scotland participated. 10,11 In England, the Department of Health repeated the February campaign in exactly the same way in November, but added the EAAD logo to the materials. In July the National Institute for Health and Clinical Excellence (NICE) published guidance on the primary care management of common, acute, self-limiting, respiratory tract infections (RTIs). 12 NICE recommended that general practitioners (GPs) should agree a no antibiotic prescribing strategy or a Leaflet delayed antibiotic prescribing strategy for patients with RTIs, and that they should give advice about the usual natural history of the illness, the lack of value of antibiotics and their side effects, and how to manage symptoms with other medications. 12 A systematic review of interventions in primary care found these patient-based interventions to be the most consistently effective strategy to reduce antibiotic use. 13 The aim of our study was to use a large before and after household survey to determine the effect of the public antibiotic campaigns on the public s knowledge, attitudes and behaviour with respect to antibiotic use. The survey was conducted in both England and Scotland (where there was minimal exposure to the campaigns) to assess any differences in knowledge, attitudes and behaviour in these patient groups. As the NICE guidance was published between the dates of the 1527

3 McNulty et al. two surveys, we also aimed to determine how often offers to the public of a delayed antibiotic prescribing option and offers of alternative remedies instead of antibiotics were being used in general practice. Methods Study population In the last week of January (just before the first English antibiotic campaign) a sample of 1888 adults (aged 15 years) was selected in England (1706) and Scotland (182) using a combination of random location sampling and non-random quota sampling. A second sample of 1830 adults was selected in January (after both of the English campaigns), again in both England (1707) and Scotland (123). The interviews were conducted by Ipsos MORI, which is a market research company, as part of their weekly Capibus survey. Full details of the sampling are provided in the Supplementary data [available at JAC Online ( 14 Sample size The samples in both surveys were relatively large and of similar size. Our power calculation suggested that, with 1600 respondents in and, we would have an 83% probability of detecting at the 5% significance level a decrease from 38% to 33% in the percentage not giving the correct answer when asked about antibiotic activity against coughs and colds. Ethics This study formed part of an ongoing Omnibus survey and ethical approval is not required. Respondents were able to refuse to participate when the interviewer visited the household or were able to refuse to answer any part of the questionnaire. Respondents were not offered any incentives. Questioning of respondents All interviews were face to face and computer assisted. Our 26 questions were added to the weekly survey, which lasted a total of min and included a wide range of attitudinal, demographic and socioeconomic topics. The antibiotic questions are listed in the Supplementary data [available at JAC Online ( Respondents were told that the questions were about medicines prescribed for treating infections; antifungals, prescribed for conditions such as athlete s foot, thrush or ringworm, were not included. The respondents were asked about their antibiotic use in the last year and if they agreed or disagreed with a series of cards with statements about antibiotics that were either true or false. Respondents could respond Don t know/no opinion, but this was not shown. Respondents were asked if they remembered seeing or hearing anything about antibiotics in the last year and, if yes, where. They were then shown the English antibiotic campaign materials; the leaflet was only shown in ; they were asked if they had seen the materials before and what they felt the main messages were. Finally, to determine whether respondents could have been exposed to the campaigns, they were asked if they had personally visited a general practice or pharmacy in the past year and whether they regularly read the newspapers or magazines in which the campaign adverts were placed. Data analysis We used sampling weights provided by Ipsos MORI and based on the National Readership Survey to correct for known selection biases. Weights were defined by sex, household tenure and white ethnicity and, within sex, by age, social grade, region and working status. Subsequent to data processing carried out by Ipsos MORI, all further data management and analyses were performed by the HPA using the Stata statistical software package version 8.2. We determined the percentage of respondents with incorrect responses to each antibiotic statement. There were no respondents who did not answer this section. However, those who responded don t know were coded as incorrect. Testing for differences in the percentages between surveys was a variation on the usual Pearson x 2 test, corrected to allow for the sampling weights and the clustering of the sample within primary sampling units. 