Projects that have focused on educating children and their families to tackle antimicrobial resistance

NHS Orkney

Provide a brief overview of your project?

This County-wide challenge badge was designed to help raise awareness across the spectrum of Girlguiding members from Rainbows (ages 5-7) to the Trefoil Guild (adult members age 18+) of antimicrobial resistance and why it, and infection control, is important in a fun – and challenging – way.

The challenge consisted of five sections: Meet the microbe, Spreading bugs, Antibiotics & Antibiotic Resistance, Become an Antibiotic Guardian and Sepsis. To gain the challenge badge girls needed to have carried out the demonstration in, and completed at least one activity from, each section.

Each section included demonstrations to increase knowledge about the topic and activities for girls to choose from. As far as possible these activities were section (i.e. age) specific to ensure their appropriateness but there were also some activities that were appropriate across all sections. Wherever possible it was tried to explicitly link the activities to the themes of the new guiding programme to encourage uptake within units.  The local antimicrobial pharmacist and one of the infection control nurses (both involved in local guiding) visited units on request to help facilitate and run the challenge with the girls and their leaders.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1. The challenge was undertaken by several guiding units across Orkney and the North of Scotland covering a wide range of ages (5-16 years old) and their leaders (>100 girls).
   2. The challenge received press coverage in weekend edition of the Press and Journal (regional newspaper covering northern and highland Scotland, circulation approx. 48,000) getting the AMR message out to a much wider audience.
   3. Significant interest was shown in the challenge from other NHS Scotland colleagues as many are Scout and Guide leaders themselves.

How is the project to be developed in the future?

A national joint Girlguiding and Scout badge is being developed which will use work done with this badge as part of the development process

South Gloucestershire Council

Provide a brief overview of your project

The aim of the e-Bug project was to promote infection prevention and control (IPC) and antibiotic resistance (ABR) within schools. The project promoted the Public Health England e-Bug training package for teachers and children, at four pilot schools in South Gloucestershire.

The project ran in the academic year 2017- 2018, with four primary schools taking part. Schools received the e-Bug teacher training in the following e-Bug modules:
• Introduction to Microbes
• Hand Hygiene
• Respiratory Hygiene
• Antibiotics Awareness

The pilot schools were given flexibility in how to implement the e-Bug modules and run the project, in order to assess the measurable outcomes they were hoping to achieve, through their Health in Schools silver award.
Schools selected pupils by class/ year group or targeted pupils with high sickness absence rates. Some schools also ran whole school assemblies using the e-Bug materials, for wider awareness raising. One school ran a parent workshop, where pupils demonstrated their learning.

Preliminary findings from the teacher surveys were overall very positive; teacher and students enjoyed and engaged in the e-Bug activities, teachers felt the e-Bug resources were easy to use, , and saw an improvement in students’ appropriate health behaviours i.e. hand washing before lunchtime.

159 pupils completed pre-learning questionnaires across the four pilot schools. One school completed learning for two modules only; Hand Hygiene and Respiratory Hygiene. The other three schools completed all four modules.
Across all modules 95% of pupils improved or maintained their level of knowledge after the e-Bug teaching. The modules where the most significant improved learning took place was:
• Antibiotics Awareness – 77% knowledge increase
• Respiratory Hygiene – 67% knowledge increase

One school successfully measured behaviour change comparing how much hand soap was used in the pupil toilets in the term before the e-Bug intervention, and the term after.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

• Increased student knowledge and understanding of infectious causes of disease (microbiology); principles and practice of infection prevention and control; and the concept and prevention of antimicrobial resistance (AMR) – as per NICE guideline 63: Antimicrobial stewardship: changing risk-related behaviours in the general population• Promoting interactive learning through school will promote cultural and behavioural change needed to address key health protection issues, including the prevention of illness, prevention of infectious disease/ infectious disease spread, and AMR. Antimicrobial stewardship: changing risk-related behaviours in the general population• The project supported the South Gloucestershire Health in Schools work programme, supporting further partnership and collaborative working.
  The project supports the approach to adopt a joint working strategy with colleagues across the local health community and will meet joint objectives and continue to develop and build strong networks. A multi-sectoral approach to tackling AMR is required.

How is the project to be developed in the future?

Following the success of the pilot project, colleagues at South Gloucestershire Council are running another project promoting e-Bug in schools. This project will aim to measure behaviour change through soap use before and after the intervention, across all participating schools. Pupil learning before and after the teaching will also be captured, and data analysed.

The project design will follow a cluster randomised crossover approach, where half of the participating schools receive the e-Bug teacher training and deliver the intervention in schools, to be compared with the remaining schools who are not yet running the intervention.