15,16 We used the modified sandwich estimator of variance and a significance test as suggested by Rao and Thomas. 16 For comparison of the overall awareness of the campaign posters in England versus Scotland we calculated the difference in absolute change from baseline, as recommended by the Cochrane Effective Practice and Organisation of Care Group. 17 Results The survey was completed by 1706 English and 182 Scottish adults in January and by 1707 English and 123 Scottish adults in January. Exposure to the campaigns and the public s knowledge, attitudes and behaviour with respect to antibiotic use in England before and after the campaigns In England 83% of respondents could have been exposed to the materials through visiting their GP surgeries (70%), pharmacies (44%) or reading relevant magazines/newspapers (35%) [see the Supplementary data, available at JAC Online ( oxfordjournals.org/)]. There was a significant increase in the percentage that recalled any of the three campaign posters from 19.2% in (when they could not have previously seen the posters) to 23.7% in after the campaigns (P¼0.03). There was greatest recollection of the hand poster (featuring a handful of antibiotic capsules with the slogan Unfortunately, no amount of antibiotics will get rid of your cold ) from 11.6% in January to 15.5% in January after the campaigns; P¼0.01. Only 5.2% of English respondents in January recalled seeing the general practice patient leaflet. There was no significant change between the two surveys in English respondents agreement with 9 of the 10 attitude statements, including the statement Antibiotics work on most coughs and colds, which was the main attitude the public campaigns aimed to change (Table 1). Respondents in were significantly more likely not to agree with the statement Resistance to antibiotics is a problem in British hospitals (37% versus 30%; P¼0.03). Reported antibiotic use did not improve. A similar percentage of English respondents reported being prescribed an antibiotic in the year to January as in the year to January (34% and 35%) or reported asking their GP for an antibiotic in the year to January as in the year to January (28% and 29%). Moreover, there was a significant increase in the percentage of English respondents retaining some leftover antibiotic from their last course, from 2.2% in the 12 months to January to 7.0% in the 12 months to January (P 0.001). 1528

4 Did the English antibiotic campaign work? JAC Table 1. Reported knowledge and attitudes of respondents to antibiotics and their use Statements about antibiotics and resistance Correct response (1706) % Respondents incorrect/don t know England Scotland Scotland versus England (1707) P (182) (123) P P Antibiotics work on most coughs and colds disagree Antibiotics can kill bacteria agree Antibiotics can kill viruses disagree A course of antibiotics should be stopped when a person disagree feels better If taken too often antibiotics are less likely to work in the agree future It is OK to keep leftover antibiotics and use them later disagree without advice from a doctor, nurse or pharmacist Antibiotics can kill the bacteria that normally live on the agree skin and in the gut Bacteria that normally live on the skin and in the gut are agree good for your health Resistance to antibiotics is a problem in British hospitals agree Antibiotic-resistant bacteria could infect me or my family agree Table 2. Reported antibiotic use by respondents and behaviour of GPs Reported antibiotic use by respondents and prescribing behaviour of GPs in the past year England, % of respondents (1706) (1707) P (182) Scotland, % of respondents Scotland versus England (123) P P Prescribed an antibiotic Kept any leftover antibiotic , Taken antibiotics without being told to do so Asked GP or nurse for antibiotics in the past year If respondent asked, prescribed antibiotic after some discussion If respondent asked, prescribed antibiotic without discussion If respondent asked, GP/nurse refused to prescribe antibiotic Offered an antibiotic prescription to be cashed in at the pharmacy ONLY if you felt no better, or felt worse, after several days Offered the opportunity to return to surgery to pick up an antibiotic prescription ONLY if you felt no better, or felt worse, after several days Offered any type of delayed antibiotic prescription Advised about other remedies for cough and cold symptoms instead of being given an antibiotic prescription , Comparison of knowledge, attitudes and behaviour in Scotland, where there was minimal exposure to the campaigns, with England Only 33% of Scottish respondents could have been exposed through reading the relevant magazines/newspapers. The proportion of Scottish and English respondents reporting having seen one of the three campaign posters in before the campaigns (Scotland 17.5% versus England 19.2%; P¼0.71) and in after the campaigns (Scotland 19.7% versus England 23.7%; P¼0.4) was similar. Because there was a small increase in both England and Scotland, the absolute change from baseline as a result of the campaigns was only 2.3%. Knowledge, attitudes and behaviour in Scotland and England were similar in (Tables 1 and 2), except that 1529

5 McNulty et al. Scottish respondents in were less likely to agree with the statement It is OK to keep leftover antibiotics and use them later without advice than English respondents (Scotland 4% versus England 14%; P¼0.01). Scottish respondents were more likely to report keeping leftover antibiotics in the year to January than in (4% in versus 0% in ; P¼0.04), a change that was matched by their English counterparts. However, overall, Scottish respondents were significantly less likely than English respondents to have taken an antibiotic without being told to do so by a doctor or nurse in the year to January (Scotland 3% versus England 7.8%; P¼0.04). Reported offers of a delayed antibiotic prescribing option or discussion about antibiotics There was a significant increase in English and a non-significant increase in Scottish respondents who said that they had heard or seen anything about antibiotics in their GP surgery (Table 3, England 22.0% versus 15.3%, P¼0.006; Scotland 19% versus 11%, P¼0.21). In, 29% of English and 34% of Scottish respondents Table 3. Respondent recollection of information about antibiotics and campaign materials reported asking their GP or nurse for antibiotics in the past year. Most were prescribed antibiotics after some discussion (73% of English and 80% Scottish respondents who asked for antibiotics; P ¼0.49). Only 5% of English respondents and 8% of Scottish respondents reported that their request was refused (P ¼0.66). In comparison with Scottish respondents, a higher proportion of English respondents reported receiving a delayed prescription in the year to January (19% versus 8%; P ¼0.01). The option to cash in the prescription after several days was used almost twice as often as the option to return to the surgery to pick up the prescription if they felt no better after several days (13% versus 7% England and 5% versus 3% Scotland). The use of delayed prescriptions increased a little in England between and (16% versus 19%; P ¼0.25), but not in Scotland (12% versus 8% ; P ¼0.4). English respondents were more likely to report being advised about other remedies for coughs and cold symptoms instead of being given an antibiotic prescription in the year to January than the year to January (13% versus 7%; P, 0.001); there was no change between and in Scotland (7% versus 8%; P¼0.73) (Table 2). England, % of respondents (1706) (1707) P Scotland versus England (123) P P Scotland, % of respondents Remembered hearing or seeing anything about antibiotics in last year on television or radio in magazine or newspaper in general practice poster in general practice leaflet in general practice general practice other source Of respondents who had visited a surgery in the past year recalled any poster about antibiotics in the last year recalled any leaflet about antibiotics in the last year recalled any other material about antibiotics in the last year Of respondents who had visited a pharmacy in past year recalled any poster about antibiotics in the last year recalled any leaflet about antibiotics in the last year recalled any other material about antibiotics in last year (182) Recollection of campaign materials in the last year antibiotic sweets in the hand poster raining antibiotics under the weather poster antibiotic football goalkeeper no defence against a cold poster recalled one of the three posters recalled poster message Don t take antibiotics for coughs/colds/ sore throat recalled message Don t take antibiotics as often, or without advice patient leaflet Get well soon without antibiotics