By the end of the project all participating schools will have received the e-Bug teacher training and delivered the intervention in their schools.

Berkshire Antimicrobial Stewardship Group

Provide a brief overview of your project:

The AMS group agreed on hand hygiene as the key message for a single issue campaign for 2017 WAAD / EAAW. It was agreed that this was a simple message that was relevant to health professionals and the public and was especially relevant to children and families who are often most at risk of GI and other infections.

The campaign had three elements;

1. a) a suite of three letters targeting families, care home workers and residents and health professionals was created. There letters were sent to all primary schools, care homes and cascaded to health professionals through CCG and NHS Trust Comms.
2. b) Slough Borough Council PH Team and the AMS group engaged with a primary school that had experienced a GI outbreak to deliver a hand-washing assembly to the whole school. Children heard about how good hand washing before eating and after going to the toilet removes bugs that can make them sick and can stop them needing medicines. Children also got to see how good they were at washing their hands using a light box. Children from the school starred in a hand-washing video which has now been shared with other primary schools and made available to other partners across Berkshire. The head-teacher was provided with the e-bug KS1 pack.
3. c) NHS organisations championed hand-washing as part of their organisational WAAW activities.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

1. Entire primary school attended the assembly and learned about how washing hands before meals and after the toilet removes the bugs that make you sick and stops you needing medicine.
2. Head-teacher received the e-bug lesson plans
3. A letter was sent to all primary schools highlighting how hand hygiene is an important tool in reducing infections and preserving antibiotics.

How is the project to be developed in the future?:

• The video made by the children has been shared with other schools across Berkshire.
• The AMS Group will invite local stakeholders who are interested in becoming e-bug leads to take part in a train the trainer session.
• The AMS Group have developed an assembly pack for primary schools using the e-bug resources and aim to work with stakeholders who have received e-bug training to offer the assembly in local primary schools.

Buckinghamshire Healthcare NHS Trust

Provide a brief overview of your project:

We emailed all the primary and secondary schools in Buckinghamshire and invited students to design a poster to “Keep Antibiotics Working”. We sign-posted the Junior and Family Antibiotic Guardian, eBug and the National media AMR campaign resources. All entries were displayed throughout public areas of the hospital during World Antibiotic Awareness Week and some have continued to be displayed. One winner from each of the categories  (Early Years; Infant; Junior; Senior) was awarded a Giant Microbe and some chocolates during a prize giving ceremony at the hospital. Each winner was invited to attend together with parents and teachers.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

We received over 300 posters much to our surprise although only about 8 schools entered. We also received personal messages from teachers informing us that they had linked this competition into teaching sessions for example around Louis Pasteur.  One school arranged an outside speaker to talk about the importance of infection prevention. Two pharmacists from the hospital attended the nursery on site to perform some “hand washing experiments” using glitter and pepper in water and taught the children the hand washing song.

How is the project to be developed in the future?:

We would like to do something similar next year in response to the positive feedback received and are thinking about a “Build a Bug” project where by students can create a bug model which demonstrates some mechanisms of resistance, e.g. efflux pump.

Centre of Excellence for Public Health Northern Ireland

Provide a brief overview of your project:

Engaging school children with antibiotic awareness: This was a collaboration initiated by the Public Health Agency (http://www.publichealth.hscni.net/) with the Centre of Excellence for Public Health Northern Ireland (https://www.qub.ac.uk/research-centres/CentreofExcellenceforPublicHealthNorthernIreland/) to pilot the implementation of the E-bug (http://www.e-bug.eu/) resources in Northern Ireland Schools. The aim of the project was to educate children on anti-microbial resistance and appropriate antibiotic use and therefore influence parental behaviour and knowledge in this regard.

To achieve this we introduced the children to the concept of microbes and developed the idea of good and bad microbes to help the children to differentiate between the various types of viral, bacterial and fungal infections and to dispel some common myths surrounding antibiotic use. We then built on this new acquired knowledge by introducing the concept of antimicrobial resistance and the actions the children (and their parents) could take to reduce the burden of this issue.

We chose to first pilot the E-bug activities in a Northern Ireland primary school (Templepatrick Primary School). We undertook two visits (2 x 1 hour sessions), two weeks apart to two primary 6 (Key-stage 2) classes (n=60 children). In the first visit we followed the e-bug activities 1.1 Introduction to microorganisms and 1.3 harmful microbes. In the return visit we consolidated this prior learning with activity 4.1 (treatment of infections: Antibiotic use and medicine) including an introduction to antimicrobial resistance.