6 Did the English antibiotic campaign work? JAC Discussion Main findings There was a small but significant increase in recollection of the antibiotic campaign posters in England, but the increase in England was only 2.3% greater than the increase in Scotland. The hand poster was recalled most often. We could not detect any positive effect of the campaigns. We did not detect any improvement in either England or Scotland, or any differences between England and Scotland in the public understanding of the lack of benefit of antibiotics for coughs and colds. We did not detect any improvement in the reported use of antibiotics in either England or Scotland. Moreover, we did detect an increase in retention of leftover antibiotics in the year to January compared with in both England and Scotland, and English respondents were significantly more likely to disagree with the statement Resistance to antibiotics is a problem in British hospitals in than there were in. Patient-based interventions are being used in general practice, as.20% of all respondents reported discussing antibiotics with their GP or nurse in the year to January. The offer of a delayed antibiotic prescription was reported significantly more often by English than by Scottish respondents in (19% versus 8%; P¼0.01), and English respondents were significantly more likely to be advised to use other remedies for coughs and colds in the year to January compared with the year to January (13% versus 7%; P, 0.001). Strengths and weaknesses This study questioned a large sample of English and Scottish respondents at the same time of year before and after the Public Antibiotic Campaigns, as recommended in the previous 2003 Omnibus antibiotic survey. 4 The large English sample size was based on the ability to detect a decrease from 38% to 33% in the percentage not giving the correct answer to the statement about antibiotic activity against coughs and colds, the basis of the antibiotic campaigns. The inclusion of Scottish respondents provided a control group, although this was not a perfect control as 33% of Scottish respondents could have been exposed to the campaigns through the newspapers and magazines. Our study has several weaknesses. Although we know that the Department of Health commissioned a third party to distribute the campaign materials to all general practices and pharmacies in England in February and November, we do not know what percentage used or displayed the materials. Thus, we cannot determine from our survey whether the lack of recollection and success was due to poor materials or because they were not used by the practices or pharmacies. Another confounding issue may be exposure of the public to local antibiotic campaigns, which are run by many NHS Boards in Scotland and Primary Care Trusts (PCTs) in England. Local campaigns in Scotland may have reduced the differences between Scottish and English respondents; however, there is no evidence of a change in Scottish respondents reported use of antibiotics. Local campaigns in England may have improved the results but again there is no evidence that this is so. Our survey relies on reported behaviour and this may be open to acquiescence bias (a tendency to agree with statements when in doubt), although as we asked the same questions in and this bias should be similar in the two years. Capibus interviewers fail to recruit from one in four households they visit. This may lead to some recruitment bias, if those who were out when the interviewer called or who refused to participate had different opinions or different antibiotic use to those who did participate. However, this bias should be similar in both years and is to some extent limited by the setting of target quotas for interviewers, the spreading out of visits over the week and the setting of weights in the analysis. Since we have made many comparisons in our analysis there is an increased risk that one or more of the significant findings is due to chance alone. This should also be borne in mind when interpreting the significant findings relating to retaining leftover antibiotics, delayed antibiotic prescribing and advising patients about alternative remedies for coughs and colds. Whatever slight evidence there is of a campaign effect on the public s understanding and use of antibiotics is even less impressive when considering the number of analyses used to detect a possible improvement. Other work in this area Antibiotic campaigns, like the English one, that have not used television tend to have much less or no impact on public attitudes or knowledge. 18,19 In contrast, other antibiotic campaigns in Belgium, England and France that included high impact communication with television and have been repeated consistently for several years have led to improved antibiotic use and changes in professional and public attitudes The French campaign included radio and television advertising and was conducted annually from 2002 to A time series analysis showed a progressive reduction in antibiotic use following each campaign; the cumulative effect was a 27% reduction in antibiotic use by The local Moxy Malone campaign in North-East England in 2004 and 2005 was associated with a 5.8% absolute reduction in antibiotic prescribing compared with controls. 23 This Moxy Malone campaign was run for 2 years with accompanying local radio and television and some professional education and prescribing support. 23 The successful campaigns in Belgium were also linked with education targeted at primary care doctors. 21 Over 90% of our respondents who asked their GP for an antibiotic were prescribed one. This is similar to recent American and Belgian general practice studies. 24,25 However, 80% of respondents reported discussing the antibiotic prescription with their GP, so there is an opportunity for GPs to discuss with patients the need for an antibiotic prescription. The evidence for effectiveness of interventions aimed at improving communication between GPs and patients in the consultation for reducing antibiotic use in primary care was already strong in A recent Dutch study shows that GPs trained in enhanced communication skills for the management of acute lower RTI prescribed antibiotics half as often as clinicians with no such training. 26 Improving communication with patients and improving their understanding has also been the focus of another GP-based study in which clinicians were trained to use an interactive booklet on RTIs with parents or carers of children attending with RTI. Providing this evidence-based information and tool, which helped to set realistic expectations, aided communication and reduced antibiotic prescribing by about two-thirds. 27 Such 1531

7 McNulty et al. communication-based education focuses on the non-medical parameters that influence clinicians decisions to prescribe antibiotics, and emphasizes eliciting and responding to patients feelings, ideas, fears and expectations to increase patients understanding of antibiotic prescribing decisions. 27 Although 20% of respondents did report being offered a delayed prescription there may be an opportunity to increase this in line with the NICE guideline recommendation, 12 especially in Scotland where this was reported significantly less often. Implications Our evidence suggests that a carefully planned approach that targets both the public and clinicians will be a more effective way of improving prudent antibiotic use across the UK. As the recollection of the campaign materials was small and there was no improvement in antibiotic use or attitudes, the Department of Health should reconsider the key messages in the campaign posters and leaflets and undertake process evaluation of future campaigns, auditing how many and where surgeries and pharmacies display posters and use the leaflets, and what patients recall about the materials after a visit to their practice or pharmacy where they are displayed. Future public antibiotic campaigns should include higher profile radio or television spots similar to the Sexual Health Campaign launched in. 28 As the general public are already discussing antibiotics with their general practices, this route of public education about antibiotics should be promoted strongly in parallel by the Department of Health. Clinicians will need support to develop their communication skills with patients; this could be attained if the relevant professional bodies produce appropriate educational modules. The European Centre for Disease Prevention and Control has produced evidencebased materials aimed at improving primary care clinicians understanding of the risks of antibiotic resistance in the primary care setting, how they are related to antibiotic use and how they can help to improve their use of antibiotics. 29 The materials include an algorithm to help improve clinicians communication with patients presenting with RTI and how they can address patients expectations for antibiotics. Acknowledgements We wish to thank: the staff at Ipsos MORI who were involved in the household survey, in particular Paul Liles; Jill Whiting for administration; and Sally Wellsteed, Esmita Charani and COMMS at the Department of Health, who were involved with the Public Education Campaigns. Funding This study was supported by the Department of Health and the HPA. Transparency declarations C. A. M. M. has the following non-financial interests that may be relevant to the submitted work: membership of the Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare-Associated Infections and the Prescribing and Public Education Sub-Groups of this Committee; and member of the NICE self-limiting respiratory tract infection guideline development group. M. W. is a paid member of a data monitoring committee for a study on pneumococcal vaccine sponsored by Wyeth. P. D. s institution has unrestricted research grants (not product related) from Janssen-Cilag and Pfizer. P. D. has the following non-financial interests that may be relevant to the submitted work: member of the Scottish Antimicrobial Prescribing Group, supported by the Scottish Government as a programme of the Scottish Medicines Consortium under NHS Quality Improvement Scotland. All other authors: none to declare. Author contributions C. A. M. M. had the idea to undertake the study. All authors were involved in questionnaire development and study design. T. N. undertook the statistical analysis and all authors discussed the results and had full access to all of the data (including the statistical report and tables). C. A. M. M. wrote the paper and all authors commented on and approved the manuscript. All authors take responsibility for the integrity of the data and accuracy of the data analysis. Supplementary data Supplementary data are available at JAC Online ( org/). References 1 Council of the European Union. Conclusions on Antimicrobial Resistance (AMR).. Data/docs/pressdata/en/lsa/ pdf (16 April 2010, date last accessed). 