Given the very positive feedback of this material from the Primary 6 teachers and pupils we also sought to pilot the programme in one of the province’s special schools (Longstone Special School), for children and young adults with moderate learning difficulties. A school leaver’s class was selected and we modified the delivery for this setting with less didactic teaching and a primary focus on hands on activities to augment new learning.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

Bacteria are becoming resistant to the antibiotics that are currently available – meaning that the few antibiotics that we have developed in our arsenal may be ineffective for the same infection in that individual in the future. The issue with antibiotic resistance has arisen primarily due to the overuse and misuse of antibiotics.

Example 1: Good Hand hygiene.  We used a UV light and ‘Glo germ’ kit and ‘snot gun’ activity to visually demonstrate the spread of microbes (and potentially resistant bacteria) to other people. We emphasised the ‘six step approach’ to handwashing and the importance of washing your hands before, during and after food preparation/eating, after using the bathroom, after being near animals or animal waste, after coughing, sneezing or blowing your nose, and when you are unwell or around other people who are sick.

Example 2: Antibiotic use and resistance. Following the guidelines of the e-bugs materials (section 4.1) we talked the children through various scenarios, allowing them to decide on the causal agent (i.e.: virus/bacteria/fungus) and hence the appropriate form of treatment for the specific infection. We highlighted the potential for antimicrobial resistance to arise if antibiotics were misused i.e.: by not finishing the prescribed course (leaving residual bacteria to develop resistance to the antibiotic), and taking antibiotics inappropriately i.e.: for a viral infection, or sharing antibiotics with family members/friends. In an interactive activity balloons were used to demonstrate the principle of antibiotic resistance (duct tape applied to balloon) and antibiotic treatment (pin used to burst balloon/bacterial cell wall).

Example 3: Superbugs – Longitude Prize Game. Using iPads, this addictive and competitive game, was used to highlight the problem of antimicrobial resistance and the importance of keeping our current supply of antibiotics working for as long as possible. The children/team with the highest longevity scores (antibiotic champions) were acknowledged in the class.

How is the project to be developed in the future?:

The Public Health Agency have been working from an early stage in this project with the Council for the Curriculum, Examinations and Assessment (CCEA) to map the e-bugs resources onto the Northern Ireland curriculum. The long-term aim of this project is to have the usual teachers in the primary/secondary school settings deliver the e-bugs resources themselves, as has already been successfully attained in other parts of the UK.

To build the capacity to achieve this aim, the Public Health Agency have arranged for members of the original e-bugs team to come to Northern Ireland for a few days in June 2018 to facilitate two workshops (‘teach the teacher’ events) one in Cookstown and one in Belfast. These will provide Northern Ireland teachers with an introduction and overview of the e-bugs resources and a run through of the various interactive activities involved.

Plans are also in place to formally evaluate the e-bugs resources in various school settings and key-stage levels, engaging researchers from the School of Social Sciences, Education and Social Work and the Centre for Public Health in Queen’s in conjunction with the Public Health Agency Northern Ireland.

Leicestershire Scouts

Provide a brief overview of your project:

Two antimicrobial pharmacists (Ryan Hamilton and Emma Cramp), a local Scout leader and community pharmacist (Louise Bailey), and the deputy commissioner for Leicestershire Scouts (Lyn Rowe) produced an interactive “programme on a plate” that has been distributed to Scout leaders across Leicestershire. The programme is delivered through fun, interactive, activities so children learn through play, rather than traditional teaching methods. Participants learn about hygiene, preventing the transmission of infection, the appropriate use of antibiotics, and how to protect antibiotics for the future.

The programme includes the following activities and learning, inspired by materials from e-Bug alongside original activities:

1. A game to demonstrate the spread of germs and disease.
2. Seeing how far and fast a sneeze can travel including the importance of sneezing into a tissue and washing hands afterwards.
3. Using UV disclosing gel to learn how to wash hands properly (singing happy birthday twice and using the 5 moments of hand washing).
4. Finally, for the Cubs and Scouts, using colour changing science to show antibiotics only work for bacterial infections and not for viral infections.

The final activity of the session involves watching the keep antibiotics working advert and asking the children to write a unique pledge about how they will keep antibiotics working, based on what they have learned during the session. The children are also asked to produce a Keep Antibiotics Working poster at home then bring it back to be awarded the Antibiotic Guardian badge.

The first sessions saw over 60 children being awarded the Antibiotic Guardian Badge. A train-the-trainer session was held in February, showing scout leaders the session and activities in action so they can deliver the session with their own groups. The programme has already been delivered to another 75 children, with over 200 more planned to participate.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

1. Children learned about how far and fast sneezes travel, and how this can spread germs and illness. They were taught about Catch it, Bin it, Kill it and this was linked to handwashing. UV disclosing gel was used to demonstrate how standard hand washing did not remove all dirt and germs and how the correct method (following RPS, WHO and NHS guidance) was better. The children discussed when they should wash their hands, and how this can prevent them from getting ill and therefore needing antibiotics in the first place.