2 Davey PG, Pagliari C, Hayes A. The patient s role in the spread and control of bacterial resistance to antibiotics. Clin Microbiol Infect 2002; 8: Del Mar C. Prescribing antibiotics in primary care. BMJ 2007; 335: McNulty CAM, Boyle P, Nichols T et al. The public s attitudes to and compliance with antibiotics. J Antimicrob Chemother 2007; 60 Suppl 1: i Grigoryan L, Burgerhof JG, Degener JE et al. on behalf of the SAR Consortium. Attitudes, beliefs and knowledge concerning antibiotic use and self-medication: a comparative European study. Pharmacoepidemiol Drug Saf 2007; 16: WHO. World Health Organization Report on Infectious Diseases Overcoming Antimicrobial Resistance. 7 Department of Health. Antimicrobial Resistance: Up Against The Ropes. In: CMOs Annual Report,. London, uk/en/publicationsandstatistics/publications/annualreports/dh_ 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, Lancet Infect Dis 2004; 4: Department of Health. Antibiotic Campaign. gov.uk/en/publichealth/patientsafety/antibioticresistance/dh_ European Centre for Disease Prevention and Control. European Antibiotic Awareness Day 18 November. eaad/pages/home.aspx 11 Department of Health. European Antibiotic Awareness Day. dh.gov.uk/en/publichealth/patientsafety/antibioticresistance/dh_

8 Did the English antibiotic campaign work? JAC 12 Centre for Clinical Practice at National Institute for Health and Clinical Excellence. Prescribing of Antibiotics for Self-Limiting Respiratory Tract Infections in Adults and Children in Primary Care. NICE Clinical Guideline 69, Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev ; issue 4: CD Ipsos MORI. Face-to-Face Omnibus (Capibus). omnibusservices/capibus.aspx 15 Rogers WH. Regression standard errors in clustered samples. Stata Technical Bulletin 1993; 13: Reprinted in Stata Technical Bulletin Reprints 1994; 3: Rao JNK, Thomas DR. Chi-squared tests for contingency tables. In: Skinner CJ, Holt D, Smith TMF, eds. Analysis of Complex Surveys. New York: John Wiley & Sons, 1994; Cochrane Effective Practice and Organisation of Care Group. EPOC Resources for Review Authors: Presentation of Data from RCT and CBA Study Designs. (17 March 2010, date last accessed). 18 Curry M, Sung I, Arroll B et al. Public views and use of antibiotics for the common cold before and after an education campaign in New Zealand. N Z Med J 2006; 119: Wutzke SE, Artist MA, Kehoe LA et al. Evaluation of a national programme to reduce inappropriate use of antibiotics for upper respiratory tract infections: effects on consumer awareness, beliefs, attitudes and behaviour in Australia. Health Promot Int 2006; 22: Sabuncu E, David J, Bernede-Bauduin C et al. Significant reduction of antibiotic use in the community after a nationwide campaign in France, PLoS Med ; 6: e Bauraind I, Lopez-Lozano J-M, Beyaert A et al. Association between antibiotic sales and public campaigns for their appropriate use. JAMA 2004; 292: Goossens H, Guillemot D, Ferech M et al. National campaigns to improve antibiotic use. Eur J Clin Pharmacol 2006; 62: Lambert MF, Masters GA, Brent SL. Can mass media campaigns change antimicrobial prescribing? A regional evaluation study. J Antimicrob Chemother 2007; 59: Boyd SD, Edgar T, Foster S. Patient behaviours and beliefs regarding antibiotic use: implications for clinical practice. In: Paper presented at the Annual Conference of the American College of Preventive Medicine, Austin, TX, USA,. 25 Coenen S, Michiels B, Renard D et al. Antibiotic prescribing for acute cough: the effect of perceived patient demand. Br J Gen Pract 2006; 56: Cals JW, Butler CC, Hopstaken RM et al. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ ; 338: b Francis NA, Butler CC, Hood K et al. Effect of using an interactive booklet about childhood respiratory infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ ; 339: b Department of Health. Sexual Health Campaign. Sex, Worth Talking About. aspx 29 European Centre for Disease Prevention and Control. European Antibiotic Awareness Day: Toolkit of Briefing Materials Aimed at Primary Care Prescribers. CarePrescribers.aspx 1533

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