2. Appropriate use of antibiotics was taught using a pH indicator and giving each child a common viral or bacterial illness (colour change observed). They were all given antibiotics and those with bacterial infections were cured (as shown be reversal of the colour change). A viral illness was given lots of antibiotics but was still not cured (no further colour change). Children then discussed that overuse of antibiotics when they are not needed can mean the germs become immune/resistant to the antibiotics. Towards the end this activity the children discuss and learn not to go to the GP demanding antibiotics for sneezes and colds, go to the community pharmacist first, and follow the advice from their GP if they do get given antibiotics. They also learned not to keep extra doses, or use other people’s medicines.

3. At the end of the session the whole scout group discusses what they have learned, with the leaders highlighting how all the above can prevent the need for infections, ensure they are used correctly, and protect them for the future. The risk of antibiotic resistance to health and healthcare is discussed in more detail in the Scout groups (due to age).

How is the project to be developed in the future?:

The following work streams are underway to progress this initiative:

• The programme on a plate information pack has been used by a number of Beaver, Cub, and Scout groups across Leicestershire. Feedback is being used to ensure the programme materials are useful for everyone, even those with little baseline understanding of infections and antibiotics.
• Another train the trainer session is planned for late June so Scouting groups can plan the session for the autumn and winter, lining up with the 2018 Antibiotic Awareness Week.
• Guiding leaders will be invited to the June train the trainer session so the programme can be trialled in regional Brownies and Guide groups to prove that this programme is universal and can be used across a number of youth organisations.
• There is an appetite from a number of Scouting groups from across the UK wishing to run the programme in their regions. The refined programme on a plate should allow for this to happen.
• There has also been interest from local primary schools and Ryan is currently working with a primary school to see how this programme could work in that setting.
• We are liaising with stakeholders including West Lancashire Scouts and e-Bug to widen the reach of the programme and aim for national delivery and recognition of the programme. The aim is to have this become a formal UK Scouting activity badge as it has links through to a number of other activity badges.

Newent Community School and Sixth Form

Name: Di Harrill

Provide a brief overview of your project? Newent Community School worked with E Bug and the Forest of Dean District council to run a peer education programme. The five workshops – Microbe Mania – Sneeze Machine – How clean in your Kitchen – Anti-biotic Awareness and hand Washing were demonstrated to all the year 8 students. The workshops were practical and fun. 20 year 8 students were selected to be peer educators.
These students were each given a T shirt and then had the opportunity to practice their workshop with the support from E Bug and environmental health team.
Second day- year 8 Peer educators taught the year 7’s, they moved around each workshop learning about all the different elements. After the year 7 sessions, the year 8 peer educators did the workshops with the local primary school.  This is the fourth year we have run this 2 day event.

List any supporting partners or organisations worked with: E Bug
Forrest of Dean District council – environmental health team
Newent Students also helped to trial the new E Bug website and evaluate it

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category?: Several hundred students have now gone through this E Bug peer education programme. The workshops are interactive and fun, and the peer educators do an amazing job of passing on the information to the students. Students are encouraged to share the information with their families.
The messages are reinforced when primary school students attend Newent, they can be peer educators.
The local paper had an article and there are photographs of the event in our school prospectus and on our website.
The message is further followed up in PSHE and science.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?: Microbe Mania – this workshop was very practical, the students talked about the different types and looked at images of them. They also talked about how they can be treated and transmitted. Students then made a microbe out of modelling clay and took it home in a petri dish
Understanding Antibiotics – this involved the use of balloons – again a practical demonstration that help the students understand the difference s between bacteria and a virus. The visual nature of the demonstrated helped them to retain the knowledge. They also learnt about antibiotics – why we shouldn’t over use them, and why if we prescribed them we should make sure we take the full dose.
Hand Washing – this again was a visual and practical activity – which showed them under ultraviolet light – the importance of thorough hand washing and the use of soap to kill bacteria. They also learnt about when it is important to wash your hands.

Key outcomes of project?: Several hundred students have learnt, in a visual, practical fun way many of the issues around antibiotics and health. The peer educators also had the added impact of practicing presentations skills – speaking to an audience – things that helped them to develop confidence. We also found that the students appeared to be more attentive when being taught by a peer.
What and why illnesses become resistant to antibiotics.
They learnt about thorough hand washing – catching a sneeze – and food hygiene.

How is the project to be developed in the future?: This project has now been run for four years. It is a two day event – which has a big impact on the whole school. The main hall is left set up for students to walk around and read the large poster.

It also means that students get the opportunity to revisit the learning points – year 5, 6, 7 and 8.

NHS Greater Glasgow and Clyde

Name: Kate Stock

Provide a brief overview of your project? Our project was focused on European Antibiotic Awareness day 2016, with the aim of promoting infection control and antibiotic awareness with children and their family members. We had a brightly coloured ‘pop up’ stall in the atrium of the Royal Hospital for Children in Glasgow and this featured a variety of promotional material and information on how to become an antibiotic guardian.

Our main focus was on the children themselves and we consulted with a primary school teacher on how best to create a display that was both inviting for children and interactive, to create learning through fun. We also accessed e-bug junior to help us design our activities.

As EAAD was at the start of the winter season we decided to teach children about the importance of infection control with coughs and sneezes. We created our own ‘snot gun’ which the children could spray against an easel to demonstrate how far harmful microbes travel, we told them that other people can breathe in these microbes causing them to get ill, so it is important that they should cover their mouths. We also had a hand washing glow box so we could ask them to wash their hands after ‘sneezing’ to see if they had washed all of the germs away and we were then able to teach them how to wash their hands properly and explain the importance of good hand hygiene. Parents and carers were also encouraged to use the hand washing glow box. To emphasise hand hygiene we had a set of huge hulk hands holding a cuddly e.coli, the children were able to try these on and see that ‘dirty hands carry bugs’. Whilst the children were undertaking the activities, we were also able to engage with their parents to enforce the message that antibiotics do not work against viruses and the importance of prudent use of antibiotics.
Both children and parents were encouraged to become antibiotic guardians and signposted to the e-bug website to try other fun activities. Young children were given the EAAD colouring picture and pencils to take away and we gave older children and adults antibiotic guardian leaflets and promotional pens with which to complete them.

Please list any supporting partners or organisations worked with: Greater Glasgow and Clyde Infection Control Team
Greater Glasgow and Clyde Hand Hygiene Co-ordinator
Scottish Antimicrobial Prescribing Group Public Partners
Greater Glasgow and Clyde Infectious Disease and Microbiology Teams

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? Specific outcomes from EAAD promotion were not measured, however the main focus from the day was to raise awareness of antimicrobial stewardship within families as the children we are treating now are the ones that will face the adverse outcomes of antibiotic resistance as adults. As the stand was in the main atrium of the children’s hospital it also attracted attention from hospital staff, which we were able to use to raise the profile of the Antimicrobial Management Team.

Following this, we were able to establish invaluable links with clinicians and engage with them further to develop strategies to improve antibiotic prescribing and management of patients with infections. In particular:
– An invitation to present to a non-medical prescriber study day about antimicrobial   stewardship.
– Engagement with Emergency Department staff to look at front line empiric prescribing.
– Establishing a carbapenem drug use evaluation project in paediatric intensive care.
– Interest for further EAAD activities within the childrens hospital.

Together with positive feedback from parents, children and healthcare staff on the day, this achieved our objective for the day with respect to promoting antimicrobial stewardship and encouraging infection control. It far surpassed our expectations with regard to clinician engagement and the further work that has ensued. All of this can only have a positive impact on safeguarding antibiotics for the future of our children.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?

1) Encouragement to sign up to become an antibiotic guardian
2) Use of ‘Guide to treat your infection’ endorsed Public Health England, NHS Scotland and other bodies. Advising patients/parents that common ailments are self limiting and when they should consult their GP.
3) Teaching children (and parents!) the importance that good hand hygiene prevents the spread of infection. Good infection control measures reduce antibiotic use.

Key outcomes of project?: Our main desired outcome was to engage families and teach the importance of infection control through fun and spread the word regarding antibiotic resistance.
Other key outcomes were that created invaluable links with other members of the healthcare team and highlighted the importance of antimicrobial stewardship being the responsibility of everyone. We raised the profile of the local AMT, even in simple terms of being able to put names to faces and establish friendly links for people to ask questions. Development of further improvement projects as a result of our EAAD promotion which embeds antimicrobial stewardship into local and national practice.

How is the project to be developed in the future?: We hope to expand on our success, by running further promotional days within the children’s hospital with different fun and interactive activities with the desired aim of recruiting more antibiotic guardians. We have also reported back our success to the Association of Scottish Antimicrobial Pharmacists and have put forward an agenda to educate other children and families within other health boards. Our ultimate goal would be to engage with local councils to see if we could incorporate the importance of antimicrobial stewardship into schools